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Three Things: Good (Family) News, Bad (COVID-19) News

[NB: Check the byline, thanks! / ~Rayne]

It’s absurd that I’m happy my college student child tested positive for strep throat. Whew, what a freaking relief that they only had a bacterial infection which has killed humans throughout history! Thanks to science we have effective antibiotics to treat this kind of infection, one of which is already working away and making said student feel better. …

Literally just heard from my student that Michigan State University now has one confirmed case associated with its campus. I can’t find a published report yet, more details later; so much for the brief respite provided by streptococcus.

Brace yourself for the bad news which so far is the nature of COVID-19.

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Drugs. Let’s get into them.

Beleaguered Italy is using the rheumatoid arthritis medication tocilizumab off-label to treat patients in ICU. It may become their protocol for treatment of patients who develop acute respiratory distress syndrome (ARDS).

COVID-19 apparently spawns a “cytokine storm” the same way the 1918 Spanish flu virus did. Health care professionals say COVID-19 kills via fulminating viral cardiomyopathy, (inflamed heart tissue), not hypoxia (suffocation due to lung failure).

The onset of inflammation can be sudden with the cytokine action but at a later stage in the infection, which is different from the 1918 bug. The Spanish flu affected mostly younger people whose immune systems over-responded to the virus, where COVID-19 affects older people whose bodies may already have inflammatory responses at work because of cardio vascular disease or diabetes.

(We don’t know yet why some young people without preexisting conditions have become very ill and in some cases have died. Some may be related to smoking, others could be related to an undiagnosed condition. More study will be necessary; in the mean time, young people should protect both themselves and the older and sicker people who could catch COVID-19 from them.)

China tried tocilizumab on roughly 20 patients and found this monoclonal antibody halted the storm, acting on interleukin 6. There’s a preprint unreviewed study online but I can’t open it now or would include it. An immunologist in Italy came to similar conclusion about the use of this med and consulted with Chinese docs. See this story in an Italian news outlet (open in Chrome and translate).

There are other meds being tested in China — antivirals remdesivir (mentioned in a previous post), favipiravir, lopinavir/ritonavir, umifenovir — but there I haven’t seen any information about their application treating COVID-19 cases as detailed as there is for tocilizumab.

Pharma manufacturer Roche has agreed to provide to Italy the tocilizumab which should not only help reduce burden on hospitals’ intensive care units but build a body of data about the drug’s success in short order. China has also approved the drug’s use on certain COVID-19 patients.

I want to emphasize here this is NOT a cure for COVID-19. It’s a treatment for patients whose heart and lungs are in distress, requiring intensive care and a ventilator. What this drug may do for many of these patients is prevent them from needing ICU and ventilation, while their bodies continue to fight off the virus.

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And more drugs — this time, antivirals.

A number of existing drugs have been revisited for repurposing against COVID-19 instead of their original intended purpose. Antiviral remdesivir and antimalarial chloroquine are among them.

Chinese researchers posted a paper about in vitro results, not peer reviewed (at least I didn’t see that it was).

There’s a paper about chloroquine alone; in vitro studies suggest it may work against COVID-19. Chinese researchers have a number of in vivo studies in progress, but no data has been released.

Chloroquine by itself as an effective therapy would be a miracle in that it’s an old drug now off patent and available as a generic, super cheap to produce. Can’t imagine Big Pharma would like this. But we won’t even face this conflict if we don’t get data from in vivo studies.

What I haven’t seen yet is adequate research related to the ACE2 receptor to which the COVID-19 binds itself to attack the body. There’s a study under way about a decoy protein drug called APN01, but I haven’t seen any details yet. A discussion about the ACE2 receptor can be found at this link.

I’d like to see more work done in related to ACE2 receptor mechanism. I’m worried we’ll end up too focused on antiviral remdesivir because there may be some political hijinks behind this drug.

Gilead Sciences, the drug’s manufacturer, shipped a bunch of this drug to China without federal approval, for tests which I assume mean human experimentation on actual COVID-19 patients.

About the same time this happened two weeks ago Gilead launched a merger/acquisition of Forty-Seven Inc, a clinical-stage immuno-oncology firm. It looks fishy yet likely to go unexamined because of the mounting desperation to have a drug therapy in hand before the anticipated explosion of cases arrives at hospital doors. In short, it’d be too easy to extort the U.S. into using this drug.

What really takes the cake is that a former Gilead lobbyist, Joe Grogan, is now the director of White House Domestic Policy Council. Grogan has already undermined Trump’s drug pricing initiative to the benefit of pharmaceutical companies. How do we know Grogan isn’t still representing Gilead’s interests, perhaps encouraging the government to turn a blind eye to corner-cutting on remdesivir?

~ 1 ~

Now it’s time for some more blunt talk with the family members.

I have a health care power of attorney or a health care directive prepared, signed, witnessed, copies distributed with one copy in my fire safe. If the worst should happen and the doctors need direction if I become incapacitated, my patient advocate is authorized to order what I want done. I have more than one advocate in a chain in case the primary advocate can’t act on my behalf.

I also have a will prepared, signed, witnessed, etc. If I’m picked off this month my kids will be disappointed that I haven’t yet finished Swedish Death Cleaning in the basement, but such is life and death. (Sorry, kids. You’re stuck dealing with all of the grandmas’ china sets and fragile antique lamps. Heh.)

I put the question to you now: are you ready? Have you done the legal legwork to help your loved ones whether family and/or friends if you’re incapacitated or *knock-on-wood* die?

Get it done if you haven’t. Stop putting it off because there’s no more time for lollygagging. We’d all like to deny we could get very sick, lose control of our lives, even die, but nature has a way of having the very last word if you don’t provide one.

Need a resource for that health care directive? See the folks at AARP — they have links to free resources for each state.

Just as important is establishing a plan for what friends/family should do if they can’t reach you. Trusted friends/family members should have current phone numbers, addresses, alternate key locations, emergency contacts, so on. They should also know who the patient advocates are and how to obtain access to the relevant documents if advocates don’t already have them.

This doesn’t have to be heavy; some of this effort we should have been doing all along as part of your disaster preparedness planning. Think about the families and friends affected by hurricanes Katrina and Maria, and imagine COVID-19 as a kind of hurricane which won’t flood your house but could certainly upend your life. You’d be prepared for a hurricane. Be ready for this one.

~ 0 ~

Treat this as an open thread. Tell us what’s in your basement or closets you need to unload because no one in your family wants it.

We Are In A Liminal Space In The COVID-19 Outbreak

Jim here.

This will be a short post, mostly to give us a new conversation thread.

But there are a few things that show us that reality is setting in in our society, if not necessarily in the White House. Virtually all professional and college sports are now shut down. Most universities are online only now. Many public schools have closed. More and more businesses are allowing employees to work from home.

We are now in a liminal space. Our church introduced me to that term while we are searching to replace a minister who recently retired. A liminal space is that time between what was and what will be. Thanks to COVID-19, normal is what was. It is gone and will be gone for quite some time.

Sadly, the beneficial effects of the social distancing that is finally coming into being will be delayed. Before we get to the benefits, we will experience the whirlwind that has been unleashed by months of denying the virus. This is just my estimate, but from all the published comparisons between the US outbreak and Italy’s, we are just a few days, probably less than a week, away from hospitals in the hot zones being over capacity and having to resort to excruciating levels of triage, literally choosing who lives and who dies.

Also, Republicans are being dragged kicking and screaming into the realization that our healthcare system and our gig economy mean that huge swathes of our population, without government intervention, face bankruptcy and death with no chance of treatment.

Each of us will have to choose how we live in this liminal space. For those who are able to go along with social distancing, we will need to learn to eat all our meals at home. We will need to find ways to occupy our time if we aren’t working and the usual sports entertainment is unavailable. But it is vital that we realize that despite being physically separated, we must embrace our shared humanity and the shared experience of facing the unknown together.

Maybe there’s someone who lives close to you who is even higher risk than you are. Perhaps you can give them a call and ask if they’d like you to leave a meal at their door. Maybe you have acquaintances whose employment has disappeared today. Maybe you can slip them a few bucks if you can afford it. Maybe they’d also like a meal at their door.

Even more frightening, is the “what will be” for folks who must continue working. Somehow, grocery stores will have to stay open. Police and fire services have to continue, along with EMS, of course. Healthcare workers are soon to be completely overwhelmed and most likely sequestered for the duration of the outbreak in areas where hospitals near capacity. If you know families of those workers, maybe they could use a hand with errands or meals. They will be terrified about their loved ones staying healthy while on the front lines of this battle. Support those families any way you can.

In the meantime, many thanks to all in this wonderful emptywheel community who have been chiming in with timely updates and analysis. Please keep it coming. So many people are getting so much help from you. But also, let’s have some fun too, to ease the tension. Share a joke. Share ideas for entertainment streaming for those sequestered. Above all, know that we are all in this together and our best bet for getting through it is to work together (just don’t cough on me or touch me).

Three Things: More Family Fun with COVID-19

[NB: Check the byline, thanks! / ~Rayne]

My second kid, who attends a Big 10 university, is sick. They’re running a temp, have a headache and sore throat. Fortunately they have no other symptoms like a dry cough and chest congestion. They wouldn’t meet the criteria for COVID-19 testing even if they develop a dry cough common to 68% of those infected with the virus

We had the awkward conversation about avoiding coming home for at least two weeks — even if the school shuts down, which it now has. This scenario is increasingly likely for all other Michigan and Midwestern colleges/universities. With the damage to my lungs from an autoimmune disorder we can’t take the chance my kid has something besides a common cold. I never expected to have to tell one of my kids not to come home.

~ 3 ~

By now you’ve probably heard about the initial quarantine of Lombardy region of Italy, and then the subsequent quarantine of the entire country. It’s bad. Italy is about two weeks ahead of Washington state in the virus’s spread.

Twitter thread by a UK anesthesia and intensive care registrar passes on a report from a friend in A&E (ER department) in northern Italy (includes Lombardy).

Tweets by an academic in Austria (next to Italy):

The “codice nero” or “black code” to which she refers is a label applied to patients who are DOA or for whom death is imminent. During triage they are apparently applying this to patients over 60-65 years old who arrive in respiratory distress because they have no equipment for them. Other accounts from Italy mirror both the news reports about hospital conditions.

A news report from France covering Italy’s crisis (open in Chrome and translate) notes concerns about COVID-19’s possible impact on southern Italy because it has even fewer resources. Hence the failed quarantine in the north.

In this news report from Brescia which is in northern Italy (open in Chrome and translate) you’ll note they are out of beds and are putting patients on cots, evident in the photo at the top  of the page.

Some better news: China agreed to supply Italy with 1,000 ventilators and 2 million masks. Additionally, they are donating 100K respirators, 20K protective suits, and 50K test kits as part of an aid package. Must have leftover supplies now that China is closing down their rapidly-built emergency COVID-19 dedicated hospital. See story (open in Chrome and translate).

These purchases and aid will not be enough fast enough, though. The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care has now published a guidance document today which appears to codify triage under current conditions. It’s grim.

Tom Bossert, Trump’s first Homeland Security Advisor, wrote an op-ed for the Washington Post published yesterday. He told Ken Dilanian/NBC, “We are 10 days from the hospitals getting creamed.”

ER doctor Rob Davidson from Ottawa County in West Michigan spelled out the anticipated challenge at video in this link:

Up to this video, Michigan had been lucky, having 39 negative tests out of the 375 tests it was allotted by CDC. Last night the state announced there had been two positive cases; Gov. Gretchen Whitmer then declared a state of emergency. In an email today, Michigan State University indicated a third likely case was associated with its campus — hence an announcement moving coursework offline as of noon today. MSU is one of four Michigan schools to make such a move.

We need to see more moves like this to increase social distance if we are going to “flatten the curve” of demand for medical services. It will not be just COVID-19 cases affected by the additional demand on the system, but all other health care needs including emergencies. If we don’t slow down the spread of the virus, ALL mortality may increase in addition to COVID-19 cases.

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Particularly aggravating as the U.S. tries to wrap its head around this growing crisis is the active, malign action of the White House.

A House Oversight and Reform Committee (HORC) hearing today focused on U.S. coronavirus response; the White House interfered with its continuation by calling an emergency meeting requiring the attendance of the hearing’s witnesses, including CDC Director Robert Redfield, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and Terry Rauch, director of the defense medical research and development program for the National Institute of Health.

The HORC meeting was cut short without having answered all questions the committee had, although not before Dr. Fauci was able to provide a reality check to the committee.

“Is the worst yet to come, Dr. Fauci?” Rep. Carolyn Maloney, chairwoman of the House Committee on Oversight and Reform, asked Fauci on Wednesday.

“Yes, it is,” Fauci replied.

While this coronavirus is being contained in some respects, he testified, the U.S. is seeing more cases emerge through community spread as well as international travel.

“I can say we will see more cases, and things will get worse than they are right now,” Fauci said. “How much worse we’ll get will depend on our ability to do two things: to contain the influx of people who are infected coming from the outside, and the ability to contain and mitigate within our own country.”

He added: “Bottom line, it’s going to get worse.”

A report published at 12:29 p.m. after the meeting was suspended revealed the Trump White House ordered public health officials to treat certain meetings on COVID-19 as classified.

The sources said the National Security Council (NSC), which advises the president on security issues, ordered the classification.”This came directly from the White House,” one official said.

This is absolutely unacceptable. The public has both a right and need to know about the course of the virus’s spread and its government’s response. There is no constructive, positive reason for secrecy apart from hiding corrupt or incompetent decisions, which in this case could result in Americans’ deaths.

In fact, this arbitrary secrecy may already have resulted in Americans’ deaths if state and local public health authorities could not make informed decisions because necessary information was denied them.

U.S. Vice-President Mike Pence, the administration’s point person on coronavirus, vowed on March 3 to offer “real-time information in a steady pace and be fully transparent.” The vice president, appointed by President Donald Trump in late February, is holding regular news briefings and also has pledged to rely on expert guidance.

The classification order also makes Pence’s vow look like a lie to the public if on March 3 Pence knew there was information about the government’s response withheld by classification.

Constituents should demand their representatives and senators address this both by holding more investigative hearings into this unwarranted secrecy, and by disclosing whatever information they can obtain about COVID-19 and executive branch response so that the public and their health care system can act appropriately. Further, they need to provide support in a way that states can use without interference by the White House.

Congressional switchboard: (202) 224-3121

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This weekend’s real live drama revolving around cruise ship Grand Princess’s docking at the port of Oakland hints at a solution to the bullshit obstruction and abuse of power surrounding the federal government’s COVID-19 response.

Note in the video that California’s Gov. Gavin Newsom takes center stage, leads and directs the release of information.

And yet the docking and debarking and transportation to quarantine facilities required considerable effort on the part of federal officials. Newsom thanked Pence, saying “His team is truly exceptional.”

Gilding the lily a bit, because the real work was done much farther below Pence’s office.

What was particularly interesting was the lack of response from Trump. We could have expected him to badmouth Newsom the way he badmouthed Inslee, but he didn’t. Perhaps Trump was too busy playing golf.

Or perhaps he didn’t want to draw attention to Newsom.

The docking happened, people were moved, and it happened without a lot of hullabaloo.

That’s exactly what we want — effective, speedy resolution meeting the problem head on.

This same model could work across the entire country if governors work cooperatively and collaboratively to share information and best practices, and are willing to be the point person out in front. The National Governors Association could provide the bipartisan vehicle for networking; it’s outside the purview of the White House, can’t be forced to operate under federal classification.

Granted, taking this approach means governors run the risk of mean tweets from Trump. Screw him and his germy iPhone. Residents in every state want calm and effective leadership they can trust and see in the days ahead. Governors should provide it — particularly since governors are a lot closer to their constituents than Trump is.

Every state should already have in place a process by which their residents can decide what action to take if they believe that they or their family members are infected with COVID-19. There have been far too many reports of individuals making calls to 911 and asking for ambulance rides to the hospital for testing. Such unnecessary use of resources, from calls to 911 operators to ambulance response to demands on hospital personnel represent heightening the curve, not flattening it.

States’ departments of health should have a published decision tree online for residents to use to decide their next course of action. It’s clearly not enough to tell the public “What to do if you’re sick” if they are calling 911 for non-emergency situations.

Website design has also been poor, forcing people who may already be panicky for lack of information to wade through a website to get what they need to make a health care decision, and in some cases design ignores that many residents rely on mobile devices.

Nor has the information process made it all the way down to county and city level.

More effective outreach across broadcast and social media is also needed to manage expectations in the days and weeks ahead.

A collaborative effort by governors could reduce costs to create a comprehensive communication plan across each state and across the U.S. — all while avoiding the obstructive influence of the White House.

Until governors catch on, though, each of us will have to push our state and local health departments to do better BEFORE the coming crisis. There is no extra time, there is no room for failure. Check to see how your state and local health departments are working right now.

And in saying this I’ll tell you my own county is screwed up. The web page with FAQ about COVID-19 doesn’t render on mobile devices. It doesn’t tell residents what to do if they have symptoms matching COVID-19. I really need to call and have a little constructive chat with them because the county hospital is less than a mile from my house. I don’t want problems I can anticipate on my back porch.

A pretty good example of how a county health department’s COVID-19 website should look is Santa Clara County, CA. See SCCPHD — the only nit I have with the site is that it needs a decision tree, something a little less fuzzy to help residents who are either panicky or not well educated.

Santa Clara County has also published a nice handout on social distancing. Really worth copying by other state and local health departments.

Wish I could give you a link to the websites and phone numbers you’ll need to address this personal assignment but I can’t. Do share in comments what you’ve learned in your search.

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One more thing for the physicians among us who might be willing to translate this into layperson’s English:

Threadroll link here.

This is an open thread.

Fiscal Policy For The COVID-19 Outbreak

The internet is full of ideas for dealing with the economic problems associated with the outbreak of COVID-19. As usual, the first suggestions are for tax cuts to protect the corporations facing problems. I assume tax cuts for business entities like the airlines are the logical outcome of my general rule that the point of neoliberal caitalism is to protect the interests of capitalists. But tax cuts are the only bipartisan policies possible, because Republicans only care about tax cuts and have no interest in sound policy; while Democrats are happy to oblige their donor class, and wring their hands about the mean Republicans who won’t let them do anything for their voters. Another widespread ideas is a payroll tax cut; that would benefit people who keep their jobs in the downturn.

Good policy starts with the identification of the problem. At a first approximation, I think the problem involves the following:

1. Sick people. They require medical care, and many can’t afford it, even if it’s available, and even if they have insurance.

2. Unemployment. There will be an uptick in unemployment. Maybe employers close down, maybe business is slower, maybe people don’t want to be out in public and around possible vectors of the illness.

3. Shortages of goods. This will include many of the goods we get from China, but it will also include medical supplies and equipment, and drugs. There will be spot shortages of other goods.

Tax cuts aren’t going to address those problems. Sick people don’t have income, and tax cuts won’t matter to them. Unemployed people won’t have income either. Increasing the amount of money in the hands of consumers and businesses will only create inflation in goods in short supply if the money is spent. Using the money to pay down debt will stabilize some companies and people, but any money used to buy stocks or bonds will not stimulate anything except the wallets of Wall Streeters. I doubt that people will increase their spending on restaurants or movies or other public activities because of fear of contagion even if they have more money from the tax cuts.

The thing that will work is direct government spending on infrastructure. It puts the unemployed back to work. It won’t increase prices for goods that are not in short supply. For goods in short supply, increases in prices will encourage businesses to expand to supply the new needs. Hopefully this will include mostly resources we have here in the US, or can set up here in reasonably short order. We don’t need vast amounts of plastic crap, more computers or smart phones, and other tech goods. What we need are roads, efficient electrical transmission lines, more solar power, better internet service, and other basic electronics that rely mostly on simple sturdy chips. We need new schools, new state and local agencies for a variety of purposes, more buses and subways and light rail, more affordable housing especially in urban areas, more research facilities, more drug manufacturers and a long list of things I don’t know about.

This is a public crisis. Therefore we have a social responsibility to pay for all medical treatment for infected people, all testing, and all necessary medicines. No one should be bankrupted or financially hurt by the cost of treatment of COVID-19. Also we should build public facilities to provide that treatment.

But alone, this isn’t enough. If people use the income from these jobs to bid up the prices of consumer goods in short supply, we will see an increase in inflation. Therefore the goal is to get people to pay down debt and to save the extra income for the future. This should be relatively easy. The fear induced by this crisis should make it obvious that things are going to change, and conservative finances are the best protection for all of us.

One more thing. I don’t believe in pay-fors as a general rule. But the fact is that almost all politicians either actually do believe or pretend to believe in them. This is a great time to demand higher taxes on the 1%, not because we need the cash, but to reduce their obscene domination of our politics (I’m looking at you Michael Bloomberg). Raise taxes on the rich to cover the costs of at least a portion of the expenditures I have described. That means at least the amount of payroll tax cuts, medical treatment for infected people, increased research into viral diseases, vaccines, and production of vaccines, and any additional cuts for corporations and other business entities.

So there’s my take. Please treat this as an open thread on these issues.

John Galt Is Impotent In A Pandemic

Discontinuity.

Abrupt change.

Collapse.

Chaos.

Whatever term you might choose to use, there’s no disputing that if the epidemiologists are correct, the COVID-19 pandemic will be the largest, most impactful world event since 9/11. How we respond to the pandemic will define our society, likely for generations to come.

The response to 9/11 was close to exactly the opposite of what I would consider best. Instead of asking why small groups of people felt so ostracized and minimized that violence was their last resort and then acting to address the root causes, the US chose to demonize and further ostracize Muslims in generally, thereby creating a much larger and endless supply of new terrorists to fight. Over a million people died, many more millions were displaced and an entire generation of US military lives were wasted. But a handful of people got filthy rich off it.

The business and political worlds of today live for these discontinuities. Back when I was running an agricultural biotechnology startup, we were instructed that Monsanto and their spin-offs were so successful because they stood ready to respond to market discontinuities in their areas of operation. Regular, 1-3% annual changes in markets were for chumps. Giant change is what mattered, and so be it if mom and pop seed operations were obliterated by consolidating the entire seed industry. Likewise, in business generally in that era, the rise of the big box store was seen as a John Galt-like hero development as the parasitic small stores disappeared. Today, Big Bezos seems to be feasting off even those big boxes.

On the political front, Naomi Klein laid out in excruciating detail in Shock Doctrine how various disasters have been exploited by the political class to advance the interests of the oligarchy. Both civil rights and economic opportunity for huge portions of the population have been eroded.

Naomi Wolf warned us a few days ago to be on guard against deterioration of our rights in the COVID-19 outbreak:

Today, CNN reports on ongoing discussions between the Trump Administration and the airline industry. It appears that at least some in the industry are concerned that data collection being demanded under a public health guise will be used “for other purposes”:

The US aviation industry and the Trump administration are in a pitched battle over the response to the coronavirus pandemic, three sources familiar with recent calls between officials from several government agencies and US airlines have told CNN.

In a series of contentious conversations, agency officials and aviation executives have clashed over the administration’s demand that airlines collect new kinds of data from passengers to help officials track potential virus carriers.

Okay, on the surface, I’m all for public health officials being able to access information quickly on who was sitting near whom on a flight with an infected person and quickly contact those who need to self-quarantine and get tested. But how do we make sure that data doesn’t wind up being misused? Also, it appears that the Trump Administration also wants the airlines to collect information on recent other travel by passengers:

This industry official says it took the US aviation industry two years to meet post-9/11 requirements, which also involved data collection.

Airlines are concerned that the Federal Register gives no clear end date on the data collection and worry that the US government could continue forcing them to collect it “for other purposes.”

“It seems they want us to do this for forever and we are pushing back,” the first source familiar said. The airlines — particularly their lawyers — are worried about what Customs and Border Protection officials will do with the information.

Yeah, I wouldn’t trust the Trump Administration on that, either. I will leave it to Rayne to address what seems to be a real argument between the administration and the industry on just what information the airlines already have and whether their existing technology can provide it to the government. And Marcy can address whether it’s feasible or even possible to have any kind of effective firewall between public health officials and intelligence, criminal or immigration investigators when it comes to access to this information. There are serious competing interests here and recent experience suggests it won’t be resolved in favor of civil rights for many groups of people.

But what of the COVID-19 disruption? Rayne’s post yesterday provided much of the stark data. This tweet thread from Eli Pariser even goes so far as to suggest that we are just days away from the point at which Italy shut down large regions:

When hospitals are completely overwhelmed, there will be no Galt’s Gulch where heroes can wait out the outbreak. If we really see 20, 30 or even more than 50% of the global population being infected, the concept of isolation breaks down. No heroic action can be taken, because every single individual will be at risk for infection.

This impotence against the virus is because public health, in the end, is a social exercise. Will the outbreak become the discontinuity needed to convince the US to join the rest of the civilized world in making health care a social effort rather than a perk reserved for the very rich? If this doesn’t do it, it’s hard to imagine how it will ever happen.

Three Things: Endemic COVID-19 Edition

[NB: Note the byline, thanks! /~Rayne]

By now we’ve all seen that disastrous presser with dementia-addled Trump at the Center for Disease Control yesterday, his yes men all standing around him bobbing their heads like useless bobble-head dog figurines folks used to put in their car’s rear window deck.

It was really bad when my 79-year-old mother, a retired RN, SCREAMED about that presser in her email this morning, yelling, “He has NO business spouting anything about this health situation!”

Yup. The man should leave it to the public health experts.

Mom’s not a Democrat. Neither is my dad. They will NOT be voting for Trump this November, if they manage to stay away from COVID-19 on their own.

Here are three things that I consider must-reads. We need to know more about what we’re up against.

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Here’s a tweet thread which runs the numbers based on our current understanding of COVID-19.

If you don’t get through this, the kicker is that this is an engineer running the numbers. She calls herself an engineer but this is a minimization of a Chemical & Biomolecular Engineering degree from Johns Hopkins and her PhD from UCSD. This is no lightweight assessment.

The follow-on gut punch: if the states and federal government do not develop and implement a comprehensive plan to mitigate contagion, the U.S. will run out of hospital beds in early May.

That’s in a little over eight weeks.

If we don’t have adequate beds let alone mechanical ventilators and intubation equipment, the mortality rate will jump from an estimated 2-2.3% to at least 5%.

~ 2 ~

Jackasses like Rep. Matt Gaetz will make fun of the numbers, calling it overreaction. (By the way, how’s that crow tasting today, Gaetz, after one of your constituents died of COVID-19 since you made fun of it by wearing a gas mask the day before?)

But hospitals are taking COVID-19 seriously. They have also run the numbers and discussed among themselves what the increasingly endemic virus will demand of them. Here’s a summary from a presentation made in a webinar on February 26 by the American Hospital Association (AHA):

Here’s a comparison between influenza burden on hospitals versus AHA’s anticipated COVID-19 burden:

COVID-19

Influenza, 2018-2019 season

96,000,000 infections 35,500,000 infections
4,800,000 hospitalizations 490,600 hospitalizations
1,900,000 ICU admissions 49,000 ICU admissions
480,000 deaths 34,200 deaths

Flu data from CDC.

Grim — 14 times more deaths than the flu based on data currently available about COVID-19.

What the hospitals see confirms we will run out of hospital resources and more if there is no more aggressive effort made to slow contagion.

We don’t need to wait for proof. We can see it in Lombardy region of Italy as they quarantine 10-16 million people to prevent worse from happening.

~ 1 ~

We know something has been very wrong about the way in which the Trump administration responded to COVID-19, particularly its approach to testing. What’s not clear is why this was such a problem when the U.S. has responded to SARS, MERS, Ebola, Zika, H5N1, so on. Clearly this administration is not up to the job; clearly Trump is an idiot who shouldn’t be allowed near crises like hurricanes, fires, and pandemic threats. We can all see something is very off each time there’s a report that a credible claim of COVID-19 infection has been denied testing — including first responders.

But something more is going on here besides a bunch of yes men propping up a malignant narcissist with dementia. Jon Stokes laid down his thoughts in a tweet thread:


Has the delay in testing been due to Trump’s dementia-addled decision making, waiting out what he believes is a different kind of influenza? Has he been told by some hostile entity, foreign or domestic to wait and let the virus burn itself out? Has one of the crypto-fascist end-times Christianists around him advocated letting God take the wheel?

Or is the failure to act a result of Trump’s manifold conflicts of interest, this time a possible investment in a drug or testing manufacturer?

Amee Vanderpool wonders if Trump or his family is poised to profiteer from COVID-19:

Axios reported this evening that Gilead Sciences shipped an antiviral drug to China — without CDC approval required by law.

Does some member of Team Trump have an interest in Gilead? Or has Gilead invested in Trump, perhaps through his campaign?

Or is this some dark means of fucking with the Census, anticipating urban centers which trend blue to suffer the worst of this pandemic, killing off people who’d rely on government funding and congressional representation in the next decade?

Is this a means to ratfuck voter turnout this fall, literally killing voters by neglect with the anticipation of depressing turnout?

Is this a shadowy method to weaken the public before Team Trump decides they aren’t going to vacate the White House should they be voted out of office? You’ll note CBP has ramped up and militarized their presence in sanctuary cities — why now?

Whatever is driving Trump and his minions to do nothing to deter contagion and help the public already suffering from COVID-19, it’s a dereliction of his duties to the nation, a rapidly growing national security threat which demands Congress’s immediate attention.

Investigate Trump right now and find out why he’s failing the country yet again.

And every member of the GOP congressional caucus owns this disaster because they’ve failed their oath of office.

~ 0 ~

A lagniappe, if not a happy bonus: watch this video interview from Channel 4-UK with Dr. Richard Hatchett, CEO of the foundation Coalition for Epidemic Preparedness Innovations (CEPI).

Distasteful as the idea may be, a war footing may be necessary to fight this pandemic.

COVID-19: The Gift of Family Discussion Topics [UPDATE-1]

[NB: Note the byline – I’m stepping on Jim White’s beat today. Updates will appear at the bottom. /~Rayne]

There’s nothing quite like receiving an email from my father first thing in the morning. He’s not a chatty dude; I can count on two hands the number of emails I’ve received from him in the last five years. When he pops me a note I know he’s been stewing on whatever he sent.

Today he sent me and my siblings a link to a report about study of CT scans used to screen COVID-19 patients:

CT provides best diagnosis for COVID-19
Date: February 26, 2020
Source: Radiological Society of North America
Summary: In a study of more than 1,000 patients published in the journal Radiology, chest CT outperformed lab testing in the diagnosis of 2019 novel coronavirus disease (COVID-19). The researchers concluded that CT should be used as the primary screening tool for COVID-19.

Dad was also worried about the reliability of Chinese tests. Okay, so noted — if I go to China any time soon I’ll treat them with suspicion. Thanks for the email, Pop, and thanks to my siblings for the flurry of follow-up messages.

~ ~ ~

I’m far more worried about the U.S. tests which are still extremely limited after the CDC’s screw up by devising its own test instead of using effective tests already available.

The CDC designed a flawed test for COVID-19, then took weeks to figure out a fix so state and local labs could use it. New York still doesn’t trust the test’s accuracy.
by Caroline Chen, Marshall Allen, Lexi Churchill and Isaac Arnsdorf Feb. 28, 12:13 a.m. EST

There’s been a contamination issue in the government lab responsible for the tests as well — negative control reagent not handled properly in kits.

By Jon Cohen Feb. 28, 2020 , 5:45 PM – ScienceDaily

. . .

by Jonathan Swan, Caitlin Owens for Axios
Updated Mar 1, 2020 – Health

I don’t have a lot of faith this problem will be fixed promptly. FDA is supposed to approve the tests, but…

Sent to help the administration’s coronavirus response, a test specialist was stopped at CDC’s door and made to wait overnight.
By DAN DIAMOND 03/03/2020 03:23 PM EST – Updated: 03/03/2020 03:53 PM EST

We’re also seeing continued problems with testing due to lack of supply affecting first responders. Here’s a letter from a quarantined nurse in California who has had symptoms matching COVID-19, whose doctor and county public health officer signed off on getting her tested, and the CDC refused to test her.

The key symptom distinguishing COVID-19 from influenza is the chest pressure and cough. Influenza has a productive ‘wet’ cough where COVID-19 infection is more likely to manifest a dry cough with more chest pressure and shortness of breath as the virus moves down the body. From WHO’s China Mission report:

Symptoms of COVID-19 are non-specific and the disease presentation can range from no symptoms (asymptomatic) to severe pneumonia and death.As of 20 February 2020 and based on 55924 laboratory confirmed cases, typical signs and symptoms include: fever (87.9%), dry cough (67.7%), fatigue (38.1%), sputum production (33.4%), shortness of breath (18.6%), sore throat (13.9%), headache (13.6%), myalgia or arthralgia (14.8%), chills(11.4%), nausea or vomiting (5.0%), nasal congestion (4.8%), diarrhea (3.7%), and hemoptysis (0.9%), and conjunctival congestion (0.8%).

People with COVID-19 generally develop signs and symptoms,including mild respiratory symptoms and fever, on an average of 5-6 days after infection (mean incubation period 5-6 days, range 1-14 days). …

(Source: https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf, page 11-12)

Because we can’t expect adequate numbers of test kits for weeks — no matter what those goddamned lying jackasses in the White House say — asking for a CT scan if you need treatment can be a good move. Haven’t seen other reports yet whether other forms of imaging like chest x-ray will work. However, the results of CT will change during course of infection:

Varied CT, clinical findings
In the second study, researchers at Sun Yat-sen University in Guangzhou, China, detailed the CT findings and clinical characteristics of six women 27 to 63 years old with COVID-19.None of the patients had such underlying diseases as diabetes, cancer, or respiratory disease. Five had had Wuhan or Hubei exposures.

They found that COVID-19’s wide variety of manifestations on CT can vary over time. Early in the disease, lesions can appear round and nodular in the central lung, unlike their common patchy appearance between the membrane surrounding the lung and the body wall. One patient had 3 follow-up scans 4 to 14 days later that showed diverse lesions and that the primary lesions had been absorbed and replaced elsewhere by new ones.

On testing blood samples, the researchers observed normal or slightly decreased counts of leucocytes and lymphocytes and identified mildly decreased eosinophil counts in four of the patients. Four days later, follow-up testing revealed that the low eosinophil counts remained abnormal and had dropped even further. “The decrease of eosinophil count may be helpful for the early diagnosis of the disease,” they wrote, calling for further study of the phenomenon. …

(Source: http://www.cidrap.umn.edu/news-perspective/2020/03/study-reveals-sharp-increase-covid-19-kids-shenzhen)

Blood test may work in tandem with CT, certainly faster to get than a CDC test for COVID-19.

Another potentially predictive risk factor for severe-critical cases: smoking, whether current or a past history. Explains why more men than women were severe-critical cases in China as men smoke more than women.

Guoshuai Cai
Version 1 : Received: 3 February 2020 / Approved: 5 February 2020 / Online: 5 February 2020 (02:56:53 CET)

Americans overall may have fewer severe-critical cases because tobacco smoking has dropped considerably over the last three decades. A good thing since severe-critical cases need mechanical ventilators or intubation and we simply don’t have enough equipment in our crappy health care system.

We don’t know yet if vaping is another risk factor; it may depend on substances in vapor, with tobacco being most suspect. I haven’t seen anything about marijuana use yet, whether smoked or vaped.

And disinfect (not just clean) your cell phones. Rather high nosocomial (hospital-acquired) infection rate with this bug in spite of aggressive PPE like full suits with hoods, booties, gloves, face shields means we’re dealing with possible airborne bug OR there’s some other fomite (surface) transmission not being documented.

As of Monday it was estimated there were ~600 asymptomatic cases walking around Seattle. This short-ish piece is a must-read, especially the paragraph which begins, “We know that Wuhan went from an index case”

2 Mar 2020 by Trevor Bedford – Bedford Lab

The Emerald City Comic Con convention begins on March 12 in Seattle, at which ~100K people from around the country and world are expected; the event has not been canceled.

March 5, 2020 at 6:00 am Updated March 5, 2020 at 7:08 pm

Wouldn’t want to cancel this massive social event and cause stock market disruption, oh no. *shaking my head*

I’d expect an explosion of cases across the U.S. in about 9 weeks based on Bedford’s estimate.

I know CT test may be inconclusive for me if I get this crap because an autoimmune disorder did a number on my chest ten years ago. I’m at high risk because of this pre-existing condition, as are family members because of their CVD and diabetes.

Must say there’s nothing like a documented mortality rate of 7-13% for CVD and diabetes to put the fear of god in certain at-risk family members about vigorous frequent handwashing.

Now I have to stop family from going full apocalyptic prepper. Somebody bought this household a half gallon of Lysol concentrate and three times more bleach than I’ve used in a year’s time.

I can hardly wait to hear from my family again first thing in the morning.

~ ~ ~
I do want to make one point perfectly clear, all snark aside.

** The Republican Party is responsible for every COVID-19 fatality in the U.S. **

They could have done the right thing and removed Trump by convicting him for obvious abuse of power and obstruction of Congress instead of being chickenshits afraid of Trump’s mean tweets. He’s a clear and present national security threat — this pandemic proves it.

VP Mike Pence has done a crappy job so far but we can’t tell how much of this disaster is his alone, or a result of also trying to keep his malignant narcissist from melting down while handling a mounting pandemic. As long as Trump’s in office they will both continue to screw this up.

The GOP could have done more to assure the pandemic response team remained in place with funding after Trump’s Senate-approved appointee John Bolton rejiggered the National Security Council in May 2018.

But no, the Republican Party is as incompetent and unequal to the job of protecting the American people as their leader in the White House.

Vote these walking disasters out of office in November; the life you save in doing so may be your own.

UPDATE-1 — 2:10 P.M. ET —

Wouldn’t you know it but as soon as I pressed Publish there was a message in my inbox that Emerald City Comic Con will be rescheduled to later this year, some time this summer.

This is the right thing to do given the number of cryptic COVID-19 cases in Seattle. It’s unfortunate the burden of this decision fell solely on the convention organizers in the absence of public guidelines about social isolation from the federal government.

US COVID-19 Cases Now Spreading Due To Trump’s Testing Restrictions And Dismantling Of Pandemic Response Teams

Back on January 31, Pulitzer Prize winner Laurie Garrett warned us how Donald Trump has dismantled the country’s ability to respond to a pandemic. Her Foreign Policy piece, headlined “Trump Has Sabotaged America’s Coronavirus Response“, Garrett opened with a description of the extreme measures taken in China:

The epidemic control efforts unfolding today in China—including placing some 100 million citizens on lockdown, shutting down a national holiday, building enormous quarantine hospitals in days’ time, and ramping up 24-hour manufacturing of medical equipment—are indeed gargantuan. It’s impossible to watch them without wondering, “What would we do? How would my government respond if this virus spread across my country?”

The problem, though, is that although Barack Obama built a working pandemic response structure during the Ebola outbreak (which of course Trump criticized incessantly on Twitter), that structure has now been obliterated:

In the spring of 2018, the White House pushed Congress to cut funding for Obama-era disease security programs, proposing to eliminate $252 million in previously committed resources for rebuilding health systems in Ebola-ravaged Liberia, Sierra Leone, and Guinea. Under fire from both sides of the aisle, President Donald Trump dropped the proposal to eliminate Ebola funds a month later. But other White House efforts included reducing $15 billion in national health spending and cutting the global disease-fighting operational budgets of the CDC, NSC, DHS, and HHS. And the government’s $30 million Complex Crises Fund was eliminated.

In May 2018, Trump ordered the NSC’s entire global health security unit shut down, calling for reassignment of Rear Adm. Timothy Ziemer and dissolution of his team inside the agency. The month before, then-White House National Security Advisor John Bolton pressured Ziemer’s DHS counterpart, Tom Bossert, to resign along with his team. Neither the NSC nor DHS epidemic teams have been replaced. The global health section of the CDC was so drastically cut in 2018 that much of its staff was laid off and the number of countries it was working in was reduced from 49 to merely 10. Meanwhile, throughout 2018, the U.S. Agency for International Development and its director, Mark Green, came repeatedly under fire from both the White House and Secretary of State Mike Pompeo. And though Congress has so far managed to block Trump administration plans to cut the U.S. Public Health Service Commissioned Corps by 40 percent, the disease-fighting cadres have steadily eroded as retiring officers go unreplaced.

But it’s even worse than that. Until sometime over this last weekend, the Trump Administartion, through the CDC, blocked all entities other than CDC from running tests for COVID-19. They only allowed testing under such extremely narrow circumstances that pitifully few tests have been carried out to this point.

In an interview yesterday on KPFA (that I’m only halfway through listening to but just had to stop and write this part up) Garrett pointed out that New York City has had its own dedicated lab ready to go for testing for the past six weeks. Coupling that with the various reports coming out today on just how long it’s going to take for testing kits to get widespread distribution now that manufacturing is FINALLY kicking into high gear, we are presented with direct evidence of just how much damage Trump’s COVID-19 policies have done.

As Garrett points out, we are now seeing “community transmission” of the virus, meaning that cases are appearing in patients who have not traveled to known hot spots and who are not known to have had direct contact with someone confirmed to have the virus. Once community transmission is seen, the correct public health policy with respect to testing is to switch from narrow testing criteria to widespread testing. China was remarkably quick in developing and mass manufacturing DNA-based tests for the virus as soon as the sequence became available. That this was not done in the US is criminal, and the mounting death toll, now at 9, will drive this point home. That’s because, if you listen to the early part of Garrett’s interview, she compares COVID-19 to the 1918 flu pandemic. She describes characteristics of the spread of the virus that make widespread testing an incredibly important tool in containing its spread. Today’s news says we are weeks away from widespread testing. I fear just what we will see when wider testing is available.

 

Preparing For The Inevitable Coronavirus Disease 2019 Outbreak

Jim here.

I am quite late to getting to a post on the new coronavirus, but headlines yesterday finally forced me to move ahead and gather info today. First, watch this incredibly informative video from the World Health Organization. It gives very good information on the biology of the virus and what’s going on in the outbreak:

Although Donald Trump and his media partners have been denying that Coronavirus Disease 2019 (COVID-19) is a real cause for concern, there were multiple statements yesterday from US health officials that ranged from quite alarming to somewhat more reassuring. The announcements were summarized well by the Washington Post. Perhaps the most attention was paid to portions of what Dr. Nancy Messonnier provided in a telephone briefing yesterday morning. Dr. Messonnier is the Director of the National Center for Immunization and Respiratory Diseases. A recording of the briefing and a full transcript can be found here.

Of most note from the briefing is when Messonnier stated:

Ultimately, we expect we will see community spread in this country.  It’s not so much a question of if this will happen anymore but rather more a question of exactly when this will happen and how many people in this country will have severe illness.

So, yes, spread of COVID-19 in the US is inevitable. Messonnier continued, discussing what can be done to try to contain the disease. Because there’s no vaccine or specific treatment for the virus, control has to be through what is termed non-pharmaceutical interventions or NPIs:

There are three categories of NPIs.  Personal NPIs which include personal protective measures you can take every day and personal protective measures reserved for pandemics.  Community NPIs which include social distancing measures designed to keep people who are sick away from others.  And school closures and dismissals.  And environmental NPIs which includes surface cleaning measures.

It’s in the category of potential community NPIs where the biggest concerns start to appear:

Now I’d like to talk through some examples of what community NPIs look like.  These are practical measures that can help limit exposure by reducing exposure in community settings.  Students in smaller groups or in a severe pandemic, closing schools and using internet-based teleschooling to continue education.  For adults, businesses can replace in-person meetings with video or telephone conferences and increase teleworking options.  On a larger scale, communities may need to modify, postpone, or cancel mass gatherings.

Messonnier expanded on the disruptions:

Secondary consequences of some of these measures might include missed work and loss of income.  I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe. But these are things that people need to start thinking about now.

So, yes, there may well be significant disruptions to everyday life in parts of the US. We of course don’t know when this would occur, or where in the US it would be. But this is a good time to start thinking about how a disruption to moving around for a couple of weeks would affect you. Here in Florida, we regularly have to prepare for a week or more of loss of electricity during hurricane season. Preparing for community control measures would be a bit different. Right now, my thoughts for our household are that I will stockpile a few extra large cuts of meat in the freezer. These are things I’d eventually use anyway, so it won’t hurt to have them around. I’ll increase a few of the pantry items that I wouldn’t otherwise increase until the start of hurricane season. I’ll beef up my supplies for baking bread. If a disruption starts looking more likely locally, I’ll even add some frozen veggies to my stockpile, but for now I’m going to rely mostly on my ongoing CSA supply.

But I’m not going to rush out and buy an N95 respirator facemask. The current recommendations from CDC do not recommend facemasks for the general public. They are only recommended for people who are sick or for those who are caring for someone who is sick. This and the other CDC recommendations for treatment and prevention can be found on this helpful page.

The key thing to remember in trying to avoid catching COVID-19, as described in the video above and on the CDC page linked just above, is to avoid being very close to sick people. The guideline mentioned is six feet. If you see someone who looks symptomatic, it shouldn’t be too hard to stay six feet from them. Also, if the virus is known or suspected to be in the area where you are, be especially careful to keep your hands below your shoulders at all times and to wash your hands frequently if visiting public places. As CDC describes here, transmission is thought primarily to be through aerosol droplets such as sneezes and coughs, but it remains possible that the virus could be picked up by touching contaminated surfaces.

Finally, people are also quite concerned about the prediction discussed here by Professor Marc Lipsich, an epidemiologist at Harvard. He has stated that it’s possible that a COVID-19 pandemic could result in 40-70% of people world-wide becoming infected. As Lipsich points out, however, that estimate must be coupled with the realization that we currently have no good estimate for what percentage of people who become infected develop few or no symptoms. In fact, moving out from his discussion, there currently are widely ranging estimates of what percentage of infected people die. Inside Wuhan, where the virus first emerged, estimates now are that 2.8% of those infected die. Outside Wuhan, however, that number drops to 0.18%, a difference of over 15-fold. For a discussion of how early we are in the process of understanding the epidemiology of this virus and why these numbers differ, see this paper.

For perspective, it appears that COVID-19 spreads far more efficiently than SARS and MERS, but conversely, SARS and MERS killed a higher percentage of those infected. We see more COVID-19 deaths because many more people have been infected.

The featured image for this post is in the public domain and comes from CDC. Here is the caption CDC provides: “This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).” Credit for the image goes to Alissa Eckert, MS, Dan Higgins, MAM.