It is week 30 of the Chinese-sourced scourge that is the COVID pandemic. Throughout the country, cases are soaring. Everything is increasing including the percentage of positive PCR tests, the number of hospitalizations, and to a lesser extent deaths. Happily, the ratio of hospitalizations to new cases remains significantly better than in spring.
This matters to me, as I too have become a statistic.
I was feeling fine until Saturday. I have had a very nice prime beef brisket in my freezer probably since the winter. With no possibility to socialize, it remained frozen. This week I decided to cook it, either to share with friends or freeze it for further use. Cooking a brisket at 225° can be an 18-hour event. I started it late at night and then tended to it periodically until morning. When I woke up Saturday morning feeling tired, it was no surprise.
I went to bed early that night and awakened on Sunday, nine hours later having apparently slept well. If anything I was more fatigued and began to notice muscle aches and pains, and a cough. I figured I had developed a more mundane viral infection, but realized as a practical matter I would have to be tested before going to work at the hospital on Monday. I ultimately had a rapid COVID test in our hospital emergency room Sunday morning which turned out to be positive.
I was uncomfortable most of Sunday, with fatigue caused undoubtedly by the interleukin levels provoked by the virus. In the late evening as I prepared for bed I had a sensation of flushing and brief nausea which cleared after about 10 minutes. 15 minutes later, I was no longer fatigued and felt better. Other than some minimal sporadic headaches, I have basically felt fine since.
Therapeutically, I have been taking zinc and vitamin D on a fairly regular basis. Back in March, I had obtained a course of hydroxychloroquine, and azithromycin; despite the conflicting data, I elected to take them in the morning right after I was diagnosed. I’m not sure whether they were helpful or not but I’ve experienced no unpleasant side effects.
I think the worst part of this has been the isolation. I’m lucky to live in a big old rambling Victorian, and it’s easy enough for my wife and me to isolate from each other. I have been basically existing in my office at the back of the home which has my computer, and a pullout couch (not particularly comfortable). There is an outside entrance so that I can go up to my shed/workshop in the back. I distance myself from my wife and wear a mask in her presence.
I don’t know why, but she seems pretty happy with the arrangement.
This is not meant in any way to trivialize the pandemic. I know that my friends working in other healthcare facilities are once again under stress. People are really sick. I suspect, if my good fortune continues, it is because of the fact that for 37 years as a physician I have been quite intimate with the coronavirus family of viruses, and thus probably have some immunity. Obviously, others have not been so lucky.
With my newfound perspective, it is interesting to watch the states respond to this surge. I’m actually sympathetic to Governor Wolf in this situation, as his options are very, very limited. Hopefully, he understands that another shutdown like the one in March would truly devastate the economy, wiping out the businesses that barely survived the restrictions in the spring. The new Pennsylvania restrictions tighten up on interstate travelers except those that have to travel every day (which kind of makes this moot) and increased mask-wearing to include certain outdoor circumstances, and indoors when your family has a visitor.
Governments, after all, have to be seen to do something about crises. But as I’ve said before, it’s becoming more and more clear that this virus is on its own schedule. It’s likely to run its course, at least until there’s a viable vaccine. This will hopefully be soon. Happily, the current surge means that a lot of people’s immune systems are becoming familiar with this coronavirus, and will hopefully have relative immunity to it. I suspect over the years it will join the rest of the coronavirus family, as merely a periodic irritant.
Meanwhile, I’ll continue my exile, and maybe even wallow in self-pity.
At least there’s brisket.
As always, I’d be honored if you’d share this post.
It has been 29 weeks or 8 calendar months since we locked down our society to battle the scourge of COVID 19. Nationally, we are clearly in the third run of new cases. The graphs from the Atlantic’s COVID Project reveal escalating peaks with July higher than April’s, and this new peak already exceeding July’s peak.
Interestingly, there are also 3 peaks of hospitalization, though so far they are roughly equal in size. Considering the ratio of cases to hospitalizations, it appears that a significantly lower percentage of people require admission. There is a small surge in deaths, though nowhere near as many as in April (so far).
Here in Pennsylvania, the pattern is slightly different. We had a large peak in new cases in April and a comparatively tiny peak in July.
Cases are now heading upward again in Pennsylvania with daily rates roughly double that in the spring. There have been however roughly 3 times a number of tests done compared to April however suggesting a lower positivity rate. Despite doubling the new cases the rate of hospitalization remains about 40% of what it was in the spring. Deaths have not yet surged since the summer numbers.
As mentioned, 2 weeks ago, my hospital is seeing sporadic cases of COVID, but we now have an excellent treatment protocol including remdesivir, convalescent plasma, and when necessary, steroids. I think it’s worth saying that there is much less fear among the doctors and staff this time around. Other hospital systems in town are also admitting COVID patients once again. Unlike the spring, the hospitals are now better prepared, so that elective surgeries and other procedures are still going on.
There is also recent news of a COVID strain affecting mink populations in Denmark. This virus can apparently pass from humans to mink, and then back to humans. To my knowledge, this is the first mammal with whom there is a back-and-forth spread of the virus. Still, there is no evidence that this is a more virulent strain, or that the mutation, will render it resistant to vaccines.
Speaking of vaccines, of course, the big news this week other than the election, was the announcement by Pfizer that the preliminary results of their COVID vaccine suggest a 90% effectiveness, and that immunization might be available as early as late December. This is wonderful news.
One wrinkle in this however is that Pfizer decided to try to decouple vaccine from the Trump “Warp Speed” program, instituted earlier in the year to try to speed along vaccine development. It clearly was a part of that program as evidenced by Pfizer’s contemporary press releases.
Though it’s easy to accuse them of perfidy, especially if you’re a Republican, I suspect this was actually an attempt to decrease public resistance to the inoculation. Both “anti vaxxers” and some Democrats, expressed concern about the safety of a vaccine produced so rapidly.
There is of course a related reluctance to give any credit to the president. In this vein, Andrew Cuomo actually expressed regret that the vaccine was released during the Trump administration, rather than presumably waiting till late January?
Forgive me, but what a callous, pompous ass.
Pfizer clearly wants to sell doses, and not have the vaccine sink into a political morass. I think any reasonable person is hopeful that it will be effective, no matter who gets the credit.
Trying to look on the bright side, the end of this mess may be in sight, as vaccination begins, and as a large number of positive tests means even more immunity throughout the community. In the meantime, we need to continue with masks, distancing, and protection of the vulnerable.
Oh, and I’d avoid Danish minks.
Just to be safe.
As always, I’d be honored if you would share this post.
Header image: Path through the Barberry (Sony RX100 III)
It is week 27 of the COVID restrictions in the Commonwealth of Pennsylvania. We are definitely seeing another surge now that fall has arrived.
We’ve actually set a record number of new cases per day with 2200 new Pennsylvania “cases” on 23 October compared to the Spring peak in mid-April at about 1700 cases per day. Happily, at this new peak, hospitalizations are only 37% of their peak in the spring. The death curve remains flat.
Around here we are seeing some activity, including in my own hospital, but so far it is not overwhelming. And we have tons of potential ICU capacity based on our reshuffling of beds earlier this year.
A little perspective however is in order. According to the most recent data on the Pennsylvania COVID 19 dashboard, the test positivity rate for the state is still around 5%, and the overall percentage of ER visits for “COVID like illness” is .8%. There is considerable variation among the counties.
Other states are surging also. States like Minnesota, Wisconsin, and Ohio are having what one might say is their first big peak, with an accompanying admission peak, more commensurate to what we saw in April.
Governor Wolf has so far resisted the temptation to re-impose our Spring restrictions. I’m hoping he realizes that for many businesses, another shutdown would be fatal to their existence. This virus is apparently going to be persistent, at some level we are going to have to figure a “workaround “.
It should be a hopeful sign, that President Trump, and his affected staff, have emerged from their infections essentially unscathed. I do recognize there are people reading this that may have wished for another outcome. I also note that he was by current practice rather aggressively treated. When you compare his disease course to that of Boris Johnson, who became ill in the spring there is a symbolic cause for optimism.
Mr. Johnson is you may recall in early April, contracted the virus. He became rather seriously ill to a point of needing an ICU, and by contemporary accounts required considerable supplemental oxygen. Much like his American counterpart, I am sure he received the maximum therapy available through the National Health Service of Britain at the time. But now we have Remdesivir, antibody cocktails, anticoagulation, and dexamethasone. 5 months later, our head of state, despite being older, had a much milder illness and quickly returned to a rather vigorous schedule.
If I keep writing these articles on a 2-week schedule, the next one will be after the election. It is been fashionable to accuse our Democratic Governors of playing politics with the virus, I myself have been guilty of this. At times, like in mid-July when restrictions were reimposed while cases were still flat, it seemed likely.
There are those who find the current case surges in swing states suspicious. They note that many democrats have already voted by mail, whereas Republicans tend to wait to cast their votes directly. They suggest that these case “surges” are manufactured to discourage Republicans from in-person voting. I might have been open to this concept except as mentioned above, there appears to be real illness associated with the increasing case numbers, at least in our commonwealth. Still, with masks and distancing, I have no fear of the polling stations.
in response to these articles in the past, I have been criticized, particularly on Facebook, for what some people feel is a cavalier approach to this outbreak. I think I’ve been fairly consistent, suggesting that we not react merely to the number of positive tests, but to factors such as hospital utilization, and of course deaths, to decide public policy regarding COVID 19. Given what been going on in the last week, I think it is time to be more careful now. We need to go back to more frequent handwashing, the wearing of masks (for what it’s worth) social distancing, and protection of the vulnerable. We need to carefully balance our understandable desire to socialize, with the risks of gatherings indoors.
There is some reason for cautious optimism. Obviously, with every new case that is either asymptomatic or recovers, that’s one less person who can transmit the virus. With over 5000 positive tests for instance in Luzerne County, if you factor in the asymptomatic’s that were never tested, you may have a lot of immune people in the region.
We also note that the virus is thought to be getting less virulent as time goes on, which is predictable. So far it seems to be the case, that in regions that are having their second or third peak, hospitalizations and death are far lower than when the virus first appeared.
Also, according to Dr. Fauci, we are perhaps 3-4 months from when a vaccine will be available. It is my hope that we can all find safe ways to patronize our small businesses to keep them afloat until the end of the pandemic but still avoid unnecessary spread. We need to come out of this, intact and healthy both as individuals and as a society.
We need to be not fearful, just careful.
As always, I would be honored if you would share this post.
We have officially hit week 31 of curve flattening, infection prevention, disease curing, bizarro world. With the weather growing colder here in Pennsylvania there has been an uptick in positive coronavirus “cases”, meaning positive PCR tests. There has been a small increase in hospitalizations, but the death curve is so far flat.
Remember that the New York Times reported that by the current method of PCR testing, up to 90% of people who are PCR positive may be noninfectious. My fear about the rising case numbers is that our governor and health secretary will use the occasion to increase the restrictions upon us. Remember the severe “red phase” lockdowns in spring. All that misery and lots of people still got sick.
Of course, the big news in the last week was the fact that President Trump and a significant number of White House staff have tested positive for coronavirus. Although there have been allegations, that the president was cavalier about masking, the bottom line was that he has been tested frequently if not every day, along with apparently anyone who was in contact with him in the White House. This clearly was an extraordinary effort to protect him from the virus. Yet it failed. It did so for one reason: this virus is ubiquitous in the environment.
He was admitted to Walter Reed Hospital, not so much because he met the criteria for admission, but because he is the president. Though apparently never requiring oxygen, or getting particularly sick, he was treated with a very aggressive regimen of medications including the antibody preparation from Regeneron which is clearly experimental. After a 2 day admission, he was discharged.
Apparently, he is testing negative for coronavirus now and has been deemed “noncontagious”. The other “infected” staffers, including the first lady, have all done well. As I understand it, no one else was hospitalized.
The Pennsylvania new “case“ numbers are impressive. On October 7 there were roughly 1400 cases reported, roughly the same number, as were reported on April 23 for instance. The difference is that on October 7 there were roughly 700 patients admitted to the hospital with COVID, versus 2700 in April. Whether these patients are actually sick from the virus, or merely PCR positive is anyone’s guess.
It’s also was noting there was far less testing being done in the spring. Clearly, either the tests are oversensitive, or the virus has changed. Maybe it’s a little bit of both.
The search for a vaccine apparently is continuing at a rapid pace. Apparently, the Johnson & Johnson candidate may have provoked some unusual symptoms in one of its test subjects and for now hold has been placed on their efforts.
So now we have increasing cases and so far, God willing, little morbidity. Given the availability of more sophisticated care for those to become ill, I continue to believe that continued numbers of asymptomatic and mildly symptomatic COVID infections is actually good news about our journey to a helpful degree of herd immunity.
Remdesivir is also in the news. On October 8 a study comparing the drug to placebo in ICU patient’s revealed that the median time to recovery, defined by the study as either discharged from the hospital or to a custodial situation was 10 days in the treatment arm and 15 days in the placebo arm. This is a fairly significant result suggesting the drug is a useful part of our growing options for the treatment of COVID 19.
I continue to believe that given the persistence of the virus, it’s declining virulence, the improvements in treatment, that we should relax the regulations killing specific industries and small businesses. We need to react, not to PCR tests, but to actual illness, hospitalizations, and death from COVID, not PCR positives with other acute medical problems.
Finally this week, the World Health Organization seems to change its mind on the advisability of lockdowns. In an interview, Dr. David Nabarro, the WHO’s Special Envoy on Covid-19, warned against using lockdowns as the primary control method for the coronavirus, for fears that global poverty and malnutrition may ultimately result. He expressed concern that for instance, the suppression of the tourist industry has impacted many destination countries severely.
In other words… after eight months of masks and misery, people continue to be exposed to this virus. Time for plan “B”.
Hopefully, Governor Wolf is listening.
As always, I’d be delighted if you’d share this with your friends.
Header image: Maple in the Glen (Fujifilm X100V, TCL X100 II)
We are now in week 29 of what is apparently an endless state of behavior control by our omnipotent masters: the executive branch of Pennsylvania government. Once again, another legislative effort to loosen up the restrictions, in this case on the restaurant industry, has been vetoed by the governor. This is despite the fact that while we are seeing modest numbers of positive PCR tests, there is very little actual illness resulting.
I remind myself that when I posted my first “viral” article back in mid-March, I assume naïvely that this topic would die out by midsummer. That my cover image for this edition now features autumn foliage, is quite discouraging.
Meanwhile, our governor, in a conversation with Rep. Wendy Ullman of Bucks County, is caught on an open mike discussing the concept that for our elected elites, wearing masks in public is “political theatre”. Good to know.
In Pennsylvania, the small peak of cases we had over the summer is waning. The number of hospitalizations, ventilated patients are all decreasing from already modest levels and the percentage of emergency room visits devoted to COVID-like symptoms is well below 1%.
I think we know this anecdotally. Other than a few patients whom I have attended, I know perhaps 3 people who tested positive for this illness. One of them had a fairly severe flu-like illness from which she recovered. Another had a short period of mild respiratory symptoms. The third was absolutely asymptomatic and was retested in 4-5 days and found to be negative. Most people I talk to have similar impressions. I understand that I didn’t live or work in NYC or similar hotspots. I’m referring to Pa. and I think, most of the rest of the country.
One of the things I have been pondering about is the disparity I have noted between my liberal and conservative friends, and their attitude towards the pandemic. In general, my liberal friends tend to be much more concerned about the possibility of contracting the illness and are much more careful about human contact. My more conservative friends seem more willing to interact, and in general, are more casual about their behavior. In my mind, this crosses all intelligence levels in both political persuasions. While this disparity is not absolute, to me it seems pretty consistent.
Let me say that I am excluding from this discussion the more militant “anti-maskers” from this as #1 I don’t know anyone who is a complete nonconformist to the rules, and #2 given their lack of courtesy, I would tend to discount their opinions.
I don’t see anything innate in one’s political leanings that should lead to this effect. I refuse to believe for instance, that all my liberal friends, want to keep us shut down to affect the upcoming elections.
I am left to believe that it is the media that we consume that forms our attitudes. It is clear to me that conservative media is more willing to entertain a certain skeptical approach to the pandemic through their pundits. The liberal media tends to emphasize the case numbers and the strains on the healthcare system where they occur. If there is a political motivation for this, I think it exists within the media and their allies in the political parties. This is a potentially dangerous game as it inhibits a purely rational approach to this outbreak.
So I shall once again restate my current thinking. Yes, there is/was a pandemic. Each of the states has had different peaks depending on travel patterns and other factors. There has been an “excess of deaths” throughout the country, though the numbers don’t precisely match the COVID death numbers. There is a reasonable case to be made that some of the additional deaths may be consequences of the lockdown, particularly suicides, addiction, and the fear of hospitals by people who required medical attention.
Currently, I believe that per a number of sources including the New York Times article, that PCR testing is oversensitive and maybe creating a lot of false positive “cases”. I believe that rather than worry about the numbers of additional positive tests, we should scale our precautions based on actual disease burden which for now is modest at best.
I look at the pandemic the way I would look at a critically ill patient during my years as an intensivist. Let’s say a patient is admitted to the intensive care unit, with sepsis and low blood pressure. We would intervene in this, often by giving a large amount of IV fluid, plus drugs that can compress the blood vessels, raising the pressure. These modalities though, have long-term side effects that can be life-threatening, so in these situations, we are constantly testing. If the patient’s blood pressure appears to stabilize, we begin to withdraw the interventions. If the patient deteriorates then we may need to re-increase the therapy, but ultimately the goal is to discontinue these measures before they do the patient more harm.
This experience informs my attitude towards the current status of COVID in most of the country. The measures we took back in March, were certainly appropriate then, but they have been continued in situations where the “patient” seems to have stabilized. The problem is that prolonged intervention has done a lot of damage to large and small businesses that are now either crippled or deceased.
The goal of therapy needs to be the return of the “patient” to normal life as soon as possible. I suspect we would be doing this more aggressively if governor Wolf was not a “lame duck”, and if a presidential election were not imminent.
It’s now Autumn. Time to end the political theatre.
As always, we would be honored if you would share.
Header Image : Scene Along Glenside Road (Fujifilm X100V)
It is now 6 months into the dictatorial restriction of our liberties sold to us as “2 weeks to flatten the curve”. There do not appear to be any goalposts being offered to give us hope.
We can surmise, that the availability of an effective vaccine for SARS Cov-2 will liberate us, but this was squelched by the eminent Dr. Fauci, who claims that even with a vaccine, restrictions will need to be maintained until at least the middle of next year. I read that as until June/July 2021.
Meanwhile here in Pennsylvania, the number of new cases per day, after a small late July peak, has once again begun to decline, along with the number of hospitalizations. The average percentage of emergency room visits for COVID-19 type symptoms is 0.6%. The highest percentage comes out of Sullivan County with 3.8% though they still have no documented cases of COVID 19. The average PCR positivity rate is 4.2% throughout the Commonwealth. I’m sorry but this no longer feels like a pandemic.
Meanwhile, we continue, with what is becoming ritualistic behavior vis-à-vis masking. I have made it clear in the past, that I have been compliant up to now, out of courtesy, and out of the desire not to cause problems for businesses I frequent. But as this disease fades, so should we see our precautions fade. Instead, it’s becoming ingrained.
So now I walk into a restaurant. Shortly before entering, I slip my mask on my face. Throughout the summer this is largely been out of doors, and I walk at a distance from other patrons over to a table (no bar seating allowed), either with my wife or to join a group of friends. At the table, we are permitted to unmask. This is despite the fact that we are now sitting much closer to each other (often no further away than we would be at a bar). None of this makes any bloody sense, not only given the minimal incidence of the virus now but by the mechanics of respiratory droplet spread.
Another issue has to do with the persistence of the virus. The experts seem to be preparing us to understand that this particular virus is going to be persistent in the environment. This is really shouldn’t be any great surprise, as it is true of the adenoviruses, rhinoviruses, and other coronaviruses that circulate year-to-year. It’s only by repeated exposure that most of us have at least partial immunity to these common viruses. This means unless you’re very debilitated, you are unlikely to get very sick. Sound familiar?
I hope we have not squandered the opportunity over the summer, through more unfettered social interaction in outdoor spaces, for healthy people to get small exposures to the virus. This would be important in the pursuit of some level of “herd immunity”. I am concerned that as the cold and flu season begins, that we will overreact as respiratory illnesses become more common.
As many of you know, I have been using the Atlantic magazine’s COVID Project among other resources, for some of the data in these articles. As a left of center publication, one would hardly think they would shave the data in a conservative way.
I looked at South Dakota, now 4 weeks from the Sturgis motorcycle rally. South Dakota, it is one of the few states that does not have a mask mandate. The event was accused of being inappropriate, and later of being a “super spreader”. On the website, there are multiple graphs documenting a number of parameters including new cases, number of tests, number of hospitalizations, and number of deaths.
At first glance, the numbers are concerning. South Dakota had had very few cases of COVID, with small peaks in April and May. The curve was then flat until roughly August 16 (right around the end of the rally) when an upward spike began, peaking in early September. Hospitalizations, also peaked, interesting to roughly the same level seen in May with a much smaller number of total cases. The graph of deaths also had a small peak.
All of this looks discouraging except for something I initially overlooked. The graphs used by the Atlantic, have a different scale for each state. This makes it easier to track smaller numbers but also makes small changes look much more dramatic. For instance, the second large peak of hospitalizations post-Sturgis looks impressive, but the number was only 83 admissions for the state. The death peak was 2. Sturgis hardly appears to have been a “super spreader”.
There is more encouraging news. We talked about the CDC reports of “excess deaths ” several weeks ago. This is a comparison of the agency keeps between the actual number of deaths throughout the US for a particular time of year, versus the expected number of deaths. For the first time since April, in the third week of August, there were no excess deaths, and in the fourth week of August, we’re actually 14% below the expected death rate for the week. This certainly seems consistent with our impression that although there are significant numbers of positive PCR tests, the morbidity and mortality associated with this are very low. This may be due in part to the over sensitivity of the PCR test, and possibly a better understanding of how to treat the smaller numbers of those who become critically ill. If we remain below the expected death rate, it might rightfully be said that this outbreak is over.
At any rate, in Pennsylvania, there appears to be no end in sight. A federal judge ruled that a portion of the Wolf/ Levine unilateral restrictions are unconstitutional. I’m not well versed in law but I understand this suit was brought by plaintiffs in a variety of businesses, whose complaints have been largely dealt with as the state partially reopened. Members of the hospitality industry were not a party to this, thus their issues were not addressed in the ruling. The main effect of this may be to relax the restrictions on public gatherings. The Wolf administration is expected to ask for a stay, while they appeal.
I’m uncomfortable with the idea of becoming a militant “antimasker”. The extreme viewpoints on either side of an issue tend to be wrong. Then again, I think we need to find a way to cut through the unwarranted fear, both for our health and for legal liability, the politics, and the religion-like virtue signaling that has become a part of the public reaction to the pandemic. If the virus is here to stay, we’re gonna have to learn to live with it. To me that means moving back towards a normal state of existence.
People keep saying “follow the science”. I completely agree.
As always, I would be honored if you would share this.
Header image: Old Trail near Ray Brook (Fujifilm XE3, XF 18-55 f2.8-4)
We are now in week 25 of the two-week effort to flatten what has become the flattest curve that can still be a curve. Pennsylvania seems to be over a slight bump in cases we had in July and August. The number of new deaths remains flat.
Nationwide statistics are interesting. I’m looking at the curves on the Atlantic’s COVID Project. Overall, in the US were clearly two peaks of new cases: 1 in early April and a second peak this summer. The latter produced roughly double the number of new cases per day as the peak in April. Of course, the number of tests performed during the summer surge was significantly higher than those performed in April.
Interestingly the number of hospitalizations for both of the peaks was roughly the same, but the number of deaths was significantly lower in the summer (April peak daily deaths were around 1800, in early August around 1200. This tends to confirm the impression on multiple fronts that the virus has become less virulent, or we have figured out better therapies. Or… maybe our testing is a problem. More on this below.
Despite the favorable Pennsylvania numbers, our governor has thoughtfully extended his emergency powers for another 90 days, thus, of course, past election day. He can get away with this and continue this virtual dictatorship because his fellow Democrats control the Pennsylvania Supreme Court. I’m not sure I can see an end to this. Though he touts the various benefits the state receives from this emergency declaration, the fact remains that we probably wouldn’t need the benefits if he didn’t insist on the restrictions on businesses and churches.
There has been some news from the CDC on the characteristics of patients who have died carrying COVID as a diagnosis. Turns out that only 6% of the patient’s died of the virus without the contribution of comorbid conditions. Yes, this coronavirus is dangerous and potentially lethal. However with the overall death rate of COVID per Dr. Fauci currently at 0.6%, the death rate for healthy people who contract the virus is thus 0.0036%.
Now I have written before about death certificates. If the patient denies of respiratory failure secondary to congestive heart failure but has COVID as a contributing factor on the death certificate, is that counted as a COVID death? Remember a diagnosis of CoV-2 infection was financially advantageous for hospitals that were struggling because of the cancellation of all of their elective procedures. In light of this, here is another interesting guideline from the CDC website regarding the coding of COVID deaths:
COVID-19 deaths are identified using a new ICD–10 code. When COVID-19 is reported as a cause of death – or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation (italics mine).
So in other words, if the patient presented let’s say in early spring with a respiratory syndrome, perhaps with a fever and URI symptoms, and ultimately died, the patient can be coded as a COVID death even in the absence of a positive test. And the coding in that way would benefit the hospital with an increase in reimbursement.
When you look at the CDC’s COVID mortality numbers, they are in a category known as “deaths involving COVID”. Not deaths “from COVID” or “caused by COVID”. This is the roughly 160,000+ US deaths being reported secondary to the virus. This apparently includes deaths from other causes when COVID 19 is listed on the death certificate. Even George Floyd may have qualified in this way.
As we have discussed before, death certificates typically have two or three lines where the causes of death would be entered. An in-hospital death would likely be filled out by an intensivist, or a hospitalist often employed by the facility. The first line is for the “disease state that caused the death”. The second and third lines are for “significant conditions contributing to death that did not contribute to the underlying cause of death”( per Pa’s Death Certificate Manual). Once filled out, it ultimately goes to the county coroner where it is reported to the state Health Department. Depending on the motivations of the state government, these numbers could certainly be subject to some “sleight of hand” if one wished to increase the numbers of Deaths related to COVID.
Before I get accused of being a COVID denier, let me say that on the same CDC website there is a graph showing monthly US death rates as far back as 2017, with a line just above the graft showing the point of so-called “excess deaths”. In every month since March, we have been above that line, so clearly there has been illness and death beyond the norm. It’s just that for many of us, the wave has passed.
The PCR test (deep nasal swab) for the coronavirus has recently come under scrutiny. A recent article in the New York Times does a nice job of explaining the methodology of the PCR test, and the likelihood of false-positive results.
PCR testing, also known as gene amplification testing, becomes more or less sensitive depending on the number of amplification cycles the lab specifies. It is thought that most labs have made the test so sensitive that it detects tiny amounts of virus or viral fragments that would not lead to clinical illness or disease spread. In the article, it is suggested that 85-90% of positive tests would be negative if testing were conducted more appropriately.
The risk of false positives in PCR testing has been recognized before. In previous viral epidemics such as SARS-CoV-1, Zika, Ebola, or MERS-CoV, the CDC and WHO recommended that tests should only be performed on patients who either were symptomatic or were known exposures. It was also recommended that a positive test be followed with a second confirmatory test before assigning a diagnosis.
For some reason with the current virus (SARS-CoV-2), testing until recently was not limited to symptomatic patients, and still, no confirmatory tests are necessary. One positive PCR is enough.
There have been a variety of testing errors that have come to light. Most notably the 77 NFL players tested positive for the virus in late August in preparation for training camp. The players were all then retested and came out negative. Apparently, there was contamination at the testing lab. I think of other labs in Florida the reported having 80-100% positive results. Then there are the anecdotes of patients who registered to be tested, but never actually had a sample taken, but still received positive results. I continue to be concerned that our current testing regimen is deeply flawed.
All of the above is why I continue to believe and have stated multiple times, that the best marker for disease activity in the community is hospitalizations and deaths actually caused by SARS-CoV-2. It is these parameters that should be used to determine the government and public response.
So we in the “early states” where the actual COVID illness has come and gone, remain stuck with business and worship suppressed, following illogical regulations with no end in sight. Oh, maybe there will be a rushed vaccine of questionable efficacy and safety that many will refuse.
The curve is officially flattened.
Now we’d like our lives back.
I would be honored if you’d share this.
Image: Summer evening at Fountain Lake (Samsung Galaxy S8)
It is week 24 of “two weeks to flatten the curve”. Pennsylvania’s recent bump in cases, mainly in Western Pennsylvania has subsided with a minimal increase in hospitalizations and no real increase in the rate of death which was already quite low.
There are a few counties said to be “problematic” because their PCR positivity rate is greater than 5% (the overall rate in the state is 3.4%). Most counties report that the percentage of their emergency room visits for COVID-like symptoms are less than 1%.
In the southern states, almost without exception, their rates of infection have peaked and are now decreasing. As I have said before, there was definite morbidity and mortality as a consequence of these surges. Those numbers too are either flat or improving. You can see this most easily on the Atlantic’s COVID project page where each state’s data is numerically and graphically displayed.
Almost without exception, all of the recent trouble spots were in essence experiencing their first onslaught, much like the Northeast experienced in April. One gets the impression that the virus is moving through the country like a wave that started in the Northeast and moved south and west. Interestingly the Dakotas seem like the next hot spot, but although their numbers are rising, they are rather low compared to other states.
To me, it seems that the virus’s behavior in the Northeast over the summer months has been similar to the seasonal behavior of other respiratory viruses. We remain aware of its presence because uniquely among respiratory viruses, we are continuing to test for it in the population. Given the burden of disease suggested by the emergency room and admissions data, it would otherwise likely go unnoticed.
Some would say that it is through our masking and social distancing, that we have controlled the pandemic. I would argue that this virus is observing its own timeline, with a minimal impact from our suppressive efforts. Like most viral infections once it enters the population it spreads, peaks, and declines. That is happening all over the country, we’re just several months ahead.
I still wear a mask and respect people’s space. But after the onslaught, this spring and the many months since only 1% of Pennsylvania’s population has been documented to have an infection. Maybe we need to relax a bit.
There is certainly reasonable concern about opening schools and colleges. This has already happened in much of Europe and Asia with generally good success. Middle school and younger children have a low amount of the ACE2 viral receptor and generally are thought not to be contagious. Older children are “spreaders” but usually with fewer, milder symptoms. Teachers of course are older and a concern, but are exposed much the same as anyone who deals with the public. The good news is we can watch other countries as they move forward.
I do want to speak to another virus that infects us and is far worse than coronavirus. I speak of the rampant disrespect and intolerance online and in the community, at large. As a baby boomer, I would be tempted to ascribe it mainly to younger people, but I know that isn’t true. Somehow, we got to a point where people have no regard for others, especially if they hold views that they find disagreeable.
The incubator and breeding ground for this is social media. Facebook and Twitter have provided an arena for arguments in the “ether” where people feel unbridled from the courtesies we generally employ when arguing in person. This is extremely pernicious in our increasingly selfish, areligious, and amoral society.
As many of you are aware I’ve seen this first hand. I spend a lot of time researching these articles before they’re published and I genuinely hope to convey what I believe is truthful information, even if it flies against what is being said in the media. I have been guilty of some snark when it comes to the governor and the secretary of health. I only began to be critical of them in mid-May, after we passed our infection peak, and there was no sign that they had any interest in listening to voices in the legislature, or those of small business owners being driven out of business. I have tried to keep my criticisms based on their actions, and not their political party.
For several weeks now, I have had rather persistent, and militant, commenters on my Facebook page. These aren’t people that are pointing out specific errors they feel I’ve made. They prefer to condemn my viewpoint without evidence, and quickly go “Ad hominem” when rebutted. They accuse me of lying and are arrogant enough to report a post to Facebook for removal. They’re vicious and very persistent. The last person was posting under an account that appeared brand-new and had very little personal information. When pressed, the person admitted that the account was anonymous to avoid facing responsibility for their comments.
If I read something on Facebook for instance that I disagree with, I may post a retort. Usually, I reserve this attention for friends. I try to use irony rather than sarcasm as the latter tends to come off as mean. And I don’t persist. Friendships are worth more than winning an argument.
This angry self-righteousness in our citizens is far more dangerous than COVID. Because, as we see in places like Portland, Kenosha, Seattle, and Minneapolis, this pandemic has the potential to literally tear apart our society if it is not stopped. If anyone should be “quarantined”, it is the vicious purveyors of hatred and mayhem who infect and highjack peaceful protests.
I remain extremely grateful to those of you who share these posts and offer support and encouragement. I feel the same for those of you who disagree politely, either with a critique, or your silence.
It’s only with kindness and respect that we will cure this virus.
It is week 20 of the coronavirus lockdown. For a man of my age, between the pandemic, the sometimes illogical/irrational Government response, and the everlasting urban mayhem, this is clearly the most bizarre time period of my entire life.
Here in Pennsylvania, presumably due to a rise in cases in western Pennsylvania, our governor has re-imposed restrictions on bars and restaurants. The first version of this specified that there could be no bar seating, and customers had to buy food if they wanted a drink.
Understandably, many already struggling taverns created inexpensive food items for patrons who wish to have a libation while sitting at a table. Curiously, Governor Cuomo in New York, imposed the same rules on his state. This occurred despite the fact that the number of new cases in that state were minimal.
Apparently, New York bars and restaurants followed the Pennsylvania practice, and soon there were “Cuomo chips” made available to patrons.
For absolutely no discernible reason, other than perhaps pique, both Governors imposed additional rules requiring that A “substantial meal” be served. Andrew Cuomo made it clear that for instance “chicken wings” don’t qualify, undoubtedly endearing him to western New York voters.
All of this is ridiculous. I think of restaurants that I frequent in places like Sullivan County, Pennsylvania (5 confirmed cases), or Hamilton County New York (same statistics) which were forced to stay closed from March to June, only to have restrictions re-imposed once again for no good reason. No wonder that a recent Yelp survey reported that 53% of their member restaurants were closing for good.
I recently visited an establishment where I sometimes go for lunch on my day off. I usually sit at the bar, talk to friends, have a beer, and a single slice of sausage pizza (I love the crispy texture of re-baked crust). The slices are large and it’s more than enough food for me.
My waitress on that day was unfamiliar. I dutifully sat alone at a table, no friends around. I ordered my usual slice of pizza with a beverage and waited.
She came to the table with the pizza and beer and then informed me that although they would honor my order today, the slice of pizza was inadequate to be considered a meal, and they would not do this again. I was also told that I could not have another beer regardless of whether the pizza was finished. The restaurant, often quite busy on a Thursday, was minimally occupied. I can’t imagine why.
What kind of madness is this? Is the state now determining what I eat for lunch? And how does this protect anybody from COVID? Or is it just meant to add to the general misery? You decide.
I would be remiss if I didn’t discuss the surge in cases throughout the southern US. There are likely multiple reasons for this from the parallel surge in Mexico, to the loosening of COVID restrictions. Spring break activities may well have played a role.
The climate may also have something to do with this. While the Northeast in March April and May were “hotspots”, the South had minimal problems with really no “peak” like we experienced in April. It was a cold spring in the North and for most of us, we were trapped indoors, while people in the South presumably spent more time outside.
Now in summer things have reversed themselves, with those in the South, escaping the summer heat indoors with air conditioning, and those of us in the North are enjoying the outdoors. I do wonder whether HVAC systems are helping to spread the virus. There is some emerging interest in this possibility.
So, let’s talk about hydroxychloroquine. I’ve been writing about the pandemic since March 21st. In that first article, I already noted that there was some evidence that hydroxychloroquine, along with azithromycin might have some efficacy. I also noted that a research-based physician such as Dr. Fauci would culturally be uncomfortable recommending a medication without multiple double-blind studies. This is entirely understandable. But Dr. Fauci doesn’t treat anybody. Practicing caregivers in the middle of a pandemic are sometimes forced to innovate for the benefit of the patients.
Even in March, there was in vitro data suggesting that HCQ inhibited coronavirus replication, and since then, we have come to understand that there perhaps for other mechanisms on a cellular level where the drug may prevent viral contents from entering human cells. There were also non-blinded trials strongly suggesting that the drug was useful. In later articles, I discussed other papers that had been published with similar views. Finally, there was the controlled study from Detroit where HCQ halved the mortality rate of hospitalized COVID patients.
Unfortunately, when Donald Trump mentioned the drug in one of his briefings, all hell broke loose. I think I understood what he was trying to do, namely offer some optimism during frightening times. I honestly believe that another president, at another time might have been given the benefit of the doubt. Not in this case. Hydroxychloroquine became “Trump’s drug” and its use must not be allowed.
On Monday, a group of physicians calling themselves America’s Frontline Doctors held a press event in front of the Supreme Court. There they discussed their experiences using hydroxychloroquine in the treatment of COVID. The most prominent and controversial speaker was Dr. Stella Immanuel, who was apparently a pediatrician, born in Cameroon. She also claims to be a minister. She is convinced that hydroxychloroquine is effective having by her account treated 350 patients with it with minimal morbidity and no mortality.
What she seems to believe is that “Big Pharma” is suppressing information on the drug’s efficacy in order to boost profits from drugs such as remdesivir, as well as from vaccines to be developed. Having dealt with pharmaceutical companies for much of my career, I do not find this idea completely fantastic.
It was her opinion, that if hydroxychloroquine was used more often for prophylaxis and treatment, that no masks or other restrictions would be necessary. She was, to say the least, very fervent in her beliefs.
I saw this video on Monday night. It was interesting, but I’d never heard of the physician group and thus wasn’t sure what to make of it. Nonetheless, if her treatment claims are truthful, it is another data point. I couldn’t really figure an ulterior motive when the drug is off-patent for 40 years.
Tuesday morning, I was perusing Facebook when I noticed that multiple friends of mine had posted the video. They also were reporting that Facebook and YouTube were deleting it. I despise “Big Data” censorship, and thus I shared the video with the comment that I was posting this because it was being removed, but I found the video “interesting”.
I was then beset upon by a young lady of my acquaintance, who works in health sciences who was extremely offended that I would post what she considers to be essentially anti-science. She informed me that either I should take down the post, or undoubtedly Facebook would, as she had already reported the post to their “editors”.
Dr. Immanuel, as it turns out as a somewhat “colorful” online presence and holds some controversial opinions as part of her ministry. Websites like the Daily Beast, eschewing their usual love of diversity, quickly did a “deep dive” in order to debunk her. They claimed that Dr. Immanuel claimed that masks are not necessary, without the qualifier she provided.
Nonetheless, if her claims about her medical practice and her treatment of coronavirus are true, then the information may be useful. Again, it’s information to be processed and then believed or discarded. Information is generally helpful.
Given the significant number of articles that I have quoted in the past, some controlled, some anecdotal, but all supporting hydroxychloroquine as a COVID antiviral (here is a recent one from Newsweek), the virulence of opposition to this video would suggest that there are people who just don’t want to know if the drug works. Logically, it suggests that they may not wish for any chance to see the pandemic brought under control so that the economy can fully reopen. And why would they feel that way? Maybe it has something to do with the presidential election in 3 months or so?
I for one cannot imagine being such a nihilist- so politically driven that I would be willing to discard a potential treatment and prolong people’s physical and economic distress. I do not understand on an interactive forum like Facebook, why people who disagree with a viewpoint, would want to erase it, rather than just to make their case in opposition.
I just want to know what works so I can treat my patients.
And perhaps selfishly… sit at a bar with a beer and eat a piece of pizza.
By my count, it is week 18 of restrictions imposed upon us by the COVID-19 pandemic. It feels like “the new normal” has set in. Here in Pennsylvania, all of the state is in the so-called “green” phase, where the remaining businesses have opened, and we can now go to bars and restaurants albeit with masks and appropriate distancing. Our case numbers per day continue to trend downward except in Allegheny County (Pittsburgh). There the numbers are slowly increasing.
There is been great concern about the surge in new coronavirus cases in multiple states. Florida for instance has seen a significant increase in new cases over the last several weeks. If you look at the long-term graph of cases per day however, this surge looks like the state’s first true peak. Deaths are on the rise there. Interestingly there are reports out of Florida that a significant number of sites had an 80-100% positivity rate (our positivity rate in April was around 27% which is typical). This sounds like there are testing issues in the Sunshine State.
Georgia, which up to now had been fairly quiet, has seen its own increase, but so far deaths are flat. Another hot spot, Texas, new cases, and deaths are continuing to rise at this point. This is mainly centered in the cities and much of Texas remains quiet.
I should point out that the Texas hotspots of Houston, El Paso, and Austin were the site of significant protesting/mayhem in previous weeks. This is also true of Miami, Seattle, and Portland Oregon, where cases are also rising.
My concern about this situation regards the data on which it is based. Because it appears there are serious problems with the acquisition and reporting of COVID testing that could lead to bad decisions down the road.
There have been several interesting articles published in the last several weeks. Several sources I’ve pointed out that state by state, reporting of new cases uses different methodology. The CDC and apparently some states report both positive PCR tests (swab test), and positive antibody tests (blood test) as new cases (I understand this is true in PA). This is problematic.
First off, PCR test, or polymerase chain reaction test looks for pieces of the coronavirus RNA. This RNA can be present on your mucous membranes whether you’ve been merely exposed to the virus but not infected. The test detects segments of RNA that can either represent either intact virus actively spreading, or fragments of virus successfully destroyed by your antibodies or T cells. So, it may report a failed infection as positive.
Also, it is important to remember that we are reporting positive tests, not positive patients. If the patient has a positive PCR test, and weeks later has a repeat study and it remains positive, then that’s counted as another positive test even though it’s on the same person. And again there is the thought that the positive PCR in that situation may reflect the presence of viral debris at the end of the infection. So any way you look at it, it is bad data.
The antibody test, as most people know is geared to discover whether someone has been infected in the past. If we count these positives in the same way we count the PCR, then we can give the false impression of additional viral spread occurring in real time when that is not necessarily a valid conclusion.
Also, the dynamics of testing have changed radically in the last 3 months. It used to be that you needed to have very specific symptoms and be in a high-risk group to obtain a nasal swab test. Now you can essentially obtain testing on a whim. Thus, it is likely that many more asymptomatic patients are being tested.
We do know that the uptick in cases has also involved a roughly 10 years shift in average age downward. This means that the average person exposed is likely much less vulnerable.
So, if a younger patient tests positive by PCR but has no symptoms is this really an actual infection or an aborted one? These are questions I don’t think we really understand. But we still count them as positives.
So, it would appear that the actual impact of each additional positive coronavirus test in July may be different than one in early April.
Need evidence of this? There is recent data from the University of Pittsburgh suggesting that the recent strain of COVID being encountered is perhaps less virulent than previous sprains. They note that only 2% of people who test positive now require hospitalization. And only 0.2% of cases result in death, far lower than previous statistics. Given the different profile of patients getting tested this might actually have been true all along.
There is another thing to consider. When we locked things down in March, we had little to no knowledge of how to treat these patients. We had shortages of hospital beds, PPE’s and of course ventilators.
Now, 4 months later, the healthcare system has adequate supplies and additional expertise in the care of these patients. We figured out how to reprioritize and add additional patient care units and negative pressure rooms. New discoveries in therapeutics are reducing the severity of illness and shortening the length of admissions. We are far more ready and capable than we were in the spring.
I should mention the hydroxychloroquine study out of Henry Ford Hospital in Detroit. They studied patients hospitalized with COVID. In one leg of the study, the patients were treated with hydroxychloroquine alone. These were compared to patients but did not receive the drug. The mortality rate for those in the treatment arm was 13% as opposed to roughly 26% in the nontreatment arm. There were negligible cardiac difficulties, which is the main concern over the use of the drug. This is a peer-reviewed study, the first significant evidence for use of the drug. So it is likely we can finally add this medication to remdesivir, and dexamethasone in our anti-coronavirus armamentarium.
There is also emerging information that many people may well have had some degree of both antibody and T-cell immunity to this particular coronavirus based on previous exposure to the “common cold” coronavirus that we have all encountered for most of our lives. This virus may not be so “novel” as we have been told.
I guess what I really want to say is this: We need to be careful about how we react to these surges. In places where the healthcare services start to become strained, then we need to react strongly to avoid further spread. But in places where the numbers merely go up without much impact, then we need to remain vigilant,. We need to protect the vulnerable, but continue to go about our business with precautions in place.
As I am a compliant soul, I will wear my mask and observe the CDC recommendations. I will respect the businesses I visit, and obey the rules so they will not be penalized by the state.
So I wrote the words above between Monday 7/13 and Wednesday afternoon 7/15. I just needed a punchy way to end it.
I get home and turn on the news only to find that his Majesty the Governor has reimposed lockdowns?… on the whole state? He has targeted the bar-restaurant trade which I suspect he views as a more frivolous business and the least defendable (tell that to the owners and employees).
There is no justification for this in the state’s own data. First off, cases were bound to kick up a bit when we went to green several weeks ago. Then there is the fact that the increases are limited to a few counties in the west. Remember the announcement above from UPMC?
So I went to the State’s own COVID Early Warning Dashboard. In Allegheny county, the PCR positivity rate is 7.9%. The percentage of ER visits related to COVID is 0.9%. Pittsburg has multiple very large hospitals. There are 80 patients admitted with COVID, only 9 on ventilators. All of this in the State epicenter.
I’m sorry, but this feels purely political. It is tyranny in the Commonwealth of Pennsylvania.
