A Common Sense Approach to Weather COVID19

March 19, I scurried to move my son out of his dorm in Chicago, because my gut was telling me something was up. It was in February when my eldest who lives in Hong Kong messaged me to send him as many masks as I can find. Asia? How can they run out of masks when all the masks we use at work are made in China? Having to go to several stores only to find that there were no masks available in Las Vegas, Nevada was a very perplexing thought. I was glad to find a hundred masks in an out of the way Walgreens.

That travel from Chicago back to Las Vegas, with a son who did not want to leave his dorm, was quite an experience. Several flights were canceled at Midway on the day of our flight, but we were hoping that our flight won't. With my son's gear (about 6 huge boxes that contained his college life) we were told to catch a later flight as we were checking in. As soon as we were about to board, we were told all flights were canceled. Knowing that I wasn't the only parent who was trying to get their kid back home, I decided to rent a drive back to Nevada. Mind you, my son is at that stage in his life where having to sit with me for hours in a car would be the same as being in the most stressful job interview of his life, for a job he didn't want in the first place. To think that I'd be driving 1700 plus miles, approximately 4 days (my speed) with someone who thinks that I am overreacting, and just pulled his out of the dorm just because isn't quite a holiday either. If not for my love for this amazing human, Id be sitting with the rest of the world watching how this disaster unfolds.

Im not sure if anyone who reads this have seen the movie Harold and Kumar Goes to White Castle? Well we had several misadventures, ended up in Nebraska, Denver, several overnight stops (with our luggage ofcourse) and canceled flights. But it was all worth it because my son realized during that time, that his worst interview was actually done by someone who really cares about him. During one of our conversations, we pondered about what was going on. He told me that in middle school he played a video game called Plague 2008 (https://en.wikipedia.org/wiki/Plague_Inc.)where the object of the game is to strategize on how to spread the plague to everyone, in the least amount of time and annihilate everyone. In my mind, "oh no, all those times that I was passed out after several PM shift, my 10 year old son was in a virtual world figuring out how to eradicate the human race."

"Well, my strategy was to first infect people who are healthy so they can spread the disease wherever they go. The symptoms would be so mild for asymptomatic carriers, that they won't even know they carry the virus. The virus though is so virulent that if a person is weak (there are specific people who will have really bad symptoms and die in a few days after contact) these people will show symptoms and won't last long, they will die. Once the virus is in everyone's system poof that's it," my son enthusiastically narrated his winning game plan. Asymptomatic carriers....

When I got to Las Vegas, I called a colleague and we had a long conversation about the structural DNA of the SARSCOV2 and how similar it was to the measles and if that was the case, that would justify those who had no symptoms, mild symptoms, and maybe some folks whose measles titers are waning (30-50 age group may have the disease but will have moderate symptoms).

It was in March 20, 2020 when we first posted our research proposal hoping that someone would look into what we have have observed and perhaps if we measured the measles titers upon ER presentation and correlate this to the patient's symptoms, we will have some sort of founded association between measles vaccination and the protection it provides to people who gets infected with SARSCOV2. Well to make the long story short, my colleague Michelle and I spent the rest of March, April, May, June calling on everyone and anyone in academia, Nursing and Medical organizations, researchers, local physicians and ER's to listen to what we had to say. Sonsiel got us an audience with leaders in England and Boston, Merck, but no one, believed in our thought process. Since then several studies have surfaced evaluating the association of measles titers, and that is simply what we want, someone who will be granted that opportunity to save

Fast forward to November 9, 2020. There has been 10.1M cases and 238,000 deaths. There is a pattern, there are trends that we have been missing. Here are 2 recent articles that should have raised huge red flags about how WE HAVE a readily available protective mechanism to protect the vulnerable from SARSCOV2.

In Samoa, there was a recent measles outbreak. How many SARSCOV2 cases are there? How many deaths? ZERO CASES and ZERO DEATHS!!! Click on the link to find out why. But that is beside the point because healthcare is not driven by common sense and perhaps not even doing the right thing...

As a healthcare provider, it is my responsibility to throw my ideas out there amidst the recognized health care leaders in this country. We have been rejected many times that another one would not matter. The article below is a proposal on how to strategically risk stratify people based upon vulnerability to the disease and severity of symptoms. When common sense becomes the least sense perhaps we should look at what could possibly make sense.

Team Name: Chiron Consulting

Michelle Norvelle and Estrella Evangelista Data Analytics Intern Seth Hoffman

Las Vegas, NV

I Abstract

Le Bon Sense (The Common Sense Approach)

The epidemiological presentation of COVID19 seem puzzling to everyone, yet the answer is staring all of us right on the face: Le Bon Sense. The purpose of this proposal is to challenge people's minds to make sense of what is, and that which we overlooked and neglected to acknowledge. The overall vision of this project is to identify those who have had COVID19 using antibody testing and provide those who have not been infected with temporary protection while waiting for a vaccine.

Part 1: Require every citizen to have an antibody testing. Those who test positive indicates previous exposure/disease thus rendering this folks to have some protection from COVID19, including a second wave. Those who test negative will be risk stratified based upon severity of symptoms, comorbidities and taking into consideration variables that point to risk for mortality.

Part 2: Concurrently, current data will be analyzed, variables and narrowed down and what commonalities among those age group who have the least mortality rate are going to be evaluated/analyzed. Other than age and health, the common variable, that which this proposal hypothesizes is immunization status. Among the required immunizations, the COVID19 virus is most similar to measles. Measles vaccine will provide temporary immunization to those who test negative for the virus. Exclusion criteria for measles vaccination are allergies to measles vaccine, severe immunosuppression or no clearance from their primary physician. A safety protocol will be developed for those who test negative but meet measles vaccine inclusion criteria, as well as those who are not able to meet the criteria at all. The small portion of the population who are considered vulnerable i.e. do not have any protection at all, would be approximately 5-10% of the population. They can remain quarantined until a vaccine is available while the rest can continue living the new normal: a continuous daily effort to stay active and healthy in all dimensions of human life.

II. Background of analytical approach and use of existing data set:

Part A There are so many inconsistencies in case reporting, as well as state reporting of data. If one refers to the CDC, Johns Hopkins COVID19 website, cases are not specifically separated into whether they are positive via PCR testing or positive from antibody testing. People who go for PCR are either experiencing symptoms, have been exposed to a known or suspected COVID19 patients or those who have been required by employers, school or just wanted to get tested for the sake to be tested. If we look at the factors that are associated with the accuracy of PCR testing, consider: patient’s viral load, and stage of infection (false negative if the patient’s viral load is not high enough to be detected); processing error (is there enough specimen, was the specimen processed correctly, temperature etc.); finally, is the kit itself sensitive enough to detect the virus and how much virus does it need to test positive. With the lack of control over manufacturers and desperation over testing, there exists a huge variance between the real data (positive results and negative results).

Antibody testing is very simple. People either test positive, where they had previous disease or exposure to the disease that triggered an immune response, their immune system was strong enough to protect them and they survived. Testing everyone, in a test city, perhaps a city with a small population, would be an option. Those who test negative, will be risk stratified as those who will be safe to receive an already known and tested vaccine, measles. Those who do not meet inclusion criteria will be quarantined until a vaccine is available.

Part In March, 2020, this author and a colleague called on several teaching hospitals and academic institutions to test a simple hypothesis after looking at the common denominator of the several age groups that had the least mortality rate: 1-25 Other than being young, with no diagnosed or suspected co morbid medical issues, everyone in this age group regardless of where they were born were required to have childhood vaccinations. As this author and the colleague were not affiliated with any academic institution, and with the hope of offering a simple insight on how people can be protected from severe symptoms while a vaccine is being developed, the proposal was published in LinkedIn for leaders in medicine to ponder upon (please refer to attached file) hypothesizing that MMR titers on people who test positive should be evaluated and associated with the patient’s severity of symptoms.

Part B of this proposal consists of several options (see methodology) on options of how association of MMR with COVID10 symptoms and outcomes can be evaluated using electronic health records and reported symptoms. Both a quantitative and qualitative analysis of data can be use to look at the strength of the association of these variables. Factor analysis can also be used to look at the all the variables associated with patient survival and severity of symptoms.

Once an association between COVID19 symptom severity is established, then offering that protective factor to those who test negative for COVID19, when infected, will limit the symptoms of the virus.

Summary:

Antibody testing will identify those who have had the virus and have survived. Those who do not have COVID19 antibodies, will be quarantined while being medically evaluated for potential and/or undiagnosed medical or immunosuppression issues, then risk for severity of symptoms/mortality score will be calculated based upon medical evaluation and predisposing and mitigating factors (age, sex, race, socioeconomic status, stress level, exposure level) . A risk for illness severity/mortality score will be calculated and people will be classified as low, medium and high risk. All those who do not have any allergies to the measles vaccine, or will get approval from the physician to get the measles vaccine will receive a vaccine. Those who are allergic to the measles vaccine, are severely immunosuppressed will be quarantined until a COVID19 vaccine is available. The premise is that herd immunity is the ultimate key to contain the virus. The approach is cost effective, efficient and will help identify people who can be offered some protection from deadly symptoms while waiting for a vaccine.

III Methodology: Mitigation of Symptoms of Potential Cases: Identify Positive Survivors, Quantify Symptoms and find Commonalities

Part A. Offer COVID19 Antibody testing for everyone

Mass COVID19 antibody testing (or power analysis for generalizability)

a. Test everyone for COVID19 antibody and measles titers which means prior disease and or exposure.

b. Group 1 Those who are positive with negative/low measles titers will get a measles vaccination.

Group 2 Positive antibody with positive measles titer. Measles booster shot.

c. Safety protocol: Both groups will maintain social distancing, universal precautions, and boost their immune system (see suggested immune system booster protocol) for potential virus mutation and reinfection. Report any symptoms for potential association of COVID19 virus with patient’s immune system state. It is important to entertain the fact that the virus can lay dormant because the person’s immune system was able to prevent the increase in viral load. But with fluctuation is the immune system state of an individual, constant/repeated exposure to the virus (nurses without PPE) or people staying close together regardless of mask in an enclosed space, reinfection may occur; or virus may mutate.

d. Identify their contacts and test those contacts.

B. Those who are negative will be separated into the following groups:

Group 1. Negative antibody with no comorbidities, high measles titer

Group 2. Negative antibody with no comorbidities, negative measles titer

Group 3. Negative antibody with co morbidities (risk for severe symptoms) and negative measles titer

Group 4. Negative antibody with co morbidities with high measles titers (greater than 2)

C. Group Specific Safety Protocol Other than Usual Universal Precautions

Group 1 Will be instructed to do the usual social distancing obtain measles booster shot, and take vitamins to boost immune system, isolate from positive family members/people until a vaccine is available. If the person is in a line of work that would increase risk of exposure, consider working at home.

Group 2 Will be instructed to do the usual social distancing, PPE, obtain measles vaccination, and take vitamins to boost immune system, isolate from positive family members until a vaccine is available. Consider working at home, and avoid gathering in enclosed spaces that doesn’t allow social distancing.

Group 3 This group need to isolate, maintain health and use immune system boosters; Once their comorbidities are under control, they will be evaluated for allergies or potential for reaction to measles vaccine. If they don’t have any immunosuppression or allergies, administer measles vaccine to limit symptoms once infected with the virus. In the meantime quarantine while waiting for a vaccine.

Group 4 This group need to isolate, maintain health and use immune system boosters; Once their comorbidities are under control, they will be evaluated for allergies or potential for reaction to measles vaccine. If there is no immunosuppression, or allergies, administer booster measles shot to limit symptoms once infected with the virus. In the

meantime quarantine while waiting for a vaccine. Extra precautions over the winter re gathering in an enclose space that doesn’t allow social distancing.

D. Create a state specific disease registry for each state/city identifying core measures.

Part B. Factor Analysis of existing datasets/data warehouses and identify variables that are common among the age group with the highest survival rate. Associate those factors with COVID19 severity of symptoms and outcomes

Current data show that mortality and morbidity (data doesn’t show whether positive cases in this age group were tested for PCR vs antibody) are lowest on age group 25 and below.

Fact: A majority of people in this age group has had either measles disease or measles vaccination as required by pediatricians, prior to entry in day care, elementary school and college.

Question: How can the association of MMR with COVID19 symptoms be evaluated? Option 1ER Based Data:

• Identify Past COVID Cases
• Evaluate COVID 19 Patient Outcomes (Discharged, Inpatient Admission and Death)
• Quantify Presenting Symptoms (mild, moderate or severe)
• Factor in Medical co morbidity
• Obtain consent to get a copy of immunization records.

Option 2 ED Based Surveillance:

All patients who present as PUI will have their symptoms stratified as mild, moderate or severe.

Ask about whether they have had an MMR or have been sick with measles in the past. Obtain a copy of immunization records.

Factor in co morbidities and then evaluate these patient’s outcomes Obtain consent to add on measles titer with ED lab draw.

Option 3 Public Surveillance:

All those who have tested positive through antibody testing will be asked to provide a record of measles immunization or previous measles disease and symptoms quantified as mild, moderate severe. Do a power analysis to determine how many patients who have tested positive and survived have had a measles shot or have had measles in the past.

Option 4 DOD Data

Obtain DOD data and determine the immunization status of all cases who tested positive for COVID19. Ask cases to quantify symptoms. Military personnel are required to have immunizations. If the mortality rate and morbidity of cases with medical issues that affect the immune system are accounted for, with age not being a factor, measles, being the

closest in genetic make up to SARSCOV would account for the low mortality and morbidity of military personnel.

IV. Study Results:

The study result is strictly anecdotal and, le bon sense: common sense, however, let us look at what is our current reality. COVID19 has raised havoc all over the world and worst of all in a country, like the United States, it is so disheartening to have been privy to so much inconsistencies in treatment protocol, misinformation, that has resulted in fear and confusion among the populace. Neglecting to see what common sense has to offer may cost more unnecessary lives when protection is available while waiting for an actual vaccine. Many people have lost their jobs, school aged kids are forced to stay home missing out on the social interaction that they need, mental health issues and associated substance use problems are now plaguing all age groups. There is no time to lose.

The testing of cases using PCR is going to delay the quarantining of patients who are high risk for mortality. Using antibody testing for everyone and separating those who are negative, will allow to others who have had the disease to continue on living their lives to alleviate the mental and financial burden of a piecemeal approach. Those who are negative and do not have any issues with measles vaccination, can obtain the vaccine and have a line of defense to limit the virus symptoms. Those who are vulnerable can be isolated and their immune system bolstered until a vaccine is available. Those who test positive, their information can be entered into a disease registry where patient related variables can be easily accessible and then analyzed for a pattern or trend. The use of MMR vaccination is based upon the common denominator among the sailors who tested for COVID19. Those who tested positive had little or moderate symptoms and the commonalities among them, among those whose mortality rate is very minimal (Ages 25 and below) is that MMR vaccination was required for all of those people in that age group. The military are required to obtain vaccinations. In Las Vegas 60 kids (12-18 years old) from April to date have been practicing and playing baseball using social distancing measures. None of them have shown signs and symptoms of the disease. No one in their families have shown symptoms. The common thread other than being young, athletic is that they have received their immunization.

V. Implications:

Vaccination is key to decrease morbidity and mortality however while waiting for a safe vaccine, there are alternative options that could have saved the lives of many as well as protect those who are still currently vulnerable. Basic epidemiology states that length of exposure, the susceptibility of the host, virulence of the virus are major factors in disease prevention and spread . Social distancing and masks will limit exposure; boosting the immune system of the host, maintaining health, and control and maintenance of co morbid conditions will decrease the susceptibility of the host; the measles virus is very similar to COVID19. administering measles vaccination is a cheap alternative to the lives that we will continue to lose while waiting for a vaccine to be approved. In identifying cases using antibody testing, we can separate those who have not been exposed to the virus . Those are the people who need to be quarantined and evaluated for co morbid conditions. Those who test positive for antibodies , their data will allow us to further look into the variables that predispose, mitigate the infectious process and whose plasma can help those who are severely ill. Everyone should be tested and those who are more likely to get severe symptoms should be quarantined. Herd immunity is the answer to the end of this virus, unless it mutates, However, if we rely on PCR, and the creation of treatment guidelines without a disease registry we are merely grasping on straws like we have since the pandemic started. PCR will only test positive if the patient has enough viral load to show symptoms and that is the time that they are contagious. Have these people quarantine instead of going to testing centers. If we look at the accuracy of PCR, the viral load, the swabbing process, the processing of specimen can produce many false negatives. We cannot test all people who have sniffles this winter. Use military data and EHR data. Sometimes the solution lie inside the simplest of minds.

LINK to any public datasets used by your analytic approach (Please note, only public data sets can be used in your application)*

https://coronavirus.jhu.edu/map.html

Please note the geographic span of COVID-19 Symptom Survey data set(s) used*

USA