My last post discussed a study from Stanford that suggested 50-85 times greater Infection Rate (IR) compared to the Case Rate (CR) in Santa Clara County. The Wall Street Journal published a discussion of this Study (which has not yet been peer reviewed) claiming that it was good evidence of a much lower fatality rate for COVID-19. Turns out that study was deeply flawed. The test used likely had a false positive rate of 13%, not 0.5% assumed by the authors. That alone makes the conclusions completely bogus. In addition, the study population was not truly a random sample and likely had significant selection bias. For a complete expose watch this:

One would expect something better from Stanford, but like I said, this was not yet peer reviewed.

“This article is a preprint and has not been peer-reviewed [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.”

But the Wall Street Journal reported on it in a favorable way, not revealing that one of the authors of the study was also the author who wrote the WSJ article!

A brief note about false positives and false negatives.

Suppose you are looking at a population of 1,000,000 people with an infection rate of 1% (990,000 do not have the disease)

Assume a sensitivity of 93% (the test is positive in 93% of true positives)

Assume a specificity of 96% (false positive rate of 4%)

If you test everyone, 9300 of the 10,000 true cases will be detected, 700 of the cases will not be detected.

BUT 40,000 false positives will be found for a total of 49,300 positives. You will publish an infection rate of 4.93% while the real infection rate is only 1%.

Statistics are tricky. The sensitivity and specificity of a test are extremely important.

Be careful about what you read. We all would like to be reassured that it would be safe to relax restrictions but we still do not yet know  the true IFR. The true infection rate depends on widespread testing with an accurate test and we have not yet done that.

Besides the economic downturn associated with shelter in place, there are valid clinical concerns about the damage being caused (depression, anxiety, suicide, spousal abuse, child abuse, reluctance to call 911 for a real emergency, etc..) We will need to return to less restrictions in an incremental way based on regional circumstances (NYC not the same as Northern California).

For a detailed discussion about how and when we should relax restrictions read this.

There has been allot of comparing apples with oranges in the social media. People keep trying to compare COVID-19 to the flu. They are very different with respect to the fatality rate and ease of transmission. (In addition, whereas we have had a vaccine for Influenza A and B, we do not have one for COVID-19 or any other Corona Virus)

Review:

Case Rate (CR) is the # of known cases based on nasal swab PCR test divided by population.

Infection Rate (IR) is the actual # of cases divided by population. This is estimated by performing a reliable serology test on a large random sample of people, testing for infection by measuring antibodies (there are a few tests available but their sensitivity and specificity remain controversial and crucial)

A recent analysis comparing the 2009 H1N1 influenza A pandemic to COVID 19 suggested this:

Some folks on social media have been comparing the CFR of the flu to the IFR of COVID-19. That is comparing apples to oranges.

The data in the table above are based on what appears to be the most recent and reliable information from New York City. The data on 2009 H1N1 is reported here.

In the old news clip below, 2920 adult deaths associated with 12 million cases of H1N1 calculates out to a 0.02% IFR which is exactly the same IFR described in the study linked above..

In this same report and in other discussions of H1N1 it was clear that children were more severely effected compared to COVID-19.

The table above would indicate that the IFR (infection fatality rate) of COVID-19 IS 25 TIMES GREATER than the IFR of the 2009 H1N1 Influenza A pandemic. The CFR of COVID-19 IN NEW YORK CITY is 40 times greater. This represents a much greater difference than the relative fatality rates suggested by the highly questionable conclusions of the Stanford Study of Santa Clara County.

There is a possibility that the New York City strain of COVID-19 might be more lethal than the strain of COVID-19 on the West Coast. That suggestion is PURELY SPECULATIVE and so far there is no data to support it. This possibility has been suggested because  NYC and New Jersey hospitals are much closer to capacity with COVID-19 compared to the West Coast experience and there are portable refrigerator truck morgues outside of hospitals in NYC and New Jersey where the local morgues filled up weeks ago. Again I would point to the major differences of the apparent CFRs between various countries and regions within countries which have not yet been explained (as discussed in my last post).

We have much more to learn, we need more testing (both nasal PCR and blood serology) to understand the spread and lethality of this disease. Those in the social media who claim we already have herd immunity are spewing nonsense. Herd immunity requires > 80% infection rate. Our measured IRs are highest in NYC (about 15%) and much lower in other areas where “reliable” serology has been performed.

One great failure in our country has been the prolonged lack of adequate testing. Shelter-in-place should have been a time-out to collect data and access where we are. That can only happen with reliable wide-spread testing. To AVOID overwhelming our hospitals and health care workers we must identify cases, trace contacts, isolate positives and isolate contacts. Isolation would ideally not be at home where the disease could easily spread to the entire household. Isolation at home is only reasonable when that home has a separate bedroom and bathroom for the infected person AND the household follows strict isolation and hygiene.

We must all recognize that the primary objective of shelter in place is to avoid overwhelming the health care system. Eventually, unless a treatment or vaccine becomes available, the disease will infect most of our population before we reach herd immunity. To return to economic activity and a more “normal life” we will necessarily accept a large number of deaths, primarily but not exclusively amongst the elderly and infirm. Generally it would seem reasonable to begin incrementally relaxing restrictions in areas of low impact, wearing masks, working from home where possible, avoiding public gatherings especially in confined spaces, and following good personal hygiene. So far the best information on risk (of death) appears to be in the table above, stratifying for age and risk factors.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

After posting the letter from an ER doc who eloquently expressed the danger, concerns, and most importantly, call for action I realized that some explanation for the lay person is necessary.

Intubation is the placement of a breathing tube into the windpipe for a person in respiratory failure. During the procedure the doctor and all providers in the immediate area are in a very high risk situation because the droplets filled with billions of virus can become aerosolized. I previously explained the difference between spread by droplet vs aerosol. Droplets fall to the floor and surfaces where virus can be infectious for hours. But when aerosolized, the virus remains suspended in the air for hours and anyone entering the area can become infected by simply breathing the air.

During intubation the doctor has his/her face inches from the patients mouth and nose. During this procedure droplets can become aerosolized. Even wearing a perfectly fitting N95 mask, goggles, gown, gloves the doctor (and those assisting) is/are not completely protected.

I received a warning letter from an ENT surgeon at Stanford, warning colleagues about cases of ENT and Neuro-surgery (endoscopic surgery through the nose) where despite FULL PPE, all practitioners in the operating room became infected and  surgeons have died. The ENT surgeon warned that PPE with N-95 mask was not fully protective and recommended PAPRs be used (Powered, Air Purifying Respirators.) Here is what the surgeon reported he received from his international colleagues:

“All 14 people who came in and out of the OR during that case became infected. He saw this repeat with other endoscopic cases

He has also shared that a significant number of doctors who died in China were ENTs and Ophthalmologists, possibly due to the high viral shedding from the nasal cavity. This has now been confirmed in the media as well.[i]

[i] https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese-doctors-say?fbclid=IwAR2ds9OWRxQuMHAuy5Gb7ltqUGMZNSojVNtFmq3zzcSLb_bO9aGYr7URxaI”

All 14 people who entered and left the operating room during the surgery became infected despite wearing PPE!!!!!!!!!!

“we have additionally heard from Iran that at least 20 ENTs are currently hospitalized with COVID-19, with 20 more in isolation at home.” 

Although SARs had a higher mortality rate, IT WAS NOT AS CONTAGIOUS.

This demonstrates how contagious this virus can be, and that was early on in China and Iran, before it mutated. Mutations can make the virus more contagious and more lethal. There has already been a SECOND STRAIN IDENTIFIED.

In my career I have performed more than 10,000 intubations. Many under emergency circumstances. Donning full PPE correctly takes time and when in a hurry the N95 mask may not be perfectly fitted. (WATCH THE VIDEO BELOW)

Although I have intubated people with sepsis and TB under emergency conditions, I have never been exposed to the level of danger that doctors and other providers around the world are now experiencing. The PPE (personal protection equipment) is already running short in hot zones. Many hospitals are a few days away from running out. MANY PROVDERS are reusing PPE that is not meant to be reused.

AS more doctors, nurses, and techs become infected (which is inevitable) there will be less personnel to care for patients so MORTALITY RATES WILL INCREASE.

This has not been factored into the epidemiologic models and projections.

Temporary emergency hospital tents are great, but useless without personnel. There is a limited # of ICU and ER doctors, nurses and techs. And they all need PPE.

That is why flattening the curve is so important.

That is why folks who ignore the behavioral guidelines are reckless and endangering others in the community and in hospitals.

We need to hear this every day from Doctors like FAUCI.

Misinformation from uninformed and anti-science politicians is tragically harmful.

EASTER WILL NOT BE MAGICAL.

Ventilators are useless without doctors, nurses and respiratory therapists to manage them. So production of ventilators is futile unless PPE are prioritized, WHICH HAS NOT YET HAPPENED. Shortages abound and the executive branch has not coordinated the private sector in addressing production and distribution. Instead leaving it up to the MARKET!

This has been described as a WAR, but we are not mobilizing the way we did during WW2. Mobilization requires central coordination, not bidding wars between states and hospitals for PPE, bleach and other sanitizers.

Here is the link to AN instructional video on donning PPE. Watch how long it takes and the steps required to achieve proper fit and seal for the N95 mask. Now imagine doing that while a patient is blue/hypoxic, or in cardiac and/OR respiratory arrest.

Later I will post practical precautions for groceries, mail, gas stations etc. A separate page on this website will document that.

I will also create a COVID 19 page with cut and pasted excerpts from documents as well as links to informative documents, videos and websites.

STAY SAFE.

I do not wish to create or contribute to panic, if you follow the recommendations of shelter in place and social distancing and follow good hygiene you and everyone around you will be MUCH SAFER. I merely want to emphasize why flattening the curve and following recommendations are so important. The more people comply, the shorter will be the time when we can prudently start to return incrementally to normal activity.

Testing still remains inadequate with backlogs of 10 days in hot zones. So the information we are getting on # of cases is almost 2 weeks behind what is out there and even if we had 45 minute turn around, the testing kits are being rationed. So we are just seeing the tip of the iceberg. And that will be the UNFORTUNATE situation for a while.

Although we have seen TOO LITTLE TOO LATE, we can still flatten the curve by following recommended practices. We can still save lives, prevent disability and suffering, and get to a point where we can return to a more “normal” life. The longer we wait for every state to institute necessary measures (Florida is an example of inadequate measures) the longer will be our restrictions.

Remember, you can boost your immune system by getting adequate restorative sleep, rest, exercise, sunshine, stress reduction and eating an anti-inflammatory diet. Avoid alcohol (which impairs your immune system) and quit smoking. You can help prepare your body to mitigate a cytokine storm by increasing in your cell membranes, the omega 3 marine fats (EPA and DHA) which are the precursors for RESOLVINS that help regulate the inflammatory response. The inflammatory response is protective but when out of control it can be lethal in the ICU or on your way to the hospital. Your body’s defense systems can be optimized by eating an anti-inflammatory diet rich in nutrients that support immunity and regulate inflammation. A healthy diet can only be beneficial. All of these measures can be practiced while sheltering in place and practicing social distancing.

THIS WEBSITE PROVIDES INFORMATION FOR EDUCATIONAL PURPOSES ONLY. CONSULT YOUR HEALTH CARE PROVIDER FOR MEDICAL ADVICE.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob

On March 10 a panel discussion/conference of Infectious Disease and PANDEMIC experts convened at UCSF (University of California San Francisco). Here are the panelists.

• 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 doctor

Unless bracketed, these are direct quotes of the panelists. This was forwarded to me by a physician friend whose colleague prepared it. The “I” refers to that colleague.

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

March 10, 2020

• 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.  [MoreI found online.]
  • 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 health, especially respiratory or cardio-vascular illness.  These conditions are higher in older adults.
    • Risk of pneumonia is higher in older adults.

• 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 Labcorp 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 UC Berkeley 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.

So that is the synopsis provided by my friend’s colleague.

Unfortunately, the Trump administration has been dangerously incompetent in addressing-mitigating the public health and economic impact. Trump STILL HAS NOT DECLARED THIS A NATIONAL EMERGENCY!

Whitehouse spokespeople have stated Trump does not want to declare this an emergency because it would contradict his earlier statements that COVID19 is not a serious problem (he tweeted and stated it is less serious than the flu). If declared a NATIONAL EMERGENCY it would free up large amounts of money and resources for public health, FEMA, and economic assistance, yet it has not been done. INSTEAD, TRUMP is waiting for his son-in-law (who has no scientific training) to research COVID19 and make recommendations for national policy!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

SERIOUSLY???????????

This post and all posts are for informational, educational purposes and should not be taken as medical advice. Consult your health care practitioner for medical advise.

Eat clean, drink filtered water, love, laugh, exercise outdoors in a greenspace, get some morning sunlight, block the blue light before bed, engage in meaningful work, find a sense of purpose, spend time with those you love, AND sleep well tonight.

Doctor Bob