On COVID-19

Old_Joe

Note: This information was first posted in the current MFO thread "a deeper panic, perhaps". I'm posting it here separately for those who may not have checked out that post.

I've just received all of this information via email from a close personal friend. He is retired, previously held the position of Chief of Medicine at one of our San Francisco hospitals, and specialized in pulmonary medicine.

I realize that much of this information has appeared in various places at various times, but this seems to be a comprehensive summary of all that is known and suspected in medical circles. Due to the length, I'm posting this in two sections.

Part 1:

University of California, San Francisco BioHub Panel on COVID-19
March 10, 2020

Panelists
Joe DeRisi: UCSF’s top infectious disease researcher. Co-president of ChanZuckerberg BioHub (a JV involving UCSF / Berkeley / Stanford). Co-inventor of the chip used in SARS epidemic.
Emily Crawford: COVID task force director. Focused on diagnostics
Cristina Tato: Rapid Response Director. Immunologist.
Patrick Ayescue: Leading outbreak response and surveillance. Epidemiologist.
Chaz Langelier: UCSF Infectious Disease doc

What’s below are essentially direct quotes from the panelists. I bracketed the few things that are not quotes.

Top takeaways
■ At this point, we are past containment. Containment is basically futile. Our containment efforts won’t reduce the number who get infected in the US.

■ Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak. In other words, the goal of containment is to "flatten the curve", to lower the peak of the surge of demand that will hit healthcare providers. And to buy time, in hopes a drug can be developed.

■ How many in the community already have the virus? No one knows.

■ We are moving from containment to care.

■ We in the US are currently where at where Italy was a week ago. We see nothing to say we will be substantially different.

■ 40-70% of the US population will be infected over the next 12-18 months. After that level you can start to get herd immunity. Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.

■ [We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die. The panelists did not disagree with our estimate. This compares to seasonal flu’s average of 50K Americans per year. Assume 50% of US population, that’s 160M people infected. With 1% mortality rate that's 1.6M Americans die over the next 12-18 months.]
... • The fatality rate is in the range of 10X flu.
... • This assumes no drug is found effective and made available.

■ The death rate varies hugely by age. Over age 80 the mortality rate could be 10-15%. [See chart by age Signe found online, attached at bottom.]

■ Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did

■ I can only tell you two things definitively. Definitively it’s going to get worse before it gets better. And we'll be dealing with this for the next year at least. Our lives are going to look different for the next year.


What should we do now? What are you doing for your family?

■ Appears one can be infectious before being symptomatic. We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms. We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).

■ How long does the virus last?
On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this. The virus is very susceptible to common anti-bacterial cleaning agents: bleach, hydrogen peroxide, alcohol-based.

■ Avoid concerts, movies, crowded places. We have cancelled business travel.

■ Do the basic hygiene, eg hand washing and avoiding touching face.

■ Stockpile your critical prescription medications. Many pharma supply chains run through China. Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.

■ Pneumonia shot might be helpful. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.

■ Get a flu shot next fall. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.

■ We would say “Anyone over 60 stay at home unless it’s critical”. CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.

■ We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes. Then are not letting them out of the house. The other members of the family are washing hands the moment they come in.

■ Three routes of infection
... • Hand to mouth / face
... • Aerosol transmission
... • Fecal oral route


What if someone is sick?

■ If someone gets sick, have them stay home and socially isolate. There is very little you can do at a hospital that you couldn’t do at home. Most cases are mild. But if they are old or have lung or cardio-vascular problems, read on.

■ If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER

■ There is no accepted treatment for COVID-19. The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease. ie to prevent sepsis.

■ If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use" of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China. Need to find a doc there in order to ask to enroll. Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19. If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.

■ Why is the fatality rate much higher for older adults?
... • Your immune system declines past age 50
... • Fatality rate tracks closely with “co-morbidity”, ie the presence of other conditions that compromise the patient’s hearth, especially respiratory or cardio-vascular illness. These conditions are higher in older adults.
... • Risk of pneumonia is higher in older adults.

(Part 2 follows)

Old_Joe

Part 2:

What about testing to know if someone has COVID-19? Bottom line, there is not enough testing capacity to be broadly useful. Here’s why.

■ Currently, there is no way to determine what a person has other than a PCR test. No other test can yet distinguish "COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.

■ A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA. However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.

■ The PCR test requires kits with reagents and requires clinical labs to process the kits.

■ While the kits are becoming available, the lab capacity is not growing

■ The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day. For the nation.

■ Expanding processing capacity takes “time, space, and equipment.” And certification. ie it won’t happen soon.

■ UCSF and UCBerkeley have donated their research labs to process kits. But each has capacity to process only 20-40 kits per day. And are not clinically certified.

■ Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.


How well is society preparing for the impact?
■ Local hospitals are adding capacity as we speak. UCSF’s Parnassus campus has erected “triage tents” in a parking lot. They have converted a ward to “negative pressure” which is needed to contain the virus. They are considering re-opening the shuttered Mt Zion facility.

■ If COVID-19 affected children then we would be seeing mass departures of families from cities. But thankfully now we know that kids are not affected.

• School closures are one the biggest societal impacts. We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects. If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.

■ Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis. They do not have the capacity to sustain for outbreaks that last for months. Other solutions will have to be found.

■ What will we do to handle behavior changes that can last for months?
... • Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
... • Kids home due to school closures

■ [Dr. DeRisi had to leave the meeting for a call with the governor’s office. When he returned we asked what the call covered.] The epidemiological models the state is using to track and trigger action. The state is planning at what point they will take certain actions. ie what will trigger an order to cease any gatherings of over 1000 people.



Where do you find reliable news?
■ The John Hopkins Center for Health Security site. Which posts daily updates. The site says you can sign up to receive a daily newsletter on COVID-19 by email. [I tried and the page times out due to high demand. After three more tries I was successful in registering for the newsletter.]
■ The New York Times is good on scientific accuracy.


Observations on China
■ Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.

■ While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.

■ Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand. Wuhan built 2 additional hospitals in 2 weeks. Even so, most patients were sent to gymnasiums to sleep on cots.

■ Early on no one had info on COVID-19. So China reacted in a way unique modern history, except in wartime.

Every few years there seems another: SARS, Ebola, MERS, H1N1, COVID-19. Growing strains of antibiotic resistant bacteria. Are we in the twilight of a century of medicine’s great triumph over infectious disease?
■ "We’ve been in a back and forth battle against viruses for a million years."
■ But it would sure help if every country would shut down their wet markets.
■ As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa. See article on Wired magazine on sequencing of virus from Cambodia.

catch22

Thank you.
Catch

Mark

Good info OJ. Thanks for posting. However I do wish I wasn't in that most susceptible group. I feel healthy AF most of the time and I tend to self-isolate with my puppies most of the time anyhow.

Anna

I'm near the epicenter and the biggest problem today is no toilet paper anywhere, even Amazon. If a rumor started about a supply of tp, crowds would probably violate the 250 max assembly rule set by the WA governor.

Mark

@Anna - possibly Target or Walmart online? Or similar. Not that you already didn't know this. An Aldi's I went to this a.m. had a stack.

msf

Here's a NYTimes article on the TP panic buying.

"A retail analyst, Burt Flickinger of Strategic Resource Group, said big box retailers like Costco and BJ’s Wholesale Club have been able to restock most empty shelves within a few hours, or by the next morning, according to his survey of hundreds of stores across the country this week."

Part of the problem (per the article) is that manufacturers know that people stocking up makes no sense - they are not going to consume it any faster now than before. And when they discover this spring that they've got a cupboard full of the stuff, they won't be buying for a long time. Manufacturers don't want to be stuck with inventory then because they ramped up production now.

https://www.nytimes.com/2020/03/13/business/toilet-paper-shortage.html

Anna

Mark said:

@Anna - possibly Target or Walmart online? Or similar. Not that you already didn't know this. An Aldi's I went to this a.m. had a stack.

Thanks, I tried both last night and didn't find anything. I did order 12 bamboo biodegradable rolls from Amazon today for delivery at the end of the month. Actually, I'm thinking that when the internet runs out, it affects more than people in the hot states and the supply chain will be fixed soon. We were planning just to buy it as needed when we found out we might not be able to get any. The problem with what the manufacturers are saying is that people that didn't even think of hoarding become victims of the hoarders so some people will "discover this spring that they've got a cupboard of the stuff" and others will go until spring without wiping. It doesn't even out so they will need to at least once resupply the panic states under rationing or something.

Old_Joe

@Anna- I'm sorry , but dealing with this issue would require some degree of concern on the part of your federal government for the day-to-day problems of the general population. Unfortunately, by voting for the present administration the general population has indicated that such governmental concern is neither desired nor important to them.

Anna

Then s dirty a bottom it is.

Actually I do realize that a dirty bottom is nothing in comparison to people who are sick or dying but it's stupid (and real) and I really hate stupid.

WABAC

Hi Anna. Try eBay. You might be able to get local pickup, or faster shipment. Seems to be plenty available. But I didn't look too hard at the price.

Good luck.

davidrmoran

dirty bottom is the name of the times, has been for years

Anna

WABAC said:

Hi Anna. Try eBay.

Thanks I'll have a look.

johnN

In few wks?months you may buy ad many toilets tissues /alcohol wipes /sanitizers as desired..
At least numbers have flatlined/stabilized in KSorea and china past wk...usa may follow in 4 -8??? wks [best scenario]...worst scenarios things may last up to 6 12 months


So much price gauchers in our areas though...feel very bad consumers

Old_Joe

"worst scenarios things may last up to 6 12 months"

@johnN: If it's not too much trouble, perhaps you should try reading the contents of the original post at the top of this thread before making more foolish comments. I'm sorry for the need to be so blunt, but having to endure the president making such statements is quite enough without reading similar trash here on MFO.

msf

Old_Joe said:

What about testing to know if someone has COVID-19? Bottom line, there is not enough testing capacity to be broadly useful. Here’s why.

■ The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day. For the nation.

■ Expanding processing capacity takes “time, space, and equipment.” And certification. ie it won’t happen soon.

■ UCSF and UCBerkeley have donated their research labs to process kits. But each has capacity to process only 20-40 kits per day. And are not clinically certified.

What caught my eye was the statement that Quest's capacity, nationwide, is just 1000/day. That is consistent with the UC figures given since Quest has "dozens of clinical laboratories throughout the U.S.", and three dozen x 30 tests/day is around 1000/day. Why are these labs so slow?

One lab at the University of Washington Medical Center ran more than 1,300 tests on Wednesday [March 11] and may ramp up to 2,300 per day by Friday, said Alex Greninger, assistant director of clinical virology laboratories.

He said the main bottleneck is a lack of personnel to receive, log and label samples. The lab has put out a university-wide call for more staff.

“We’re doing one specimen a minute and need to get down to one every five seconds,” he said.

https://www.reuters.com/article/us-health-coronavirus-usa-testing/despite-entry-of-large-private-labs-coronavirus-tests-remain-scarce-in-u-s-idUSKBN20Z3XP

Vox also notes that "Some labs have much higher capacity than others. Even the corporate diagnostic companies like Quest and LabCorp only have the capacity to run 1,000 and 1,500 tests a day, respectively."
https://www.vox.com/science-and-health/2020/3/12/21175034/coronavirus-covid-19-testing-usa

It includes this graphic showing orders of magnitude difference in the speed of different labs:

Old_Joe

Thanks very much @msf. Info like that is a great supplement to the original post.

Regards- OJ

johnN

https://m.youtube.com/watch?v=HPGtrxym66Q

Testing centers are miles and miles long
Probably end up dead prior to being tested

hank

Continuously Updated MAP - Confirmed Coronavirus Cases U.S.
https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html

Thought this might be helpful in assessing current risk in your area. If already linked, please advise and I’ll delete.

Old_Joe

Good grief, hank! What bloody difference does a duplicate link make? Let's not get started on that stuff again.

Mark

Inside the administrations coronavirus response.

With apologies to clowns everywhere.

But wait, there's more. Remember how WHO offered to send test kits to the US and we didn’t take them? Then Jared Kushner was put in charge of the response?

Oscar

Two guesses who’s brother owns this company...

About Oscar

Mark

Remember when we were the ones to send aid to other countries? Good times.

Chinese businessman to donate 500,000 test kits and 1 million masks to the U.S.

catch22

The following is my own form of comic relief, with a shoulder shrug and side to side head shake; combined with the serious side. I'm reluctant to post, but.....

In the way back days I lived in Taiwan for 2 years. There would be, as there are now; times when one wouldn't have a full understanding or full thought or reply to a question or circumstance.

One phrase I used, at times, in Taiwan was:

我能说什么
Wǒ néng shuō shénme , which in English is; "What can I say?" One could also use the side to side head movement with the should shrug while speaking.

Not to write as a smart ass, but I noted somewhere here several weeks ago in a reply to a "black swan" event, that COVID could be a problem going forward. I had started watching, on a daily basis; the events in Asia on January 21. Well, the world is where we're at today; and I'm saddened for those in many countries, but this country, Michigan and my home is now the priority.

A few points that cause me to say/think,.......today
我能说什么
Wǒ néng shuō shénme

I've expressed to others my concerns about a few events. These folks are kind and loving, but I know now that they are not always paying attention or thinking ahead.
I'll provide two items where I intervened my thoughts without success.
--- 1. An aunt and 8 of her children/spouses (live in Michigan) decided to go to Florida last Wednesday and remain until the first week of April. When I became aware of this, a phone call was necessary. I stated that the area to where they were traveling already had 2 active COVID cases. "Oh, everything will be okay." "Alright then."
--- 2. Nephew and wife, age 40. Scheduled vacation, they could have; but chose not to cancel. They arrived in New Zealand 3 days ago. NZ now locked down all travel into their country today; although one may leave. I wish them well upon return and that they are not blocked from U.S. entry (not the case right now).

Relative for Michigan this time of the year, are many 1,000's of snow birds returning after several months in the winter warm states. CRAP !!!

I'll add this CNN link. And yes, I know there are many; but this is well done. Refresh the page with each visit for current data. Also, many states now have excellent sites with great, real data. I simply search "state name" then the words "covid cases". I use this method to know more about other states where family and friends reside.

Lastly, I'm so pleased that "states" , companies and other organizations have taken actions to help restrict large group gatherings; as they did not find any proper thoughts arriving from D.C.-land.

ADD: I forget to express, that there remains a lot of bitching about toilet paper hoarding, etc. I've not heard the question asked whether folks are buying for others, too. For us, we have two elderly ladies in the neighborhood and my mother is 94. No way in hell are they are going to a large grocery store to shop for themselves among the large crowds.

Okay, I'm done. Thank you for your time.
Take care of you and yours,
Catch

Old_Joe

Good points, Catch. Thanks.
OJ

msf

catch22 said:

In the way back days I lived in Taiwan for 2 years. There would be, as there are now; times when one wouldn't have a full understanding or full thought or reply to a question or circumstance.

One phrase I used, at times, in Taiwan was:

我能说什么
Wǒ néng shuō shénme , which in English is; "What can I say?" One could also use the side to side head movement with the should shrug while speaking.

Fortunately, even early on, the government of Taiwan had a lot to do (and say) about handling COVID-19, and epidemics in general.

Here's a JAMA opinion piece that's been making the rounds there. (We got the link from someone who knows the author's wife.) It includes a list of hundreds of actions taken by the government, along with a timeline.

Taiwan has been on constant alert and ready to act on epidemics arising from China ever since the severe acute respiratory syndrome (SARS) epidemic in 2003. ...

COVID-19 occurred just before the Lunar New Year during which time millions of Chinese and Taiwanese were expected to travel for the holidays. Taiwan quickly mobilized and instituted specific approaches for case identification, containment, and resource allocation to protect the public health. Taiwan leveraged its national health insurance database and integrated it with its immigration and customs database to begin the creation of big data for analytics; ...

Response to COVID-19 in Taiwan
Big Data Analytics, New Technology, and Proactive Testing
https://jamanetwork.com/journals/jama/fullarticle/2762689

Mark

@msf - exactly how responsible and caring society's and leaders are supposed to act. So far we're coming up a might short here.

catch22

@msf and @Mark
I will add that the current benchmark, IMHO; is South Korea and their actions and abilities.
And that Taiwan, has been going forward in their thinking since opening their economy to outside investments in the late 1960's with letting "foreign" companies to begin investing and building at a tax free zone site. The country has been on a forward path since.....

msf

Mark said:

But wait, there's more. Remember how WHO offered to send test kits to the US and we didn’t take them? Then Jared Kushner was put in charge of the response?

Oscar

Two guesses who’s brother owns this company...

About Oscar

Not to get too far off the topic, I'll try to be brief regarding Oscar.

This is a health insurance startup founded on the premise that all you need to do to succeed in a highly regulated industry is to introduce some technology and apps that would appeal to millennials. It started as an ACA insurer in 2014 by offering an incredibly wide network with all the largest hospital systems (including Memorial Sloan Kettering that takes almost no insurance).

That was a massive failure - it dropped Sloan Kettering after the first year. It dropped the largest hospital network, NY Presbyterian (including Columbia and Weill Cornell) after March 2016. At the end of 2016 it cut its network in half (40K doctors to 20K, dropping NYU Langone and Northwell Health [formerly Northshore/LIJ] - two of the five largest hospital networks).
https://www.vox.com/2016/7/26/12257926/oscar-health-networks-new-york

The bottom line is that Oscar was a startup that lost money hand over fist. It survived because investors (including Fidelity) poured $1.3B into it, and because Trump didn't succeed in killing the ACA. Funny how politics works that way.
https://www.crunchbase.com/organization/oscar#section-funding-rounds

Old_Joe

And they have the shamelessness to talk about Ukrainian corruption...

PRESSmUP

FYI...the Governor of Ohio, Mike DeWine, just ordered all bars/restaurants in Ohio to be closed at 9:00 PM this evening. I must say, DeWine isn't waiting for federal guidance in the moves the state has been making. The financial impact though, is severe.

carew388

@catch22 OT, but great job on remembering the Traditional Chinese Characters ! I had enough problems just learning the Simplified Characters(PRC Mandarin Chinese textbook) in high school !