Just curious, anyone have a plan, or preps for global pandemic?

[Mike41]

https://www.nationalreview.com/2020/04/coronavirus-kills-more-americans-in-one-month-than-the-flu-kills-in-one-year/?referringSource=articleShare
 

a very conservative magazine’s take on the Covid 19 outbreak and why it is NOT like the annual flu. 

[Gordo]

Only time will tell.  There have been some significant new "flare ups" around the world in the last 24 hours (Mexico, India, Russia, Iran).  US deaths just passed 50,000.  Not looking like those prior lower estimates of US deaths (like 60,000) will end up aging well.  Lots of people are anticipating a Summer lull followed by another wave in the Winter as well, so there will likely be a multiyear death toll here.  On the optimistic side, it seems likely that treatments will start to be recognized for efficacy and early treatment may prevent most deaths.

The previously mentioned NY Dr. Zelenko has given some updates and says he will be publishing "a meta study" within a few days.  His claimed numbers to date: 1,450 patients treated, two deaths, four ventilator cases (all fully recovered) and all others recovered. Zelenko and other physicians using the treatment are releasing the world’s largest Meta-study to date within the next few days that will examine more than 2,000 confirmed cases.  He says several clinics in Brazil adopted his treatment protocol (hydroxycholoroquine, azithromycin, & zinc cocktail, normally just a 5 day treatment) and saw a 95% reduction in deaths and hospitalizations.  He did a radio interview about this yesterday.  He also says the studies being published recently criticizing hydroxycholoroquine are "incredibly dishonest" because they are using patients that are already at such an advanced stage that the treatment protocol is no longer effective.  "There are politics at play here".  He also expressed his dismay about how so few studies are actually focused on keeping people out of hospitals (vs. studies on people already in hospitals).  Again only time will tell - duped by anecdote and bias, or onto something big?   I believe there are numerous large clinical trials already underway that can shed more light.  Personally I'd be inclined to "risk it" and take the 5 day treatment protocol (that includes low dose hydroxycholoroquine+zinc) if I became infected and had any sort of breathing problem (which isn't a very likely scenario to begin with).

 

[mccoy]

19 hours ago, Ron Put said:

Right now, excess mortality rates are lower than previous years for the US as a whole and for Europe.  Which should at least give you pause.

I wonder how thsoe data have been processed. In Italy the excess mortality issue has been examined for some time and it turns out that it is actually higher, of a quantity up to 215% with respect to the inception of the outbreak. Higher in the Northern regions, the hardest-hit, lower in the southern regions.

https://www.ilsole24ore.com/art/mortalita-covid-19-il-picco-decessi-triplicati-lombardia-ADv6VNL

 

 

 

 

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Used in the past to monitor the impact of summer heat waves, the system examines the most current mortality data. The latest report, updated on 11 April, confirms excess mortality especially in the North and, starting from mid-March, also in the South. In particular, there is an excess of mortality in the North which varies from + 58% in Bolzano and + 51% in Trento, + 215% in Brescia or + 96% in Milan. The trend also involves Aosta (+ 142%), Turin (+ 55%), Verona (+ 33%), Venice (+ 16%), Genoa (+ 81%) and Bologna (+ 40%). While among the central-southern cities, where Covid arrived later, a more modest increase is observed, despite the significant increases observed in Rome (+ 6%), Civitavecchia (+ 41%), Potenza (+ 35%), Bari (+ 43%) and Messina (+ 22%).

 

[Gordo]

You also have to modify conclusions about "total mortality" when you consider that the SARS-CoV-2 mitigation efforts are likely dramatically reducing ALL infectious disease, lowering car accidents, probably even dramatically lowering the spread of STDs.  I suspect people are also eating far less junk food (before the pandemic on average in America 1/3 of the population was eating at restaurants) and I suspect people are losing weight (my fat in-laws have lost 55 lbs in the last 5 weeks as my little anecdote, I also saw a joke going around on facebook about how the minus 19 in covid-19 represents how much weight you've lost) - these behavior changes may in fact be lowering heart attacks and strokes (its a huge CR study!).  There were several "alarming" news stories just in the last two days about the drop in strokes and heart attacks being due to people refusing to go to the hospital (with the implication that they are suffering and/or dying at home) - while there may be a few goofy real reports of idiots having heart attacks and refusing to get treatment, does it really seem likely to anyone here that this is the PRIMARY reason for the drop in reported heart attacks and strokes?

[Sibiriak]

Quote

(Bloomberg) -- The death toll from the new coronavirus reached 50,000 in the U.S., now the epicenter of the global outbreak, according to data compiled by Johns Hopkins University.

 

In New York’s largest hospital system, 88 percent of coronavirus patients on ventilators didn’t make it
 

Quote

Researchers found that 20 percent of all those hospitalized died — a finding that’s similar to the percentage who perish in normal times among those who are admitted for respiratory distress.

But the numbers diverge more for the critically ill put on ventilators. Eighty-eight percent of the 320 covid-19 patients on ventilators who were tracked in the study died. That compares with the roughly 80 percent of patients who died on ventilators before the pandemic, according to previous studies — and with the roughly 50 percent death rate some critical care doctors had optimistically hoped when the first cases were diagnosed.

“For those who have a severe enough course to require hospitalization through the emergency department it is a sad number,” said Karina W. Davidson, the study’s lead author and a professor at the Feinstein Institutes for Medical Research at Northwell.

[...] The paper also found that of those who died, 57 percent had hypertension, 41 percent were obese and 34 percent had diabetes which is consistent with risk factors listed by the Centers for Disease for Control and Prevention. Noticeably absent from the top of the list was asthma. As doctors and researchers have learned more about covid-19, the less it seems that asthma plays a dominant role in outcomes.

One other surprising finding from the study was that 70 percent of the patients sick enough to be admitted to the hospital did not have a fever. Fever is currently listed as the top symptom of covid-19 by the CDC, and for weeks, many testing centers for the virus turned away patients if they did not have one.

 

Edited April 24, 2020 by Sibiriak

[drewab]

This podcast isn't quite as new given that it is about two weeks old, so the odd thing might be slightly out of date, but I found it to be very informative on the topic. And the fact that it's one of the favorites around here, David Sinclair, makes it all the better.

 

[Ron Put]

On 4/23/2020 at 5:20 PM, Todd Allen said:

Dean has a good track record of carefully building cases for his opinions supported with references and while there are times I'm not in full agreement with his conclusions I'd be hard pressed to find something he has written I'd be willing to argue was "terribly wrong".   By contrast you have made no case at all for your accusation that he has made terribly wrong predictions.  What are the predictions in Dean's exact words and how are they terribly wrong?

For what it's worth, I too appreciate Dean's input and find it often very valuable.  As I do much of the input from others. But in this case, I feel that Dean is wrong, very wrong.  Part of it is the immediate politicization of the pandemic and the response to it, which unfortunately colors perceptions of threat and "leadership."

I disagree with your assertion that I "have made no case at all."  You might wish to reread some of my posts, including the one about ventilator overuse posted during the hysteria about the US being short of hundreds of thousands ventilators....  Back during Cuomo's repeated public speeches thanking China for the 1,000 ventilators they sent to him. Of course, Cuomo was trying to score against Trump, while China used Cuomo to score against the US.  Symbolism takes precedence in populist politics.

I just saw this Mark Twain quote elsewhere and it seems so on point here: 

It’s easier to fool someone than to convince someone that they are being fooled.

----

On 4/23/2020 at 6:14 PM, Todd Allen said:

What is the prediction Dean withdrew?  Quote the words....

The point many are missing is not that I and others are claiming that this is not a hard pandemic. It is hard, and the number of dead is significant, although highly unlikely to surpass the really hard pandemics through which some here have lived since the 1950s.

But the politicians who drove parts of the world here did it based on bad information. And many experts said it was bad information at the time, and argued that such momentous decisions which can destroy the lives of many should not be based on bad data.

Unfortunately, WHO politicized the first news about the pandemic and in the current polarized climate, political affiliations determined which experts were believed and which were attacked. It happened in Italy, it happened in the UK, it happened in the US. China is likely to emerge as the only winner in the global power shift which will almost certainly follow this mess, but they couldn't have done it without the block of liberal democracies doing it to themselves. I really hope I am wrong, because the world will be a much worse place without a dominant Western democratic allience.

Anyway, I'll indulge you and do a search.

On 3/21/2020 at 3:09 PM, Dean Pomerleau said:

Even severe flu seasons stress the nation’s hospitals to the point of setting up tents in parking lots and keeping people for days in emergency rooms. Coronavirus is likely to cause five to 10 times that burden of disease, said Dr. James Lawler, an infectious diseases specialist and public health expert at the University of Nebraska Medical Center. Hospitals “need to start working now,” he said, “to get prepared to take care of a heck of a lot of people.”

Dr. Lawler recently presented his own “best guess” projections to American hospital and health system executives at a private webinar convened by the American Hospital Association. He estimated that some 96 million people in the United States would be infected. Five out of every hundred would need hospitalization, which would mean close to five million hospital admissions, nearly two million of those patients requiring intensive care and about half of those needing the support of ventilators.

This is not a "worst case scenario" - this the "best guess" projection of a top infectious disease public health professional. He's saying it will be 5 to 10x the burden of a severe flu season and two million patients will require admission to intensive care. We only have ~100K intensive care beds, with most of them already occupied (and likely to remain so) by people who don't have coronavirus. 

So again, your apparent confidence that it won't get that bad seems wildly optimistic to me, given what credible experts are saying.

 

 

On 4/1/2020 at 1:51 PM, Ron Put said:

It's hard to admit that one is wrong, but I will make a prediction that the US death toll will be less than 100000, probably between 60000 and 80000, based on deadlier flu seasons. Hopefully lower.

The world's economy is another matter.

 

On 4/1/2020 at 2:54 PM, Dean Pomerleau said:

... I'll stick my neck out and say I think it will be higher than 100k, but I'm hoping not dramatically so in this first wave. ...

 

Edited April 25, 2020 by Ron Put

[Ron Put]

Some common sense, sent to me by my own internist, who is a personal friend.

What is actually sad is that he asked me not to publicise his views on the lock-down, because he doesn't want his business to suffer. Given the attacks on those who disagree with the "party line," it's of course understandable.  This should be rather disturbing to anyone who values free discourse as a cornerstone of liberal democracies.

[Ron Put]

Sweden resisted a lockdown, and its capital Stockholm is expected to reach ‘herd immunity’ in weeks

“In major parts of Sweden, around Stockholm, we have reached a plateau (in new cases) and we’re already seeing the effect of herd immunity and in a few weeks’ time we’ll see even more of the effects of that. And in the rest of the country, the situation is stable,” Dr. Anders Tegnell, chief epidemiologist at Sweden’s Public Health Agency, told CNBC on Tuesday.

[Dean Pomerleau]

Here is a really interesting website I haven't seen posted before. It is called Rt.live, and no it doesn't have anything to do with the Russian news outlet RT.

It is devoted to trying to estimate the effective transmission rate (R_t) of the coronavirus by US state. It basically looks at the rate of new cases over the last 7 days to estimate the number of new transmissions that are occurring for each existing case. Here is a description of the methodology.

Here is what it looks like for each of the 50 states, sorted by R_t. Green represents states with an R_t less than 1.0 and red means an R_t of greater than 1.0. Although it's worth noting that the 50% and 95% confidence intervals are pretty large.

As you can see, most states currently have an R_t are between 1.0 and 1.2 with 10 at or below 1.0 (in the green). Here is what it looked like a month ago, right around when most states implemented the stay-at-home orders. Every state but Washington had an R_t greater than 1.0:

Here is the graph of R_t over time for the state of Georgia, which is one of the first to start relaxing its stay-at-home order. Again notice the confidence interval is pretty wide:

 

Overall it looks like most states are hovering around an R_t of 1.0 under the current modestly strict social distancing interventions, which seems consistent with the data showing total new daily cases in the US have plateaued at a pretty high level (~25-30k per day). This doesn't bode very well for what will happen when states start to open up. Time will tell and it will be interesting to see how these R_t estimates changes as different states start to relax various social distancing measures.

--Dean

 

[Mike41]

13 hours ago, Ron Put said:

Some common sense, sent to me by my own internist, who is a personal friend.

What is actually sad is that he asked me not to publicise his views on the lock-down, because he doesn't want his business to suffer. Given the attacks on those who disagree with the "party line," it's of course understandable.  This should be rather disturbing to anyone who values free discourse as a cornerstone of liberal democracies.

Ok, I listened to this and I shake my head. Again Lies, damn lies and statistics. So They are looking at real data and coming to much different conclusions then Fauci etc. I think everyone following this thread should listen to this. At least the first 15 minutes. My only doubt is are they cherry picking data. Unless I missed it they did not address Italy for instance. But my take on what they are saying seems consistent with the Lancet study which was worldwide stats and that too indicated flu like mortality rates and disease severity when you consider the limited data and lack of widespread testing such that the .066 mortality is most likely going to be lower as these gentleman indicate based on more updated information with higher testing results

Edited April 25, 2020 by Mike41
A

[Mike41]

https://www.bbc.com/news/5231101
 

Lies, damn lies and statistics!

[Dean Pomerleau]

I think this may have been mentioned here before, but there appears to be growing evidence that covid-19 is triggering strokes among younger, relatively healthy people. Here are excerpts from a Washington Post article on the issue:

Now for the first time, three large U.S. medical centers are preparing to publish data on the stroke phenomenon. The numbers are small, only a few dozen per location, but they provide new insights into what the virus does to our bodies.

Thomas Jefferson University Hospitals, which operates 14 medical centers in Philadelphia, and NYU Langone Health in New York City, found that 12 of their patients treated for large blood blockages in their brains during a three-week period had the virus. Forty percent were under 50, and they had few or no risk factors.

"We are used to thinking of 60 as a young patient when it comes to large vessel occlusions,” Raz said of the deadliest strokes. “We have never seen so many in their 50s, 40s and late 30s.”

Raz wondered whether they are seeing more young patients because they are more resistant than the elderly to the respiratory distress caused by covid-19: “So they survive the lung side, and in time develop other issues.”

On average, the covid-19 stroke patients were 15 years younger than stroke patients without the virus.

“These are people among the least likely statistically to have a stroke,” Mocco said.

In a letter to be published in the New England Journal of Medicine next week, the Mount Sinai team details five case studies of young patients who had strokes at home from March 23 to April 7. They make for difficult reading: The victims’ ages are 33, 37, 39, 44 and 49, and they were all home when they began to experience sudden symptoms, including slurred speech, confusion, drooping on one side of the face and a dead feeling in one arm.

One died, two are still hospitalized, one was released to rehabilitation, and one was released home to the care of his brother. Only one of the five, a 33-year-old woman, is able to speak.

--Dean

[Ron Put]

25 minutes ago, Dean Pomerleau said:

I think this may have been mentioned here before, but there appears to be growing evidence that covid-19 is triggering strokes among younger, relatively healthy people. ...

Dean, while this seems scary in of itself, as I have mentioned before, Covid-19 is no different than the flu in this respect. There are a number of studies which show increased mortality from causes such as heart attacks and strokes related to the viruses which comprise the "flu," both among the old and the young.

Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection
"We found that the incidence of admissions for acute myocardial infarction was six times as high during the 7 days after laboratory confirmation of influenza infection as during the control interval"


Flu, flu-like illnesses linked to increased risk of stroke, neck artery tears
"In the first study, researchers found that having a flu-like illness increased the odds of having a stroke by nearly 40 percent over the next 15 days. This increased risk remained up to one year. ...

In a second study from the same institution, researchers found an increased risk of tearing neck arteries within one month of battling a flu-like illness. Non-traumatic cervical artery dissection is a leading cause of ischemic stroke in patients 15- to 45-years old."


Also, I hate to have to point out again that alarmist models such as the one you posted above suffer from the same "garbage in/garbage out" problem of previous, now shown to be grossly inaccurate models. Imposing what is effectively marshal law based on such poor data should and must be challenged.

[AlPater]

BMJ Open Published on: 30 March 2020
COVID-19, shortages of masks and the use of cloth masks as a last resort
Chandini R MacIntyre, Academic physician The Kirby Institute, University of New South Wales
Other Contributors:
Chi Dung Tham, Academic physician
Holly Seale, Academic
Abrar Chughtai, Academic physician
Critical shortages of personal protective equipment (PPE) have resulted in the US Centers for Disease Control downgrading their recommendations for health workers treating COVID-19 patients from respirators to surgical masks and finally to home-made cloth masks. As authors of the only published randomised controlled clinical trial of cloth masks, we have been getting daily emails about this from health workers concerned about using cloth masks. The study found that cloth mask wearers had higher rates of infection than even the standard practice control group of health workers, and the filtration provided by cloth masks was poor compared to surgical masks. At the time of the study, there had been very little work done in this space, and so little thought into how to improve the protective value of the cloth masks. Until now, most guidelines on PPE did not even mention cloth masks, despite many health workers in Asia using them.
Health workers are asking us if they should wear no mask at all if cloth masks are the only option. Our research does not condone health workers working unprotected. We recommend that health workers should not work during the COVID-19 pandemic without respiratory protection as a matter of work health and safety. In addition, if health workers get infected, high rates of staff absenteeism from illness may also affect health system capacity to respond. Some health workers may still choose to work in inadequate PPE. In this case, the physical barrier provided by a cloth mask may afford some protection, but likely much less than a surgical mask or a respirator.
It is important to note that some subjects in the control arm wore surgical masks, which could explain why cloth masks performed poorly compared to the control group. We also did an analysis of all mask wearers, and the higher infection rate in cloth mask group persisted. The cloth masks may have been worse in our study because they were not washed well enough – they may become damp and contaminated. The cloth masks used in our study were products manufactured locally, and fabrics can vary in quality. This and other limitations were also discussed.
There are now numerous reports of health workers wearing home made cloth masks, or re-using disposable mask and respirators, and asking for guidance. If health workers choose to work in these circumstances, guidance should be given around the use.
There have been a number of laboratory studies looking at the effectiveness of different types of cloth materials, single versus multiple layers and about the role that filters can play. However, none have been tested in a clinical trial for efficacy. If health workers choose to work using cloth masks, we suggest that they have at least two and cycle them, so that each one can be washed and dried after daily use. Sanitizer spray or UV disinfection boxes can be used to clean them during breaks in a single day. These are pragmatic, rather than evidence-based suggestions, given the situation.
Finally for COVID-19, wearing a mask is not enough to protect healthcare workers – use of gloves and goggles are also required as a minimum, as SARS-CoV-2 may infect not only through the respiratory route, but also through contact with contaminated surfaces and self-contamination.
Governments and hospitals should plan and stockpile proper disposable products such as respirators and surgical masks to ensure the occupational health and safety of health workers. This appears to have been a failure in many countries, including high income countries.
Conflict of Interest:
We were the authors of the 2015 RCT , which was funded by an Australian Research Council Linkage Grant with 3M as the partner on the grant.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
A cluster randomised trial of cloth masks compared with medical masks in healthcare workers.
MacIntyre CR, Seale H, Dung TC, Hien NT, Nga PT, Chughtai AA, Rahman B, Dwyer DE, Wang Q.
BMJ Open. 2015 Apr 22;5(4):e006577. doi: 10.1136/bmjopen-2014-006577.
PMID: 25903751 Free PMC Article
Abstract
OBJECTIVE:
The aim of this study was to compare the efficacy of cloth masks to medical masks in hospital healthcare workers (HCWs). The null hypothesis is that there is no difference between medical masks and cloth masks.
SETTING:
14 secondary-level/tertiary-level hospitals in Hanoi, Vietnam.
PARTICIPANTS:
1607 hospital HCWs aged ≥18 years working full-time in selected high-risk wards.
INTERVENTION:
Hospital wards were randomised to: medical masks, cloth masks or a control group (usual practice, which included mask wearing). Participants used the mask on every shift for 4 consecutive weeks.
MAIN OUTCOME MEASURE:
Clinical respiratory illness (CRI), influenza-like illness (ILI) and laboratory-confirmed respiratory virus infection.
RESULTS:
The rates of all infection outcomes were highest in the cloth mask arm, with the rate of ILI statistically significantly higher in the cloth mask arm (relative risk (RR)=13.00, 95% CI 1.69 to 100.07) compared with the medical mask arm. Cloth masks also had significantly higher rates of ILI compared with the control arm. An analysis by mask use showed ILI (RR=6.64, 95% CI 1.45 to 28.65) and laboratory-confirmed virus (RR=1.72, 95% CI 1.01 to 2.94) were significantly higher in the cloth masks group compared with the medical masks group. Penetration of cloth masks by particles was almost 97% and medical masks 44%.
CONCLUSIONS:
This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated.
KEYWORDS:
Cloth mask; Influenza

Edited April 25, 2020 by AlPater

[TomBAvoider]

Coronavirus: Has Sweden got its science right?

Will Swedes develop immunity?

History will judge which countries got it right. But the latest scientific discussion is focused on the number of Swedes who may have contracted the virus without showing any symptoms.

This is important because many scientists here believe Swedes may end up with much higher immunity levels compared with those living under stricter regulations.

A public health agency report this week suggested around a third of people in Stockholm will have been infected by the start of May.

That was later revised down to 26% after the agency admitted a calculation error. But several high-profile scientists have offered even greater numbers.

Prof Johan Giesecke, ex-chief scientist of the European Centre for Disease Prevention and Control (ECDC), believes at least half of all Stockholmers will have caught the virus by the end of the month.

It could even be up to half the population of Sweden, suggests Stockholm University mathematician Tom Britton.

[corybroo]

A link that allows you to see the stats for your city.   https://www.nytimes.com/interactive/2020/04/23/upshot/five-ways-to-monitor-coronavirus-outbreak-us.html?action=click&module=Well&pgtype=Homepage&section=The Upshot

https://www.nytimes.com/interactive/2020/04/23/upshot/five-ways-to-monitor-coronavirus-outbreak-us.html?action=click&module=Well&pgtype=Homepage&section=The Upshot

I live in Nashville so I selected it.

https://www.nytimes.com/interactive/2020/04/23/upshot/five-ways-to-monitor-coronavirus-outbreak-us.html?action=click&module=Well&pgtype=Homepage&section=The Upshot

 

 

 

[Todd Allen]

22 hours ago, Ron Put said:

>By contrast you have made no case at all for your accusation that he has made terribly wrong predictions.  What are the predictions in Dean's exact words and how are they terribly wrong?

Anyway, I'll indulge you and do a search.

22 hours ago, Ron Put said:

On 3/21/2020 at 5:09 PM, Dean Pomerleau said:

Even severe flu seasons stress the nation’s hospitals to the point of setting up tents in parking lots and keeping people for days in emergency rooms. Coronavirus is likely to cause five to 10 times that burden of disease, said Dr. James Lawler, an infectious diseases specialist and public health expert at the University of Nebraska Medical Center. Hospitals “need to start working now,” he said, “to get prepared to take care of a heck of a lot of people.”

Dr. Lawler recently presented his own “best guess” projections to American hospital and health system executives at a private webinar convened by the American Hospital Association. He estimated that some 96 million people in the United States would be infected. Five out of every hundred would need hospitalization, which would mean close to five million hospital admissions, nearly two million of those patients requiring intensive care and about half of those needing the support of ventilators.

This is not a "worst case scenario" - this the "best guess" projection of a top infectious disease public health professional. He's saying it will be 5 to 10x the burden of a severe flu season and two million patients will require admission to intensive care. We only have ~100K intensive care beds, with most of them already occupied (and likely to remain so) by people who don't have coronavirus. 

So again, your apparent confidence that it won't get that bad seems wildly optimistic to me, given what credible experts are saying.

 

 

 

 

That's not a prediction by Dean.  He is quoting an expert to make the case that you were significantly underestimating the risks of Covid-19.

You then went on to say

Quote

We'll know who is right in a few months, but I am fairly certain that the mortality rate of Covid-19 is shaping up to be comparable to that of the flu, based on the information I have.

Less than a month later we have >54,000 US Covid-19 deaths which is worse than the average US death toll attributed to flu and we are quickly approaching that of the worst years of seasonal flu without a named novel strain from an animal source.  Unlike the flu which is mostly done for the season yesterday the US set a new record for the daily number of new Covid-19 cases and within the last week set a new record for daily deaths and the number of active cases has increased every single day since your above statement and is now > 788,000.  Some yet to be known percentage of active cases will not recover and contribute to the rapidly growing death toll.  

I do not see justification for your confidence or your assertion of Dean's predictions being terribly wrong.

 

Edited April 26, 2020 by Todd Allen

[Sibiriak]

Huntington Beach, California  April 25, 2020

[Dean Pomerleau]

On the topic of the effectiveness of stay-at-home orders and the likelihood that economic activity will snap back after they are lifted, the University of Maryland Transportation Research Institute has several really interesting relevant graphics.

They have found what they call "social distancing inertia" that is largely independent of the onset of stay-at-home orders. I don't really like their term for it, but what they are suggesting is that people started social distancing prior to stay-at-home orders in most states and that the degree of social distancing has plateaued even as cases continue to rise pretty precipitously.

Here is one of their graphics showing percent of people staying home (top two rows, blue lines) and number of trips people have been making (bottom two rows, green lines) relative to the number of covid-19 cases (red lines) both nationally and in various US states:

The vertical black bars represent the date of stay-at-home orders in each of the states. What you can see is that both the percent of people staying home had already rose and the number of trips per person had already dropped pretty substantially by the time the stay-at-home orders were instituted and changed relatively little subsequently, even as cases continued to rise.  One way of looking at this is that the formal stay-at-home orders were pretty superfluous - people were already concerned enough about the risk of infection prior to the stay-at-home orders due to public education efforts to be voluntarily reducing their exposure.

One the one hand this is good news for those who think stay-at-home orders should be lifted. Since people were social distancing before the stay-at-home orders were put in place out of concern of infection, presumably rational people won't irresponsibly congregate after they are lifted as a result of the same concern, although "cabin fever" may cause some fraction of people to do so despite the risk.

But on the other hand, this supports the idea that several people (e.g. Gordo and Bill Gates 🙂) have suggested, namely that even when states start to open up, the restoration of economic activity is likely to be slow since most people won't rush back to their same old level of social and economic activity out of concern they'll get infected.

The fact that social contact measures have plateaued at a relatively high level compared e.g. to Wuhan, may be one important factor explaining why the estimate of China's effective transmission rate was below 0.5 after their lockdown, while the effective transmission rate in the US (and much of Europe) seems to be hovering in the neighborhood of 1.0. Recall in Wuhan only one member of a family was allowed to leave their dwelling place every three days. Contrast this with our hardest hit state NY, where the average person is still making ~2.5 trips out per day.

The modest degree of drop in personal travel is evident in this statistic from the Maryland researchers, "On average, stay-at-home orders have reduced miles traveled per person by 4.5 miles per person from 27.1 to 22.6 miles.'

People are also still doing a lot of trips from one county to the next, "Inter-county trip share was 29% of all trips before COVID-19 and has only dropped to 25% nationwide in the most recent week. There are still a large portion of trips that cross county borders."

This obviously undermines the idea that you could effectively open up some counties while keeping other hard-hit ones nearby locked down to slow the spread while bring the economy back on-line.

Note - very few of the trips (~15%) that people are making in the US are work-related, according to the Maryland researchers and that percentage hasn't changed since before the virus.

--Dean

 

[Dean Pomerleau]

Several people have wondered about the potential negative health consequences  of mild or asymptomatic cases of covid-19. This study [1] goes some way towards addressing this issue, and the takeaway isn't great. They took chest CT scans from ~100 previously infected passengers from the Diamond Princess cruise ship that docked in Japan and had a large number of covid-19 cases.  

Once the passengers and crew were allowed to leave the ship they were taken to a Japanese hospital where they were screened for covid-19 (if they hadn't been already while on the ship) and given a chest CT scan to determine how they should be quarantined further. 

Of the ~100 infected people screened in the study, 73% were asymptomatic. Of those, 54% showed abnormality in the lungs, mostly in the form of what is called ground glass opacity (GGO). In the 27% who were symptomatic, 79% showed lung abnormalities.

Before anyone jumps on me by saying the same thing happens in the seasonal flu, study [2] found that only 50% of seasonal flu sufferers with symptoms severe enough to land them in the hospital emergency department exhibited lung abnormalities. So 54% of asymptomatic people with covid-19 having lung abnormalities is quite a distinction.

Finally, this review article [3] addresses the issue of whether such lung abnormalities (specifically GGO) has long-term negative health consequences. It says that GGO is not associated with smoking, ruling out smoking as the root cause of any negative health consequences associated with GGO:

A GGN [Ground Glass opacity Nodules] is not associated with smoking unlike smoking-related lung cancer. GGNs occur at a relatively young age. Moreover, they develop in the peripheral portion of the lung and many of them show a multifocal origin. 

The author of [3] also says that less than half of GGO Nodules disappear within three months:

My research group found that 37% of pure GGNs (pGGNs) and 48% of mixed GGNs (mGGNs) regressed or disappeared within 3 months, which suggested their inflammatory nature (1).

Study [4] looked at the long-term consequences of the majority of GGNs that don't disappear. A good fraction of them eventually grow and become cancerous:

Retrospective and prospective studies have revealed that approximately 20% of pure GGNs and 40% of part-solid GGNs gradually grow or increase their solid components, whereas others remain stable for years. Most persistent or growing GGNs are lung adenocarcinomas or their preinvasive lesions. To distinguish GGNs with growth from those without growth, GGNs should be followed for at least 5 years. 

In other words, it would appear the type of ground glass opacity that is showing up in the lungs of asymptomatic covid-19 patients can both persist and eventually turn into lung cancer. Note - some fraction of the Cruise ship folks who were asymptomatic at the time of the CT scan may have eventually developed symptoms, but given how long they were isolated prior to leaving the ship, many positive folks must have remained asymptomatic.

--Dean

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[1] Chest CT Findings in Cases from the Cruise Ship “Diamond Princess” with Coronavirus Disease 2019 (COVID-19)
Shohei Inui , Akira Fujikawa, Motoyuki Jitsu, Naoaki Kunishima, Sadahiro Watanabe,  … See all authors 
Author Affiliations
Published Online:Mar 17 2020
https://doi.org/10.1148/ryct.2020200110
Sections
PDF
Abstract
Purpose
To evaluate the chest CT findings in an environmentally homogeneous cohort from the cruise ship “Diamond Princess” with Coronavirus Disease 2019 (COVID-19).

Materials and Methods
This retrospective study comprised 104 cases (mean age, 62 years ± 16, range 25-93) with COVID-19 confirmed with RT-PCR. CT images were reviewed and the CT severity score was calculated for each lobes and the entire lung. CT findings were compared between asymptomatic and symptomatic cases.

Results
Of 104 cases, 76 (73%) were asymptomatic, 41 (54%) of which had lung opacities on CT. Other 28 (27%) cases were symptomatic, 22 (79%) of which had abnormal CT findings. Symptomatic cases showed lung opacities and airway abnormalities on CT more frequently than asymptomatic cases [lung opacity; 22 (79%) vs 41 (54%), airway abnormalities; 14 (50%) vs 15 (20%)]. Asymptomatic cases showed more GGO [Ground Glass Opacity - DP] over consolidation (83%), while symptomatic cases more frequently showed consolidation over GGO (41%). The CT severity score was higher in symptomatic cases than asymptomatic cases, particularly in the lower lobes [symptomatic vs asymptomatic cases; right lower lobe: 2 ± 1 (0-4) vs 1 ± 1 (0-4); left lower lobe: 2 ± 1 (0-4) vs 1 ± 1 (0-3); total score: 7 ± 5 (1-17) vs 4 ± 2 (1-11)].

Conclusion
This study documented a high incidence of subclinical CT changes in cases with COVID-19. Compared to symptomatic cases, asymptomatic cases showed more GGO over consolidation and milder extension of disease on CT.

An earlier incorrect version appeared online. This article was corrected on April 8, 2020.

Summary
We revealed a high incidence of subclinical CT changes in COVID-19 infected cases, which showed more GGO predominance over consolidation and milder severity on CT than symptomatic cases.

Key Points
■ Of 104 cases analyzed, 76 (73%) were asymptomatic, 41 (54%) of which had pneumonic changes on CT. Other 28 (27%) cases were symptomatic, 22 (79%) of which had abnormal CT findings.

■ Asymptomatic cases showed more GGO predominance over consolidation (83%), while symptomatic cases were more likely to show a consolidation predominance over GGO (41%).

■ Asymptomatic cases showed milder CT severity score than symptomatic cases.

--------------

[2] Radiologia. 2011 Mar-Apr;53(2):159-65. doi: 10.1016/j.rx.2010.09.005. Epub 2011

Apr 1.

[Is H1N1 flu different from seasonal flu on initial plain chest films?].

[Article in Spanish]

Martí-de-Gracia M(1), Pinilla I, Quintana-Díaz M, Rodríguez-Requena H,
Prados-Sánchez C.

Author information: 
(1)Servicio de Radiodiagnóstico, Hospital Universitario La Paz, Madrid.

Erratum in
    Radiologia. 2011 Nov-Dec;53(6):583-4.

OBJECTIVES: To determine whether there are differences in the findings on the
initial plain chest films of patients with H1N1 influenza and those of patients
with flu symptoms during the flu season.
MATERIAL AND METHODS: All patients underwent plain-film chest radiography in the 
Emergency Department for flu symptoms; 95 patients had H1N1 influenza confirmed
between July 2009 and December 2009 and 95 patients were attended for symptoms of
seasonal flu in January 2009. We analyzed the views obtained, the distribution
and location of the radiologic findings, and patients' age, sex, and previous
disease.
RESULTS: Patients with H1N1 influenza were younger than those with seasonal flu
symptoms (mean 40.2 vs 50.9 years; p<0.001) and fewer had prior disease (48 vs.
63; p<0.001). Plain films were acquired with patients in the standing position in
75 patients in the H1N1 group and in 77 in the seasonal flu group; pathological
findings were present in nearly 50% of the patients in each group. The most
common findings in the H1N1 group were multifocal patchy consolidations (41.2%;
p<0.001) and peribronchial-vascular opacities (16.3%), whereas in the seasonal
flu group the most common finding was consolidation in a single lobe (43.9%).
CONCLUSION: We found significant differences between the radiologic findings of
patients with H1N1 influenza (severe) and those of patients with symptoms of flu 
during the flu season: the incidence of multifocal patchy consolidation was
greater in H1N1 patients and H1N1 patients were younger.

Copyright © 2010 SERAM. Published by Elsevier Espana. All rights reserved.

DOI: 10.1016/j.rx.2010.09.005 
PMID: 21458832  [Indexed for MEDLINE]

------------------

[3] What do we know about ground-glass opacity nodules in the lung?
Choon-Taek Lee1,2
1Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea; 2Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
Correspondence to: Choon-Taek Lee, MD, PhD. Department of Internal Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-Ro,
Bundang-Gu, Seongnam 463-707, Korea. Email: ctlee@snu.ac.kr.
Abstract: Ground-glass opacity nodules (GGNs) in the lung attract clinical attention owing to their
increasing incidence, unique natural course, and association with lung adenocarcinoma. A long and indolent
course of a GGN makes it difficult to manage. Current extensive clinical, radiological, pathological, and
genetic studies on GGNs have shed light on their pathogenesis and allowed development of a reliable
strategy of management. The present editorial provides answers to clinical questions related to GGNs,
such as the natural course, follow-up, prediction of growth, and resection techniques. Finally, I discuss the
etiology of GGNs, which has not been fully elucidated so far.
Keywords: Ground-glass opacity nodules (GGNs); growth; epidermal growth factor receptor (EGFR); lung
adenocarcinoma
Submitted Mar 20, 2015. Accepted for publication Mar 31, 2015.
doi: 10.3978/j.issn.2218-6751.2015.04.05
View this article at: http://dx.doi.org/10.3978/j.issn.2218-6751.2015.04.05

-----------

[4] Ground-glass nodules of the lung in never-smokers and smokers:
clinical and genetic insights
Yoshihisa Kobayashi1,2, Chiara Ambrogio2, Tetsuya Mitsudomi1
1Department of Thoracic Surgery, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka 589-8511, Japan; 2Department of Medical
Oncology, Dana-Farber Cancer Institute, Boston, MA 02215, USA
Contributions: (I) Conception and design: Y Kobayashi, T Mitsudomi; (II) Administrative support: Y Kobayashi, T Mitsudomi; (III) Provision of study
materials or patients: Y Kobayashi, T Mitsudomi; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors;
(VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Tetsuya Mitsudomi. Department of Thoracic Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-Higashi, Osaka-Sayama,
Osaka 589-8511, Japan. Email: mitsudom@med.kindai.ac.jp.
Abstract: Pulmonary ground-glass nodules (GGNs) are hazy radiological findings on computed
tomography (CT). GGNs are detected more often in never-smokers. Retrospective and prospective studies
have revealed that approximately 20% of pure GGNs and 40% of part-solid GGNs gradually grow or
increase their solid components, whereas others remain stable for years. Most persistent or growing GGNs
are lung adenocarcinomas or their preinvasive lesions. To distinguish GGNs with growth from those without
growth, GGNs should be followed for at least 5 years. Lesion size and smoking history are predictors of
GGN growth. Genetic analyses of resected GGNs have suggested that EGFR mutations are also predictors
for growth but a subset of KRAS- or BRAF-mutated GGNs may undergo spontaneous regression because the
frequencies of KRAS or BRAF mutations decrease with the advance of pathological invasiveness. Although
lobectomy is the standard surgical procedure for lung cancer, limited surgery such as wedge resection or
segmentectomy for lung cancers ≤2 cm with consolidation/tumor ratio ≤0.25 can be a viable alternative based
on the recent clinical trial. Further genetic analyses and clinical trials can contribute to elucidation of the
biological aspects of preinvasive adenocarcinoma and the development of less invasive management strategies
for patients with GGNs.
Keywords: Adenocarcinoma; ground-glass opacity (GGO); lung cancer; subsolid nodule
Submitted Jan 01, 2018. Accepted for publication Jul 04, 2018.
doi: 10.21037/tlcr.2018.07.04
View this article at: http://dx.doi.org/10.21037/tlcr.2018.07.04

 

[Gordo]

Thanks Dean, so we may not know for many years, but it will be interesting to see if there is a rise in lung related health problems over time that may be linked to the pandemic.

Unrelated, but I was reading an article about people moving out of cities as a result of the pandemic, but what caught my attention was the addendum:

ADDENDUM: It will probably not surprise you to learn I think Senator Tom Cotton has the assessment of the likelihood of SARS-CoV-2 arising from an accidental exposure of a naturally occurring virus just about right:

While the Chinese government denies the possibility of a lab leak, its actions tell a different story. The Chinese military posted its top epidemiologist to the Institute of Virology in January. In February Chairman Xi Jinping urged swift implementation of new biosafety rules to govern pathogens in laboratory settings. Academic papers about the virus’s origins are now subject to prior restraint by the government.

In early January, enforcers threatened doctors who warned their colleagues about the virus. Among them was Li Wenliang, who died of Covid-19 in February. Laboratories working to sequence the virus’s genetic code were ordered to destroy their samples. The laboratory that first published the virus’s genome was shut down, Hong Kong’s South China Morning Post reported in February.

This evidence is circumstantial, to be sure, but it all points toward the Wuhan labs. Thanks to the Chinese coverup, we may never have direct, conclusive evidence—intelligence rarely works that way—but Americans justifiably can use common sense to follow the inherent logic of events to their likely conclusion.

[TomBAvoider]

Does that mean Sweden will see an explosion of lung cancer in the future, tied to their laissez faire attitude to the spread of CV-19 in their country? 

On another note, if CV-19 becomes endemic, is this going to be a leading cause of lung cancer among non-smokers the world over? The WHO is suggesting that any acquired immunity to CV-19 might be very temporary, so this just becomes another permanent hazard.

Is there data suggesting that GGNs in severe flu strains are already causing lung cancer on a population level?

Other than cancer down the road, what are the other consequences of the GGN condition in the lungs - is there a loss of lung function, increased susceptability to future bacterial or viral infections etc.?

[Dean Pomerleau]

54 minutes ago, TomBAvoider said:

Does that mean Sweden will see an explosion of lung cancer in the future, tied to their laissez faire attitude to the spread of CV-19 in their country? 

I don't think anyone knows. A lot depends on whether the Ground Glass Nodules (GGNs) clear up quickly on their own or persist over time. This study [1] suggests a mixed blessing. They looked at samples of GGNs from ~127 young patients (avg age ~36) who had their GGNs surgically removed.

Of the 141 GGNs removed from these patients, 115 of them (82%) were malignant. The good news is that none of the patients died or saw a recurrence of GGNs during two years of follow-up after the surgery. 6.3% and 7.6% of patients experienced short and long-term complications post-surgery, respectively.

--Dean

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[1] Clinical characteristics and prognosis of ground-glass opacity
nodules in young patients
Jun Wang1, Han Ma1, Chong-Jun Ni2, Jing-Kang He1, Hai-Tao Ma1, Jin-Feng Ge1
1Department of Thoracic Surgery, 2Department of Respiratory Medicine, the First Affliated Hospital of Soochow University, Suzhou 215006, China
Contributions: (I) Conception and design: JF Ge, J Wang; (II) Administrative support: JF Ge, HT Ma; (III) Provision of study materials or patients: JF
Ge; (IV) Collection and assembly of data: J Wang, H Ma; (V) Data analysis and interpretation: J Wang, H Ma; (VI) Manuscript writing: All authors;
(VII) Final approval of manuscript: All authors.
Correspondence to: Jin-Feng Ge, MD. Department of Thoracic Surgery, the First Affliated Hospital of Soochow University, No. 188 Shizi Road,
Canglang District, Suzhou 215006, China. Email: gejinfeng@netease.com.
Background: The detection rate of ground-glass opacity (GGO) in young patients has increased year
by year with the increasingly widespread use of high-resolution computed tomography (HRCT) and the
increased resolution of HRCT imaging. However, no scholars have reported the clinical characteristics and
prognosis of GGO in young patients systematically. The purpose of this study is to investigate the clinical
characteristics and prognosis presenting as GGO in young patients.
Methods: Clinical data of 127 young patients who were diagnosed as GGO and who underwent videoassisted thoracoscopic surgery (VATS) and had routine pathological examination were collected from January
2016 to January 2017. Nodules were classifed according to benign and malignant: 26 benign nodules (Group
A) and 115 malignant nodules (Group B). The pathological types, nodules size, surgical methods were
analyzed, and the clinical characteristics and prognosis were evaluated.
Results: The results of pathological examination of 91 pure ground-glass opacities (pGGOs) revealed 16
adenocarcinoma in situs (AISs), 42 micro invasive adenocarcinomas (MIAs), 13 invasive adenocarcinomas
(IAs), 8 atypical adenomatous hyperplasias (AAHs), 1 infammatory granuloma, 2 pulmonary infammatory
pseudotumors (IPTs) and 9 other benign nodules. The results of pathological examination of 50 mixed
ground-glass opacities (mGGOs) revealed 6 AISs, 29 MIAs, 9 IAs, 1 AAH, 2 infammatory granulomas and
3 other benign nodules. All patients had no lymph nodes invasion. The rates of perioperative complications
were 6.30%, compared to 7.63% for long-term complications. None of the patients with GGO experienced
a recurrence and death [2-year recurrence-free survival (RFS), 100%; 2-year overall survival (OS), 100%].
Conclusions: The GGO in young patients that received VATS has a high proportion of malignant, its
prognosis is satisfed.
Keywords: Ground-glass opacity (GGO); pathological classifcation; clinical characteristics; prognosis
Submitted Nov 07, 2018. Accepted for publication Jan 05, 2019.
doi: 10.21037/jtd.2019.01.32
View this article at: http://dx.doi.org/10.21037/jtd.2019.01.32

[TomBAvoider]

Fascinating. Thanks, Dean. Many questions, few answers. I wonder if there are factors that influence whether you get GGO - things like nutritional status (the way f.ex. it is claimed that having high zinc status slows down viral infections) - and it's amazing to think smoking might be protective in this context!