SARS-CoV-2; CoVID-19; Coronavirus; Updates and Information

Re re-opening the economy, is 100% mask adherence in public both necessary and sufficient?

I don't really get the reliance on mass testing in the US at this late date. All tests have some rate of false negative (and false positive). 100% mask wearing has no false results.

Obviously the virus will still spread but it will do that no matter what. Would copious quantities of masks and Purell® limit the numbers to what our US health system can deal with?

If not then we either stay shelter-in-place for a long while, or open up in May, blow up the infection curve in some new states, and repeat the lockdown. Possibly more than once.

@Baal

Well, I've read a lot about "Early Versus Late Intubation".

Recently amongst our leading anesthesiologists a dispute started what is the meaning of Early and Late.
Their statement is that there is no "early and late", but only Proper, while "early and late" means $earlyer or later than proper".
But in some articles I've read different statements, even something like "standards" about when to use Early and when to use Late intubation.

Can you please clarify the matter and please give some links, if available, where the exact meaning is described.

Thank you

I'll try to do some reading and see if I can at least clarify what the issues are maybe why people disagree. Right now I cant provide any insight at all, u fortunately. I think that pasifid or Dr Evil could weigh in once they can get some time, they would know a lot more than I do about a clinical procedure like that.

Edit. I really cant find much in the literature on this. I'll keep trying.

Brs said:

Re re-opening the economy, is 100% mask adherence in public both necessary and sufficient?

I don't really get the reliance on mass testing in the US at this late date. All tests have some rate of false negative (and false positive). 100% mask wearing has no false results.

Obviously the virus will still spread but it will do that no matter what. Would copious quantities of masks and Purell® limit the numbers to what our US health system can deal with?

If not then we either stay shelter-in-place for a long while, or open up in May, blow up the infection curve in some new states, and repeat the lockdown. Possibly more than once.

Click to expand...

One thing about Hong Kong, Singapore and Taiwan is people wear masks. Their outcomes have been better.

Here people cant even get them.

But it would make me feel more secure personally.

langel said:

@Baal

Well, I've read a lot about "Early Versus Late Intubation".

Recently amongst our leading anesthesiologists a dispute started what is the meaning of Early and Late.
Their statement is that there is no "early and late", but only Proper, while "early and late" means $earlyer or later than proper".
But in some articles I've read different statements, even something like "standards" about when to use Early and when to use Late intubation.

Can you please clarify the matter and please give some links, if available, where the exact meaning is described.

Thank you

Click to expand...

Not an expert. From my long ago days in med school and residency: Sometimes it's not clear whether a patient needs to be intubated. Then you can either intubate ("early"), or give the patient a chance to breathe on their own. If intubation becomes necessary then you do it ("late"). Studies in some contexts like COPD have shown what you might expect, that if a patient will eventually need to be intubated, better to do it early. And so doctors have come up with various algorithms to try to predict which patients will eventually need intubation. Given the amount of data collected in a typical ICU, this sounds like a job for artificial intelligence. Maybe it is already in some places, not sure. Do they have a standard algorithm for COVID-19 patients? Probably not yet, but no doubt this discussion is taking place every day in hospitals all over the world.

Dr Evil said:

Not an expert. From my long ago days in med school and residency: Sometimes it's not clear whether a patient needs to be intubated. Then you can either intubate ("early"), or give the patient a chance to breathe on their own. If intubation becomes necessary then you do it ("late"). Studies in some contexts like COPD have shown what you might expect, that if a patient will eventually need to be intubated, better to do it early. And so doctors have come up with various algorithms to try to predict which patients will eventually need intubation. Given the amount of data collected in a typical ICU, this sounds like a job for artificial intelligence. Maybe it is already in some places, not sure. Do they have a standard algorithm for COVID-19 patients? Probably not yet, but no doubt this discussion is taking place every day in hospitals all over the world.

Click to expand...

Thank you.
And yes, its a great discussion here too.
But here the anesthesiologists put the accent on the meaning of "early and late".
Because we have different words for Early as "early in the morning" and Early as "untimely early",
and different words for Late as "late in the evening" and "I'm sorry to be late".
So they think of Early and Late to be both untimely.
And for me that's strange, because in all materials on the matter I find Early and Late with a meaninig of "early in the morning and late in the evening".

This is a seminar from Tong Zhaohui, VP of Beijing Chaoyang Hospital, top Chinese expert in respiratory diseases and critical medicine, talking about the intubation for severe COVID patients. He went to Wuhan on Jan 18, still in Wuhan now and won't return to Beijing until most COVID ICU wards are out of use.
http://zhishifenzi.com/depth/depth/8589.html


Impossible to translate the whole video, you can look through the terms and numbers in the slides (I'll try to summarize his points below to address your questions about intubation). Some of the contents were translated in this English report.
http://www.china.org.cn/china/2020-03/30/content_75877166.htm


Tong Zhaohui suggested for ARDS patients, late intubation is with poor prognosis.
Intubation timing:
If PaO2/FiO2<150 mmHg after 2h of non-invasive ventilation with high O2, intubation should be applied immediately.


ECMO timing:
At the optimal ventilation conditions (FiO2≥0.8， tidal volume 6 ml/kg，PEEP≥10 cmH2O), if any of the following criteria is met, ECMO should be conducted if possible.
(1)PaO2/FiO2 <50 mmHg, over 3h
(2)PaO2/FiO2 <80 mmHg, over 6h
(3)FiO2=1.0, PaO2/FiO2 < 100 mmHg
(4)arterial blood pH<7.25 AND PaCO2>60 mmHg, over 6h, and >35 breaths/min
(5)>35 breaths/min, arterial blood <7.2 AND plateau pressure>30 cmH2O
(6)severe air-leak syndromes
(7)co-occurring cardiac shock and arrest


He also discussed about other interventions for patients on ventilators and ECMO, such as sedation/muscle relaxants, vasoconstriction, deep vein thrombosis prevention, nutrient supplies.


For my understanding, a guideline/protocol really depends on the capacity and resources of a healthcare system/hospital at the moment. In Jiangsu where COVID was not hard hit, doctors even did lung transplantation for critically ill patients whose lungs were largely damaged by COVID and the transplantation worked well. It is almost impossible for the hard-hit regions to do so where ventilators and ECMOs are in short, where patients of old age and with underlying diseases are on the bottom list of ECMOs. That's why I asked earlier about DNR/DNI. In China, it is not as common as in Western countries. According to Tong Zhaohui's ECMO criteria, if a severe COVID patient got cardiac arrest, ECMO would be considered in China. If the patient signed DNR (not likely in China but more likely in West), what would the doctor do?

langel said:

Thank you.
And yes, its a great discussion here too.
But here the anesthesiologists put the accent on the meaning of "early and late".
Because we have different words for Early as "early in the morning" and Early as "untimely early",
and different words for Late as "late in the evening" and "I'm sorry to be late".
So they think of Early and Late to be both untimely.
And for me that's strange, because in all materials on the matter I find Early and Late with a meaninig of "early in the morning and late in the evening".

Click to expand...

A good study below. It’s what a lot of us Have been suspecting
==========================================

https://www.medrxiv.org/content/10.1101/2020.04.02.20051524v2
“Evidence that higher temperatures are associated with lower incidence of COVID-19 in pandemic state, cumulative cases reported up to March 27, 2020”


Abstract

Seasonal temperature variation may impact the trajectories of COVID-19 in different global regions. Cumulative data reported by the World Health Organization, for dates up to March 27, 20201, show association between COVID-19 incidence and regions at or above 30° latitude. Historic climate data also show significant reduction of case rates with mean maximum temperature above approximately 22.5 degrees Celsius. Variance at the local level, however, could not be well explained by geography and temperature. These preliminary findings support continued countermeasures and study of SARS-CoV-2/COVID-19 transmission rates by temperature and humidity.

Free bird said:

A good study below. It’s what a lot of us Have been suspecting
==========================================

https://www.medrxiv.org/content/10.1101/2020.04.02.20051524v2
“Evidence that higher temperatures are associated with lower incidence of COVID-19 in pandemic state, cumulative cases reported up to March 27, 2020”
View attachment 21184

Abstract

Seasonal temperature variation may impact the trajectories of COVID-19 in different global regions. Cumulative data reported by the World Health Organization, for dates up to March 27, 20201, show association between COVID-19 incidence and regions at or above 30° latitude. Historic climate data also show significant reduction of case rates with mean maximum temperature above approximately 22.5 degrees Celsius. Variance at the local level, however, could not be well explained by geography and temperature. These preliminary findings support continued countermeasures and study of SARS-CoV-2/COVID-19 transmission rates by temperature and humidity.

Click to expand...

I really hope this is true! There are lots if reasons to think it will be. But there are a lot of parameters going on at once. That would certainly be a good thing where I live. Soon it will be a steady furnace (we've already had a few days around 90 F).

It's nice to be positive but confirmed cases in Singapore, which is located way below the 30° latitude as covered in the above study, have been climbing like a rocket launch, over 3200 as of this writing. The experts here have been debating the past few days how SARS-CoV-2 can withstand the heat unlike SARS-CoV.

20/4/14
Coronavirus: Mandatory for all in Singapore to wear mask when out, except for kids under 2 and those doing strenuous exercise
https://www.straitstimes.com/singap...when-out-with-exceptions-for-kids-under-2-and

https://www.bloomberg.com/news/arti...r-singapore-shows-early-social-distance-works

Singapore took a different approach, leaving schools and government offices open. Prime Minister Lee Hsien Loong advised that healthy people don’t need to wear masks, in part because it could give a false sense of security while precautions such as washing hands regularly are more effective.

In the early days of the outbreak, this calm approach by Singapore’s leaders won global praise. But the guidance to limit mask-wearing -- then in line with what the World Health Organization suggested -- has since been reconsidered given how infected people with no outward signs of illness can still spread the virus. Singapore now advises that wearing a reusable mask could provide some basic protection.

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Even scarier is the size of that second wave.

The problem with this particular model is that it depends heavily on accuracy of case rate data, which is not uniformly accurate as it depends on how many people are tested in places at a particular mean maximum temperature. For example, testing in the US is a huge limiting factor, and is not even uniform within the US. And in the case of SARS, experts have pointed out that the decline of cases in spring and summer coincided not just with temperature, but also with onst of more effective public health efforts, such as social distancing ( studies from Harvard School of Public Health). Finally, assuming this model reflects reality, it also would correlate with average day length and therefore, most likely, with circulating levels of active forms of vitamin D in various populations.

Earlier when I did some reading on this (and it's not my area) the prevailing view in the literature is that seasonality of viral infections is common, different viruses peak at different times, but that the mechanisms are almost always unknown, and are extremely difficult to study. Temperature is just one of many factors, although intuitively and biochemically it makes sense for respiratory viruses spread in the air and deposited on surfaces.

High temperature helps but that doesn’t mean high temperature alone will end the pandemic. Actually what have happened in Singapore should be a wake up call to policy makers in US who may want to Open too aggressively.

One thing, us the increase in Singapore real, or have they just been doing more testing?

We dont know for sure if its temperature or even that it has anything to do with the virus as opposed to people's susceptibility. Again, that is an important point. Biochemically the virus is less stable on surfaces at higher temperatures. But how big of an effect is it? Is is not known for sure.

Marc Lipsitch, DPhil, Professor of Epidemiology and Director of the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health, is skeptical that warmer weather will put the brakes on COVID-19. “While we may expect modest declines in the contagiousness of SARS-CoV-2 in warmer, wetter weather, and perhaps with the closing of schools in temperate regions of the Northern Hemisphere, it is not reasonable to expect these declines alone to slow transmission enough to make a big dent,” he wrote in a commentary for the center.

How should pathologists and clinical laboratories in this country prepare for COVID-19? Lipsitch wrote that Influenza does tend to be seasonal, in part because cold, dry air is highly conducive to flu transmission. However, “for coronaviruses, the relevance of this factor is unknown.” And “new viruses have a temporary but important advantage—few or no individuals in the population are immune to them,” which means they are not as susceptible to the factors that constrain older viruses in warmer, more humid months.

So, we may not yet know enough to adequately prepare for what’s coming. Nevertheless, monitoring the rapidly changing data on COVID-19 should be part of every lab’s daily agenda.

My guess (unproven, of course) is that besides high temperature another factor that can contribute to reduction of Covid-19 cases is how immune nations below the 30th latitude have developed over time. Singapore folks as being in a richer country may not have developed immunity level like folks in Laos, Cambodia, Vietnam, India where poorer living conditions may strengthen their immunity. Of course much restrictive measures to stop the spreading help a lot. In case of Vietnam they will by force take away anyone who they suspect infected with the virus. In a country where access to medicine is many levels below US, there is zero death cases. Is that due to stronger immune system? I am not sure I believe their data but this is still something to think about.

I don't buy the ideas that COVID will magically settle down when the summer comes in the northern hemisphere or the tropical regions get less affected by COVID. For those who work or stay indoors most of the time, hot weather outside does not make a difference and central AC may make things even worse.
For an infectious disease, old textbook says: identify and isolate the infected, cut off the transmission chain, gain immunity by infection or vaccination. SARS-CoV-2 is very challenging as it is not easy to identify the infected (mild or no symptoms), it is not ethical to get people naturally infected with such a high mortality, no vaccine will be available within months. But still we can do sth, like one can self isolate for enough time till symptoms-free even one just got a common cold at first, one can wear masks in the crowds, and more importantly, experts had better not take any chances in order to please political leaders or to save economy.
I've mentioned a friend of mine got COVID in NYC. He got discharged from hospital without RNA testing (hospitalized for 10 days, receiving oxygen and HCQ); his fever was gone but he was not fully recovered from pneumonia. He was taken off no-fly list early this week and he flew to west coast. If I were him, I would self isolate in NYC for another 2 weeks to take no chance to infect others. He was not told to do so by the doctors and I don't blame him for his choice.

In Vietnam, as there are very few infected cases compared to the rest of the world and zero deaths one theory is that a large population (older generation) already took smallpox and tuberculosis vaccines when they were young thus may already develop immunization against the Covid-19 (I still have scars from those shots) What do you think?

No, unfortunately. Immunity to smallpox, influenza, chickenpox, measles, polio, TB, etc.etc. will not make you immune to coronavirus. Previous exposure to some other coronavirus MIGHT help a very little if they have a few similar antigenic sites in the S-proteins. Most people in the world receive those vaccines, unfortunately fewer than in the past in the US. Low cases in Vietnam could be due to early shutting off of the country, effective social distancing, lots of masks, underreporting or the government is lying, or some combination of those things. I dont actually know what they have done there.

Edit added in response to rain's post directly below. I maybe shouldnt be so categorical, it could be there are a few antigens in those vaccines also found in Covid-19. But I would need a lot of direct evidence before I believed it. I have not actually seen any but maybe I'm just not looking in the right place.

It has been speculated that broad BCG vaccination after birth helps certain countries against COVID. There are now several clinical trials across the globe testing whether BCG vaccination on front line healthcare workers protects them from COVID. I don't think it hurts to take such shot, as well as thymosin, interferon alpha shot, to boost immune system for the front line or essential workers. But when one gets COVID, boosted immune system can be a double-edged sword. Better not get infected at the first place (more PPE please)!


COVID hit USS Theodore Roosevelt pretty hard and I read something like the sailors were exposed to COVID in Vietnam, in a hotel with some UK tourists who were infected. I am curious if that's the real case and how Vietnam dealt with people who interacted with US sailors. Did they get tracked and tested?

One way to evaluate the outbreak/containment situation in a region is from the # and % of the infected people travelling/evacuating from that region. This approach was used by many to estimate the outbreak in Wuhan. We now can use the same approach for other regions. On 3/29, China reported 1 (very likely the 1st) travel-related case from Vietnam when Vietnam reported 194 cases and by 4/13, China reported no more travel-related case from Vietnam when Vietnam reported 265 cases. In comparison, by 3/17 China reported 4 travel-related cases from Philippines when Philippines reported 169 cases. By 3/27, China reported 37 travel-related cases from Philippines when Philippines reported 803 cases. By 4/13, China reported 43 travel-related cases from Philippines when Philippines reported 4932 cases. Since late Mar, China has been doing RNA tests and mandatory 14-day quarantine on everyone who enters China. The above numbers suggest that Vietnam has a better situation containing COVID compared to Philippines; and Philippines is improving but may still undertested. Of course flight numbers and frequency, travel screening/ban policies, travel purposes should be considered to interpret the info from travel-related cases.


Guess what, by 4/13, China reported 1464 travel-related cases, the ranks are not the same as the countries with most cases! 510 from Russia, 296 from UK, 159 from US, 89 from Spain, 85 from France, 53 from Italy, 48 from Iran and 43 from Philippines. 20ish were from Germany (I haven't found the exact number), much fewer compared to other countries with most cases, suggesting an effective containment there. By 3/17, China reported 47 travel-related cases from Iran and 1 more case for 4 weeks suggested an effective containment recently. And Russia is very concerning.

langel said:

@Baal

Well, I've read a lot about "Early Versus Late Intubation".

Recently amongst our leading anesthesiologists a dispute started what is the meaning of Early and Late.
Their statement is that there is no "early and late", but only Proper, while "early and late" means $earlyer or later than proper".
But in some articles I've read different statements, even something like "standards" about when to use Early and when to use Late intubation.

Can you please clarify the matter and please give some links, if available, where the exact meaning is described.

Thank you

Click to expand...

Ok, apparently this is an issue all over the world. ICU specialists are starting to think that Covid-19 does not behave exactly like Acute Respiratory Distress Syndrome, and intubateing patients earlier in the course of the disease (as was recommended originally in China) may be leading to worse outcomes.

Nothing teaches as well as experience and real data.

I found this lay summary of what experts are thinking now:

In recent days, intensive care specialists have questioned whether standard respiratory therapy protocols for Acute Respiratory Distress Syndrome (ARDS) in the management of patients with COVID-19 is really the optimal solution for all, at least on initial presentation to hospital.

The discussion rests on the findings, both data-driven and anecdotal, that suggest understanding of COVID-19 physiology may differ from that originally thought. Medscape Medical News reported on a letter published in the March 30th edition of the American Journal of Respiratory and Critical Care Medicine by Dr Luciano Gattinoni of the Medical University of Göttingen in Germany, which made the case that protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good.

Dr Gattinoni noted that COVID-19 patients in intensive care units (ICUs) in Northern Italy had an atypical ARDS presentation with severe hypoxaemia and well-preserved lung gas volume. He and his colleagues suggest that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation, practicing patience to "buy time with minimum additional damage".

​It is possible thathat the mechanical veventilator is addiadding further damage to the alveoli.

passifid said:

it's hard to tell because beds =/= ventilators. but lets hope for the best

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in Sweden the number of ICU beds is very low, 5.8 per 100k, (in Italy it's TWICE as much, and Germany has more than FIVE times with 34 per 100k). So naturally it's the same with ICU doctors. The number of ventilators is tiny 570 units. Sorry, but that doesn't sound good.