Hard Truths From Infectious Disease Specialists

We should expect more deaths from COVID-19 than previously predicted, leaders of the Infectious Diseases Society of America (IDSA) said at a press briefing Friday.
The models on which the current national estimate of US mortality from COVID-19 are based assume that optimal social distancing will be practiced across the country, said Rochelle Walensky, MD, vice chair of IDSA’s HIV Medicine Association and chief of the infectious diseases division at Massachusetts General Hospital in Boston. Under that scenario, the White House has said, the range of mortality would be 100,000 to 240,000 deaths.
However, Walensky noted, “We’re not properly social distancing. We’re not doing enough. And in that case, the models were wrong. Our prevention activities were not as robust as the models suggested, so the number of deaths will be higher.”

When the number of COVID-19 cases declines, Walensky cautioned, some degree of social distancing will still be needed. “We can’t think about not social distancing anymore until we can understand what it means to go from mitigation back to containment [of the coronavirus].
“When we go from mitigation to containment, that means that anyone who is symptomatic has access to a test, and we have to make sure that a person who tests positive is able to self-isolate and that we can ‘contact trace’ all of those people. We’re talking about blanketing tests so they’re universally available to anyone at any time.”
Thomas File Jr, MD, president of the IDSA and chair of the infectious disease division at Summa Health in Akron, Ohio, added, “As we go back from mitigation to containment, everyone is anxious to get back to business as usual. But I’m not sure we’ll ever get back to business as usual. The whole concept of promoting good health practices is going to have to continue even after we’re in the downslope. By that, I mean staying home if you’re sick, washing your hands, avoiding touching your face. We’ll have to continue those practices, even if there’s a downslope of this virus epidemic in our country and in the world pandemic.”

Test Accuracy

Walensky noted that the COVID-19 test now being used in hospitals is only 70% sensitive for negative results. “Therefore, we’re doing results review for every patient we take off precautions from the hospital to make sure they’re not a false negative.”
She clarified, “We believe the test is pretty good if it gives you a positive result. We think we can trust that to say the person really has the disease. But if it gives a negative result, the reported sensitivity of that is only about 70%.”
One reason for this, she said, is that there can be a sampling problem if the clinician doesn’t stick the test swab far enough into someone’s nose. “Second, as patients get sicker, the virus migrates from the nasopharynx to the oropharynx and into the respiratory tract. We don’t know, when it migrates down, whether it has left the nasopharynx.”
Patients aren’t being retested near the end of their clinical course, although that would be ideal to ensure they were free of infection, File said. “After people are afebrile for a certain period of time, usually after 14 days, we’ve considered that they’ve resolved their illness to the point where we can reduce the quarantine aspect of their care,” he said.
Infected healthcare workers, on the other hand, are not only quarantined for 2 weeks but also must have two negative tests, 24 hours apart, before they’re allowed to return to work at Massachusetts General, Walensky said.

Social Distancing Works

With most of the country on some form of lockdown, Walensky stressed there is abundant evidence that social distancing can slow the spread of COVID-19. “There have been empirical data going back to the 1918 flu epidemic that demonstrate that social distancing measures delayed the peaks in mortality, had lower mortality, and took longer for that mortality to happen,” she said. “We also have new data from China showing the infectivity of the SARS COVID virus. We know from those data that social distancing almost halved the infectivity and the reproductive number of SARS.”
The Trump Administration has signaled that everyone in the most infected areas will soon be urged, but not required, to wear masks in public. Walensky emphasized that people should continue to adhere to social distancing even if they wear masks. Also, she noted, “You’re not protecting yourself if you wear a mask, you’re protecting someone else from something you might transmit to them asymptomatically and unknowingly.”
Walensky acknowledged that “vulnerable communities,” including the poor, have less ability to socially distance than other people do. “They may not have the space, and they may have more need to go to work and get paychecks. And, where less social distancing is occurring, we’re seeing a higher incidence of the epidemic.”
Walensky said she hasn’t seen any triaging of patients by their ability to pay for care. But some vulnerable groups have less access to healthcare than more affluent people do, File noted.
A reporter asked Walensky whether doctors are collecting observational data on the effects of hydroxychloroquine, which was recently approved by the Food and Drug Administration (FDA) for emergency use against COVID-19, and whether the data would be useful if they did. She said that 35 clinical trials of the drug are now being conducted, and a lot of physicians are already prescribing it. However, she added, “We need a big observational cohort, because not every hospital has the capacity to look through these charts and see what people got.”
https://www.medscape.com/viewarticle/928146#vp_1

Bill Gates on coronavirus, epidemics, testing and cures

On March 24 Bill Gates gave a highly revelatory 50-minute interview to Chris Anderson. Anderson is the Curator of TED, the non-profit that runs the TED Talks.
https://youtu.be/Xe8fIjxicoo
https://youtu.be/Xe8fIjxico
The Gates interview is the second in a new series of daily ‘Ted Connects’ interviews focused on COVID-19. The series’s website says that:

TED Connects: Community and Hope is a free, live, daily conversation series featuring experts whose ideas can help us reflect and work through this uncertain time with a sense of responsibility, compassion and wisdom.”

Anderson asked Gates at 3:49 in the video of the interview – which well over three million views now – about a ‘Perspective’ article by Gates that was published February 28 in the New England Journal of Medicine.

“You wrote that this could be the once-in-a-century pandemic that people have been fearing. Is that how you think of it, still?” queried Anderson.
“Well, it’s awful to say this but, we could have a respiratory virus whose case fatality rate was even higher. If this was something like smallpox, that kills 30 percent of people. So this is horrific,” responded Gates.
“But, in fact, most people even who get the COVID disease are able to survive. So in that, it’s quite infectious – way more infectious than MERS [Middle East Respiratory Syndrome] or SARS [Severe Acute Respiratory Syndrome] were. [But] it’s not as fatal as they were. And yet the disruption we’re seeing in order to knock it down is really completely unprecedented.”

Gates reiterates the dire consequences for the global economy later in the interview.

“We need a clear message about that,” Gates said starting at 26:52.
“It is really tragic that the economic effects of this are very dramatic. I mean, nothing like this has ever happened to the economy in our lifetimes. But … bringing the economy back and doing [sic] money, that’s more of a reversible thing than bringing people back to life. So we’re going to take the pain in the economic dimension, huge pain, in order to minimize the pain in disease and death dimension.”

However, this goes directly against the imperative to balance the benefits and costs of the screening, testing and treatment measures for each ailment – as successfully promulgated for years by, for example, the Choosing Wisely campaign – to provide the maximum benefit to individual patients and society as a whole

As noted in an April 1 article in OffGuardian, there may be dramatically more deaths from the economic breakdown than from COVID-19 itself.

“By all accounts, the impact of the response will be great, far-reaching, and long-lasting,”

Kevin Ryan wrote in the article. Ryan estimated that well over two million people will likely die from the sequelae of the lock-downs and other drastic measures to enforce ‘social distancing.’
Millions could potentially die from suicide, drug abuse, lack of medical coverage or treatment, poverty and lack of food access, on top of other predictable social, medical and public-health problems stemming from the response to COVID-19.
Gates and Anderson did not touch on any of those sequelae. Instead, they focused on rapidly ramping up testing and medical interventions for COVID-19.
Gates said at 30:29 in the interview that he and a large team are moving fast to test anti-virals, vaccines and other therapeutics and to bring them to market as quickly as possible.

The Gates Foundation and Wellcome Trust with support from Mastercard and now others, created this therapeutic accelerator to really triage out [candidate therapeutics]…
You have hundreds of people showing up and saying, ‘Try this, try that.’ So we look at lab assays, animal models, and so we understand which things should be prioritized for these very quick human trials that need to be done all over the world.”

The accelerator was launched March 10 with approximately $125 million in seed funding. Three days later Gates left Microsoft.
Not long before that, on January 23, Gates’s organization the Coalition for Epidemic Preparedness Innovations (CEPI) announced it will fund three programs to develop COVID-19 vaccines. These are the advancing of DNA-vaccine candidates against MERS and Lassa fever, the development of a “‘molecular clamp’ platform” that “enables targeted and rapid vaccine production against multiple viral pathogens,” and the manufacture and Phase 1 clinical study of an mRNA vaccine against COVID.

“The programmes will leverage rapid response platforms already supported by CEPI as well as a new partnership. The aim is to advance nCoV-2019 vaccine candidates into clinical testing as quickly as possible,” according to a news release.

Then at 32:50 in the video, Anderson asked whether the blood serum from people who have recovered from a COVID infection can be used to treat others.

“I heard you mention that one possibility might be treatments from the serum, the blood serum of people who had had the disease and then recovered. So I guess they’re carrying antibodies,” said Anderson.
“Talk a bit about that and how that could work and what it would take to accelerate that.”

[Note that Anderson did not ask Gates about, instead, just letting most of the population – aside from people most vulnerable to serious illness from the infection, who should be quarantined — be exposed to COVID-19 and as a result very likely recover and develop life-long immunity. As at least one expert has observed, “as much as ninety-nine percent of active cases [of COVID-19] in the general population are ‘mild’ and do not require specific medical treatment” to recover.]

“This has always been discussed as, ‘How could you pull that off?’” replied Gates.
“So people who are recovered, it appears, have very effective antibodies in their blood. So you could go, transfuse them and only take out white cells, the immune cells.”

However, Gates continued, he and his colleagues have dismissed that possibility because it’s “fairly complicated – compared to a drug we can make in high volume, you know, the cost of taking it out and putting it back in probably doesn’t scale as well.”
Then a few seconds later, at 33:45, Gates drops another bomb:

We don’t want to have a lot of recovered people…
To be clear, we’re trying – through the shut-down in the United States – to not get to one percent of the population infected. We’re well below that today, but with exponentiation, you could get past that three million [people or approximately one percent of the U.S. population being infected with COVID-19 and the vast majority recovering]. I believe we will be able to avoid that with having this economic pain.”

It appears that rather than let the population be exposed to the virus and most develop antibodies that give them natural, long-lasting immunity to COVID-19, Gates and his colleagues far prefer to create a vast, hugely expensive, new system of manufacturing and selling billions of test kits, and in parallel very quickly developing and selling billions of antivirals and vaccines.
And then, when the virus comes back again a few months later and most of the population is unexposed and therefore vulnerable, again selling billions of test kits and medical interventions.
Right after that, at 34:14, Gates talked about how he sees things rolling out from there.

Eventually what we’ll have to have is certificates of who’s a recovered person, who’s a vaccinated person…
…Because you don’t want people moving around the world where you’ll have some countries that won’t have it under control, sadly.
You don’t want to completely block off the ability for people to go there and come back and move around.
So eventually there will be this digital immunity proof that will help facilitate the global reopening up.”

[Some time on the afternoon of March 31 the last sentence of this quote was edited out of the official TED video of the interview. Fortunately, recordings of the complete interview are archived elsewhere.]
In the October 2019 Event 201 novel-corona virus-pandemic simulation co-sponsored by the Bill & Melinda Gates Foundation, the World Economic Forum and a division of the Johns Hopkins Bloomberg School of Public Health, a poll that was part of the simulation said that 65% of people in the U.S. would be eager to take a vaccine for COVID-19, “even if it’s experimental.”
This will be tremendously lucrative.
Vaccines are very big business: this Feb. 23 CNBC article, for example, describes the vaccine market as six times bigger than it was 20 years ago, at more than $35 billion annually today, and providing a $44 return for every $1 invested in the world’s 94 lowest-income countries.
Notably, the Bill & Melinda Gates Foundation – which has an endowment of $52 billion – has given more than $2.4 billion to the World Health Organization (WHO) since 2000, according to a 2017 Politico article. (While over the same time frame countries have reduced their contributions to the world body, particularly after the 2008-2009 depression, and now account for less than one-quarter of the WHO’s budget.) The WHO is now coordinating approximately 50 groups around the world that are working on candidate vaccines against COVID-19.
The Politico article quotes a Geneva-based NGO representative as saying Gates is “treated liked a head of state, not only at the WHO, but also at the G20,” and that Gates is one of the most influential people in global health.
https://www.zerohedge.com/geopolitical/did-bill-gates-just-reveal-real-reason-behind-lock-downs
 

Japan to boost Avigan drug stockpile as part of coronavirus stimulus

Japan is considering increasing the stockpile of Fujifilm Holding Corp’s Avigan anti-flu drug during this fiscal year so it can be used to treat 2 million people, according to a planning document seen by Reuters.
Local media reported on Sunday that Japan was hoping to triple the production of the drug from current levels, which is enough to treat 700,000 people if used by coronavirus patients.
Avigan, also known as Favipiravir, is manufactured by a subsidiary of Fujifilm, which has a healthcare arm although it is better known for its cameras. The drug was approved for use in Japan in 2014. Avigan is being tested in China as a treatment for COVID-19.

In the emergency stimulus package expected to be rolled out on Tuesday, the government also planned to prioritise the clinical trial process of the drug so it can be formally approved to be used in treating coronavirus patients.
According to the document, Japan also plans to boost subsidies to domestic companies that supply masks and disinfectants and will secure enough capacity to supply 700 million masks a month.
The Nikkei newspaper reported on Sunday that in efforts to reduce its dependence on China as its manufacturing hub, it will subsidise companies that will move some of their production facilities back to Japan.

Prime Minister Shinzo Abe said on Friday a stimulus package to combat the coronavirus pandemic will target small firms and households hardest hit by social distancing policies that are affecting consumption.
The package will include cash payouts to small firms and households facing sharp falls in income, Abe said.
The government will also urge private financial institutions to join government-affiliated lenders in offering zero-interest rate loans to cash-strapped small and midsized firms, he said.
https://www.reuters.com/article/us-health-coronavirus-japan-avigan/japan-to-boost-avigan-drug-stockpile-as-part-of-coronavirus-stimulus-idUSKBN21N026

Germany reports third straight drop in daily rate of new coronavirus infections

Germany’s confirmed coronavirus infections rose by 5,936 in the past 24 hours to 91,714 on Sunday, the third straight drop in the daily rate of new cases, according to data from the government’s Robert Koch Institute.
Sunday’s figure amounted to a drop of 146 cases compared with 6,082 new infections recorded on Saturday, itself a fall from 6,174 new infections on Friday.
The reported death toll rose by 184 to 1,342.
https://www.reuters.com/article/us-health-coronavirus-germany-infections/germany-reports-third-straight-drop-in-daily-rate-of-new-coronavirus-infections-idUSKBN21N0EF

As COVID-19 deaths steady, Italy’s health minister eyes next phase

Roberto Speranza said it was too early to say when Italy would be able to lift the measures imposed across the country on March 9, when it became the first country in Europe to impose a general lockdown to slow the spread of the virus.
With more than 15,000 dead, Italy has the world’s highest death toll from disease, accounting on its own for almost a quarter of all deaths globally. But the government is also grappling with the economic devastation caused by the sudden halt to business across the country.
“There are difficult months ahead. Our task is to create the conditions to live with the virus,” at least until a vaccine is developed, he told the daily La Repubblica newspaper, adding that some social distancing measures would also have to remain.
The smallest daily rise in COVID-19 deaths for nearly two weeks on Saturday and the first fall of the number of patients in intensive care have fed hopes that the epidemic may have reached a peak in Italy and focused attention on the next phase in the crisis.
The national lockdown, strictly limiting people’s movements and freezing on all non-essential economic activity, will officially last until at least April 13 but it is widely expected to be extended.
“If we’re not rigorous we risk throwing away all the efforts we’ve made,” Speranza said in separate comments to the Corriere della Sera daily.
Speranza said he had issued a note outlining five principles around which the government planned to manage the so-called “phase two” of the emergency, when lockdown restrictions begin to be eased but before a full return to normal conditions.

He said social distancing would have to remain, with wider use of individual protection devices such as face masks, while local health systems would be strengthened, to allow a faster and more efficient treatment of suspected COVID-19 cases.
Testing and “contact tracing” would be extended, including with the use of smartphone apps and other forms of digital technology while a network of hospitals dedicated solely to treating COVID-19 patients would be set up.
“Until a vaccine is distributed, we cannot rule out a new wave of the virus,” he said.
https://www.reuters.com/article/us-health-coronavirus-italy/as-covid-19-deaths-steady-italys-health-minister-eyes-next-phase-idUSKBN21N0GA?il=0

Non-COVID medical emergencies take a back seat, putting patients at risk

“I would rather die than risk getting coronavirus right now.”

That’s what a patient told Dr. Comilla Sasson, an emergency medicine physician in Denver, after she advised the patient during a telemedicine visit that she was showing signs of a heart attack and should go to a hospital.

“I asked if I could talk to one of her family members and she said ‘no’ — that she had already made up her mind,” Sasson told NBC News. It’s unclear what the woman’s diagnosis turned out to be, because she did not reach out to Sasson again.

In the midst of the coronavirus pandemic, medical emergencies unrelated to COVID-19 still occur. Sasson, who works at three hospitals in the Denver area, is among a number of doctors who worry that people experiencing warning signs of life-threatening conditions are delaying seeking emergency help out of fear of going to coronavirus-strained emergency rooms.

“Every minute that you delay, the likelihood of you having a worse outcome increases,” said Sasson, who is also vice president for science and innovation for emergency cardiovascular care at the American Heart Association.

She used a heart attack as an example: “If you get to the hospital within a few minutes, we can open up that heart vessel and get blood flowing to your heart, but if you delay even a few hours, that could be the difference between life and death.”

Fear or benevolence?

At the height of the coronavirus outbreak in Hong Kong, doctors observed the same trend that U.S. doctors are seeing now. In a letter in the journal Circulation: Cardiovascular Quality and Outcomes, physicians wrote that people who were experiencing symptoms of a heart attack waited to seek care after hospitals had suspended nonessential visits. Treatment for a heart attack, however, is essential.

According to Dr. Dhruv Kazi, a cardiologist at Beth Israel Deaconess Medical Center in Boston, putting off seeking medical care for potentially life-threatening conditions unrelated to COVID-19 is likely fueled by multiple factors: people choosing not to go to the hospital out of fear of contracting the virus, lack of transportation to the hospital, and citizens concerned about clogging the medical system.

“Whether it’s benevolence or fear of exposure, we need to address that,” he said.

Kazi is most worried about people who are experiencing acute symptoms that could snowball into a severe condition if left untreated.

“Individuals who are having very extreme heart attacks are going to get help, but at the fringes you have people who have acute symptoms who are staying home,” said Kazi. “I am worried that these patients could suffer severe consequences weeks or months down the road that could have been avoided if we had intervened.”

Most hospitals have instituted telehealth programs that allow patients to seek a medical evaluation remotely. In a situation that is not potentially life-threatening, these lines should always be used over showing up at a hospital, but people should still follow typical protocol for all medical emergencies during the pandemic, not just those related to the virus, Kazi said.

“I do not recommend that if patients are having warning signs of a heart attack or stroke that they should try and use telehealth to reach their doctor,” Kazi said. “These warning signs should result in a 911 call, and because EMS may be busy, calling 911 in a timely manner is even more important right now.”

Delaying care could also put more strain on the health care system in the long run.

“If people defer calling 911 for life-threatening emergencies or put off life-saving procedures because they’re afraid of getting exposed to the coronavirus in emergency rooms or hospitals, we can expect to see an increase in deaths among these people that is not reflected in COVID-19 death toll numbers,” said Kazi.

Emergencies in New York City

In New York City, the national center of the pandemic, 911 calls are at all-time highs, fleets of first responders are coming down with COVID-19 and wait times for ambulances have exceeded six hours in recent weeks.

But according to Oren Barzilay, president of the FDNY EMS Local 2507, which represents 4,500 first responders in New York City, call priorities, which determine where help is sent first, have not changed because of COVID-19. Low-priority calls are the ones experiencing these significant delays, not high-priority emergencies.

In fact, holding off on calling 911 until heart attack symptoms worsen could make it impossible for New Yorkers to get to a hospital at all. The Regional Emergency Medical Advisory Committee of New York City announced on Tuesday, March 31, that if an adult is in cardiac arrest and emergency responders are unable to restart their heart at the scene after 20 minutes, that person will not be taken to the city’s overburdened hospitals for further revival attempts, as is normally the case. This means seeking help when symptoms start is even more crucial.

“If anybody is experiencing a true emergency, we will always be there for you. We will never turn anyone away,” Barzilay said.

That goes for doctors working in New York City hospitals as well, though they are carefully weighing treatment options to keep emergency patients from staying in the hospital when possible, said Dr. Daniel Herron, the chief of general surgery at Mount Sinai Health System.

One example is appendicitis: “If a patient presents with abdominal pain which is strongly suggestive of appendicitis, which can be treated with surgery or with antibiotics, we would lean very heavily toward the treatment option that minimizes the use of hospital resources, which would be the antibiotic option,” Herron said. But “in cases where there is only a surgical option, then surgery is still available.”

https://www.nbcnews.com/health/health-news/coronavirus-surges-non-covid-medical-emergencies-take-back-seat-putting-n1175871

India curbs diagnostic testing kit exports as virus spreads

India is restricting the export of most diagnostic testing kits, as coronavirus cases in the South Asian nation topped 3,350 on Sunday despite a three-week nationwide lockdown to slow the spread of the respiratory disease.

India, which in recent weeks already banned the export of certain drugs, along with ventilators, masks and other protective gear needed by both patients and medical staff, issued the latest directive on Saturday.
The move comes even as U.S. President Donald Trump urged Prime Minister Narendra Modi in a phone call on Saturday, to release supplies of anti-malaria drug hydroxychloroquine, which is being tested as a possible treatment for patients with COVID-19 – the disease caused by the coronavirus.
“The two leaders agreed to remain in touch on the issue of global supply chains for critical pharmaceuticals and medical supplies and to ensure they continue to function as smoothly as possible during the global health crisis,” White House spokesman Judd Deere, said in a tweet on Saturday.
In a briefing note on the conversation, India said the two leaders “agreed to deploy the full strength of the India – U.S. partnership to resolutely and effectively combat COVID-19.”

BANGLADESH STIMULUS PLAN

The total number of confirmed COVID-19 cases in South Asia, home to roughly 1.9 billion people, climbed close to 7,000 on Sunday, even as the death toll from the respiratory disease in the Indian subcontinent rose to 143.
While the figures are relatively low in comparison with the United States, China, Italy and Spain, health experts fear that the spread of the pandemic in South Asia would overwhelm already weak public health systems in the region.
Bangladesh’s Prime Minister Sheikh Hasina on Sunday unveiled a 727.50 billion taka ($8.56 billion) stimulus package to help the economy overcome the impact of the coronavirus outbreak.
“The amount is equivalent to 2.52 percent of gross domestic product,” Hasina said in a televised address.
Reuters earlier this month reported that Bangladesh, the second-largest apparel producer after China, is set to lose roughly $6 billion in export revenue this financial year amid order cancellations from some of the world’s largest brands and retailers.
Bangladesh has so far recorded 88 cases of the disease that has so far claimed nine lives.
Following are government figures on the spread of the coronavirus in South Asia:
– India has 3,374 cases, including 77 deaths
– Pakistan has 2,880 cases, including 45 deaths
– Afghanistan has 337 cases, including 7 deaths
– Sri Lanka has 166 cases, including 5 deaths
– Bangladesh has 88 cases, including 9 deaths

– Maldives has 32 cases and no deaths
– Nepal has nine cases and no deaths
– Bhutan has five cases and no deaths
https://www.reuters.com/article/us-health-coronavirus-southasia/india-curbs-diagnostic-testing-kit-exports-as-virus-spreads-idUSKBN21N0BE?il=0