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You are here: Home / Archives for Healthcare / COVID-19 Coronavirus

COVID-19 Coronavirus Update: Friday/Saturday, May 29-30

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I’m not convinced yet, but this link was retweeted by respected virologist Ian M. McKay:

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COVID-iocy Will Tank the Economy

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Today my region in New York entered Phase 2 of reopening, which means that non-mall retail is open (with masks) as well as hairdressers. Hairdressers need to wear a mask and a face shield, and customers must wear a mask. It’s like getting a haircut in an operating room—no thanks.

My daughter works in a customer service role in a place that could be open in Phase 2, but isn’t. She’s working remotely. A friend of hers is a hairdresser, on unemployment. Neither one of them are interested in going back to their place of business right now for a simple reason: the majority of the people who will show up will probably be COVID-iots. They will be the folks who don’t give a shit — they’re the kind who would come to your place of business even if they feel ill, and they will probably have to be coaxed to wear a mask.

There are a couple of retail outlets that I could visit, but I’m sure as shit not going there this weekend. I might go, cautiously, in a couple of weeks, as soon as I can judge whether COVID-iots are being slapped down and thrown out. If retail outlets are letting people without masks enter the premises, I’ll stick to my once-a-week grocery run, at most.

I’m sure there’s going to be an uptick in people shopping this weekend, and non-COVID-iots will be the majority. Still, it only takes one to start an outbreak, and I’m not going to risk that in order to get a new set of sheets at Bed, Bath and Beyond. I’m sure that I’m not the only one, and this is why empowering stupidity will make our inevitably anemic recovery even weaker than it was destined to be.

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COVID-19 Coronavirus Update: Thursday / Friday, May 28-29

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A less-than-cheering thread:

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The Long Haul is Masks, but Masks Endanger My Freedoms

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The Post has a long piece detailing how we’re in for a long haul with COVID-19. This stood out:

One hospital in New York tested every pregnant woman who came in to deliver and found 15 percent had the coronavirus. Most of those testing positive — 88 percent — showed no symptoms, a sign of how crucial such testing could be.

Josh Marshall pointed out this lit review in Science, which concluded that the sum of evidence points towards mask wearing as a reasonable public health step. Cuomo just signed an executive order giving businesses the authority to kick out customers who don’t wear a mask. The clear, obvious conclusion, based on facts as we know them, is that reopening won’t work without widespread wearing of masks.

Even so, all of my red state relatives tell me that very little mask wearing is going on — one of them was the only person wearing a mask in a Home Depot last night. It’s enough to make the governor of North Dakota cry. This article details the fight with COVID-iots at different healthcare facilities in FOXland. Sample:

Confusion about when and where masks should be worn is also playing out in other high-risk places that provide medical care, like nursing homes. Sue Krohn-Taylor is an administrator at a 72-apartment low-income senior living facility in the large town of Grand Island, Nebraska, where a resident has tested positive for Covid-19. She says she’s been battling some residents who refuse to wear masks, and is exhausted.

“This week, the son of one of the residents told me I was taking away their liberties by making them wear a mask in the common areas,” she says. “If they were only harming themselves, I would back off, but they are placing each and every resident here, and my staff, and our families in harm’s way.”

“I can fight the virus, but fighting the lies is what becomes overwhelming,” she says.

What’s interesting to me is that this is one case where the politics of mask wearing is getting away from Trump. Mitch McConnell broke with him on it today. He’s lost Sean Hannity, too. Only the Trumpiest Trumpers are going to stick with him, but that will probably be enough to spark a good number of outbreaks.

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COVID-19 Coronavirus Update: Wednesday/Thursday, May 27-28

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One note of grace:

… The world’s largest book fair will take place in Frankfurt as scheduled in mid-October, a sign of some return to normality.

Organisers said they were able to persuade city authorities the fair could go ahead after outlining comprehensive sanitary measures. The event, which dates back to the 15th century when Johannes Gutenberg introduced the mass printing of books in nearby Mainz, usually draws more than 300,000 visitors…

(Of course, bibliophiles are notorious good at social distancing!)

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Remdesivir and its value

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The New England Journal of Medicine has the first trial report out on the effectiveness of remdesivir, an anti-viral medication made by Gilead, for treating hospitalized individuals with COVID-19.

METHODS
We conducted a double-blind, randomized, placebo-controlled trial of intravenous remdesivir in adults hospitalized with Covid-19 with evidence of lower respiratory tract involvement. Patients were randomly assigned to receive either remdesivir (200 mg loading dose on day 1, followed by 100 mg daily for up to 9 additional days) or placebo for up to 10 days. The primary outcome was the time to recovery, defined by either discharge from the hospital or hospitalization for infection-control purposes only.

RESULTS
Preliminary results from the 1059 patients (538 assigned to remdesivir and 521 to placebo) with data available after randomization indicated that those who received remdesivir had a median recovery time of 11 days (95% confidence interval [CI], 9 to 12), as compared with 15 days (95% CI, 13 to 19) in those who received placebo (rate ratio for recovery, 1.32; 95% CI, 1.12 to 1.55; P<0.001). The Kaplan-Meier estimates of mortality by 14 days were 7.1% with remdesivir and 11.9% with placebo (hazard ratio for death, 0.70; 95% CI, 0.47 to 1.04).

This is good evidence that remdesivir is useful as a therapeutic. The study is a gold standard randomized clinical trial without the typical confounding seen in observational studies. It does not have selection effects and the statistics indicate a high confidence in at least recovery effects. Median recovery time is 26% (4/15) faster for people administered the drug than people who received placebo and regular care. Remdesivir does not have proven mortality effects at this time.

So what is its value?

I think remdesivir has two value propositions in the United States. In the current environment where hospitals are currently not overrun, it has real value in reducing hospital stays by 26% and reducing PPE, supportive medication and staff time demands to treat any one patient. This is valuable.

In an environment where a region’s hospitals are being overwhelmed, surging remdesiver into a region has both the baseline value and then an add-on value. A region with an overwhelmed hospital system will have a case fatality rate several times higher than the same region with hospital capacity to spare. The faster recovery time means beds clear faster and the staff that would be committed to helping two patients recover per month would be available to care for almost three patients per month. This would be a fast way to surge effective care capacity into a region that is the equivalent of deploying a hospital ship or an army field hospital with the attached train staff.

In that scenario, remdesivir will likely have indirect mortality effects. Shorter lengths of stay means the effective hospital throughput is higher which means the length of time that a region is in an overload scenario is shorter. Some individuals who would have been admitted to the hospital during a slam period without remdisivir will be admitted to the hospital during normal(ish) operations with far lower mortality risk due to the increased throughput.

Using this logic, remdesivir has both immediate resource replacement value and mortality prevention value in some scenarios. These two value streams can be modeled to be a fairly large number under some modeling assumptions. The value of the mortality prevention by minimizing periods of slam will be a function of modeling both COVID-19’s inherent response to seasonality, our social responses, our public health responses and the length of time to widespread, effective vaccine deployment. The less optimistic an analysis is about any of these parameters, holding all else equal, the more valuable remdesivir will be. But a fairly large number could be justified under standard cost effectiveness models depending on the underlying assumptions about disease spread and regional overload scenarios.

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COVID-19 Coronavirus Update: Tuesday / Wednesday, May 26-27

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Guest Post: “Denial of Science”

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Thank you, Schroedinger’s Cat:

We are in the middle of a global pandemic, a cold virus gone viral. The death toll due to Covid-19 is rising everyday. May isn’t even over and we have already crossed 100,000 deaths in the United States alone.

The virus has bought the whole world to it knees. Almost no one alive today has seen an epidemic on this scale. So paranoia is running amok even among people who should know better. The closest parallel is the Spanish Flu that swept the globe almost a hundred years ago. First it was China and then it was Italy and now we are at the eye of this storm. So far our response has been anything but surefooted. States are scrambling to get medical supplies while the federal response has been halting and inadequate to combat the scale of the unfolding disaster. A microscopic virus invisible to the naked eye has brought the behemoth of the global economy to a complete standstill.

But was this inevitable? The federal response to the pandemic has been guided more by wishful thinking and posturing than by hard scientific data. What explains all the missteps and the fits and starts to combat this pandemic? At the heart of this unfolding tragedy is the scientific and numerical illiteracy that plagues our society, from ordinary citizens to the President. Climate change deniers, anti-vaxxers and people who believe that the earth is flat have been proliferating for sometime now. Some of them have ascended to the highest positions of power. Isaac Asimov said it better than I ever could in his 1980 essay.

The strain of anti-intellectualism has been a constant thread winding its way through our political and cultural life, nurtured by the false notion that democracy means that my ignorance is just as good as your knowledge.- Isaac Asimov

This cult of ignorance is proving costly to our health as the death toll keeps rising due to the COVID-19 pandemic. Infectious diseases experts have been warning about a pandemic at the scale of the 1918 flu pandemic for a while now. The President and his team had been warned by experts as far back as January that a catastrophe was looming. They knew yet they did nothing. They disregarded the scientific consensus about the virus just like they have disregarded the scientific consensus about climate change.

One look at the graph of the exponential spread of infection should have scared anyone. Unfortunately for us some one didn’t pay attention in their high school math class or their intelligence briefings for that matter.

People who disregard science forget one thing, you don’t have to believe in science for it to be true. The laws of nature work whether or not you believe in them. The earth’s gravitational acceleration is g =9.8 m/s2 even if you think that the earth is flat. Viruses can infect you even if you are an anti-vaxxer. But ignorance of science and math is not without consequence. People who promote falsehoods that vaccines cause autism are bringing back infectious diseases like measles which were considered eradicated. They also vote into office elected officials who deny climate change and twiddle their thumbs as a virulent virus ravages the nation. They gut budgets that fund our research infrastructure from the CDC to the NIH and NSF. They want to gut CDC funding during a pandemic. The research budgets which were trimmed because of sequestration (across the board funding cuts to the funding of government agencies to enforce fiscal discipline enacted in 2012) never bounced back when the economy did. Gutting research funding while cutting taxes for the wealthy and corporations is like burning seed corn to have a party right now.

Everyone wants a vaccine for COVID-19 in a hurry now but scientific expertise and research excellence don’t happen in a day or even a year. There is no just-in-time research. It has to be funded generously and in a consistent manner so that people are willing to dedicate their lives to careers in science which for the most part is hard lonely work with little glory. And who else but the government can do this when the rewards, if they exist, are distant?

Investment in science and math is essential for our very survival. This includes support for science and math education, K-12 and beyond and robust federal funding for both pure and applied research. I hope that this pandemic has taught us that ignorance of science comes at a steep price, the price tag is 100,000 dead Americans and counting.

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1332 waivers and state budget crunches

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49 of 50 states have balanced budget requirements. States are experiencing a massive revenue shortfall due to the COVID pandemic. State budgets have core priorities of education, medical care, criminal justice and civil courts, transportation, infrastructure and recreation on public lands. State budgets also have short run fixed costs of pensions and debt upkeep as well. After those expenses, other add-ons can be included.

One of the add-ons that about a dozen states have chosen to spend money is Section 1332 reinsurance waivers for the ACA individual market. These waivers have a couple of different flavors but fundamentally they are similar. A source of money that is not tied to premiums is injected into the claim paying pool. This external money takes on a share of the claims and allows premiums to drop. The lower premium level triggers lower federal subsidy payments which then gets recycled back into the external source of money. The key here is the external source of money. Some states use general fund revenues, others use a general insurer assessment while others have other dedicated funding streams.

These waivers serve a fairly small number of people in the state. The waivers make insurance cheaper for individuals earning over 400% FPL and slightly more expensive for subsidized individuals who choose a plan that costs less than the benchmark plan. The marginal cost of insuring one extra person is fairly high.

States will have to make very hard choices in the next several weeks as updated revenue and expenditure projections come in. 1332 waivers can be either reduced or eliminated to free up the funding stream that went to the waiver. The freed up funds could be redirected to other, higher priority programs.

Below is the language from the Colorado 1332 waiver approval letter that outlines early termination procedures. The key is a notification by July 1st.

1332 waiver termination language

If a waiver was to be terminated, we should hear rumbles in the next week or so and then comment periods in two or three weeks.

This is worth keeping an eye on.

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COVID-19 Coronavirus Update: Monday/Tuesday, May 25-26

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More Longer Pandemic Reads, Prior to the ‘Work’ Week

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This actually is a good, “sensible” at-this-point-in-time guide (with charts, for science!), if you want something not too depressing to share:

… In particular, so-called superspreading events seem to be a major cause of infections. One London School of Hygiene analysis suggested that 80% of the secondary transmissions were caused by just 10% of infected people. In other words, if you want to avoid getting COVID-19, one of your major focuses should be avoiding a superspreading event.

So as Utahns leave their homes and reengage with society, we thought now would be a good time to scour the research to note where these events have been documented and where they haven’t. We can also learn about the circumstances that led to each superspreading event, and do our best to avoid them…

TL; DR — Stay away from bars, clubs, buffets, and sports venues. Be cautious about buses, planes, gyms, malls, and offices. Grocery stores (grab & go) and (possibly? probably?) voting sites should be okay, though! As for church-going and family gatherings: “Churches can be the site of community-changing superspreading events… Avoid hugging and sharing food, especially while sick.”

(Jesus and your grandma both love you, but they didn’t raise you to be an idiot.)


This, on the other hand, is just plain terrifying:

When you talk to intensive care doctors across the UK, exhausted after weeks of dealing with the ravages of Covid-19, the phrase that emerges time after time is, “We’ve never seen anything like this before.”

They knew a new disease was coming, and they were expecting resources to be stretched by an unknown respiratory infection which had first appeared in China at the end of last year.

And as the number of cases increased, doctors up and down the UK were reading first-hand accounts from colleagues in China, and then in Italy – in scientific journals and on social media – about the intensity of infection.

“It felt in some ways like we were trying to prepare for the D-Day landings,” says Barbara Miles, clinical director of intensive care at Glasgow Royal Infirmary, “with three weeks to get ready and not a great deal of knowledge about what we would be facing”.

But what arrived in the UK as winter turned into spring took even the most experienced ICU specialists by surprise.

Most people infected with the coronavirus have only mild symptoms, or sometimes none at all. But in many thousands of patients who fall critically ill, Covid-19 is a disease of alarming complexity.

What follows is a summary, often in their own words, of what doctors have learnt about how Covid-19 attacks the human body, and what they still need to know…

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COVID-19 Coronavirus Update: Sunday/Monday, May 24-25

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(This is very much a “Show Us on the Doll Where the Invisible Hand Touched You” situation; rural counties, desperate for funding & jobs, leapt at the chance to permit penitentiaries and meat-packing plants rejected by more urbanized areas with better financial options… and the prisons / plants were happy to base themselves in areas where fewer residents and cash-strapped local officials were less likely to complain about shoddy standards. But those same rural counties still don’t have the funds, or the personnel, to fight a pandemic — and the big corporations responsible for the ‘hotspots’ have damned little incentive to help out.)

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COVID-19 Coronavirus Update: Saturday / Sunday, May 23-24

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Saturday-Service Open Thread: If Trump Loves ‘His’ Evangelicals So Much, Why Is He Trying to Get Them Killed?

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(When I was growing up “in the Church”, there was an ongoing mostly-underground war between the bishops (as representatives of the official Catholic hierarchy) and the parish priests (representatives of their local communities). That may have changed in the past forty years, but the argument went back to at least the Dark Ages, so… )

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