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Ian Lipkin Finally Gets Caught

“If it can hit me, it can hit anybody.” Ian Lipkin

Ian Lipkin, one of just a handful of renowned researchers to aggressively advocate for more funding for ME/CFS, has reported he has the virus. If anyone knows how to protect himself, Lipkin does.

Lipkin flew to China during the SARS outbreak, flew to Saudi Arabia during the MERS outbreak, and flew to China during the present COVID-19 outbreak – and caught the virus, ironically, in New York City. Lipkin, who I’ve been told is careful about pathogens anyway, said:

“If it can hit me, it can hit anybody. I know where I think I got it but that’s not the same as proving. But it doesn’t matter. This virus can be found all over the United States.”

He said it was “miserable”.

Lipkin lead the XMRV investigation, runs an NIH ME/CFS research center, and was about to embark on one of the most exciting ME/CFS studies I’ve come across. A 68-year-old male, Lipkin is in two high risk categories.

Lipkin’s team has been developing a new, very rapid coronavirus test. More on that in the next blog.

The United States

Right now, confirmed U.S. cases are rising at breakneck speed. With 14,000 plus new cases yesterday – an increase of 40% in one day – we’ll probably go roaring past China tomorrow to become the country with the most confirmed coronavirus cases.

At this point in the epidemic, China had turned things around. The U.S., and other countries in the West, though, are still on an upward trajectory with no end in sight.

Columbia University researchers believe that 11 times as many people are infected (@660,000 as of today) as have been confirmed infected (@60,000), and the spread of the virus will depend on how strict social distancing measures are employed.

The below map represents the expected spread of the virus by July 1st using no, limited or severe social distancing measures by July 1st. (You can adjust times etc. on the interactive map itself.)

COVID-19 Spread U.S.

Estimates of COVID-19 infections by July 1st given different social distancing scenarios (from New York Times – https://www.nytimes.com/interactive/2020/03/20/us/coronavirus-model-us-outbreak.html)

That the U.S. has gotten hit hard is no surprise, though. As the most connected and most visited country in the world, it makes sense that any contagious virus would hit us hard.

Of all the issues, the inability to rapidly test, diagnose and separate infected people has loomed largest.

The Testing Conundrum

“It’s hard to express in words how our inability to test early and to contact trace has set us back. And I think it’s honestly launched us into a new reality that none of us have clear or clever ideas about what to do.” Christopher Kirchoff – Author of a 2016 Ebola report on federal readiness.

Without adequate testing, we can’t isolate people or track their contacts. Nor do we know how many people actually have the virus and what the real death rate is – a critical factor in determining how to proceed.

Last Friday, the three major players representing the country’s state-level public health system jointly delivered an astonishing statement. Weeks after being told that we would soon be awash in millions of test kits, the groups warned about a different problem – the ability to use them.

They reported that “widescale shortages of laboratory supplies and reagents” for COVID-19 testing made it necessary to reserve testing for three groups: health-care workers and first responders; the elderly; and people with underlying conditions for whom a COVID-19 diagnosis could change their treatment plan.

Shortages of simple ingredients – like the media that stabilizes the samples as they’re sent to the lab, the reagents used to assess if the virus is present, and even the cotton swabs that get inserted into the nose – are holding things up.

In some cases, we just got unlucky. It turns out that a major manufacturer of cotton swabs is located in Lombardy, Italy – one of the heaviest hit areas in the world. The National Guard reportedly filled a C-17 cargo plane with 800,000 swabs and flew them back to the U.S. recently.

In the face of the reagent issue, the CDC has gotten creative as well and posted a “how-to” recipe (which requires fetal cow serum!) on their website.

New York City – the worst hit city in the nation – is so jammed up that the Department of Health and Mental Hygiene ordered that only hospitalized patients be tested.

It’s not as if the Feds haven’t been moving. Allowing labs to develop their own tests on Feb 29th – as tardy as that move was – helped. So did the March 12th announcement that the FDA would allow commercial labs to use Emergency Use Authorizations to produce their own tests.

Even that apparently wasn’t enough. On Monday, the FDA threw its playbook out the window when it announced it was allowing state public-health laboratories to authorize tests from other labs without federal approval. Now the states, some of which don’t have the capability to assess which tests are accurate or not, are in charge of validating COVID-19 tests.

The good news is that if the disease has been spreading exponentially, so has our ability to test.  The COVID Tracking project – probably the best source of state-by-state testing and infection information – indicates that the U.S. is now testing about 70,000 people a day and that number is jumping daily.

As of March 25rd, the U.S. had tested 418,000 people. Over the past day the U.S. tested 75,000 people. Just eight days ago the total number of tests done was 55,000.

The U.S. – Striking Out on Its Own

We’re clearly not going to be Singapore, Taiwan or Hong Kong, all of which have at least tentatively throttled the COVID-19 epidemic by quickly identifying people who are sick, finding how who they’ve contacted and isolating them.

Nor are we likely to be Germany, which has a vanishingly small death rate thus far (0.4% vs 4.3% France vs. Italy 9.5%). How has Germany, with its 16 different Health Ministries, done it? With a focus on diagnostics, and meticulous tracking of the infected and those they came into contact with. (As ZeroGravitas points out in a comment, though, Germany’s more thorough testing has probably resulted in a lower death rate overall (See Italy discussion below)). Angela Merkel, a former physicist, may have basically scared Germany into compliance as well, with her message a couple of weeks ago that suggested 2/3rds of Germans might get infected.

What about Italy? Could we be Italy? Italy’s mixed messaging and very restrictive testing policy – similar to that employed here – allowed the virus to suddenly explode with a devastating impact (9.5% mortality rate) even though Italy has a modern health care system.

Italy presents a case history in how quickly things can go wrong. On Feb 27th, the leader of the governing Democratic Party posted a picture of himself drinking an aperitivo with friends, urging his fellow Italians “not to change our habits.”

Just 400 cases had been confirmed. Ten days later, almost 6,000 people were confirmed infected (among them, that leader) and hundreds were dead. Skip forward about three weeks and Italy now has 74,000 confirmed cases and 7,500 dead.

Let’s hope we’re not Italy.

Are We All New York Waiting to Happen?

“There’s widespread community transmission in New York City. If you have symptoms of influenza—like a cough, shortness of breath, fever, sore throat—the pre-test probability that you have covid-19 is very, very high.” Jennifer Rakeman, Director of the NYC public-health laboratory.

With 25,000 cases – almost 8 x’s the number of any other state, New York contains a third of all the infected cases in the U.S.

Why is the Big Apple getting hit so hard? Perhaps because it was the top U.S. travel destination from Wuhan – the heart of the epidemic. Unfortunately, the travel ban initiated on Jan 31st occurred a week after Dubei and other cities in Wuhan were shut down and a month after infected travelers were surely entering the U.S. (About 300,000 people flew from China to the U.S. monthly.)

The severe acute respiratory virus #2 (COVID-19) is making the number of ventilators a major concern

Plus, because the travel ban only affected non-U.S. residents, plenty of people have been flying back and forth from China. In early March, Ron Klain, the former White House Ebola response coordinator, reported that 30 flights a day from China were landing in Los Angeles and San Francisco from China. He called the travel ban a travel “band-aid“.

Ventilators are in short supply – the shortage of ventilators beginning to occur in New York City indicates once again how much better it would have been to act “while the sun is shining”; i.e. when the caseload was low. February studies indicated that severe ventilator shortages were coming which private industry couldn’t begin to fill.

One thing the coronavirus is sparking is creativity. Ford Motor Company and General Motors are repurposing their machinery to produce ventilators but they won’t be available until June – a month after projections suggest the peak of the virus hits the U.S.

Facing potentially dire shortages of ventilators, a team of engineers, clinicians, students and manufacturers from Oxford University and King’s College in the U.K. have jury-rigged a very basic, simple “IKEA-type ventilator” made out of readily available parts that could be shipped in a kit and put together onsite.

Just out from the U.K., James Dyson of Dyson vacuum cleaners reports that in ten days he’s created a cheap ventilator called CoVent that can be “manufactured quickly, efficiently and at volume”. The British government has ordered 10,000 of them.

Yesterday, Vice President Pence reported  that the government has figured out a way to easily convert devices used by anesthesiologists for outpatient surgery into useful ventilators – adding possibly tens of thousands of needed machines.

Governor Cuomo predicted a peak of 33,000 ICU beds—with ventilators—would be needed in approximately 21 days.

How bad has it gotten in New York? The New York Times just reported that a refrigerated truck has been parked outside one particularly hard-hit hospital to hold the bodies of the dead. New York has reportedly asked FEMA for 85 trailers to store the dead.

All of the cities 1,800 intensive care units are expected to be full by Friday.  Four 250 bed temporary hospitals are being built and should be up by next week and a 2000 person naval hospital ship should be docking in a couple of weeks.

Let’s hope that every major city is not New York waiting to happen.

The Next Month?

Governor Cuomo has warned that New York is what other major cities will look like in 3-4 weeks.

Did the Mardi Gras celebration ending on Feb 25th trigger the greatest increase in infections in the world?

It’s already happening in New Orleans. The growth rate in infections in New Orleans may be the fastest in the world. Some believe that the big Mardi Gras celebration that ended on Feb. 25. ignited a smoldering fire.

The sun seemed to be shining at the time. President Trump had told the nation that the virus was “under control”, and no one in Louisiana was to test positive for almost two weeks.

Now doctors are wondering if the packed streets during Mardi Gras kicked off, according to one study, the most rapid increase in coronavirus infections yet seen.  One infectious disease expert called the celebration “the perfect incubator” for the disease. It may have triggered outbreaks across the South.

With hospitals expected to exceed capacity by April 4, Louisiana has begun “building out” hotels to provide more hospital beds, and state parks are being outfitted with trailers to house patients.

On the other hand in California – a favorite travel destination from China – the Bay Area, Los Angeles, San Diego – have nowhere near the number of cases that New York (or New Orleans) does.

Social distancing efforts can be very effective if the infection rate in a community is below 1% but after that their effectiveness declines. Nobody knows if the cities in relatively good shape right now are dodging a bullet, or if they’ll be in New York’s shoes in a couple of weeks.

The fact that the confirmed cases are randomly scattered around Santa Clara county suggests a lot of community transmission is occurring. Officials tried to start testing back in January, were rebuffed by the CDC, and only were able to use their own lab in late February.

Despite being the wealthiest county in California, the Santa Clara Country health department doesn’t have the resources to track the contacts of even the limited number of people who have been infected thus far (@300). If they don’t, no one does.

Oregon has not been very hard hit but two Oregon models suggests that even using social distancing, hospitals there will be overrun in mid-April. They believe a point of no return – either Oregonians engage in strict social distancing or the virus runs amok – is happening right now (March 24-29th).

Seattle Update

But are the models correct? Since Seattle was hit hard early, it may provide a template for other cities. Seattle’s hospitalizations for coronavirus have doubled in the past two weeks but beds, contrary to their models, are still available. (Supplies are a problem, right now, in Washington hospitals – not beds.)

On March 17th, Governor Inslee, in a letter to President Trump, stated that their models indicated that Washington hospitals would be overwhelmed by the end of the month. (Washington has about 1,500 intensive care units of which about 1,000 are typically being used.)

Could the models be wrong?

With about a week to go to the end of March, though, Seattle hospitals have not been overwhelmed and retired Navy Vice Adm. Raquel Bono suggested that the models may not have been correct, stating: “Candidly, many of those models predict large numbers of patients and we could quickly be overwhelmed.”, but it’s not happening yet.

Another sign that the expected surge in infections has not occurred is that the predicted spike in people testing positive over time hasn’t materialized either.

Social Distancing Helping?

A huge question, of course, is how effective the social distancing efforts done to date have been in stopping the spread of the virus.

We know that extreme social distancing plus widespread testing worked in China. Whatever their authoritarian ways, the Chinese government was very nimble and brought in 1,500 workers to trace every contact in Wuhan City during the outbreak.  In just 20 days, China turned the epidemic around, with rapid diagnostics and extreme social distancing.

States are engaging in very different levels of suppression measures (From Covid_Act Now)

We’re not doing that. We’re a large, very heterogeneous country which is attacking the coronavirus in very different ways – some stringent – some not so stringent.

Recent evidence suggests that social distancing efforts in Seattle and other areas are having an effect. The growth in infections in New Rochelle, New York – an early hot spot – has recently slowed – as has the number of hospitalizations in the state. Before New York shuttered all non-essential businesses, the number of those hospitalized was expected to double every 2 days. After the closure, that number is now expected to double every 5 days.

The Way Forward (???)

The argument, now, is whether to ramp up social distancing – and incur more economic pain – or to lessen it and get the country “back to work”.

A Columbia University map from the New York Times shows how dramatically control measures can slow and blunt the infection. The economic cost to employing those measures – including possibly shutting down much of the countries economy for four months – would be quite extremely high, though.

President Trump – understandably agog at the incredible economic impact of the virus – has been pushing for a mostly back-to-normal date of Easter.  The deficit – which had already blossomed over the past couple of years – has skyrocketed to levels not even contemplated before.

Whether the cure is worse than the disease is indeed a legitimate question.  While President Trump has the biggest bully pulpit of all, ultimately, it’s the governors, though, who will be deciding how their states go.

Some promising lines of evidence suggest that coronavirus could be much, much more prolific than we think – which would also make it much less deadly than we think.

One group estimates that if the virus entered the U.S. on January 1st of this year, then 6 million people in the U.S. have already been infected, most of them unknowingly. Another U.K. model proposes that half the U.K. has already been infected – rendering economically damaging suppression efforts pretty much unnecessary at this point.

Dr. John P.A. Ioannidis, an epidemiologist and co-director of Stanford’s Meta-Research Innovation Center points out that without proper randomized, epidemiological studies, it’s impossible to know the true mortality rate in any country, and suggests it could be as low as 0.3% which would not, economically, be worth temporarily tanking the U.S. economy.

Antibody testing is the way to get at the true prevalence of the disease and understand just how deadly – or not deadly – it is. This is starting to happen and that, as well as emerging testing and treatment options, will be covered in the next post.

The Coronavirus Series From Health Rising

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