Lunchtime pandemic reading.
Standard disclaimer: this is a roundup of informative pieces I've read that interest me on the severity of the crisis and how to manage it. I am not a qualified medical expert in ANY sense; at best I am reasonably well-read laity. ALWAYS prioritize advice from qualified healthcare experts over some person on Facebook.
This is also available as an email newsletter at https://lunchtimepandemic.substack.com if you prefer the update in your inbox.
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Commentary: the world has passed 25 million cumulative cases. The United States at 6 million, Brazil at almost 4 million, India at 3.6 million. 851,000 global deaths so far, 183,700 deaths in the United States, 121,000 deaths in Brazil. I was speaking to a colleague this morning in Luxembourg and they saw a true second wave in July and August. The pandemic is far from over. Stay vigilant.
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More evidence that testing should move to saliva-based tests. "Recent studies have shown that SARS-CoV-2 can be detected in the saliva of asymptomatic persons and outpatients.1-3 We therefore screened 495 asymptomatic health care workers who provided written informed consent to participate in our prospective study, and we used RT-qPCR to test both saliva and nasopharyngeal samples obtained from these persons. We detected SARS-CoV-2 RNA in saliva specimens obtained from 13 persons who did not report any symptoms at or before the time of sample collection. Of these 13 health care workers, 9 had collected matched nasopharyngeal swab specimens by themselves on the same day, and 7 of these specimens tested negative (Fig. S2). The diagnosis in the 13 health care workers with positive saliva specimens was later confirmed in diagnostic testing of additional nasopharyngeal samples by a CLIA (Clinical Laboratory Improvement Amendments of 1988)–certified laboratory.
Collection of saliva samples by patients themselves negates the need for direct interaction between health care workers and patients. This interaction is a source of major testing bottlenecks and presents a risk of nosocomial infection. Collection of saliva samples by patients themselves also alleviates demands for supplies of swabs and personal protective equipment. Given the growing need for testing, our findings provide support for the potential of saliva specimens in the diagnosis of SARS-CoV-2 infection."
Source: https://www.nejm.org/doi/full/10.1056/NEJMc2016359
Commentary: Saliva-based detection of SARS-CoV-2 has been known for months now. Why we (globally) aren't adapting our testing protocols to it is beyond me - and again, this is a global issue, not one limited to a specific region. Advocate to your public health officials to push for more saliva-based testing.
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The former director of the National Institutes of Health has shocking guidance: ignore the CDC. "We were startled and dismayed last week to learn that the Centers for Disease Control and Prevention, in a perplexing series of statements, had altered its testing guidelines to reduce the testing of asymptomatic people for the coronavirus.
These changes by the C.D.C. will undermine efforts to end the pandemic, slow the return to normal economic, educational and social activities, and increase the loss of lives.
Like other scientists and public health experts, we have argued that more asymptomatic people, not fewer, need to be tested to bring the pandemic under control. Now, in the face of a dysfunctional C.D.C., it’s up to states, other institutions and individuals to act.
Understanding what needs to be done requires understanding the different purposes of testing. Much of the current testing is diagnostic. People should get tested if they have symptoms — respiratory distress, loss of smell, fever. There is no argument about this testing, and the altered C.D.C. guidelines do not affect it.
But under its revised guidelines, the C.D.C. seeks to dissuade people who are asymptomatic from being tested. Yet this group poses both the greatest threat to pandemic control and the greatest opportunity to bring the pandemic to an end. It is with this group that our country has failed most miserably.
These are practical and essential actions that need to be taken now. In the absence of sensible guidance from the C.D.C., what can the country do to control the pandemic? We urge at least three actions.
State and local leaders should be emboldened to act independently of the federal government and do more testing. Some governors and local public health officials, from both parties, are already doing so and are ignoring the C.D.C.’s revisions. This position is legally sound, since the C.D.C. is an advisory agency, not a regulatory one. Still, such discord undermines confidence in public health directives.
Insurance companies, city and state governments, and the Center for Medicare and Medicaid Services should recognize the economic and health benefits of testing prioritized, asymptomatic populations and provide reasonable reimbursement for these tests. A major impediment to more widespread testing has been the lack of coverage in the absence of symptoms or known contacts with infected individuals. The costs of testing are decreasing as new methods, like antigen testing, are introduced, and may be further reduced as the pooling of samples makes testing more efficient.
While more widespread testing for the virus is an essential factor in pandemic control, we need to make it part of a broad program that helps prevent transmission — mask-wearing, hand-washing, quarantining and use of personal protective equipment.
The C.D.C., the federal agency that should be crushing the pandemic, is promoting policies that prolong it. That means that local, state and organizational leaders will have to do what the federal government won’t."
Source: https://www.nytimes.com/2020/08/31/opinion/cdc-testing-coronavirus.html
Commentary: I believe there's some nuance here; the clinical data the CDC shares is still worth investigating, as are many of its analyses. However, the Trump administration has shown no hesitation in pressuring top officials to adhere to their wishes, and that guidance should definitely be verified against known scientific evidence. It's a sad day for the organization and an even sadder one for the United States of America. As always, continue to follow real, credentialed experts from multiple labs and institutions to triangulate on what is accepted, peer-reviewed data and guidance.
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Public transit and enclosed spaces spread the virus. "In this cohort study of 128 individuals who rode 1 of 2 buses and attended a worship event in Eastern China, those who rode a bus with air recirculation and with a patient with COVID-19 had an increased risk of SARS-CoV-2 infection compared with those who rode a different bus. Airborne transmission may partially explain the increased risk of SARS-CoV-2 infection among these bus riders.
In this cohort study and case investigation of a community outbreak of COVID-19 in Zhejiang province, individuals who rode a bus to a worship event with a patient with COVID-19 had a higher risk of SARS-CoV-2 infection than individuals who rode another bus to the same event. Airborne spread of SARS-CoV-2 seems likely to have contributed to the high attack rate in the exposed bus. Future efforts at prevention and control must consider the potential for airborne spread of the virus."
Source: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2770172
Commentary: Another study reinforcing the airborne nature of the virus. An airborne disease means that 6 feet/2 meters of distance IS NOT ENOUGH TO PROTECT YOU ALONE. You must also combine other measures like wearing the best mask available to you, whatever that is.
Remember, COVID-19 is like radiation. The more of it you're exposed to for longer durations, the more likely you'll contract it and the more likely it is your course of illness will be severe. Minimize your exposure to indoor places, to closed airspaces, to people in general to reduce your risk overall, and use as many countermeasures as possible like masks, washing and sanitizing your hands, etc.
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Expect some refunds in health insurance over time. "The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented financial stress on most of the US health care system, including physician practices, emergency medical service systems, and hospitals. But there is one notable exception: health insurance companies. Sharp declines in elective care during the pandemic have reduced health care expenditures and contributed to earnings that are twice as large as those earned last year. For example, the UnitedHealth Group’s net income during the second quarter grew from $3.4 billion in 2019 to $6.7 billion in 2020 and Anthem Inc’s net income increased from $1.1 billion to $2.3 billion.
Under the law, insurers must return a large portion of these excess revenues back to individuals, families, and employers. Insurers can keep only 15% or 20% of premiums for administration and profit; if they fail to spend the remainder on health services and efforts to improve quality, they must rebate the difference.
This process, however, was designed to account for modest annual variation and not precipitous drops in expenditures, and it moves slowly. Funds returned to families and employers this year are based off unspent funds from 2017 to 2019. Accordingly, reductions in medical spending from 2020 will not be fully rebated until 2023.
There is a better option for this unprecedented situation. Amid a national crisis, the unspent premiums generating these windfalls represent an opportunity to urgently fight the pandemic, as well as buffer the economic shock of the recession today.
Thus far, insurers have handled their financial good fortune in a variety of ways. Some have advanced funding or loaned money to health care organizations. Others have pursued stock buybacks, which can create wealth for shareholders. A few are following the lead of auto insurance companies and are offering early rebates to enrollees, with encouragement by the US Department of Health and Human Services.
At a time of growing fiscal strain, budget deficits, and layoffs, health insurers are well positioned to be a critical source of support for their communities. Now is not the time to be cautiously holding onto extra revenues for a rainy day. Now is the rainy day."
Source: https://jamanetwork.com/channels/health-forum/fullarticle/2770148
Commentary: Insurance companies are inherently for-profit entities and thus will maximize shareholder value to the fullest extent permitted under the law. I would expect them to behave no differently, despite the author's earnest ideas and ideals. To reform health spending, insurance itself will have to be reformed.
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Kids are germ bombs. "The first important take-home point from this study is that not all infected children have symptoms, and even those with symptoms are not necessarily recognized in a timely fashion. A major strength of this study is the inclusion of asymptomatic children (20 of 91 [22%]), presymptomatic children (18 of 91 [20%]), and symptomatic children (53 of 91 [58%]).13 Most symptomatic infected children had experienced symptoms a median (range) of 3 (1-28) days prior to being diagnosed by testing, despite the fact that they were presumably under closer scrutiny by nature of being identified as a known contact. Presymptomatic children remained symptom free for a median (range) of 2.5 (1-25) days before exhibiting any symptoms, despite detectable virus. Only a minority of children (6 [7%]) were identified as infected by testing performed concurrent with onset of their symptoms. This highlights the concept that infected children may be more likely to go unnoticed either with or without symptoms and continue on with their usual activities, which may contribute to viral circulation within their community.
The authors’ inclusion of asymptomatic patients in the study is particularly important and has rarely been addressed in the pediatric population. Interestingly, this study aligns with adult data in which up to 40% of adults may remain asymptomatic in the face of infection.14 The true burden of unrecognized asymptomatic disease is still not known but is emerging as both viral molecular testing as well as antibody testing to establish seroprevalence have become more broadly available and applied. Application of these methodologies to specifically characterize the pediatric population is sorely needed. In the absence of test-based strategies for social reentry or the ability to aggressively perform contact tracing, asymptomatic infected individuals remain undetected and not isolated. The study by Han et al13 corroborates that children are no exception. In this study, the authors estimate that 85 infected children (93%) would have been missed using a testing strategy focused on testing of symptomatic patients alone. A surveillance strategy that tests only symptomatic children will fail to identify children who are silently shedding virus while moving about their community and schools. In regions where use of face masks is not widely accepted or used by the general public, asymptomatic carriers may serve as an important reservoir that may facilitate silent spread through a community.
The second important take-home point from this study is that the duration of symptoms in symptomatic infected pediatric patients varies widely. The median (range) duration of symptoms for the full cohort was 11 (1-36) days.13 However, the group of children who were presymptomatic at the time of laboratory diagnosis had the shortest median (range) duration of symptoms (3.5 [1-21] days), which was significantly shorter than the median (range) duration of symptoms in children who had symptoms develop concomitant with diagnosis (6.5 [1-12] days) and those who were symptomatic preceding their diagnosis (13 [3-36] days). Although the majority of symptomatic children (41 of 71 [58%]) had upper respiratory tract disease, there was no difference in the duration of symptoms between those with upper vs mild or moderate lower respiratory tract infection. This suggests that even mild and moderately affected children remain symptomatic for long periods of time."
Source: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2770149
Commentary: Kids spread the disease and do so for a long period of time - often escaping detection. If you have the means to do so and you have members of your household at risk, consider educating your children at home regardless of what the local school system is doing. Schools (and any indoor gathering place) are a strong risk vector.
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A reminder of the simple daily habits we should all be taking.
1. Wash/sanitize your hands every time you are in or out of your home for any reason. Consider also spraying the bottoms of your shoes with a general disinfectant (alcohol/bleach/peroxide) when you return home. Remember that cleaners are never to be ingested or injected.
2. Wear a mask when out of your home and if going to a high risk area, wear goggles. Respirators are back in stock at online retailers, too.
3. Stay home as much as possible. Minimize your contact with others and maintain physical distance of at LEAST 6 feet / 2 meters, preferably more. Avoid indoor places as much as you can; indoor spaces spread the disease through aerosols and distance is less effective at mitigating your risks.
4. Get your personal finances in order now. Cut all unnecessary costs.
5. Replenish your supplies as you use them. Avoid reducing your stores to pre-pandemic levels in case an outbreak causes unexpected supply chain disruptions.
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Common misinformation debunked!
There is no genomic evidence at all that COVID-19 arrived before 2020 in the United States and therefore no hidden herd immunity:
Source:
There is no evidence SARS-CoV-2 was engineered, nor that it escaped a lab somewhere.
Source: https://www.washingtonpost.com/world/2020/01/29/experts-debunk-fringe-theory-linking-chinas-coronavirus-weapons-research/
Source: https://www.nature.com/articles/s41591-020-0820-9
Source: https://www.nationalgeographic.com/science/2020/05/anthony-fauci-no-scientific-evidence-the-coronavirus-was-made-in-a-chinese-lab-cvd/
There is no evidence a flu shot increases your COVID-19 risk.
Source: https://www.factcheck.org/2020/04/no-evidence-that-flu-shot-increases-risk-of-covid-19/
Source: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa626/5842161
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A common request I'm asked is who I follow. Here's a public Twitter list of many of the sources I read.
https://twitter.com/i/lists/1260956929205112834
This list is biased by design. It is limited to authors who predominantly post in the English language. It is heavily biased towards individual researchers and away from institutions. It is biased towards those who publish or share research, data, papers, etc. I have made an attempt to follow researchers from different countries, and also to make the list reasonably gender-balanced, because multiple, diverse perspectives on research data are essential.