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Let’s get real about coronavirus testing . . .

We do not know how severe the covid-19 epidemic will be or how much economic and social pain it will cause, but it clearly has the potential to kill hundreds of thousands or even millions of Americans, and the economic consequences could include a deep recession and even a financial crisis that will cause misery to tens of millions of people.

Testing is key to getting the epidemic under control, and it is not clear to me that policymakers are being nearly as aggressive about expanding testing capacity as they should be.  Think of two alternative testing strategies.  One strategy is to selectively test people who have symptoms or who may have been exposed to someone with the disease.  The alternative strategy is to develop the ability to do mass screenings for the virus among the general population.  (There are various intermediate strategies one can imagine, such as doing mass screenings in local areas with a high incidence of disease.)  Of course, selective testing is the place to start, but the ability to do mass screenings would allow us to pro-actively identify and isolate almost all carriers and would thus avoid the need for widespread social isolation which is wreaking havoc on the economy.  Selective screenings, in contrast, may or may not be able to contain the epidemic sufficiently to allow normal economic activity to resume.

I am not sure what is being done to expand our testing capacity, but if we want to develop the ability to do mass screenings, we need to make it a priority nowThe government will need to contract with equipment manufacturers and other suppliers (of reagents, swabs, protective gear, etc.) for large capacity commitments on a short timeline.  I have no idea what this would cost or even if it is feasible, but if there is even a small chance that the epidemic will last for six months or return next winter, it seems that a $10 or $20 billion investment in testing capacity would be short money.

The Democrats should jump on this as they take up the next coronavirus response bill.  Not only is it good policy, it will give them an opportunity to highlight the fumbling, timid response of the Trump administration to the crisis.

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Remdesivir II

This is, in fact, another post on Coronavirus, but it will take me a while to get to the point. To put the conclusion here, I think that it is important to get the FDA out of the way (by executive order if necessary).

The Food and Drug Act, as currently interpreted, requires the assumption that people should (generally) not be treated with pharmaceuticals which haven’t been proven to be safe and effective. The rule is first do no harm, second do no harm. This only makes sense if results with current standard of care are acceptable. In this case, they aren’t. I think there should be mass production and use of Remdesivir starting on the 5th of March, based on one case where it seems to have cured a patient overnight.

To be honest, I think it should have been approved based on evidence that it is safe (from failed efforts to treat Ebola) and evidence that it inhibits the RNA dependent RNA polymerase of the MERS Coronavirus

Obviously one case is not proof. Still more obviously a pre-clinical study of a related organism isn’t strong evidence about the novel coronavirus.

So ?

It isn’t as if the current approach is working so well, that we should stick with it until there is proof that a new approach works better.

I think the trace of information is enough that, given almost no knowledge and a very diffuse posterior, one can conclude that the expected welfare of a patient treated with Remdesivir is higher than of one not treated with Remdesivir.

At this point, the standard ethical rule that decisions should be made in the patients’ intererests would mandate use of Remdesivir
(I personally do not accept that rule)

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CORONA VIRUS AND SOCIAL SECURITY, ANOTHER GRAND BARGAIN?

by Dale CoberlyCORONA VIRUS AND SOCIAL SECURITY, ANOTHER GRAND BARGAIN?

Republicans are showing what they are made of. After claiming that the Corona Virus was not serious, or was well contained, or was Democrat fake news; they are now admitting it is serious and calling it a Chinese virus.

Fox News explained to a reporter they don’t expect “turning the ship around” to cause any problem with their viewers. They did not say that is because their viewers will believe anything they tell them to believe. Nor did they tell the reason for their turnaround of their seeing how to make money out of the pandemic. Even more so, they have seen how to use it to destroy Social Security.

These guys are akin to inviting your boss to dinner and noticing he couldn’t take his eyes off of your teenage daughter. Well, you think, at least he has kept his hands off her. Then your daughter comes over and says, ”Dad, Mr Peterson has been telling me about his house on the beach. It sounds so cool. And guess what, he said I could come and spend the weekend there if I want to. Can I? Can I? Please.”

So Trump has said he will spend some money fighting the epidemic, but he wants to get the money from Social Security. He wants a “payroll tax holiday.” The government won’t collect the payroll tax, and people can keep the money and spend it to help stimulate the economy.

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Reporting from Germany: “Welt am Sonntag”

Welt am Sonntag is reporting our honorable President is attempting to bribe lure a German company CureVac to develop a vaccine  to be used only in the US.

Germany’s Health Ministry confirmed a report in the newspaper “Welt am Sonntag”, which said President Donald Trump had offered bribes funds to lure the German company CureVac to the United States, and the German government was making counter-offers to tempt it to stay.

Welt am Sonntag quoted an unidentified German government source as saying Trump was trying to secure the scientists’ work exclusively, and would do anything to get a vaccine for the United States, “but only for the United States.”

CureVac’s chief production officer and co-founder Florian von der Muelbe told Reuters the company had started with multitude coronavirus vaccine candidates and was now selecting the best two to send into clinical trials.

The privately-held company based in Tübingen, Germany hopes to have an experimental vaccine ready by June or July to then seek the go-ahead from regulators for testing on humans.

Earlier this month CureVac CEO Daniel Menichella met Trump, Pence, members of the White House Coronavirus Task Force, and senior representatives of pharmaceutical and biotech companies to discuss a vaccine.

Professor of Health Economics and Epidemiology Karl Lauterbach, a senior lawmaker with the Social Democrats and a junior partner in Chancellor Angela Merkel’s coalition stated:

“The exclusive sale of a possible vaccine to the USA must be prevented by all means. Capitalism has limits.”

Germany tries to stop US from luring away firm seeking coronavirus vaccine, CNBC, March 15, 2020

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Coronavirus Treatment Case Report

“First Case of 2019 Novel Coronavirus in the United States” Holshue et al 2020

I quote

Treatment with intravenous remdesivir (a novel nucleotide analogue prodrug in development10,11) was initiated on the evening of day 7, and no adverse events were observed in association with the infusion. Vancomycin was discontinued on the evening of day 7, and cefepime was discontinued on the following day, after serial negative procalcitonin levels and negative nasal PCR testing for methicillin-resistant Staphylococcus aureus.

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

This suggests that Remdesivir is an effective treatment for Covid 19. I told you so. A guess in Angry Bear March 2 2020 a Case in the New England Journal of Medicine March 5 2020.

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Life in Rome

I am in a city with a curfew (enforced ?) where only pharmacies, supermarkets and those stores where someone from China sells all sorts of household stuff are open. Rome hasn’t reached the dread levels of Wuhan and Milan, but the Italian government is trying to get ahead of the curve.

It is strange and alarming that there is little traffic (it is also impressive that Romans don’t obey the traffic code even when there is little traffic). People are really trying to stay home all the time (I was semi home bound before it was cool).

I have learned about the activities which people consider absolutely necessary. A large fraction of people walking around are walking dogs. Many people are wearing masks (absolutely sold out everywhere) and gloves. I discover there are some things I have to touch. These include an ATM (alarmingly often) and cash.

One striking thing is that people wait outside of the supermarkets and pharmacies. This is a rule that does not have to be enforced — people are scared. Good thing it’s not cold in Rome during March (or February or actually ever at all in the globally warmed year of our lord 2019/2020). This makes me notice the high rates of infection in Iceland and Norway. I guess up there (where I have been in July with a rain coat) the choice is risk of Covid 19 or of frostbite.

The extreme measures (not just ordered but orders which are actually obeyed, by Romans) are impressive because as of the day before yesterday there were only 200 cases in Lazio (region which includes Rome). The fact that one of the cases was governor Zingaretti (also head of the Italian Democratic Party) might have made a difference.

The news spreads even faster than the virus. Down here the health care system is under strain but not overwhelmed (yet) but people read about (and see on TV) reports on how in Lombardy Triage has reaquired it’s original meaning. During World War I, It was red = critical, yellow = serious monitor but not critical, black = doomed. In normal times black now means deceased.

In Lois Armstrong Airport New Orleans during Katrina there were living people with black tags (for will not survive a flight and so will die here). I was appalled. Now in parts of Northern Italy there aren’t enough respirators for patients who would die without one. This is part of why the Italian case fatality rate is high. It is also important that Italians have had low fertility for decades and are old on average.

I guess I haven’t written anything that people don’t know already. I will update when the wave of contagion overwhelms us. I fear that I will be giving readers a hint of future action in their home town.

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This is what exponential growth looks like

This is what exponential growth looks like

I’ve placed an added emphasis on high frequency indicators, as they will be the first to show the impact of coronavirus on the economy.

This morning chain store sales for last week were reported. They were:

– Redbook +6.0% YoY
– Retail Economist unchanged w/w, +0.9% YoY

Needless to say, there was no impact at all on the Redbook number. While the Retail Economist number was definitely weak, there have been other, similar weak weeks earlier this year, so that number is equivocal. I suspect that this situation will change in no more than two weeks.

Meanwhile, here is a graph of the number of coronavirus cases in a number of countries including the US, compared with Italy, the epicenter of the outbreak in Europe (via Mark Handley, a Professor of Networked Systems in the UK):

Notice that the graph is in log scale, where exponential growth is shown as a straight line. South Korea and Japan, both of which have taken very aggressive testing and quarantine measures, show a slow spread, and in South Korea the number of *new* cases has actually declined in the past few days, leading to the total number shown above to level out. The US, by contrast, is on track to have the same number of cases Italy has now in about a week and a half.

This is what exponential growth looks like. The spread of the disease looks manageable, until all of a sudden it very much is not. This is why, even if the disease abates with warmer weather, exactly *how* warm the weather has to be makes an important idfference between a contained and a calamitous  outbreak<.

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Turn Up the Humidity in Your House

This is coming from MEDPAGE TODAY, “Track the U.S. COVID-19 Outbreak in Real Time,” Comments Section (3 comments), March 11, 2020 with regard to  COVID-19

“The mechanism of seasonal effect for seasonal respiratory virus spread is believed to be humidity, not temperature. In New York state which has 220 cases, fomites lose moisture where indoor humidity is low, allowing the lighter particles to stay longer in the aerosol. In Florida and Arizona, with 38 cases, fomites gain moisture and weight from the humid air and fall to the floor faster. Northern Italy, where people wear winter coats in the media reports has dry, heated indoor air, while Southern Italy has humid indoor air.

Humidifying indoor air in schools, stores, churches, etc. may reduce seasonal influenza, respiratory syncytial virus, coronoviruses which produce the common cold, rhinoviruses and Covid-19, Airports, airliners, airport shuttles should be the highest priority. The goal should be humidifying to the level seen in summer without transmitting Legionella.”

“The Philippines, Indonesia, Malaysia, Australia, Hong Kong have warmer, more humid air and much less Covid-19. Southern Italy has warmer, more humid indoor air than Northern Italy where indoor air is dry. The photographs in the media from places with the highest rate of Covid-19 spread show people wearing winter jackets.”

“In warm humid climates, fomites absorb water from indoor air and sink to the floor. There is a fine layer of dust everywhere indoors and viral particles attach to charged dust particles.

The mechanism for seasonal respiratory virus transmission is: fomite size in dry heated indoor air promotes viral spread. Larger fomites in humid air fall to the floor and react with charged dust particles.”

fomite definition: objects or materials which are likely to carry infection, such as clothes, utensils, and furniture.

microbiology definition: A fomites (pronounced /ˈfoʊmiːz/) or fomite (/ˈfoʊmaɪt/) is any inanimate object that, when contaminated with or exposed to infectious agents (such as pathogenic bacteria, viruses or fungi), can transfer disease to a new host.

This would include counter tops, etc.

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Conversational Points about Coronavirus and Administration Answers

Newcastle ban handshakes at training ground: “There’s a ritual here that everybody shakes hands with everybody as soon as we see each other every morning,” said Bruce as he prepared for Saturday’s game against Burnley at St James’ Park. “But we’ve stopped that on the advice of our club doctor. Thankfully, we’ve got a superb doctor here and he will keep us informed of what we have to do. We’re like everybody else, we’re glued to the TV for where it’s going to go next and let’s hope it doesn’t get any worse in this country.”

Dettol sales surge as markets fall again The disinfectant is seen as providing protection against the spread of the disease, although its effectiveness has not yet been scientifically proven.

Dettol owner Reckitt Benckiser said in its results on Thursday. “We are seeing some increased demand for Dettol and Lysol products and are working to support the relevant healthcare authorities and agencies, including through donations, information and education. We do see increased activity online for our consumers in China,”

Rep. Ron Kind (D-Wis.) held a telephone Town Hall Wednesday night. Rep. Ron Kind asked Azar how confident he was that rural providers were up to the task when;

“one out of every three calls into it was talking about the coronavirus. Certainly the concern, if not the fear, is starting to permeate throughout our communities and especially in rural areas. It’s coming, and I’m concerned whether we’re ready for that.”

Azar: “One of the bedrocks of our system is our great hospitals, our great public health infrastructure, and our providers, I worry about infection control protocols in rural facilities, just because they don’t see it as much … I think we have to up the game nationwide around immediate infection control on suspect cases so we don’t get nosocomial infections.”

Past the leap Mulvaney and Cruz are fools

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Conversational Points about Coronavirus and the White House’s Panic

The Incompetency of this man comes to light in a potentially catastrophic period. He instills fear rather than confidence.

White House Moves To Screen Scientists’ Statements On Coronavirus
As fears grow of a politicized White House response to the coronavirus outbreak, the White House has placed Vice President Mike Pence in charge of messaging about the virus, the New York Times reported Thursday.”

“Pence, who Trump said Wednesday night would be the White House point person on the outbreak, will clear public health officials’ statements on the virus, the Times reported citing several unnamed people familiar with the matter.”

Not to worry, The Reverend Henry Kane from Indiana takes charge.

White House Reportedly Ordered Infectious Disease Chief ‘Not to Say Anything’ About Coronavirus Without Clearance

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, has told associates that he has received directions from the White House “not to say anything else without clearance” about the potential coronavirus pandemic.

Writing for the Times, Michael Scherer and Maggie Haberman report about recent efforts by the Trump administration to “tighten control of coronavirus messaging by government health officials and scientists, directing them to clear all statements and public appearance with the office of Vice President Mike Pence, according to several officials familiar with the new approach.”

Early missteps and state secrecy in China probably allowed the coronavirus to spread farther and faster

“An analysis of those early weeks — from official statements, leaked accounts from Chinese medical professionals, newly released scientific data and interviews with public health officials and infectious disease experts — reveals potential missteps by China’s overburdened public health officials.”

In my mind, there is no doubt this happened in China. Since the White House is more worried about markets than the spread of this contagion, it will spread rapidly with little to contain it. It will be months before an adequate vaccine is found.

President’s budget would hinder US public health progress: Huge cuts proposed“.

The Nation’s Health: “Trump released his fiscal year 2020 federal budget proposal in March, recommending huge cuts across the federal government, including a 12 percent cut to the U.S. Department of Health and Human Services and a 10 percent cut for the Centers for Disease Control and Prevention.

At CDC, a reduction of that magnitude equates to a $750 million spending cut over fiscal year 2019. APHA member John Auerbach, MBA, president and CEO of Trust for America’s Health, said the proposed CDC cuts not only threaten federal public health capacity, they would have a “devastating” impact on state and local public health departments, which depend heavily on CDC dollars flowing down to the community level.

“Auerbach told The Nation’s Health. “Local health departments are still down more than 50,000 jobs from where they were in 2008. If large cuts like these were passed, it would seriously harm the overall capacity of state and local public health departments to respond.”

Donald Trump Is Worried About . . . The Stock Market!

“Trump is highly concerned about the market and has encouraged aides not to give predictions that might cause further tremors….In a Twitter post, he misspelled the word ‘coronavirus’ as ‘caronavirus’ and wrote that two cable news stations “are doing everything possible to make the Caronavirus look as bad as possible, including panicking markets, if possible. Likewise their incompetent Do Nothing Democrat comrades are all talk, no action. USA in great shape!”

As far as the markets, I would be concerned with the China supply chain to the US. At most there is 5-weeks, three on the ocean and a week on each side getting board ship, unloading, and customs. Perhaps companies will have 2 -4 weeks in stock already. We are two-3 weeks into this. China plants are more than likely closed or are half-staffed. Ships woill not call on Chinese ports till the crisis is over or is pronounced safe. The Chinese have fumbled the ball initially by not declaring an emergency sooner. While the epidemic started in a Wuhan fish market, it is now believed the virus originated elsewhere.

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