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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The importance of the ACA in the pandemic. "Before the Affordable Care Act (ACA) was implemented, people who lost their jobs had limited choices for health insurance. Newly disabled people could apply for Medicaid if their savings and assets were low enough for them to qualify for Supplemental Security Income, or they could enroll in Medicare after receiving 2 years of benefits from Social Security Disability Insurance. For adults without a disability, many states’ income cutoffs for Medicaid were well below the poverty line, and only people with dependent children could apply. An individual private-insurance market existed, but without insurer regulations — such as guaranteed issue, community rating, actuarial-value standards, and coverage of essential health benefits — plans were skimpy, excluded people with preexisting conditions, and were often unaffordable. Married people who lost their jobs could potentially switch to their partner’s employer-sponsored insurance (ESI) plan. Finally, the Consolidated Omnibus Budget Reconciliation Act of 1985, known as COBRA, allowed former employees and their dependents to temporarily continue their enrollment in employer-based insurance. Former employees who opt for COBRA coverage must pay 102% of the full premium cost (the employee plus employer shares), however, which has led to very low levels of take-up.
The ACA, having created several new options for health insurance unrelated to employment, will protect many recently unemployed people and their families from losing coverage. In the 36 states that opted to expand their Medicaid programs, expansion removed asset tests and categorical eligibility requirements (for example, policies that required enrollees to be disabled, pregnant, or parents of dependent children) and extended eligibility to all U.S. citizens and qualifying documented immigrants with incomes below 138% of the federal poverty level. Many newly displaced workers will therefore be able to apply for Medicaid. Under another ACA provision, young adults can stay or go back on their parents’ plans as dependents through 26 years of age. And by establishing health insurance marketplaces supported by consumer protections and premium tax credits, the law has allowed people to shop directly for subsidized, comprehensive coverage."
Source: https://www.nejm.org/doi/full/10.1056/NEJMp2023312
Commentary: The ACA may be the only stopgap available for millions of unemployed Americans; without it, they would be unable to seek care during the pandemic. If the pandemic should have taught America anything, it's that universal healthcare is a necessity, a basic safety net that can be leveraged when times are tough.
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An early mutation, documented. "In this cohort study, we identified 39 patients across three transmission clusters in Singapore who were infected with the Δ382 variant of SARS-CoV-2. Ten (26%) harboured a mix of wild-type and ∆382-variant viruses, while 29 (74%) had only the ∆382 variant. A multivariable logistic regression model indicated that the variant was associated with less severe infection in terms of hypoxia requiring supplemental oxygen (adjusted odds ratio 0·07 [95% CI 0·00–0·48]). Patients infected with the Δ382 variant also had lower concentrations of proinflammatory cytokines, chemokines, and growth factors that are strongly associated with severe COVID-19.
ORF8 is a hotspot for coronavirus mutation. The clinical effect of deletions in this region appears to be a milder infection with less systemic release of proinflammatory cytokines and a more effective immune response to SARS-CoV-2. Further study of these variants could have implications for development of treatments and vaccines."
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31757-8/fulltext
Commentary: It's unfortunate that the 382 mutation didn't catch on and become the dominant form of SARS-CoV-2 instead of the D614G mutation. The pandemic might have been mitigated much sooner and with fewer deaths had it been.
That said, any mutation has the potential to be better or worse in its outcome. Continued vigilant monitoring of the virus is essential for when it mutates next - and as all things do, it will. The worst case scenario with SARS-CoV-2 would be a mutation increasing infectivity and also increasing disease severity, both of which are possible. The D614G mutation appears to have increased infectivity already.
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After-care impact. "In this case series of 247 patients hospitalized with COVID-19 in 3 hospitals in Boston, Massachusetts, we found that a substantial number of patients were Hispanic (30%) and of low socioeconomic status as suggested by the proportion of patients insured by Medicaid or dual-eligible for Medicare and Medicaid (33%). Many patients were either retired (36%) or unemployed (8.5%). We found prescriptions of hydroxychloroquine (72%), and statins (76%; newly initiated in 34% of all patients) were very common early in the pandemic. The majority of patients have survived their hospitalization (86%), however, approximately one third required post-acute care, and one in seven required supplemental oxygen, one in eleven required tube feeding, and one in six required new prescriptions for antipsychotics, benzodiazepines, methadone, or opioids on discharge. Among patients readmitted over the follow-up period (10%), 41% were due to respiratory symptoms."
Source: https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30248-0/fulltext
Commentary: The alarming part of this study is how many patients needed significant care after hospitalization. A full third needed substantial care, and 16% needed mental health medication. When we talk about the effects of COVID-19, we must stop thinking of it as either died or recovered - the quality of life after the disease must be accounted for as well.
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Breastfeeding appears to be safe. "Although SARS-CoV-2 RNA was detected in 1 milk sample from an infected woman, the viral culture for that sample was negative. These data suggest that SARS-CoV-2 RNA does not represent replication-competent virus and that breast milk may not be a source of infection for the infant. Furthermore, when control samples spiked with replication-competent SARS-CoV-2 virus were treated by Holder pasteurization, no replication-competent virus or viral RNA was detectable. These findings are reassuring given the known benefits of breastfeeding and human milk provided through milk banks."
Source: https://jamanetwork.com/journals/jama/fullarticle/2769825
Commentary: Good news for nursing mothers.
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Race not a factor in actual treatment. "After adjustment for age, sex, insurance, comorbidities, neighborhood deprivation, and site of care, there was no statistically significant difference in risk of mortality between Black and White patients (hazard ratio, 0.93; 95% CI, 0.80 to 1.09).
Although current reports suggest that Black patients represent a disproportionate share of COVID-19 infections and death in the United States, in this study, mortality for those able to access hospital care did not differ between Black and White patients after adjusting for sociodemographic factors and comorbidities."
Source: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769387
Commentary: A wonderful affirmation for the healthcare heroes we already knew they were. Economic status is closely correlated with race, but when controlled for, race itself is not a factor in mortality, indicating that the same standard of care is being dispensed.
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The importance of readability. "We found that official information about COVID-19 exceeded the recommended reading level, exhibited complex syntax, and used technical terminology. The significant difference in use of difficult terms between the CDC and state resources may reflect the influence of federal oversight mandating government communication that is understandable to the public. Limitations included the focus on text, with no evaluation of multimedia communication, and lack of data about actual comprehension or relevant outcomes such as adherence to mitigation strategies.
Nonadherence to readability standards may have a greater influence in communities with lower health literacy, potentially exacerbating the disparate effects of the pandemic. As such, efforts should focus on the urgent development of plain-language COVID-19 resources that conform to established guidelines for clear communication and are more accessible to all audiences."
Source: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2769382
Commentary: Readability of language matters, especially when you're trying to communicate important information in a crisis. That the CDC is publishing information at the 11th grade level and states are publishing information even higher means that substantial numbers of people aren't learning what they need to know - and it's left up to interpretation or regular media outlets to water it down, potentially losing important clarifications or nuance.
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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.