Author Topic: How long can we wait while flattening the curve?  (Read 248143 times)

Luz

  • Bristles
  • ***
  • Posts: 455
Re: How long can we wait while flattening the curve?
« Reply #550 on: April 11, 2020, 02:16:35 PM »
Anyone see the news about farmers destroying millions of pounds of food? What might this mean for the food supply?
https://www.nytimes.com/2020/04/11/business/coronavirus-destroying-food.html?action=click&module=RelatedLinks&pgtype=Article

I've also been thinking about remittances sent to low and middle income countries. My husband, who thankfully still has his job, supports his family in Mexico. But minorities (including the 44 million+ in the US who are foreign-born) have been especially hard hit with job losses. That will surely have a huge effect on a number of economies in the global South (who are also dealing with currency devaluation). According to the World Bank, over $550 billion worth of remittances were sent in 2019. Each remittance helped provide an average of 4 people with essential goods like healthcare, food and education. I wonder what the remittance amount will be in 2020, and what impact the reduction will have.

On a separate note, there have been some interesting articles about ventilator use and treatment for COVID-19.
https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems?ecd=wnl_spr_040720&ctr=wnl-spr-040720_nsl-LeadModule_cta&mb=NsX4TDGa29wOP4UZt7HlX3g0WleHxvIq8lar%2fYm30fc%3d
https://www.the-sun.com/news/663895/coronavirus-doctors-warn-ventilators-harm-than-good/

Although the treatment protocol for Acute Respiratory Distress Syndrome (ARDS) has been adopted for COVID-19, doctors are now finding that many COVID-19 cases are more similar to altitude sickness, where ventilator use and the related levels of forced pressure may do more harm than good. I wonder what this means for the the $490 million Defense Production Act contract with GM. Any healthcare professionals care to share what's happening with ventilator use in their hospitals?
« Last Edit: April 11, 2020, 02:28:23 PM by Luz »

Telecaster

  • Handlebar Stache
  • *****
  • Posts: 2315
  • Location: Seattle, WA
Re: How long can we wait while flattening the curve?
« Reply #551 on: April 11, 2020, 02:57:32 PM »
I don't quite understand the optimism about this vaccine. We still don't have a vaccine for SARs, that this is most similar to.....
Compared to a Covid-19 vaccine, do you think 1/1000th the resources are being devoted to a SARS vaccine? I'd be quite surprised if yesterday alone more money wasn't spent developing a Covid-19 vaccine than was ever spent on a SARS vaccine.

SARS burnt itself out before a vaccine could be developed.   It only lasted about a year. 

Wrenchturner

  • Handlebar Stache
  • *****
  • Posts: 1259
  • Age: 32
  • Location: Canada
Re: How long can we wait while flattening the curve?
« Reply #552 on: April 11, 2020, 03:09:22 PM »
I agree we can probably reopen rural areas once we have good evidence that the rate of infection in those areas is low. Even areas that have already had a surge, if there is a high rate of resolved sub clinical infection that means the risk of subsequent transmission is low. Until then, we donít have much to go on. Hopefully those tests will be out soon.
I hope that weíll have the tests soon as well.

One thing Iíd like to segue into that doesnít seem to be discussed so much is compliance. I say this because my city has the dubious honor of getting an F grade on social distancing. Iím complying and my family is complying, but a whole lot of folks arenít. We can analyze the best information. We can provide policy based on the best information. But if people wonít follow that policy, itís for naught.

I do wonder if weíre going to end up in a sort of worst case scenario where we get both a trashed economy due to the shut downs and COVID 19 just the same.

My grandmother lives in a retirement community, and she is in great health considering her advanced age at 94 years.  She says that most protocols are being followed except at dinner, when people socialize and chat close to one another.  When so many people are hard of hearing it's no wonder they stand close to each other.  It's a big risk though, and I don't think they'll shut down the dining hall before COVID gets inside.  Delivering room service to the residents is not something they're eager to do.

I wonder if some of those people, my grandmother included, are simply comfortable with their mortality.  Perhaps they don't see the fear as being worthwhile.  How long can you hide from a virus that's probably going to kill you?  For better or for worse, we don't have much openness towards discussing death and mortality in western culture.

It's only a matter of time before COVID works through all the retirement communities, and I wonder how much quality of life is diminished in the meantime in the interest of flattening the curve.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #553 on: April 11, 2020, 06:21:40 PM »
Anyone see the news about farmers destroying millions of pounds of food? What might this mean for the food supply?
https://www.nytimes.com/2020/04/11/business/coronavirus-destroying-food.html?action=click&module=RelatedLinks&pgtype=Article

I've also been thinking about remittances sent to low and middle income countries. My husband, who thankfully still has his job, supports his family in Mexico. But minorities (including the 44 million+ in the US who are foreign-born) have been especially hard hit with job losses. That will surely have a huge effect on a number of economies in the global South (who are also dealing with currency devaluation). According to the World Bank, over $550 billion worth of remittances were sent in 2019. Each remittance helped provide an average of 4 people with essential goods like healthcare, food and education. I wonder what the remittance amount will be in 2020, and what impact the reduction will have.

On a separate note, there have been some interesting articles about ventilator use and treatment for COVID-19.
https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems?ecd=wnl_spr_040720&ctr=wnl-spr-040720_nsl-LeadModule_cta&mb=NsX4TDGa29wOP4UZt7HlX3g0WleHxvIq8lar%2fYm30fc%3d
https://www.the-sun.com/news/663895/coronavirus-doctors-warn-ventilators-harm-than-good/

Although the treatment protocol for Acute Respiratory Distress Syndrome (ARDS) has been adopted for COVID-19, doctors are now finding that many COVID-19 cases are more similar to altitude sickness, where ventilator use and the related levels of forced pressure may do more harm than good. I wonder what this means for the the $490 million Defense Production Act contract with GM. Any healthcare professionals care to share what's happening with ventilator use in their hospitals?

Regarding the ventilators - itís elementary critical care to not use excess pressure or oxygen, so while interesting it isnít really that significant for management. Also itís well known that x-ray changes are delayed by several days from onset of symptoms with most lung injury, so it may just be thereís not much to see yet, and an x-ray several days later in these patients would show the edema. Thereís a lot of anecdotal pet theories being thrown out by physicians on the Internet (see hydroxychloroquine), but not much real data to back it up. Also, ventilation at appropriate settings does not cause ARDS-like damage. Iím not sure how they do it in Germany, but in the US low pressure, low volume ventilation is well established as standard of care. The only way youíd cause barotrauma is if youíre using volume control to get the 4-6 mL/kg volume but not using pressure regulation, and keep them at a low oxygen level. That may be an issue if youíre using an anesthesia machine rather than ICU ventilator (some models donít allow for PRVC and may not have set flow limits so you can get transient barotrauma).

The editorial basically says that patients may initially present with hypoxia and non-compensating respiratory rate that can be treated with nasal cannula. If their work of breathing increases they need to be intubated. They are recommending unusually high tidal volumes for treating hypercapnia in intubated patients (8-9 mL/kg), whereas we would increase the respiratory rate to improve ventilation.  The rest is supposition without any provided evidence.
« Last Edit: April 11, 2020, 06:44:43 PM by Abe »

Paper Chaser

  • Bristles
  • ***
  • Posts: 315
Re: How long can we wait while flattening the curve?
« Reply #554 on: April 11, 2020, 07:02:03 PM »
My grandmother lives in a retirement community, and she is in great health considering her advanced age at 94 years.  She says that most protocols are being followed except at dinner, when people socialize and chat close to one another.  When so many people are hard of hearing it's no wonder they stand close to each other.  It's a big risk though, and I don't think they'll shut down the dining hall before COVID gets inside.  Delivering room service to the residents is not something they're eager to do.

I wonder if some of those people, my grandmother included, are simply comfortable with their mortality.  Perhaps they don't see the fear as being worthwhile.  How long can you hide from a virus that's probably going to kill you?  For better or for worse, we don't have much openness towards discussing death and mortality in western culture.

It's only a matter of time before COVID works through all the retirement communities, and I wonder how much quality of life is diminished in the meantime in the interest of flattening the curve.

When this all started near me, I had my 80 something neighbors offer to go to the grocery for me if I'd stay home (I'm healthy, mid-30s). They basically said, "We've already lived our lives. We're not going to spend a bunch of what time we have left imprisoned in our home from fear of getting sick/dying. You've got a family to protect and a long life ahead."

We obviously didn't take them up on their offer and persuaded them to reconsider, but it was an eye opening conversation that has impacted my view of this situation a bit.

Wrenchturner

  • Handlebar Stache
  • *****
  • Posts: 1259
  • Age: 32
  • Location: Canada
Re: How long can we wait while flattening the curve?
« Reply #555 on: April 11, 2020, 08:10:30 PM »
My grandmother lives in a retirement community, and she is in great health considering her advanced age at 94 years.  She says that most protocols are being followed except at dinner, when people socialize and chat close to one another.  When so many people are hard of hearing it's no wonder they stand close to each other.  It's a big risk though, and I don't think they'll shut down the dining hall before COVID gets inside.  Delivering room service to the residents is not something they're eager to do.

I wonder if some of those people, my grandmother included, are simply comfortable with their mortality.  Perhaps they don't see the fear as being worthwhile.  How long can you hide from a virus that's probably going to kill you?  For better or for worse, we don't have much openness towards discussing death and mortality in western culture.

It's only a matter of time before COVID works through all the retirement communities, and I wonder how much quality of life is diminished in the meantime in the interest of flattening the curve.

When this all started near me, I had my 80 something neighbors offer to go to the grocery for me if I'd stay home (I'm healthy, mid-30s). They basically said, "We've already lived our lives. We're not going to spend a bunch of what time we have left imprisoned in our home from fear of getting sick/dying. You've got a family to protect and a long life ahead."

We obviously didn't take them up on their offer and persuaded them to reconsider, but it was an eye opening conversation that has impacted my view of this situation a bit.

Your neighbors sound like very good people.

OtherJen

  • Magnum Stache
  • ******
  • Posts: 3602
  • Location: Metro Detroit
Re: How long can we wait while flattening the curve?
« Reply #556 on: April 11, 2020, 08:40:03 PM »
Interesting. I (early 40s) have offered to shop for my parents and my friends who are in their 70s and 80s. They are all of sound mind and relatively good physical health (i.e., unlikely to die of natural causes any time soon) and yet as an immunologist, I know that my outcome with COVID-19 would most likely be better than theirs simply as a function of age.

Paper Chaser

  • Bristles
  • ***
  • Posts: 315
Re: How long can we wait while flattening the curve?
« Reply #557 on: April 12, 2020, 05:11:26 AM »
Interesting. I (early 40s) have offered to shop for my parents and my friends who are in their 70s and 80s. They are all of sound mind and relatively good physical health (i.e., unlikely to die of natural causes any time soon) and yet as an immunologist, I know that my outcome with COVID-19 would most likely be better than theirs simply as a function of age.

We are super fortunate to have such good neighbor's in our lives. They've become surrogate grandparents to us. We want to keep them around as long as possible. But that's also a selfish way to think, and doesn't really consider their thoughts on the matter, which is why the conversation was illuminating for me. They remain very active, independent and capable people for their age. They're handling the new isolation ok. And it helps tremendously that the weather has turned and they can enjoy the outdoors most days. But they really miss the social aspects of church, and contributing to their family business. They used to wake up with motivation and purpose, and a lot of that has been taken from them through this. If the shelter in place directives last much more than a couple of weeks longer (lightly impacted rural area) I do worry about how long they can endure. After a certain age, some people really need a reason to get up in the mornings. It keeps them going.

Our conversation was early in the whole situation, so I'm not sure they really had a thorough understanding yet of the odds based on demographics. Cooler heads prevailed, and younger family members have been doing the bulk of their shopping for them for weeks now. We also have a standing agreement that we'll check with them before shopping so we can pick up any odds/ends they might need in between their family member's trips.
« Last Edit: April 12, 2020, 05:13:14 AM by Paper Chaser »

js82

  • Bristles
  • ***
  • Posts: 469
Re: How long can we wait while flattening the curve?
« Reply #558 on: April 12, 2020, 09:14:40 AM »
My grandmother lives in a retirement community, and she is in great health considering her advanced age at 94 years.  She says that most protocols are being followed except at dinner, when people socialize and chat close to one another.  When so many people are hard of hearing it's no wonder they stand close to each other.  It's a big risk though, and I don't think they'll shut down the dining hall before COVID gets inside.  Delivering room service to the residents is not something they're eager to do.

I wonder if some of those people, my grandmother included, are simply comfortable with their mortality.  Perhaps they don't see the fear as being worthwhile.  How long can you hide from a virus that's probably going to kill you?  For better or for worse, we don't have much openness towards discussing death and mortality in western culture.

I'm not sure it's comfort with one's mortality, so much as a very rational perspective on their life situation.

If you're 90 years old, you realize that you likely don't have much time left - maybe a couple years, more if you're lucky.  At that age, you're not building for the future - enjoying the present is what you have.  6 months locked up not being able to see your loved ones probably feels entirely different when that could represent a quarter of your remaining life, than it does for someone in their 20's or 30's.

When you're living entirely in the present because you know that your remaining time is limited(as opposed to being future-oriented) you're going to have a different perspective on risk in a situation such as this as well.  This obviously isn't limited to the coronavirus, either.

Michael in ABQ

  • Handlebar Stache
  • *****
  • Posts: 1092
    • Military Saints
Re: How long can we wait while flattening the curve?
« Reply #559 on: April 12, 2020, 09:28:11 AM »
The John Hopkins Coronavirus map has been updated today with several new features.
https://coronavirus.jhu.edu/map.html

You can now show the incidence rate per 100,000 people in each country/state, case-fatality ratio, testing rate, and hospitalization rate. The last two are US only. 

They've also added a section with charts and graphs.
https://coronavirus.jhu.edu/data#charts

Including one about the flattening curve - https://coronavirus.jhu.edu/data/new-cases

Finally, they've fixed the time scale on the map so when you look back and forth between countries you can see when the growth curve started to shoot up and when it flattened out.

Accountant

  • 5 O'Clock Shadow
  • *
  • Posts: 27
Re: How long can we wait while flattening the curve?
« Reply #560 on: April 12, 2020, 02:03:07 PM »
I have been thinking about the impact on commerce as i am in finance for a publicly traded company.  I think even in the best scenario we are going to see mass layoffs soon.  First quarter earnings will be released soon which were impacted, but not to the extent as we will see in the second quarter.   Some companies like mine are putting on a good face but will react sometime between now and july.  Any opinions on the economics over the next 9 months and what and when a recovery would look like?  I am starting to think this could drastically change many fa ets of society.

Luz

  • Bristles
  • ***
  • Posts: 455
Re: How long can we wait while flattening the curve?
« Reply #561 on: April 12, 2020, 02:16:30 PM »
Anyone see the news about farmers destroying millions of pounds of food? What might this mean for the food supply?
https://www.nytimes.com/2020/04/11/business/coronavirus-destroying-food.html?action=click&module=RelatedLinks&pgtype=Article

I've also been thinking about remittances sent to low and middle income countries. My husband, who thankfully still has his job, supports his family in Mexico. But minorities (including the 44 million+ in the US who are foreign-born) have been especially hard hit with job losses. That will surely have a huge effect on a number of economies in the global South (who are also dealing with currency devaluation). According to the World Bank, over $550 billion worth of remittances were sent in 2019. Each remittance helped provide an average of 4 people with essential goods like healthcare, food and education. I wonder what the remittance amount will be in 2020, and what impact the reduction will have.

On a separate note, there have been some interesting articles about ventilator use and treatment for COVID-19.
https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems?ecd=wnl_spr_040720&ctr=wnl-spr-040720_nsl-LeadModule_cta&mb=NsX4TDGa29wOP4UZt7HlX3g0WleHxvIq8lar%2fYm30fc%3d
https://www.the-sun.com/news/663895/coronavirus-doctors-warn-ventilators-harm-than-good/

Although the treatment protocol for Acute Respiratory Distress Syndrome (ARDS) has been adopted for COVID-19, doctors are now finding that many COVID-19 cases are more similar to altitude sickness, where ventilator use and the related levels of forced pressure may do more harm than good. I wonder what this means for the the $490 million Defense Production Act contract with GM. Any healthcare professionals care to share what's happening with ventilator use in their hospitals?

Regarding the ventilators - itís elementary critical care to not use excess pressure or oxygen, so while interesting it isnít really that significant for management. Also itís well known that x-ray changes are delayed by several days from onset of symptoms with most lung injury, so it may just be thereís not much to see yet, and an x-ray several days later in these patients would show the edema. Thereís a lot of anecdotal pet theories being thrown out by physicians on the Internet (see hydroxychloroquine), but not much real data to back it up. Also, ventilation at appropriate settings does not cause ARDS-like damage. Iím not sure how they do it in Germany, but in the US low pressure, low volume ventilation is well established as standard of care. The only way youíd cause barotrauma is if youíre using volume control to get the 4-6 mL/kg volume but not using pressure regulation, and keep them at a low oxygen level. That may be an issue if youíre using an anesthesia machine rather than ICU ventilator (some models donít allow for PRVC and may not have set flow limits so you can get transient barotrauma).

The editorial basically says that patients may initially present with hypoxia and non-compensating respiratory rate that can be treated with nasal cannula. If their work of breathing increases they need to be intubated. They are recommending unusually high tidal volumes for treating hypercapnia in intubated patients (8-9 mL/kg), whereas we would increase the respiratory rate to improve ventilation.  The rest is supposition without any provided evidence.

Thanks for insight!

I don't have a medical background, so I hope I'm understanding this correctly, but aren't more doctors questioning the effects of ventilator use, "not because," according to Dr. Martin Gillick of Harvard Medical School, "the problem is not getting oxygen into the lungs, but from the lungs into the bloodstream?" The doctor (Luciano Gattinoni) writing the editorial is also one of the world's foremost experts on/created the protocol for ARDS and ventilation, no? He's not just some doctor tweeting his opinions.

My understanding is that, in at least 1/2 to 2/3rds of cases, COVID-19 is presenting differently than ARDS in that patients on ventilation show very low concentrations of blood-oxygen levels. The theory (again, as I understand it) is that the blood vessels of COVID-19 patients who aren't presenting with classic ARDS are not properly redirecting blood from damaged to healthy areas of the lungs (which is the mechanism that protects the body from such drastic drops in oxygen levels). It's essentially an issue of the oxygen-carrying capacity of the red blood cells (at least that's the hypothesis). Because of this, positive pressure may aggravate the disease process. A doctor on NPR also said that ventilators have been seen as critical in COVID-19, because for patients with pneumonia, they are a life-supporting measure that buys time for antibiotics to do their work. But with COVID-19, there's nothing like antibiotics at this point to treat it.

Anyway, the theory definitely needs evidence and it'll be interesting to see how things develop since all this is so new and perplexing. But I think it's good that doctors are questioning the effectiveness of current protocols as they apply to COVID-19. Isn't that how medical science evolves?

dandarc

  • Magnum Stache
  • ******
  • Posts: 4022
  • Age: 37
Re: How long can we wait while flattening the curve?
« Reply #562 on: April 12, 2020, 02:21:55 PM »
@Luz - Replace "antibiotics to do their work" with "the immune system to do its work". Point of the treatment is still to keep you alive long enough for something to beat down the disease in your body.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #563 on: April 12, 2020, 03:53:04 PM »
Anyone see the news about farmers destroying millions of pounds of food? What might this mean for the food supply?
https://www.nytimes.com/2020/04/11/business/coronavirus-destroying-food.html?action=click&module=RelatedLinks&pgtype=Article

I've also been thinking about remittances sent to low and middle income countries. My husband, who thankfully still has his job, supports his family in Mexico. But minorities (including the 44 million+ in the US who are foreign-born) have been especially hard hit with job losses. That will surely have a huge effect on a number of economies in the global South (who are also dealing with currency devaluation). According to the World Bank, over $550 billion worth of remittances were sent in 2019. Each remittance helped provide an average of 4 people with essential goods like healthcare, food and education. I wonder what the remittance amount will be in 2020, and what impact the reduction will have.

On a separate note, there have been some interesting articles about ventilator use and treatment for COVID-19.
https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems?ecd=wnl_spr_040720&ctr=wnl-spr-040720_nsl-LeadModule_cta&mb=NsX4TDGa29wOP4UZt7HlX3g0WleHxvIq8lar%2fYm30fc%3d
https://www.the-sun.com/news/663895/coronavirus-doctors-warn-ventilators-harm-than-good/

Although the treatment protocol for Acute Respiratory Distress Syndrome (ARDS) has been adopted for COVID-19, doctors are now finding that many COVID-19 cases are more similar to altitude sickness, where ventilator use and the related levels of forced pressure may do more harm than good. I wonder what this means for the the $490 million Defense Production Act contract with GM. Any healthcare professionals care to share what's happening with ventilator use in their hospitals?

Regarding the ventilators - itís elementary critical care to not use excess pressure or oxygen, so while interesting it isnít really that significant for management. Also itís well known that x-ray changes are delayed by several days from onset of symptoms with most lung injury, so it may just be thereís not much to see yet, and an x-ray several days later in these patients would show the edema. Thereís a lot of anecdotal pet theories being thrown out by physicians on the Internet (see hydroxychloroquine), but not much real data to back it up. Also, ventilation at appropriate settings does not cause ARDS-like damage. Iím not sure how they do it in Germany, but in the US low pressure, low volume ventilation is well established as standard of care. The only way youíd cause barotrauma is if youíre using volume control to get the 4-6 mL/kg volume but not using pressure regulation, and keep them at a low oxygen level. That may be an issue if youíre using an anesthesia machine rather than ICU ventilator (some models donít allow for PRVC and may not have set flow limits so you can get transient barotrauma).

The editorial basically says that patients may initially present with hypoxia and non-compensating respiratory rate that can be treated with nasal cannula. If their work of breathing increases they need to be intubated. They are recommending unusually high tidal volumes for treating hypercapnia in intubated patients (8-9 mL/kg), whereas we would increase the respiratory rate to improve ventilation.  The rest is supposition without any provided evidence.

Thanks for insight!

I don't have a medical background, so I hope I'm understanding this correctly, but aren't more doctors questioning the effects of ventilator use, "not because," according to Dr. Martin Gillick of Harvard Medical School, "the problem is not getting oxygen into the lungs, but from the lungs into the bloodstream?" The doctor (Luciano Gattinoni) writing the editorial is also one of the world's foremost experts on/created the protocol for ARDS and ventilation, no? He's not just some doctor tweeting his opinions.

My understanding is that, in at least 1/2 to 2/3rds of cases, COVID-19 is presenting differently than ARDS in that patients on ventilation show very low concentrations of blood-oxygen levels. The theory (again, as I understand it) is that the blood vessels of COVID-19 patients who aren't presenting with classic ARDS are not properly redirecting blood from damaged to healthy areas of the lungs (which is the mechanism that protects the body from such drastic drops in oxygen levels). It's essentially an issue of the oxygen-carrying capacity of the red blood cells (at least that's the hypothesis). Because of this, positive pressure may aggravate the disease process. A doctor on NPR also said that ventilators have been seen as critical in COVID-19, because for patients with pneumonia, they are a life-supporting measure that buys time for antibiotics to do their work. But with COVID-19, there's nothing like antibiotics at this point to treat it.

Anyway, the theory definitely needs evidence and it'll be interesting to see how things develop since all this is so new and perplexing. But I think it's good that doctors are questioning the effectiveness of current protocols as they apply to COVID-19. Isn't that how medical science evolves?

I ran this by a friend who also does critical care and he agreed with my points. He says that Dr Gattitoni is an expert in this field, but his editorial doesn't really say what these article (and other ones like it) writers are saying. It is an issue of hypoxia and shunting, which is common in many cases of lung injury that may or may not progress to ARDS (which by definition requires findings on chest x-ray or CT), and Dr Gattinoni points that out in the editorial. Also, not all patients with COVID develop ARDS so they don't need high pressure ventilation. His editorial and recommendations don't say not to ventilate patients with standard protocols, it just raises the point that they need to be monitored closely and to avoid excess pressure (which is part of the protocol). It's not different than anything we normally do. Dr Gillick's point is technically correct (it's easy to push any amount of oxygen into a lung), but the issue of getting it into the bloodstream is exactly what ARDS (or really any severe pneumonia even without ARDS) causes, and why people who are hypoxic get put on ventilators.

My point regarding the theories isn't really directed to the doctors, who are experts, it is more towards the reporters. It's kind of aggravating when they try to stir up a controversy that doesn't exist and try to portray physicians as non-thinking and protocol-driven. They also imply the high mortality rate is from ventilator mis-management. However, patients in the trial cited had unusually low rates of co-morbidities. All Dr Gattitoni is doing is reminding people to think carefully, not everyone with COVID has ARDS, and adjust ventilators only as much as needed to oxygenate (per the protocols for ARDS. I have the card in my coat pocket and that is literally what it says).

TLDR; not everyone with COVID-19 will progress to ARDS. Some of them are hypoxic without classic findings. These people don't need as much pressure when ventilating, which if you follow standard protocols (and basic practices) will be self-evident.

I hope that clarifies things.
« Last Edit: April 12, 2020, 04:06:36 PM by Abe »

Telecaster

  • Handlebar Stache
  • *****
  • Posts: 2315
  • Location: Seattle, WA
Re: How long can we wait while flattening the curve?
« Reply #564 on: April 12, 2020, 05:48:45 PM »
I have been thinking about the impact on commerce as i am in finance for a publicly traded company.  I think even in the best scenario we are going to see mass layoffs soon.  First quarter earnings will be released soon which were impacted, but not to the extent as we will see in the second quarter.   Some companies like mine are putting on a good face but will react sometime between now and july.  Any opinions on the economics over the next 9 months and what and when a recovery would look like?  I am starting to think this could drastically change many fa ets of society.

This is my SWAG:   The last three major recessions, the Great Recession, inflation in the 1970s (actually several recessions, but I'll lump them all in together), and the Great Depression were all caused by systemtic economic problems that had to be sorted out before the economy could grow again.   I've argued previously here in MMM that because there isn't a systemic economic problem here, the recovery should be fast and steep.   I no longer believe that to be the case. 

We are in the first phase of this.  Lock everything down so we don't overload the medical system.  We're starting to get to the end of Phase I.  Now it is time to start thinking about opening up the country in a careful, limited way (actually the time to start thinking was long ago).   

People won't go to a stadium, restaurant, plane, cruise ship, or even into the office until they feel reasonably safe. If there is no plan or method to do widespread testing and contact tracing, people won't feel reasonably safe and the country will remain in a state of de facto shut down. Maybe not shut down like it is now, but economic activity will be reduced.  The only way to make people feel reasonably safe is with a robust testing and contact tracing program such that cases can be quickly identified and isolated and we don't have new major outbreaks.   

Twice this week the president made it clear there will be no federal testing program. That means a quick economic recovery is impossible.  Even if we ease the social distancing recommendations, COVID will keep springing up and people will continue to social distance on their own.   Factories will continue to erupt in COVID clusters (like Boeing, Smithfield) and be forced to shut down.   Offices won't open back up, which means restaurants who service office workers won't open up either. 


Luz

  • Bristles
  • ***
  • Posts: 455
Re: How long can we wait while flattening the curve?
« Reply #565 on: April 12, 2020, 09:25:30 PM »
Anyone see the news about farmers destroying millions of pounds of food? What might this mean for the food supply?
https://www.nytimes.com/2020/04/11/business/coronavirus-destroying-food.html?action=click&module=RelatedLinks&pgtype=Article

I've also been thinking about remittances sent to low and middle income countries. My husband, who thankfully still has his job, supports his family in Mexico. But minorities (including the 44 million+ in the US who are foreign-born) have been especially hard hit with job losses. That will surely have a huge effect on a number of economies in the global South (who are also dealing with currency devaluation). According to the World Bank, over $550 billion worth of remittances were sent in 2019. Each remittance helped provide an average of 4 people with essential goods like healthcare, food and education. I wonder what the remittance amount will be in 2020, and what impact the reduction will have.

On a separate note, there have been some interesting articles about ventilator use and treatment for COVID-19.
https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems?ecd=wnl_spr_040720&ctr=wnl-spr-040720_nsl-LeadModule_cta&mb=NsX4TDGa29wOP4UZt7HlX3g0WleHxvIq8lar%2fYm30fc%3d
https://www.the-sun.com/news/663895/coronavirus-doctors-warn-ventilators-harm-than-good/

Although the treatment protocol for Acute Respiratory Distress Syndrome (ARDS) has been adopted for COVID-19, doctors are now finding that many COVID-19 cases are more similar to altitude sickness, where ventilator use and the related levels of forced pressure may do more harm than good. I wonder what this means for the the $490 million Defense Production Act contract with GM. Any healthcare professionals care to share what's happening with ventilator use in their hospitals?

Regarding the ventilators - it’s elementary critical care to not use excess pressure or oxygen, so while interesting it isn’t really that significant for management. Also it’s well known that x-ray changes are delayed by several days from onset of symptoms with most lung injury, so it may just be there’s not much to see yet, and an x-ray several days later in these patients would show the edema. There’s a lot of anecdotal pet theories being thrown out by physicians on the Internet (see hydroxychloroquine), but not much real data to back it up. Also, ventilation at appropriate settings does not cause ARDS-like damage. I’m not sure how they do it in Germany, but in the US low pressure, low volume ventilation is well established as standard of care. The only way you’d cause barotrauma is if you’re using volume control to get the 4-6 mL/kg volume but not using pressure regulation, and keep them at a low oxygen level. That may be an issue if you’re using an anesthesia machine rather than ICU ventilator (some models don’t allow for PRVC and may not have set flow limits so you can get transient barotrauma).

The editorial basically says that patients may initially present with hypoxia and non-compensating respiratory rate that can be treated with nasal cannula. If their work of breathing increases they need to be intubated. They are recommending unusually high tidal volumes for treating hypercapnia in intubated patients (8-9 mL/kg), whereas we would increase the respiratory rate to improve ventilation.  The rest is supposition without any provided evidence.

Thanks for insight!

I don't have a medical background, so I hope I'm understanding this correctly, but aren't more doctors questioning the effects of ventilator use, "not because," according to Dr. Martin Gillick of Harvard Medical School, "the problem is not getting oxygen into the lungs, but from the lungs into the bloodstream?" The doctor (Luciano Gattinoni) writing the editorial is also one of the world's foremost experts on/created the protocol for ARDS and ventilation, no? He's not just some doctor tweeting his opinions.

My understanding is that, in at least 1/2 to 2/3rds of cases, COVID-19 is presenting differently than ARDS in that patients on ventilation show very low concentrations of blood-oxygen levels. The theory (again, as I understand it) is that the blood vessels of COVID-19 patients who aren't presenting with classic ARDS are not properly redirecting blood from damaged to healthy areas of the lungs (which is the mechanism that protects the body from such drastic drops in oxygen levels). It's essentially an issue of the oxygen-carrying capacity of the red blood cells (at least that's the hypothesis). Because of this, positive pressure may aggravate the disease process. A doctor on NPR also said that ventilators have been seen as critical in COVID-19, because for patients with pneumonia, they are a life-supporting measure that buys time for antibiotics to do their work. But with COVID-19, there's nothing like antibiotics at this point to treat it.

Anyway, the theory definitely needs evidence and it'll be interesting to see how things develop since all this is so new and perplexing. But I think it's good that doctors are questioning the effectiveness of current protocols as they apply to COVID-19. Isn't that how medical science evolves?

I ran this by a friend who also does critical care and he agreed with my points. He says that Dr Gattitoni is an expert in this field, but his editorial doesn't really say what these article (and other ones like it) writers are saying. It is an issue of hypoxia and shunting, which is common in many cases of lung injury that may or may not progress to ARDS (which by definition requires findings on chest x-ray or CT), and Dr Gattinoni points that out in the editorial. Also, not all patients with COVID develop ARDS so they don't need high pressure ventilation. His editorial and recommendations don't say not to ventilate patients with standard protocols, it just raises the point that they need to be monitored closely and to avoid excess pressure (which is part of the protocol). It's not different than anything we normally do. Dr Gillick's point is technically correct (it's easy to push any amount of oxygen into a lung), but the issue of getting it into the bloodstream is exactly what ARDS (or really any severe pneumonia even without ARDS) causes, and why people who are hypoxic get put on ventilators.

My point regarding the theories isn't really directed to the doctors, who are experts, it is more towards the reporters. It's kind of aggravating when they try to stir up a controversy that doesn't exist and try to portray physicians as non-thinking and protocol-driven. They also imply the high mortality rate is from ventilator mis-management. However, patients in the trial cited had unusually low rates of co-morbidities. All Dr Gattitoni is doing is reminding people to think carefully, not everyone with COVID has ARDS, and adjust ventilators only as much as needed to oxygenate (per the protocols for ARDS. I have the card in my coat pocket and that is literally what it says).

TLDR; not everyone with COVID-19 will progress to ARDS. Some of them are hypoxic without classic findings. These people don't need as much pressure when ventilating, which if you follow standard protocols (and basic practices) will be self-evident.

I hope that clarifies things.

Interesting! That does help clarify. 2 more questions (though I know it's a little off topic now): it sounds like your hospital follows the proper recommendations, but has there been a problem in other places with doctors being too quick to put patients on ventilation and with excess pressure (hence Dr. Gattinoni's reminder)? Also, what do you think is contributing to the high mortality rate of COVID-19 patients on ventilation? It sounds like in NYC, nearly double the number of COVID-19 patients versus non-COVID-19 patients with severe respiratory distress died while on ventilation. I read that nearly 90% of patients hospitalized with COVID-19 have co-morbid conditions. Would that account for much of the difference? (I'm not sure of the rate of co-morbid conditions of non-COVID-19 patients on ventilation with severe respiratory distress).
« Last Edit: April 12, 2020, 10:08:11 PM by Luz »

Luz

  • Bristles
  • ***
  • Posts: 455
Re: How long can we wait while flattening the curve?
« Reply #566 on: April 12, 2020, 09:58:37 PM »
@Luz - Replace "antibiotics to do their work" with "the immune system to do its work". Point of the treatment is still to keep you alive long enough for something to beat down the disease in your body.

That makes sense, but I think the question was whether ventilation (in the case of COVID-19) is truly a neutral, time-buying mechanism or if there are complications related to ventilation of COVID-19 patients that contribute to an accelerated death.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #567 on: April 12, 2020, 10:56:21 PM »
Anyone see the news about farmers destroying millions of pounds of food? What might this mean for the food supply?
https://www.nytimes.com/2020/04/11/business/coronavirus-destroying-food.html?action=click&module=RelatedLinks&pgtype=Article

I've also been thinking about remittances sent to low and middle income countries. My husband, who thankfully still has his job, supports his family in Mexico. But minorities (including the 44 million+ in the US who are foreign-born) have been especially hard hit with job losses. That will surely have a huge effect on a number of economies in the global South (who are also dealing with currency devaluation). According to the World Bank, over $550 billion worth of remittances were sent in 2019. Each remittance helped provide an average of 4 people with essential goods like healthcare, food and education. I wonder what the remittance amount will be in 2020, and what impact the reduction will have.

On a separate note, there have been some interesting articles about ventilator use and treatment for COVID-19.
https://www.webmd.com/lung/news/20200407/doctors-puzzle-over-covid19-lung-problems?ecd=wnl_spr_040720&ctr=wnl-spr-040720_nsl-LeadModule_cta&mb=NsX4TDGa29wOP4UZt7HlX3g0WleHxvIq8lar%2fYm30fc%3d
https://www.the-sun.com/news/663895/coronavirus-doctors-warn-ventilators-harm-than-good/

Although the treatment protocol for Acute Respiratory Distress Syndrome (ARDS) has been adopted for COVID-19, doctors are now finding that many COVID-19 cases are more similar to altitude sickness, where ventilator use and the related levels of forced pressure may do more harm than good. I wonder what this means for the the $490 million Defense Production Act contract with GM. Any healthcare professionals care to share what's happening with ventilator use in their hospitals?

Regarding the ventilators - itís elementary critical care to not use excess pressure or oxygen, so while interesting it isnít really that significant for management. Also itís well known that x-ray changes are delayed by several days from onset of symptoms with most lung injury, so it may just be thereís not much to see yet, and an x-ray several days later in these patients would show the edema. Thereís a lot of anecdotal pet theories being thrown out by physicians on the Internet (see hydroxychloroquine), but not much real data to back it up. Also, ventilation at appropriate settings does not cause ARDS-like damage. Iím not sure how they do it in Germany, but in the US low pressure, low volume ventilation is well established as standard of care. The only way youíd cause barotrauma is if youíre using volume control to get the 4-6 mL/kg volume but not using pressure regulation, and keep them at a low oxygen level. That may be an issue if youíre using an anesthesia machine rather than ICU ventilator (some models donít allow for PRVC and may not have set flow limits so you can get transient barotrauma).

The editorial basically says that patients may initially present with hypoxia and non-compensating respiratory rate that can be treated with nasal cannula. If their work of breathing increases they need to be intubated. They are recommending unusually high tidal volumes for treating hypercapnia in intubated patients (8-9 mL/kg), whereas we would increase the respiratory rate to improve ventilation.  The rest is supposition without any provided evidence.

Thanks for insight!

I don't have a medical background, so I hope I'm understanding this correctly, but aren't more doctors questioning the effects of ventilator use, "not because," according to Dr. Martin Gillick of Harvard Medical School, "the problem is not getting oxygen into the lungs, but from the lungs into the bloodstream?" The doctor (Luciano Gattinoni) writing the editorial is also one of the world's foremost experts on/created the protocol for ARDS and ventilation, no? He's not just some doctor tweeting his opinions.

My understanding is that, in at least 1/2 to 2/3rds of cases, COVID-19 is presenting differently than ARDS in that patients on ventilation show very low concentrations of blood-oxygen levels. The theory (again, as I understand it) is that the blood vessels of COVID-19 patients who aren't presenting with classic ARDS are not properly redirecting blood from damaged to healthy areas of the lungs (which is the mechanism that protects the body from such drastic drops in oxygen levels). It's essentially an issue of the oxygen-carrying capacity of the red blood cells (at least that's the hypothesis). Because of this, positive pressure may aggravate the disease process. A doctor on NPR also said that ventilators have been seen as critical in COVID-19, because for patients with pneumonia, they are a life-supporting measure that buys time for antibiotics to do their work. But with COVID-19, there's nothing like antibiotics at this point to treat it.

Anyway, the theory definitely needs evidence and it'll be interesting to see how things develop since all this is so new and perplexing. But I think it's good that doctors are questioning the effectiveness of current protocols as they apply to COVID-19. Isn't that how medical science evolves?

I ran this by a friend who also does critical care and he agreed with my points. He says that Dr Gattitoni is an expert in this field, but his editorial doesn't really say what these article (and other ones like it) writers are saying. It is an issue of hypoxia and shunting, which is common in many cases of lung injury that may or may not progress to ARDS (which by definition requires findings on chest x-ray or CT), and Dr Gattinoni points that out in the editorial. Also, not all patients with COVID develop ARDS so they don't need high pressure ventilation. His editorial and recommendations don't say not to ventilate patients with standard protocols, it just raises the point that they need to be monitored closely and to avoid excess pressure (which is part of the protocol). It's not different than anything we normally do. Dr Gillick's point is technically correct (it's easy to push any amount of oxygen into a lung), but the issue of getting it into the bloodstream is exactly what ARDS (or really any severe pneumonia even without ARDS) causes, and why people who are hypoxic get put on ventilators.

My point regarding the theories isn't really directed to the doctors, who are experts, it is more towards the reporters. It's kind of aggravating when they try to stir up a controversy that doesn't exist and try to portray physicians as non-thinking and protocol-driven. They also imply the high mortality rate is from ventilator mis-management. However, patients in the trial cited had unusually low rates of co-morbidities. All Dr Gattitoni is doing is reminding people to think carefully, not everyone with COVID has ARDS, and adjust ventilators only as much as needed to oxygenate (per the protocols for ARDS. I have the card in my coat pocket and that is literally what it says).

TLDR; not everyone with COVID-19 will progress to ARDS. Some of them are hypoxic without classic findings. These people don't need as much pressure when ventilating, which if you follow standard protocols (and basic practices) will be self-evident.

I hope that clarifies things.

Interesting! That does help clarify. 2 more questions (though I know it's a little off topic now): it sounds like your hospital follows the proper recommendations, but has there been a problem in other places with doctors being too quick to put patients on ventilation and with excess pressure (hence Dr. Gattinoni's reminder)? Also, what do you think is contributing to the high mortality rate of COVID-19 patients on ventilation? It sounds like in NYC, nearly double the number of COVID-19 patients versus non-COVID-19 patients with severe respiratory distress died while on ventilation. I read that nearly 90% of patients hospitalized with COVID-19 have co-morbid conditions. Would that account for much of the difference? (I'm not sure of the rate of co-morbid conditions of non-COVID-19 patients on ventilation with severe respiratory distress).

Canít say whatís going on at other hospitals except where my friends are, and they all agreed with the high oxygenation, low pressure plan for non-ARDS patients. They are also at major medical centers and have been preparing since January. Thatís really something we learn in training, so itís not complicated. My guess regarding mortality rates is itís a bit higher than most ARDS patients (usually mortality is quoted as 40-50%, but with covid weíre seeing 60-70%). The co-morbidities probably contribute, but itís too early to know. I highly doubt barotrauma from ventilation explains the difference. My thought is part of it is the severity of the outbreak - normally patients would come in much sooner to the hospital or clinic if they have symptoms like cough, fever, etc that can progress to respiratory distress. Itís a bit unusual to arrive to the ER with respiratory failure from pneumonia in normal circumstances, but they are seeing a lot of that in NY/NJ due to the overwhelmed hospital and EMS system. For comparison, Southern California has about the same number of people, but we have had fewer deaths total than theyíre having in a day! Thatís exactly why flattening the curve is so important (short term benefit - the long term goal is to delay cases as far as possible to when we have a vaccine or drug treatment).

I reviewed the Johns Hopkinsí database for cases and deaths for the top 10 states in terms of both statistics, and so far all of them except NY and NJ have slower trajectories. Thatís overall a good sign that weíre getting somewhat ahead of this. If someone can explain how to post an image I can present the graphs for everyone.
« Last Edit: April 12, 2020, 11:01:32 PM by Abe »

secondcor521

  • Magnum Stache
  • ******
  • Posts: 3131
  • Age: 51
  • Location: Boise, Idaho
  • Big cattle, no hat.
    • Age of Eon - Overwatch player videos
Re: How long can we wait while flattening the curve?
« Reply #568 on: April 13, 2020, 12:24:56 AM »
@Abe I'm curious your opinion of why it is so much worse in NY/NJ.  It's over half the US deaths in those two states with approximately 5% of the population.

Mariposa

  • Pencil Stache
  • ****
  • Posts: 526
  • Location: NYC
Re: How long can we wait while flattening the curve?
« Reply #569 on: April 13, 2020, 02:06:44 AM »
I'm a medical provider in NYC. 3 reasons I can think of why our area has so many deaths. NYC and the most affected parts of NJ are one contiguous metro area.

1. Community spread happened earlier here than most other places in the US because we're an international hub. At a time when testing wasn't happening. For a long time, we kept saying there were no cases here, but we ran EIGHT tests because of overly narrow CDC guidelines.

2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

3. The NY metropolitan area, which includes NYC, Long Island, Hudson Valley, and parts of NJ, PA, CT, is the densest place in North America, with a contiguous metro area of ~20mil people.

Even though testing ramped up quickly in NY, there are still not nearly enough tests to capture all the cases in the population. The positivity rate here is an astounding 40%. I'm guessing there are 2mil+ actually infected here. This is based on my sense of the numbers of people I'm seeing getting sick and unable to get a test. We're officially discouraging anyone not sick enough to get hospitalized from seeking out testing. My sense of things is also based on the estimates from Italy that their death numbers resulted from 5-10mil of their population actually infected.

The medical care in NYC is excellent, with some of the smartest people around writing hospital protocols, and generally more minimalist than other parts of the country. We don't put people on ventilators unless absolutely necessary. Just read the ER protocol for Northwell Hospitals saying to first put people on 15L non-rebreather with 10L nasal cannula under that. And they will only intubate if PaO2 is proven to be <60 on ABG with all that O2 on first. Protocol specifically says not to intubate based on work of breathing.

TL;DR: The high number of deaths in NY/NJ is NOT from putting people on ventilators too quickly.

Accountant

  • 5 O'Clock Shadow
  • *
  • Posts: 27
Re: How long can we wait while flattening the curve?
« Reply #570 on: April 13, 2020, 08:22:31 AM »
I have been thinking about the impact on commerce as i am in finance for a publicly traded company.  I think even in the best scenario we are going to see mass layoffs soon.  First quarter earnings will be released soon which were impacted, but not to the extent as we will see in the second quarter.   Some companies like mine are putting on a good face but will react sometime between now and july.  Any opinions on the economics over the next 9 months and what and when a recovery would look like?  I am starting to think this could drastically change many fa ets of society.

This is my SWAG:   The last three major recessions, the Great Recession, inflation in the 1970s (actually several recessions, but I'll lump them all in together), and the Great Depression were all caused by systemtic economic problems that had to be sorted out before the economy could grow again.   I've argued previously here in MMM that because there isn't a systemic economic problem here, the recovery should be fast and steep.   I no longer believe that to be the case. 

We are in the first phase of this.  Lock everything down so we don't overload the medical system.  We're starting to get to the end of Phase I.  Now it is time to start thinking about opening up the country in a careful, limited way (actually the time to start thinking was long ago).   

People won't go to a stadium, restaurant, plane, cruise ship, or even into the office until they feel reasonably safe. If there is no plan or method to do widespread testing and contact tracing, people won't feel reasonably safe and the country will remain in a state of de facto shut down. Maybe not shut down like it is now, but economic activity will be reduced.  The only way to make people feel reasonably safe is with a robust testing and contact tracing program such that cases can be quickly identified and isolated and we don't have new major outbreaks.   

Twice this week the president made it clear there will be no federal testing program. That means a quick economic recovery is impossible.  Even if we ease the social distancing recommendations, COVID will keep springing up and people will continue to social distance on their own.   Factories will continue to erupt in COVID clusters (like Boeing, Smithfield) and be forced to shut down.   Offices won't open back up, which means restaurants who service office workers won't open up either.

I watched an interview with the CEO of the minnesota Fed.  Basically said a v shaped recovery is unlikely and there will likely be rolling outages in next 18 months unless there is a vaccine or therapy.  I think 2020 and 2021 are impaired for a lot of industries unless something drastic happens soon.  Good time to have horded cash and have the ability to ride it out.  The next challenge for many will be trying to establishing careers again during or after.

js82

  • Bristles
  • ***
  • Posts: 469
Re: How long can we wait while flattening the curve?
« Reply #571 on: April 13, 2020, 08:29:05 AM »
My point regarding the theories isn't really directed to the doctors, who are experts, it is more towards the reporters. It's kind of aggravating when they try to stir up a controversy that doesn't exist and try to portray physicians as non-thinking and protocol-driven. They also imply the high mortality rate is from ventilator mis-management. However, patients in the trial cited had unusually low rates of co-morbidities. All Dr Gattitoni is doing is reminding people to think carefully, not everyone with COVID has ARDS, and adjust ventilators only as much as needed to oxygenate (per the protocols for ARDS. I have the card in my coat pocket and that is literally what it says).

I've been thinking on this - and I've come to conclusion that there's a systemic failure here - but it doesn't lie with the doctors/nurses/etc. - they're doing the best they can.  We haven't set up the infrastructure to collect and share data that could be used to optimize treatment practices and potentially save thousands of lives.

What we have right now is a failure to collect and aggregate data.  Whether it's the usage of hydroxychloroquine in treatment, or variations in ventilator/oxygen protocols, right now we're essentially doing an experiment on a massive scale, and yet we're not effectively collecting and sharing the data that's being generated.  Instead we have observations/experiences from individual physicians, but it takes the form of anecdotes - and scientists want hard, numerical data before making concrete recommendations - thus there are probably best practices out there that aren't being shared as quickly and completely as they should be.

Imagine for a moment if Trump had used the Defense Production act to compel Google to build a database that could be used to aggregate patient data with treatment protocols and outcomes - and then we got other individuals to help with getting this data into a database(I say "other individuals" because we need to be giving doctors/nurses help here, not asking them to do more).  We'd have tens, if not hundreds of thousands of data points on things ranging from ventilator/oxygen protocols to treatment with antiviral drugs.  Data scientists could quickly begin to tease out any potential trends regarding whether certain treatment protocols were more effective than others in helping people survive/recover from this disease.

Given this data, doctors around the globe would be better positioned to select the most effective treatment protocols for any given patient.

I'm not saying it would be trivial to set up a system like this, but science/medicine aren't used to collecting data and integrating it into their practices at pandemic speed - and before the next pandemic hits, we should figure out how to do that.  It feels to me like the data science/analytics world has a role they could be playing to help our medical professionals save lives and chart a better course through this pandemic, but right now that's not happening - largely because we haven't set up a real data infrastructure for Covid-19 data beyond cases and deaths.

Michael in ABQ

  • Handlebar Stache
  • *****
  • Posts: 1092
    • Military Saints
Re: How long can we wait while flattening the curve?
« Reply #572 on: April 13, 2020, 08:44:20 AM »
My point regarding the theories isn't really directed to the doctors, who are experts, it is more towards the reporters. It's kind of aggravating when they try to stir up a controversy that doesn't exist and try to portray physicians as non-thinking and protocol-driven. They also imply the high mortality rate is from ventilator mis-management. However, patients in the trial cited had unusually low rates of co-morbidities. All Dr Gattitoni is doing is reminding people to think carefully, not everyone with COVID has ARDS, and adjust ventilators only as much as needed to oxygenate (per the protocols for ARDS. I have the card in my coat pocket and that is literally what it says).

I've been thinking on this - and I've come to conclusion that there's a systemic failure here - but it doesn't lie with the doctors/nurses/etc. - they're doing the best they can.  We haven't set up the infrastructure to collect and share data that could be used to optimize treatment practices and potentially save thousands of lives.

What we have right now is a failure to collect and aggregate data.  Whether it's the usage of hydroxychloroquine in treatment, or variations in ventilator/oxygen protocols, right now we're essentially doing an experiment on a massive scale, and yet we're not effectively collecting and sharing the data that's being generated.  Instead we have observations/experiences from individual physicians, but it takes the form of anecdotes - and scientists want hard, numerical data before making concrete recommendations - thus there are probably best practices out there that aren't being shared as quickly and completely as they should be.

Imagine for a moment if Trump had used the Defense Production act to compel Google to build a database that could be used to aggregate patient data with treatment protocols and outcomes - and then we got other individuals to help with getting this data into a database(I say "other individuals" because we need to be giving doctors/nurses help here, not asking them to do more).  We'd have tens, if not hundreds of thousands of data points on things ranging from ventilator/oxygen protocols to treatment with antiviral drugs.  Data scientists could quickly begin to tease out any potential trends regarding whether certain treatment protocols were more effective than others in helping people survive/recover from this disease.

Given this data, doctors around the globe would be better positioned to select the most effective treatment protocols for any given patient.

I'm not saying it would be trivial to set up a system like this, but science/medicine aren't used to collecting data and integrating it into their practices at pandemic speed - and before the next pandemic hits, we should figure out how to do that.  It feels to me like the data science/analytics world has a role they could be playing to help our medical professionals save lives and chart a better course through this pandemic, but right now that's not happening - largely because we haven't set up a real data infrastructure for Covid-19 data beyond cases and deaths.

I imagine HIPAA would make this nearly impossible.

While healthcare is a huge potential opportunity for tech companies, just like finance there are a lot of regulations around it and it's not easy navigating those. Nor is it easy to change those regulations or the underlying laws that led to their creation.

cerat0n1a

  • Handlebar Stache
  • *****
  • Posts: 1910
  • Location: England
Re: How long can we wait while flattening the curve?
« Reply #573 on: April 13, 2020, 09:17:43 AM »
2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

For comparison, England has roughly 2.5x the death rate of Ireland, and rising. Two pretty similar countries, right next door, same level of intensive care beds (around half the European average.) Ireland closed down a lot sooner. Schools closed at the same time that Johnson was telling people to wash their hands. Pubs closed before St. Patricks Day, at the same time the UK had a horse racing event with 250 000 people in attendance.

former player

  • Walrus Stache
  • *******
  • Posts: 5796
  • Location: Avalon
Re: How long can we wait while flattening the curve?
« Reply #574 on: April 13, 2020, 10:38:45 AM »
2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

For comparison, England has roughly 2.5x the death rate of Ireland, and rising. Two pretty similar countries, right next door, same level of intensive care beds (around half the European average.) Ireland closed down a lot sooner. Schools closed at the same time that Johnson was telling people to wash their hands. Pubs closed before St. Patricks Day, at the same time the UK had a horse racing event with 250 000 people in attendance.
Boris has a lot to answer for, but whether the arrogant shit will admit that is an interesting question. 

the_fixer

  • Pencil Stache
  • ****
  • Posts: 899
  • Location: Colorado
  • mind on my money money on my mind
How long can we wait while flattening the curve?
« Reply #575 on: April 13, 2020, 10:42:42 AM »
2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

For comparison, England has roughly 2.5x the death rate of Ireland, and rising. Two pretty similar countries, right next door, same level of intensive care beds (around half the European average.) Ireland closed down a lot sooner. Schools closed at the same time that Johnson was telling people to wash their hands. Pubs closed before St. Patricks Day, at the same time the UK had a horse racing event with 250 000 people in attendance.
Is that adjusted for the significant difference in population between England and Ireland?

Just looked it up and here are the stats according to worldometer

England Tot Cases per 1m population
1,305
England Deaths per 1m population
167

Ireland Tot Cases per 1m population
1955
Ireland Deaths per 1m population
68

So Ireland has more cases per 1m but less deaths







Sent from my iPhone using Tapatalk
« Last Edit: April 13, 2020, 10:48:18 AM by the_fixer »

bacchi

  • Walrus Stache
  • *******
  • Posts: 5004
Re: How long can we wait while flattening the curve?
« Reply #576 on: April 13, 2020, 11:09:41 AM »
2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

For comparison, England has roughly 2.5x the death rate of Ireland, and rising. Two pretty similar countries, right next door, same level of intensive care beds (around half the European average.) Ireland closed down a lot sooner. Schools closed at the same time that Johnson was telling people to wash their hands. Pubs closed before St. Patricks Day, at the same time the UK had a horse racing event with 250 000 people in attendance.
Is that adjusted for the significant difference in population between England and Ireland?

Just looked it up and here are the stats according to worldometer

England Tot Cases per 1m population
1,305
England Deaths per 1m population
167

Ireland Tot Cases per 1m population
1955
Ireland Deaths per 1m population
68

So Ireland has more cases per 1m but less deaths

Ireland has tested 2.7x more than England has tested, too.

the_fixer

  • Pencil Stache
  • ****
  • Posts: 899
  • Location: Colorado
  • mind on my money money on my mind
Re: How long can we wait while flattening the curve?
« Reply #577 on: April 13, 2020, 11:21:23 AM »
England test / 1m population
5,416
Total tests
367,667


Ireland tests / 1m population
14,581
Total tests
72,000


Sent from my iPhone using Tapatalk

cerat0n1a

  • Handlebar Stache
  • *****
  • Posts: 1910
  • Location: England
Re: How long can we wait while flattening the curve?
« Reply #578 on: April 13, 2020, 11:55:44 AM »
Is that adjusted for the significant difference in population between England and Ireland?

Per capita, obviously.

There are plenty of caveats, as in all such comparisons. The Irish figures include deaths in care homes, the British ones don't. Ireland has no equivalent of London, which accounts for half of UK deaths currently. But even if you compare Ireland with Scotland, or rural England, it's still significantly lower and the obvious reason is that they started flattening a good bit earlier on the exponential rise part of the curve.

YttriumNitrate

  • Handlebar Stache
  • *****
  • Posts: 1047
  • Location: Northwest Indiana
Re: How long can we wait while flattening the curve?
« Reply #579 on: April 13, 2020, 12:36:50 PM »
I don't quite understand the optimism about this vaccine. We still don't have a vaccine for SARs, that this is most similar to.....
Compared to a Covid-19 vaccine, do you think 1/1000th the resources are being devoted to a SARS vaccine? I'd be quite surprised if yesterday alone more money wasn't spent developing a Covid-19 vaccine than was ever spent on a SARS vaccine.

I donít think thereís a linear relationship between vaccine development and money allocated.  By which I mean spending 1000x doesnít get you a vaccine 1000x faster.  Sure, throwing more resources at a disease certainly helps, but the complexity remains.  Thereís no certainty that an effective vaccine will be developed and readily available by next year, or even the following year.

I certainly don't think anyone believes there is a linear relationship between the amount spent and the speed at which a vaccine is developed. If there was (assuming 1000x increase in spending) we would have already had a vaccine since every day in April would have been equivalent to three years of SARS vaccine research. A more realistic expectation would be that for a 1000x increase in spending we increase the speed of vaccine development by 10-30x which would hopefully have something available in late 2020.

YttriumNitrate

  • Handlebar Stache
  • *****
  • Posts: 1047
  • Location: Northwest Indiana
Re: How long can we wait while flattening the curve?
« Reply #580 on: April 13, 2020, 12:42:07 PM »
Is that adjusted for the significant difference in population between England and Ireland?

Per capita, obviously.

There are plenty of caveats, as in all such comparisons. The Irish figures include deaths in care homes, the British ones don't. Ireland has no equivalent of London, which accounts for half of UK deaths currently. But even if you compare Ireland with Scotland, or rural England, it's still significantly lower and the obvious reason is that they started flattening a good bit earlier on the exponential rise part of the curve.

Why wouldn't Dublin and London be equivalent? They both have about 4,500-4,800 inhabitants per square kilometre [1][2]. Dublin repents 28% of the population of Ireland while London represents 16% of the population of England.

nereo

  • Senior Mustachian
  • ********
  • Posts: 13536
  • Location: Just south of Canada
    • Here's how you can support science today:
Re: How long can we wait while flattening the curve?
« Reply #581 on: April 13, 2020, 01:28:54 PM »
I don't quite understand the optimism about this vaccine. We still don't have a vaccine for SARs, that this is most similar to.....
Compared to a Covid-19 vaccine, do you think 1/1000th the resources are being devoted to a SARS vaccine? I'd be quite surprised if yesterday alone more money wasn't spent developing a Covid-19 vaccine than was ever spent on a SARS vaccine.

I donít think thereís a linear relationship between vaccine development and money allocated.  By which I mean spending 1000x doesnít get you a vaccine 1000x faster.  Sure, throwing more resources at a disease certainly helps, but the complexity remains.  Thereís no certainty that an effective vaccine will be developed and readily available by next year, or even the following year.

I certainly don't think anyone believes there is a linear relationship between the amount spent and the speed at which a vaccine is developed. If there was (assuming 1000x increase in spending) we would have already had a vaccine since every day in April would have been equivalent to three years of SARS vaccine research. A more realistic expectation would be that for a 1000x increase in spending we increase the speed of vaccine development by 10-30x which would hopefully have something available in late 2020.

Why is that a reasonable assumption?

Iím not trying to be argumentative here - for reference my labs specialty is cultivation of microorganisms. No vaccine work, but a lot of the processes are the same. The challenge with cultivating any novel organism is there are a series of sequential steps involved, and you canít move on to the next one until the previous one has been installed.

Not long ago we were talking about how limiting money and personnel were for cultivating - the consensus was while throwing money and resources at the problem would speed it up somewhat, very quickly you would still run into other barriers.

Like many things in medicine, vaccines sometimes wind up being both quick to develop and very effective at prevention. But we also have a long list of communicable diseases which have had no effective vaccine even with decades of research. Malaria is a good example: collectively across multiple nations we have spent tens of billions and several decades, yet thereís no vaccine and the anti malaria drugs are awash with terrible side effects.

I sincerely hope thereís an effective vaccine for Covid very soon. It just might take longer than many are hoping, and resources will only do so much good.

cerat0n1a

  • Handlebar Stache
  • *****
  • Posts: 1910
  • Location: England
Re: How long can we wait while flattening the curve?
« Reply #582 on: April 13, 2020, 02:35:20 PM »
Why wouldn't Dublin and London be equivalent? They both have about 4,500-4,800 inhabitants per square kilometre

New York probably has the same population density as Miami, or Philadelphia or somewhere, I cant be bothered to check but it's still self evidently massively different in terms of opportunities for viruses to spread quickly. Look at how many people go in and out of London each day. Compare the airport figures for London with Dublin - London is the busiest city airspace in the world. Look at the numbers of people crammed into London underground trains every day compared with Dublin's yet-to-be-built metro system.

Anyway, seems pretty clear with the benefit of hindsight that Leo Varadkar played this much better than Boris Johnson.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #583 on: April 13, 2020, 07:54:13 PM »
@Abe I'm curious your opinion of why it is so much worse in NY/NJ.  It's over half the US deaths in those two states with approximately 5% of the population.

The reasons @Mariposa gave and the density predisposed that area to faster transmission. I think the mortality cannot be estimated that well due to lack of testing or asymptomatic people. In Southern California only 10% of symptomatic or exposed people are testing positive, so I think the overall percent of infected population is much lower than in NY/NJ. Thus the reported mortality rate in that area is likely an overestimate. Same issue in Italy and Spain vs. Germany. Not enough tests to establish a denominator.

This is a separate issue from the hospitals being at capacity. I donít think care in the hospital is suffering enough to cause excess mortality at this point but there is a delay in getting to the hospital as people who are not severely ill are advised to stay at home. Covid pneumonia can progress very rapidly, so people may deteriorate before they (or family) realize how bad the person is doing. Those patients would be better served being monitored in a field hospital as they did in China and S Korea.

YttriumNitrate

  • Handlebar Stache
  • *****
  • Posts: 1047
  • Location: Northwest Indiana
Re: How long can we wait while flattening the curve?
« Reply #584 on: April 13, 2020, 09:23:35 PM »
I certainly don't think anyone believes there is a linear relationship between the amount spent and the speed at which a vaccine is developed.... A more realistic expectation would be that for a 1000x increase in spending we increase the speed of vaccine development by 10-30x which would hopefully have something available in late 2020.
Why is that a reasonable assumption?

Well, there are already two vaccine candidates in clinical trials, and another 42 in pre-clincal trials [1]. Considering a 2-6 year pre-clincal time period [2] for standard vaccine development, at least so far I'd say development is occurring in the 10-30x range. It wouldn't surprise me if we see some challenge studies this summer to further speed things along.

we also have a long list of communicable diseases which have had no effective vaccine even with decades of research. Malaria is a good example: collectively across multiple nations we have spent tens of billions and several decades, yet thereís no vaccine and the anti malaria drugs are awash with terrible side effects.

Unless there is another vaccine for any other eukaryotic parasite of humans[3][4], I would disagree that malaria is a good example.

aspiringnomad

  • Pencil Stache
  • ****
  • Posts: 936
Re: How long can we wait while flattening the curve?
« Reply #585 on: April 13, 2020, 10:54:31 PM »
I certainly don't think anyone believes there is a linear relationship between the amount spent and the speed at which a vaccine is developed.... A more realistic expectation would be that for a 1000x increase in spending we increase the speed of vaccine development by 10-30x which would hopefully have something available in late 2020.
Why is that a reasonable assumption?

Well, there are already two vaccine candidates in clinical trials, and another 42 in pre-clincal trials [1]. Considering a 2-6 year pre-clincal time period [2] for standard vaccine development, at least so far I'd say development is occurring in the 10-30x range. It wouldn't surprise me if we see some challenge studies this summer to further speed things along.

Your info is dated (March 20) and the picture is a bit better now. As of April 11, there are three vaccine candidates in clinical trials, or four if you count the Oxford candidate which finished volunteer recruitment after receiving a "high volume" of applicants. That seems to be among the more promising candidates (at least from what this layperson has read). In addition to those four candidates, there are now another 66 candidates in pre-clinical trials.

https://www.who.int/blueprint/priority-diseases/key-action/Novel_Coronavirus_Landscape_nCoV_11April2020.PDF?ua=1


frugalnacho

  • Magnum Stache
  • ******
  • Posts: 4217
  • Age: 37
  • Location: Madison Heights, Michigan
Re: How long can we wait while flattening the curve?
« Reply #586 on: April 14, 2020, 07:06:14 AM »
Bill Gates did an interview on the Daily Show where he talked about the process of creating a vaccine and the problem of the multi part sequential steps.  Essentially you pick all the top candidates and move on to the next step in the process prematurely knowing that you are going to abandon several of them.  You will build entire factories and equip them, only to abandon them completely when that particular vaccine doesn't pan out.  This results in a lot of money being wasted unnecessarily building infrastructure, but on the ones that do pan out it will end up shaving months off the timeline.  The goal is to expedite the mass production of a vaccine, not to profit or make the vaccine economically efficient, so that is the tradeoff you make.  I believe he is funding 7 factories right now, and is only anticipating using 1 or 2 of them.

Wolfpack Mustachian

  • Pencil Stache
  • ****
  • Posts: 744
Re: How long can we wait while flattening the curve?
« Reply #587 on: April 14, 2020, 08:17:47 AM »
On the topic of accelerated vaccination development, I'm curious as to the thoughts of people on here, especially those with much more knowledge of vaccines and their development than I have.

I'm going to start out to avoid unnecessary arguments or accusations - I am not by any stretch an anti-vax person. I have had all my vaccinations, take flu vaccinations, etc. I ensured my kids were vaccinated fully and on time.

Do any of you have any concerns about a vaccine in this situation that has the development sped up so much? I have no background in vaccine development, but I do have a background in manufacturing and product development. From that framework, when something is pushed for this hard with money thrown at it in the seeming hope that money can do miracles, it can be very easy to cut corners (the clichť fast, good quality, or cheap - pick two). What would the likely risks be if there were issues - actual health problems or simply reduced/lack of efficacy?

YttriumNitrate

  • Handlebar Stache
  • *****
  • Posts: 1047
  • Location: Northwest Indiana
Re: How long can we wait while flattening the curve?
« Reply #588 on: April 14, 2020, 08:34:16 AM »
Do any of you have any concerns about a vaccine in this situation that has the development sped up so much? I have no background in vaccine development, but I do have a background in manufacturing and product development. From that framework, when something is pushed for this hard with money thrown at it in the seeming hope that money can do miracles, it can be very easy to cut corners (the clichť fast, good quality, or cheap - pick two). What would the likely risks be if there were issues - actual health problems or simply reduced/lack of efficacy?

Obviously we are not going to know the long term effects of a vaccine (or vaccines) before they are rolled out to the public. Since everyone isn't going to be able to get a vaccine the first day it is made available, my bigger concern would be people selling counterfeit vaccines to take advantage of the huge demand, and who knows what will be in those fake vaccines.

Cassie

  • Walrus Stache
  • *******
  • Posts: 6655
Re: How long can we wait while flattening the curve?
« Reply #589 on: April 14, 2020, 11:13:28 AM »
I vaccinated my kids and I am vaccinated. I have a problem with the flu shot because you must get it every year and itís effectiveness some years is low. I donít get them. I hope the vaccine developed will be a one and done.

ender

  • Walrus Stache
  • *******
  • Posts: 5574
Re: How long can we wait while flattening the curve?
« Reply #590 on: April 14, 2020, 12:35:45 PM »
Back on the original topic of "How long can we wait while flattening the curve?" - I'm curious what the impact on the medical field and hospitals will be from lack of work, too, if things stay reasonably controlled.

Basically all elective operations have been cancelled and for a lot of medical employees. This means anyone not considered essential is basically furloughed .

I wonder if that will result in significant portions of hospitals/clinics basically going bankrupt and/or their employees also having major financial problems. Or how long those in non-exploding areas will sit mostly idle.

A lot of folks we know in the medical field (docs, nurses, etc) are not working because of covid and are becoming worried about the financial impact on them. We are lucky in that our area has had minimal major growth. But a lot of doctors/dentists/etc are paid per patient/procedure and with effectively a mass shutdown of hospitals except for covid, it might get financially pretty rough for "non essential" medical personnel if covid doesn't materialize meaningfully and as a society we wait say 6 months on standby for all non-covid/non-immediately essential medical activity.


Wolfpack Mustachian

  • Pencil Stache
  • ****
  • Posts: 744
Re: How long can we wait while flattening the curve?
« Reply #591 on: April 14, 2020, 12:48:04 PM »
Do any of you have any concerns about a vaccine in this situation that has the development sped up so much? I have no background in vaccine development, but I do have a background in manufacturing and product development. From that framework, when something is pushed for this hard with money thrown at it in the seeming hope that money can do miracles, it can be very easy to cut corners (the clichť fast, good quality, or cheap - pick two). What would the likely risks be if there were issues - actual health problems or simply reduced/lack of efficacy?

Obviously we are not going to know the long term effects of a vaccine (or vaccines) before they are rolled out to the public. Since everyone isn't going to be able to get a vaccine the first day it is made available, my bigger concern would be people selling counterfeit vaccines to take advantage of the huge demand, and who knows what will be in those fake vaccines.

I mean, you're of course right that we'll never know until we know. I hadn't thought about the fake vaccines part, although that is quite scary. I guess, out of all the ridiculousness about vaccines, my concerns about this particular one seemed legitimate to me. If it seems that way to me, and I am on the side of vaccinations, I would imagine it would seem that way or even stronger to people who are less sold on vaccinations causing ripple effects for getting people vaccinated. It may not make much of a difference, but again, I am curious enough about it to at least ask and see if anyone had any perspective on how it could be ensured to be safe given the extreme pressure for speed in its development.

Wolfpack Mustachian

  • Pencil Stache
  • ****
  • Posts: 744
Re: How long can we wait while flattening the curve?
« Reply #592 on: April 14, 2020, 12:57:49 PM »
Back on the original topic of "How long can we wait while flattening the curve?" - I'm curious what the impact on the medical field and hospitals will be from lack of work, too, if things stay reasonably controlled.

Basically all elective operations have been cancelled and for a lot of medical employees. This means anyone not considered essential is basically furloughed .

I wonder if that will result in significant portions of hospitals/clinics basically going bankrupt and/or their employees also having major financial problems. Or how long those in non-exploding areas will sit mostly idle.

A lot of folks we know in the medical field (docs, nurses, etc) are not working because of covid and are becoming worried about the financial impact on them. We are lucky in that our area has had minimal major growth. But a lot of doctors/dentists/etc are paid per patient/procedure and with effectively a mass shutdown of hospitals except for covid, it might get financially pretty rough for "non essential" medical personnel if covid doesn't materialize meaningfully and as a society we wait say 6 months on standby for all non-covid/non-immediately essential medical activity.

Depending on how long it lasts, it is certainly impactful for those individuals. Two are members of my family - one that works in a hospital and one that is a nurse at a regular doctor's office. The doctor's office is eliminating all in person visits, which is eliminating most general nursing staff. The number of patients has declined in the hospitals, so workers are getting their hours cut drastically. It has generally sucked for these people, and they're ones in the high risk situations working with covid patients so it seems doubly sucky.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #593 on: April 14, 2020, 01:11:47 PM »
My wifeís clinic closed and she is not salaried, so sheís basically unemployed. Iím salaried but still in training (underpaid) so weíve got 30% of our usual income. Unclear how long weíre going to be living off my income alone. We keep expenses low so itís not a huge deal. My guess is mass layoffs will happen in healthcare within a few months, and then hospitals will appeal to ďvolunteersĒ. Very cynical but not impossible. NY has not offered payment to people theyíve asked to help out in hospitals despite the significant risks to their health.

T-Money$

  • Stubble
  • **
  • Posts: 215
  • Location: New York
Re: How long can we wait while flattening the curve?
« Reply #594 on: April 14, 2020, 02:36:25 PM »
I'm a medical provider in NYC. 3 reasons I can think of why our area has so many deaths. NYC and the most affected parts of NJ are one contiguous metro area.

1. Community spread happened earlier here than most other places in the US because we're an international hub. At a time when testing wasn't happening. For a long time, we kept saying there were no cases here, but we ran EIGHT tests because of overly narrow CDC guidelines.

2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

3. The NY metropolitan area, which includes NYC, Long Island, Hudson Valley, and parts of NJ, PA, CT, is the densest place in North America, with a contiguous metro area of ~20mil people.

Even though testing ramped up quickly in NY, there are still not nearly enough tests to capture all the cases in the population. The positivity rate here is an astounding 40%. I'm guessing there are 2mil+ actually infected here. This is based on my sense of the numbers of people I'm seeing getting sick and unable to get a test. We're officially discouraging anyone not sick enough to get hospitalized from seeking out testing. My sense of things is also based on the estimates from Italy that their death numbers resulted from 5-10mil of their population actually infected.

The medical care in NYC is excellent, with some of the smartest people around writing hospital protocols, and generally more minimalist than other parts of the country. We don't put people on ventilators unless absolutely necessary. Just read the ER protocol for Northwell Hospitals saying to first put people on 15L non-rebreather with 10L nasal cannula under that. And they will only intubate if PaO2 is proven to be <60 on ABG with all that O2 on first. Protocol specifically says not to intubate based on work of breathing.

TL;DR: The high number of deaths in NY/NJ is NOT from putting people on ventilators too quickly.

Thanks for your post, it was very informative.

One of the epidemiologists in this video wrote an opinion in The New York Times yesterday:

https://externalmediasite.partners.org/Mediasite/Play/45a9a74f18ec45deb338e00ac4cf4e281d?fbclid=IwAR0LH6aEbjwNeW0txxFH2ItnixksVs8y-SkZBXOzf-8L980CwYi3yCf7kUs

https://www.nytimes.com/2020/04/13/opinion/coronavirus-immunity.html

One of the estimates of herd immunity for COVID-19 is 50% of the population infected.  Assuming for arguments sake that is the case, if over 2 million New Yorkers are already infected could herd immunity begin to be taking hold? 

AnnaGrowsAMustache

  • Handlebar Stache
  • *****
  • Posts: 1919
  • Location: Noo Zilind
Re: How long can we wait while flattening the curve?
« Reply #595 on: April 14, 2020, 05:14:19 PM »
I'm a medical provider in NYC. 3 reasons I can think of why our area has so many deaths. NYC and the most affected parts of NJ are one contiguous metro area.

1. Community spread happened earlier here than most other places in the US because we're an international hub. At a time when testing wasn't happening. For a long time, we kept saying there were no cases here, but we ran EIGHT tests because of overly narrow CDC guidelines.

2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

3. The NY metropolitan area, which includes NYC, Long Island, Hudson Valley, and parts of NJ, PA, CT, is the densest place in North America, with a contiguous metro area of ~20mil people.

Even though testing ramped up quickly in NY, there are still not nearly enough tests to capture all the cases in the population. The positivity rate here is an astounding 40%. I'm guessing there are 2mil+ actually infected here. This is based on my sense of the numbers of people I'm seeing getting sick and unable to get a test. We're officially discouraging anyone not sick enough to get hospitalized from seeking out testing. My sense of things is also based on the estimates from Italy that their death numbers resulted from 5-10mil of their population actually infected.

The medical care in NYC is excellent, with some of the smartest people around writing hospital protocols, and generally more minimalist than other parts of the country. We don't put people on ventilators unless absolutely necessary. Just read the ER protocol for Northwell Hospitals saying to first put people on 15L non-rebreather with 10L nasal cannula under that. And they will only intubate if PaO2 is proven to be <60 on ABG with all that O2 on first. Protocol specifically says not to intubate based on work of breathing.

TL;DR: The high number of deaths in NY/NJ is NOT from putting people on ventilators too quickly.

Thanks for your post, it was very informative.

One of the epidemiologists in this video wrote an opinion in The New York Times yesterday:

https://externalmediasite.partners.org/Mediasite/Play/45a9a74f18ec45deb338e00ac4cf4e281d?fbclid=IwAR0LH6aEbjwNeW0txxFH2ItnixksVs8y-SkZBXOzf-8L980CwYi3yCf7kUs

https://www.nytimes.com/2020/04/13/opinion/coronavirus-immunity.html

One of the estimates of herd immunity for COVID-19 is 50% of the population infected.  Assuming for arguments sake that is the case, if over 2 million New Yorkers are already infected could herd immunity begin to be taking hold?

You're talking about herd immunity like you know what it means, and you clearly don't. We have herd immunity to the common cold - that's taken a thousand years and we still have seasonal outbreaks. Covid 19 is showing signs of being similar in the kind of immunity you might get from an exposure - ie not total and not long term. If that's the case, even with a vaccine, even with herd immunity, you will still get seasonal outbreaks that may kill thousands. That could go on for a thousand years, and THEN it'll be no more than a common cold to us. Do you understand? Herd immunity is a concept that applies to a species over a long period of time. It is NOT the result of one outbreak. There's no "herd immunity" that can protect the human species from covid-19 now, or this year, or in the next ten years..... unless we develop a vaccine and people are regularly vaccinated.

T-Money$

  • Stubble
  • **
  • Posts: 215
  • Location: New York
Re: How long can we wait while flattening the curve?
« Reply #596 on: April 14, 2020, 05:30:19 PM »
I'm a medical provider in NYC. 3 reasons I can think of why our area has so many deaths. NYC and the most affected parts of NJ are one contiguous metro area.

1. Community spread happened earlier here than most other places in the US because we're an international hub. At a time when testing wasn't happening. For a long time, we kept saying there were no cases here, but we ran EIGHT tests because of overly narrow CDC guidelines.

2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

3. The NY metropolitan area, which includes NYC, Long Island, Hudson Valley, and parts of NJ, PA, CT, is the densest place in North America, with a contiguous metro area of ~20mil people.

Even though testing ramped up quickly in NY, there are still not nearly enough tests to capture all the cases in the population. The positivity rate here is an astounding 40%. I'm guessing there are 2mil+ actually infected here. This is based on my sense of the numbers of people I'm seeing getting sick and unable to get a test. We're officially discouraging anyone not sick enough to get hospitalized from seeking out testing. My sense of things is also based on the estimates from Italy that their death numbers resulted from 5-10mil of their population actually infected.

The medical care in NYC is excellent, with some of the smartest people around writing hospital protocols, and generally more minimalist than other parts of the country. We don't put people on ventilators unless absolutely necessary. Just read the ER protocol for Northwell Hospitals saying to first put people on 15L non-rebreather with 10L nasal cannula under that. And they will only intubate if PaO2 is proven to be <60 on ABG with all that O2 on first. Protocol specifically says not to intubate based on work of breathing.

TL;DR: The high number of deaths in NY/NJ is NOT from putting people on ventilators too quickly.

Thanks for your post, it was very informative.

One of the epidemiologists in this video wrote an opinion in The New York Times yesterday:

https://externalmediasite.partners.org/Mediasite/Play/45a9a74f18ec45deb338e00ac4cf4e281d?fbclid=IwAR0LH6aEbjwNeW0txxFH2ItnixksVs8y-SkZBXOzf-8L980CwYi3yCf7kUs

https://www.nytimes.com/2020/04/13/opinion/coronavirus-immunity.html

One of the estimates of herd immunity for COVID-19 is 50% of the population infected.  Assuming for arguments sake that is the case, if over 2 million New Yorkers are already infected could herd immunity begin to be taking hold?

You're talking about herd immunity like you know what it means, and you clearly don't. We have herd immunity to the common cold - that's taken a thousand years and we still have seasonal outbreaks. Covid 19 is showing signs of being similar in the kind of immunity you might get from an exposure - ie not total and not long term. If that's the case, even with a vaccine, even with herd immunity, you will still get seasonal outbreaks that may kill thousands. That could go on for a thousand years, and THEN it'll be no more than a common cold to us. Do you understand? Herd immunity is a concept that applies to a species over a long period of time. It is NOT the result of one outbreak. There's no "herd immunity" that can protect the human species from covid-19 now, or this year, or in the next ten years..... unless we develop a vaccine and people are regularly vaccinated.

The Harvard epidemiologist in the article above would disagree with you.

The only way the COVID-19 pandemic will end will be when a high percentage of the population develops immunity — so-called “herd immunity” — either through a vaccine or through exposure to the disease, according to experts. In this opinion piece, writer Jeff Howe discussed disease models from epidemiologist Marc Lipsitch and Yonatan Gssistant professor of immunology and infectious diseases, which show that intermittent periods of social distancing may be the best option to control the pandemic. This on-again, off-again approach would protect hospitals from being overwhelmed with sick patients, buy them time to gather adequate medical supplies, and allow the population to slowly gain immunity, the article said.

The seasonal influenza outbreaks kill 20,000 to 60,000 people in the US alone, depending on severity and annual strain only 50% of flu vaccination is typically effective.

By the way, the last stage of grief is acceptance.  I think you've got a few stages to go...


AnnaGrowsAMustache

  • Handlebar Stache
  • *****
  • Posts: 1919
  • Location: Noo Zilind
Re: How long can we wait while flattening the curve?
« Reply #597 on: April 14, 2020, 05:53:21 PM »
I'm a medical provider in NYC. 3 reasons I can think of why our area has so many deaths. NYC and the most affected parts of NJ are one contiguous metro area.

1. Community spread happened earlier here than most other places in the US because we're an international hub. At a time when testing wasn't happening. For a long time, we kept saying there were no cases here, but we ran EIGHT tests because of overly narrow CDC guidelines.

2. The shutdowns here came a few days later than California. With exponential spread, each day matters.

3. The NY metropolitan area, which includes NYC, Long Island, Hudson Valley, and parts of NJ, PA, CT, is the densest place in North America, with a contiguous metro area of ~20mil people.

Even though testing ramped up quickly in NY, there are still not nearly enough tests to capture all the cases in the population. The positivity rate here is an astounding 40%. I'm guessing there are 2mil+ actually infected here. This is based on my sense of the numbers of people I'm seeing getting sick and unable to get a test. We're officially discouraging anyone not sick enough to get hospitalized from seeking out testing. My sense of things is also based on the estimates from Italy that their death numbers resulted from 5-10mil of their population actually infected.

The medical care in NYC is excellent, with some of the smartest people around writing hospital protocols, and generally more minimalist than other parts of the country. We don't put people on ventilators unless absolutely necessary. Just read the ER protocol for Northwell Hospitals saying to first put people on 15L non-rebreather with 10L nasal cannula under that. And they will only intubate if PaO2 is proven to be <60 on ABG with all that O2 on first. Protocol specifically says not to intubate based on work of breathing.

TL;DR: The high number of deaths in NY/NJ is NOT from putting people on ventilators too quickly.

Thanks for your post, it was very informative.

One of the epidemiologists in this video wrote an opinion in The New York Times yesterday:

https://externalmediasite.partners.org/Mediasite/Play/45a9a74f18ec45deb338e00ac4cf4e281d?fbclid=IwAR0LH6aEbjwNeW0txxFH2ItnixksVs8y-SkZBXOzf-8L980CwYi3yCf7kUs

https://www.nytimes.com/2020/04/13/opinion/coronavirus-immunity.html

One of the estimates of herd immunity for COVID-19 is 50% of the population infected.  Assuming for arguments sake that is the case, if over 2 million New Yorkers are already infected could herd immunity begin to be taking hold?

You're talking about herd immunity like you know what it means, and you clearly don't. We have herd immunity to the common cold - that's taken a thousand years and we still have seasonal outbreaks. Covid 19 is showing signs of being similar in the kind of immunity you might get from an exposure - ie not total and not long term. If that's the case, even with a vaccine, even with herd immunity, you will still get seasonal outbreaks that may kill thousands. That could go on for a thousand years, and THEN it'll be no more than a common cold to us. Do you understand? Herd immunity is a concept that applies to a species over a long period of time. It is NOT the result of one outbreak. There's no "herd immunity" that can protect the human species from covid-19 now, or this year, or in the next ten years..... unless we develop a vaccine and people are regularly vaccinated.

The Harvard epidemiologist in the article above would disagree with you.

The only way the COVID-19 pandemic will end will be when a high percentage of the population develops immunity ó so-called ďherd immunityĒ ó either through a vaccine or through exposure to the disease, according to experts. In this opinion piece, writer Jeff Howe discussed disease models from epidemiologist Marc Lipsitch and Yonatan Gssistant professor of immunology and infectious diseases, which show that intermittent periods of social distancing may be the best option to control the pandemic. This on-again, off-again approach would protect hospitals from being overwhelmed with sick patients, buy them time to gather adequate medical supplies, and allow the population to slowly gain immunity, the article said.

The seasonal influenza outbreaks kill 20,000 to 60,000 people in the US alone, depending on severity and annual strain only 50% of flu vaccination is typically effective.

By the way, the last stage of grief is acceptance.  I think you've got a few stages to go...

Your quote just said exactly the same thing I did, except he hasn't put a time scale on it. The bit he's not saying is that this will take generations. You're not understanding the underlying concepts that these people are speaking about. Allowing a population to slowly gain immunity is a multi-generational process. Herd immunity happens over time, long periods of time. No epidemiologist is going to support your wish that this virus, with it's not clearly understood levels of "immunity" (although it looks o be similar to the cold), will give us some kind of instant, this year style of herd immunity. Not even with a vaccine speeding up the process.

The problem you're having here is that your research is all underpinned by your misunderstanding of the basic concepts, like herd immunity. That then means that you read quotes to mean something that they don't quite mean. And then you haul out the quotes to support your view, but they don't ...... because you haven't understood the basic premise that they're talking about.

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #598 on: April 14, 2020, 07:38:07 PM »
Herd (community) immunity doesn't have a specific timeline. It depends on how long it takes for a critical percentage of a population to be immunized (either through being infected or vaccination). For example, the polio vaccines provided herd immunity within a period of a few years due to their efficacy and the long-term immunity they provided. (https://www.cdc.gov/vaccines/pubs/pinkbook/polio.html - Section on Secular Trends in the United States).

Similarly, the measles vaccines when they first came out did the same thing. https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html (section on Secular Trends in the United States)

Smallpox, in contrast, took longer to eradicate as it was (when still endemic) the most contagious of the human viruses. Now there's actually no herd immunity as the smallpox vaccine is no longer administered.

HPV, which is probably the most common chronic viral infection in adult humans, can be suppressed with only 20% vaccination. Community immunity in some populations has been identified in 4 years. This is due to its lower risk of transmission (as it is not transmitted by droplets). Lancet Public Health. 2016 Nov;1(1):e8-e17 - Figure 6.

If a vaccine is developed and sufficient number of people are immunized with it, then herd (community) immunity can be achieved in a relatively short period of time. There is no reason to suspect it can't be done. Also, if an isolated population is exposed, then herd immunity can be developed the hard way (through large % being infected and high number of deaths). Both of these assume that there are no new people entering into the population. This is obviously not ideal in any scenario, and probably not feasible in a big city like New York. Regarding whether it is happening, I think that is unlikely. Assuming the "true" case fatality rate of this virus is ~1% (based on S Korean and German data), and with a current 4% case fatality rate in New York, we can assume 4x as many people are infected as have been identified. That means 200k x4 = 800k people have it in New York, but there's about 14m people in that metropolitan area. We'd need 14x more people infected (14m * 0.8 = 11.2m / 800k = 14). That'd amount to 140,000 deaths in NY alone. These are clearly very rough calculations but demonstrate that we can't allow this virus to run through our population.
« Last Edit: April 14, 2020, 07:46:59 PM by Abe »

Abe

  • Handlebar Stache
  • *****
  • Posts: 1648
Re: How long can we wait while flattening the curve?
« Reply #599 on: April 14, 2020, 11:25:59 PM »
Some interesting theoretical models regarding social distancing and its efficacy from Harvard's Public Health department (https://science.sciencemag.org/content/early/2020/04/14/science.abb5793)

They created a model of transmission using two known coronavirii, fitted this model to prior records, then added the new coronavirus using estimated parameters from current data (the major limitation of this study).

The basic summary is: social distancing duration (4, 8, 20 weeks) only affects the onset of a second wave, but not its ability to overwhelm current hospital capacity. If the social distancing is very effective (60% reduction in transmission rate from a baseline 2.2 estimated from other coronavirii), then the second peak is nearly the same as without distancing measures. (Figures 4 - assuming no seasonal variation and 5 assuming seasonal variation, left panels). In nearly all scenarios, current critical care bed capacity will be overwhelmed at some point regardless of measures taken, other than indefinite social distancing until a vaccine is developed. In this case, a 40% or 60% reduction would stay below this threshold. The obvious advantages of longer social distancing time are the ability to increase critical care capacity and longer time to develop a vaccine. Obvious disadvantage is the economic fall-out.

The second prediction is that having cut-offs for opening up and shutting down society will allow intermittent exposure and ultimately herd immunity without overwhelming critical care capacity (Figure 6), but this would take to 2025 with current capacity, or until 2022 with doubling of capacity, with >75% of the time spent shut down in the former scenario. If we get a break in the summer, then significantly less time is spent shut down (especially if critical care capacity increases).

So it seems the best option is moderate social distancing to spread out the pain, and ramping up both ventilator capacity and re-tooling the majority of inpatient healthcare for the next 1-2 years towards managing COVID. Unfortunately there really is no good scenario in any of this.

Two trials on chloroquine/azithromycin were stopped due to high risk of fatal arrhythmias and lack of efficacy in reducing viral load. Other trials are ongoing.

In more positive news, there is promising signs on vaccine development. Both the NHS and Johnson & Johnson estimate clinical randomized trials to start by September, with preliminary results by December and potential manufacturing to start in January. Everyone hang in there, it's going to be a bumpy ride.