Ebola Update:

–One new confirmed case this past week, so up to 119 positive.  There have been 53 deaths due to disease thus far.  Although trends remain very positive, there remains cause for concern.  The new concern is inadequate laboratory supplies of all types.  In short, I am not sure they are testing as often as they probably should be, and the WHO this week specifically reported that funerals in the area are not being tested as often as they would like.  On the other hand, death by Ebola is hard to miss, and if the curve was really exponential, that should, in theory, be obvious.  But it’s hard to say.  “Community resistance” remains high and they still have trouble getting staff trained and paid.  Further, not on the ground to get a sense of how big and where the gaps in the available data might be.  With so much else sucking up the reporting oxygen (other than these, would you know there is an active Ebola outbreak?), we see through a mirror darkly.  All we can say is trends remain optimistic, and we have both vaccines and treatments on the ground and engaged.  We didn’t have those in the big West Africa outbreak a few years back, and they make a huge difference–especially in a region easier to get to than the last one.  So we will stay cautiously optimistic, but cognizant that a major reason West Africa Ebola happened was an unrecognized disconnect between where testing and surveillance -thought- the virus was and how far it had actually been spreading. 

Coronavirus:

–Yeah, no special weekend update on Trump getting coronavirus.  That’s because I really cannot speak to his condition or treatment decisions, and again, appreciate your understanding on that.  I will say the main treatments that the President’s doctors opted to go with are remdesivir and an antibody cocktail from Regeneron.  The former is already approved and is thought to be most effective at this early stage of infection (when symptoms are just starting).  Same for the cocktail, which are antibodies made in the lab and targeted to SARS-CoV-2.  There are similar antibody cocktails from other manufacturers at the same stage of development (just a different source of the antibodies), which is why I am limiting commentary.  The idea behind both remdesivir and the antibody cocktail is to block viral replication at this early stage.  This is made possible by rapid test results for COVID diagnosis.  Later stage COVID, where the immune system is though to have shifted to that Ah-nold reaction we have discussed is often addressed by drugs meant to calm the immune system down.

That’s what the dexamethasone the President reportedly received as well is meant to do.

–Given the reported prophylactic use of hydroxychloroquine by Trump, I, too, am a little surprised it was not on the list of medications reported.  No word on if the President got coronavirus on top of HCQ prophylaxis–and I’m not sure if the media has even thought to ask that.  Too busy speculating on reflections of paper on a desk surface and if he looks paler than usual and “was that an edited cough,” I guess.  

–I will make a couple very general comments though.  As we discussed just last week with the CDC data on IFR, the chances of a 70 year old plus individual (like Trump) surviving SARS-CoV-2 infection are much higher than not, even though this is the highest risk category.  For every 70 year old plus patient who succumbs, 19 will survive just fine.  The President’s odds of recovery were already pretty good off the top–his major risk factor happened to be the biggest risk factor for a bad COVID time, though.  Trump is a little on the heavy side. 

–He’s also the President.  Speaking as a physician, and running the mental exercise of “if I were the personal physician to the President of the United States, what would I do,” the biggest challenge is the strong professional temptation to excessive caution.  Put politely, you, the physician, will be your biggest challenge, because you know you are President’s doc, and you know everyone else knows you are the President’s doc, and you know that it is very poor form for the President to die in your care.  He/she gets a sniffle and a confirmed test for pandemic respiratory disease as a member of the highest individual risk category with the single highest risk factor for mortality from it and you are got dam right they are going to Walter Reed for at least a bit of observation.  Chucking everything with a solid safety profile and at least some hint of efficacy at it too is a likely course of action.  Again, because everybody knows you are the President’s doc, and thus the death of the President would be extra no bueno.  “Abundance of caution” and “tendency to treat as much as possible” will rule the day, even if it’s a mild case.

I am quite confident all of the physicians reading this are nodding their head running the same mental exercise. 

–So in short, I don’t think looking from the outside in that there is anyway to know, for sure, how mild or serious the case is.  The former because it will get treated like it could become severe at any moment because of professional psychology, and the latter because the President, whomever they are, has a vested interest in looking tough and unstoppable and will try to “game on” through whatever treatment their doctor tries.  Avoid the temptation to armchair prognose. 

–Other main takeaways from “the President got the ol’ corona”, in general?  Well, first, what a brilliant example of themes we have covered many times already. We should listen to our ancestors who lived when the Black Death reigned.  Remember the “choose your own adventure”–what you did, or did not do, ultimately does not matter.  As soon as cases are confirmed in your town, you can safely assume everyone is exposed.  Eventually.  Again, the President is a well-protected individual, and this President happens to be at elevated personal risk from the virus.  Individual choices aside, I can assure you the people around the President were taking as many precautions as they could get compliance with to reduce the chance that the President catches the virus.  Still got it! 

Princess Joan of England caught the plague, despite being the “most protected person in Europe” at the time, on the way to cement an alliance between Spain and England.  Disease, particularly infectious disease, doesn’t care much for titles.

Other general takeaways–the current outbreak in the White House speaks to the general trend.  Of the 30 or so people reportedly positive in that outbreak, Trump is the only one I have read of who spent any time in the hospital, and he’s the one with known personal risk factors.   It’s a slightly different virus from earlier this year–highly contagious, yes, but the severe disease attack rate, by all appearances, is not quite what it used to be.  
The weekly zeitgeist speaks to this as well.  The US remains in a mini-wave, as pockets across a great many states at this point are experiencing elevated case numbers.  As a percentage of total tests, though, they are still way down from March-May, but certainly a bit higher than last month.  May have something to do with colder weather putting more people indoors together.  But these outbreaks remain concentrated hot spots in these states, among people and places that did not have a lot of coronavirus activity yet.  The virus is just gradually getting to all the remaining fuel it can find.  For example, Indiana’s creeping higher positivity rate is driven largely by the rural counties in the tail and to a lesser extent pockets in the biggest city.  This week New York City managed to get throngs of hasidic Jews into the street in protests (yes, you read that right) because the recent cases in the city are concentrated in the private schools of their community–so the mayor threatened to close synagogues.  So again, the New York City example is probably the clearest example of the current trend being driven by very focal hot spots (and in fairness, you can see the slight uptick in New York this week without last week’s meme picture), and I would go so far as to say that shows you that draconian lockdown will be difficult to enforce going forwards even without this week’s string of state constitutional defeats for lockdown orders across the country. 

We’re all Sweden now. 

Along with that, a reader sent the following earlier this week showing that lockdowns did not halt the spread of the virus, at least (and that much we knew):  https://www.nationalreview.com/2020/10/stats-hold-a-surprise-lockdowns-may-have-had-little-effect-on-covid-19-spread/  You can see this in live action in Europe right now too.  Sweden still not having much of a problem.  Spain, France, parts of the UK–same cannot be said. 

6,000+ scientists of various kinds even signed a petition against lockdowns based on arguments similar to the linked article above–evidence of effectiveness is limited (for the record, no one sent this petition to me) at best.  With data this week also coming out suggesting that airborne particulate spread may be pretty common for coronavirus (duh) but in particulates too small for a N95 mask to filter and even some of the personal measures may be limited.  In short, an N95 will reduce, but not eliminate your risk.

So am I particularly upset that a masked up Trump went on a drive to wave at supporters in front of the hospital putting at risk the equally masked up Secret Service (who, presumably, have been in close quarters, including that same heavily armored and airtight car all through his weekly schedule when he was getting sick) because it unnecessarily and inevitably put the guys who volunteered for a job where they might have to catch a bullet at risk, if even the masks might not be fully effective?  Not especially.  Give them a choice between a bullet and an X% chance they might catch the ‘Rona (which, demographically by appearance they are pretty likely to survive), and I suspect they will be able to make the best decision based on odds.  So you can quit clutching those pearls now–your knuckles are looking awfully white.  And again, it’s the Joan of England and “choose your own adventure” lesson.  Everyone is exposed.  Assume it.  It’s just a matter of time. 

Now, that said, I think a brief lockdown was warranted to slow transmission, even if it could not possibly stop transmission.  Remember, the goal was this:

Flattening the curve by slowing transmission stopped hospital overload and deaths via “bed’s taken”–the main public health risk to all demographics from this pandemic.  It also bought necessary time for testing capacity and hospital overflow capacity to be built.

Lockdown was quite useful for that (to disagree a tiny bit with my apparently 6,000+ colleagues).  Did it need to go as long as it did?  Not so sure of that.  Do we need them now?  Definitely not convinced of that, at least not at country level, and in that I do agree with apparently 6,000+ other scientists and doctors.  More locally/regionally, they may still be useful tactically.  But by keeping them in place for so long, you have lost a lot of your ability to effectively enforce them.

Take Wisconsin for example as a place where you might tactically be thinking about encouraging new restrictions.  Wisconsin is having a huge outbreak centered in just a few towns.  They actually are running into hospital capacity issues in places like Green Bay–but hospital case diversion is working so far, and the debate right now isn’t “Oh, God, we’re about to be overwhelmed by cases,” it seems to be mostly “do we trigger our overflow plan now?  How about now?  Okay, now?  Maybe not right now but soon?”  And that’s the only part of the Upper Midwest/Big Sky outbreak that’s even got rumblings of that (Indiana is starting to march up in numerical cases, positivity rate per volume tested, and hospital admissions/census though too).  I imagine there is temptation to pump the breaks in Wisconsin a bit just to flatten the curve a tad more, so the overflow capacity isn’t overwhelmed if triggered.  But again, whether they can politically enforce that right now is an open question. 

After all, this was Wisconsin last night: https://twitter.com/Julio_Rosas11/status/1314025827496087552

Lockdown yes/no, how hard, how long, was always going to be a delicate balance, and the toughest part of this, and I am not sure that the proper balance, to allow these tactical restrictions to come back when possibly necessary, was reached.  Anywhere.

But the good news is that Wisconsin still has emergency capacity to trigger and use.  The spike doesn’t threaten the dotted line in the graph above yet.  Better still, the US as a whole is a successfully flattened curve.  Most places never got close to hospital overrun, and are not likely to now.  Instead, it’s just been increasingly smaller spikes and waves stretching over time.  Nationally, hospitalizations continue to go down.  Your local results may vary.

–For all of the angst over the daily US case rates and how they are still slowly, steadily declining from March-May, that’s what a flat curve does.  Look at those curves again–the area under the curve, the total number of people who will be infected before herd immunity kicks in does not change.  Flattening the curve, when successful, does exactly what US cases show.  Spreads that AUC out over a longer time span.  Which makes it a grind, but avoids a curve that goes too high too fast with an elevated death rate from hospitals getting overwhelmed.

Like Sweden, in the early days of its massive, take-the-pain peak.  Or New York City and Northern Italy, which got hammer timed before they had a chance to try and flatten the curve. 

–Why did England get the Black Death?  Because the AUC never changes.  Because your choice in the choose your own adventure does not ultimately change your odds–just the timing of when you get your exposure to an infectious dose.  Once it’s out, it’s out, and only time to herd immunity or time to effective treatment matter. 

–That said, on social issues and fallout from a longer, flatter curve and lockdowns: https://www.washingtonpost.com/business/2020/10/02/food-bank-shortage-feeding-america/

As another wave of layoffs, particularly in travel and leisure, restaurants/bars and associated businesses hit, consider donations if you are blessed to have the means at the moment.  I doubt the US is unique in this regard right now.

Housekeeping notes:
–There will be no update next week.  50/50 for the week after too. 

–Finally got the PREDICT 2 write up done.  You can find it here (delay was I wound up running data collection to 12 weeks, not 8). 

–Your chances of catching Ebola are equivalent to the chances the Secret Service guys in the SUV for the Walter Reed drive by waving now have Ebola.

–Your chances of catching coronavirus are equivalent to the chances the Secret Service guys guarding the President for the past week have been exposed to an infectious dose of coronavirus at some point in that span. 

<Paladin>