Jump to content

mloub

Member
  • Posts

    86
  • Joined

  • Last visited

Everything posted by mloub

  1. thanks for this. however, I dont see 1. as being a big problem. everyone with RA that is successfully treated by biologics (millions of people) get injections or self inject every week or two weeks, with delivery of medicine in cold packs and keeping medicine in fridges. this is no big deal. as well, the manufacture of these biologics is a difficult process, but not so difficult so as to prevent pumping out millions of doses. as you say, this dosing would have to be repeated, but I could see this as being a complement to various other therapies/vaccines being worked on...assuming that this is not a big scam Agreed, Humira is a great drug. But all the issues I outlined in (1) means it costs about $3,000 per month. That might work for a relatively rare disease affecting less than one percent of the population, but scaling it would be very hard. The typical vaccine on the other hand costs less than $100 per dose. With Ebola, it was the vaccine that turned the tide, not these biologics. The Ebola vaccine is 97.5% effective at a fraction of the cost. More importantly it prevents the disease. The Ebola biologics only treat you after you get it. https://www.statnews.com/2019/04/12/the-data-are-clear-ebola-vaccine-shows-very-impressive-performance-in-outbreak/ All of which is moot, because Sorrento's "treatment" is only effective at blocking binding in cell cultures. It has not been tested in Humans and there is a long way to go to prove its efficacy. You'd think we would have learned to reserve judgement after Chloroquine, and Remdesivir, but why not. Everyone is desparate, let's add $2bn in market cap to this textbook pump and dump name. M.
  2. Yeah, this is on the face of it bunk. Here are the reasons why: 1) An antibody is a protein that is unstable. (For a great analogue, take a look at Humira, an antibody that is used to treat inflammatory diseases like Crohns). Because it is unstable, it needs to be refrigerated, has a short shelf-life, and needs to be injected (it can't survive the digestive system) frequently as its effect wears off. 2) Antibodies that you inject are ultimately cleared by your body and so they only have a temporary effect (think weeks) versus a vaccine which confers active immunity for years. Antibodies are used as a treatment, for example, when someone who is not immune to tetanus is exposed to it. They get the antibody to get them over the acute exposure. Then the body clears the antibodies and then they are back to square one, only in the meantime hopefully the antibodies gave them some short term protection. Now people generally know when they are exposed to Tetatnus - "Doc I just stepped on a rusty nail!" - but Covid-19 exposure is often invisible. How do we make sure the right people get the antibody in time? 3) Antibodies are very hard to produce at scale. You essentially have to set up these bioreactors of genetically altered cells that spit out these antibodies. It is very finicky and any contamination at any step in the process destroys the whole line. Think of the clean rooms for manufacturing microprocessors, only harder. 4) This antibody has not been tested on humans yet, apparently. (Should have listed this as point 1). This is not a small deal. Antibodies bind to proteins and either gum up how those proteins work (like Humira) or help target them for destruction by the immune system. There is a lot that can go wrong between seeing this binding effect in a lab culture and having it work as expected in a human. There are a limited number of proteins in a lab culture, in a human there are all sorts of proteins hanging around that can screw things up. "There's many a slip 'twixt the cup and the lip". These guys aren't even in the same room as the lip yet. So with 1-4, I would be very wary of promotional claims like this - "Given the very effective data that we've seen, how potent this antibody is, we are very confident this could actually work out". But you know, hucksters be huckstering. M.
  3. This is an important question, and there is an answer which hopefully will be useful in thinking about this even if it is imprecise. If we think about R0, it is the measure of how infectious a virus is in a population of people who are fully susceptible to it. We know Covid-19 has a high R0 (about 2.5). But the rate of spread in the "real world" is a bit different, because not every host is fully susceptible, especially if we assume that those who have gotten Covid-19 and survived are likely immune (or at least, partially immune), which while unproven would be a safe assumption given past experience. So when can we declare this thing over? When the rate of immune hosts (those who have developed natural immunity after recovering, or those that have received a vaccine, when one becomes available) is high enough to limit the rate of spread to a manageable level. Call this a real-world adjusted R0. That is why many smart folks are warning that this won't be over until we have a vaccine. I would just add to that, or until enough folks have been infected and recovered. Here's to hoping the vaccine comes first. M. Edit: Just to add a more positive thought. We don't necessarily have to exist in a state of lock down until the vaccine arrives. Once we have brought the level of current infection down to a more manageable level through the current lockdowns, we can then shift back to a surveillance, tracking and quarantine model to fight off any local outbreaks. Something which could have saved us all this grief if it was done successfully in February/early March.
  4. I mean could we ever really know if the bullet killed the man, or if he happened to die from complications of hypertension just as the bullet entered his skull? Causation can be tricky after all, and we should study it further before deciding conclusively! M. Nope, no debate at all. The bullet killed the guy. But, the question is how much quality of life the guy gave up due to the bullet? Was it a day, a month, a year, a decade of quality of life? And this is the point that Eric and I made about two weeks ago about Covid-19 mortality. If you look at the existing mortality rates of people by age, and then if you look at the Covid-19 mortality rates by age, you can observe something basic. If you are sick enough that you need medical attention and you are actually clinically diagnosed with Covid, you seem to incur about 2 or 3 years of incremental mortality risk, ignoring pre-existing co-morbidities. So, as Eric noted, if you are 40 right now and you are formally diagnosed with Covid, it's more or less like worrying about whether you'll make it to 42 in the absence of Covid. And it's roughly the same deal if you are 80. If you catch covid at 80 and it's bad enough that you are tested and formally diagnosed, your risk of dying is more or less the same as your risk of whether you make it to 82 or 83. So, no debate at all about what ends up killing the guy, but lots of room to reflect upon what exactly he "lost" due to the illness. SJ This is a fair and rational point. And from a population perspective losing a large proportion of folks who are already at the later stages of their lives is, as you say, not a huge loss in terms of life-years. But we should also consider the retail side of things. When those 80 year olds, who likely would have died in the next 1-3 years, all die in a short span, it causes bedlam. Each of their families will bring them in, want them treated, want them ventilated. Even more so for the 60 year olds and the 70 year olds with pre-existing conditions. The strain those cases cause is real. And from my experience, folks don't tend to take an actuarial view of their own mortality. When they or their family members are the ones gravely ill, they almost always want everything done that could possibly extend their lives. The truth is almost all our healthcare capacity is already going to treat folks between 60-80 who have pre-existing conditions. Most healthcare expenditures a person incurs are in the last years of their life. While a respiratory virus that disproportionately killed the young would be more damaging economically, C19, which mainly harms those over 60, still has the capacity to bring our healthcare system to its knees. That is the cause for concern, in my eyes. M.
  5. That was a really good post. I have had a conference I was to be at in early July Cancelled. It was to have 30000 - 50000 in attendance. July... think about that for a minute. Hundreds of full time jobs for months eliminated. Multiply that across the globe out to July and August now. Even if Covid were bought under control tonight, it would take months for the economy to recover. And it doesn't matter what the public is told in terms of social distancing, the damage is done. It doesn't matter if a President says everything opens back up in three weeks, he will be ignored. The 24 hour news cycle will keep feeding the hysteria whether it is justifiable or not. The economy and the markets are going way down. Last week was just a head fake. Eventually, some semblance or normalcy will assert itself either due to better treatment, protections, or an outright vaccination, but it will still take months to recover after that. And Elon Musk should stick to his circle of competence, which is building great companies, with exciting vision, not opining on public health. Agreed re: Musk. Here's his latest unsupported tweet claiming many doctors are not treating patients because they are afraid of getting or transmitting C19 - https://twitter.com/elonmusk/status/1244034540995137536 While ofcourse the opposite is happening as thousands of doctors of all specialties, and some in retirement, volunteer to come forward and help in the pandemic - https://bit.ly/2JqyFnC Musk seems hellbent on destroying any goodwill he has earned with Tesla and SpaceX by shooting his mouth off on C19. I have to say, his poor judgement on this topic - one where I feel slightly more knowledgealbe because of my training - makes me wonder what other terrible choices he is making in other domains that I am not as equipped to notice. M.
  6. I mean could we ever really know if the bullet killed the man, or if he happened to die from complications of hypertension just as the bullet entered his skull? Causation can be tricky after all, and we should study it further before deciding conclusively! M.
  7. Agreed. It would be nice to see this study reproduced by othe researchers not related to Prof. Didier Raoult. I believe the CDC is currently studying these treatments in NY, so if there is any promise, we should know soon enough. M.
  8. Yeah, I think the people that have this view are basically misunderstanding five things: [*]Exponential growth [*]It takes weeks between infection and hospitalization and death [*]Hospitals are not infinitely expandable--if enough people come in, hospitals run out of resources [*]If you're in the ICU with this, you are likely in there for weeks [*]That without ventilators, the death rate increases dramatically Everyone I've seen who's taken a "there's no problem" position seems to have basically missed at least one of these points. In that post, he's certainly completely misunderstanding points 1 and 2. He'll probably miss points 3, 4, and 5, but hasn't got to that point yet, because he's so busy missing 1 and 2. If only I had read this earlier it would have saved me so much grief. Great summary! I want to turn this into a printed cue card and just give it to folks when we discuss covid-19 with the appropriate misunderstandings checked off. I don't know what I'll do with all the time I'll save! M.
  9. Well, to be fair to Musk, while cause of death can indeed be reasonably determined, Italy isn't doing it (or at the very least, their statisticians aren't). For some mysterious reason, any death in Italy that ever tested positive for covid-19 is reported as a covid-19 death in their statistics regardless of anything else. Source: quite a few, but for example https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2020/03/24/15/33/case-fatality-rate-and-characteristics Covid-19 (SARS-CoV-2) is a severe respiratory virus whose closest analogue is the 2003 SARS (SARS-Cov). That argument by Musk is a red herring, and he knows it. Every death in Italy will have an official death certificate completed by the pronouncing physician where they will record a cause of death. The statisticians may be using covid-19 infection status as a proxy because it will take time to compile all the paper death certificates. I will bet almost anything that when they do compile the official paper records - you know after they've finished dealing with this pandemic - the numbers between laboratory reported infection status and cause of death will be remarkably similar. It's telling that Musk, who has down-played Covid-19, and then latched on to a questionable study about chloroquine and azithromycin says his conversations with Bill Gates, the person who years ago warned we should prepare for a global pandemic, were "underwhelming" - https://twitter.com/elonmusk/status/1229568241552502784 M.
  10. The second doctor is a boob. He is making some very interesting logical errors. Firstly, he claims, without proof that covid-19 is widespread - at some points he conflates covid-19 with other strains of coronavirus, which he says represent 10-17% of common colds, and then uses that conflation to claim that covid-19 is probably as widespread as the common cold. Then he takes the unfounded leap that if covid-19 is so widespread, maybe we are mis-attributing mortality. Someone who dies and tests positive with covid-19, according to this guys faulty logic, may have died from something else. Musk made a similar dubious argument regarding the Italy death data on twitter, arguing since the dead often had other underlying conditions, maybe it was those conditions that resulted in their death and not covid-19. This line of reasoning lacks even the most basic understanding of pathology and causation. If an elderly person with heart disease, for example, died and tested positive for covid-19, the cause of death can be reasonably determined. Covid-19 infection serious enough to cause death presents with a severe ground-glass pattern pneumonia, decreased oxygenation, fever, increased white blood cell count (and a myriad of other objective measurements) that are NOT present in a cardiac death. To disingeniously claim that we can not tell the difference is so ignorant of the basic facts it would be laughable in any other circumstance. M. I’m not claiming the validity of eithers arguments. Simply saying it’s interesting to see differing opinions. Hence the (fwiw). What were your thoughts on the first? I know. I appreciate you posting it. It's helpful to see the divergent view points. The first guy is using numbers that don't correlate with anything I've read from any other reputable sources, and of course does not cite his sources. I would not consider him a reliable source either. They're both trying to reassure folks. An understandable impulse, but one not supported by verifiable facts. For example, his assertion that 99.5% of cases are asymptomatic. Where does that assertion come from? M.
  11. I know some have complained that this thread has gone off the rails and is of little or no value from an investment perspective. Let me share some thoughts that hopefully have some investment merit, along with my level of conviction. 1) We are in the bottom of the third as far as this pandemic is concerned (High Conviction). This pandemic still has a long way to run - maybe 3-6 months (maybe longer), and the worst in terms of headlines and quarantines is in front of us, imho, not behind us. It is clear now that the response has been botched, especially in the United States, and what comes next is likely to have a deep and lasting impact on our collective psyches and the economy. Even now, before the infection rate has peaked, hospitals across the country are running low on personal protective equipment for their health staff. As supplies run out, and HCWs are forced to improvise, the infection rate among them will soar. This will weaken our capacity to care for infected patients even further. Our mortality rate in North America will likely track somewher between Italy and China's, but I would guess closer to Italy. Those who are comforted by the low mortality rate are celebrating too soon. Once the healthcare system starts to creak under the strain, and the new infections of the past weak start weakening their hosts the mortality rates will go up significantly; 2) The effects of the pandemic on unemployment, consumer spending, and credit will be long lasting (Medium Conviction). Just because case rates start to fall in the spring/summer doesn't mean we will be economically out of the woods. If we look at the number of folks who will be financially wrecked by this pandemic - service workers, small business owners, uber drivers, hair stylists, plumbers, construction works,... - it is not a stretch to say that the impact will likely be as large as the GFC, if not larger. Those who think everyone will pick up where they left off, and the damage will be minimal need to think more about human behaviour, and the typical household's balance sheet. So actionable investment insights: 1) It's not too late for Cash or Hedges - There is a lot of talk of lifting hedges and starting to buy out there. In my opinion, that talk is premature. If you are the sort of person who is inclined to hedge or buy long-dated puts in the first place, there are still opportunities to do so out there. For example, Shopify (SHOP) trades at a 48B market Cap ($46B EV) currently and is about 20% off of it's all time highs, even though it had operating losses of $141m in 2019 (and as far as I can tell, has never turned a profit). In fact, operating losses in 2019 increased by 53.5%, while revenue increased by 47%, a modern 2020 business miracle, which of course explains why the market has wisely priced it at 30.5x its 2019 Sales even in the middle of the worst global pandemic in living memory. 2) Wait to make new investments, or if you just can't help yourself, buy Berkshire - If you think all the bad news re: covid-19 is already priced into the market, refer to SHOP above. The vast majority of the market seems to believe the worst is behind us and happy days will be here again very soon. I would not be inclined to jump in to hotels, airlines, cruise lines or any of the battered names until we have more clarity on covid-19's course. Prices remain too high if you assume we are entering a recession or even just reverting to mean valuations. Of course there maybe some truly under-valued gems out there, but I would stress test even these ideas against a very bleak potential demand situation. And, ofcourse, YMMV. TL;DR - We still have along way to go before this thing is over. M. Edited: SHOP is 20% off of it's all time highs
  12. The second doctor is a boob. He is making some very interesting logical errors. Firstly, he claims, without proof that covid-19 is widespread - at some points he conflates covid-19 with other strains of coronavirus, which he says represent 10-17% of common colds, and then uses that conflation to claim that covid-19 is probably as widespread as the common cold. Then he takes the unfounded leap that if covid-19 is so widespread, maybe we are mis-attributing mortality. Someone who dies and tests positive with covid-19, according to this guys faulty logic, may have died from something else. Musk made a similar dubious argument regarding the Italy death data on twitter, arguing since the dead often had other underlying conditions, maybe it was those conditions that resulted in their death and not covid-19. This line of reasoning lacks even the most basic understanding of pathology and causation. If an elderly person with heart disease, for example, died and tested positive for covid-19, the cause of death can be reasonably determined. Covid-19 infection serious enough to cause death presents with a severe ground-glass pattern pneumonia, decreased oxygenation, fever, increased white blood cell count (and a myriad of other objective measurements) that are NOT present in a cardiac death. To disingeniously claim that we can not tell the difference is so ignorant of the basic facts it would be laughable in any other circumstance. M.
  13. Looks like they have it in WA https://www.npr.org/2020/03/08/813486500/coronavirus-drive-through-testing-centers Well its not available in New York. Where can we source them? NY will need about 40 million of them. This is a bit of a red herring. The nasal swabs just pick up epithelial sells, mucus and whatever else is around and put them in a fixative medium - the red stuff. You can run any PCR test you want on those swabs, there is nothing magical about the swabs. And we have the PCR tests ready to go. That is what Dr. Chu in Seattle did on her pre-existing Flu nasal swabs, and how she identified the 17-year old with the community acquired case that gave officials there a head start in tracking down the community spread. I know we may not have an FDA approved, clinically validated nasal kit for covid-19, but we are past that aren't we? If it is scientifically sound, we should use it now. And to be clear I don't advocate testing all 75 million people, just the ones with Upper respiratory tract infections not explained by another diagnosis. In case of asymptomatic spread, I'm not sure we can do much about that, nor should we focus on it, until we know more about its prevelance. Current sources are conflicting on whether it plays a role at all. Hopefully, social distancing and general precautions can help deal with that. M.
  14. There are actually 4,284 reported deaths as of yesterday.. So in about 3 days the number of deaths went up by 42.8%, give or take. So if we just let this thing run it's course and focus on the flu, what do you project the number of deaths will be in 30 days? 60 days? (Coronaviruses handle the heat better than the flu, after all). M. who knows how fast it is spreading with mortal effect, though we know your 42.8% figure is wrong since you calculated with such false precision ignoring the more than qualifier. dont use data in this argument since the data proves this is a covid-19 panic given the far greater incidence and mortality for flu. data is not your friend in this argument. you are just supporting a panic thesis, and you seem to have a lot of company From the article you referenced: "The death rate from seasonal flu is typically around 0.1% in the U.S., according to The New York Times. The death rate for COVID-19 appears to be higher than that of the flu. In the study published Feb. 18 in the China CDC Weekly, researchers found a death rate from COVID-19 to be around 2.3% in mainland China. Another study of about 1,100 hospitalized patients in China, published Feb. 28 in the New England Journal of Medicine, found that the overall death rate was slightly lower, around 1.4%." So, the death rate from the flu is 0.1% and for COVID-19 anywhere from 1.4%-2.3%. I know these sound like small numbers. But that is a 14-23x higher death rate than the flu. I'm not sure we should be running a natural experiment to see how long it would take covid-19 to overtake the seasonal flu in terms of absolute deaths, but reasonable people can disagree. M.
  15. There are actually 4,284 reported deaths as of yesterday.. So in about 3 days the number of deaths went up by 42.8%, give or take. So if we just let this thing run it's course and focus on the flu, what do you project the number of deaths will be in 30 days? 60 days? (Coronaviruses handle the heat better than the flu, after all). M.
  16. In the greatest health care system in the world, basic public health containment measures are impossible? If so, how did the Koreans manage it with less resources per capita than the US has at its disposal? M. shouldn't everyone presenting with respiratory symptoms self quarantine, by applying our current logic relating to covid-19? many more people die from flu. I dont understand the emphasis on something that is novel but quite small and not on something that is much large, more lethal and something we have at least some prior experience with. also if >80 are at greater risk, why are we not focusing on preventing them from getting it, as opposed to just quarantining those younger who have it...unless it is a bloomie "oh you will die soon" thing Definitely folks who are sick should self isolate. This is important and I am in no way minimizing that. I'm proposing that relying on folks to self-isolate would not be sufficient. As evidence I point to the demonstrable effects that large outbreaks have had in Wuhan, and Northern Italy where presumably sick people were also aware they should self-isolate. The Italian healthcare system is now on its knees. They are scraping together every ICU bed they can. In Northern Italy they are cancelling all elective procedures and emptying out their hospitals of non-covid cases so they can focus on the outbreak. We need to avoid a similar outcome. Believe me the reported number of deaths you are seeing is just the tip of the iceburg. Check back on the death rate in Italy in 14 days and let me know if you still feel this is a minor issue that is being overblown. M.
  17. In the "greatest health care system in the world", basic public health containment measures are impossible? If so, how did the Koreans manage it with less resources per capita than the US has at its disposal? M.
  18. Interesting strategy. Couple questions for you. 1. As I'm sure you know symptoms are cough, difficulty breathing, fever, as well as common cold symptoms. We are still in cold and flu season as you know. That means since symptoms are similar we would need to test 10s of millions of people over the period of a couple of weeks with cold symptoms, pneumonia symptoms, strep throat symptoms, mono symptoms, asthma symptoms, COPD symptoms, flu symptoms, CA, viral URI symptoms, etc etc. You laid out your ABCs, how do you plan on doing this? Honestly? You guys are worried about overload of the medical system with ventilators, ICU beds etc. Jesus Christ. Its not feasible. 2. Im assuming you mean isolating those that test positive. Not above, not realistic. 3. How do you trace the known contacts of someone who traveled with virus? Who is doing this? The physician? The DOH? the CDC? The family? Your going to call the airline?, the hotel?, the restaurant?, etc and trace all known contacts? Honestly? I could see friends and family, but those are not all known contacts. Great idea but what your suggesting is impossible. These are great questions, and this is how I would approach them. First, concentrate on the states with the currently highest known case loads (I know this is a moving target), but let's say Washington, Oregon, California, NY, MA. In these highest risk states, public health officials should be out in the hot spots testing anyone who is symptomatic - just like they did in Korea with their road side checks. Everyone who presents to a doctor with Upper respiratory tract infection symptoms anywhere in the country, who also does not have another proven diagnosis (i.e. Strep Throat, Flu, bacterial pneumonia, etc) should get a nasal swab sent for Covid-19 PCR. This would add a total of 15 seconds to the patient encounter while you uncork the swab stick it up their nose and apologize for the discomfort. There is already an infrastructure in place for flu PCR testing and surveillance across the country, you would basically bolt on the covid-19 testing to the flu surveillance network. People who are symptomatic with no known cause should self-isolate while they wait for their test results. Those who test positive go into quarantine and the source contact tracing and testing pathway. To answer your second question, I would only quarantine folks who tested positive, not all symptomatic people. To answer your 3rd question, the Department of Health should be tracing contacts of known infected cases. This is of course an inexact process, but we should try. There is a well established methodology for doing this and we've been systematically doing this as a society for a couple of hundred years - https://www.theguardian.com/news/datablog/2013/mar/15/john-snow-cholera-map The Koreans were publishing infection travel patterns on a public health website and sending push notifications to phones of folks in the effected areas. For example, "A patient with Covid-19 was identified who was at Jim's Bar at 11pm, and at a Conference in 'So-and-So' building this morning at 8am. If you were at either location and have upper respiratory tract infection symptoms, please present to medical care for testing". I understand this might all seem overwhelming, but it is manageable. The government recently announced $8.5billion in emergency economic aid around Covid-19. All of the measures I describe above, would cost less than half that much money, and would have cost even less if they were started earlier. M. PS. Let's assume it costs $100 per test to test all 10 million folks in the US who currently have upper respiratory tract infections. That would still only cost $1billion, but as I mentioned above, likely less because those with obvious clinical explanations for their symptoms like Strep Throat, Ear infections, Pneumonia, flu, etc would be exluded.
  19. This mealy mouthed defense from the feds quoted in the same article is especially infuriating: "Federal and state officials said the flu study could not be repurposed because it did not have explicit permission from research subjects; the labs were also not certified for clinical work." Covid-19 is clearly a global emergency. Officials are discussing quarantining folks, and restricting their liberties. And the Feds were worried that they didn't have the right consents and protocols in place to test the samples from Seattle in the middle of one of the worst pandemics we've seen in decades... M.
  20. Thanks for sharing, Liberty. This will be an important part of the post-hoc analysis that will happen after this outbreak is contained, I'm sure. The key to controlling these pandemics is acting quickly and working with what you have. Here was a team near the first US cases that had thousands of community collected respiratory samples from patients who had flu like symptoms. They should have tested any sample that was negative for flu for covid-19 right away, if for nothing else, to establish a baseline of any community transmission patterns. If these are PCR tests, similar to the flu tests we use arond here, each test would have cost about $15. This excerpt from the article was especially painful to read: "By Feb. 25, Dr. Chu and her colleagues could not bear to wait any longer. They began performing coronavirus tests, without government approval. What came back confirmed their worst fear. They quickly had a positive test from a local teenager with no recent travel history. The coronavirus had already established itself on American soil without anybody realizing it." Thank god for scientifically literate renegades. If Dr. Chu and her team hadn't broken ranks and tested those samples, we might have been further behind in containing the cluster in Washington state. M.
  21. The medical reports from Italy should serve as a warning for healthcare systems everywhere. I have to say, the attitude that the Italian situation is somehow symptomatic of Italian bureaucracy, or inefficiency, or whatever is unfortnate. The lesson from Italy is that to flatten the curve on this outbreak, governments and healthcare systems need to act swiftly and decisively in the early stages. There is nothing uniquely Italian in the difficulties they are now experiencing. If we don't focus on containment here, the same thing could happen to us. The whole situation is like a fire in a building. You want to detect it and start fighting it as soon as possible - that's why we have sprinklers and smoke detectors, etc. But when it comes to public health, we seem to have gutted the systems that would help us quickly address an outbreak like this. Folks who look at SARS sometimes draw false comfort from how quickly that disease was contained, but not many people know the story of why that was possible. The head of the WHO's Western Pacific Region at the time of the SARS outbreak was an Italian Doctor by the name of Carlo Urbani. When he received a report of an atypical viral pneumonia case in Vietnam, he hopped on the first plane and went to check for himself. It was Urbani who quickly realized that what he was seeing was a novel repiratory virus. When nurses and other medical staff became ill, he examined them too and collected samples that allowed the WHO to raise the first alarms about SARS. Urbani's dispatches from the field identifyingt SARS and the samples he collected helped give the world a jump start on developing testing and containment strategies. Urbani risked his own life to collect those samples and ultimately contracted SARS himself and died. Now imagine if someone else was at Urbani's post and responded to the first reports by brushing them off, or sending some lackey to take a look, and wasting precious weeks and months in the process. Or worse yet, imagine if Urbani was detained and told not to discuss the outbreak like Li Wenliang was in Wuhan after he raised the first alarm in late December when there were only a handful of cases at the Wuhan fish market. It is not too late for us to bend the trendlines in North America closer to those in South Korea, and away from those in Italy, but we have to shake off our complacency and demand better from our political leaders. They are flailing about with no clear idea what to do. There is a rule of thumb in medicine when faced with a catastrophic injury or situation, focus on the basics. We call them the ABCs: airway, breathing, circulation. You do not move off of the ABCs until you've made sure that they are all secured and stable. The ABCs of this outbreak would be A) Identifying as many infected people as possible by testing symptomatic patients regardless of travel history, B) Isolating those infected people as quickly as possible, C) tracing all known contacts of infected people and asking them to self-quarantine; and then repeat. Our governments should be mobilizing any and all resources at their disposal to accomplish A-C; like the Koreans did in their country. We are not anywhere near doing enough, and time is quickly running out. M.
  22. The uncertainty is definitely part of what makes this tricky from a public policy perspective. The influenza and corona virus families, which cause the flu and "colds" respectively, are medically interesting because they keep mutating, versus, say the measles virus, which doesn't. That is why you can only ever get the Measles once, or only need a few measles vaccinations to give you lifetime immunity, whereas you can catch a cold or the flu every year. So, because the influenza and corona viruses keep mutating, we are basically running this ongoing evolutionary lottery. Every once in a while a strain will emerge that has a higher rate of infection, or mortality, or in the worst scenario, both. For example, the Spanish Flu, the Flu outbreak of 1957, SARS, H1N1, MERS, etc. These outbreaks matter, and tracking them and preparing for them is akin to tracking hurricanes. Sometimes the public balks at the imprecision - "Last time you told us a hurricane was coming, we all evacuated and then it veered off into the Ocean!" - but I don't think we should discard the science or the concern of those in the field. A highly infectious, severe coronavirus is a major issue. Containing it should be a major priority. That is not alarmism, it is just common sense, just like preparing for a category 5 hurricane. We know that covid-19 (the "coronavirus") is a highly infectious, severe virus, even though we may not know exactly how severe because of the reporting issues. It is not like a cold or the regular seasonal flu. When was the last time you heard of a 34 year old health care worker dying after catching a cold? https://www.nytimes.com/2020/02/06/world/asia/chinese-doctor-Li-Wenliang-coronavirus.html There is more than enough data for governmens and health systems to be concerned, but of course there is no need for alarm. Both the flu and coronavirus are droplet spread; they are not airborne. That is a huge advantage. That means you have to get a droplet of spit from an infected person somehow into your respiratory system by either rubbing that droplet of spit into your eye, or breathing it in, to become infected. So common sense hygiene practices like covering your sneezes and coughs, frequently washing your hands (especially before rubbing your face and eyes), and standing back from people who are clearly sick will go a long, long way to preventing spread. That being said I am a proponent of quarantining and trying to isolate clusters as soon as we identify them as long as that is feasible. Once we have general spread, that strategy will no longer work, but we should forestall general spread for as long as possible. Folks who try to minimize the severity by saying "it's no big deal, my friend got it and he just had a runny nose" are missing the bigger picture, imho. We will most certainly get through this, I have no doubt of that. But I hope we can aim for more than just getting through it, and come out the other side knowing we minimized the excess morbidity and mortality this virus could have caused by taking the appropriate actions on a national, regional and individual level. That's about all I have to say about this virus. Hopefully it veers off course and ends up in the ocean! M.
  23. I was at a recent public health talk where they showed that flu infections \were significantly lower than expected in our region in February. They attributed it to the public taking more precautions around Coronavirus, so yes, you can argue that is one benefit of the outbreak! Hopefully we can keep it up in future flu seasons. M.
  24. Triage is best thought of as a two part process. The first, as you mentioned, is that the sickest should get your attention. You would then formulate a plan (based on the resources you have available). If you are resource constrained, the second part of triage is deciding who gets the resources you have available (manpower, drugs, ventilators, etc). The modern thinking is to provide those resources to those most likely to survive with the given resources. In essence it is a utilitarian argument - you try to save the maximum number of lives possible. So given one ventilator and two patients who need it, you give it to the patient most likely to live if they get it. This has been the thinking with organ transplants, which has probably been one of our most resource contrained treatments in medicine for a long time.
  25. Another doctor here. (Never realized how many of us frequented this board until now!). For non-medical folks the concept of Healthcare Capacity is squishy and abstract, but for those in the system it is very concrete. The capacity to ventilate patients (breath for them using a breathing machine is one example of very specific healthcare capacity). While the recorded mortality rate of Coronavirus is about 2% (give or take), we know that about 10% of identified infected patients develop severe pneumonia. Severe pneumonia effects your lungs capacity to exchange oxygen. If it gets severe enough, you would need a ventilator. The ability to ventilate patients using a machine is a very specific kind of healthcare capacity. In the Western world patients who are on a breathing machine are in the ICU and get round the clock monitoring. So they have a nurse at their bedside (that's 3 shifts of nurses per day), they have a respiratory therapist nearby to help trouble shoot issues with the machine (pressure settings, secretion suction, tube displacement, etc), and usually a team of doctors who round on them and oversee everything and make adjustments as needed. I don't have hard statistics, but I would be shocked if the number of ventilators (even counting those in operating rooms and in storage) exceeded 200-300 per 1,000,000 residents in most healthcare systems. That is the biggest bottleneck, imho. And that capacity is already being used at anywhere from 50-100% just dealing with the existing reasons people need ventilation (i.e. after major surgeries, from trauma, infection, etc). If you get a sudden wave of folks needing ventilatory support, they will most likely not be able to get it. We will be triaging folks who will get a ventilator and those who won't based on their overall chances of surviving the illness. This would be heart wrenching and very painful for healthcare workers, and patients' families. We had the same discussions when SARS and H1N1 hit. I remember as a young trainee sitting in on an ICU meeting where they were hashing out how they would portion the 40 ventilators in their ICU if those infections began spreading widely. It was a very sobering discussion. When I see some of our political leaders speaking about Coronavirus, I often find myself wondering if theyv'e counted the ventilators in their jurisdictions and worked backwards with the math to seem how many infections their systems could handle before reaching the venitlator breaking point. That is the kind of math most frontline workers are doing in their heads, and frankly that is why they are so focused on containing the outbreak. They understand the consequences if they don't. M. EDIT: Found this article after my original post. Looks like someone did a survey in canada and found we have capacity for 100-160 ventilated patients per million residents. (They expressed it as 10-16/100,000). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426537/
×
×
  • Create New...