Coronavirus

[mikevbf]

if it's taken early enough in terms of softening the trajectory for some patients but we don't even know that.

This is the part I wish we had a good study on. Agreed that this approach has not been shown to help late stage even from anecdotal evidence.

 

[SageBrush]

Time for a poll:
If your daily fare is magic bullet stuff -- vaccine, meds, herd immunity ...

A question: Do you wear a mask outside the home ?
Do you wash your hands before eating or preparing food ?
Do you wash your hands after you go to the bathroom ?
Do you maintain social distancing outside the home ?

 

[Papafox]

There has been a lot of discussion in this forum about the pros and cons of hydroxychloroquine use, so what do doctors who are treating patients think? An American Thoracic Society‐led International Task Force recently issued "Interim Guidance on Management Pending Empirical Evidence" on treatments such as hydroxychloroquine and remdesivir.

Wrestling with the question of whether to recommend covid-19 treatments with imperfect evidence, they "suggest" use of hydroxychloroquine in hospitalized patients who have evidence of pnemonia on a case-by-case basis, but don't recommend routine use for covid-19 patients.

The recommendations were based on a survey of members who were working on the frontlines treating covid-19.

73% were in favor of intervention, 11% against, and 16% no suggestion.

"For hospitalized patients with COVID‐19 who have evidence of pneumonia, we suggest hydroxychloroquine (or chloroquine) on a case‐by‐case basis. Requirements include all of the following: a) shared decision‐making in which the patient is informed about the possible benefits and potential side effects, b) collection of data in a manner that enables studies that use valid methods for causal inference and control of confounders for the purpose of interim assessment, c) the patient’s clinical condition is sufficiently severe to warrant investigational therapy, and d) there is not a shortage of drug supply."​

Interestingly, the Task Force did not "suggest" use of remdesivir even in hospitalized patients with evidence of pneumonia. Support for that option fell slightly below its somewhat arbitrary 70% cut-off needed for a "suggestion." I suspect this will change after the results of the most recent remesdivir data are factored in.

https://www.thoracic.org/profession...sease-related-resources/covid-19-guidance.pdf

Thanks for posting this survey of what front-line physicians are saying about current COVID-19 anti-virals. What's interesting is that the results parallel the battle we're seeing within this forum regarding HCQ and Remdesivir. One side says HCQ is snake oil unless proven otherwise in a broad, scientifically-conducted study, and the other side says there's enough evidence from the front lines to justify selective treatment until those broad-based, scientifically-conducted tests come out. The main difference is that physicians willing to treat with HCQ in certain circumstances are in the majority in the study, whereas on this thread proponents of careful use of HCQ are a minority.

One cannot conclude HCQ is just snake-oil and silence the discussion because the evidence clearly is anything but one-sided. There's simply too much evidence out there that HCQ MIGHT BE a worthwhile option. Meanwhile, I'm hoping we see more test data on remdesivir because the small recent study suggests it is the most effective anti-viral to use with a patient who is on a ventilator.

 

[dfwatt]

This is the part I wish we had a good study on. Agreed that this approach has not been shown to help late stage even from anecdotal evidence.

Well lots of folks would love to see decent research data on hydroxychloroquine in various stages of disease severity. And at least we know whether it has any utility or whether it's just distraction. Perhaps the most interesting idea is that it may interfere with viral replication by opening up ion pores on cell membranes and allowing metal ions specifically zinc but perhaps other metal ions as well to disrupt the ribosome factories. That's been shown in vitro but nobody knows if it has relevance to en Vivo. And unfortunately the list of promising in-vitro candidates that bombed in Vivo either due to toxicity effects or other compensatory mechanisms that prevented the in Vivo result from mirroring the in vitro results have to be in the five figures at least if not six figures. The living system literally tries to undo every single intervention that you put into it because it interprets that intervention (if I can use the word interpret here) as a departure from some kind of homeostatic set point or set points and it tries to get back to that ground state.

 

[SageBrush]

2. Opening up country wide may become very difficult to do without starting new spreads.

Correct, which is why the focus has to be on reducing infectivity

Infectivity is reduced in two main ways:
1. Early quarantine of infection
2. Reduction in transmission in those not caught by (1)

Notice that Ab testing is irrelevant in the pursuit of these goals.

S. Korea remains an important lesson. They are down to ~ 4k tests a day for a population of 50M, and daily non-imported new cases are under 10 a day. The key point here is that tests that are only leading to head counts are not effective unless they lead to a drop in infectivity, meaning removal of those infected people from the community or improved behaviours that reduce the infectivity. Notice that a person who self-quarantines due to URI symptoms and a fever is just as effective as one who is quarantined by the state after a positive test. A person who wears a mask at the first signs of a URI or fever is MORE effective than one who waits for a test.

Due to the range of symptoms and a fraction of infections that are "aymptomatic,", universal mask use is needed. And in that case, the utility of Ag testing is low. The utility of Ab testing is minimal.

Trumpeting more testing is missing the point.

 

[NicoV]

Belgium is a curious case. Implemented lockdown quite early - still now has more deaths than China and fatality per 1M population next only to Spain & Italy (excluding tiny countries).

1) Belgium includes each death presumably caused by Corona in our death stats. If we would use the same way of counting as in The Netherlands (i.e. only count hospital deaths with confirmed Corona test), we’d have the same death count per million as The Netherlands.
2) The majority of the deaths now comes from elderly people in nursing homes. These were the first to lock down, even earlier than the general lockdown. But the personnel of the nursing homes had no protective materials and so we got some infections in the nursing homes, and rapid spread. Apparently elderly people can very easily infect other people with Corona. I’m told this is very unexpected, for other infectueus diseases just the opposite is true, and our doctor/medical personnel didn’t expect this.
3) We have a fairly ‘lite’ lockdown (compared to Spain and Italy), people can still go to work if social distancing is obeyed, and we can still go outside to walk/bike/run.
4) Unfortunately a minority of the population violates the lockdown rules.

 

[Norbert]

Correct, which is why the focus has to be on reducing infectivity

Infectivity is reduced in two main ways:
1. Early quarantine of infection
2. Reduction in transmission in those not caught by (1)

Notice that Ab testing is irrelevant in the pursuit of these goals.

1. More testing only helps with early quarantine. What other means do you have to determine infection before symptoms?
2. So if it will take 18 months to find a vaccine, you want us to wear masks for 18 months ?

EDIT: BTW, I'm not talking about antibody testing, you are.

 

[SageBrush]

2. So if it will take 18 months to find a vaccine, you want us to wear masks for 18 months ?

Likely.
It is not a case of what I "want," it is a case of what works.

 

[SageBrush]

What other means do you have to determine infection before symptoms?

Some 97+ percent of the population are susceptible. It is nonsensical to advocate testing them all every couple of days.

 

[AlanSubie4Life]

Not that anybody reading this thread actually thought there was SARS-CoV-2 novel coronavirus circulating in California in December, but this Twitter thread puts that to rest, definitively:

Trevor Bedford on Twitter

Enjoy! Very clear solid exposition of the available data which can put everybody's mind at rest who was sick in December and even early January in California - you did not have (SARS-CoV-2) coronavirus!

 

[jhm]

Today came in at 18,701, just a little above projection. This boosts the ultimate to 185k (from 160k) and pushed the peak daily out to April 23 (from 22). Here's a new 10-day dumb-ass projection:

2020-04-10 18,701
2020-04-11 20,784
2020-04-12 22,953
2020-04-13 25,199
2020-04-14 27,512
2020-04-15 29,884
2020-04-16 32,307
2020-04-17 34,772
2020-04-18 37,271
2020-04-19 39,798
2020-04-20 42,344

View attachment 531295
View attachment 531298

Ok a little slow, but this is for last night. 20,577 came in a little under projected 20,784. So the ultimate adjusts down to 107, and the peak date moves up to Apr 18.

It's nice to see the death rate slow down.

2020-04-11 20,577
2020-04-12 22,651
2020-04-13 24,780
2020-04-14 26,953
2020-04-15 29,160
2020-04-16 31,389
2020-04-17 33,633
2020-04-18 35,882
2020-04-19 38,129
2020-04-20 40,364
2020-04-21 42,583

 

[AlanSubie4Life]

Likely.
It is not a case of what I "want," it is a case of what works.

It's not clear that masks will work. Of course they will help, and everyone should be wearing them, but it's far from clear to me that we can just go back to normal (or even close to normal) while wearing masks - even if everyone is wearing N95s.

Seems to me that without driving case loads down, and getting good surveillance testing and readily available tests for anyone interacting with the health care system and anyone with any sort of symptoms, the masks won't help at all to bring back gatherings, open up nursing homes, allow use of public transit, open restaurants, open sporting events, etc. Without extensive testing & tracing we'll be at like a 70% economy - not even 80%.

 

[Norbert]

Likely

Good luck enforcing masks on the < 40 years population for 18 months.

Some 97+ percent of the population are susceptible. It is nonsensical to advocate testing them all every couple of days.

Not every couple days. I didn't say that. But as often as possible.

 

[AlanSubie4Life]

It's nice to see the death rate slow down.

Remember last weekend, the death rate dramatically "underperformed" the trend. I'd expect the same this week. And I'd be very (pleasantly) surprised if we didn't get up to deaths per day of 2500-3000 this coming week (high likelihood for a high count on Monday). I would view numbers that stay below 2500 as some sort of indication that US healthcare has figured out some clever ways (through medication or mechanical means) to get the sickest patients off of ventilators and into the survivor category.

I know someone (mother-in-law of my brother-in-law) who has been on a ventilator since early last week in New Jersey. At the end of last week, her kidneys shut down, and now she is on dialysis. Apparently there has been some improvement in her oxygen levels recently, but looks pretty iffy at this point. My point is that it sounds like they keep them hanging around for at least a week to give them a chance. As long as you have enough ventilators you can try everything, as long as they keep hanging on!

 

[Daniel in SD]

He didn't say what test he uses. He mentioned 85% sensititivity. That means it catches 85 out of 100 cases. The other 15 get a green armband and go breathe on everyone. Better than nothing, but probably not what we want as the centerpiece of our disease control system.

More than just the 85% metric is the issue that these antibody tests haven't been very good at picking up early-stage infections. Imagine a test that was 100% accurate on day 8, but always signaled negative until then. So everyone gets green armbands the first week....

What about the selectivity (false positives!)? That's way more important than sensitivity at this point during the pandemic. The FDA approved Cellex test only has 96% (95% CI: 92.8% to 97.8%) selectivity which makes it pretty useless right now. I also wonder whether the selectivity would vary by population if the false positives are caused by antibodies to other viruses.

 

[HG Wells]

Ok a little slow, but this is for last night. 20,577 came in a little under projected 20,784. So the ultimate adjusts down to 107, and the peak date moves up to Apr 18.

It's nice to see the death rate slow down.

2020-04-11 20,577
2020-04-12 22,651
2020-04-13 24,780
2020-04-14 26,953
2020-04-15 29,160
2020-04-16 31,389
2020-04-17 33,633
2020-04-18 35,882
2020-04-19 38,129
2020-04-20 40,364
2020-04-21 42,583

View attachment 531774

View attachment 531775

Any chance of getting the peak on April 15th ?
We could make it a day of celebration every year !

 

[jerry33]

Time for a poll:
If your daily fare is magic bullet stuff -- vaccine, meds, herd immunity ...

A question: Do you wear a mask outside the home ? Yes.
Do you wash your hands before eating or preparing food ? Yes, so much that my hands (particularly the back of my hands) start to crack and bleed).
Do you wash your hands after you go to the bathroom ? Always have.
Do you maintain social distancing outside the home ? Yes.
Do I disinfect the keyboard cover and pad? Every day.

 

[heltok]

He didn't say what test he uses. He mentioned 85% sensititivity. That means it catches 85 out of 100 cases. The other 15 get a green armband and go breathe on everyone. Better than nothing, but probably not what we want as the centerpiece of our disease control system.

More than just the 85% metric is the issue that these antibody tests haven't been very good at picking up early-stage infections. Imagine a test that was 100% accurate on day 8, but always signaled negative until then. So everyone gets green armbands the first week....

Think you misunderstood him. If you get false negative you still get to keep your yellow armband. Green is for people with antibodies, red for people with the virus, yellow for everyone without a positive test.

 

[mikevbf]

Seems like a very worthwhile place to donate to protect the front line with face shields:
Sponsor Face shields


I sponsored 10.

 

[dhanson865]

Some 97+ percent of the population are susceptible. It is nonsensical to advocate testing them all every couple of days.

If this goes on for years (more than 18 months) how often would you do a widespread testing? yearly, quarterly? not at all?

I totally understand why it won't happen but a part of me would love absurd levels of frequent testing.