Tagged SARS-COV-2

The Virus Has a Vote: Update to Students April 12, 2020

“Whatever happens over the summer, this virus is going to be back with us in the fall. And so we have to prepare for the fall as well.” Dr. Ashish Jha, Harvard School of Public Health, 4-5-20
“What we are doing is working, and therefore we need to keep doing it.” Dr. Anthony Fauci, 4-9-20
“If we are not expecting a second wave, or a mutation of this virus, then we have learned nothing.” Gov. Andrew Cuomo, 4-10-20
“The worst thing that can happen is we make a misstep and we let our emotions get ahead of our logic and facts and we go through this again in any manner shape or form.” Gov. Cuomo, 4-11-20
“Well you know I did just finish a 24 hour shift overnight so forgive me if I’m a little brutally honest, but at some point we have to accept that we open up the economy and X amount of people are going to die and the question is what is that number and what are we willing to accept. You know as we flatten the curve, if we don’t time this right there may be another spike, and this won’t be flattening the curve, it will be flattening the roller coaster. So myself, the front line health providers, we don’t want to flatten this curve, we want to crush this curve.” Dr. Sudip Bose, Emergency Physician & Iraq War hero, 4-11-20

These quotes from experts and leaders over the past week, in order of when they were said, are more eloquent in their message than I could be. The so-called first law of medicine, If it’s working, keep doing it, is operating here. But so is the first law of life: Hope for the best, but prepare for the worst.

Good News

There is a lot of good news to celebrate this Easter Sunday, and it’s more than just hope.

  1. New York, by far the worst hotspot in the U.S., has convincingly passed its peak of intubations, and that means the worst of the worst is over for New York. Daily death rates continue to be tragically high, but they are a lagging indicator and they too are plateauing. The overwhelming of hospitals has happened, but it may not get worse.
  2. Christopher Murray’s model, often cited by the Federal government task force, from the University of Washington’s Institute for Health Metrics and Evaluation (IHME), is now projecting a total of 61,545 deaths for the U.S., down from 100,000 or more projected just a few weeks ago.
  3. The West Coast states, notably Washington where the first U.S. cases were, but also Oregon and enormous California, have done an amazing job of keeping this in control from the beginning.
  4. Clinical trials of convalescent plasma, antibodies from same, hydroxychloroquine, remdesivir (an antiviral), and other potential treatments are proceeding. Some are being prescribed under the principle of “compassionate drug use” approved by the Food and Drug Administration (FDA), although their effectiveness is a long way from proven. Many promising vaccine candidates are under study.
  5. Testing is being gradually ramped up, with viral testing (to see if you have it) up to between 100,000 and 200,000 a day. Antibody testing (to see if you’ve had it) has begun in some areas.
  6. Some top Washington officials say the country may go back to normal activity on May 1. Others see a carefully planned phase-in of normal activity over the subsequent weeks to months, guided by testing, testing, testing.

Bad News

  1. Many parts of the country are behind New York on the curve. Some will succeed as the West Coast states have. Others, where social distancing has not been followed, may be disaster zones.
  2. When you read the fine print on the IHME website, you find that they are only claiming to model “the first wave” of the pandemic. They have nothing to say about future waves. (Below I discuss a more realistic conceptual model that is speculative but helps me to think about what our longer-term future may look like.)
  3. Very few states have done what the West Coast states have done from the outset, and some have done the opposite. If Los Angeles relaxes its controls too soon, it is projected to look like New York by late summer.
  4. Early results from small clinical trials have concluded that it is ethical to continue them. This means two things: a) they are not doing obvious harm to volunteers; b) they are not so dramatically effective that the trials have to be stopped so that everyone gets the treatment and no one gets a sugar pill. They could still turn out to be useful, or have bad side effects, or both. If a vaccine is available in 12 to 18 months, it will be by far the fastest vaccine development time for any novel virus.
  5. Testing remains woefully inadequate across the board, and claims to the contrary are demonstrably false. There are not enough viral tests for health workers at risk, much less for a suitable sample of Americans. If we do 200,000 tests a day, it will take half a year to test 10% of the country. Antibody tests, which if they work well enough can probably clear many people to go back to normal activity, have barely begun.
  6. The IHME models, which are the ones quoted by and guiding Federal government officials, are premised on current strict levels of social distancing continuing through May. Earlier relaxation of vigilance is projected to increase deaths, as mentioned by Dr. Sudip Bose, the emergency physician and war hero quoted above.

The model in the graph below (or attached) is a conceptual rather than precisely mathematical model, and I have problems with it, but I think it broadly shows how we should be thinking. It comes from an odd place, namely Morgan Stanley investment research (thanks to Dr. Craig Hadley for alerting me to it; the head of the unit that produced the graph is Matthew Harrison). It has errors (it assumes that children can’t pass the virus on and it is too optimistic about the timetable for a vaccine). It may have been updated today, and I will let you know if I can access it. Meanwhile, it is conceptually valuable in showing us how to think about how this will unfold. You know I consider you leaders. Use your excellent brains to navigate uncertainty, especially when so much depends on how we steer.

Note: I made a mistake in an earlier announcement about the effect of the Great Recession on life expectancy. It actually increased life expectancy and reduced mortality at all ages. The improvement was due to decreased deaths from heart disease, auto accidents, and homicides, among other causes. There were increases in opioid related deaths and suicides but these did not offset the improvements. Improved life expectancy in the Great Recession has been shown in both the U.S. and Europe. A similar paradoxical effect has been clearly shown for the Great Depression of the 1930s and is probably true of other economic downturns. I did see one study claiming to show the opposite, and that’s what I expected, but the weight of evidence goes against my expectation. That’s science for you.

Stay safe, Dr. K

 

 

Letter to my students on COVID-19, April 5, 2020

“I skate to where the puck is going to be, not where it has been.”

Wayne Gretzky, widely viewed as the greatest hockey player of all time

Volunteers
Volunteer Georgia health professionals on their way to New York

Dear Students,

This is my outlook on the COVID-19 pandemic as of Sunday, April 5, 2020. I pay close attention to many sources of information and sift or curate them as best I can. This is a constantly changing situation and you should not rely too much on me. As I’ve told you before, you are the future leaders of our country and our world and you must ultimately lead, not follow. Please let me know if you have information that is different or if you think I’ve made a mistake.

In my favor, I have been talking to you about this virus since our class began in January and I updated you every Tuesday and Thursday until Emory closed. Since then, I’ve been updating you every few days to a week. I try hard to get this right and not to scare you too much. I did try to scare you when we talked about Ebola, polio, and the flu pandemic of 1918-19, and I always said the next pandemic was a matter of when, not if. I did not know that this was it when I first mentioned it in January, but now everyone knows.

Good News

  1. The CDC has found that homemade masks or bandanas covering your mouth and nose when you leave your house will help to slow the spread. First Lady Melania Trump endorsed this, as have many other opinion influencers. It is not a substitute for social distancing, hand washing, and other measures, and it would be disastrous if people thought it was. It is an added measure on top of all those things. It is designed mainly to protect others, not you. When you breathe, talk, laugh, cough, or sneeze into the mask, the cloth will capture half or more of the moisture, and that means half the viruses if you are infected but don’t have symptoms. (You can experiment by spraying water into a glass through a cloth; only some moisture gets through.) If you do have symptoms, you must assume you have COVID-19, and self-quarantine completely until you are symptom free for three days. Call your health professional for specific instructions, and don’t dial 911 unless you are short of breath. Do not try to buy medical-grade masks; you will be taking them away from medical professionals and you may cause some of them to become sick and die. An example of how to make a mask is here.
  2. Rapid tests for the virus itself are slowly becoming more available, and antibody tests for whether you have already had the virus but recovered will become available more slowly. Widespread testing will be a game changer for control of the American epidemic, as it has been in China, South Korea, and other places.
  3. We have real leaders in this country who are regularly speaking out: Gov. Andrew Cuomo of New York, (Republican) Gov. Larry Hogan of Maryland, Speaker Nancy Pelosi, Dr. Anthony Fauci, and others. They speak honestly and to the best of their ability accurately about how to beat the virus and mitigate its economic effects. They don’t just call it a war, they act like it’s a war. Governors of many states are bypassing a mostly passive Federal government and attempting to help each other.
  4. Fortunately not all states are experiencing this wave of the pandemic simultaneously, so people and equipment are beginning to move where they are most needed. New York has by far worst crisis, so it is calling loudly for help. The state of Oregon sent 140 ventilators* to New York; this is a small fraction of what will be needed but it is a very important symbol. Twenty-two thousand health professionals from other states have gone to New York to volunteer. New York is worst now, but it will be better first, probably within a few weeks. It will then have excess ventilators and professional volunteers to send to other states as the crest of the wave moves around the country.
  5. Studies of treatments are proceeding, including convalescent plasma donated by people who have recovered from COVID-19; antibodies derived from that blood fraction; hydroxychloroquine, which has antiviral action in lab studies (and which I took for years to prevent malaria when I was in Africa, and then again for years for a skin condition); azithromycin, an antibiotic with possible antiviral actions; and specific newer antiviral drugs. I am hopeful that one or more of these will prove effective within weeks to months, much sooner than we have a vaccine. However, it is immoral to take hydroxychloroquine for prevention or self-medication at this time; it is not proven to work, and it is in short supply for people with lupus and other autoimmune diseases, who desperately need it.

Bad News

  1. We have inadequate leadership at the very top in Washington, giving out inconsistent messaging, with no national strategy for supply and logistics for COVID-19 care—ventilators, N-95 masks, shields, gowns, and other personal protective equipment (PPE), and consistent only in predicting unrealistic time frames for ending the pandemic and getting the country back to work. The government in Washington has declined to order a national lockdown for social distancing, to mobilize the armed forces to help the hospitals and the states, to order manufacturers to make desperately needed ventilators and PPE, or even to set an example for our people in things like social distancing and wearing of masks.
  2. The hospitals in New York, Detroit, and New Orleans are already overwhelmed, but the word overwhelmed will be given new meaning in those cities in the next week or two. Large numbers of health professionals, police officers, firefighters, EMTs, and other first responders are already sick and more will be. Many who are not sick are crying every day. Some, understandably, are quitting in fear of bringing this deadly virus home to their families. Similar effects will be felt in other cities throughout the country over the coming weeks. Hospitals built out in convention centers and mega-tents were ready but almost empty for days until they were allowed to take COVID-19 patients. U.S. Navy hospital ships are almost empty because they still will not take COVID-19 patients.
  3. Many people still do not take social distancing seriously. Gov. Kemp of Georgia reopened the beaches and parks in our state after closing them. In many states social distancing is not enforced and not likely to be until it is too late. According to current official government projections, the United States will see a minimum of 100,000 to 240,000 deaths if we strictly follow social distancing and other precautions. We are not yet doing that. The number of deaths in the U.S. passed 9,000 today and is doubling approximately every 3 days, which would put us over a hundred thousand in 10 days or so. If we act properly and lengthen the doubling time to 4, 5, or 6 days, it will take longer to get there. But bear in mind that the increase continues to be exponential at those longer doubling times.
  4. The Congress, especially the Senate, has offered too little too late to offset much of the disastrous economic effects of the pandemic, and as usual the poor and minorities will suffer most of the consequences, including worsening health, inadequate access to care, and premature and preventable death. Poor families have the greatest psychological vulnerability to the post-traumatic effects of this experience. Families at all socioeconomic levels have seen increases in domestic violence.
  5. Something that I have been reluctant to mention in these announcements, but which more and more authorities are considering, is the possibility that this is only the first wave. The flu pandemic of 1918-1919 had three waves. We must watch closely what happens in China, South Korea, and Japan as they declare the virus beaten and relax social restrictions. The virus is currently spreading in the Southern Hemisphere of the planet and may get worse in their winter, even as it may get better at the same time in our summer. I wish I could promise you that Emory will have live classes again in the fall.

We all need to adapt to situations that are psychologically abnormal. You can do it. Facetime or Skype with your friends and family. Have Zoom rituals, club meetings, and parties. Go outside with a homemade mask and run or walk while social distancing. Watch those movies you always wanted to see, binge-watch those hot TV series, even maybe read a book that’s not assigned for school.

Whether we have one wave or more, we will in time have treatments and a vaccine. Those who have had the virus and recovered will slowly begin normal life again. They will help restart the economy. This will end.

Your great-grandparents lived through World War I and the flu pandemic of 1918-1919. Your grandparents lived through the Great Depression and World War II. Your parents lived through the Vietnam War, 9/11, terror of terrorism, and the Great Recession. If any of your generations were in the developing world, they saw and lived through other terrible things. You can live through this. Just do what you’re supposed to do and help others as best you can. Do your homework and study. Come to class online. You are still a college student and you still have great dreams. You will live to see your dreams come true.

Dr. K

  • A note on terminology: I said in an earlier announcement that a ventilator is the same as a respirator. The Medline Plus dictionary of the U.S. National Library of Medicine says, “A ventilator is a machine that breathes for you or helps you breathe. It is also called a breathing machine or respirator.” However, other authorities use the word “respirator” to mean something entirely different, namely the top-flight hospital grade N-95 masks that screen out at least 95 percent of airborne particles not carried in oil. Because of the two meanings of “respirator,” I will avoid this word going forward. COVID-19 is the name of the disease caused by one of many coronaviruses; this coronavirus is designated SARS-COV-2. However, we all know that today “coronavirus” or even just “the virus” will pretty much get the message across.

Summary I sent my students on Wednesday, with preface/update Saturday

Photo by CDC on Unsplash

Since Wednesday the number of identified cases in the US has gone from 3,500 to 20,000, partly because of increased testing. Testing remains woefully inadequate so the real number of cases must be much higher. The US deaths have passed 200. More young people are sick and dying. Mardi Gras (Feb. 26) made New Orleans a hot spot and Carnival encouraged transmission throughout Latin America. Spring Break on Miami Beach will have a similar effect. US hospitals are begging for supplies, personal protective equipment (PPE), and ventilators (respirators),  and the government in Washington is so far not demanding that factories repurpose to produce these items. Barring drastic action, hospitals will be overwhelmed in two or three weeks, heroic health professionals will be dying at higher rates, and remaining doctors will have to decide who lives and who dies. Don’t become one of those casualties. Protect them, yourself, and those around you.

Use this source for daily future updates, interactive maps, and reliable information in days to come: https://www.nytimes.com

COVID -19 UPDATES

WEDNESDAY March 18, 2020, 8am

Here is what has changed in the past week:

  1. The WHO declared a worldwide pandemic last Wednesday
  2. Italy is probably the worst hit, with hospitals completely overwhelmed; Iran may be worse, but we have no reliable information from there.
  3. France announced a nationwide lockdown two days ago, noting a rise in severe cases in young people around the country.
  4. The U.S. President announced a national emergency & discouraged gatherings of more than 10 people.
  5. Testing became more widespread, but still lags far behind that in other countries.
  6. Testing proved that the virus is being spread by people who have no symptoms, mainly the young; the young may not know it, but they are killing the old.
  7. Stock markets crashed & economies shut down in many countries and U.S. states.

Here is where we are this morning:

  1. Many leading U.S. hospitals are seeing a dramatic rise in cases and expect to be overwhelmed soon.
  2. Many governors are calling for U.S. army and other national aid that isn’t there yet.
  3. Approximately 3,500 cases are identified in the U.S.; experts say there are 10 unidentified cases for every identified one, so the real number is around 35,000.
  4. Despite lockdown in many areas & the closing of restaurants, bars, gyms, theaters, sports events, etc. by law, experts agree social distancing is far less than needed.
  5. Hospitals are running out of supplies needed to protect health care workers.
  6. Ventilators (respirators; breathing machines) cannot be manufactured fast enough to keep up with the need; doctors will have to decide who will get treatment & who will be let go of, just like in a war zone.
  7. Doctors and nurses are getting the virus from their patients and going home; they cannot be replaced, even if machines and supplies can.
  8. The Secretary of the Treasury now warns that U.S. unemployment can go from 3 to 20 percent.
  9. Economists widely agree that we are in or are “sliding into” a recession which cannot be avoided, and which could be worse than the Great Recession of 2008.
  10. No one can tell us how long this will last or how bad it will get.
  11. Epidemics in warm countries seem to disconfirm the hypothesis that summer weather reduces the number of cases.

My advice to you right now:

  1. Stay home and urge anyone in your family who is not performing a vital service (hospital work, food and medicine deliveries, grocery stores, pharmacies) to stay home too.
  2. Maintain contact with friends and family by phone, Skype, etc.
  3. If you must leave your home, stay six feet away from any other person.
  4. If you have traveled anywhere by air, train, or bus, stay away from your grandparents & all older people for at least 14 days. Stay in touch with older people by phone & have food and medicine delivered to them if you can.
  5. Develop, & urge everyone you know to develop, skills for working, preventing isolation & sadness, & being entertained at home. If you must get out, walk in the woods or in a park where you can avoid getting within 6 feet of another person. If you have to walk the dog, use the same precautions.
  6. If you are coughing & sneezing without a fever, stay home & call your doctor. Do not just show up at a medical office or emergency room. Get a test if you can find one.
  7. If you develop a fever and feel very weak, call 911.
  8. If you are in the U.S., check the CDC web page every day:

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-in-us.html (Links to an external site.)

  1. Wherever you are, check your national, state or provincial, and city or local health department websites every day.
  2. Wash your hands for 20 seconds many times a day; avoid touching your face as much as possible; frequently wipe down all surfaces from cell phones to kitchen counters with alcohol wipes; gloves & masks are in short supply, so use them wisely.

(Note: the photo above shows viruses in the coronavirus family, not SARS-COV-2, the causal agent of COVID-19, currently pandemic.)