Deadly cost of lockdown policies

Many years ago, one of my duties as a young surgical intern was to fill out death certificates for recently deceased patients. Under “cause of death,” Part I asked for the immediate cause, other conditions leading to it, and the underlying cause. Part II asked for “other significant conditions contributing to death but not resulting in the underlying cause given in Part I.” If you think this is confusing, you’re right. Did the post-operative patient found dead in bed really die of a heart attack, a pulmonary embolism, or some operative complication, like bleeding? Where do you list their colon cancer or hypertension?

The task has not gotten any easier during the Covid-19 pandemic. People are still dying of heart disease, stroke, cancer, and accidents. But now there is a new respiratory illness to account for. Not every decedent who tested positive for the virus that causes Covid-19 died from it—in fact, the disease is mild for most people. Conversely, some deaths due to Covid-19 may be erroneously assigned to other causes of death because the people were never tested, and Covid-19 was not diagnosed. Nearly everyone dying of Covid-19 has concurrent health problems—the average decedent has 2.5 co-morbid conditions—and hypertension, heart disease, respiratory diseases, and diabetes are among the most common. The presence and interaction of these co-morbid conditions is what sometimes changes Covid-19 from a relatively benign disease into a killer. But co-morbidities can also cause death regardless of Covid-19.

A common way to distinguish the mortality burden of a new infectious agent from other causes of death is to estimate the excess deaths that occurred beyond what would be expected if the pathogen had not circulated. A recent study of 48 states and the District of Columbia estimated 122,300 excess deaths during the pandemic period of March 1 to May 30, compared with expected deaths calculated from the previous five years. Deaths officially attributed to Covid-19 accounted for 78 percent of the total; approximately 27,000 deaths (22 percent) were not attributed to Covid-19. A second study, using the same database with different statistical methods for the period March 1 to April 25, found that 65 percent of 87,000 excess deaths were attributed to Covid-19.

Only part of the discrepancy between excess deaths and official Covid deaths results from undercounting of Covid deaths. In New York City, when excess deaths between March 11 (the first recorded Covid-19 death) and May 2 were examined, only 57 percent had laboratory-confirmed Covid-19. Yet when probable deaths—deaths for which Covid-19, SARS-CoV-2, or an equivalent term was listed on the death certificate as an immediate, underlying, or contributing cause of death, but that did not have laboratory confirmation of Covid-19—were added in, 22 percent of excess deaths were still not attributed to Covid-19.

The indirect effect of the pandemic—deaths caused by the social and economic responses to the pandemic, including lockdowns—appears to explain the balance. For instance, people delayed needed medical care because they were instructed to shelter in place, were too scared to go to the doctor, or were unable to obtain care because of limitations on available care, including a moratorium on elective procedures.

Inpatient admissions nationwide in VA hospitals, the nation’s largest hospital system, were down 42 percent for six emergency conditions—stroke, myocardial infarction (MI), heart failure, chronic obstructive pulmonary disease, appendicitis, and pneumonia—during six weeks of the Covid-19 pandemic (March 11 to April 21) compared with the six weeks immediately prior (January 29 to March 10). The drop was significant for all six conditions and ranged from a decrease of 40 percent for MI to 57 percent for appendicitis. No such decrease in admissions was found for the same six-week period in 2019. These emergency conditions did not become any less lethal as a result of the pandemic; rather, people simply died from acute illnesses that would have been treated in normal times.

Deaths from chronic, non-emergent conditions also increased as patients put off maintenance visits and their medical conditions deteriorated. In the second study of excess deaths, the five states with the most Covid-19 deaths from March through April (Massachusetts, Michigan, New Jersey, New York, and Pennsylvania), experienced large proportional increases in deaths from non-respiratory underlying causes, including diabetes (96 percent), heart diseases (89 percent), Alzheimer’s disease (64 percent), and cerebrovascular diseases (35 percent). New York City—the nation’s Covid-19 epicenter during that period—experienced the largest increases in non-respiratory deaths, notably from heart disease (398 percent) and diabetes (356 percent).

Cancer diagnoses were delayed for months as patients were unable to obtain “elective” screening procedures. For some, this will result in more advanced disease. Diagnosed cancer cases—normally treated with surgery or inpatient medical treatments—were treated with outpatient treatments instead. While some oncologists rationalized that the results might be just as good, physicians were clearly deviating from the standard of care.

The lockdowns led to wide unemployment and economic recession, resulting in increased drug and alcohol abuse and increases in domestic abuse and suicides. Most studies in a systematic literature review found a positive association between economic recession and increased suicides. Data from the 2008 Great Recession showed a strong positive correlation between increasing unemployment and increasing suicide in middle aged (45–64) people. Ten times as many people texted a federal government disaster mental-distress hotline in April 2020 as in April 2019.

As we consider how to deal with resurgent numbers of Covid cases, we must acknowledge that mitigation measures like shelter-in-place and lockdowns appear to have contributed to the death toll. The orders were issued by states and localities in late March; excess deaths peaked in the week ending April 11. Reopening began in mid-April, and by May 20 all states that had imposed orders started to lift restrictions. In June, as the economy continued reopening, excess deaths waned.

Our focus must be on ensuring that the health-care system can simultaneously treat Covid-19 and other maladies and reassuring patients that it is safe to seek care. Otherwise, today’s young physicians will have to start entering a new cause of death on death certificates—“public policy.”

Joel Zinberg, M.D., J.D., is a Senior Fellow at the Competitive Enterprise Institute in Washington, D.C., and an associate clinical professor of surgery at the Mount Sinai Icahn School of Medicine in New York. He served as general counsel and senior economist at the Council of Economic Advisers from 2017 to 2019, where he specialized in health policy.

https://www.city-journal.org/deadly-cost-of-lockdown-policies

Gov: Lack of masks, COVID-19 spike may spur ‘necessity of closing Texas down’

In an interview with CBS19 on Friday, Governor Greg Abbott said a lack of masks and a spike in COVID-19 could, as a last resort, lead to “the necessity of closing Texas down.”

He also said he’s disappointed some local governments refuse to enforce his recently issued Executive Order.

“It’s disappointing,” Gov. Abbott said. “And again, I can understand the mindset being a kid who grew up in Longview myself, that this may not be the top priority. A murderer, or a rapist or a robber is far more serious to concentrate on. However, I know this also, and that is if we do not all join together and unite in this one cause for a short period of time, of adopting a mask, what it will lead to is the necessity of having to close Texas back down. That should be the last thing that any government wants ⁠— the last thing that any business owner wants. Your business owners in Tyler ⁠— in Longview, they should be demanding that their government officials enforce this face mask order now to make sure they will be able to stay open. And the only way those businesses are going to stay open is to make sure people wear masks to slow the spread of the coronavirus.”

The order, which was issued July 2, requires all Texans to wear a face covering over the nose and mouth in public spaces in counties with 20 or more positive COVID-19 cases, with few exceptions.

The Texas Department of Emergency Management (TDEM) will maintain a list of counties that are not subject to the face-covering requirement. The list can be found here.

Exceptions to the mask requirement include:

• Any person younger than 10 years of age;
• Any person with a medical condition or disability that prevents wearing a face covering;
• Any person consuming food or drink, or when seated at a restaurant to eat or drink;
• Any person exercising outdoors or engaging in physical activity outdoors while also maintaining a safe distance from other people not in the same household;
• Any person driving alone or with passengers who are part of the same household as the driver;
• Any person obtaining a service that requires temporary removal of the face covering for security surveillance, screening or a need for specific access to the face, such as while visiting a bank or while obtaining a personal care service involving the face, but only to the extent necessary for the temporary removal;
• Any person while the person is in a swimming pool, lake or similar body of water;
• Any person who is voting, assisting a voter, serving as a poll watcher, or actively administering an election, but wearing a face covering is strongly encouraged;
• Any person who is actively providing or obtaining access to religious worship, but wearing a face covering is strongly encouraged;
• Any person while the person is giving a speech for a broadcast or to an audience;
• Any person in a county that meets the requisite criteria regarding minimal cases of COVID-19;
• Any person whose county judge has affirmatively opted-out of this face-covering requirement by filing with TDEM the required face-covering attestation form.

According to the order, people not exempt from the face-covering requirement are those attending a protest or demonstration involving more than 10 people and those not practicing safe social distancing of six feet from other people not in the same household.

Following a verbal or written warning for a first-time violator of Gov. Abbott’s face-covering requirement, a person’s second violation shall be punishable by a fine not to exceed $250. Each subsequent violation shall be punishable by a fine not to exceed $250 per violation.

The order went into effect at 12:01 p.m. on July.

The governor also issued a proclamation giving mayors and county judges the ability to impose restrictions on some outdoor gatherings of more than 10 people, and making it mandatory that, with certain exceptions, people cannot be in groups larger than 10 and must maintain six feet of social distancing from others.

“Wearing a face covering in public is proven to be one of the most effective ways we have to slow the spread of COVID-19,” said Gov. Abbott. “We have the ability to keep businesses open and move our economy forward so that Texans can continue to earn a paycheck, but it requires each of us to do our part to protect one another — and that means wearing a face covering in public spaces. Likewise, large gatherings are a clear contributor to the rise in COVID-19 cases. Restricting the size of groups gatherings will strengthen Texas’ ability to corral this virus and keep Texans safe. We all have a responsibility to slow the spread of COVID-19 and keep our communities safe. If Texans commit to wearing face coverings in public spaces and follow the best health and safety practices, we can both slow the spread of COVID-19 and keep Texas open for business. I urge all Texans to wear a face covering in public, not just for their own health, but for the health of their families, friends, and for all our fellow Texans.”

https://www.khou.com/article/news/gov-abbott-lack-of-masks-spike-in-covid-19-could-lead-to-necessity-of-closing-texas-down/501-b62b3933-0f6c-494e-b4af-7ea8422effcf

Pandemic exposes scientific rift over proving when germs are airborne

The coronavirus pandemic has exposed a clash among medical experts over disease transmission that stretches back nearly a century – to the very origins of germ theory.

The Geneva-based World Health Organization acknowledged this week that the novel coronavirus can spread through tiny droplets floating in the air, a nod to more than 200 experts in aerosol science who publicly complained that the U.N. agency had failed to warn the public about this risk.

Yet the WHO still insists on more definitive proof that the novel coronavirus, which causes the respiratory disease COVID-19, can be transmitted through the air, a trait that would put it on par with measles and tuberculosis and require even more stringent measures to contain its spread.

“WHO’s slow motion on this issue is unfortunately slowing the control of the pandemic,” said Jose Jimenez, a University of Colorado chemist who signed the public letter urging the agency to change its guidance.

Jimenez and other experts in aerosol transmission have said the WHO is holding too dearly to the notion that germs are spread primarily though contact with a contaminated person or object. That idea was a foundation of modern medicine, and explicitly rejected the obsolete miasma theory that originated in the Middle Ages postulating that poisonous, foul-smelling vapors made up of decaying matter caused diseases such as cholera and the Black Death.

“It’s part of the culture of medicine from the early 20th century. To accept something was airborne requires this very high level of proof,” said Dr. Donald Milton, a University of Maryland aerobiologist and a lead author of the open letter.

Such proof could involve studies in which laboratory animals become sickened by exposure to the virus in the air, or studies showing viable virus particles in air samples – a level of proof not required for other modes of transmission such as contact with contaminated surfaces, the letter’s signatories said.

For the WHO, such proof is necessary as it advises countries of every income and resource level to take more drastic measures against a pandemic that has killed more than 550,000 people globally, with more than 12 million confirmed infections.

For example, hospitals would have to provide more healthcare personnel with heavy-duty N95 respiratory masks – personal protective gear already in short supply – and businesses and schools would need to make improvements to ventilation systems and require wearing masks indoors at all times.

“It would affect our entire way of life. And that’s why it’s a very important question,” said Dr. John Conly, a University of Calgary infectious disease expert who is part of the WHO’s group of experts advising on coronavirus guidelines.

Conly said that so far the studies have not shown viable virus particles floating in the air.

“In my mind, I want to see evidence in those fine mists,” Conly said.

HOW FAR CAN A DROPLET TRAVEL?

The WHO’s latest guidance document, released on Thursday, called for more research on coronavirus aerosol transmission, which it said “has not been demonstrated.”

The agency also repeated a firm cutoff on the size of infectious droplets expelled in coughing and sneezing, noting that most larger droplets are unlikely to travel beyond one meter (3.3 feet) – the basis for their one-meter social distancing guidelines. Milton and others have said larger particles have been shown to spread much farther.

Conly and others maintain that if the virus were truly airborne like measles, there would already be many more cases.

“Would we not be seeing, like, literally billions of cases globally? That’s not the case,” Conly said.

WHO spokeswoman Dr. Margaret Harris rejected the claim by critics that the agency is biased against the idea of aerosol transmission, saying it recognized the possibility of airborne transmission during medical procedures from early on in the pandemic.

Harris said it is “quite possible” that aerosolization is a factor in some so-called super-spreading events in which one infected person infects many others in close quarters. Many of these events have occurred in places such as nightclubs where people are packed together and are not likely to be careful about protecting themselves or others from infection.

“Most super-spreading events have occurred in indoor places with poor ventilation, with crowding, where it’s very difficult for people to socially distance,” Harris said.

That is why, Harris said, the agency has called for urgent studies to figure out “what really happened in these clusters and what were the big factors.”

https://www.reuters.com/article/us-health-coronavirus-airborne/pandemic-exposes-scientific-rift-over-proving-when-germs-are-airborne-idUSKBN24B2YG

Insurers eye Legionnaires’ safeguards as buildings reopen after Covid shutdowns

Commercial insurers are scrutinizing building managers’ efforts to avoid outbreaks of Legionnaires’ disease as they re-open movie theaters, gyms, schools and offices that had been closed for months due to the coronavirus pandemic, industry sources told Reuters.

Legionnaires’ disease is a severe, sometimes-lethal form of pneumonia caused by the Legionella bacteria that builds up in pipes. Environmental insurers, which collect roughly $2 billion in annual premiums, would be on the hook for damages if there are outbreaks at buildings they cover.

“Legionella could be the deadliest waterborne illness in the U.S. and another deadly consequence of COVID,” said Veronica Benzinger, environmental service group leader for insurance broker Aon PLC, referring to the illness caused by the novel coronavirus.

The pandemic shutdown of businesses and schools has led to an unprecedented amount of stagnant water in dormant buildings. It becomes a breeding ground for Legionella bacteria, which can be spread from toilets, sinks, showers and air-conditioning systems.

Some insurers are intensifying Legionnaire’s precautions before adding new clients or renewing coverage, insurers and brokers said. For instance, they may ask customers to document how they maintain plumbing and cooling systems.

Large commercial office buildings and manufacturing plants have professional maintenance staff who likely kept water flowing throughout the crisis. Smaller buildings that insurers cover are at higher risk, experts said.

To avoid contamination, they must flush and sanitize pipes and disinfect cooling towers that use water to lower air temperature, they said.

The bacteria and disease get their name from a deadly outbreak following a 1976 American Legion convention in a Philadelphia hotel.

Nearly 50,000 people have been infected with Legionnaires’ disease between 2000 and 2015, according to the U.S. Centers for Disease Control and Prevention. [L3N2CC376]

Allianz SE has added Legionnaires’ prevention to broader discussions with large industrial clients about the coronavirus pandemic, said Scott Steinmetz, global head of risk consulting within an Allianz specialty insurance.

Allianz has engineers helping customers prepare for reopening, he said. Allianz and AXA SA are also sending bulletins to clients about water system maintenance.

Insurers might limit Legionnaire’s coverage amounts or impose higher deductibles if building systems are outdated, brokers said.

Insurers were already worried about possible outbreaks, because of elevated lawsuits and claims. They are stepping up their scrutiny even more due to the coronavirus pandemic.

In April, Illinois agreed to pay $6.4 million to families of patients who died of Legionnaires’ disease at a state-run veterans home. Other deaths have occurred in New York and Michigan.

https://www.reuters.com/article/us-health-coronavirus-insurance-legionna/u-s-insurers-eye-legionnaires-disease-safeguards-as-buildings-re-open-from-pandemic-shutdowns-idUSKBN23P3G9

Walmart a ‘sleeping giant’ in health care – Morgan Stanley

Already the third largest pharmacy in the U.S., Walmart’s (NYSE:WMT) efforts to open health clinics and acquire technology that will help patients manage their medical care make it a “sleeping giant to watch,” Morgan Stanley says.

“A multi-pronged approach makes a lot of sense, and recent steps are clear indications this is what Walmart is pursuing,” the Stanley analysts write, citing the company’s “huge customer base” and the “gigantic market opportunity to reduce inefficiencies” in the industry.

Stanley sees the health care opportunity as a potential “silver bullet” for the company over the longer term, especially as it prepares to launch the Walmart+ membership program this month.

“Walmart’s step into insurance likely has few major industry implications in the near to medium term, but this may change later,” the firm says.

The company recently posted job openings on its careers website that indicate it is looking to hire insurance agents in the Dallas area to sell Medicare insurance.

https://seekingalpha.com/news/3590407-walmart-sleeping-giant-in-health-care-morgan-stanley-says

Ozone disinfection could safely allow reuse of personal protective equipment

A new study shows that ozone gas, a highly reactive chemical composed of three oxygen atoms, could provide a safe means for disinfecting certain types of personal protective equipment that are in high demand for shielding healthcare personnel from COVID-19.

Conducted by researchers at the Georgia Institute of Technology using two pathogens similar to the novel coronavirus, the study found that ozone can inactivate viruses on items such as Tyvek gowns, polycarbonate face shields, goggles, and respirator masks without damaging them—as long as they don’t include stapled-on elastic straps. The study found that the consistency and effectiveness of the ozone treatment depended on maintaining relative humidity of at least 50% in chambers used for disinfection.

“Ozone is one of the friendliest and cleanest ways of deactivating viruses and killing most any pathogen,” said M.G. Finn, chair of Georgia Tech’s School of Chemistry and Biochemistry, who led the study. “It does not leave a residue; it’s easy to generate from atmospheric air, and it’s easy to use from an equipment perspective.”

Findings of the research are described in a paper posted to the medRxiv preprint server and will be submitted to a journal for peer review and publication. Ozone can be produced with inexpensive equipment by exposing oxygen in the atmosphere to ultraviolet light, or through an electrical discharge such as a spark.

During local and regional peaks in coronavirus infection, shortages of personal protective equipment (PPE) can force hospitals and other healthcare facilities to reuse PPE that was intended for a single use. Facilities have used ultraviolet light, vaporized hydrogen peroxide, heat, alcohol and other techniques to disinfect these items, but until recently, there had not been much interest in ozone disinfection, Finn said.

Ozone is widely used for disinfecting wastewater, purifying drinking water, sanitizing food items, and disinfecting certain types of equipment—even clothing. Ozone disinfection cabinets are commercially available, taking advantage of the oxidizing effects of the gas to kill bacteria and inactivate viruses.

“There was no reason to think it wouldn’t work, but we could find no examples of testing done on a variety of personal protective equipment,” Finn said. “We wanted to contribute to meeting the needs of hospitals and other healthcare organizations to show that this technique could work against pathogens similar to the coronavirus.”

Phil Santangelo, a virologist in the Wallace H. Coulter Department of Biomedical Engineering, recommended two respiratory viruses—influenza A and respiratory syncytial virus (RSV) – as surrogates for coronavirus. The two are known as “enveloped” viruses because, like coronavirus, they are surrounded by a lipid outer membrane. Influenza and RSV are less dangerous than the SARS-CoV-2 coronavirus, allowing the Georgia Tech researchers to study them without high-containment laboratory facilities.

Santangelo, Finn, and their team devised a test procedure in which solutions containing the two viruses were placed onto samples of the PPE materials under study. The solutions were allowed to dry before the samples were placed in a chamber into which ozone was introduced at varying concentrations as low as 20 parts per million. After treatment for different lengths of time, the researchers tested the PPE samples to determine whether or not any of the viruses on the treated surfaces could infect cells grown in the laboratory. The entire test procedure required about a day and a half.

“The protocol we set up reports very sensitively on whether or not the virus could reproduce, and we found that the ozone was very successful in rendering them harmless,” Finn said. “Oxidizing biological samples to a significant extent is enough to inactivate a virus. Either the genetic material or the outer shell of the virus would be damaged enough that it could no longer infect a host cell.”

Loren Williams, a professor in School of Chemistry and Biochemistry, introduced the research team to a manufacturer of ozone disinfection chambers, which allowed evaluation of the equipment using the test protocol. During the test, the researchers learned that having sufficient relative humidity in the chamber—at least 50%—was essential for rapidly inactivating the viruses in a consistent manner.

After subjecting face masks and respirators to ozone disinfection, the team worked with Associate Professor Ng Lee (Sally) Ng from the School of Chemical and Biomolecular Engineering to evaluate the filtration capabilities of the items. The ozone treatment didn’t appear to negatively affect the N-95 filtration material.

But it did damage the elastic materials used to hold the masks in place. While the elastic headbands could be removed from the masks during ozone disinfection, removing and replacing them on a large scale may make the treatment technique impractical. Otherwise, however, ozone may offer an alternative technique for disinfecting other types of PPE.

“Ozone would be a viable method for hospitals and other organizations to disinfect garments, goggles, and gloves,” Finn added. “It is inexpensive to produce, and we hope that by sharing information about what we’ve found, healthcare facilities will be able to consider it as an option, particularly in low-resource areas of the world.”

https://medicalxpress.com/news/2020-07-ozone-disinfection-safely-reuse-personal.html

In autopsies, COVID-19 victims had blood clots in ‘almost every organ’ – pathologist

Autopsies found blood clots in “almost every organ” of coronavirus victims, according to a top New York City pathologist, who called the results “dramatic.”

Early on, doctors found blood clots “in lines and various vessels” of COVID-19 patients, Dr. Amy Rapkiewicz told CNN on Thursday.

But then autopsies showed the damage was far worse.

“The clotting was not only in the large vessels but also in the smaller vessels,” said Rapkiewicz, chairman of the department of pathology at NYU Langone Medical Center.

“And this was dramatic because though we might have expected it in the lungs, we found it in almost every organ that we looked at in our autopsy study.”

The autopsies also revealed that large bone marrow cells called megakaryocytes — which typically don’t travel outside the bone and lungs — circulated to other parts of the body.

“We found them in the heart and the kidneys and the liver and other organs,” said Rapkiewicz. “Notably in the heart, megakaryocytes produce something called platelets that are intimately involved in blood clotting.”

The findings are similar to those in April, when doctors at Mount Sinai spotted signs of blood thickening and clotting in different organs.

Rapkiewicz said myocarditis, or inflammation of the heart, wasn’t detected in the autopsies, though the condition was initially suspected in the early days of the coronavirus outbreak.

https://nypost.com/2020/07/10/covid-19-victims-had-extensive-blood-clots-doctor/