PlagueWatch 2020-23 - Coronavirus

[sagegrouse]

His ~ 50 small businesses probably employ 1,500 or more aggregate employees. Maybe he only gets $20 million for free. It’s a hard life!

Great, I’m back to my $25-50 million estimate. Life is not so hard anymore!

He might not qualify under the affiliation rules. Curious if you have read about the program?

I don't regularly work these rules but am involved with three small businesses are applying for loans through CARES PPP.

The Small Business Administration will determine who is deemed "small," as it does for thousands of federal contractors. There is a size standard based on industrial codes (NAICS), expressed either in revenue or number of employees. Moreover, an owner or a large company cannot just create a bunch of small businesses that qualify. That's the "control issue." Then there are the "affiliation rules," in which a single individual is not allowed to create multiple supposedly independent businesses.

SBA will be very busy the next few weeks or months.

[House G]

An Australian lab determined that ivermectin is effective against SARS-CoV-2 virus in vitro. This adds another hopeful avenue toward treating COVID-19 with a long-established, readily available med.

Perhaps more immediately interesting news, though, is that emergency & critical care physicians in the US are compiling loads of experience in the past week. As a result, there **may** be a paradigm shift in management of COVID-19 in the emergency and ICU settings - note, this is still very early in the process...if it happens at all. Thus far, COVID-19 has been approached using established protocol for acute respiratory distress syndrome (ARDS), with current guidance including a quick readiness for invasive ventilation if necessary. Here's an excellent technical video walking through the rationale of the clinical care management (eg prone positioning, cardiac monitoring, ventilation settings).

However, some physicians are signalling that the COVID-19 disease process is not behaving like typical ARDS and caution AGAINST intubating when the data would normally suggest intubation (specifically, oxygen saturation levels which would normally indicate that an ARDS pt was crashing...COVID-19 pts seem able to tolerate this hypoxemic state and may be more similar to pts with dyshemoglobinemia or high altitude pulmonary edema). This is significant because:

1. intubated COVID-19 patients have high mortality and are anecdotally known to go downhill suddenly and quickly. It is possible that intubated pts simply do worse because the worst pts are the ones who need intubation, but it's also been suggested that the intubation/ventilation itself is worsening the condition (probably due to pressure injury to the alveoli (air sacs), causing extravasation of fluid into the lungs, or secondary to a cardiovascular response)
2. there may be a shift toward extended management of pts without invasive ventilation. This is good news because pts would be maintained on more available resources, including things like CPAP machines designed for home use if need be! However, it is unclear if CPAP and high flow nasal cannula would aerosolize the virus, increasing the risk of spreading. Sooooo, there would be less need for ventilators but stricter need for personal protective equipment
3. if we find that the process is analogous to dyshemoglobinemia or HAPE, it gives hints at more treatment approaches

Bonus 1: Clinical management guidelines 1 and guidelines 2 for DBR members who want to get in the weeds. These guidelines have already incorporated the new paradigm to avoid invasive ventilation
Bonus 2: An NYC MD's Video1 and Video 2 about his dissatisfaction with intubation in COVID-19, for DBR members who need to get their information in a more dramatic form (his Twitter)

Very interesting to me. I think it’s amazing how quickly this information can be disseminated through the internet/social media so that other physicians may benefit from the experiences of those in these hot zones. I also find it interesting that most younger (and presumably healthier) patients seem to be able to weather this thing but
that’s not always the case. I remember reading Michael Crichton’s book “The Andromeda Strain”.
There may be some parallels with regard to the investigation into Covid-19 and its treatment.

[budwom]

I've seen an emergency room physician from Teaneck, NJ (major outbreak area) on TV a lot recently, noting that he's benefiting from reading papers from China and Italy wherein they discuss a lot of interesting observations which are helpful. Not studies, of course, but relevant anecdotal information.

[Dr. Rosenrosen]

I've seen an emergency room physician from Teaneck, NJ (major outbreak area) on TV a lot recently, noting that he's benefiting from reading papers from China and Italy wherein they discuss a lot of interesting observations which are helpful. Not studies, of course, but relevant anecdotal information.

So does anyone here know if there is some central repository or “clearinghouse” somewhere that is collecting all this potentially valuable information to further enhance the dissemination of such potentially valuable information? I imagine some physicians/clinicians/nurses have time to read up but others may be too flat out on the frontlines to be able to look for, let alone consume and apply, such knowledge.

Anyone know?

[fisheyes]

So does anyone here know if there is some central repository or “clearinghouse” somewhere that is collecting all this potentially valuable information to further enhance the dissemination of such potentially valuable information? I imagine some physicians/clinicians/nurses have time to read up but others may be too flat out on the frontlines to be able to look for, let alone consume and apply, such knowledge.

Anyone know?

Found this:

https://www.zdnet.com/article/as-cov...sualized-ever/

[bedeviled]

management of a new, bizarre disease from pulmonary/hemodynamic/physiologic/critical care perspectives

As y'all know, the ventilation-perfusion transition is complex and absolutely critical, not just for fuel & waste, but for pH/buffering. I can't imagine how difficult it could be for ICU providers to make life&death decisions against their hard-earned instincts. In one of the links, there's a pic of a lady playing on her phone with a O2 sat of 54%, lol.

is there theoretically a role for a pulmonary vasodilator such as sildenafil (serious question)? I'm not a critical care doc, but I might be called upon by the hospital to help if there are shortages

Shortages of personnel or of sildenafil??? Is that what you hoarded instead of bathroom tissue? I thought donating my N95s was a sacrifice. Well, thanks for whichever manpower you can provide!

The push for permissive hypoxemia and theories of why it's possible are still novel, but sildenafil has been thrown out there. There is a small Covid-19/sildenafil clinical trial currently recruiting in Wuhan.

I've seen an emergency room physician from Teaneck, NJ (major outbreak area) on TV a lot recently, noting that he's benefiting from reading papers from China and Italy

As House G notes, it's super cool how the clinicians are coming together to share info. There are COVID clues that seem to have surprised some in the US (eg rashes & disseminated intravascular coagulation), but we have China's & Italy's thoughts in English now, and the US is rolling!

So does anyone here know if there is some central repository or “clearinghouse” somewhere that is collecting all this potentially valuable information to further enhance the dissemination of such potentially valuable information?

It probably depends on what the specific needs are. There's so much investigation out there (modeling, management, treatment, prevention); I haven't seen a repository.
fisheyes' link for epidemiology data is thorough.
For the practical management stuff, my post this AM had links to a couple frequently updated critical care management guidelines compiled from worldwide physician input. And, the COVID-19 Data Sharing Project, out of NYC, is "making anonymized patient-level data from our COVID ICU openly available to assist clinicians who haven't seen critically ill coronavirus patients yet–but will, soon. Data updated in near real time."
If any treatment proves to stand above the crowd, I suspect we'll hear about it without having to search around.

[devildeac]

As y'all know, the ventilation-perfusion transition is complex and absolutely critical, not just for fuel & waste, but for pH/buffering. I can't imagine how difficult it could be for ICU providers to make life&death decisions against their hard-earned instincts. In one of the links, there's a pic of a lady playing on her phone with a O2 sat of 54%, lol.

Shortages of personnel or of sildenafil??? Is that what you hoarded instead of bathroom tissue? I thought donating my N95s was a sacrifice. Well, thanks for whichever manpower you can provide!

The push for permissive hypoxemia and theories of why it's possible are still novel, but sildenafil has been thrown out there. There is a small Covid-19/sildenafil clinical trial currently recruiting in Wuhan.

As House G notes, it's super cool how the clinicians are coming together to share info. There are COVID clues that seem to have surprised some in the US (eg rashes & disseminated intravascular coagulation), but we have China's & Italy's thoughts in English now, and the US is rolling!

It probably depends on what the specific needs are. There's so much investigation out there (modeling, management, treatment, prevention); I haven't seen a repository.
fisheyes' link for epidemiology data is thorough.
For the practical management stuff, my post this AM had links to a couple frequently updated critical care management guidelines compiled from worldwide physician input. And, the COVID-19 Data Sharing Project, out of NYC, is "making anonymized patient-level data from our COVID ICU openly available to assist clinicians who haven't seen critically ill coronavirus patients yet–but will, soon. Data updated in near real time."
If any treatment proves to stand above the crowd, I suspect we'll hear about it without having to search around.

I found these two articles from links you provided:

COVID-19: consider cytokine storm syndromes and immunosuppression: https://www.thelancet.com/journals/l...628-0/fulltext

"...suggesting that mortality might be due to virally driven hyperinflammation." To me, this raises the question of a role for steroids for treatment.

Japanese flu drug 'clearly effective' in treating coronavirus, says China: https://www.theguardian.com/world/20...rus-says-china

"...Zhang Xinmin, an official at China’s science and technology ministry, said favipiravir, developed by a subsidiary of Fujifilm, had produced encouraging outcomes in clinical trials in Wuhan and Shenzhen involving 340 patients.

“It has a high degree of safety and is clearly effective in treatment,” Zhang told reporters on Tuesday."

[budwom]

^ seems to me that we are seeing signs of a very good bottoms up approach to dealing with the crisis, and a poor tops down approach (if I may use some business jargon).

[wilson]

^ seems to me that we are seeing signs of a very good bottoms up approach to dealing with the crisis, and a poor tops down approach (if I may use some business jargon).

"Bottoms up" is pretty much my approach to life these days...

[budwom]

"Bottoms up" is pretty much my approach to life these days...

I read where the Governor of Massachusetts is being prodded by some to close liquor stores (fears of spousal abuse)...Prohibition got an early start that way...I suspect he has the wisdom to ignore this advice, though we all hope those who drink can behave themselves.

[swood1000]

A few things:

1. As I said before, having a test that can be applied to the masses will be hugely important. But not because it will help us determine when we have reached herd immunity though. Instead, it will be because we can reduce the R dramatically with better ability to identify cases.

I use the standard definition of herd immunity given in this article:
 

Herd immunity is "the resistance of a group to attack by a disease to which a large proportion of the members are immune, thus lessening the likelihood of a patient with a disease coming into contact with a susceptible individual."

See also the medical dictionary definition:
 

a reduction in the probability of infection that is held to apply to susceptible members of a population in which a significant proportion of the individuals are immune because the chance of coming in contact with an infected individual is less

Under this definition herd immunity is an incremental thing that is increased as a larger percentage of the population becomes immune, as well as when the contact rate among those susceptible to the disease decreases. When herd immunity reaches a certain level (the herd immunity threshold) then the infection will theoretically be eliminated in the population. An antibody test will tell us what level of herd immunity currently exists in the population. It is true that you can find some articles using the term herd immunity as shorthand for the herd immunity threshold. However, I use the standard definition given above, which I made abundantly clear in my last post when I used the term “partial herd immunity,” similar to how it is used in these studies:

From Healthline: “People in Norway successfully developed at least partial herd immunity to the H1N1 virus (swine flu) through vaccinations and natural immunity.”
NCBI study: “Vaccination against pertussis has resulted in reduction of the infection pressure of Bordetella pertussis (partial herd immunity), but the circulation of B. pertussis has persisted as a consequence of waning of vaccine-induced and naturally acquired immunity.”
NCBI study: “Factors believed to be responsible include partial herd immunity limiting virus spread in all but the most favorable circumstances…”
Influenza study: “The “partial” herd-immunity generated by past history of invasions on the host
population can have a huge impact on the quantitative dynamics of the “flu” at the population level.”
Pandemic flu study: “Vaccination reduces the size of the epidemic through both direct protection of 15% of the population and indirect protection of others through partial herd immunity.”

Why you ignore this and insist that the only use of herd immunity is when the herd immunity threshold has been reached (when the disease can no longer spread and which would require that 60% or more of the country be infected) is puzzling.

2. Worth pointing out that even if only 14% of China’s cases (per that Science article) have actually been documented, that would put their case fatality rate around 0.6%, or six times greater than that of the flu. Further evidence that this thing is much more deadly than the flu, even ignoring infectiousness.

In your responses you keep bringing up a comparison with flu but none of my posts on this topic has made any comparison between Covid-19 and the flu so it’s an extraneous argument. The bottom line is that we lack the data so it’s all just guesswork.

If we see a 0.6% fatality rate in the US, with 60% of the US population needing to get infected to achieve herd immunity, that would mean over 1 million deaths.

You are describing the "herd immunity threshold” (HIT). We don’t need to infect 60% of the population before the number of people with immunity starts to provide a benefit to those who are susceptible. Partial herd immunity exists prior to the point at which we reach HIT. It just makes common sense. If on an average day a susceptible person interacts with ten people his risk is lower if two of the ten can’t transmit Covid-19 to him, and his risk is reduced as that immune percentage of the population rises.

Applying that same 86% undiagnosed percentage to the US data would suggest our case fatality rate is at least 0.3%, and that is assuming nobody else who has it right now dies of it. Given the death rates the last few days, it seems safe to assume we’ll at least double our death rate among currently-active cases.

The 86% came from one study. Another study said that half of Great Britain has been infected. An article said that if we assume that there was an epidemic seed in the U.S. on Jan. 1, then by March 9 about six million people in the U.S. would have been infected, doubling roughly every three days, so that by this time there must be a huge number of people with immunity. You talk about the “death rates the last few days” but you have no idea what the death rates have been. You only know the number who have died. My point is that it’s all just guesswork until we get representative samples and do the antibody testing.

3. R_0-based herd immunity relies on homogeneity of the population. If you relax restrictions within a state, the cases will shift to where the susceptibles are. It takes a VERY delicate balancing act and/or a really low number of active cases to walk the tightrope or relaxing restrictions.

Agreed

4. The real point of social distancing is to NOT reach the point of herd immunity. It is to try to reduce the R_0 much as possible. Social distancing extreme enough and the R gets well below 1. Keep the R well below 1 long enough and the disease should die out - not because of herd immunity, but because it stops reproducing.

Again herd immunity as herd immunity threshold. R₀ is a measure of the average number of secondary cases generated by a “typical” infectious person. This average depends on how the various members of the population interact, including their social distancing habits. Herd immunity is the resistance of a group to attack by a disease to which a large proportion of the members are immune, thus lessening the likelihood that a patient with a disease will come into contact with a susceptible individual.

If you relax social distancing/lockdown while there are still plenty of new cases occurring (even if the number of new cases is rapidly declining) there will be a rebound of disease. Because we aren’t going to get anywhere near herd immunity. What you’ll see is that the hot spots will just keep bouncing around to where the proportion of susceptibles is high. As long as the infected population is well below 70%, the R will go right back up when you open things up. The hope is not to win because of herd immunity, but rather win by reducing the interactions until the disease is starved out (or until there is a treatment or a vaccine).

So the hope with the lockdown is to bring the R down low enough for long enough that we weed out the cases to the point that when we reopen there are very few active cases, and as many are known as possible. Social distancing allows us to ramp up testing and reduce new infections and growth rate and bleed out the known active cases, all while reducing the burden on the healthcare. If we can slow the infection rate to the point that we can catch up on testing and track cases, we can work to REALLY reduce the R even more and avoid hitting a point where herd immunity stops the disease. And in doing so, avoid having A LOT more deaths.

The only way herd immunity would help us is if the case identification rate is more like 1% (I.e., that 99% are going undiagnosed). Otherwise, the death rate is just too high to make waiting for infection-based herd immunity to save us a realistic option.

You seem to believe that the spread of a disease in a population is not slowed when a certain percentage of the population is immune. Is that correct? Certainly social distancing inhibits the spread of a disease, but so does partial herd immunity, and both will be taken into consideration when considering when we should start going back to a normal life.

Do you accept former Food and Drug Administration Commissioner Scott Gottlieb’s recommendation that we can begin lifting the physical distancing measures and allow the vast majority of businesses and schools to open when these conditions exist:
 

• There is a sustained reduction in cases for at least 14 days,
• Hospitals in the state are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care,
• The state is able to test all people with COVID-19 symptoms, and
• The state is able to conduct active monitoring of confirmed cases and their contacts.

[richardjackson199]

I read where the Governor of Massachusetts is being prodded by some to close liquor stores (fears of spousal abuse)...Prohibition got an early start that way...I suspect he has the wisdom to ignore this advice, though we all hope those who drink can behave themselves.

It's interesting. I think it's wise to keep liquor stores open. Cutting some alcoholics off from supply immediately is dangerous. What we don't want is them going into delirium tremens withdrawal and showing up into emergency rooms taking up more needed critical care resources right now. Alcohol withdrawal and DT's can be quite lethal and life-threatening.

I understand the counter argument that we don't want people drinking more right now causing more problems, and some of that is going to happen too. It's a tricky issue.

My gut is it's best to keep the liquor and beer stores open. And my gut is definitely biased.

[Bob Green]

...though we all hope those who drink can behave themselves.

My biggest behavioral issue these days is falling asleep way too early.

[devildeac]

It's interesting. I think it's wise to keep liquor stores open. Cutting some alcoholics off from supply immediately is dangerous. What we don't want is them going into delirium tremens withdrawal and showing up into emergency rooms taking up more needed critical care resources right now. Alcohol withdrawal and DT's can be quite lethal and life-threatening.

I understand the counter argument that we don't want people drinking more right now causing more problems, and some of that is going to happen too. It's a tricky issue.

My gut is it's best to keep the liquor and beer stores open. And my gut is definitely biased.

Somewhere upthread, after I wondered about this same "dilemma," bundabergdevil postulated that people in his area would begin rioting and/or looting if the ABC/liquor stores were closed. Interesting perspective from either side.

[devildeac]

My biggest behavioral issue these days is falling asleep way too early.

You need a bigger garden to occupy your spare time .

[richardjackson199]

You need a bigger garden to occupy your spare time .

Or like Roy Scheider or more recently probably Governor Cuomo once said, "you're gonna need a bigger boat"

(Or perhaps more accurately some better admissions criteria for the USNS Comfort)

[budwom]

Our governor has been pretty solid during the crisis, but when asked why he allowed liquor stores to be open, he said it was because many are attached to grocery stores. That's true, but seriously, most people are able to enjoy moderate drinking without misbehaving, and shutting off the liquor / alcohol supply at this point would simply be a very poor decision.

[richardjackson199]

Somewhere upthread, after I wondered about this same "dilemma," bundabergdevil postulated that people in his area would begin rioting and/or looting if the ABC/liquor stores were closed. Interesting perspective from either side.

does bundabergdevil live in College Park?
(rather than Australia)

[Neals384]

Response to the bolded remark. Imagine getting paid $53,000 or less a year and being asked to continue in a high risk position without adequate PPEs. The worst of people? I hardly think leaving a low paying job that cannot provide adequate protection against a potentially deadly virus is "the worst" of people. I'm mostly talking about those working in assisted living facilities, but, really, all of these essential business employees probably deserve some hazard pay.

My brother-in-law has one of those jobs. He's not in Vermont, but if he gets a chance to increase his pay without the work and risk of his current job, he'll do it in a heartbeat. I won't think any less of him if he does.

[Devilwin]

does bundabergdevil live in College Park?
(rather than Australia)

Got nearly three gallons of good old NC Shine, straight out of Wilkes County..Willing to share!