This is an excerpt from a MEDSCAPE article. MEDSCAPE is a clinical on-line source of information.

“Clinicians across the United States are petitioning the federal government to follow the lead of South Korea, China, and other nations by imposing an immediate nationwide quarantine to slow the inevitable spread of COVID-19. Without federal action, the creators say, their lives and the lives of their colleagues, patients, and families are being put at increased risk.

In addition to the quarantine, the petition, posted on the website Change.org, calls on US leaders to institute emergency production and distribution of personal protective equipment for healthcare workers and to rapidly increase access to testing.

The petition, which garnered more than 40,000 signatures in just 12 hours and as of this writing was approaching 94,000, was started by an apolitical Facebook group to focus attention on what members see as the most critical issues for clinicians: slowing the spread of the virus through a coast-to-coast quarantine; protection of medical personnel with adequate supplies of essential equipment; and widespread testing.”

Meanwhile, growth curves for various countries show US is on the same path as ITALY. The doubling time of cases in the US appears to be about 2 days! See the slope for the US on the chart below. Compare it to the double-every-2-day line.

You can see the direct source of this curve here. But on the curve below the US has been superimposed. (added) Please note that # cases is on a logarithmic scale.

Doctors at the front line are trying to protect everyone, including their own families who are at risk from their daily exposure while at work.

“The COVID-19 US Physicians/APP Facebook group includes 20 volunteer moderators who handle hundreds of posts per hour from persons seeking information on the novel coronavirus, what to tell patients, and how to protect themselves.”

While initially denying the problem, CHINA subsequently took drastic measures and the results are evident in the curve above. Almost complete cessation of growth has occurred in China (but this could rebound as restrictions are removed).

China is not an open society and personal freedom, that we cherish so dearly and appropriately defend, in combination with ineffective leadership, has produced the deadly and alarming situation in the US.

The response in the US has been TOO LITTLE, TOO LATE.

Finger pointing at this critical time will distract from our country uniting to fight this. But we need thoughtful and effective leadership at the highest level, which has been tragically lacking.

At the same time we must learn from our mistakes and the mistakes of others.

“When health authorities in Wuhan, China ― widely cited as the epicenter of the global pandemic ― cordoned off the city, the infection rate dropped from one person infecting 3.8 others to one infecting 1.25, thereby significantly slowing the rate of transmission.”

Early on, WHO-approved test kits (made in Germany) were available but the US did not use them and instead waited for kits to be produced in the US. (Whitehouse mandate) Our testing is still FAR behind other countries, delaying a full scale response.

Doctors from around the country have reported shortages of test kits and PPE (sources: personal phone calls to my colleagues across the country, various press reports, and The COVID-19 US Physicians/APP Facebook group)

The present administration eliminated, soon after taking office, the Pandemic Emergency Response Team that would have coordinated multiple Federal Agencies responding to a PANDEMIC.

Why? “Unnecessary duplication”.

If a centralized coordinating TEAM  was not necessary why are we seeing such an ineffective response to the crisis (rapid growth rate of cases)?

Hospitals in hot zones will soon be running short on masks, gloves, gowns (PPE, personal protection equipment) that protect health workers from contracting the disease. Previous OSHA rules would have required (before COVID-19 existed) that hospitals  stockpile these supplies in adequate amounts to meet the demands of a PANDEMIC. This measure was tragically removed from OSHA requirements by the present administration. (too expensive)

We must stop making mistakes and respond forcefully, quickly, more intensely and learn from these and other mistakes to avoid this in the future.

So think about  the petition signed by 94,000 (and growing) US doctors and other providers which asks for an immediate coast to coast quarantine and immediate emergency-funded production/distribution of PPE and test kits.

White House press conferences have promised allot but produced very little. Germany has ordered 10,000 new ventilators and asked a manufacturer to immediately increase production. The Whitehouse, after stating that “many, many ventilators” would be available later told governors to fend for themselves in getting ventilators. (no instructions for where/how were provided)

Because we have, as a nation, done too little too late, we must now take EVEN MORE drastic measures. We must unite, cooperate,  and listen to the doctors and nurses on the front lines (as described in the petition).

Last week FOX NEWS was still describing COVID-19 as less serious than the flu! Apparently they have thankfully started to change their tune.

BEWARE OF FAKE NEWS.

Here is a comparative chart by country. Please note that # cases is on a logarithmic scale..

This shows how South Korea quickly flattened the curve with fast and effective action while the US continued to demonstrate rapid rates of growth. South Korea instituted major closures, shelter-in-place,  and widescale rapid testing. South Korea responded appropriately with strong and effective leadership. South Korea is much closer to the original source and has as much international travel as the US.

US citizens must think and act responsibly and listen to the petition of >94,000 doctors and other providers.

Yesterday’s Bay Area testing was 1700 total tests, 55 positives.  About 3%.  This ties with the Wuhan rate before drastic measures were instituted.

STAY AT HOME except for essential items and urgent medical care. Do not travel. If you have any symptoms self-quarantine. Follow home hygiene recommendations. Go to the CDC website for details on protection..

Here are some other CDC links

Are You at Higher Risk for Severe Illness? 

Caring for Someone at Home

All A-Z TopicsCoronavirus Disease 2019 (COVID-19)

In my rural county there has only been one case reported (a traveler who returned home) but this is the tip of the iceberg here and testing has not been widespread. Although compared to other areas our Department of Public Health states we are still low risk it is only a matter of days or weeks before that changes. The risks increase on a daily basis EVERYWHERE. Rural areas are just a week or two behind major cities.

We must all do our part to flatten the curve.

Please share this discussion widely with friends, family and colleagues.

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

Read  the words of this Italian journalist and take heed!

“So here’s my warning for the United States: It didn’t have to come to this.

We of course couldn’t stop the emergence of a previously unknown and deadly virus. But we could have mitigated the situation we are now in, in which people who could have been saved are dying. I, and too many others, could have taken a simple yet morally loaded action: We could have stayed home.”

“According to several data scientists, Italy is about 10 days ahead of Spain, Germany, and France in the epidemic progression, and 13 to 16 days ahead of the United Kingdom and the United States. That means those countries have the opportunity to take measures that today may look excessive and disproportionate, yet from the future, where I am now, are perfectly rational in order to avoid a health care system collapse. “

Now some facts about US hospital beds and ventilators.

Although Europe has TWICE AS MANY HOSPITAL BEDS PER 1000 PEOPLE compared to the US, THE US HAS MORE ICU BEDS. (Our hospitals have disproportionately more ICU beds)

But COVID-19 patients in respiratory failure will need more than an ICU bed, they will need a ventilator (and healthcare personnel to manage the ventilator and other aspects of care.)

From the AMERICAN SOCIETY OF CRITICAL CARE MEDICINE

“Supply of mechanical ventilators in U.S. acute care hospitals: Based on a 2009 survey of AHA hospitals, U.S. acute care hospitals are estimated to own approximately 62,000 full-featured mechanical ventilators.⁷ Approximately 46% of these can be used to ventilate pediatric and neonatal patients. Additionally, some hospitals keep older models for emergency purposes. Older models, which are not full featured but may provide basic functions, add an additional 98,738 ventilators to the U.S. supply.⁷ The older devices include 22,976 noninvasive ventilators, 32,668 automatic resuscitators, and 8,567 continuous positive airway pressure (CPAP) units.”

The later mentioned “older devices” are not useful for treating Acute Respiratory Distress Syndrome associated with COVID-10. The use of these devices is contra-indicated for COVID-19 because they create an aerosol which is highly contagious. A patient with COVID-19 in respiratory failure needs intubation and mechanical ventilation with a “full-featured” ventilator. Other “non-invasive” measures for respiratory support cannot/should not be used.

There are already many patients in ICUs on ventilators for other problems like Flu, pneumonia, trauma, burns, COPD exacerbations, sepsis, asthma, post operative care after emergency surgery, etc. We cannot just take those patients off of ventilators to care for COVID-19 cases.

So the 62,000 fully featured ventilators in the US will not all be available for COVID-19 patients (which could easily cause 200,000 cases of respiratory failure in the US).

And if all the remaining unoccupied ventilators are used for COVID-19 then what happens to other critically ill patients with other problems that require mechanical ventilation? (Like your son, daughter, spouse, parent who is in a car wreck, develops bacterial or viral pneumonia, asthma attack, complicated pregnancy, premature baby, or has emergency surgery for any reason and requires ventilator support)

That is why flattening the curve is so necessary.

The protective measures needed to adequately flatten the curve HAVE NOT BEEN TAKEN.

Take heed of the Italian journalist’s warnings. They did not act quickly enough, they did not act intensively enough. What seems like “excessive measures” ARE NOT EXCESSIVE.

1.  STAY HOME EXCEPT FOR FOOD AND URGENT MEDICAL CARE AND OTHER NECESSITIES (BUT WALK OUTSIDE FOR EXERCISE IF YOU ARE NOT SYMPTOMATIC, MAINTAINING 6  FEET BETWEEN YOU AND OTHERS)
2.  ANYONE WITH SYMPTOMS OF AN UPPER RESPIRATORY ILLNESS MUST SELF QUARANTINE AT HOME (FEVER, CHILLS, COUGH, SORE THROAT, FUNNY NOSE, ETC.) WHICH MEANS SOMEONE ELSE MUST GET FOOD INTO THE HOME.
3.  FOLLOW THE CDC PUBLISHED GUIDANCE REGARDING how to clean and disinfect your home,
4.  AVOID PUBLIC TRANSPORTATION
5.  NO SOCIALIZING EXCEPT WITH FAMILY THAT LIVES WITH YOU
6.  WASH HANDS WITH WARM WATER AND SOAP FOR AT LEAST 20 SECONDS EVERY TIME YOU ENTER YOUR HOME FROM OUTSIDE.
7.  IF SOMEONE IS SICK IN YOUR HOME THE SICK PERSON SHOULD BE WEARING A MASK TO PROTECT OTHERS IN THE HOME, NOT THE OTHER WAY AROUND.
8. WASH CLOTHING AND SHEETS FREQUENTLY.
9. WIPE SHOPPING CART HANDLES WITH DISINFECTANT BEFORE YOU USE THEM AND WEAR GLOVES WHEN SHOPPING.
10.  NO KISSING, HUGGING, SHAKING HANDS. (Physical contact with infants, children of course is necessary)

The US still has not instituted adequate measures. “Shelter In Place” along with proper social distancing (when you must absolutely leave home) and hygiene precautions are all necessary to prevent a repeat of the Italian disaster in the US. Some services are essential such as first responders, grocery stores, urgent medical/dental care, mail, pharmacies, utilities etc. These must continue.

Do not eat in a restaurant. Be cautious with take out food. Every time you touch a door handle to a store or shop, your hands are potentially contaminated. So wash hands as soon as you get home, wear gloves whenever possible outside the home. You can use work gloves and disinfect them/leave them in a bag etc.

In my community people are still going for manicures, pedicures, etc. That is NUTS AND IRRESPONSIBLE.

Again the Italian journalist says:

“I heard from a manager in the Lombardy health care system, among the most advanced and well-funded in Europe, that he saw anesthesiologists weeping in the hospital hallways because of the choices they are going to have to make.”

“Until last week, the Italian public health care system had the capacity to care for everyone. Our country has universal health care, so patients aren’t turned away from hospitals here. But in a matter of days, the system was being felled by a virus that I, and many other Italians, had failed to take seriously.”

“The way to avoid or mitigate all this in the United States and elsewhere is to do something similar to what Italy, Denmark, and Finland are doing now, but without wasting the few, messy weeks in which we thought a few local lockdowns, canceling public gatherings, and warmly encouraging working from home would be enough to stop the spread of the virus. We now know that wasn’t nearly enough.”

Please share this as widely as possible with your network of friends, family, colleagues.

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 green space, 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 (but shelter at home), AND sleep well tonight.

Doctor Bob

This video, produced by a colleague, is very informative.

Sleep well, exercise outdoors, laugh, love, engage in meaningful work, drink filtered water, eat clean, eat whole foods, get plenty of sunshine, spend time with those you love.

Doctor Bob

A report from the Imperial College in UK summarizes the results of a model utilizing the most up to date data available. Very sobering!!

Some key points.

We find that that optimal mitigation policies (combining home isolation of suspect cases, home quarantine of those living in the same household as suspect cases, and social distancing of the elderly and others at most risk of severe disease) might reduce peak healthcare demand by 2/3 and deaths by half.

However, the resulting mitigated epidemic would still likely result in hundreds of thousands of deaths and health systems (most notably intensive care units) being overwhelmed many times over.

For countries able to achieve it, this leaves suppression as the preferred policy option.

We show that in the UK and US context, suppression will minimally require

• a combination of social distancing of the entire population,
• home isolation of cases and household quarantine of their family members.
• This may need to be supplemented by school and university closures

The major challenge of suppression is that this type of intensive intervention package – or something equivalently effective at reducing transmission – will need to be maintained until a vaccine becomes available (potentially 18 months or more) – given that we predict that transmission will quickly rebound if interventions are relaxed.

We show that intermittent social distancing – triggered by trends in disease surveillance – may allow interventions to be relaxed temporarily in relative short time windows, but measures will need to be reintroduced if or when case numbers rebound

Last, while experience in China and now South Korea show that suppression is possible in the short term, it remains to be seen whether it is possible long-term, and whether the social and economic costs of the interventions adopted thus far can be reduced.

Certainly this is very sobering. We are in this for the long haul. Reports of some beneficial effects of drugs presently used for other purposes are providing hope for the critically ill.

Various cities and counties have instituted curfews and local ordinances, closing non-essential business under penalty of criminal charges. These measures are necessary for immediate mitigation and suppression.

San Francisco  instituted a “shelter in place” starting at 12:01am this morning in order to enforce enhanced social distancing measures. Again, a wise measure in a hot zone.

Anthony Fauci MD, Director of Infectious Disease and Allergy at NIH has sated “if someone tells you that you are over-reacting then you are doing it right”.

“Younger people should be concerned for two reasons. You are not immune or safe from getting seriously ill. Even though when you look at the total numbers, it’s overwhelmingly weighted toward the elderly and those with underlying conditions. But the virus isn’t a mathematical formula. There are going to be people who are young who are going to wind up getting seriously ill.

So protect yourself, but remember that you can also be a vector or a carrier. And even though you don’t get seriously ill, you could bring it to a person, who could bring it to a person, that would bring it to your grandfather, your grandmother or your elderly relative. That’s why everybody has to take this seriously, even the young.”

Too many in our community are under-estimating the gravity of this situation and the measures necessary to save lives. Those who ignore these recommendations increase risk for their families, friends, and society at large.

Stay at home except for necessities which include food, medicines, urgent medical care.

Immediately wash your hands with soap and water for at least 20 seconds when you come home or come in contact with anything from the outside. Soap and water more effective than hand sanitizer.

Wipe down hard surfaces with Clorox type disinfectants in kitchen, bathroom, phone, door knobs, car door handles, steering wheels, etc.

When out in public for necessities wear gloves, eye protection. Disinfect shopping cart handles before touching them AND wear gloves.

Any item brought into the home handled by other folks should be wiped with disinfectants.

Wash clothing and sheets frequently. Droplets from asymptomatic carriers of COVID-19 can remain on clothing and hard surfaces for a few days and remain infectious. If a retail worker touches their face then touches the item you purchase (or coughs or sneezes on an item) it could transmit disease.

Keep your immune system optimal:

1.  No alcohol. Alcohol suppresses the immune system for several days
2.  Get plenty of sleep, at least 8 hours.
3. Follow good sleep habits.
4.  Eat an anti-inflammatory diet.

Stay safe.

Sleep well, exercise outdoors, laugh, love, engage in meaningful work, drink filtered water, eat clean, eat whole foods, get plenty of sunshine, spend time with those you love.

Doctor Bob

Here is the link to a great interactive tool that shows the risk reduction or increase with early/aggressive vs. late/mild intervention with respect to social distancing etc. I highly recommend visiting this site. You can move the time line through various scenarios. The site also provides very useful information. Hat tip to my friend Joe Andresen MD for sending me the link.

Be Safe.

Doctor Bob

Here it is, you can subscribe to receive daily email update.

Stay safe.

Daily updates on the emerging novel coronavirus from the Johns Hopkins Center for Health Security. The Center for Health Security will be analyzing and providing updates on the emerging novel coronavirus. If you would like to receive these daily updates, please sign up here and select COVID-19. Additional resources are also available on our website. March 13, 2020 Note: although we include case counts to help provide situational awareness to our readers, the numbers are constantly changing. Please refer to the WHO or the public health agencies of affected countries for the latest information. EPI UPDATES The WHO COVID-19 Situation Report shows a total of 125,048 confirmed cases (4,613 deaths) worldwide. There have been 6,729 new cases in the past 24 hours. French Polynesia, Turkey, Honduras, and Cote d’Ivoire have all reported their first COVID-19 cases in the last day. The Johns Hopkins Center for Systems Science and Engineering (CSSE) dashboard is reporting 137,066 cases and 3,337 total deaths as of noon today. Iran’s Ministry of Health reported 1,289 new cases of COVID-19 and 85 new deaths, bringing the total there to 11,364 cases and 514 deaths. The Italian Ministry of Health reported a total of 12,839 cases and 1,016 deaths. The Singapore Ministry of Health reported200 total cases, of which 103 are currently hospitalized and 11 are in critical condition. Spain reported a total of 4,209 cases and 120 deaths. The US CDC reported a total of 1,215 cases and 36 deaths across 42 states and Washington, DC. Of those cases, 125 are travel-related, 102 are close contacts of known cases, and 988 are still under investigation. The South Korean CDC reported a total of 7,979 confirmed COVID-19 cases, including 67 deaths. Epidemiological links have been identified for 79.8% of cases. The most recent report provides an updated breakdown of cases by region, sex, and age group, providing additional insight into the ongoing epidemic. Females represent 61.9% of cases but only 41.8% of deaths. The unadjusted case fatality ratio for individuals aged 80 years and older is 8.30% (21 deaths out of 253 cases), and it is 4.74% for those 70-79 years old and 1.42% for those 60-69 years old. For cases under the age of 60, the case fatality ratio is only 0.12%. Notably, there have been only 2 deaths below the age of 50, despite 4,712 confirmed cases. The epidemic in South Korea has been driven largely by the community around the Shincheonji religious group (4,780 cases; 59.9% of all cases). REPORTS OF HEALTH SYSTEM BURDEN IN ITALY The New York Times reported that Italy’s health system has become rapidly overwhelmed in just 3 weeks, leading to severely limited availability for ventilators and necessitating difficult decisions regarding how ration medical care among patients. The rapid spread and increase in the number of severe cases prompted Italy to enforce radical social distancing measures and to strongly encourage other countries to rapidly implement these measures as well. As reported yesterday, Italy implemented strict quarantine measures nationwide, including closing many businesses. People will still be able to access public areas under certain conditions, but they are encouraged to remain at home and avoid non-essential gatherings. A pre-print recent report from faculty here at the Johns Hopkins Center for Health Security and collaborators also addresses the need for rapid implementation of social distancing measures to slow the spread of epidemic and mitigate health system burden. SINGAPORE ANNOUNCES NEW RESTRICTIONS Singaporerecently expanded its travel restrictions to include visitors with travel history to Italy, France, Spain, and Germany in the last 14 days. These individuals will not be allowed entry or transit through the country, and those already in the country with travel history from those countries will receive stay-at-home notices. Singapore already had travel restrictions in place for China, Iran, and South Korea. US RESPONSE The US Senate will cancel the recess scheduled to begin today in order to remain in session to draft and debate legislation related to the US COVID-19 response. Senate Majority Leader Mitch McConnell was under pressure, including from fellow Republican Senators, to keep the Senate in session in order to finalize coronavirus legislation. The US House of Representativesand the White House are still negotiating a legislative package that aims to address economic and other effects of the COVID-19 epidemic in the United States. Reportedly, the bill is close to being finalized, with hopes that the House of Representatives could vote on it today. Key issues include free coronavirus testing, paid sick leave for COVID-19 patients, and increased support for states to address funding for unemployment and food assistance programs. According to NPR, the Office of Personnel Management now requires agencies to incorporate telework into their continuity of operations plans, reversing a trend of scaling back telework infrastructure among government employees in recent years. ECONOMIC DECLINES CONTINUE TO BEAR MARKET NPRreported that recent wide-scale stock sell-offs have now led to the start of a “bear market,” which could potentially forecast an impending recession. The Dow Jones Industrial Average has dropped 28% since its high point on February 12. The South China Morning Post also reported similar declines in Asian financial markets. US SCHOOL CLOSURES AND SOCIAL DISTANCING MEASURES Note: for the most up to date information about individual communities, please visit the relevant jurisdiction’s website directly. Ohio Governor Mike Dewine announced that all K-12 schools will be closed through April 3, and the state banned all mass gatherings of more than 100 people. Michigan Governor Gretchen Whitmer also announced that all K-12 schools will be closed through April 5. Notably, Governor Whitmer also expanded access to telemedicine statewide, and she called for President Trump to initiate a special enrollment period for the ACA to ensure access to healthcare during the COVID-19 pandemic. Maryland Governor Larry Hogan announced closure of all schools through March 27 as well as a series of other response measures, including a ban on gatherings larger than 250 people, the closure of cruise ship terminal in Baltimore, and the activation of the Maryland National Guard to support the response. The announcement comes on the heels of Maryland detecting its first reported instance of community SARS-CoV-2 transmission. Washington, DC, public schools will be closed from March 16 – March 31. Spring Break for these schools has been rescheduled for March 17-23 (formerly scheduled for April), and students will participate in distance learning from March 24-31. Meals will be made available for all students during that period at designated schools throughout the District. In addition to Ohio, Michigan, Maryland, and Washington, DC, several other states have closed schools in certain higher-risk areas. Washington Governor Jay Inslee ordered K-12 schools closed in King, Pierce, and Snohomish counties through April 24, affecting 600,000 students in high-risk areas. Schools in San Francisco and part of nearby Contra Costa County in California are also closed, but the state has not mandated closures statewide. Pennsylvania Governor Tom Wolfe announced that schools in Montgomery County (13 reported cases) will be closed for 2 weeks. Pennsylvania is also mandating remote work for state employees, and the state is implementing a 10-day paid leave policy for individuals who cannot work remotely. The governors in Georgia and Kentucky both recommended that schools consider closing, but they did not mandate closures. Many government agencies are recommending or mandating that people avoid crowded spaces and large gatherings, particularly if they are exhibiting COVID-19 symptoms, but this may be more difficult (or impossible) for individuals experiencing homelessness. In Washington, DC, the Department of Health Services (DHS) is coordinating with homeless shelters and local healthcare systems to provide support for these individuals who may need to undergo quarantine. DHS Director Laura Zeilinger said that individuals who seek care for symptoms would not be returned to shelters or other congregate settings. DHS is also providing additional assistance to increase access to hand sanitizer and improve hygiene and sanitation at shelters and locations where food is served. Considering the elevated risk to older individuals, some adult long-term care facilities (e.g., nursing homes) are taking additional measures to protect their residents and patients. As seen in Seattle, nursing homes can be high-risk environments for spreading SARS-CoV-2 among a particularly vulnerable population. Nursing homes are beginning to screen and limit visitors in order to reduce their residents’ risk of exposure, and efforts are ongoing to increase the quality and effectiveness of disinfection and hygiene efforts to reduce the risk of transmitting within facilities. Concerns remain, however, about the toll of prolonged isolation from friends and family for residents of these facilities. The NCAA announced yesterday that all remaining winter and spring sports championships, including the Men’s and Women’s basketball national championships (also known as March Madness), are cancelled due to concerns about coronavirus. The NHL announced yesterday that it is suspending the 2019-20 seasonindefinitely. Major League Baseball, Minor League Baseball, and Major League Soccer all announced a range of cancelations, restrictions, or suspensions in response to COVID-19 as well. Additionally, officials from the Boston Athletic Association and Boston Mayor Martin Walsh announced that the Boston Marathon will be postponed until September 14. CLINICAL COURSE OF COVID-19 A study published on March 11 in The Lancet provides analysis of the progression of the COVID-19 disease in survivors and non-survivors. The study involved 191 hospitalized COVID-19 patients (54 deaths, 137 discharged) in Wuhan, China. Notably, the study describes the timing of various aspects of disease progression in hospitalized patients, including the time from first symptom onset to the onset of various symptoms/conditions, including dyspnoea, sepsis, and ARDS as well as their duration. The article also reports the time to and duration of ICU admission. The study found an increase in the odds of death with increased age, and the mean duration of viral shedding was 20 days from symptom onset in survivors and continuously until death in non-survivors (maximum duration: 37 days). The study found no evidence that antiviral treatment reduces the duration of viral shedding. SPOUSE OF THE PM OF CANADA TESTED POSITIVE Prime Minister Justin Trudeau’s wife, Sophie Grégoire Trudeau, tested positive for SARS-CoV-2, according to a statement by the Prime Minister’s Office. At this time, her symptoms do not appear to be serious, and she will be self-isolating for at least 14 days. Prime Minister Trudeau will not be tested at this time because he is not exhibiting symptoms, but he will self-quarantine for 14 days as well. He does not expect this to affect his duties as Prime Minister. There are growing reports of political leaders from various countries becoming infected or exposed to COVID-19. Subscribe to our newsletter

On March 10, 2020 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 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.  i.e. 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”, i.e. 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, i.e. 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.   i.e. 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.  i.e. 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