My 3rd ICU Covid-19 patient is not doing well; I can now get testing and millions of unemployed will lose their health insurance.
My third Covid patient ICU patient is not doing well. He is intubated. For the past two weeks I speak to family members every night around 7pm giving them an update. (The ICU staff calls me as I am the primary care physician). Every Covid-19 death is a tragedy; these deaths were largely avoidable. But this patient, who is only 38 year years old, is especially painful for me. I spoke with him the day before he was hospitalized. He called me about symptoms that were likely Covid-19, but he said he was feeling much better. In a familiar Covid-19 scenario, the next day he had trouble breathing, was hospitalized and has been intubated on a ventilator ever since.
I am now able to order Covid-19 tests. Of course, nothing is that simple. There are false negatives. But I do feel that I am making a little progress: yesterday I was able to order the Covid-19 test for someone who had been exposed to the virus and was coming down with symptoms.
By now the (barest) outline of how the United States will emerge out of this totally avoidable human tragedy is becoming clear. The two main questions that remain are.
(1) Will the executive branch of the federal government be held to account for its sheer incompetence, brazen mendacity, and obvious authoritarian tendencies? Will Congress assert its authority and pass significant legislation checking the executive branch? Thus far Congress has been on the sidelines and Fauci is doing a balancing act, And this includes issues like the false hope spread about hydroxychloroquine.
At this time, it also appears that the important recommendations of Scott Gottlieb and Mark McClelland, two excellent health policymakers who served under Republican Presidents, for a strong federal response will not come to pass. States will do their best to respond and many will do just fine; though the political polarization even to Covid-19 will stop for example NY and Florida from working together. (Partisanship, Health Behavior, and Policy Attitudes in the Early Stages of the COVID-19 Pandemic)
(2) Will we, similar to what occurred in the aftermath of the Great Depression, be able to take this unique once in a century opportunity to address the gross inequities in our health system? These will come into sharp relief as millions of people, especially the young, lose their health insurance and are unable to buy it. The Trump administration’s unrelenting opposition to “Obamacare” could become an obstacle for millions of uninsured people in the coronavirus outbreak, as well as many who are losing coverage in the economic shutdown. Health Coverage for the unemployed will be harder to come by in some states.
It is not just the young but as we already know, Covid-19 discriminates: the “pre-existing health conditions” that put a person at risk of severe disease and death from COVID-19 are over-represented in communities of color and poor communities as a result of long-term disinvestment and neglect.
The answers to this “once in a century opportunity” are completely dependent on citizen group mobilization and the extent to which groups such as the hospital industry, health professionals small business groups and unions see it in their interest to collaborate.
‘Ask Nurses and Doctors’ (AND) is doing its part by working with health professionals in competitive Congressional districts organizing for election of incumbents and/or candidates who prioritize universal coverage; we are also organizing in swing states such as Florida and Michigan to help elect a Democratic President. This once in a century opportunity is dependent on policymakers coming up with feasible ideas that can be quickly implemented. Akin to what the states of Mass. and Washington are doing. In essence, the initiatives use traditional public health measures for a debilitated public health system. I will summarize what I and other colleagues are calling Community Centered Population Health (CCPH) – as our response to this once in a century opportunity. CCPH is community centered (not patient centered) health care that links public and personal health with community health workers as the first line.
Long Island needs a leader right now, not a rubber stamp for the Trump administration’s irresponsible policies and erratic procedures. That’s not how a member of Congress should act.
Congressional District NY-01 in Suffolk County should have a representative who will demand fairness for his residents. Instead, we have Lee Zeldin, who is too busy covering for Donald Trump’s antics and failure to respond responsibly to this crisis.
Recently, Congress passed a 3rd stimulus package with support from both parties. But guess what? New York State got short-changed and Zeldin did nothing, despite two important facts:
Our state has suffered more than any other state from the pandemic with 35% of confirmed Coronavirus cases and 42% of all the deaths in the US. The Trump administration has ignored our plight and decided to allocate hospital aid based on old data, instead of basing it on the number of Coronavirus cases. This decision will bankrupt our hospitals and leave healthcare workers to do without. It is a slap in the face to our heroes on the frontlines.
New Yorkers have the highest costs of living nationally, particularly in the New York Metro region. Yet we face the same financial criteria for direct cash payments as people from other parts of the country with a much lower cost of living.
These two problems that New Yorkers are facing must be addressed in the next stimulus package. Lee Zeldin should be doing everything in his power to make sure that our state gets the relief it needs. But he won’t. Instead, he will just raise his hand and vote however the leadership in his party tells him to. That’s unacceptable. A good member of Congress should fight for his constituents.
In Italy, men made up nearly 60 percent of people with confirmed cases of the coronavirus and more than 70 percent of those who died of COVID-19. In China men and women were infected in roughly equal numbers, but the death rate among men was 2.8 percent, compared with 1.7 percent among women. The same applies to South Korea and numerous other countries. In New York City, men are dying at nearly twice the rate of women. As of recently, men made up 59 percent of overall hospitalizations in New York City and 62 percent of fatalities. In 13 states with sufficient death numbers for analysis, men died more frequently than women.
Men were also disproportionately affected by SARS and MERS, caused by related, but different coronaviruses. For SARS, in Hong Kong in 2003, the case-fatality ratio was 13.2 % for women and 22.3 % for men. Also, 32% of men with Middle East Respiratory Syndrome (MERS) died, compared with 25.8% of women.
The question is: Why?
At first, risk factors were blamed. For instance, smoking rates among men exceed those among women in much of the world. 2% of Chinese women smoke, compared with more than 50% of Chinese men.
Chinese men also have higher rates of Type 2 diabetes and high blood pressure than Chinese women, both of which increase the risk of complications following infection with the coronavirus causing COVID-19 (SARS Cov2). Rates of chronic obstructive pulmonary disease are almost twice as high among Chinese men as among women.
Women are more proactive about seeking health care than men. Since the start of the outbreak, public health officials have emphasized the importance of washing hands to prevent infection. But studies have found that men — even health care workers — are less likely to wash their hands or to use soap than women. While these 2 considerations might affect the number of diagnoses made and perhaps the rate of hospitalization, they are unlikely to affect mortality in my view.
Moreover, rates of smoking in the US are quite similar comparing men to women (unlike in China): in 2015, 16.7 percent of adult males and 13.6 percent of adult females smoked cigarettes in US. Yet the death rate from COVID-19 is clearly much higher among US men compared to US women.
Let’s consider biological differences. Women have more robust immune systems, some scientists have noted, which helps to fight off infections, although it does make them more prone to autoimmune disorders.
When it comes to mounting an immune response against infections, men are apparently the weaker sex. “This is a pattern we’ve seen with many viral infections of the respiratory tract — men can have worse outcomes,” says Sabra Klein PhD, a scientist who studies sex differences in viral infections and vaccination responses at the Johns Hopkins Bloomberg School of Public Health.
Says Dr. Klein: “We’ve seen this with other viruses. Women fight them off better. Women also produce stronger immune responses after vaccinations, and have enhanced memory immune responses.”
A recent research paper from Huazhong University of Science and Technology in Wuhan, using plasma of 331 confirmed coronavirus patients, found that in the most severe cases, women had higher levels of antibodies than men.
For almost all infectious diseases, women are able to mount a stronger immune response then men. Women with acute HIV infections have 40 percent less viral genetic material in their blood than men. Women are less susceptible to the viruses that cause hepatitis B and C. Men infected with coxsackie virus (which can infect the heart) are twice as likely to die of the disease than women.
Female birds show higher antibody responses to infection than males, especially during mating season. The immune cells that eat up microbes and cellular debris are less active in male lizards than in their female counterparts.
Some 60 genes involved in immune function are located on the X chromosome (according to Dr. Sabra Klein). Genetic females have two of these molecules — one from their mother, one from their father — whereas genetic males have only one. When there are two copies of a gene, one copy is often turned off. But as many as a quarter of X-linked genes can escape this inactivation, giving women a “double dosage” of the genetic instructions needed to fight disease.
One such gene codes for a protein called “toll-like receptor 7,” This receptor recognizes strands of viral RNA (the Coronavirus is an RNA virus)
Generally, female immune cells respond faster and more powerfully to viral attacks, producing higher amounts of interferons — proteins that stop viruses from replicating — as well as antibodies that neutralize the virus
Testosterone, has been shown to tamp down inflammation. Estrogen, meanwhile, can bind to immune cells and activate the production of disease-fighting molecules.
A recent study demonstrates a direct role for estrogen signaling in limiting influenza virus replication in nasal epithelial cells derived from humans
ACE2 is a receptor for SARS Cov2. It allows the virus to gain access and infect cells. ACE2 is regulated differently in men and in women.
Experiments published in 2017, in which mice were exposed to the SARS virus (SARS Cov), showed that male mice developed SARS at lower viral exposures, had a lower immune response and were slower to clear the virus from their bodies. They suffered more lung damage and died at higher rates – see the graph below! When researchers blocked estrogen in the infected female mice or removed their ovaries, they were more likely to die, but blocking testosterone in male mice made no difference, indicating that estrogen may play a protective role.
Solid squares are female mice; open squares are male mice. 12 days after infection, 80% of female mice and only 10% of male mice were still alive. 5000 PFU is the dose of virus used to infect each mouse (PFU = Plaque Forming Unit)
Despite all of this, the coronavirus vaccine trials underway in the U.S. aren’t really considering sex yet, according to Dr. Klein. If past experience holds up, vaccines will be more effective in women than in men!
STATEMENT FROM STATE SENATE CANDIDATE DEMOCRAT LAURA AHEARN (SD-1)
“The first 30 billion dollar distribution of federal coronavirus aid for hospitals is not being allocated based upon the incidence of COVID-19, but instead upon the number of Medicare recipients in 2019.
The use of this formula is disastrous as New York State and Long Island, the epicenter of the pandemic in the US, are slotted to receive minimal funding, far below what is desperately needed as our state and local governments attempt to manage this human catastrophe.
New York currently has 35% of the cases nationwide and is getting just 6% of the $30 million being distributed. According to Newsday, New York will receive $1.86 billion — less than the $2.9 billion for California with only 4% of the cases, $2.2 billion for Florida with only 3.6% of the cases, and $2.1 billion for Texas with only 2.2% of the cases.
State
% of all COVID cases
Billion
as % of 30 billion total aid
New York
35.0%
1.86
6.2%
California
4.0%
2.9
9.7%
Florida
3.6%
2.2
7.3%
Texas
2.2%
2.1
7.0%
I strongly urge all of our Federal Representatives to stand up and fight to ensure that any additional federal aid is geared towards communities hardest hit and in the most need, like ours. For decades, New York residents have paid more in federal taxes than what we get back in return. Now is the time for Washington DC to be there for New Yorkers.”
By Laura Ahearn
Comment by D. Posnett: New York State is being ripped off and representatives, like Congressman Zeldin, will bear responsibility if this does not change.
I am not sure why, but for the first time, each day this past week found me on multiple Zoom conference calls. Each of these was for a different group that I belong to, from my local Southampton Democratic Club to the national grassroots women’s group, SuperMajority. It is as if we all collectively woke up to the reality that this lockdown is going to be a long haul and this is the new normal not just for a few weeks but for a few months.
Like everyone, I am shaky with anxiety over this pandemic, worried that the people I know and love could become a statistic of this disease. I live in the suburbs outside of New York City where we have our own rising cases, though nothing like the five boroughs of the city. I lived on the Upper West Side of Manhattan for 25 years and my heart is breaking for what I will always consider “my city.” But my worst, chest-tightening moments of panic come when I think of my family members who are nurses on the front lines of this crisis. How can it be that in the United States, a healthcare provider is now taking his or her life in their hands just going to work? Every single one of these heroes deserves more than thanks from a grateful nation, they deserve wartime hazardous duty-pay. In lieu of that, the least this government can do is have their student debt wiped off the books for the job they are doing, risking their lives to save ours. We need to all start a movement to make this a reality. What would be a great hashtag for this mission, #thanksarenotenough?
Two weeks ago my anxiety reached a maximum level when my husband, son and I all came down with a cold. How surreal that the common cold induced frantic days obsessively taking my temperature and sleepless nights of pure dread, kept awake by coughing that I could not determine if it was wet or dry. It was hard to get through to the primary care physician’s office, the line was always busy, but once I did speak to a nurse my question was, “at what point should we worry?” Since there was no fever, chills or shortness of breath, she told me it was probably exactly what it appeared to be, a simple cold, but if any of those three symptoms appeared, to call right back. Call right back, I thought? It took me hours to get through this time when I didn’t have fever, chills and shortness of breath. But each day the cold lessened and by week’s end had passed as colds are wont to do. But this simple cold left a residue of fear in its wake that made me reluctant to even go outside for a socially-distant walk.
So, I have asked myself if in the midst of this once-in-a-century public health and economic crisis, should I take a break from politics, if only to help maintain my sanity? On our Democratic Club call the focus was on how can we reach out and help those in our township who are really suffering because they can no longer afford to buy food. It felt good to be helping out with something that was not political. I also gave up watching my MSNBC line-up at night. I listen to music while riding my exercise bike rather than watching Rachel Maddow. Some nights we watch movies, particularly movies that make us laugh. I still read the newspaper each morning but I skim through a lot and I have tried not reading headlines on my phone all day. It has helped quiet some of the panic.
But even digesting a much lighter diet of news, I cannot escape one undeniable fact, that this crisis, all of it, from the number of infected and dead, to the dire shortage of personal protective equipment for our healthcare providers, to the shuttering of businesses and skyrocketing unemployment, to the food shortages for low-income families, every bit of this trauma the country is now enduring, has been made much worse by the incompetence, selfishness and corruption of the Trump administration. And this inescapable fact sits in the pit of my stomach and emits a rage so white-hot that I can’t ignore it. And because of that, I can’t stop worrying about politics and in particular, the election this fall.
The Washington Post put together a complete accounting of just how much of a mess the Trump administration has made of our preparedness for this crisis. The April 4th article is entitled “The U.S. was beset by denial and dysfunction as the coronavirus raged: From the Oval Office to the CDC, political and institutional failures cascaded through the system and opportunities to mitigate the pandemic were lost.” It is a big, investigative deep-dive into the dysfunction. It is gut-wrenching and infuriating but maybe the most important article every single American needs to read.
On March 30th the Editorial Board of The Boston Globe, put the blame for this failure of leadership squarely where it belongs. The title of the editorial says it all: “A President Unfit for a Pandemic. Much of the Suffering and Death Coming was Preventable. The President Has Blood on His Hands.”
To quote the editorial: “As the American public braces itself for the worst of this crisis, it’s worth remembering that the reach of the virus here is not attributable to an act of God or a foreign invasion, but a colossal failure of leadership.”
Much like The Washington Post article, the editorial goes through the entire timeline of failure on the part of the Trump administration and ends with the statement, “But come November, there must be a reckoning for the lives lost, and for the vast, avoidable suffering about to ensue under the president’s watch.”
It is this need for a reckoning that mandates we stay focused on politics and keep our eyes on the November election, despite the pandemic that rages around us. When Trump was elected, our outrage sparked the Women’s March and created the anti-Trump Resistance. That movement powered the blue wave in 2018. Despite the fears that now haunt our days and plague our nights, we must not lose sight of what has always been our prime directive, to make sure Trump is a one-term president. Our work in the Resistance was how we channeled our rage then and it must be how we channel our rage now.
But unlike the last three years, we cannot organize and attend rallies, we cannot knock on doors and speak directly to voters, we cannot even be together in a planning meeting or a Happy Hour social event. All last week, on every Zoom call with every organization, we struggled to answer the same question, “How are we going to get the public engaged when we are stuck in our homes?”
In an article on, April 5th, The New York Times addressed this dilemma from a campaign’s point of view. “With Campaigns in Remote Mode, Pandemic Upends Battle for Congress: As retail campaigning has become all but impossible amid the public health crisis, candidates tread carefully in an uncertain political environment.”
This article did not address the dilemma from the non-candidate point of view, meaning how are we in the grassroots going to function this year if we cannot go outside? The next day, April 6th, The New York Times corrected that oversight with an article looking at the impact on progressive campaigns and on the grassroots movement from the pandemic. “Progressives Built an Organizing Juggernaut for 2020. Then the Virus Hit: After a disappointing turn in the presidential race, grass-roots progressive groups focused on congressional races and down-ballot campaigns. In weeks, the coronavirus has destroyed their plans.”
To quote from that article: “The grim picture may have a profound political impact for the general election and beyond. Democrats were poised to have an organizing juggernaut ready for the 2020 election, with the goal of both reaching new voters and helping reverse the state and local losses they experienced during President Barack Obama’s years in power. Even more, liberal groups hoped this election cycle would formalize their political infrastructure, so the activism that erupted in response to Mr. Trump’s election could be harnessed going forward. That may still happen, but it will require creative financial and digital solutions, according to interviews with several leaders of progressive political organizations and left-wing candidates running for office in states like New York and Ohio. Optimists have called it a time for political innovation, while others worry the structural barriers could stymie the progressive movement at a critical crossroads.”
The article zeroed in on the bind we are all in. We spent 2017 learning how to get out of our houses and speak in person to voters. Then in 2018 we utilized that knowledge and those skills to propel the largest voter turnout for a midterm election in 40 years. Now we have to learn how we are going to be effective without person-to-person contact.
Below are a few initiatives that are trying to address that need. The first is an app called Outvote that is mentioned in this article. Here is the description on their website: “Outvote is an app that makes it easy to support the causes and campaigns you care about. The goal of the app is to promote voter participation within progressive campaigns. Our larger mission is to build a community of organizers that remain active between election cycles. By partnering with the biggest campaigns, advocacy organizations, and nonprofits, the Outvote community will be able to mobilize around current events, elections, and critical moments in policy formation for social equality and justice.” https://www.outvote.io/
But Outvote seems to be primarily for organizers, a valuable resource but not really a direct conduit to voters. Indivisible has an ongoing project with a direct line to voters that activists can participate in from their homes. It is called VoteFWD and involves writing letters to voters in swing states. Here is the description from the Indivisible website: ‘Want to get out the vote in key states from the comfort of your own home?Indivisible is excited to be partnering this election cycle with VoteFWD. VoteFWD provides activists with names, addresses and a data-driven proven template to write letters to voters in important states. Letter writers will save their letters and send them right before the election so that voters receive them at the perfect, most-strategic moment.”https://indivisible.org/resource/write-letters-voters-votefwd
On my Zoom call with SuperMajority, which joined with Pantsuit Nation, I heard about two projects. The first is called Turnout Tuesday where they are asking their members to call their state Secretaries of State and press them on how they are going to use the federal funds to make sure the vote in November is secure, particularly if they are going to invest in mail-in ballots. The second is text messaging to voters and they have been conducting training seminars to teach members how to do “rapid response textbanking” to alert voters about important issues. https://supermajority.com/
At my local Indivisible group, East End Action Network (EEAN), we were already planning postcard-writing parties, creating and mailing personal postcards to voters in our district, as we did in 2018. This will be a joint project with Indivisible North Fork. These events will begin in July, after the New York primary on June 23rd when we have a Democratic congressional nominee. While it is certainly more fun to party together (you can read the descriptions of these events in my book, The Resistance and Me, available on Amazon), we can convert this initiative to home-based postcard writing rather than in groups if we are still not able to gather together by the summer. The end goal of getting the postcards out there can still be achieved.
These are all good ideas. But they don’t go far enough. The voter suppression outrage by the GOP in Wisconsin underscores the extreme lengths the Republicans will go to keep people from voting. We are going to need bigger and bolder ideas to take the place of speaking to voters in person if we are going to be able to counter those GOP schemes. Possibly because they are aware of this challenge, Indivisible will be hosting a series of training webinars in April for Indivisible leadership on how to better use the virtual space during this lockdown period. If you are a member of an Indivisible group, someone in your leadership has probably already received an email about signing up. If not, reach out to your Indivisible contact. I tried to find a link for these webinars on their general website and could not find one. I look forward to whatever ideas come out of these webinars and will include them in later blog posts.
I am particularly worried what happens to voter registration. Normally the spring and early summer are key periods to focus on voter registration but how can that be done digitally and from our homes? I have been wondering if it is at all possible to conduct a virtual voter-registration drive and I would love to hear back if anyone has any ideas about this. How can we reach residents in the district who are not registered to vote? Is that even possible? They wouldn’t be in MiniVAN but would there be a way to cross reference residents with voter registration rolls to determine constituents who aren’t registered? We could mail them personal letters including the voter registration form if they cannot register online through the state motor vehicle department. Is there any way at all we could create such a list?
Along with my fear that we are not going to be able to register new voters, is a concern that our digital efforts are not going to reach the Independents and Unaffiliated voters we need to win in November. Maybe we should think about sending postcards right now to these voters with the facts about how the Trump administration has mishandled the pandemic, facts that would break through the fog of misinformation that Trump and his propaganda machine at Fox News are spewing out. These postcards could also have contact information for services that many constituents need during this crisis, such as food banks and how to file for unemployment benefits. And these voters are in MiniVAN. We would have to figure out how to pay for printing the postcards and the postage since these would not be funded by the campaigns.
We know from the midterm election how much time, effort and boots on the ground it took to power the blue wave. It is a process that starts months before with voter registration, educating the public, supporting primary candidates and then getting-out-the-vote. We do not have the luxury of waiting for the crisis to pass, waiting until we are able to knock on voters’ doors, not while Trump and the right-wing media saturate the airwaves with lies about this pandemic while at the same time erecting barriers to voting. If we are going to hold Trump and the GOP accountable in November, we need to act now and to do that we need bigger and bolder ideas of how we are going to reach voters, counter the lies and protect the ability for every American to vote.
By Barbara Weber-Floyd
Author, The Resistance and Me: An Insider’s Account of the Two-Year Mission to Stop the Trump Agenda and Take Back the House
(Available on Amazon and at Canio’s Books, Sag Harbor)
There has been talk about the flattening of the curve of new reported COVID-19 cases indicating at the very least a slowing growth of the caseload in New York City. I found the following data in an interesting “working paper” by Jeffrey E. Harris from the National Bureau of Economic Research: The Coronavirus Epidemic Curve is AlreadyFlattening in New York City. It was posted April 7th. Others have also opined on the same topic: Joseph Goldstein in the NY Times; Bob Herman on Axios.
Here is a brief summary of the Harris paper.
Note the inflection of the curve of new reported cases/day around March 20, 2020, in NYC but not in Los Angeles. Also note the different case numbers: Y-axis 1-1000 for LA, 1-100,000 for NYC. Most certainly the situation in LA reflects an earlier time point in the progression of the local Coronavirus outbreak. NYC may be an indicator of what is yet to come in LA.
The most valuable part of the Harris paper (I think) is the discussion of the possible confounding variables.
(1) Constraints on Testing: on March 20 New York City issued a directive “Healthcare resources must be saved to treat the sickest patients who require inpatient and critical care.” The Department directed providers and hospitals to “immediately stop testing non-hospitalized patients for COVID-19 unless test results will impact the clinical management of the patient. In addition, do not test asymptomatic people, including HCWs [healthcare workers] or first responders.”
In deed there was an immediate dip in the number of tests by about 50% and a simultaneous dip in the number of reported cases by about 30%. But the dip in hospitalizations was much less prominent (about 10%) and they provide further data that show that the tests performed on hospitalized patients remained constant at about 17-23% of all tests performed:
Note: the Y axis is a logarithmic scale.
(2) Asymptomatic cases not considered: as many as 50% of COVID-19 cases may be asymptomatic and untested, yet infectious and contributing to the rise in the counts of newly diagnosed each day. But Harris argues: “…there is no clear reason to believe
that the extent of understatement has changed significantly since the one-month takeoff period covered in Figure 1. So long as the ratio of undetected asymptomatic cases to detected symptomatic cases has remained constant”
(3) We are missing the false negatives: tests based on nasal swabs (RT-PCR tests) have a false negative rate in the range of 26.7–46.4% (Yang et al. 2020). That means routine nasal swab testing could be missing a lot of coronavirus infections. But has the percentage of false negatives changed significantly during the month of March 2020 to explain the flattening of the curve in NY City?
(4) What is the breakdown of the data by borough: There are reports of hospitals in Queens and the Bronx being overwhelmed and a heat map from the Dep. of Public Health, shows high levels of pos. tests in the Bronx, Queens and Brooklyn. Harris presents data on new cases since March 21 broken down by borough. All the doubling times remain longer than the initial 1.3 days doubling time in early March, regardless of the borough. But the data for Manhattan are particularly good suggesting a flattened peak and leveling off.
(5) Diaspora from the city: assuming that those that fled the city (for their Hamptons 2nd homes, for example) have equal rates of infection than those that did not or could not, Harris has calculated that 90% of the New York City’s inhabitants would have needed to flee the city in order to cause the flattening of the curve in the top figure.
(6) Is the initial rapid progression realistic? The Ro number (‘basic reproductive number’, or number of people infected by one positive person) differs slightly depending on the city:
New York City: Ro=3.4 population density 27,016/square mile
Los Angeles: Ro=1.8 population density 7,544/square mile
Wuhan: Ro =2.2 -2.4 population density 3,200/square mile
This is most consistent with the high population density in NYC compared with LA, or even Wuhan. Population density in NYC has previously been discussed in the context of the pandemic. This is the most plausible cause of the rapid progression observed in New York City.
(7) Super-Spreaders: this theory suggests that the apparent flattening of the incidence curve is a result of extreme heterogeneity in the infectivity of the New York City
population, with a small proportion of the total population – on the order of 5,000 individuals – subject to the super-spread of the virus. While there are anecdotal reports of such super-spread in the New York City area (Williamson and Hussey 2020), Harris has not found clear evidence of a major source comparable to the 77 COVID-19 cases reportedly emanating from a late February Biogen meeting.
(8) Supporting Ancillary Data? Harris correctly discusses daily death rates as a poor and lagging indicator. By one estimate, it takes an average of 16 days from the onset of symptoms until a patient dies of complications and the time from initial
infection to death may average about 3 weeks. Harris also looks at thermometer data from Kinsa! I have previously posted on this blog about this exciting new way of assessing pandemic progression.
The downward slope of the red line is interpreted as a resolution of the Coronavirus outbreak. BUT it is very indirect data and there is no data presented for Los Angeles !!! Why not? If Harris is correct there should be no downward slope for Los Angeles.
In asking what makes the curve flatten, Harris discusses the obvious: social distancing, aggressive case tracking and effective public policy such as De Blasio’s order limiting gatherings, closing gyms and other places of congregation and reinforced by subsequent orders that all New Yorkers (except workers in essential businesses) must stay at home.
The discussion of voluntary behaviors is very relevant. Ridership on New
York City subways was already down 19 percent by March 12 and 60 percent by March 16 (Metropolitan Transportation Authority 2020).
The critical ingredient in the public policy mix may have been the successful communication of consistent, clear, accurate and timely information to millions of individuals, who responded by taking action without government coercion. Put bluntly, what flattened the curve was no more than the naked truth.
Finally, in NY City about 1/226 residents have so far contracted COVID-19. In Los Angeles, by contrast, it is about 1/4,100. The corresponding probability of knowing at least one infected person in a comparable size social circle is much less in L.A. than in NYC. People are therefore more motivated to take action to reduce risk in New York.
They analyzed levels of 48 cytokines (!) in COVID-19 patients and healthy controls.
Key Findings:
• Many cytokines were elevated with COVID-19
(IFNy, IL-1Ra, IL-2Ra, IL-6, IL-10, IL-18, HGF, MCP-3, MIG, M-CSF, G-CSF, MIG-1a, and IP-10). IP-10, IL-1Ra, and MCP-3 (esp. together) were associated with disease severity and fatal outcome.
• IP-10 was correlated to patient viral load (r=0.3006, p=0.0075).
• IP-10, IL-1Ra, and MCP-3 were correlated to loss of lung function (PaO2/FaO2 (arterial/atmospheric O2) and Murray Score (lung injury) with MCP-3 being the most correlated (r=0.4104 p<0.0001 and r=0.5107 p<0.0001 respectively).
• Viral load (Lower Ct Value from qRT-PCR) was associated with upregulated IP-10 only (not IL-1Ra or MCP-3) and was mildly correlated with decreased lung function: PaO2/FaO2 (arterial/atmospheric O2) and Murray Score (lung injury).
• Lymphopenia (decreased CD4 and CD8 T cells) and increased neutrophil correlated w/ severe patients.
Caution: Collection time of clinical data and lab results was not reported directly making it very difficult to determine if cytokines were predictive of patient outcome or reflective of patient compensatory immune response. Small numbers for cytokine analysis (N=2 fatal and N=5 severe/critical, and N=7 moderate or discharged). @sinaiimmunologyreviewproject
What is IP-10? Also known as CXCL10: it is a chemoattractant for various types of white blood cells and promotes inflammation.
What is IL-1Ra? The interleukin-1 receptor antagonist (IL-1Ra) blocks the IL-1 receptor and is a natural inhibitor of the pro-inflammatory effect of IL1 (which causes fever for example). A slightly modified version of IL-1Ra, called anakinra, is used in the treatment of rheumatoid arthritis, an autoimmune disease in which IL-1 plays a key role
What is MCP-3? Also known as CCL7. It is a chemokine that attracts monocytes, a type of white blood cell.
It is beginning to look like a familiar scenario. Too much of an immune response is not a good thing. Cytokine storms have famously contributed to the lethality of influenza such as the Spanish flu of 1918.
It may be premature, but it is the best available data to explain why some with COVID-19 have a minor disease and others have life threatening disease.
Looks like all leaders are getting a significant approval boost from COVID-19 with a few exceptions: Obrador (Mexico), Bolsanoro (Brasil), Abe (Japan), see above. Trump’s approval is up from -10 to -5. The approval ratings surged much more dramatically for Johnson (GB), Merkel (Germany), Trudeau (Canada), Morrison (Australia), and Macron (France).
And this is not reflected in consumer confidence, see below.
Insurers are weighing how best to respond to the outbreak of the novel coronavirus as cases swell in the U.S. Here is a tracker to follow the latest policy and coverage decisions from the nation’s largest insurers.
The nation’s health insurers are responding to the coronavirus pandemic with changes to coverage associated with COVID-19 as the number of cases continues to swell across the U.S.
The biggest payers have said they will waive patient cost-sharing — copays, coinsurance and deductibles — for testing. Although some, such as Cigna and Humana, have gone farther by eliminating cost-sharing for all COVID-19 treatment.
In addition to coverage decisions, insurers are weighing the ways they can reduce administrative barriers to promote quicker access to care for those infected with the novel coronavirus. All are cutting back on prior authorization in various ways to ease access to care.
Hospitals say that’s not enough, and are calling on the biggest payers to follow actions taken by Congress and CMS to help resolve cash flow issues, by accelerating payments or opting into releasing interim periodic payments. The American Hospital Association also is urging payers to eliminate administrative burdens such as prior authorizations.
“This crisis is challenging for all of us, and everyone has a role to play,” AHA said in its letter to the nation’s largest insurers. “You could make a significant difference in whether a hospital or health system keeps their doors open during this critical time.”
Despite the policy changes by payers, employers with self-funded plans can opt out of these policies. A majority of workers are covered by self-insured plans, which essentially allow employers to decide coverage decisions given they’re paying for the claims and having insurers simply perform administrative services.
Below is a tracker with the latest coverage decisions for the nation’s largest insurers.
Blue Cross Blue Shield Association
UPDATED 4/3/2020
The BCBSA is eliminating cost-sharing for COVID-19 diagnostic testing. It will also waive cost-sharing for treatment at in-network or Medciare rates through May 31, including inpatient stays.
BCBSA will remove prior authorization requirements for testing and for services that are medically necessary to treat an infected patient. BCBSA also is waiving limits on early refills to make it easier to access medications and expanding access to telehealth services.
Molina
UPDATED 4/3/2020
Molina is halting cost-sharing for testing and treatment. That policy applies to Medicare, Medicaid and marketplace members nationwide.
Aetna (CVS)
UPDATED 4/2/2020
Aetna will waive cost-sharing for certain members admitted to an in-network hospital with COVID-19 or complications from the disease. The policy applies to all of Aetna’s commercial plans, though self-insured members can opt out. The policy will apply to admissions through June 1. Aetna also is waiving cost-sharing for testing and associated visits, including telehealth.
Aetna also is attempting to make access to hospitalization faster for those with COVID-19 by easing prior authorization requirements, particularly in areas hard hit by the outbreak like New York and Washington.
Anthem
UPDATED 4/2/2020
The nation’s second largest commercial insurer will waive cost-sharing for COVID-19 treatment and will reimburse providers at either in-network or Medicare rates through May 31. The policy applies to Anthem’s fully insured, individual, Medicaid and Medicare Advantage members. Self-insured plans can opt out. Anthem also is waiving cost-sharing for COVID-19 testing and in-network visits associated with testing whether it’s conducted at a physician’s office, urgent care or ER.
Anthem also is easing its limits on early refills for 30-day prescriptions. Anthem said it would waive cost sharing for telehealth visits, including those for mental health for a period of 90 days starting March 17. Self-insured plans have the option to opt in the new virtual care policy.
Centene
UPDATED 4/2/2020
Centene will waive cost-sharing for COVID-19 related screening, testing and treatment for its Medicaid, Medicare and Marketplace members through June 30.
Centene also will eliminate prior authorization requirements for care for all its Medicare, Medicaid and Marketplace members. The company is also working to supply federally qualified health centers with personal protective equipment and assistance in providing small business loans to behavioral health providers and long-term service support organizations.
Cigna
UPDATED 4/2/2020
Cigna will waive cost-sharing for all COVID-19 treatment, including testing and telehealth screenings through May 31. The policy applies to Cigna’s fully-insured group plans, individual coverage and Medicare Advantage plans. Self-insured plans can opt out.
Cigna will reimburse providers either at in-network or Medicare rates depending on the member. Cigna also is easing access to maintenance medication by offering free shipping for a 90-day supply. Cigna is easing prior authorization requirements for patients being discharged from the hospital to post-acure stays.
Humana
UPDATED 4/2/2020
Humana is waiving cost-sharing for testing and treatment, including hospital admissions for COVID-19 cases. The policy applies to its Medicare Advantage plans, fully-insured commercial plans, Medicare supplement and its Medicaid plans. The policy is indefinite with no current end date. Cost-sharing will be waived for all telehealth visits and members can opt to refill prescriptions early.
Humana also is easing administrative barriers to allow infected patients to easily move from a hospital to post-acute care settings. It’s suspending prior authorization and referral requirements and requesting notification within 24 hours. It’s also implementing an expedited claims process to reimburse providers faster, Humana said.
UnitedHealthcare
UPDATED 4/2/2020
The nation’s largest commercial insurer, will waive cost-sharing for COVID-19 treatment through May 31. The policy applies to its fully-insured commercial, Medicare Advantage and Medicaid plans. United also is waiving cost-sharing for COVID-19 testing at approved locations in accordance with Centers for Disease Control guidelines. There will be no cost-sharing for visits related to testing including at physician offices, urgent care, ERs and telehealth visits. The policy applies to United’s commercial, Medicare Advantage and Medicaid members.
UnitedHealthcare is opening a special enrollment period for some of its commercial members who opted out of coverage during the traditional enrollment period with their employers. This enrollment period will end April 6. The insurer also is easing prior authorization requirements through May 31, suspending prior approval for post-acute care and switching to a new provider.
