ventilation pipe by Bilderjet courtesy of pixabay.com
Medscape reported on April 13 about a big set of patients from the United Kingdom who were in intensive care, a study that came out online from the Intensive Care National Audit & Research Centre (ICNARC). Here is their “Latest News” page. This is a quote from Medscape:
[the ICNARC report] … include data from 3883 patients with confirmed COVID-19 who were admitted to intensive care units (ICUs) in England, Wales, or Northern Ireland and for whom data on the first 24 hours of ICU care are available. Of those, 871 patients died, 818 patients survived to ICU discharge, and 2194 patients were still receiving ICU care. Among patients whose ICU outcome is known, 66.3% of the 1053 patients who required mechanical ventilated [sic] died, compared with 19.4% of the 444 patients who required basic respiratory support.
The conclusion is that two-thirds of the patients on ventilators died, but only about 20% of those who were on oxygen passed away. This report is similar to, but worse than, the numbers from smaller sets of patients with the new virus who were on ventilators. The ICNARC report compared these figures with those from patients with acute respiratory distress from viral pneumonia over the last two years, before the pandemic: about 35% of the earlier set of patients on ventilators died, a little over a third.
So far, there has been no explanation of why the mortality (death rate) is so much worse in patients with COVID-19 than in previously studied patients with viral pneumonia, presumably a comparable illness. This disparity deserves further study; are patients with the new virus on ventilators longer than with older viruses? Is it because of treatment for the infection?
A British-Canadian specialty physician expert in critical care wrote in the Spectator on April 4 that ventilators aren’t a panacea for severely ill patients with the new virus. He described the trauma of putting a patient on a ventilator in a short piece that is well worth reading.
In the piece, Dr. Matt Strauss explained that being on a ventilator means you can’t cough and you have to be sedated (made unconscious with drugs) in order to tolerate it. He said that when the lungs can’t exchange air due to disease that damages the tissue, the ventilator can only do so much. The lungs have to heal in order to get off the ventilator, and this takes a long time when infected with the new virus. The longer you are on a ventilator, the weaker you get from immobility (not being able to move). There is also direct ventilator-induced damage to the lungs. He said (this is also partially quoted in the Medscape piece), “It is therefore at least conceivable that putting patients on ventilators for Covid-19 pneumonia could be a bridge to nowhere.”
What is certain is that, if you are sick enough with COVID-19 to need mechanical ventilation, your chances of survival are less than 50/50. A curative drug is needed to speed up the lung’s recovery from infection with the virus, and no such drug is currently approved. Remdesivir is a promising drug that was developed for Ebola (where the prognosis is even worse) and it can be made quite cheaply (sorry, no reference for this, but one source said it could be made for $0.93 for a day’s dose). The early trial recently reported looked at 53 patients, more than half of whom were already on ventilators, and the results were hope-inducing (see previous post about this trial). Hydroxychloroquine (HCQ) has seen mixed reviews in clinical trials, succeeding in mild disease but not in severe cases (see previous post about the HCQ trials reported so far). I saw on TV this morning that a trial of the combination HCQ-azithromycin in Brazil had to be stopped because of cardiac toxicity.
The reports that have come out recently (see my previous posts) indicate that many, if not most, people who get COVID-19 have asymptomatic disease or mild cases. It is the small proportion (20% or less) who get severe disease that we need to worry about.
Coronavirus by Engin Akyurt via pixabay.com (open access)
A non-peer-reviewed study on the preprint server MedRxiv published March 30 examined a cohort of 175 patients who recovered from “mild” COVID-19 with blood tests for antibodies to SARS-COV-2. They found widely varying levels of neutralizing antibody (specific antibodies for the virus) with a correlation between age and levels. Older patients and those with higher levels of CRP (C-reactive protein, a measure of the severity of illness) had higher antibody levels (titers). Ten patients had undetectable antibody– no antibody was found; two patients had extremely high titers of antibody.
It appears that patients with more severe illness developed higher antibody titers. It is possible that the high levels of antibody may indicate more tissue damage from the infection. The authors also speculate that recovered patients with high antibody titers would be useful for obtaining serum to use in treatment of acutely ill patients.
isolation from Free-Photos courtesy of pixabay.com
This article from JAMA (Journal of the American Medical Association) Psychiatry discusses at length the looming mental health crisis we all face because of our isolation and unemployment due to the novel coronavirus. More than 20 million people (sorry, no reference for that number) have lost their jobs, and many of them are unable to access unemployment benefits because the state systems for registering have broken down. Going to the unemployment office in person is impossible, and reaching the office by phone or internet is impossible, so that extra $600 a week is just a fantasy extolled by politicians.
Facing financial ruin and unable to commiserate with our friends, many people will be driven to the brink of suicide by this pandemic. The physical toll in catastrophic illness and death will touch many older people, who would have been supported by their Social Security and retirement benefits if they had lived. But young people and black or brown people will be faced with extreme financial and mental stress, not physical illness. Coping mechanisms are vital to survival, and reaching out for help is necessary if you feel overwhelmed. There are hotlines, but who will answer now?
Then there are the people with pre-existing health conditions who develop COVID and are treated with disrespect: “I feel like you sent me home to die.” That’s what one patient told his doctor. I’m not a doctor anymore, thank heavens. I’m not sure I could treat all these stressed-out people with the calmness and reassurance that they need. Some people are so naive and helpless that they can’t think of the simplest thing and ask absurdly obvious questions that put the “clinician” (health care provider) on the spot.
The most bizarre result of this pandemic in the US is the largest increase in firearm sales ever– more than was provoked by the election of Barack Obama. Firearms are the most common method of suicide in the US, and despite a ban on research into firearm violence, it is apparent that easy access to a firearm is a risk factor for suicide.
A little-known bit of information: suicide rates in the Northern Hemisphere peak in late spring and early summer. This happens to be that season.
We need more access to mental health care, especially through “tele-health”– that is, over the phone or via internet and applications like Skype. There is no greater need than at this time.
The article referenced above lists the National Suicide Prevention Hotline at 800-273-TALK and claims that this line remains open. I was afraid to call it and check because I don’t need help right now. I hope it’s there when I need it.
photo courtesy of pixabay.com
A report in STATnews (statnews.com): Just when you thought Ebola virus was only a memory, two more cases were discovered. By the time they were ascertained (found) they had already died. These cases brought a stop to the hoped-for announcement of the end of the latest Ebola outbreak. This outbreak, which was in the Democratic Republic of the Congo in the provinces of North Kivu and Ituri, has killed at least 2,274 people out of 3,454 known to have been infected. It was the second-largest outbreak on record, and it is still not quite over.
The World Health Organization (WHO), the Congolese government, and its partners (unspecified), are still monitoring the situation in Congo. There is no excuse for the administration’s threat to end US funding for the WHO when things like this are still going on. The fickle and sociopathic, narcissistic insistence on fealty continues.
photo courtesy of PublicDomainPictures and pixabay.com
This letter published in the New England Journal of Medicine (NEJM) reinforces the previous reports that I have found in stating that the majority of people who are positive for SARS-CoV-2 are asymptomatic.
Here’s the nut of the story:
From March 22 to April 4, some 215 women delivered babies at a New York City health system. Of these, four had symptoms at admission and tested positive for SARS-CoV-2. Of the remaining 211 asymptomatic women, 210 had nasopharyngeal swabs taken, and 14% (29 women) were positive for SARS-CoV-2. Therefore, nearly 90% of women who were positive at admission were asymptomatic.
These reports are very reassuring. Most people who are infected have no symptoms. It is only people at high risk who develop symptoms and get really sick. A few will die. It is these patients who are of concern, and it is for them that we have to isolate. Despite being reassured about personal risk, I am convinced that it is necessary to keep people isolated until we find effective treatments and even then, to maintain precautions until everyone can be either vaccinated or proven to be immune by blood antibody testing.
(image courtesy of pixabay.com and Gerd Altmann)
A report on the blog “FiveThirtyEight” from April 4, written by Nate Silver (already famous for his political polling expertise), explains why the case counts for COVID-19, the disease caused by SARS-COV-2, vary so dramatically from country to country. More importantly, they explain why all case counts deeply underestimate the actual number of infections– by a rate of anywhere from double to a hundred times less.
The blog post is long and complex, but those of you with a statistical bent or who are comfortable with numbers will find it fascinating. It explains what goes into a case count and why those numbers lag behind actual cases anywhere from a few days to two weeks. There are many reasons, from lack of testing materials to political propaganda (in some cases), for this undercount.
Attempts to determine the final case fatality rate (CFR, the number of patients with infection who eventually die) will not be successful until the peak of the pandemic has long passed. It takes, usually, about five days (anywhere from two days to more than two weeks) from exposure to the time symptoms appear (if they appear) or an infection is established. Nasopharyngeal swab testing for the presence of viral RNA (the actual genome of the virus) is most likely to show positive results by day eight of infection, and may precede symptoms by up to 48 hours– that is, if symptoms ever appear. Tests at this time show about 75% of actual cases. Once the infection is established, it may take anywhere from 48 hours to three weeks before a patient succumbs (dies) from the virus. Not all deaths are recorded as being due to the virus: for example, in New York in late March, there were over five thousand excess deaths, but only half of these deaths were recorded as being due to the novel coronavirus. Many, if not most, sudden deaths at that time were assumed to be due to stroke or heart attack; if they occurred at home before medical care was sought, there may be a mystery as to what symptoms preceded the demise (death).
A single excess death, viewed alone, cannot not be ascribed to the virus unless testing is done. Evaluation of people already dead seemed like a waste of resources in light of the shortage of tests, but it impaired our ability to see the excess deaths as due to the virus. People have been found dead at home, in the subway, lying on the sidewalk under a pile of newspapers, and in other unlikely places. Handling people recently deceased from the virus could be hazardous to the health of first responders who are needed for many other things during this emergency.
Another issue which is never mentioned (except in Nate Silver’s blog post) is the false positive rate (the rate of positive tests when the patient does not actually have the disease). This rate is trivial for the RT-PCR test except when the total positive rate is very small. In cases of very rare disease, the false positive rate, even if very low, may overwhelm the true positive rate to such an extent that confirmatory tests are needed to establish actual disease. In such cases, with very rare diseases, a positive test must be considered a “suspected” case and lead to further investigation. False positives may overestimate disease prevalence (the rate of disease at any point in time) by as much as two hundred to one in cases of rare diseases such as acromegaly (abnormal bone enlargement due to high levels of growth hormone) and autoimmune disorders.
All these factors (excluding false positive rates, which are trivial in such a common disease) have led to an underestimation of the case counts and deaths related to SARS-COV-2. Despite these obvious factors, the conservative media has been pushing the conspiracy theory that deaths due to the virus have been grossly overestimated. This is obviously false, but it feeds into the conservative mind-set that believes that the whole pandemic is a Democratic hoax. Nothing could be further from the truth or more dangerous at this dangerous time.
Coronavirus by Engin Akyurt via pixabay.com (open access)
NIH announced on Friday that they are starting a clinical study and recruiting patients to determine the prevalence (overall number of people positive now) of blood antibodies to SARS-COV-2, the virus that causes COVID-19. They plan to recruit 10,000 people to participate in the study. They will conduct virtual (over the phone or Skype) clinic visits and send participants an at-home blood collection kit with a questionnaire. The micro-collection kit has been well studied, and NIH is confident that it will allow them to obtain blood samples from a finger-stick. These will be adequate to obtain both IgG (chronic) and IgM (acute) antibodies (blood proteins that fight infections).
I am excited about this study, in part because an email address was provided for people who want to participate. As I mentioned in a previous post, I have an hypothesis that I may have had an inapparent infection with the virus, contracted from my wife, who is still practicing as a PA. She works in a community clinic in a rural town outside of Fresno. In mid- to late-February, one of the MAs at the clinic came down with a cough. It turns out that her husband works “out of town” in the Bay Area, one of the local epicenters of infection. The whole clinic staff came down with similar, mild upper respiratory infections (colds or mild flu) and were mostly recovered by mid-March. This was before the state was locked down and before the virus was anything but a gleam in my eye.
image courtesy of Safa Tuncel (TuncelSafa06) thru pixabay.com
photo by Andrew Martin courtesy of pixabay.com
This article by NBC discusses the administration’s response to the novel coronavirus in all its gory details. It seems that the first son-in-law has been making personal contacts, reaching out to large companies with sources overseas, ignoring smaller companies that do all their manufacturing in the US, failing to show any transparency at all, un-necessarily contracting with private companies for airplane transportation of essential supplies when the Air Force could do the job just as well, and on and on. The article is quite long and attempts to be more informative rather than accusatory, but you’ll get the point that the response is late and confused, while relying on personal contacts instead of long-established government expertise.
Read it and weep.
photo courtesy of engin akyurt and pixabay.com
These tidbits have come from a wide search of recent literature on COVID-19 (coronavirus disease 2019) and its causative agent, SARS-COV-2 (severe acute respiratory syndrome-coronavirus 2).
First, you should have blood type O positive. Not easy to do, but if you can arrange to be born this way, that would be nice. There is an association in multiple surveys between type O blood and less COVID (sorry, no reference at hand but there are several available).
Second, any diseases that you may have, such as asthma, high blood pressure, diabetes, kidney insufficiency, coronary heart disease, in fact any disease at all, even if it’s only a genetic tendency about which you are completely unaware, you should not have. If you do have it, keep it under rigid control. Now is the time to lose that weight, get your blood sugar down, lower your blood pressure, and take long-term asthma control medications like topical corticosteroids (inhaled cortisone and/or cortisone nasal spray)– but don’t take oral cortisone or other potent anti-inflammatories, unless your doctor tells you to do so. This is common sense, and many studies show an association between chronic diseases and high mortality in COVID.
Third, if you have a vitamin D deficiency, or even think you might, you should take replacement doses of vitamin D3. This is available over-the-counter– unfortunately, the research on all-cause mortality (death for any reason) is not conclusive (yet) but it is clear that even large doses of vitamin D3 are not bad for you (I’m gonna get dissed for saying that, but so be it). Many people are low in D and don’t know it because it is still not routinely evaluated with the widely available blood test. I won’t recommend a specific dose of D3, but you can ask your nutritionist.
On the other hand, vitamin A is potentially toxic and has not been seen to have any benefit in severe COVID-19 (see the above-referenced study again). Multivitamins are fine, but they haven’t been shown to lengthen your life in general, so they’re optional unless you have a terrible diet already.
Fourth, you should be young at heart. Try singing, the song that is. You don’t have to be chronologically young (again, see the above-referenced study). A positive mental attitude will help you no matter what else is happening. You can still get sick, but having a good attitude and not being a pain in the neck will help others around you to rally to your side.
Finally, if you should have the misfortune to be exposed to a patient with COVID, try to make sure it’s a very light exposure. I’m speculating here, but the experience with many other infectious diseases (like smallpox) is that small exposures can lead to mildly symptomatic disease, while massive exposures can be overwhelming. This aspect of the new coronavirus has not yet been studied, which is not surprising given that the disease is only four months old.
Until a vaccine is widely available or we have a positive blood antibody test, it is incumbent upon us (we are obligated to) be careful and try to stay healthy in case we are exposed despite physically distancing ourselves from other susceptible people.
Conrad Theodore Seitz 