Covid-19 update

Another week, some more news and insights:

1.  What did the U.S. get wrong? An article in this week’s New England Journal of Medicine by Dr. Eric Schneider DOI:10.1056/NEJMp2014836 summarizes what we could have done better and should learn from for next time. He states, “A breakdown in the federal disaster response delayed state and local responses, allowing SARS-CoV-2 to spread rapidly in New York, New Jersey, Michigan, Louisiana, and other states. Only astute early interventions in Seattle and the San Francisco Bay Area seem to have stemmed a potential tide of cases and deaths. Covid-19 has taken more American lives in 1 month than the Vietnam War claimed over 8 years. Other countries, such as Australia, South Korea, Germany, Singapore, and Taiwan, managed to contain the virus early and are working hard to keep it suppressed as they reopen their economies.” The lack of organized, efficient testing has hampered our ability to get on top of this pandemic early. “Testing was delayed in January and February as the Centers for Disease Control and Prevention (CDC) distributed faulty test kits, then failed to approve a working test developed by the World Health Organization or those developed by local public health laboratories. Since March, the number of tests per day has never reached the number needed because of shortages of reagents, materials, and personal protective equipment.” A successful containment strategy relies upon early and effective testing followed by strict quarantine measures. Once we lost that opportunity, we had to fall back on strict social distancing and stay at home policies that incurred severe economic and social costs with hope for successful treatments or a vaccine.

 States and local communities are coming to realize that they still need to develop robust and efficient testing strategies in order to re-open safely. “Without testing, the response will continue to fall short. Shortages of test materials have forced a narrow local testing strategy dedicated to managing the care of hospitalized patients and preventing health care workers from transmitting Covid-19. As state government officials and business leaders study the success of other countries, they are realizing that testing, contact tracing, and isolation of people who test positive will be essential to successfully reopening economies. The most recent congressional rescue package featured $25 billion for testing.” The author goes on to make another important point about testing: “What decisions are the test results meant to inform? Testing has many purposes beyond diagnosis and protection of health care workers. Testing data are needed to manage all aspects of a pandemic. For instance, they are a cornerstone of epidemic forecasting models, which are sorely needed to reveal the future demand for care, including the timing of case surges and the magnitude of required emergency medical services, hospital staff, hospital beds, ventilator equipment, and mortuary services. Without good testing data, forecasters have to rely on guesswork and assumptions.”

Due to the lack of a federally coordinated testing strategy, we must deal with the consequences, described as follows: “The best database on testing for Covid-19 in the United States, created through valiant efforts by news media organizations to fill the gap left by the CDC, contains testing data limited to aggregated counts of the tests done each day, the states where tests were performed, and the number of positive results.3 The validity and reliability of the data are not fully known. Inspection of the data suggests a patchwork of inconsistent reporting from state and commercial labs. The database lacks basic information about tests such as the characteristics of the people tested, where they were tested, how they were selected for testing, and what factors led to the decision to test them. Yet these data are the best we have.” Our efforts fall far behind other countries. “That the United States is failing such a simple test of its capacity to protect public health is shocking. Collecting and reporting public health data are not rocket science. Other countries, notably Canada and Belgium, are already reporting nationwide data on testing at the individual level, including individual demographic data (using ranges for each person to protect privacy) and other key attributes for each test.4 The United States was once a leader in collecting systematic federal data on population health. Now our national disease-tracking effort seems stuck with well-meaning but scattershot efforts by tech companies using cellular phone signals, social media surveys, online searches, and smart thermometers as we try to guess where Covid-19 outbreaks may be lurking.” In part, our gutting of the Public Health infrastructure at both the state and Federal level has contributed to our current flat-footed approach. As the Chief Medical Officer for Arcadia, our national failures seem particularly painful. Creating a new vaccine for Covid-19 is scientifically daunting, but collecting and curating data on individual person’s viral status should not be that hard! Arcadia is fully capable of integrating the disparate data elements into a coherent, practical healthcare strategy. We have already assisted several of our customers with Covid-19 related tools, and I would like to be able to do this on a much larger scale.

2.  Italy reports lowest number of new cases since February. In the past 24 hours, Italy recorded only 300 new cases – the lowest daily count since February 29. The total count of “active cases” is now down to 55,300 and the total number of patients in the ICU is down to 541.

 3. The WHO temporarily pauses hydroxychloroquine study due to safety concerns. The pause in the WHO Solidarity Trial came after a study published in the Lancet on Friday described how patients treated with hydroxychloroquine were more likely to die. France went one step further and barred the prescribing of hydroxychloroquine to hospitalized patients, citing its dangerous side effects, including cardiac arrhythmias.

4. Sweden update. As of today, Sweden has recorded 4,029 deaths from Covid-19. Sweden’s chief epidemiologist, Anders Tegnell, reported that 7.3% of Stockholm residents have antibodies. It is commonly believed that at least 70% of the population needs antibodies to achieve herd immunity. Sweden has had a significantly higher death rate than their Scandinavian neighbors that took a harder line on social distancing and stay at home orders.

 5. The Republican National Convention. President Trump is threatening to move the Republican convention scheduled presently from August 24 to August 27 in Charlotte, North Carolina to Texas, Florida or Georgia. Governor Roy Cooper of N.C. is under immense pressure to balance political forces against public health forces. Keep an eye on this one!

 6. What do we know (and not know) about kids and Covid-19? The message all along is that children rarely get sick with Covid-19, which is very different from what happens with the influenza virus wherein children often get very sick. In the last few weeks, we started getting reports about the rare but very scary Multisystem Inflammatory Syndrome which has affected children and rarely been fatal. The CDC published the following guidance about this Covid-19 pediatric syndrome:

 Contact your child’s doctor, nurse, or clinic right away if your child is showing symptoms of Multi-system Inflammatory Syndrome:

• Fever
• Abdominal pain
• Vomiting
• Diarrhea
• Neck pain
• Rash
• Bloodshot eyes
• Feeling extra tired

Be aware that not all children will have all the same symptoms.

Seek emergency care right away if your child is showing any of these emergency warning signs of MIS-C or other concerning signs:

• Trouble breathing
• Pain or pressure in the chest that does not go away
• New confusion
• Inability to wake or stay awake
• Bluish lips or face
• Severe abdominal pain

How doctors will care for your child

Doctors may do certain tests to look for inflammation or other signs of disease. These tests might include:

• Blood tests
• Chest x-ray
• Heart ultrasound (echocardiogram)
• Abdominal ultrasound

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A study from Spain, reported in a letter to the New England Journal of Medicine, stated that “Children younger than 18 years of age who had Covid-19 composed only 1% of the total number of patients; 11% of these children were hospitalized, and none died.” The study looked at findings from 100 children with confirmed Covid-19 infections who were evaluated in 17 different emergency departments. “The median age of the children was 3.3 years. Exposure to SARS-CoV-2 from an unknown source or from a source outside the child’s family accounted for 55% of the cases of infection. A total of 12% of the children appeared ill, and 54% had a temperature of at least 37.6°C. Common symptoms were cough (in 44% of the patients) and no feeding or difficulty feeding (in 23%); the latter symptom occurred more often in children younger than 21 months of age. Fever, cough, or shortness of breath occurred in 28 of 54 of febrile patients (52%).” Remarkably, only 4 children presented with an oxygen saturation level of less than 95%. The breakdown of severity of the cases is as follows: “21% of the patients were asymptomatic, 58% had mild disease, 19% had moderate disease, 1% had severe disease, and 1% were in critical condition. Most of the infants presented with mild disease. Severe and critical cases were diagnosed in patients with coexisting conditions. No deaths were reported. A total of 38% of the patients were admitted to the hospital because of symptoms, irrespective of the severity of disease”

             A second letter DOI: 10.1056/NEJMc2005073 to the NEJM from Chinese physicians  made the following observations. “Less than 1% of the cases were in children younger than 10 years of age.” Of 171 children, “The median age of the infected children was 6.7 years. Fever was present in 41.5% of the children at any time during the illness. Other common signs and symptoms included cough and pharyngeal erythema (red throat). A total of 27 patients (15.8%) did not have any symptoms of infection or radiologic features of pneumonia. A total of 12 patients had radiologic features of pneumonia but did not have any symptoms of infection. During the course of hospitalization, 3 patients required intensive care support and invasive mechanical ventilation; all had coexisting conditions (hydronephrosis, leukemia [for which the patient was receiving maintenance chemotherapy], and intussusception). Lymphopenia (lymphocyte count, <1.2×109 per liter) was present in 6 patients (3.5%). The most common radiologic finding was bilateral ground-glass opacity (32.7%). As of March 8, 2020, there was one death.”

      We still have a great deal to learn about how often children get infected, how easy is it for them to transmit the virus to other children and adults, how durable is their immunity once they get it and will the frequency or severity of Multi-system Inflammatory Syndrome change. We will all very shortly face some very tough decisions about whether, when and how to reopen daycares, schools and colleges.