COVID-19 Coronavirus Containment Efforts

[StevieTNZ]

Herman Cain died from the "china virus" on 30 July (US).

The president paid tribute to Mr Cain on Thursday at the White House, saying: "He was a very special person... and unfortunately he passed away from a thing called the China virus."

-- https://www.bbc.com/news/world-us-canada-53600376

 

[BillTre]

Updates on Efforts to Have Sports Leagues Play:
(Sports as a Model for Society)

This NY Times article (‘Bubbles’ Are Working. But How Long Can Sports Stay Inside?') reviews how different leagues, using different approaches, are doing wrt controlling infections and continuing to be able to play.

This news article from Science goes into detail about how organization running The Basketball Tournament (TBT) worked with Tara Kirk Sell, who specializes in trying to reduce the health impacts of large-scale events such as disasters and terrorism, so they could run their 24 team tournament with minimal problems.
This is a really nice article with lots of details about planning out lots of contingencies ahead of time, a great testing scheme, and continual procedural improvement, all of which seem necessary for success to me.

Sell's interests in the job:

From Sell’s standpoint, TBT could be in some respects described as a natural culmination of her professional life. She has always been “intrigued” by the emotional power sports hold to advance the public health. For members of certain minority communities, star athletes from similar backgrounds in MLB or NBA can be seen as both advocates and role models for the community’s safety. When NBA basketball star Steph Curry speaks on Instagram to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and a leader of the U.S. COVID-19 response, those who admire and trust the player might pay heed to the scientist more than they would in other circumstances.

Sports, in this way, must be considered as much a part of a national public health strategy as funding for vaccines, says Sell, whose doctoral thesis evaluated the “media and policy responses to … dreaded communicable diseases” such as Ebola. She feels a particular urgency to this end—because the “loss of trust, increased division, and outright confusion” surrounding COVID-19 has meant doubt in U.S. health authorities has been mounting since April.

Description of their methods:

In late April, through a series of teleconferences with the TBT staff, Sell “pounded into our heads that the devil was in every last detail,” Mugar says. The goal, he notes, was “to leave no stone unturned to derisk every touchpoint.”

The foundation of the TBT plan was built on saliva tests meant to detect proteins associated with active infection of SARV-CoV-2: Players would take six over the course of the 11-day tournament. To ensure results would be accessible within 18 hours, TBT enlisted a Rutgers University–associated lab within driving distance, should inclement weather prevent flights. (Such saliva “antigen” tests are not as sensitive and accurate as tests looking for viral genes—but they are cheaper, faster, and if used regularly enough, some scientists say, they can still stop an outbreak quickly. TBT used viral genome assays on nasal swabs only to confirm positive saliva tests, and MLB is adopting a similar strategy.)

In turn, clear hygiene protocols, including disinfecting objects such as benches, room keys, gym equipment, and water bottles, would reduce the risk of transmission from anyone individual to another. Laundry would be handled centrally, signage defined how players should reduce the risk of transmission in shared spaces such as elevators and dining halls, and text message reminders to maintain precautions for hand washing and mask wearing would be constant.

Sell and Mugar also designed a health monitoring questionnaire that players could complete on their smartphones twice daily, in the hopes of catching COVID-19 symptoms that developed in between saliva tests—or in case of false negative tests (which could inappropriately lead a player who was sick to be cleared). An incomplete questionnaire—or one that noted worrisome symptoms such as fever or shortness of breath—would constitute criteria for isolating a player. Finally, in the near-inevitability that players tested positive, the formation of self-contained cohorts within teams for transportation to and from playing facilities—as well as dining and other group activities—would facilitate contact tracing if and when required.

This worked out for the tournament, and provides a possible guide for bringing back the economy in general, if people were to consider it.

She hopes the procedures adopted by TBT can help beyond sports, too. Symptom self-monitoring, hygiene procedures, routine testing, and strategies for cohort contact tracing have all been applied in countries such as Taiwan, Singapore, and Japan that have, for now, safely reopened their economies. “Things are not going to be 100% normal for a [while],” Sell says, “I don’t think we can afford overlooking … the tiniest details.”

Probably asking too much of some people.

 

[bhobba]

Melbourne to be in stage 4 lockdown soon. Personally I would not call it a total stage 4 lockdown (eg you can still go out for fresh air and exercise), but a stronger stage 3 and some stage 4 measures:
https://www.9news.com.au/national/v...hey-mean/2e508cdb-6cfe-4a6f-ad80-52af9601435a

Personally I think the whole state of Victoria should be put in a total stage 4 lockdown immediately (a real one) - experience has shown the sooner you go as hard as you can the better. And they must deploy the vaccine I mentioned previously to protect those in nursing homes and front line medical workers (since it is part of a stage 2 trial volunteers of course). IMHO a real leader would - but most politicians seem to prefer spin to actual action when making really tough decisions.

Thanks
Bill

 

[bhobba]

Now I am getting dejected and very disappointed. The latest on the Flinders University vaccine from todays Courier Mail:

'The US, UK and Korean governments are supporting the trials of the vaccine but Professor Petrovsky said neither Australia’s government nor our vaccine manufacturer CSL will deal with him. “They don’t return our phone calls,” he said. “It’s politics, but I would argue in the middle of a pandemic you should put politics aside”.

A funding application from the government’s Medical Research Future Fund was recently knocked back, he said. Professor Petrovsky has reached out to the Victorian Government and wants to move the next stage of his clinical trials into aged care homes in Victoria where hundreds of people have been infected with coronavirus. “They’ve got nothing to lose,” he said. “It’s frustrating to watch people dying and we have a vaccine that could stop those deaths,” he said.

The Governor of Norfolk Island which has an elderly population has asked whether his entire population can be injected with the vaccine as part of the next phase of the trial.“We’re open to looking at that but we would have to get the right ethics approvals before that could go ahead,” he told News Corp.'

I have mentioned before we have politicians and associated bureaucrats coming out of our ears - but real leaders, people with actual vision and what I call 'true grit', are few and far between. Norfolk Island, an Australian Territory, is showing some actual leadership. But as to the rest of Australia - well let's just say slogans like Australia Is The Smart Country - is looking like it has no actual substance.

I have never done this before, but I am going to ring our local member who is a MD and holds a Masters in Public Administration from Harvard. He spent time working in remote Aboriginal communities and so would know it would be a disaster if it got into those. If it will make a difference I do not know - but I feel I need to do something.

Thanks
Bill

 

[atyy]

Now I am getting dejected and very disappointed. The latest on the Flinders University vaccine from todays Courier Mail:

'The US, UK and Korean governments are supporting the trials of the vaccine but Professor Petrovsky said neither Australia’s government nor our vaccine manufacturer CSL will deal with him. “They don’t return our phone calls,” he said. “It’s politics, but I would argue in the middle of a pandemic you should put politics aside”.

Could it be that the Australian government is betting on the Queensland vaccine (ie. maybe it is not politics)?

What is the Flinders vaccine strategy?

 

[bhobba]

Could it be that the Australian government is betting on the Queensland vaccine (ie. maybe it is not politics)? What is the Flinders vaccine strategy?

That's it according to Professor Petrovsky - I only gave an extract from the entire news story. I would call that politics - but I suppose it's what you mean by politics. To be a bit more positive the UQ vaccine is only a few weeks behind the Flinders vaccine, and works in a similar way, so as far as getting Australia and other countries vaccinated it will not make much difference I think. But the situation in Victoria is now getting a lot worse, and especially bad in nursing homes where most of the deaths are occurring.

The vaccine is called Covax-19 and has collaborated with South Korean biopharma firm Medytox for its development and commercialisation.

It uses the Advax adjuvant technology, developed by Dr Peter Cooper at the ANU and Professor Petrovsky, in combination with a recombinant SARS-CoV-2 spike protein. Medytox signed a memorandum of understanding on 12 May. They will jointly carry out product and process development, clinical trial programme and commercial scale-up for the Australian and Asian markets, including Korea. It is not part of CEPI so that is a possible issue.

The more I think about it, the more I believe talking to our local federal member about it is the way to go. He has the right background to look into this issue:
https://www.aph.gov.au/Senators_and_Members/Parliamentarian?MPID=E0H

If he can't get anything done, then I do not think much more is possible.

It's just so frustrating, especially as I write this and listening to the local news you hear a doctor saying we need a vaccine ASAP to get out of this mess - and that was just the issue of deferral of surgery due the need to keep beds free. Trials are not complete, but we can make emergency use of a vaccine for critical front line medical staff and patients at high risk.

Thanks
Bill

 

[Vanadium 50]

we now know that the vaccine is completely safe

He should not say such things.

If he has 400 subjects (and that seems questionable) he is reasonably sure than the rate of serious adverse reactions is under 1%. That's a pretty big number. It's even above the CDC fatality rate of 0.26%. He needs a larger study to even show it's safer than the disease, much less "completely safe".

 

[bhobba]

He should not say such things.

If he has 400 subjects (and that seems questionable) he is reasonably sure than the rate of serious adverse reactions is under 1%. That's a pretty big number. It's even above the CDC fatality rate of 0.26%. He needs a larger study to even show it's safer than the disease, much less "completely safe".

Valid point. But he is only proposing to use it as part of a stage 2 trial which is voluntary. Actually I think the stage 1 trials would have been less than 400 - more like the 120 UQ is using which only makes it worse. But the death rate in the nursing homes is scary - 33.7%:
https://pubmed.ncbi.nlm.nih.gov/32220208/

It would need analysis by a biostatistician and could be valid reason to reject it. But at least consider it and give a rational reason.

Thanks
Bill

 

[StatGuy2000]

Current story in USA Today:

https://www.usatoday.com/story/news...t-region-second-coronavirus-spike/5526854002/

I think this is a swing and a miss on the premise (but they need something to write about...).

Starting in mid-April, New York's test positivity rate dropped smoothly and exponentially to the 1-2% range by the beginning of June and hasn't budged since. New Jersey's curve wasn't smooth due to awful early testing rates, but it also dropped below 2% by the second week of June and also hasn't budged.

Both states have largely re-opened (NYC just went to "phase 4" on July 20, which isn't quite normal), but I don't believe that New York and New Jersey have uniquely excelled at personal mitigation efforts since April while other states such as PA have experienced a resurgence as they re-opened. Whether it's 25% or nearly everyone who has been exposed, it seems pretty clear to me that NY and NJ have achieved herd immunity, and COVID is basically finished with them.

The implications of this are that we get to see what it looks like to let COVID run wild and then get back to normal quickly, and compare that to, say, Pennsylvania, which I expect will be in a state of partial shutdown for the next 6 months.

From a number of sources I have read (including the following article from John Hopkins University), for herd immunity to take into effect, approximately 70% of a given population needs immunity (whether from direct exposure to the pathogen, or from vaccines) from a particular pathogen to achieve herd immunity, depending on how contagious an infection is.

https://www.jhsph.edu/covid-19/articles/achieving-herd-immunity-with-covid19.html

I find it highly doubtful that 70% of the population of New York or New Jersey are actually immune to the SARS-CoV-2 virus (there are estimates that somewhere around 19-25% of New York City's population have already been exposed, which is orders of magnitude less than 70%). So I'm dubious about any claims that these states have achieved herd immunity. After all, even countries like China (the first country to be severely impacted by COVID-19) are seeing a resurgence of cases (although with the caveat that it appears that the new cases are based primarily around Beijing and surrounding areas, not Hubei province or its largest city, Wuhan).

https://www.ctvnews.ca/world/china-...d-19-after-lockdown-measures-lifted-1.4985866

 

[Vanadium 50]

But the death rate in the nursing homes is scary - 33.7%:

Yes it is, although that is a single home. However, the fatality rates in NJ, MA and NY are consistent with at or near 100% of the patients infected. Which is why the exhortations to the other governors to be more like Gov. Kodos Cuomo frightens me. However, you're making the implicit assumption that any vaccinne side effects are distributed uniformly, but the Covid risk is not. That is unlikely to be the way it turns out. Usually vulnerable populations are, well, vulnerable. To pretty much everything.

 

[Ygggdrasil]

He should not say such things.

If he has 400 subjects (and that seems questionable) he is reasonably sure than the rate of serious adverse reactions is under 1%. That's a pretty big number. It's even above the CDC fatality rate of 0.26%. He needs a larger study to even show it's safer than the disease, much less "completely safe".

It is worse than that. The phase I trial had 40 participants, and 30 received the vaccine (these are typical numbers for a phase I trial). The Phase II trial aims to have ~ 400 participants. Although I have found news reports of the trial, I have not seen the data underlying the claims of safety or the ability to generate an immune response, so it is difficult to assess how well these claims match the evidence (especially compared to other vaccine candidates).

The phase II trails for the Flinders University vaccine is not scheduled to begin until Sept (perhaps suggesting time needed to manufacture the necessary doses), which could suggest that it could be difficult to scale production of the vaccine (especially given some of the quotes from the team cited above regarding trouble accessing funding and manufacturing partners).

 

[atyy]

To be a bit more positive the UQ vaccine is only a few weeks behind the Flinders vaccine, and works in a similar way, so as far as getting Australia and other countries vaccinated it will not make much difference I think.

I haven't seen the details, but one issue with just using the protein is that the protein configuration will not be the same as when it is part of a virus, and this difference in configuration may lead to a less effective vaccine. It seems the Queensland vaccine has some method that is intended to hold the protein in the right configuration. I suppose if the government has enough money then both can be supported, but another possibility is that supporting both would dilute resources so that neither will succeed.
https://advance.qld.gov.au/vaccine
https://en.wikipedia.org/wiki/Molecular_clamp

 

[berkeman]

This is amazing dedication to patient care. Respect.

https://www.cnn.com/interactive/2020/07/health/coronavirus-houston-hospital/index.html

 

[mfb]

I haven't heard of a vaccine that either kills you or leaves you with no negative effects at all. If none of the 40 patients had any side effects then this vaccine is unlikely to kill 1 in 20 (something you can't rule out from death statistics alone) - but as I mentioned before, saying it's known to be completely safe is wrong.

I find it highly doubtful that 70% of the population of New York or New Jersey are actually immune to the SARS-CoV-2 virus (there are estimates that somewhere around 19-25% of New York City's population have already been exposed, which is orders of magnitude less than 70%).

A factor 3 is half an order of magnitude.
It makes it easier to keep the reproduction rate at or below 1, especially as people more likely to infect others are more likely to be immune now.

 

[Vanadium 50]

PA's positivity rate bottomed-out on June 18 and started rising again. Why? Because between May 29 and June 26, all but one county entered the "green" phase of re-opening (in groups, roughly weekly). So this tells us that at some point we reached a threshold of social interaction where R went above 1 again.

I'm not sure I would describe it that way. Here is data from The Covid Tracking Project:

To me, this tells me that pre- and post- June 15 cases are fundamentally different. In the later data, the number of new cases is proportional to the number of new tests, while the number of hospitalizations is much flatter, and the number of deaths seems unaffected - maybe there's an inflection point.

 

[mfb]

New cases per day more than doubled since the minimum June 15, new tests increased by 60% or so. That means the fraction of positive tests rises. Rising test rate and rising rate of positive tests means more people get infected. It seems to affect more healthier people now, and of course hospitals got better at keeping people alive.

 

[bhobba]

New story in the Courier Mail today about the Covax-19 vaccine making less wild claims about its safety, but otherwise basically the same. He wants to use it to dampen outbreaks in nursing homes in the second wave of outbreaks in Victoria as part of stage 2 trials. Will give our local member of parliament a ring about it just to make sure the government is on top of this.

Added Later:
Rang the MP and the staff will definitely pass the issue onto our local MP Dr Laming.

Thanks
Bill

 

[Vanadium 50]

It seems to affect more healthier people now, and of course hospitals got better at keeping people alive.

In the limit where 100% have the disease but there are zero hospitalizations and zero deaths, how much should we spend on mitigation? And if your answer is "not very much", surely PA is closer to that limit than it was in April or May.

That said, I think "new cases" is a fairly meaningless metric, as it covers someone who is asymptomatic but tests positive but also someone who died and was discovered to have Covid. And if you go to that site, you will find huge disparities between the shape of the "new cases", "new hospitalizations" and "new deaths" curves. You'd think if you knew one, you'd at least know the major features of the others. Nope - pretty much every combination imaginable is represented somewhere in the US.

 

[mfb]

In the limit where 100% have the disease but there are zero hospitalizations and zero deaths, how much should we spend on mitigation?

Depends on what other effects are there, but probably not much.

And if your answer is "not very much", surely PA is closer to that limit than it was in April or May.

And what do we conclude from that? Let everyone get infected now because hospitalization and death rate are not as bad as in April? I guess not.

 

[Ygggdrasil]

That said, I think "new cases" is a fairly meaningless metric, as it covers someone who is asymptomatic but tests positive but also someone who died and was discovered to have Covid. And if you go to that site, you will find huge disparities between the shape of the "new cases", "new hospitalizations" and "new deaths" curves. You'd think if you knew one, you'd at least know the major features of the others. Nope - pretty much every combination imaginable is represented somewhere in the US.

Mild and asymptomatic cases are not meaningless because, while the usually don't pose risk of death, they are still infectious and could pass the disease to people who could be vulnerable to suffer more severe outcomes from infection by the virus. Case counts are useful tools to tell us the extent to which transmission is occurring in the community and the relative risk of acquiring the disease from the community.

 

[Vanadium 50]

Let everyone get infected now because hospitalization and death rate are not as bad as in April? I guess not.

Did I say that, Mr. Mentor? Don't stick words in my mouth. It is the cheapest form of debate and beneath you and your office.

 

[mfb]

I didn't claim you would have said that. But my question stands: What do we conclude from that? Is there anything we can learn from it, or any action we should take based on a mathematically shorter distance to a purely hypothetical situation?

 

[Vanadium 50]

I think the conclusion is that the expenditures should match the risk.

 

[Ygggdrasil]

And if you go to that site, you will find huge disparities between the shape of the "new cases", "new hospitalizations" and "new deaths" curves. You'd think if you knew one, you'd at least know the major features of the others. Nope - pretty much every combination imaginable is represented somewhere in the US.

An important note on hospitalization data in the US: In July, the Trump administration ordered changes to the ways hospitals report hospitalization data, which has caused problems in recent hospitalization data.

Since the beginning of the pandemic, hospitals have been reporting bed capacity and other key data to CDC through its National Healthcare Safety Network COVID-19 module. No hospital staff interviewed by NPR described problems with this system. They said that it had been used by hospitals for 15 years to monitor the impact of other illnesses and that staff are comfortable with it.

The established system was disrupted by a memo dated July 10, issued to hospitals by HHS. In the memo, HHS took the unusual step of instructing hospitals to stop reporting the capacity data to CDC and to instead use a reporting platform developed recently by private contractor TeleTracking. As NPR has reported, the details of how the contract was awarded to TeleTracking are unclear.

Hospitals received only a few days notice of the change and scrambled to adapt.

The sudden reporting switch to HHS, bypassing CDC, prompted an immediate outcry.

https://www.npr.org/sections/health...t-bypasses-cdc-plagued-by-delays-inaccuracies

The NPR article notes many problems with the new reporting system including inaccuracies and delays. For example:

When HHS took over the collection and reporting of this hospital capacity data, it promised to update "multiple times each day." Later, the agency walked that back to say it would be updated daily.

Those daily updates have yet to materialize. On Thursday, an HHS spokesperson told NPR via email, "We will be updating the site to make it clear that the estimates are only updated weekly."

The HHS Protect Public Data Hub, the public-facing website set up by HHS, offers three items as a "Hospital Utilization Snapshot," all of which have data that is over a week old.

Furthermore, the Covid Tracking Project, whose charts and data @Vanadium 50 cited above, said in a recent post on their site:

But two weeks after the rules began, it’s clear that technical requirements associated with the new guidelines have caused major problems. Some of the states facing the largest COVID-19 outbreaks—such as California, Texas, and South Carolina—have warned that they are not reporting accurate hospital information due to the switchover.

These problems mean that our hospitalization data—a crucial metric of the COVID-19 pandemic—is, for now, unreliable, and likely an undercount. We do not think that either the state-level hospitalization data or the new federal data is reliable in isolation. (As we describe below, the new federal hospitalization figures are substantially higher than the same data as reported by most states.)

(emphasis their's)
https://covidtracking.com/blog/whats-going-on-with-covid-19-hospitalization-data

 

[Vanadium 50]

In July, the Trump administration ordered changes to the ways hospitals report hospitalization data, which has caused problems in recent hospitalization data.

There was also a change around then, maybe earlier, that alters the way hospitals are reimbursed. "Admitted for X but also has Covid" is different for "Admitted for Covid but also has X".

(PS How does one decide if an action is by "The Trump Administration", or some executive branch health organization (like the CDC)?")

 

[Ygggdrasil]

There was also a change around then, maybe earlier, that alters the way hospitals are reimbursed. "Admitted for X but also has Covid" is different for "Admitted for Covid but also has X".

(PS How does one decide if an action is by "The Trump Administration", or some executive branch health organization (like the CDC)?")

The post from the Covid Tracking Project describes numerous mechanisms by which the reporting change has made their hospitalization numbers less reliable (mainly because many state health department relied on reporting CDC numbers rather than getting the data directly from hospitals). Many experts had warned that this reporting switch could cause problems with reporting when it was announced, so it is very likely that the unreliability of current hospitalization data is a direct result from the change in reporting.

The post from the Covid Tracking Project does not metnion changes in the way hospitals are reimbursed as a potential factor in the changes to their data. After a quick Google Search, I could not any articles about the change in hospital reimbursement nor any information about whether public health experts expect it to affect hospitalization data reported to public health agencies.

The order issuing the change in reporting came from the Department of Health and Human Services, a cabinet-level department of the executive branch that is run directly by a member of President Trump's cabinet.

 

[Astronuc]

https://www.ucsf.edu/magazine/covid-body

SARS-CoV-2 (which stands for severe acute respiratory syndrome Coronavirus 2) is first and foremost a bad respiratory virus. If your immune system doesn’t defeat it at its landing site in your nose or throat, it will advance down your windpipe, infiltrating the cells lining your lungs’ branching air tubes. At the tubes’ ends, tiny air sacs called alveoli pass oxygen to your blood. As the virus multiplies, the alveoli may fill with fluid, shutting down this critical gas exchange. Your blood-oxygen level may drop and, typically about six days into an infection, you may start feeling short of breath.

What causes this mayhem? “Some of it is definitely caused by the virus itself,” says Michael Matthay, MD, a UCSF professor of medicine who has studied acute respiratory diseases for more than 30 years. Inevitably, a fast-replicating virus will kill or injure many of the lung cells it infects; the more cells it infects, the more ruin it will leave in its wake.

“One of the weirder things about this new Coronavirus is it doesn’t seem to be incredibly cytopathic, by which we mean cell-killing,” Krummel says. “Flu is really cytopathic; if you add it to human cells in a petri dish, the cells burst within 18 hours.” But when UCSF researchers subjected human cells to SARS-CoV-2, many of the infected cells never perished. . . .

The bigger provocation, he suspects, may be your own immune system. Like any pathogen, SARS-CoV-2 will trigger an immune attack within minutes of entering your body. This counterstrike is extraordinarily complex, involving many tactics, cells, and molecules. In a UCSF study called COMET (COVID-19 Multi-Phenotyping for Effective Therapies), Krummel and other scientists have been observing this immune warfare in more than 30 people admitted to UCSF hospitals with COVID-19 and other respiratory infections. . . .

So the appropriate treatment may be related to mitigating a severe immune response. Would diphenhydramine or chlorpheniramine work? Or rather, what mitigates a cytokine storm? How to identify those with a potential to develop a severe immune response.

 

[Ygggdrasil]

So the appropriate treatment may be related to mitigating a severe immune response. Would diphenhydramine or chlorpheniramine work? Or rather, what mitigates a cytokine storm? How to identify those with a potential to develop a severe immune response.

Researchers have found that dexamethosone, a corticosteroid that can be used to suppress inflamation and the immune system, can help reduce deaths in COVID-19 patients:

The Recovery trial, one of the biggest efforts to evaluate whether existing drugs can treat COVID-19, included 2104 patients given a relatively low dose of 6 milligrams of dexamethasone for 10 days. When their outcomes were compared with those of 4321 patients receiving standard care, the steroid reduced deaths by one-third in patients already on ventilators and by one-fifth in patients receiving supplemental oxygen in other ways, Recovery researchers announced in a press release.

https://www.sciencemag.org/news/202...rst-drug-shown-reduce-death-covid-19-patients'

The results have since been published in the New England Journal of Medicine:
https://www.nejm.org/doi/10.1056/NEJMoa2021436

A variety of companies and researchers are investigating other drugs that could potentially suppress the immune system to mitigate a cytokine storm (e.g. see https://blogs.sciencemag.org/pipeline/archives/2020/07/29/the-latest-repurposing-news).

 

[Astronuc]

The results have since been published in the New England Journal of Medicine:
https://www.nejm.org/doi/10.1056/NEJMoa2021436

The article states, "In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55)." It seems to make a greater difference to those requiring invasive mechanical ventilation, in other words, those susceptible to the SARS effect. I'm assuming that folks were started on dexamethasone at different stages, and thus it seems that if one becomes ill with COVID-19, it's best to start treatment as early as possible, but then that seems on how one responds to the infection. Some folks were sent home only to become seriously ill, and in some cases, it was too late to intervene.

Then there are the other organs/systems affected:

Gut specialists are finding that 20% to 40% of people with the disease experience diarrhea, nausea, or vomiting before other symptoms, says gastroenterologist Michael Kattah, MD, PhD, a UCSF assistant professor. If you swallow virus particles, he says, there’s a good chance they will infect cells lining your stomach, small intestine, or colon. As in the lungs and heart, these cells are studded with vulnerable ACE2 portals.

Other specialists are also raising flags. Neurologists worry about reports of COVID-19 patients with headaches, “brain fog,” loss of the sense of smell, dizziness, delirium, and, in rare cases, stroke. Nephrologists worry about kidney stress and failure. Hepatologists worry about liver injuries. Ophthalmologists worry about pink eye. Pediatricians, meanwhile, worry about a peculiar COVID-related inflammatory syndrome that’s showing up in kids and young adults.

growing evidence suggests, SARS-CoV-2 can infect cells in the walls of blood vessels that help regulate blood flow and coagulation, or clotting. If true, this behavior could explain some of the virus’s weirder (and rarer) manifestations, such as heart attacks, strokes, and even “COVID toes.”

The bottom line is that it is best not to become infected, so wash hands, use sanitizers, and when in public, observer social/physical distancing, wear a mask, otherwise, avoid being in public.

 

[mfb]

I think the conclusion is that the expenditures should match the risk.

That is not an answer to my question.

----

BBC reports that Iran had significantly more cases and deaths than reported.

 

[Ygggdrasil]

The article states, "In the dexamethasone group, the incidence of death was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%; rate ratio, 0.64; 95% CI, 0.51 to 0.81) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%; rate ratio, 0.82; 95% CI, 0.72 to 0.94) but not among those who were receiving no respiratory support at randomization (17.8% vs. 14.0%; rate ratio, 1.19; 95% CI, 0.91 to 1.55)." It seems to make a greater difference to those requiring invasive mechanical ventilation, in other words, those susceptible to the SARS effect. I'm assuming that folks were started on dexamethasone at different stages, and thus it seems that if one becomes ill with COVID-19, it's best to start treatment as early as possible, but then that seems on how one responds to the infection. Some folks were sent home only to become seriously ill, and in some cases, it was too late to intervene.

Because dexamethasone (dex) has immunosuppressive effects, it is probably not a good drug to administer early in the infection, especially in patients with mild symptoms where the patient's immune system is likely to be able to contain the disease. Accordingly, the US National Institutes of Health only recommends dex or other similar corticosteroids for severe cases where patients require mechanical ventilation or supplemental oxygen. They recommend against using dex in patients who do not require supplemental oxygen.

Fortunately, while dex is likely best used in severe cases late in the course of the disease, the other drug with good clinical evidence supporting its use against COVID-19, remdesivir, is an antivirals which is likely most effective when administered early. (Unfortunately, supplies of remdesivir are currently very limited, so the NIH recommends prioritizing use for hospitalized patients on oxygen). However, in theory, an optimal treatment plan would likely involve an antiviral like remdesivir (or some of the newly developed analogues that are orally available) upon the onset of symptoms and dexamethosone for those where the infection becomes severe and the cytokine storm causes severe respiratory issues.

The bottom line is that it is best not to become infected, so wash hands, use sanitizers, and when in public, observer social/physical distancing, wear a mask, otherwise, avoid being in public.

Agreed.

 

[morrobay]

Chloroquine phosphate also is an immune /cytokine storm suppressant. And as I believe @StatGuy2000 pointed out these other rare complications like pulmonary could be in a predisposed vulnerable subset of those infected. If this were not the case then 90% of those infected with mild/no symptoms unlikely.

 

[bhobba]

Further details have emerged of what happened in the quarantine hotels whose substandard security led to the second wave here in Aus. It makes enlightening reading about human psychology - and frightening.

From an investigation by the Australian:

'Security guards struggled to contain a “crazy floor” of locked up hotel quarantine guests at the Rydges Hotel in Melbourne’s Swanston Street. The Australian reports the poorly trained guards were overwhelmed by the screaming, crying and banging on walls of guests begging to be let out. They offered bribes to guards to escape for fresh air. In one case a distraught women made a dash for the door after collapsing in the hotel hallway complaining she needed to “breathe”. A guest, staying on the crazy floor, said “people going absolutely nuts”. “They were begging to be let out and running for the doors.” He said that the guards seemed ill-equipped to handle the situation. “The guards had no real authority … they gave the impression they could be talked around. And guests were going up to the security guards, begging and offering money to be let out. It was insane.”

The question is why? These were 4-5 star hotels - hardy a prison. Good food, admittedly not to everyones liking, was always provided. The not to everyones liking refers to what you often find in such places - chock chips cookies and other 'treats' available in abundance in the rooms. If you have diabeties etc not a good idea, but nobody was forcing it down their throats. Strange, very strange. The meals provided were from a set menu, so you had little choice, but from what I have seen were perfectly OK - I am rather picky and I would have no problem with them - eg fruit and cereal for breakfast. You could order just about anything at all via room service - but you had to pay for that. Some didn't like paying for their personal preferences, but that is no reason to go mad. I would have just paid for what I liked and chalked it up to one of the consequences of managing the virus.

Thanks
Bill

 

[Rive]

It makes enlightening reading about human psychology - and frightening.

Best non-joke from the recent science jokes thread by @BillTre

 

[bhobba]

Because dexamethasone (dex) has immunosuppressive effects,

My Rheumatologist mentioned that drug to me, but said the research he has read suggests the latest Biologics, like the one I am on, Cosentyx, were a better, although much more expensive choice. I was worried being on it would put me at greater risk of dying if I got Covid. But he said it is likely to increase your risk of getting it if exposed, but reduce your risk of dying from the cytokine storm many patients die from. If I ended up getting it he has visiting privileges at all the major hospitals here in Brisbane, and would be happy to treat me if things got that bad my already whacky immune system started to attack my body even more than it already does.

He is also the one that is dubious of Hydroxychloroquine because in his clinical experience it takes 6 weeks to work, but is generally safe so for most people its fine to give it a go. The exception is if you have, as 2-3% of the population does, psoriasis. Then you should not take it all all - it is definitely contraindicated.
https://www.jrheum.org/content/jrheum/early/2020/03/24/jrheum.200334.full.pdf

Thanks
Bill