Warning from the Virologists

 

 

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This is a very interesting paper!  It is a detailed virological and immunological study of 9 patients with COVID-19, presenting from Jan 23 – 27, 2020, all with mild upper respiratory symptoms (not requiring ICU admission or ventilators) in Germany.

I will try to summarize it.

  1. Pharyngeal virus shedding (from the back of the throat) was very high during the 1st week of symptoms, peaking at day 4 although earlier time points were often not available.
  2. During the 1st week after onset of symptoms, infectious virus (able to infect cells in a test tube) was present in throat (swab) and lung (sputum) samples (16% of  swab samples; 83% of sputum samples), but not in stool samples.  There was no infectious virus after day 8 of symptoms. Viral RNA sometimes lingered in the stools for weeks but there was no infectious virus
  3. Active viral replication in the throat was confirmed by a nifty assay which detects RNA intermediates that are only present with active replication (subgenomic viral RNA transcripts).  By comparison SARS-CoV, the virus that causes SARS, does not replicate in the upper respiratory tract, but only in the lungs (lower respiratory tract).
  4. Shedding of viral RNA (RT-PCR tests detect this) in sputum outlasted the end of symptoms
  5. Seroconversion (the appearance of IgG and IgM antibodies to the virus) occurred after 7-14 days, but was not followed by a rapid decline in viral RNA
  6. there were no co-infections – they tested at least 16 other common viral respiratory infections
  7. the titers of viral RNA (swab tests) were highest on day one of symptoms and then gradually decreased.  This was when symptoms were still minimal and “prodromal”.  The peak viral loads were at least 1000 fold higher than in SARS.
  8. A rise in antibody titers was not closely correlated with clinical improvement
  9. antibodies showed cross-reactivity to 4 endemic human corona viruses (viruses that cause the common cold).

Bottom line:

  • The COVID-19 virus replicates big time in the nose/throat and very early on, often before  symptoms – it is probably VERY infectious
  • Because RT-PCR tests for viral RNA can persist for as long as 20+ days after initial symptoms appear, one must remain concerned about current recommendations for a 14-day quarantine.  Is it really long enough?
  • The antibody response was poorly correlated with getting better.  Since antibodies are but one of several arms of the immune response, I would guess that CD8 cells, subsets of CD4 cells and perhaps cells of the innate immune system all participate in overcoming the viral infection.  A prior paper documented the response of these cells in a single patient.
  • Should therapeutic interventions such as anti-viral drugs or even convalescent plasma transfer focus on the earliest stages of the infection when symptoms have just appeared? That is when the virus is replicating massively.  Currently, these therapeutic interventions are focused on the sickest patients in the ICU and on ventilators, at a much later stage of the disease.  Paradigm shift?
  • The utility of EARLY testing for viral RNA is obvious by either throat or nasal swab or expectorated sputum
  • It will be interesting to compare these results (from patients with a milder disease course) to those of patients with severe disease.

 

PS: 17.9% of persons with COVID-19 are asymptomatic (have no symptoms what so ever) and are still producing virus and infecting others.  That is 1 in 5 infected people  have no symptoms.  Think about it.

 

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The Case for Masks

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The headlines and what the reasoning is behind them:

Austria makes masks compulsory as protection debate shifts!

Four European countries make masks mandatory!

From Czech Doctors  & Citizens – The CRUCIAL MISSING Coronavirus Protection Guideline https://www.youtube.com/watch?v=hVEVve-3QeM

A University of San Fransisco research scientist shows how anyone can make a mask using a long sleeved T shirt, scissors and a paper towel as a filter.  He shows how to cut the t-shirt and it is utterly simple and easy to do. He tells us the scientific data on masks and what materials work.

How Czech Republic Maintains Low Contagion https://www.youtube.com/watch?v=T2dOs-LhJaQ

How to make your own mask  https://www.youtube.com/watch?v=4FB–BOyTiU

I would add that I use construction masks that I got at Home Depot: less than $10 for one box with 50 masks.  Not sure whether they are still available.

 

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Quaranteam

I love it!

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Mike Francesa’s takedown of Donald Trump: ‘Treat this like the crisis it is’

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Mike Francesa has given Donald Trump the handwave.

The longtime New York-based sports radio gasbag took to the airwaves on Monday night, offering a takedown of Trump and his response to the coronavirus pandemic plaguing the nation, and specifically, New York.

“There’s a disconnect. We’re watching one thing happen in our city on the 11 o’clock news every night. We’re watching people die,” Francesa says. “And now we know people who died. And we’re not seeing one or two people die now in our neighborhood. We’re seeing them die by the 10s and 20s by the day. They’re bringing people out of the hospital in Queens in body bags. …

“Treat this like the crisis this is,” Francesa continued. “And how can you have a scoreboard that says 2,000 people have died, and tell us it’s OK if another 198,000 died, that’s a good job. How is that a good job in our country? It’s a good job if nobody else dies.”

Francesa, as you may know, is one of the kings of sports radio — but is also New York’s Numbah 1 in bad takes, inaccurate takes and “I nevah said that!”s in the history of broadcast radio.

But Francesa is also known for his political takes, as — for some reason — listeners across the tri-state area tuned in to Francesa in 2016 for his political opinions during the election year. While it’s largely speculated that Da Sports Pope cast his vote for Trump, he hadn’t publicly stated that he did. He was a big Trump supporter during his election run, however.

“I think it’s about doing a good job. His ego will not let him do anything but a good job,” Francesa said of Trump in 2016.

Francesa’s afternoon drive spot — originally from 1 p.m. to 6:30 p.m. ET — is now tucked into a nice, half-hour spot on WFAN 101.9 from 6-6:30 p.m. He was recently given another show on Sundays while the sports radio world struggles to find something to talk about.

Interesting to see if Trump will be back aftah this.

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Kinsa’s thermometers

This is probably the most exciting thing I have read related to COVID in some time.

This from the NYT

“Kinsa’s thermometers upload the user’s temperature readings to a centralized database; the data enable the company to track fevers across the United States.

Owners of Kinsa’s thermometers can type other symptoms into a cellphone app after taking their temperature. The app offers basic advice on whether they should seek medical attention.

Kinsa has more than one million thermometers in circulation and has been getting up to 162,000 daily temperature readings since Covid-19 began spreading in the country.”

The technology was first published in 2018 and used to track annual influenza outbreaks:

2018 Jul 18;67(3):388-397. doi: 10.1093/cid/ciy073.

A Smartphone-Driven Thermometer Application for Real-time Population– and Individual-Level Influenza Surveillance. Miller AC1, Singh I2, Koehler E2, Polgreen PM3.

Now Kinsa is tracking spikes of “atypical fever”, fever that does not follow the historical flu patterns and was not predicted:

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Note the red part of the curve (March 9-20) did not follow the predicted patterns, and was perhaps due to COVID-19 , designated “atypical”. Very interesting is the dip (orange) that follows after March 20 to levels below “2% ill”.  This dip in the curve is being attributed to effective social distancing measures.  It would be the first measure of the effectiveness of such regulations and it certainly would help guide public policy.

Especially interesting are the interactive maps on the Kinsa website:

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The above map shows the location of “atypical” illness (presumed COVID-19). It is the “amount of unexpected illness expressed as additional share of the population affected by influenza like illness above the expected values”

Note the concentration in Florida.  That is fascinating because the RT-PCR testing for the coronavirus has not yet really shown the expected rise in cases (Florida ranks #6):

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I presume the Kinsa technology is much faster at detecting trends, than counting positive cases and deaths.  I am thinking that most of those people that are having atypical fevers have not yet been tested for the virus of they are waiting for a result.  (Some people that I know well have been waiting for 9 days or more.)

This map is fascinating too:  it depicts trends. By placing the cursor over your county, you can get very local data:

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This is a 7 day rolling average of change in the illness level expressed as percent change up or down.

In Suffolk County, NY, the illness (atypical fevers) trend is decreasing by 4.3% and thankfully the decreasing trend is seen across the country. There is only one county in Texas (Hardeman Cty) where the trend is not decreasing.

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This map (above) shows you how much influenza-like illness is being detected throughout the country. It is a map of how severely the population is being affected by atypical influenza like disease.  I presume this data lags the data in the above graph on location of “atypical” illness where Florida was mostly in the red?

Here is what the company concludes:

(3/24/2020): Due to widespread social distancing, school closures, stay-at-home orders, etc. feverish illness levels are dropping in many regions. This does not mean that COVID-19 cases are declining. In fact, we expect to see reported cases continue to surge in the near term, but it may indicate these measures are starting to slow the spread. See CDC COVID-19 Cases in U.S. for details.

 

 

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“She didn’t deserve to die this way”

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Dated March 30, 2020

Dear Colleagues and Friends:

Three days ago I had no Covid-19 patients in the hospital. Two days ago there were two in critical care. One of the two, a patient for more than 20 years, died Sunday (March 29) at 3pm. Her daughter cried to me “She didn’t deserve to die this way, all alone.” She’s right. My first, not my last, patient to die of Covid-19. When the daughter gave me details of who else was exposed to her mother, those that need for testing, I said ashamedly that I have no access to testing or tracking of exposed individuals. Another patient of mine is intubated. I am hoping he will survive.

Before Trump’s inauguration, there was a warning from the Obama administration: ‘The worst influenza pandemic since 1918’ would be coming and Obama officials briefed the incoming administration on this exact scenario.

What’s Trump’s planning approach: “Trump ties coronavirus decisions to personal grievances”. Trump took to Twitter Sunday afternoon to tout the ratings of his news conferences, claiming without evidence that mainstream media are going “CRAZY” because of his popularity on television”.

In the absence of both medical equipment and testing in the world’s richest country, many are debating how to allocate scarce medical resources.  Patient-level decisions are being made with this perspective.

Others are thinking about estimating the cost of this pandemic. Academics are calculating how we can decrease social distancing after implementing contact tracing and adequate testing

Still, others are trying to put pen to paper imagining a better health system that includes planning for the next pandemic. Meanwhile, Scott Gottlieb and Mark McClellan (excellent Repub policymakers) have detailed options for the current pandemic.

To put any long term health reform ideas into place, we need members of Congress and an executive branch interested in long term health reform not just tearing down health systems.

Via Ask Nurses and Doctors, I am in the process of organizing round tables for incumbent members of Congress and encouraging people to write letters to the editor such as these. The picture in the excellent LTE by Barbara Floyd is worth a thousand words.  Happy to help anyone who is interested in putting “pen to paper”.

In the meantime, my physician colleague has been extubated and continues to improve but is still in the hospital.

Norbert Goldfield MD

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From London: If you are over 65 with COVID-19, good luck

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The numbers are normalized per 100,000 population.  Since the US is a far larger country the number of deaths will be far larger. Daily deaths are predicted to peak after around three months if people don’t change their behaviour. Image: Imperial College COVID-19 Response Team

 

 

 

From a medical consultant in London. This was sent initially to his family on Sat March 28th, 2020.  It is a frank assessment.  Expect the same situation here in New York and elsewhere in the USA.  (NB: this was sent to me via my British family)

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Fox News Coverage is Dangerous

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  • Fox News coronavirus coverage looks eerily similar to its climate crisis coverage — and is just as dangerous

    There are similarities between the COVID-19 pandemic and the climate crisis: The public health and economic threat, if left unaddressed, will be catastrophic and worldwide; immediate action from leaders who listen to those most knowledgeable about the issue is paramount; communication to the public on the scope of the emergency and actions necessary to mitigate its threat should be facilitated by trustworthy news sources; and Fox News has played an active role in misleading and misinforming its viewers about both.

    In the face of the emerging coronavirus pandemic, Fox News has downplayed the severity of the coronavirus, promoted misinformation and deployed other tactics to distract from, and attempt to discredit, the urgency of the crisis and the legitimacy of those issuing warnings — just as it’s done for years when reporting on the climate crisis.

  • Tactic 1: Downplay the crisis

    A hallmark of Fox News climate crisis coverage is dismissing the urgency of the threat, if not outright denying it, and labeling advocates for climate action as hysterical and alarmists, as I explained in a 2019 report for Public Citizen. Fox News opinion personalities and so-called news programs have used this same approach in an effort to downplay the seriousness of the coronavirus. Here are just a few examples:

    On March 9, Sean Hannity on his eponymous Fox News show referred to the public health crisis facing this country as a “hoax” and claimed that “they’re scaring the living hell out of people.”

    On March 8, Fox News’ Pete Hegseth stated, during a segment on New York Gov. Andrew Cuomo’s state of emergency declaration, “I feel like the more I learn about this, the less there is to worry about.”

    On February 29, the Fox & Friends hosts rallied around President Donald Trump’s claim that the coronavirus threat is a “hoax.”

    On February 28, Fox anchor Harris Faulkner suggested criticizing the administration’s response to coronavirus is “feeding hysteria.”

  • Tactic 2: Traffic in dangerous misinformation

    Climate deniers and the well-debunked misinformation they spread have made a home at Fox News. Amid this recent national crisis, the network has distributed dangerous misinformation about the severity of the coronavirus threat to its viewers, the majority of whom are among the most vulnerable to and at risk. Here are some of the most egregious examples:

    On March 15, Fox News aired dangerous misinformation from Steven Hotze, a disreputable doctor who has a history of pushing “methods [that] are not supported by science and are potentially harmful” and sells bogus colloidal silver. Hotze dismissed concerns about the coronavirus, saying that “everybody has gone totally crazy about it” and recommending that people should “conduct your life normally.” The segments were part of Fox’s purported “news” division programming.

    On March 6, Fox News medical contributor Dr. Marc Siegel appeared on Fox News’ Hannity and told the host the “worst case scenario” for coronavirus is “it could be the flu.” The appearance on Hannity was one of at least 47 weekday appearances Siegel made to discuss the outbreak in the weeks leading up to the March 13 national emergency declaration.

    In fact, Hotze and Seigel are among a handful of so-called medical experts who have appeared across the network’s programs to misinform viewers and dismiss the seriousness of the unfolding public health crisis.

  • Tactic 3: Finger-point and table-turn

    Deflection is a signature move of Fox News anchors looking to pivot away from the facts of a story or change the trajectory of its most obvious conclusion. One of the more common examples of this appearing in the network’s climate coverage is a focus on an individual’s actions to deflect away from the evidence that supports their position on climate. For example, Fox News hosts often call out the hypocrisy of climate advocates who use air travel.

    In the face of clear mismanagement of the coronavirus outbreak by Trump, Fox News has cast around for someone else to blame and landed on its go-to fake villains: Democrats and reporters.

    Media Matters has documented how Fox personalities lashed out at journalists for their coverage of coronavirus and at Democrats for their criticism of the administration.

    On March 16, Laura Ingraham went so far as to say in defense of Trump, “The media, some have been enjoying this moment that has brought great inconvenience, disruption and suffering to American workers and families, let alone all the health challenges, the deaths and the infection rate — because some people think it’s Trump’s downfall, and they are cheering that on as they did during Mueller and all these other crises.”

    On March 2, Sean Hannity got particularly creative in his attempt to deflect from Trump’s handling of the public health crisis by lying about President Obama’s 2009 “swine flu” response.

  • Tactic 4: Attack science

    The backbone of most climate disinformation is a feigned or real mistrust of science and scientific evidence. It is from this place that climate science, scientists, and the institution where they work are attacked by those whose narratives, worldviews, or values they inconvenience, including Fox News.

    The spread of the coronavirus has put our experts in the scientific community in the national spotlight as we rightfully turn to them for information and sound recommendations. It has also triggered one of Fox News’ most oft-employed attacks on the scientific community: They are politicized and therefore compromised.

    On the March 6 edition of Lou Dobbs Tonight, Fox’s Dr. Marc Siegel claims coronavirus concerns are being intentionally overblown to hurt Trump politically by dismissing the World Health Organization as “overly political” and “incompetent.”

    On the March 4 edition of The Ingraham Angle, host Laura Ingraham’s guest attempted to discredit the Center for Disease Control by calling it a “highly politicized organization.”

  • Tactic 5: Legitimize and spread conspiracy theories

    The most notorious climate change conspiracy theory — originating from then-future President Trump — is that it is a hoax “created by and for the Chinese in order to make U.S. manufacturing non-competitive.” Another commonly cited conspiracy theory is that climate scientists distort findings or tamper with evidence for financial gain. This claim, which Fox has peddled, was the basis for the manufactured scandal “Climategate,” which Fox News seized on and ferociously promoted.

    As the lethal outbreak of coronavirus spread around the world and the U.S. government warned that it would spread within the United States, Fox News was among the right-wing media outlets spreading conspiracy theories. That included one of the most prominent theories, which claims that coronavirus was manufactured and leaked by the Chinese government, and one of the most racist claims, that it was a result of people consuming animals alive.

    On February 10, Fox News prime-time host Tucker Carlson speculated about the unsubstantiated bioweapon theory, asking his guest whether COVID-19 is “not a naturally occurring virus” or was “somehow created by the Chinese government.” His theory was debunked by his guest Dr. Janette Nesheiwat, a medical director of a chain of urgent care clinics.

    Even though this theory has been widely debunked (even on air during a Fox program), on February 25, Fox Business host Lou Dobbs claimed that “we don’t know yet whether or not this was an engineered virus” and said that there is “a research lab some 300 yards from the epicenter of this outbreak.”

    Carlson, on his January 23 show, also blamed the emergence of the virus on Chinese culture, advancing the unproven theory that it was a result of people consuming animals “alive.”

    While many of the tactics Fox News has used to misinform and mislead its views about the climate crisis and the coronavirus outbreak are the same, its goals are different. As applied to the climate crisis, Fox wields these tactics in an attempt to blunt aggressive climate action. As applied to the coronavirus, Fox has deployed them to shield Trump from political backlash. Either way, these tactics are shameful and dangerous — and their impact is not easily corrected.

    This video is amusing:

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Advice from a New York City ICU Doc

Dr. Frugoni in California:  This is the best explanation of how to protect yourselves, family and friends by a knowledgeable and calm doctor working the frontlines in NYC. Well worth listening to the entire 56 minutes.

Dr. Posnett: This is from Dr. Price at New York Hospital – it is invaluable info from someone taking care of many patients every day.  This hospital is completely over-run by COVID-19. Please share widely with all your friends or patients

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https://vimeo.com/399733860?ref=em-share

 

 

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