May
19

COVID update – hope for the best, plan for the worst.

I’ve stayed away from most of the COVID stuff because Tom Lynch at WorkersCompInsider has been… as the kids say…crushing it.

Yesterday’s news that Moderna, a new company in Massachusetts reported very early results from tests of a potential vaccine was welcome indeed. The experimental vaccine appeared to help increase resistance** to COVID19 in a handful of people without undue harm.

It was also extremely preliminary.

The trial actually involved 45 people, but the press reports were based on results from 8. That’s less than a fifth of those involved…as one wag put it, “The drug trial sample size seems to be as big as 2 full of people.”

The double asterisk after “resistance” is because the experiment involved taking a blood sample from those 8 people, putting it in petri dishes with the virus, and measuring the antibodies ability to “kill” the virus. That is waaaaaay different from conveying immunity in the human body.

Perhaps coincidentally, the person charged with leading Operation Warp Speed, the White House initiative to develop a vaccine, has 156,000 shares of stock in Moderna, the vaccine research firm in question. And the company had just been awarded almost a half billion dollars in taxpayer money to help fund research.

I get that we are all looking for any hint of good news, and we all desperately hope Moderna’s vaccine:

  • is effective and preventing COVID;
  • is safe for humans;
  • can be manufactured in huge quantities quickly and cheaply.

But vaccine development is full of fits and starts, blind alleys and dead ends, promising early results leading to disappointing failures.

Fewer than one in ten vaccine candidates reach production. Vaccines typically take 10 – 15 years to develop. “And while biotechnology underlying this drug has existed for nearly 30 years, it has never yielded a working vaccine for any human disease” (quote from NatGeo).

Yet we’ve never seen the might of the entire world’s vaccine expertise focused on a single problem, an unprecedented level of effort that – hopefully – will produce an unprecedented result.

Meanwhile, the virus has killed over 90,000 of our friends, parents, neighbors and grandparents so far, while infecting over 1.5 million of us. Thousands more will die, even if the vaccine is everything we hope it is.

People and organizations who focus on what they can control – reducing the risk of infection – will come out of this far better off than those who ignore the risks that remain real and deadly.

What does this mean for you?

Hope for the best and plan for the worst.

 

 

 

 

A useful discussion of how some companies are handling this crisis is here.


Apr
30

COVID catch-up

In  less than 4 months, COVID19 has killed more of us than died in the Vietnam war’s 11 years. Some have stated this is a “great success story.”

Healthcare providers may not see this as such a great success, as COVID is crushing healthcare financials.

Research suggests almost 13 million workers have lost their health insurance due to the repercussions of COVID19. Multiplying that by 2 approximates the total number of employees plus dependents that lost coverage – 26 million.

Many will seek Medicaid coverage, but eligibility varies widely (and wildly) by state. People who don’t have coverage and contract the disease and need facility care should have their bills covered by the Feds – either at Medicare rates or via Medicaid.  Either way, reimbursement is likely half or less what their private insurer would have paid.

Anthem just informed us they expect the percentage of people covered by governmental healthcare plans to increase. The $100 billion+ health insurer saw its financial results for Q1 improve; my guess is the drop in elective procedures was a big factor.

All of this to say that COVID appears to be accelerating a trend towards a public option for health benefits – or perhaps a much bigger role for governmental programs in health insurance.

Hospital financials are getting hammered as elective procedures are way down, and many folks with all kinds of ailments are staying away for fear of coronavirus exposure. (chart from Kaufman Hall)

With receivables drying up to dust, facilities are going to redouble their efforts to collect every nickel they can from everyone they can.

Workers’ comp payers – you are hereby warned.

Willis Towers Watson has been publishing their perspectives on all things COVID19, from the impact on the LGBTQ community to a helpful discussion of paying premiums when cash is tight.

An early piece focused on employers’ considerations re workers’ comp liability for COVID19 claims. One item in particular stuck out – large employers with excess coverage should read their current communicable disease coverage details very carefully.  Friend and colleague Karen Caterino was kind enough to paraphrase for me:

For large employers purchasing excess, a multi-claimant disease incident carries the possibility of creating catastrophic financial loss.  If the transmission of a covered communicable disease is a series of incidents versus a single accident, the difference in retained loss could be significant.  A majority of work comp deductible agreements include a provision stating that the deductible applies per employee for occupational disease.  Some insurers are likely to suggest the statute requires they follow the assumption that occupational disease, by its very nature, is a series of occurrences for multiple claimant losses.

This is especially important for supermarket chains, who by now should know that paid sick leave may be the most effective risk management tool to prevent employee and patron exposure. There are many stories like this one detailing how quick, thoughtful action kept food coming while drastically reducing employee exposure.

NCCI has a helpful compendium of states‘ COVID19-related legislative and regulatory initiatives along with COVID19 FAQs.

And yes, surgical masks are quite effective at reducing viral transmission; thanks to Glenn Pransky MD for tipping me off to this research.

Finally, this is a terrific summary of what we know and don’t about how COVID19 affects the human body. It’s long, very well-written, and perfect for a lunch-time read. Spoiler alert – a lot of treatment these days is based not on extensive research but on what docs think works based on prior experience and communication with other clinicians.

From the physician author:

In the absence of data from randomized, prospective trials, we search for answers on colleagues’ Twitter accounts, in interviews with Chinese or Italian physicians, and in our patients’ charts.

What does this mean for you?

Wear a mask, and physically isolate, because we can’t take much more of this “success.”


Apr
22

COVID19 Update – what we KNOW now

Social distancing works.  Hydroxychloroquine doesn’t. Remdesivir might.  A lot of “tests” may be wrong…Just because you’ve had COVID you may not be immune to future infection.  And COVID19 may lead to long term health problems.

Social distancing works. 

A study showed social distancing significantly reduces infection risk:

estimated that current social distancing measures will reduce the average contact rate among individuals by 38% “Social distancing saves lives but comes at large costs to society due to reduced economic activity… the economic benefits of lives saved substantially outweigh the value of the projected losses to the U.S. economy.”

Hydroxychloroquine and variations thereof are no cure.

It’s becoming increasingly clear that Hydroxychloroquine and its various versions are no COVID19 cure. One study (that has NOT been peer-reviewed) showed more veterans with COVID19 that took the drug died than those that didn’t. Another study found no difference in outcomes for patients that took the drug and those that didn’t. The drug can have deadly side effects. [my March 27 post has a lengthy and citation-filled discussion of the drug and the faulty “research” used to promote it]

Remdesivir

Preliminary data from an analysis of multiple studies shows 2/3rds of patients with severe COVID19 treated with anti-viral drug Remdesivir had “promising” outcomes.

One study in Chicago had positive results as researchers saw “high fevers fall “quite quickly” in remdesivir-treated patients and patients weaning “off ventilators a day after starting therapy.”

This is PRELIMINARY; much work still needs to be done. Additional clinical trials are underway, with one posting results by the end of this month.

Remdesivir is an injectable and to date has only been administered in hospitals.

If you’ve had COVID, are you immune?

We do NOT know. There is no evidence that those who have contracted the disease have immunity from a subsequent infection.  Serology tests look for antibodies in the blood, proteins whose function is to find and kill coronaviruses.

Usually those who have had a disease gain some immunity; that’s the idea behind vaccines. However, there is a report out of China that some patients previously infected tested positive after they were ostensibly “cured”.

There are concerns that tests are inaccurate, that they may show false positives (you aren’t infected but the test results say you are) and false negatives (you are infected, but the test results show you aren’t).

One theory is the antibody tests are hitting on non-COVID19 viruses (like those that cause the common cold) and thus giving false results.

Long term health issues associated with COVID19

There’s growing evidence that people with severe cases of COVID19 may have long-term pulmonary deficits due to compromised lungs.  The most vulnerable are – as you’d expect – older folks, those with pre-existing conditions, and compromised immune systems

A study out of China found about a third of patients that had recovered from severe COVID19 had brain stem issues that manifested as dizziness, headache, seizures and other issues.

Another study found that a fifth of severe COVID19 patients had significant heart issues. Blood clots are also a common problem, one that can be deadly.

PTSD and other mental health problems are also reported – no surprise there.

There have been reports of significant kidney problems, however an earlier study in China found no acute (short term) kidney damage.

What’s clear is we are just starting to grasp the potential long-term health effects of COVID19 – and we will learn a lot more in the coming months.

There is a lot of mis- and dis-information out there, from “cures” to the assertion that 5G towers cause COVID19 to Chinese claims that COVID is a U.S.-caused disease to “evidence” that the virus escaped from a Chinese bio-research lab to ridiculous claims by “scientists’ that all the health problems are caused by an overactive immune system.

This is exactly why one needs to be very careful when reading about drugs, cures, tests, results, and infection rates...almost no one had heard of COVID just 120 days ago, all research is just getting started, and we are all learning as we go. And fear-mongers and charlatans love a crisis and get off on scaring people while they get their 15 minutes of fame.

Oh, and YouTube is NOT a reliable or credible primary source for scientific information.


Apr
16

COVID19 – how does it do its damage?

This week we’re attempting to figure out how much of an impact COVID19 will have on the country in general and workers’ comp in specific. That requires:

  • estimating the number of people infected;
  • determining how deadly it is;
  • assessing our ability to contain it;
  • evaluating other health effects of the disease; and
  • knowing if and where and how much liability will be assigned to workers’ comp.
This last is best left for later; there are obvious implications for workers’ compensation, however until there’s more clarity around the industry’s liability for COVID19 we won’t be able to even guess what that liability ultimately might be. Of note, several states have asserted WC will be presumed responsible for patients working in pubic safety, healthcare, and some retail establishments who become infected with coronavirus.
The work comp COVID19 coverage situation is fluid and evolving rapidly; Nancy Grover’s piece in workerscompensation.com provides excellent insights on the current status of state coverage from knowledgeable professionals and is well worth a read.  I’m sure Nancy and her experts will keep us informed.

Health effects

Big caveat here – as one of the articles cited below notes and as is true for pretty much everything you read about COVID19 (including this post), physicians interviewed “are speculating with much less data than is normally needed to reach solid clinical conclusions.” COVID19 is so new and so little is known that there’s very little credible research. What we’re relying on are ‘reports from the battlefield”, information from the front lines that’s coming in real time, not careful, methodological, rigorous research using controls.

Another caveat, from the LATimes –

Patients with disorders that affect the heart, liver, blood and lungs face a higher risk of becoming very sick with COVID-19 in the first place. That makes it difficult to distinguish COVID-19 after-effects from the problems that made patients vulnerable to begin with — especially so early in the game.

But for now, this is all we have. The faster we collect and assimilate information, the more able we will be to respond quickly and with the right solutions.

Broadly speaking, the physiological effects seem to vary widely between victims; women seem to fend off the virus better then men; and people with pre-existing conditions, especially hypertension, appear to be at particularly high risk. The recovery process, which at first seemed pretty straightforward (lungs get better after intubation) even for those on ventilators, appears to be more complicated and take longer than originally thought.

We are only now seeing indications that COVID19 may have long-term health effects, and its reach extends beyond just the lungs.  From an extensive piece this morning in the Washington Post:

coronavirus kills by inflaming and clogging the tiny air sacs in the lungs…clinicians around the world are seeing evidence that suggests the virus also may be causing heart inflammation, acute kidney disease, neurological malfunction, blood clots, intestinal damage and liver problems.

One study indicated some patients with relatively mild cases appeared to have significant warning signs of long-term health effects – in this instance impaired liver function.  Another study noted cardiac issues post-discharge, and a nephrologist at Yale’s School of Medicine reported that almost half of “the people hospitalized because of covid-19 have blood or protein in their urine, indicating early damage to their kidneys…”

How can this be happening?
The coronavirus attacks by attaching to the ACE2 receptor on cell surfaces. These receptors are on cells in the lungs and other organs as well. From the WaPo:
there is increasing suspicion that it is using the same doorway [ACE2 receptors] to enter other cells. The gastrointestinal tract, for instance, contains 100 times more of these receptors than other parts of the body, and its surface area is enormous.
In particularly bad cases, severe inflammation can occur, causing significant problems throughout the body. This has its own set of challenges as it appears to be driven by a hyper-active immune response. There appear to be some treatment approaches that are having positive results using lessons learned from prior viral outbreaks.
Again, this is so new that many treatments are being developed and tried on the fly as doctors scramble to learn what works and what doesn’t on which kind of patients exhibiting what signs and symptoms.
What does this mean for you?
As awful as this is, the more cases that physicians encounter, the greater the knowledge gained.
With much of our medical establishment and resident brain power focused on COVID19 and caring for its victims, things will improve.

Apr
14

COVID19 – what’s the real death count?

As of this morning 23,459 US deaths have been attributed to COVID19.

That number is almost certainly too low.

The words “have been attributed” were carefully chosen – note I did NOT write “COVID19 killed 23,459 people” or “23,459 people died of COVID19 or “there were 23,459 COVID19 deaths.”

Briefly, that’s because:

a) patients presenting at a hospital with breathing problems, a fever, and a bad headache are often not tested as COVID19 is assumed;

b) severe COVID cases typically lead to heart attack, Acute or Severe Respiratory Distress Syndrome or other problems, and the cause of death [more on this below] may be attributed to a heart attack/ARDS/SRDS and not to COVID;

c) many hospitalized victims also have other health problems; diabetes, high blood pressure, asthma, COPD, cardiac issues.  These co-morbidities greatly increase the risk of death and, absent a positive test for COVID19, may be given as the cause of death; and

d) cause of death (COD) can be a judgment call, and multiple CODs can be reported on the “death certificate”.

Here are the facts.

The CDC finally published guidelines for assigning cause of death for COVID19 earlier this month. Needless to say, a lot of people had died from COVID19 before these guidelines came out, so that’s issue One; Issue Two – as noted above, there can be multiple “causes of death”.

For physicians confronted with a deceased patient, determining and assigning a  cause or causes of death is often complicated and uncertain. For example, COVID19 leads to much greater stress on the heart as it tries to pump more blood to get more oxygen out of damaged lungs. According to the CDC, when that old, tired, sick heart gives out:

The immediate cause of death [in this case the heart attack], which is the disease or condition that directly preceded death and is not necessarily the underlying cause of death (UCOD) [in this case COVID19], should be reported on line a.  The conditions that led to the immediate cause of death  should be reported in a logical sequence in terms of time and etiology below it [on the cause of death statement]. [italics added]

Last week, CDC spokesman Scott Pauley said, “It’s likely that COVID-19 related deaths may not be included on a death certificate [italics added] or COVID-19 might be a factor related to an individual’s death but not the main cause.”

Issue Three – no test, no diagnosis (in some cases) From ABCNews last week

“There is no swabbing of deceased individuals anymore and unless the medical examiner has knowledge of a confirmed coronavirus test, then they aren’t being marked down as having coronavirus,” said [New York City Councilman Mark] Levine, whose committee has oversight for the Office of the Chief Medical Examiner.

Issue Four – A related issue is most of the victims of COVID19 are elderly; older people who contract COVID19 are much more likely to die than younger folk.

Of course, older people have more health problems than younger folks, so there are more “potential” causes of death – cancer, heart disease, stroke, hypertension, COPD, kidney failure and the like. Thus there are more opportunities for the pathologist to attribute non-COVID causes as one of the causes of death – which would further skew the numbers.

There are compelling data from New York City indicating COVID19 may be involved in many more deaths than have been attributed to the virus;

The FDNY reported a nearly 400 percent increase in “cardiac arrest” home deaths in late March and early April, [emphasis added] a spike that officials say is almost certainly driven by COVID-19, whether they were formally diagnosed or not.

Between March 20 and April 5, the department recorded nearly 2,200 such deaths, versus 450 in the same period last year,

Then there’s the issue (Five, to those still counting) that there are a LOT of “extra” deaths that can’t be directly tied to COVID19 as that specific cause of death, however these “extra deaths” happened during the COVID19 crisis.

This from Judy Melinek M.D., a forensic pathologist:

To quote Dr. Ed Donoghue, a forensic pathology colleague at the Georgia Bureau of Investigation, “No matter how these deaths are currently being attributed, after this pandemic terminates, an excellent approximation of the true fatality rate of COVID-19 deaths can be made by the calculation of the excess mortality for the period. This calculation was very helpful during the 1995 Chicago heat wave. Almost certainly, because of the scarcity of testing and other reasons, we will find that the number of COVID-19 deaths has been grossly underestimated.”

Okay, counterclaims.  There are any number of specious claims about rampant over-counting of deaths as COVID; I have yet to see any from any credible source backed by credible data. This is perhaps the best overall discussion of claims that COVID deaths are overcounted; it is thorough and detailed.

Here are just a couple debunked claims…

For those interested – The international picture

From the BBC – “it might seem simple enough: if a patient dies while infected with Covid-19, they died of Covid-19.” Perhaps – but they may have died from a car accident, or might have an underlying health condition such as COPD or asthma or heart disease. The UK counts ANYONE who dies and has tested positive for COVID as a COVID death. Even if they died in a car accident.

A related issue – reports from Italy indicate there are a lot more people dying of all causes than usual, and many of those “extra” deaths aren’t attributed to COVID. “Only 12 per cent of death certificates have shown a direct causality from coronavirus,” said the scientific adviser to Italy’s minister of health last week. [source here]

What does this mean for you?

Two things:

We do not KNOW how many deaths are directly or indirectly due to COVID19.  But medical experts, physicians, epidemiologists, and medical examiners believe it is significantly higher than the published total.

There are truckloads of BS on the interwebs about COVID; ignore anything not based on solid research from credible people with scientific and/or clinical training and experience.


Apr
13

COVID infections – what’s the real number?

Ten days ago I wrote:

Ignore anyone who says there will be this many infections and this many deaths – their “models” are based on data that is likely wildly inaccurate and [based on] assumptions that differ wildly.

Not much has changed.

Today we’ll dive into “official” infection rates and why they may be way less than the actual infection rates. (for those wanting a lot more detail, try this.)

How many of us are infected?

According to testing results, in the US about 550,000 people have tested positive for coronavirus.  However, some researchers suggest as many of 12 million may have been infected, with the vast majority showing no or mild symptoms. (original source is Reason magazine, an avowedly libertarian publication)

DO NOT take that as gospel or dismiss it outright; the researchers relied on data from testing from China as well as other sources; some have questioned the reliability of data and testing kits from China. Other scientists have employed mathematical modeling to calculate actual infection rates; their findings indicate we’re identifying about 2/3rds of COVID19 cases.

Remember, all projections rely on data that are woefully inadequate. Reality is we do NOT know how many of us are infected, because here in the US (and in many other countries) the rollout and ramp up of testing has been far too slow. As you can see, after an initial increase, in the US we’ve been averaging less than 150,000 tests per day for more than two weeks.

data from CovidTracking project; source here (btw, this is a highly credible entity with full transparency re data sources)

From the research reported by Reason:

Credible research indicates Insufficient and delayed testing may explain…Germany, which has detected an estimated 15.6% of infections compared to only 3.5% in Italy or 1.7% in Spain. Detection rates [the percentage of people who are actually infected that are tested and counted as infected] are even lower in the United States (1.6%) and the United Kingdom (1.2%)…As of March 31, [research article authors] Vollmer and Bommer calculate confirmed cases represented just 3.5 percent of infections in Italy, 2.6 percent in France, 1.7 percent in Spain, 1.6 percent in the United States, and 1.2 percent in the U.K. [emphasis added]

In other words, the true number of infections was between 29 and 83 times as high as the official tallies in those countries [emphasis added]

The countries with the highest estimated detection rates were South Korea (nearly 50 percent), Norway (38 percent), Japan (25 percent), and Germany (16 percent)…The estimated prevalence of infection ranged from 0.1 percent in India and Japan to more than 13 percent in Turkey; it was 3.6 percent in the United States.[emphasis added]

To be clear, the researchers made several assumptions, some based on other researchers’ work. And, Vollmer and Bommer’s findings are quite different from Rao and Krantz’s.

What does this mean for you?

Net – we do not KNOW how Americans are infected…but it is definitely more than a half-million.

We will not KNOW until testing using a statistically-credible sample size and methodology has been done and reported.

 


Apr
3

Don’t obsess.

Obsessing over stuff we don’t know and can’t control will make us nuts.

Instead, focus on what you can do to protect yourself and your loved ones, and help others any and every way you can.

Why you should ignore a lot of the “experts” and their models.

Just two days ago I said: Ignore anyone who says we’ll be back to normal by this date or that.

I’ll add – Ignore anyone who says there will be this many infections and this many deaths – their “models” are based on data that is likely wildly inaccurate and make assumptions that differ wildly.

(the model used in White House press briefings assumes all states impose lockdowns similar to China’s and keep them in place for months. Meanwhile, the President is talking about a lockdown that ends in a few weeks and many states were late imposing lockdowns – or haven’t yet.)

A basic rule of statistical analysis is “when different studies of the same thing don’t agree it’s probably because they aren’t counting the same stuff the same way.” (OK, I sort of made that up – but it’s entirely true.)

A percentage is based on a numerator (the top number), which in this case is the number of people who died “of COVID”, divided by the denominator – the number of people “infected”.

First, the numerator – deaths due to COVID.

The “death rate” in Germany is 1%, Italy’s is 10%, China’s 4 percent, and Israel a tenth of that at 0.4%.

What?? How can this be? Is it because Italians are older? no…Germany’s population is older than Italy’s. Are Israelis healthier? Well…

From the BBC – “it might seem simple enough: if a patient dies while infected with Covid-19, they died of Covid-19.” Perhaps – but they may have died from a car accident, or might have an underlying health condition such as COPD or asthma or heart disease. The UK counts ANYONE who dies and has tested positive for COVID as a COVID death. Even if they died in a car accident.

Here in the US, physicians have discretion; they report whether the patient died “as a result of this illness.” So, it’s not surprising that the UK would have a higher death rate than the US.

A related issue – reports from Italy indicate there are a lot more people dying of all causes than usual, and many of those “extra” deaths aren’t attributed to COVID. “Only 12 per cent of death certificates have shown a direct causality from coronavirus,” said the scientific adviser to Italy’s minister of health last week. [source here]

So, we do not know the actual number of people who have died “as a result of COVID.”

Now, the denominator – the number of people  “who have COVID.”

Different countries also report different “infection rates”;

  • China may not report people who test positive but don’t show symptoms (are “asymptomatic”). As a substantial percentage of people who get infected don’t show symptoms, that makes China’s “infection rate” seem a lot lower than it really is.
  • The number of tests isn’t as useful as the percentage of people tested. Reality is, if we aren’t testing everyone, we don’t know the real percentage of people with COVID.
  • Here in the US we are STILL way behind testing; we’re only testing about a hundred thousand people a day – about the same number we tested 9 days ago.

Oh, and there are two different “fatality rates.”

Again the BBC:

There are, in fact, two kinds of fatality rate. The first is the proportion of people who die who have tested positive for the disease. This is called the “case fatality rate”. The second kind is the proportion of people who die after having the infection overall; as many of these will never be picked up, this figure has to be an estimate. This is the “infection fatality rate”.

Head swimming yet?  Yeah, mine too.  Net is no one knows how many of us are infected and we don’t know the number of people who die of COVID-related conditions.

We DO KNOW:

  • social isolation will help keep you safe;
  • sanitizing everything will help keep you safe;
  • helping others will help keep you sane.

What does this mean for you?

Obsessing over stuff we a) don’t know and b) can’t control will just make you nuts. Focus on what you can control.

And be nice.

 


Mar
31

COVID19 – the latest data and the cost of ignoring reality

Ignore anyone who says we’ll be back to normal by this date or that.

The problem is straightforward –

  • we don’t have enough data,
  • far too many people are still doing stupid stuff, and
  • there’s still way too much happy talk from people who should know better.

Testing is only now ramping up – six weeks+ into the COVID era there have been less than a million tests in the US; we lag well behind other developed countries in the percentage of residents tested.

The painful reality is the government’s repeated missteps and screwups have left us in the dark about the real dimensions of the spread of COVID19.

Where are we today

We don’t have current, accurate data from an official governmental source on the actual number of COVID19 tests that have been conducted. The CDC’s own database reports a drop in the average daily number of tests since March 17 – but that doesn’t include all tests.

Fortunately, there’s a volunteer project documenting the test count and other key statistics; you can keep updated here. Pretty impressive effort, with data quality ratings as well so you can determine for yourself your level of comfort with the accuracy of the count.

As of 6:42 am eastern yesterday, there were 851,578 tests reported in the US, with 141,232 positive.

As of 6:42 am eastern today, Tuesday March 31, the Covid Tracking project reported 956,481 tests, with 162,399 positive.

Again according to the Covid tracking project, as of 7 am eastern yesterday March 30, 19,839 patients were hospitalized and 2,447 died.

The hospitalization count increased to 22,490 (13%), and the death count increased 21% to 2,981.

Another leading source is Johns Hopkins University; it’s numbers are slightly different than the Covid Project (143,055 positives and 2,513 deaths as of 6:11 am eastern yesterday March 30).

I’ll let you ponder why a group of volunteers and a university are able to do a better job tracking these data than the nation’s disease tracking institution. (fortunately the Trump Administration, which just three weeks ago had sought a $1.2 billion cut to CDC ‘s budget – and an additional $452 million cut to National Institute of Allergy and Infectious Diseases (NIAID)’s budget – changed it’s mind.

Then there’s the report from Wuhan China (the apparent originating location for coronavirus that 5% – 10% of people who a) tested positive, and b) recovered, have now tested positive again.

Communities and institutions that aren’t taking tough measures to control exposure are getting hammered.

Elected officials and many citizens of Fort Myers, FL listened to politicians, not scientists, keeping beaches, restaurants, and a casino open despite warnings. In a county where 30% of residents are over 60, only about 4 out of 10 residents complied with isolation guidelines last week. This may well have devastating consequences – so far there are 171 confirmed cases and 6 deaths in Lee County. with 40 hospitalized.

Those totals will certainly increase.

Many residents of The Villages, a retirement community in central Florida, ignored pleas to avoid socializing; 29 have tested positive as of last Friday.

Liberty University was one of the very few colleges that invited students back to campus after spring break; not surprisingly some showed COVID19-type symptoms, and at least one has tested positive. Yesterday Liberty President Jerry Falwell disputed some of the Times’ reporting; note earlier Falwell dismissed COVID19, comparing it to swine flu and inferring it was a North Korean plot or an effort to harm President Trump.

What does this mean for you?

I bring these to your attention to note that coronavirus doesn’t care about ideology; social distancing reduces infections and saves lives; not enforcing social distancing increases infections and kills people. Places like Ft Myers and Lynchburg VA (Liberty University’s location) – and the people who live there – will suffer from COVID deniers’ decisions.


Mar
27

COVID19 and Chloroquine – what does the science say?

The President and the Governor of my home state (New York) are all in on chloroquine and variations thereof.

Spoiler alert – there is no credible evidence that chloroquine is effective in treating COVID19.

And lots of evidence that the drug can be quite harmful.

Let’s unpack the “science”.

First, it’s important to note that this drug has been tried on numerous viral diseases; “Researchers have tried this drug on virus after virus, and it never works out in humans. The dose needed is just too high,” says Susanne Herold, an expert on pulmonary infections at the University of Giessen. source here

There appear to be two sources of “information” that chloroquine advocates cite as justification for using the drug.

Neither meets basic standards of credibility.

One is s tiny “survey” from France; you can read it here. The study’s authors concluded:

our survey shows that hydroxychloroquine treatment is significantly associated with viral load reduction/disappearance in COVID-19 patients and its effect is reinforced by azithromycin.

Well…no.  The “survey” has many flaws, which combine to make it impossible to draw any meaningful conclusions.

(The primary author, one Didier Raoult has been widely criticized for various misdeeds…this is a detailed and quite damning profile)

  • the study was tiny – 42 patients in total at the outset, of which 26 received the drug and 16 did not (these were the controls)
  • out of the 26 who got the drug, 6 were excluded from the reported results, and 4 of those 6 did not do well:
    • 1 died
    • 3 were transferred to the ICU
    • 1 stopped taking the drug due to nausea
    • and 1 left the hospital
    • “As several people wrote sarcastically on Twitter: My results always look amazing if I leave out the patients who died, or the experiments that did not work.” source here
  • the survey’s authors claimed it was a 14 day study but that doesn’t fit between the 12 days from when the study was approved till the day it was concluded
  • the study was not randomized; that is, the separation of study patients wasn’t statistically random which could lead to selection biases (for example, the control group was much younger than the study group, which reflects non-random sampling
  • the “outcome” wasn’t consistently identified or measured;
    • many control patient outcomes are presented as Positive vs Negative, rather than a count (of the actual virus load) vs Negative, as they are for patients in the active treatment group
    • instead of a typical result e.g. 28 day post-treatment mortality (death) rate, for some patients it was the presence or absence of the virus in a nose-swab test.
    • most problematic, some patients tested “negative” one day then “positive” the next; others showed the opposite results...since the final test was a single snapshot and no follow-up was done, we don’t know if the patients that were “negative” at the end of the survey didn’t subsequently become “positive”…or vice versa
    • the outcome also wasn’t specific as it didn’t indicate how much of a “viral load” existed, only if it was present or absent (defined as viral load under a certain threshold)
    • so, “negative” patients could have had the virus, just not enough to trigger a “positive” test result
    • “It would have been better if the authors would use clinical improvement (e.g. fever, lung function) as the outcome, not a throat PCR. The virus could still be rampantly present in the lungs, and the patient could still be very sick, while the virus is already cleared out of the throat. If PCR is an outcome, it would be better measured as e.g. at least 2 or three consecutive days of PCR negativity.” source here
  • There’s a lot more to this – you can read a critique here.

Next – reports from China, which were cited by the French study’s authors as a reason to consider using versions of chloroquine.

The reports included

a) opinions from Chinese physicians that were based on their personal observations, not on actual studies.  A key source for this was a letter published that did not provide any details, data, or credible evidence as to the efficacy or safety profile of chloroquine and related drugs.

Remember…a letter – often cited by opioid promoters as evidence of the drug’s safety and efficacy – helped spark the opioid epidemic, I’d be careful relying on the Chinese letter as a rationale for using chloroquine.

b) many of the clinical trials that were started some time ago were canceled or suspended, leaving no data or substantive conclusions

Fortunately the WHO has begun several major scientific studies to evaluate various drugs’ efficacy and safety…we can be hopeful that they will yield actual credible information that will help us defeat COVID19.

Here’s a handy cheatsheet you can use to evaluate news reports and Facebook posts about COVID19 “cures”,

DANGER!

Finally, this stuff can be dangerous if not deadly. Doses of chloroquine and related drugs just slightly above recommended levels can kill. The drug can damage vision, appears to be dangerous for anyone with cardiac arrhythmia, and has a host of other nasty side effects, many of which occur even when patients are taking doses far lower than “recommended” by French and Chinese doctors.

What does this mean for you?

To quote Karen Masterson, author of THE MALARIA PROJECT;

We should learn from past mistakes. Federal officials after World War II failed to listen to public health experts about the limitations of chloroquine. Our top political leaders today should avoid the same error.


Mar
25

COVID-19 quick hits

First – reminder that every April 1 I do my annual April Fool’s post. It usually catches a few folks…you’ve been warned!

Now, a few things of note that crossed my virtual desk.

Chloroquine as a treatment for COVID-19

You may have seen President Trump talking about a malaria medication…

Two news items hit this morning, one noting that a patient just died after taking a version of the chemical.

A very small study found outcomes for patients that took chloroquine were not different than outcomes for patients that received a placebo. Out of  30 patients, 15 patients got the malaria drug and 13 tested negative for the coronavirus after a week of treatment. 15 patients didn’t get hydroxychloroquine; 14 tested negative for the virus.

Last week the drug was touted extensively on Fox and the Glenn Beck Show, with that “science” based on an unpublished paper describing what happened to a handful of patients treated with the medication.

Read the link if you want to understand why the “science” was crap and the “conclusions” total bullshit.

Takeaway – this drug can be very dangerous, is far from proven effective, and current studies are too small and have other limitations that make it impossible to draw any firm conclusions regarding its efficacy and dangers.

US Infection trend

As of 9:35 am eastern March 25, there are 55,238 confirmed cases in the US and 802 COVID-19 related deaths. Caveat – the number of cases is almost certainly significantly higher (not enough tests available) as is the actual number of deaths.

Takeaway – we are nowhere near the peak of this pandemic…here in New York we have over 25,000 confirmed cases…3 in our town of 4,800 people.

Conferences

are pretty much not going to happen.  NCCI’s annual confab will go virtual; more details on the free web-based event here. The date is May 12, 2020, and it kicks off at 1 pm ET.

Work-at-Home

Briotix Health has developed a free app to help we work-at-home folks prevent injuries and other nasty stuff. Info is here.

A link to the Virtual Office is here.