Coronavirus Update

—Been a busy week in coronavirus, and I am not going to be able to capture everything.  I will try to hit what I consider to be the main points.

—Italy’s cases have taken off, and included spread to at least Spain, Germany, Austria, France and the Middle East.  Thus far, the EU has stuck to its visa-free internal travel agreement, and NOT halted travel from Italy.  This will guarantee significant additional outbreaks in the EU.

—Italy has closed much of northern Italy, canceling or postponing major sporting and cultural events.  China and South Korea have closed all schools nationwide (this despite China’s “falling” case numbers—watch what they do, not what they say).  South Korea and Japan continue to close businesses and cancel major cultural and sporting events.  US soldiers in South Korea have confirmed cases and joint exercises with the South Koreans have been canceled.  

—More cases in the Middle East, Iran particularly, have canceled Friday prayers in Tehran (kind of a big deal) and Saudi Arabia has closed the hajj to foreign pilgrims (a very big deal—the trip to the holy sites of Islam is a once in a lifetime -obligation- for the Muslim devout).  The WHO can mince words all it wants—this is a pandemic.

—Norway, Finland and Bahrain all have cases.  Spread within Bahrain and the UAE in particular leads me to believe that “summer will slow/stop the spread due to the warmer temperatures” may be overly optimistic.  Cold may also not be especially protective.

—There are multiple reports, of uncertain credibility, that patients can be re-infected.  Even if the vaccine announced by Moderna makes it into human testing in April, with readout by late this summer, re-infection and incomplete immunity, if true, raise the hurdle for that vaccine. 

—Cases have now been reported on every continent except Antarctica.  If this were a game of “Plague, Inc”, the virus would be only confirmed cases in Madagascar and Greenland (especially) away from being able to make a major push for the “win” (you play as a pathogenic virus/bacteria/fungus in that game and win by infecting all of humanity—and yes, you can play as a virus that creates a zombie outbreak.  Beyond that, its epidemiological modeling is top notch, and it’s available in the Apple App Store).

—Response has been schizophrenic, from the WHO to many countries.  I will highlight just the US to illustrate.  You have President Trump, claiming that frenzy over a “flu” is being weaponized against him, and stating that cases in the US will be “zero” soon.  [Narrator:  “That claim turned out to be inaccurate.”]  In the same press conference, you have the CDC (who, in my opinion, have been the only adults in the room so far) stating that containment and preventing spread to the US have failed and they are shifting to pandemic flu guidelines and warning all Americans to be prepared for community outbreaks across the nation.  Sure enough, as the press conference was going on, 83 people in Long Island were being quarantined for suspected Covid-19 and UC Davis confirmed that someone on a ventilator for the past 9 days!!!!!!! finally got tested by CDC over CDC’s objections (no known connection to China) and sure enough has Covid-19.  

—That is now being investigated as “community spread” of Covid-19 in Solano County, California.  That dude caught the disease probably 2-3 weeks ago.  

—Then today, of 8400 under surveillance in California, 28 and counting are positive for Covid-19.  No details yet about if they are connected to Solano County, or where in the state they are.  Rumors are that is actually 33, and 5 positives left the state.  No word on where any of the 28 are in California, let alone the 5 who may have left Cali.

—YOU CAN ABSOLUTELY ASSUME THERE ARE -AT LEAST- 5 PEOPLE IN SOLANO COUNTY WHO ARE COVID-19 POSITIVE IN THAT TIME SPAN, AND THAT NUMBER HAS PROBABLY BEEN INCREASING.  IN FACT, I WOULD BET ON A 100+ ACTIVE CASES IN CALIFORNIA RIGHT NOW–INCLUDING PATIENTS WITH ONLY MILD DISEASE WHO MAY NOT KNOW THEY HAVE IT OR HAVE BEEN EXPOSED TO IT.

—For extra fun, the level of infectious disease prevention was not adequate during the first part of that patient’s trip to the ICU to prevent healthcare workers at UC Davis from having been exposed to coronavirus, and a bunch of them are now being monitored.

—IF YOU LIVE IN OR NEAR SOLANO COUNTY, -I- WOULD BE SERIOUSLY THINKING ABOUT GOING MASKS UP.  IF YOU LIVE IN CALIFORNIA GENERALLY, START THINKING ABOUT IT TOO.  The virus is absolutely there, and at least some of the people around you have it, don’t know it, and are likely spreading it.

—And from California and Long Island, it will -absolutely- start to spread coast to coast over the next month.  Such as Twitter rumors that a school in Oregon closed over a coronavirus scare.

—Expect Trump to be doing some serious backpedaling real soon.  Over and above “invoking Defense Protection Act” to get more masks made.

—However, here’s the fun part for the US:  It won’t matter.  The time to pass an $8.5 billion preparedness bill was early January.  By the time it passes, money is available and equipment is ordered, it will be too late.  For example, Acosta, the secretary in charge of health, testified to congress that they need 300 million N95 respirators for health care workers.  Right now, they have 30 million.  I promise you, even if they got the money tomorrow, they will not be able to source and/or compel production of 270 million additional N95 respirators as quickly as they need them.   As many of you have commented, finding masks and respirators is almost impossible right now.  They needed 300 million ready and available RIGHT NOW.  The Association for Public Health Laboratories also wrote a letter to Congress and the President, highlighting significant shortfalls in personnel, equipment for diagnostic testing, and other resource shortfalls to address Covid-19.

—If they don’t have those resource gaps plugged now [Narrator:  They don’t] they will not have them plugged in time.

—Moral of the story:  We will be going to war against Covid-19 with the army we currently have.

—If you have not read “The Fall of Wuhan” on EpsilonTheory.com, you should.  Because it is exactly what is happening.

—Again, to highlight, and sticking to -just- the US experience:  The CDC published the assay they are using to test for coronavirus.  Their plan is to make kits of the test and send them to all the state public health labs.  The CDC does not do that often, and made a mistake with the manufacturer of one of the kit components, who had a quality issue with the component they made.  The kits have not been sent to state health labs yet as a result.  Despite shifting to a “community outbreak containment” and pandemic footing, if you read the CDC’s cover letter on their published assay (I have, and I am not making this up), if you make your OWN copy of the CDC’s assay to run at YOUR hospital (as what we call a “laboratory developed test”), you are not allowed to run the test on human samples.

No joke.  Go read it.  It’s apparently for research use only.

But wait!  It gets better.  If you are a big commercial lab, like LabCorp or Qiagen, and thinking about running the only assay to confirm the diagnosis of Covid-19 so the patient can be isolated, healthcare workers warned for appropriate precautions, and contacts traced (all important things in an outbreak like this), the CDC states that the assay took significant time and resources to develop.  And no doubt it did.  So before you can run the test, if you’re one of the big commercial boys, you’ll need to contact the Patent Transfer Office of the CDC first.

Again, I am not making this up.

BUT WAIT!  IT GETS EVEN BETTER!  Because the FDA has declared this a health emergency, that automatically puts Covid-19 diagnostic testing in the highest risk category for laboratory testing under FDA guidelines.  Which means, by the letter of their own law, you CANNOT RUN A LABORATORY DEVELOPED TEST FOR DIAGNOSIS.  Which this absolutely is–no matter who is running it!  You must have an officially FDA blessed assay for this highest risk category, or you are breaking the law.  Again, spoiler alert, not even the CDC test has gone through that formal review process–which takes slightly less time and effort than getting a new drug approved (trust me on that).

BUT!  

WAIT!  

IT.  GETS.  EVEN.  BETTER! 

<Paladin’s Note: This section is redacted because it contains a little too much that would identify me personally. The main point is that testing in the US at this time is being funneled to the CDC via state labs, neither of which has enough capacity available yet for mass screening for SARS-CoV-2>

What -terrifies- me about this is that Indiana is actually a pretty well run state.  And from what I am reading, this is what nearly, if not all, state public health labs nationwide are doing.  Which is why UC Davis could not test itself, and instead had to argue for a week to get CDC to run the test on that patient.

—So today, I got the Indiana physician update bulletin on Covid-19.  Consistent with CDC guidelines, testing for Covid-19 is restricted to patients with symptoms and known exposure to an already known Covid-19 patient OR connection to travel to China. 

No mention of South Korea; no mention of Japan; no mention of Iran; no mention of Italy. 

My rule of thumb is that you can take the published numbers of active cases in a country, which are the ones who showed up at a hospital for testing, and multiple it by about 5.  That is the probable number of people who actually have the disease right now in that country.  I promise you there are people traveling from South Korea, Japan, Italy, Iran etc. who are in the incubation period, are going around the world as we speak, and will start additional infection chains that won’t show up for a few more weeks.  And this is how the CDC gets “surprised” by possible community spread after refusing to run the test because “derr…no China exposure” in California.  They are a week behind updating relevant travel history at a minimum.  Realistically, EVERY FLU NEGATIVE CASE should be getting tested right now. 

CDC still hasn’t started that, despite announcing that plan.

—This is the army you are going to war with.  And it’s like this all over the world.   And remember, CDC has been the -most- responsible, thus far, in my opinion.  

—If you had any illusions that institutions you count on will overcome the moral fecklessness, where every decision is made by a nameless, faceless committee of middle managers, who got there by taking few risks, seeking no action that might Bring Blame, and waiting to do what they are told by the Appropriate Title (despite knowing full well that high and mighty Appropriate Title will put themselves, the institution and the narrative -ahead- of fast and appropriate action at least as often as not), keep watching.  Your illusions that institutions in aggregate are competent, courageous, and acting in YOUR best interests may be significantly tested before all this is over.

—IN THE MEANTIME, DO NOT COUNT ON YOUR GOVERNMENT.  PREPARE YOURSELVES, PREPARE YOUR FRIENDS, PREPARE YOUR FAMILY.  

—The other thing I keep hearing is that “it’s just 1% mortality.  That’s not bad.  It’s not like it’s the Black Death.”  And true—my frame of reference as a physician is that 1% mortality is a lot less than, say, Ebola or bubonic plague.  But aside from the necessity to avoid overwhelming your hospital system, when the mortality jumps up, all of the precautions happening around the world, all the belated and still half-ass quarantines are still a good idea–even if the execution has been hopelessly flawed so far.  Here’s why.  1% means small risk FOR YOU dying of the disease—which is what everyone focuses on first, because human nature.  1% is a small number.  Most of us feel pretty comfortable with our -individual- chances of NOT being that 1%.  And most of that 1% is the elderly, immunocompromised, or those with severe underlying diseases, so we feel even better about not being that 1% if we, -individually-, get sick (just try not to think about the 23 year old Iranian Olypmic athlete reported dead of disease today).  So let’s go back to the back of the envelope again.

Let’s call the US population a nice, round 300 million.  We’ll say 50% of them ultimately get infected with Covid-19 to keep the numbers nice and easy still.  So 150 million infected.  1% mortality rate.  

1.5 million deaths, in just the US.

To put that in perspective, that is more deaths than all of the US soldiers killed in action in every war America has fought since 1899—combined.

In fact, it’s a bit over double the combined US combat deaths over the last 120 years of war.

—For other perspective, studies have shown that the human brain can juggle about 100-160 close relationships.  These are the friends, family and colleagues on your “active” list, and old friends and acquaintances will fall off it as you meet new people and just don’t have the bandwidth for everyone anymore.  If everyone gets Covid-19, you will be a statistical LOCK to know at least one person who died of Covid-19.

—Make no mistake about it.  Covid-19 IS dangerous, even if the danger to you as an individual may be minimal based on your demographics.  The shutdowns/quarantines/travel restrictions etc. are -completely- rational and called for, because it keeps the small percentage affecting the smallest possible number.  If Covid-19 gets to even half of just the US population, that small percentage is of a big enough number that that small percentage is an awfully large number itself.

–Humanity’s best hope right now, given spread and the, well, less than encouragingly competent response, is that Covid-19 is already all over once more generalized testing really starts.  In that case, the denominator for the case fatality rate is MUCH higher and this drops much closer to the flu or lower.  Otherwise, without improved responses, without you taking care of prevention (hand washing, spacing, good sleep, good diet, no smoking, maybe some vitamin D, exercise, and yeah, maybe a mask when the time comes), for you and your family and your friends, this could be our pandemic flu.

—Regardless, to emphasize again, you -MIGHT- get Covid-19.  You -WILL- get supply chain shock from all of these quarantine and travel restrictions that will pop up, seemingly at random, all over the world and likely through the rest of the year.  PREPARE NOW, TO MINIMIZE DISRUPTION OF YOUR LIFE FROM THAT.  

Love in the Time of Coronavirus–in 4 Acts:

1)  WHO Chief Dr. Tedros praises China’s efforts at containment and calls them a model for the rest of the world in how to prevent deaths from Covid-19 at the end of the WHO’s on site visit to China.

That’s a screenshot from the WHO’s own Covid-19 situation report, 26 Feb 2020.  I’ll let you do the math.

2)  “So I’m at this conference on the West Coast last week, and we get done with the committee work and head out to dinner.  And the lady who is there from China says after we’re done eating ‘Yeah—I got super lucky I got in just before Trump put the travel ban in place.’  Silence.  Sudden scraping of chairs. And I kinda’ wish she had said that during the introductions, you know?”
—Colleague at work this week

3)  “I have a family member working as a porter in a hospital in (NON-US COUNTRY) where there are four Covid-19 positive patients.  The hospital is “relaxed” about their presence.  The porters are not allowed to go into the patients’ rooms until one hour after the patient has left to let aerosol particles do…something?  Wearing masks is optional for the porters.  Call me pessimistic, but I am expecting a larger confirmed hotspot in (REGION OF NON-US COUNTRY) soon.”
—E-mail received this week

4)  “Speaking of, some of the schools up around have been cancelled lately because so many of the bus drivers are out with the flu.”<<long silence on the phone>>”No, no.  They’re sure it’s the flu.”

—Your chances of catching coronavirus have improved to a very high bonus “scratch off” lottery ticket.  And they continue to get “better.”

—Only a couple new Ebola cases this week, all in the same region.  That said, they expect at least a few more per week for a couple additional weeks as reporting and contact tracing remain slow at the moment.  Also, more evidence that there are “Ebola Janes” carrying and spreading Ebola like “Typhoid Marys”.  So the long slow wind-down continues.  Your chances of catching Ebola this week are virtually zero.

<Paladin>