COVID-19 Conversation: Updates and meanderings

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Updates

Spain has had a major surge in Covid-19 numbers. India has more people locked down right now than any other country. Trump intends to “open up” the economy by Easter. Fortunately he is powerless to do so. The best available information suggests that Covid-19 is not mutating much, suggesting that once a vaccine is developed, it can work widely and be more effective.

Things are bad in Iran. According to Arash Karami, “Iran’s confirmed corona cases is now 27,017 with 2,077 deaths. In the last 24 hours there have been 2,206 new cases and 143 deaths. In total 43 doctors and nurses have died from corona.”

Yesterday, March 24, is the day Trump told us we would have zero cases of Covid-19 in the US. The actual number was 53,478.

I hear chest freezers are flying off the shelves.

Covid-19 is Partisan in the US

Example of the effects of social distancing on a symptomatic indicator of Covid-19, suggesting it is working well at least in some place.
The default behavior of the Covid-19 virus has almost the same pattern of spread and increase everywhere — exponential increase with a fairly high exponent, for a virus.

How different societies or regions attempt to “flatten the curve” seems to result in very different specific outcomes, but in several areas there has been real success.

It is probably true in the US that the federal response has been pretty much perfect, from the point of view of the Virus. Trump is treating Covid-19 much like he treats Putin. “What can I do for you, sir?” But fortunately, locally, it does not work that way.

Broadly speaking (with too few exceptions) Republican executives are literally supporting the virus in this manner. They want it to spike. Democratic executives are ordering serious responses and it is working to varying degrees. In states with Republican governors, Democratic (usually) mayors are responding despite what the Governors are saying, and that is working locally.

So, yes, Covid-19 response is partisan, and one of the parties is acting like a Death Panel determining that the aged, infirmed, and the less privileged be sacrificed for the benefit of the economy. The other party is trying to help. Republicans vs. Democrats.

The response in Congress is also partisan, but the Republican response is so awful that Democrats are winning out of sheer shame on Republicans. Plus at the moment, more Republcian Senators are down with the virus than are Democrats, so that seems to shift the balance of power.

In my own neighborhood, I’ve seen the Deplorable Housewives of Minnesota (yes, that is a thing) congregating in groups at the grocery store and loudly yammering about Nancy Pelosi and how she hates America, spreading viruses onto each other as they wander like a pack of hapless Gollumoids through the produce section.

(In the past the Senate Republican leadership has always been against remote voting. Now that it is in McConnell’s interest to have remote voting, expect his situational ethics to resituate.)

Bad News

The mother of NBA player Karl-Anthony Towns is very ill with Covid-19, as of this writing. Amy Klobuchar’s husband is in the hospital on O2 and quite ill. Minnesota’s Lt. Governor’s brother has died of complications of Covid-19. A minor youth in Los Angeles has died. Prince Charles has been diagnosed positive. There is a long list of famous people from Jackson Brown to Natalie Horner to Prince Albert II diagnosed. Terrence McNally dies of Covid-19. These folks happen to be famous, and the tends of thousands of non-famous victims do not exist on a lower plane. But having famous names across the spectrum of how people know them and what people think of them is, perhaps, to this pandemic what a set of really bad hurricanes is to climate change, if you get my drift.

Watching an interview with a former official from the Louisiana Health Department last night, we got two reminders. One is that Mardi Gras happened at just the right time and place to be a major incubator of the disease, and probably accounts for a lot of sick people. The number of cases in NOLA has skyrocketed. The other reminder: Official Atlantic Hurricane season starts June 1st, but actual hurricanes or tropical storms can show up in May. Gulf Coast and Eastern Seaboard hospitals and communities night have an interesting year.

Here is an interesting history of the N95 mask. An outtake:

In the fall of 1910, a plague broke out across Manchuria… “It’s apocalyptic. … It kills 100% of those infected, no one survives… within 24 to 48 hours of the first symptoms,” …

What followed was a scientific arms race, to deduce what was causing the plague and stop it. “Both Russia and China want to prove themselves worthy and scientific enough, because that would lead to a claim of sovereignty,” …

The Chinese Imperial Court brought in a doctor named Lien-teh Wu to head its efforts. … after conducting an autopsy on one of the victims, Wu determined that the plague was not spread by fleas, as many suspected, but through the air.

Expanding upon the surgery masks he’d seen in the West, Wu developed a heartier mask from gauze and cotton, which wrapped securely around one’s face and added several layers of cloth to filter inhalations. His invention was a breakthrough, but some doctors still doubted its efficacy.

“There’s a famous incident. He’s confronted by a famous old hand in the region, a French doctor [Gérald Mesny] . . . and Wu explains … his theory that plague is pneumonic and airborne,…and the French guy humiliates him . . . and in very racist terms says, ‘What can we expect from a Chinaman?’ And to prove this point, [Mesny] goes and attends the sick in a plague hospital without wearing Wu’s mask, and he dies in two days with plague.”

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20 thoughts on “COVID-19 Conversation: Updates and meanderings

  1. Re — the picture from Milwaukee. There are some astounding pictures from Chicago — downtown, Grant Park, etc. — that show the same thing, a seemingly empty city.

    Locally: hospitals here in Kalamazoo, in Grand Rapids, and U of M have put out calls for donations of masks and gloves and any other items people or businessess have, since they aren’t getting enough from the government. Friends in New York and Georgia are telling me the same thing.

    Do we need any more evidence that trump and his “team” are fucking up the response royally? No, but it keeps coming.

    1. Some of our local schools are sending the nitrile gloves they would be using in science classes to local health care facilities.

  2. In CA the recommended social distancing to reduce the spread of the bug is finally being taken seriously- in my area anyway.

    My 14 day quarantine ended today so it seems I am likely clear of the bug- but who knows without a few diagnostic tests that aren’t going to be available for a few weeks in the best case scenario for my area given my specific health profile.

    The last PSPS in our area was called off just before it was implemented last fall so we happened to have a few N95 masks that my wife and I have used when going out the last couple of weeks.

    A paper indicated there are ways to safely reuse the masks-

    “Effects of Ultraviolet Germicidal Irradiation (UVGI) on N95 Respirator Filtration Performance and Structural Integrity”

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699414/

    1. I would imagine masks could be made to be reused. I used to have reusable masks when working on furniture restoration. They weren’t very good (I think they were military surplus) but they could be dropped in the laundry. Basically, breathing in through felt and out through a rubber-ish check valve.

  3. There are several hundred [known] cases in South Africa, but I realize your remark about Sub-Saharan Africa is from Feb.

    1. Right. And, traditionally, at least in my experience, “sub Saharan Africa” does not include South Africa, if you are South African.

  4. A few meanderings from the (not very) United Kingdom:

    – Our rightwing government failed to act for weeks, issuing only ‘advice’ to stay at home.

    – Absent direct instruction to stay at home, avoid discretionary travel and milling around en mass in parks and street markets – oh, and going to the pub – lots of people did those things.

    – So when the inevitable spike in infections and deaths occurs, the government can (and will, betcha) blame the people rather than its own absence of clear direction on behaviour, enforced closure of businesses, etc.

    *****

    After many years of hollowing out the NHS, the rightwing Tory government (or perhaps Dominic Cummings) delayed action which could have prevented an overwhelming burden falling on the NHS. This could be seen – time will tell – as setting the NHS up to fail. Now why would anyone do that?

    It will be interesting to see if the NHS is subsequently privatised, with its ‘failure’ to cope with the CV epidemic as the reason – the ‘necessity’ – for selling it off to Trump.

    1. The “modern” right wing seems to have adopted reality denial as a core belief. If that only affected themselves I’s say “thinning out the herd” but, unfortunately their uninformed decisions affect others as well.

  5. I’ve been modelling Australia’s growth in cases for the last 10 days, and Im pretty certain that we had our point of inflection about 30 hours ago, from exponential to sigmoid. It’s a bit fraught trying to apply any sort of sigmoid-family curve to the data at this stage without access to both the finer details of contacts and movement of affected people, and to potential further mitigation measures, but a simplistic logistic eyeballing would suggest that Australia will start to plateau in about 2-3 weeks at around 4,500 cases give or take a few hundred.

    It’s good news in some ways, however the too-slow but ever-tightening control measures are hurting the economy and I fear a premature easing. And of course there may be enough momentum in the infection rate that the national capacity of the health system to respond may be exceeded, in which case there are going to be deadly choices to be made…

    If any good comes of this, it might be that the world finally confronts the need to similarly act with urgency (and earlier) on climate change. Oh, and to better prepare for the next few pandemics after COVID-19…

    1. I modeled things here (USA) with a simple SIR model. The results were clear: if we don’t continue with the steps we’re beginning to take as a nation, we’re royally fucked.

    2. Since I did the eyeballing last week I’ve pressed some non-logistic sigmoid fits to the Australian data: the assumption of a logistic curve’s symmetry around the point of inflection really can’t be defended in such a complex scenario, especially when we can’t apply China’s draconian control measures to our own society.

      At the moment models with floating points of inflection aren’t easily able to come up with a credible fit. A Gompertz curve (my preferrred for terrestrial poikilothermic vertebrates) still whips around like a firehose with just a few dozen cases added to a daily update, but overall there seems to be an indication with the passing of days that we’ll land somewhere between 20-40 thousand cases between the beginning and end of June, before we approach a plateau. Not great, but at least it’s not in the hundreds of thousands or the millions. Still, if our government had acted with greater alacrity the number might have otherwise been half of what will be realised.

      I’ll try a Richard’s fit soon, to see if that can project further with greater accuracy.

      One thing that has concerned me is that media commentators are quoting mortality by dividing the total number of deaths by the latest tally of infections. Given that a mortailty rate based on deaths realised to date should be predicated on the number of infections at the time that the deceased contracted their infections, the denominator should probably be the number of cases 7-10 days prior to the latest death count. On this basis Australia can expect 1-2% mortality – so somewhere between 200 to 800 dead based on the weekend’s rubbery projections. I’m just glad that it’s not the US’s death toll, which is already screaming upward past ten times that ball-park…

    3. Dean, I’m curious about how you arrived at a figure for the proportion of susceptible individuals…

    4. So further update. The sigmoid plots are converging to a final Australian tally of around (and very possibly below) 10,000 cases at plateau. The measures taken by the government are now clearly manifesting ever more strongly in the daily data. I would reiterate that if they hadn’t dithered for several weeks we’d see even less, but when I look at the mess that is the USA I am glad that I live in a First World country and not an authoritarian wannabe dictatorship run by an ignorant group of incompetents and narcissistic sociopaths…

  6. “Dean, I’m curious about how you arrived at a figure for the proportion of susceptible individuals…”

    Short answer — I didn’t start with one. I modeled based on raw figures, not proportions, and let the solver estimate the rates of movement between the three populations from that.

    I used the number of recorded USA cases from early Feb through the second week of March as my initial data. Did the solving in R (the statistics software) with the deSolve library.

    I haven’t had time to go back and update with latest numbers — going to all classes online takes a bit more time.

  7. Bernard and Dean – thank you for your informative discussion about the mathematical modeling; very much appreciated.

    ON ANOTHER ISSUE: The Renin-Angiotensin System as it Affects Pulmonary Function and Covid-19 Outcomes

    A very hot topic of current medical discussion is the interaction of ACE2 receptors in the lungs with SARS-CoV-2 virions. There is an exploding debate in the best – but (as with all-things -Covid-19, not yet peer-reviewed) – medical literature on this. Some of this literature is new; but much has been peer-reviewed, stemming from the 2002 SARS-CoV-1 pandemic of 2003.

    “The renin–angiotensin system (RAS), or renin–angiotensin–aldosterone system (RAAS) is a hormone system that regulates blood pressure and fluid and electrolyte balance, as well as systemic vascular resistance” – https://en.wikipedia.org/wiki/Renin–angiotensin_system

    However, the RAS system does far more than play around with your kidneys. It’s a major protagonist with respect to the immune system; it has even been hypothesized that it plays a role in the relative resistance of children to serious Covid-19 disease.

    Several Lancet reports from the Wuhan doctors are, to me, very convincing – hypertension patients on ACEIs or ARBs in the ICU fared far worse, with respect to serious morbidity and mortality, than other, age-matched cohorts.

    I’m not a medical doctor, and the only times I play one is when triaging and treating myself. So I’m not qualified to give any medical advice; to do so would be both pretentious and unethical.

    However, if you (or anyone you care about is on one of these medications), ask your PCP (or cardiologist or nephrologist of infectious disease doc, if you have one) for personally tailored advice.

    Currently, these three sources should give you a sense of the poles – though not the messy in-betweens – concerning positions taken vis-à-vis this intensifying controversy:

    https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19

    versus

    https://academic.oup.com/jtm/advance-article/doi/10.1093/jtm/taaa041/5809509

    versus

    • https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa235/5810479

    Keep in mind, official policy recommendations, such as that of the American College of Cardiology, always lag behind the data. So consider yourselves fortunate indeed if can keep up with the most current science and evaluate your best course of action.

    A very personal note: I am the furthest thing possible from a neutral observer. I am at major risk of dying from Covid-19 should I become sick. Not only because of so-called “pre-existing conditions” [Is not life itself, by definition, a ‘pre-existing CONDITION for us all?], but also hypertension that is well controlled with valsartan (an ARB) and three (!) other medications. I have been resuscitated and served extended time on an ICU ventilator – several times. (Spoiler alert: NOT the most enjoyable four-week ‘vacation’!!!).

    My hopefully well-informed personal decision has been to discontinue my ARB. I will increase the dosages of my other BP meds, as I deem empirically advisable, until this pandemic either kills me. or subsides.

  8. COVID-19 ON THE BRAIN

    In a much earlier comment, I said that we should be skeptical of reports that loss of smell or taste are symptoms of Covid-19: Maybe these symptoms, also characteristic of the common cold, should be taken with a grain of salt? But I also raised the possibility of olfactory bulb compromise and, hence, CNS involvement.

    Now this:

    NEUROLOGICAL COMPLICATIONS OF CORONAVIRUS INFECTIONS
    Avindra Nath, MD
    NIH–NINDS

    Preprint – Neurology (March 30, 2020)

    https://www.medpagetoday.com/infectiousdisease/covid19/85746?xid=nl_popmed_2020-04-02&eun=g1138744d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=CoronaBreak_040220&utm_term=NL_Daily_Breaking_News_Active

    https://n.neurology.org/content/neurology/early/2020/03/27/WNL.0000000000009455.full.pdf  –

    “In 1896, Sir William Osler said, “humanity has but three great enemies, fever, famine and war; of these by far the greatest, by far the most terrible, is fever”. This rings true even today. The newly emerged SARS-CoV2 virus has stricken fear and panic amongst the public, health care workers, patients, politicians and financial markets. Fear strikes the minds of the unprepared. So we must ask ourselves why have we been caught by surprise? In the recent past there have been many major epidemics. This includes Ebola, Zika, Dengue, Chikungunya, acute flaccid myelitis and H1N1 influenza, to name a few. But SARS-CoV2 is different. It struck home! And so very rapidly. It emerged in the region of Wuhan in China around December last year and by March every State in the United States and over a hundred countries have reported cases of the infection with deaths in all the adult age groups. The predictions are dire. The entire healthcare system could potentially be overwhelmed and could crumble. Signs of that are already evident in New York and Washington State. Grocery stores have empty shelves, pharmacies are running out of critical medications and there is scarcity of personal protection equipment and ventilators.”

    “The major clinical manifestations of the SARS-CoV2 infection are due to pulmonary complications. While most have mild symptoms, such as fever, headache, cough, dyspnea, myalgia and anosmia, some develop acute respiratory distress syndrome about a week into the illness which can result in death. Rhabdomyolysis can be a late complication of the infection. The mortality rate is about 3-4%. Terminally, patients go into coma which is thought to be due to hypoxia or multi-organ failure. But many unanswered questions remain. Could the headache be symbolic of viral meningitis? There is a report of detection of the virus in CSF of one patient (www.encephalitis.info/blog/coronavirus). Does anosmia suggest involvement of the olfactory bulbs? In mouse models of coronavirus encephalitis, the virus can enter the brain trans-neuronally through the olfactory pathways. Hence this relatively innocuous symptom could be indicative of a potentially more serious complication. Can the respiratory syndrome be due to brainstem involvement? Brain imaging and pathological evaluation of the brain are necessary to understand the full impact of the virus. The elderly and immunocompromised patients are particularly vulnerable. Many have underlying neurological comorbidities. Hypertension and diabetes seem to stand out as the most common comorbidities in patients with more severe manifestations of the infection. An interesting hypothesis has emerged around the use of angiotensin converting enzyme (ACE) inhibitors to treat hypertension and diabetes to explain this phenomenon. ACE2 is the receptor for SARS-CoV2. The use of ACE inhibitors leads to increased expression of ACE2 making the cells more vulnerable to infection with the virus. Clinical studies are underway to test this hypothesis. ACE2 can be found on endothelial cells in the brain and can be induced in neurons raising the possibility that strokes associated with SARS-CoV2 might be directly related to the infection and encephalitis could be a potential complication.”

    “There are several human coronaviruses. Most cause mild respiratory symptoms and resolve. However, in recent years, new coronaviruses have jumped species and infected humans with devastating consequences. Several acute neurological syndromes have been associated with coronaviruses (Table). SARS-CoV1 has been detected in the CSF of a patient with encephalitis and acute respiratory distress syndrome. MERS-CoV can cause a severe acute disseminated encephalomyelitis and a vasculopathy. A post-infectious brainstem encephalitis and Guillain-Barré syndrome has also been described. HCoV- OC43 can also cause an acute disseminated encephalomyelitis with lesions scattered throughout the brain, cerebellum and spinal cord. Immunocompromised individuals are particularly vulnerable. A fatal encephalitis can occur in immunocompromised patients with HCoV-OV43. In these patients, infection of neurons has been demonstrated at autopsy. A similar concern has been raised with SARS-CoV2. Many patients with autoimmune syndromes such as multiple sclerosis, myasthenia gravis, neuromyelitis optica or sarcoidosis are on a wide variety of immunosuppressive therapies. Drugs that cause systemic immune suppression wound be of concern. It might be prudent for such patients to take extra precautions to prevent exposure to the virus and to re-evaluate the dosages of the medications. However, it may not be advisable to take them off treatment since the underlying illness will surely re-emerge causing serve manifestations in many. With restrictions on travel being imposed and all elective patient appointments being cancelled, there is an urgent cry for teleneurology as a substitute for face to face interactions with patients. However, to make this work, we need to develop a centralized system to license physicians in the entire country and not in each state individually.”

    “Seropositivity for coronaviruses has been reported in a variety of neurological disorders which includes encephalitis, optic neuritis, multiple sclerosis and Parkinson’s disease. Virus has also been isolated from CSF and brain of patients with multiple sclerosis. Viruses implicated include HCoV-229E, HCoV- 293 and HCoV-OC43. But the significance of these findings is not clear since these viruses are very prevalent and their causative role in these diseases has not been established.

    “In the past century, we have made tremendous progress in the prevention, diagnosis and treatment of diseases. We can dissolve clots in the carotids, we can fix mutated genes before they can cause harm and we can image the brain and its networks with exquisite precision, yet we have been brought down to our knees by the tiniest of organisms; about 60 nanometers in size. We need to retool and rethink how we train physicians in the practice of neurology and physician scientists in the academic neurology, how we prioritize drug development for neurological diseases and we need to enable academia and pharma to develop treatments not based on profits but rather on costs to humanity. While we all recognize the hundreds of viruses that can cause encephalitis and result in devastation to large populations, we have no treatment for any of these organisms except for herpes encephalitis. It is time for us to recognize that we are facing a crisis in neurology. The time to take action is now. “

    —————
    • As I commented directly above – I’ve stopped MY angiotensin-receptor blocking medication. This is just more justification – f••k the American College of Cardiology.

    • Okay, notwithstanding the fact that some of us are self-isolating and/or running around in a panic – and will probably be dead soon – you’ll have to admit:

    • This is an utterly fascinating disease. What a cool time to be a YOUNG research neuroimmunologist or pathologist …

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