Lunchtime Pandemic Reading, 9-June-2020
80% of patients who incur diffuse alveolar damage see reduced lung function/capacity
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.
You are welcome to share this.
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Testing continues to be a challenge, especially with respect to accuracy. "First, diagnostic testing will help in safely opening the country, but only if the tests are highly sensitive and validated under realistic conditions against a clinically meaningful reference standard. Second, the FDA should ensure that manufacturers provide details of tests’ clinical sensitivity and specificity at the time of market authorization; tests without such information will have less relevance to patient care.
Third, measuring test sensitivity in asymptomatic people is an urgent priority. It will also be important to develop methods (e.g., prediction rules) for estimating the pretest probability of infection (for asymptomatic and symptomatic people) to allow calculation of post-test probabilities after positive or negative results. Fourth, negative results even on a highly sensitive test cannot rule out infection if the pretest probability is high, so clinicians should not trust unexpected negative results (i.e., assume a negative result is a “false negative” in a person with typical symptoms and known exposure). It’s possible that performing several simultaneous or repeated tests could overcome an individual test’s limited sensitivity; however, such strategies need validation."
Source: https://www.nejm.org/doi/full/10.1056/NEJMp2015897
Commentary: With testing accuracy as low as it has been, we need to keep continually testing to monitor for potential outbreaks. False negatives on tests create the real possibility of a super-spreader event that will be hard to get control of.
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Swabs may be limiting our testing capacity unnecessarily. "Our study shows the clinical usefulness of tongue, nasal, or mid-turbinate samples collected by patients as compared with nasopharyngeal samples collected by health care workers for the diagnosis of Covid-19. Adoption of techniques for sampling by patients can reduce PPE use and provide a more comfortable patient experience. Our analysis was cross-sectional, performed in a single geographic region, and limited to single comparisons with the results of nasopharyngeal sampling, which is not a perfect standard test. Despite these limitations, we think that patient collection of samples for SARS-CoV-2 testing from sites other than the nasopharynx is a useful approach during the Covid-19 pandemic."
Source: https://www.nejm.org/doi/full/10.1056/NEJMc2016321
Commentary: Swabs have been one of the many supplies that have run short in the pandemic. Several studies have now shown that viral loads are high in spit as well, which should open the door to greater testing possibilities. Plus, having a Q-tip stuck far up your nose isn't high on anyone's list of fun. Hopefully, testing capabilities will leverage these newer findings to make testing easier and faster - getting someone to spit in a tube is a lot easier than getting them to hold still while a 6-inch swab is shoved into their nasal cavity.
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Postmortem examination of COVID-19 damage. "We histologically examined the lung tissues of 38 patients who died from COVID-19—to our knowledge the largest post-mortem series so far reported—in two main hospitals providing care to patients with progressive breathing failure in a peak epidemic area in Italy. We focused on the detailed analysis of histological features in these patients to elucidate any distinctive lesions associated with COVID-19. To our knowledge, these data represent the first relevant provisional information regarding tissue damage specifically induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), besides the previously described diffuse alveolar damage, a feature that characterises interstitial pneumonia regardless of infectious agent.
Although our observations are provisional, they were obtained in a large cohort of patients and revealed that histopathological lung damage was characterised by expected features of diffuse alveolar damage, as well as diffuse thrombotic vascular involvement. This latter finding could be relevant in the management and targeted treatment of patients infected with SARS-CoV-2, with the potential to modify outcomes."
Source: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30434-5/fulltext
Commentary: Diffuse alveolar damage is a big deal. For those who survive COVID-19, it means a strong possibility of lung damage that will take a long time to regenerate; some studies have shown that 80% of patients who incur diffuse alveolar damage see reduced lung function/capacity. COVID-19 may not kill more than a few percentage of the people it affects, but that damage will impact many more, for a substantial part of their lives. Containing it is essential.
Source: https://www.uptodate.com/contents/acute-respiratory-distress-syndrome-prognosis-and-outcomes-in-adults
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Russia's handling of COVID-19 may have political consequences. "Regionalisation and delegation have led to a problem with overall public health messaging, a consistent feature of countries struggling to manage their COVID-19 outbreaks. On May 11, President Vladimir Putin called an end to Russia's “non-working period”, first declared on March 30. As part of these measures, wages were paid by companies for furloughed workers, rather than the state, but the removal of these measures meant companies could refuse to pay workers who did not return to work. The return to work for Russians clashed with the message from deputy prime minister, Tatiana Golikova, who subsequently explained that only 11 of Russia's 85 regions were in the position to loosen restrictions at all. Although regions have been in charge of their own lockdown measures, the message from the central powers has been the need to return to work and restart the economy.
Among all of this, public trust in Putin appears to be eroding, with his approval rating tumbling in recent weeks. There is a sense that by leaving the difficult decisions about public health to the regions he will absent himself from blame for the toll of the pandemic in Russia. The USA, Brazil, and to an extent the UK, have seen how local government and the public often have to use their own best judgment when they do not receive direct, consistent messaging from the top. There are many unique factors at play in the Russian epidemic, but a lack of clear political leadership has become a common hallmark of countries that have suffered the most."
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31280-0/fulltext
Commentary: The political implications of COVID-19 impacting a leader shouldn't be taken lightly. Such duress can make leaders act rashly, create false narratives, scapegoat, or other tactics to deflect attention away from their failures, usually with substantial consequences.
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Indigenous populations' elders are especially in danger of COVID-19, with significant cultural consequences. "Governments should anticipate the need for emergency resources to support Indigenous populations and should support them as a vulnerable and autonomous group—for example, by supporting containment measures such as limiting travel in and out of their lands, as deemed necessary and appropriate by the communities themselves. The public should recognise that government-led solutions have historically not been adequate, and make such communities a priority target for individual and private philanthropy. Such giving must first support efforts on the ground, devised and run by Indigenous communities themselves, and any COVID-19-related resources provided should be managed by the communities.
As the burden of COVID-19 increases among Indigenous communities, it will invariably take a toll on elders, who are the reservoirs of language and history. Their deaths would represent an immeasurable cultural loss. Indigenous communities have much to teach us about how to live sustainably and communally in a time when individualistic efforts seem to trump care for the most vulnerable; investing in their health is an investment in all of our futures. Valuing the unique contribution of such communities demands that our goal with respect to their wellbeing should not simply be that they survive this pandemic, but that they thrive after it."
Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31242-3/fulltext
Commentary: If you have the means, consider donating to the healthcare organizations in indigenous communities near you to help save elders' lives and preserve cultural heritage.
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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.
2. Wear gloves and a mask when out of your home. Consider wearing a face shield.
3. Stay home as much as possible. Minimize your contact with others and maintain physical distance of at LEAST 6 feet / 2 meters. Avoid indoor places as much as you can.
4. Get your personal finances in order now. Cut all unnecessary costs.
5. Donate any PPE you can. https://getusppe.org/give/
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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.