“The most important thing in treating any viral disease is that you want to treat it early. If you don’t treat it early, you’re probably going to miss the window to treat it. And then you have to deal with its complications.” — Dr. David Bernstein, vice chair of medicine for clinical at Sandra Atlas Bass Center for Liver Diseases at Northwell Health
“We are being told we can’t fight the virus without pausing the economy, yet we can’t fight the virus without the economy. Why should we assume that a crashing economy would leave the healthcare system standing? You can’t keep the hospital lights on without keeping on the lights of the economic sectors undergirding it.” — Esther O’Reilly, Arc Digital
“If we do this carefully working with the governors, I don’t think there’s a considerable risk. As a matter of fact, I think there’s a considerable risk of not reopening. You’re talking about what would be permanent economic damage to the American public.”
— US Treasury Secretary Mnuchin
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- Recent Developments and Headlines
- Numbers and Trends
- Known & Unknown: Vaccines
- New Scientific Findings
- Concerns & Unknowns
- Lockdown vs. Reopening
- Spring Forward or Lag Behind?
- Play Ball!?
A. Recent Developments and Headlines
Sources: New York Times Coronavirus Updates, New York Post Coronavirus Updates, Zero Hedge Coronavirus Updates, Drudge, Breitbart, Wall Street Journal, Coronavirus White House Task Force Briefing, NY Governor Daily Briefing, and Worldometers
- White House: May Unemployment Could Climb to 20%
- Wall Street Journal: Economic Lockdown Is the ‘Catastrophe’
- As deaths mount, Trump tries to convince Americans it’s safe to inch back to normal
- Chuck Todd: POTUS Moving Away from Fighting Disease to ‘Cheerleading’ Economy
- Bombshell report claims China pressured WHO to delay global coronavirus warning
- NY Coronavirus Deaths Lowest Since March As Cases Of Mysterious New Respiratory Syndrome Affecting Children Climb
- Virginia to Begin Reopening (with Strict Restrictions) Next Week
- ‘Mutiny’: Pennsylvania Counties Reopen in Contravention of Governor Wolf’s Edicts
- Vice President Pence To Self-Isolate After Coronavirus Exposure
- Nearly 50 Percent of California Coronavirus Deaths in Nursing Homes
- Illinois Governor: No Religious Services for More than 50 Until Vaccine or Treatment ‘Widely Available’
- Projections show California C19 cases and deaths rising more than expected
- Florida nursing home deaths from COVID-19 spike dramatically: up to 22 at a single home
- Company Layoffs Mount as Recovery Appears Elusive
- New study shows staggering effect of coronavirus pandemic on America’s mental health
- Michigan Attorney General Sends in State Police to Shut Down 77 Year Old Barber
- States build contact tracing armies to crush coronavirus
- Major US Airlines Endorse Requiring Passengers to Undergo Temperature Checks and Wear Masks
- NYC coronavirus death toll reaches nearly 20,000 in grim milestone
- Coronavirus meat shortages could potentially last through summer
- Cuomo quietly keeps finger on NY’s ‘pause’ button
- Virus: Second Wave Fears Worldwide
- Rhode Island becomes first in Northeast bloc to lift stay-at-home order
- US Has ‘Limited’ Ability To Manufacture Coronavirus Treatments, Vaccines
- China Asked WHO To Delay Pandemic Announcement, Deny Human-To-Human Transmission: German Intelligence
- New York Gov. Andrew Cuomo’s Nursing Home Scandal Grows
- Hawaii Arrests ‘Rogue Tourists’ In COVID Contagion Crackdown
- Chicago Murder Rate Soars Despite Stay-At-Home Orders, Activists Blame “Lockdown Segregation”
- A COVID State Of Mind – America’s Mental Health Suffers As Anti-Anxiety Drug Prescriptions Soar
- Pentagon Randomly Tests Units Over ‘Stealth Carriers’ Concern, Starting With Nuclear Personnel
- Georgia Records Lowest Number of Coronavirus Patients in over a Month
- Coronavirus Teaches Silicon Valley That America Needs to Build More Than Apps
- Italy also reports lowest cases since March
- China reports first new case in Wuhan since April 3
- NY reports lowest number of daily deaths since March
- Afghanistan ends lockdown as economy collapses
- Global new cases drop for 2nda day
- Germany reports rise in spread rate above 1
- Philippines reports spike in new cases
- Local officials in Spain push government to reopen more quickly
- UK urges reopening will be handled with caution as Prime Minister Johnson prepares to lay out framework
- Turkey eases lockdown restrictions for most vulnerable people
- UK testing of ‘contact tracing app’ going ‘well’
- Pope Francis urges EU to work together to battle virus
- American Shopping Malls Resemble Ghost Towns After Reopening
- As State Reopens, Ohio Urges Employers To Snitch On Workers Who Stay Home Over Virus Fears
- “Unprecedented Crisis” – Global Luxury Goods Market Collapses, No Recovery For Years
- White House On ‘High Alert’ As 11 Secret Service Agents Currently Positive For COVID-19
- Fatties Stay Home: Leaked UK Doc Shows Mandated Remote-Working Plan For Obese Brits
- ‘Not If You’re Too Hot’ – Nevada Brothels Unveil Temp-Taking, Mask-Wearing Plans To Re-Open
- Anti-lockdown Protesters Clash With German Police As Virus Spread Accelerates
- Montenegro Advertises Itself As “Corona-Free” Vacation Destination
- ‘Skynet’-Like Robot Dog Patrols Singapore’s Parks To Ensure Humans Are Social Distancing (see video at https://youtu.be/viuR7N6E2LA)
- Saudi Arabia Running Out Of Money: Riyadh To Slash Spending By $27 Billion, Suspend Cost Of Living Allowance
- Empty planes, slashed schedules and no reprieve in sight. The airline industry faces an existential crisis.
- China Unveils Pandemic-Fighting T1-Smart-Glasses That “See” People’s Temperatures In Real-Time
- UFC 249 Ushers in Fan-Free, Mask-Filled Era of Sports
- Musk threatens removing Tesla from California over virus restrictions
- Turkey: Seniors Allowed Outside for First Time Since March
- UK Supreme Court Says Criminal Can’t Be Deported to Country with Worse Healthcare than UK
- French Parents Fear Sending Children Back to School
- Boris Replaces ‘Stay Home’ Slogan with ‘Stay Alert’ Ahead of Lockdown Changes
- American Airlines, Hyatt to Give Free Vacations to Thousands of NYC Health Care Workers
- Queen ‘may NEVER return to frontline duties’: Monarch, 94, could remain quarantined in Windsor ‘indefinitely’ until a vaccine is found
- Prepare for Sex and Dating to Get Even More Complicated Once the Lockdown Lifts
- More than 1,000 queue for food in rich Geneva amid virus shutdown
- Pubs fear disaster after being left out of plans to ease lockdown
- Paris remains deserted as France prepares to lift its lockdown tomorrow and Macron’s poll numbers plummet
- Amid Coronavirus News, Many Need To Step Away
- Vast Majority of Americans Blame China for US death toll from COVID-19 Pandemic
- Employers are adopting measures against the virus. How effective they will be is unclear
- As some national parks begin to open, they too must grapple with social distancing
- NY Gov. Cuomo Reverses Policy: Hospitals can’t discharge coronavirus patients to nursing homes
- Ice cream shop closes day after reopening over harassment from patrons
- 5 people shot at Texas park during crowded, 600-person party
- Cuomo’s nursing home reversal is too little, too late for those now dead
- Colorado restaurant opens on Mother’s Day despite coronavirus restrictions
- Coronavirus has likely killed over 5 percent of NY nursing-home residents
- Al fresco dining may be key to NYC’s restaurants reopening
- Seoul’s nightlife shuttered after super-spreading club-goer linked to 50 cases
- Mystery Brooklyn street barber speaks out, moves to secret location
- No end to lockdown yet but ‘careful’ easing begins, British PM Johnson says
- NYC to use 2,300 ‘social-distancing ambassadors’ amid tension with cops
- 85 NY kids stricken with mysterious coronavirus-linked disease
- Coronavirus couldn’t close Northern California beach — but deadly shark could
- Anthony Fauci in ‘modified quarantine’ after ‘low-risk’ exposure to White House staffer
- CDC head quarantining after exposure to White House staffer with coronavirus
- Needed: Truly independent probe of coronavirus devastation in NY nursing homes
- New York leaders in denial on how badly coronavirus has crashed government revenues
- ‘Reopen NY’ protesters busted outside New York City Hall
- Six Jesuit priests from St. Joseph’s residence in Philadelphia die of COVID-19
- Recovered NYC mom: Coronavirus worse than giving birth five times
- Staffers say NYC nursing home is covering up coronavirus deaths
- China offers to help North Korea fight coronavirus pandemic
- Doctors and nurses in NYC’s coronavirus hot zone rush to draw up wills
- Over 1,000 people line up for free food in Switzerland amid pandemic
- Irish pub delivers beer by drone during coronavirus lockdown
- UK will require international travelers to quarantine for two weeks: report
- Crews stuck on cruise ships during coronavirus pandemic want to go home
- Americans want strict curbs on reopening houses of worship, poll finds
- Arkansas venue plans concert despite state’s coronavirus limits
- Drive-in concerts may be future of live music amid COVID-19
B. Numbers & Trends
Note: All changes noted in this Update are since the 5/10 Update
1. Confirmed Total Cases, New Cases and Tests
- Total Cases = 4,178,154 (+2.0%)
- New Cases = 79,866 (-10.3%) (-9,131)
- New Cases (5 day avg) = 90,727 (-0.3%) (-276)
- Total Cases = 1,367,638 (+1.5%)
- New Cases = 20,329 (-20.4%) (-5,195)
- New Cases (5 day avg) = 26,001 (-3.3%) (-894)
- Number of Tests = 9,444,525
[Note: A recent story in the New York Times citing administration projections of 200,000 cases per day by the end of May appears to be an astonishingly inaccurate report. The number of cases in the US have recently been decreasing, not increasing, and it is hard to imagine circumstances in which the number of cases in the US could increase from 20,000 to 200,000 cases per day over the next few weeks (which would be more than double the current number of worldwide new cases per day).]
- Worldwide Deaths = 283,734 (+1.3%)
- New Deaths = 3,510 (-17.4%) (-738)
- New Deaths (5 day avg) = 5,141 (-8.1%) (-455)
- US Deaths = 80,787 (+0.9%)
- New Deaths = 750 (-47.3%) (-672)
- New Deaths (5 day avg) = 1,703 (-15.8%) (-320)
[Note: A recent story in the New York Times citing administration projections of 3,000 deaths per day by the end of May appears to be an astonishingly inaccurate report. The number of cases in the US have recently been decreasing, not increasing, and it is hard to imagine circumstances in which the number of cases in the US could increase from 750 to 3,000 deaths per day over the next few weeks.]
- 5 Countries with Largest Number of Confirmed Deaths:
|Country||Total Deaths||Deaths Per 1M Population|
- 5 Countries = 69.1% of Worldwide Total Confirmed Deaths (-2.0%)
- US = 28.5% of Worldwide Total Confirmed Deaths (+0.1%)
- 5 States with Largest Number of Confirmed Deaths:
|State||Total Deaths||Deaths Per 1M Population|
|New York||26,812 (+41)||1,378|
|New Jersey||9,264 (+146)||1,043|
- 5 States = 61.2% of US Total Confirmed Deaths (-1.2%)
- NY = 33.2% of US Total Confirmed Deaths (-1.3%)
3. Countries/States To Watch
- Sweden [Note: The WHO has cited the Swedish approach as a model for reopening economies]
- Total Cases = 26,322 (+401)
- Deaths = 3,225 (+5)
- New Deaths (5 day avg) = 74 (-17.4%) (-16)
- Deaths per 1M population = 319
- Below are 5 of the States moving quickly to reopen their economies (and OK never locked down).
|State||Total Cases||Total Deaths||Deaths Per 1M Pop|
|Georgia||33,580 (+926)||1,405 (+4)||132|
|Florida||40,596 (+595)||1,721 (+5)||80|
|Texas||39,890 (+1,248)||1,133 (+22)||39|
|Ohio||24,081 (+384)||1,341 (+10)||115|
|Oklahoma||4,589 (+99)||272 (+2)||69|
|US||1,367,638 (+20,329)||80,787 (+750)||244|
C. Known and Unknown: Vaccines
- Is a vaccine available for the coronavirus?
- No vaccine is currently available. Numerous potential vaccines are being developed. Several have advanced to Phase 2 clinical trials.
- When will a vaccine be available?
- Unknown. Some are hoping that a vaccine will be available on an emergency use basis as early as this fall. President Trump has predicted that a vaccine will be available by the end of this year (2020). Some experts have predicted that a vaccine will not be available for at least 12 to 18 months (to date, 4 years is the fastest that a vaccine has been developed and approved for use). And other experts have warned that an effective vaccine may never be developed (for example, no effective vaccine has ever been developed for the common cold, which is a coronavirus).
- How often will we have to take a vaccine?
- Unknown. While some have expressed the hope that one shot would be sufficient, most experts have said that an annual vaccine shot would probably be required (like an annual flu shot).
- How effective will a vaccine be?
- Unknown. As with a flu shot, a vaccine for coronavirus may not be fully effective for everyone. Even if initially effective, many believe that a vaccine will lose effectiveness as the virus mutates (which is why an annual vaccine shot may be necessary).
- How safe will a vaccine be?
- Unknown. Although vaccines will be tested for safety in clinical trials, they can only identify the short-term side effects of a vaccine (at best). The long term effects of taking a coronavirus vaccine (if any) may not be known for years.
D. New Scientific Findings and Studies
1. Men have high levels of enzyme key to C19 infection
- Men’s blood has higher levels than women’s of a key enzyme used by the new coronavirus to infect cells, the results of a big European study showed on Monday — a finding which may help explain why men are more vulnerable to infection with C19.
- Angiotensin-converting enzyme 2 (ACE2) is found in the heart, kidneys and other organs and it is thought to play a role in how the infection progresses into the lungs.
- The study, published in the European Heart Journal, also found that widely-prescribed drugs called ACE inhibitors or angiotensin receptor blockers (ARBs) did not lead to higher ACE2 concentrations and should therefore not increase the C19 risk for people taking them.
- ACE inhibitors and ARBs are widely prescribed to patients with congestive heart failure, diabetes or kidney disease. The drugs account for billions of dollars in prescription sales worldwide.
- “Our findings do not support the discontinuation of these drugs in C19 patients,” said Adriaan Voors, a professor of cardiology at the University Medical Center (UMC) Groningen in The Netherlands, who co-led the study.
- Death and infection tolls point to men being more likely than women to contract the disease and to suffer severe or critical complications if they do.
- Analysing thousands of men and women, Voors’ team measured ACE2 concentrations in blood samples taken from more than 3,500 heart failure patients from 11 European countries.
- The study had started before the coronavirus pandemic, the researchers said, and so did not include patients with C19.
- But when other research began to point to ACE2 as key to the way the new coronavirus gets into cells, Voors and his team saw important overlaps with their study.
- “When we found that one of the strongest biomarkers, ACE2, was much higher in men than in women, I realized that this had the potential to explain why men were more likely to die from C19 than women,” said Iziah Sama, a doctor at UMC Groningen who co-led the study.
- ACE2 is a receptor on the surface of cells which binds to the new coronavirus and allows it to enter and infect cells.
- Sama and Voors noted that as well as in the lung, ACE2 is found in the heart, kidneys, in tissues lining blood vessels, and in particularly high levels in the testes.
- They said its presence in the testes might partially explain higher ACE2 concentrations in men, and why men are more vulnerable to C19.
E. Concerns & Unknowns
1. Pediatric Inflammatory Condition Possibly Linked to C19
- Six weeks ago, in the relatively early days of the U.S. C19 outbreak, Dr. Veena Goel Jones, a pediatric hospitalist with Palo Alto Medical Foundation in California, treated a six-month-old baby girl for what she calls “classic Kawasaki disease.” The infant had fever, rash and swelling characteristic of the pediatric inflammatory condition.
- Jones, who is also an adjunct clinical assistant professor at the Stanford School of Medicine, and her team also tested the girl for C19, mainly out of hospital protocol—”not necessarily because we felt very strongly like she must have the virus,” Jones says.
- But the girl did test positive for C19, despite never developing a cough and having only minor congestion. Struck by the possible combination of C19 and Kawasaki, Jones and her colleagues published a case report in Hospital Pediatrics last month.
- Now, their clinical experience seems even more noteworthy. Similar reports have since come out of the U.K., Italy, Spain and New York City.
- Fifteen children between the ages of two and 15 were treated for Kawasaki-like inflammatory symptoms in New York City hospitals between April 17 and May 1, according to a recent announcement from the New York City Department of Health. Four tested positive for C19, while six tested negative but had antibodies in their blood that suggested they had recovered from coronavirus. All of the children survived, but half required blood-pressure support and five needed mechanical ventilation, according to the bulletin. [Update: as of 5/10, NYC is now investigating 85 potential cases of the COVID-related inflammatory illness. Three children from NYC have died with these symptoms.]
- “Even though the relationship of this syndrome to C19 is not yet defined…the clinical nature of this virus is such that we are asking all providers to contact us immediately if they see patients who meet the criteria we’ve outlined,” New York City Health Commissioner Dr. Oxiris Barbot said in a statement provided to TIME.
What is Kawasaki disease?
- Kawasaki disease is a rare pediatric inflammatory condition that results in swelling throughout the body’s arteries, including those that lead to the heart. It also affects the lymph nodes, skin and mucous membranes, according to the Mayo Clinic. Early symptoms typically include fever, skin rash, red eyes, cracked lips and swelling; as the disease progresses, symptoms can also include peeling skin, gastrointestinal distress and joint pain.
- About 3,000 cases of Kawasaki disease are diagnosed each year in the U.S., according to the National Organization for Rare Disorders. It predominantly affects children ages five and younger, and is more common among boys than girls.
- If left untreated, Jones says, Kawasaki can lead to serious cardiac complications. But with medical attention, it’s usually easily treated with anti-inflammatory drugs. Jones’ patient broke her fever within a few hours of finishing an infusion of intravenous immunoglobulin, she says.
What’s the relationship between Kawasaki and C19?
- That’s still under investigation. But Dr. Roshni Mathew, Jones’ colleague and a pediatric infectious disease specialist at Stanford’s Lucile Packard Children’s Hospital, says “the general thought is this is a post-infectious trigger causing the immune system to hyper-react.” Infections of any kind can cause inflammation in the body. So it’s possible that SARS-CoV-2, the virus that causes C19, is kickstarting Kawasaki-like inflammatory responses in small numbers of children, she says.
- Some adult C19 patients are also experiencing inflammatory responses, Mathew notes. Many of the most serious lung complications reported among C19 patients tie back to inflammation in the body.
- Like C19, much is unknown about Kawasaki disease. Doctors aren’t totally sure what causes it, Jones says, but many believe it’s triggered by a viral illness. If there is a relationship between SARS-CoV-2 and Kawasaki, “I wouldn’t say that it would be that shocking to us,” Jones says.
2. Can Antibodies Protect Against Future Infection? Maybe. [By Dr. Scott Gottlieb, former FDA commissioner]
- C19 may be here for a long time. As work and activities begin to resume, there will continue to be risk and many new precautions. But for people who were exposed to the virus and recovered, the risk is much lower. Knowing if you had the infection and recovered will soon take on added importance.
- There are two main types of immunity to an infection. Innate immunity comes from circulating cells that attack any invader the body views as foreign. Adaptive immunity is specific to the pathogen presented. Through adaptive response, immune cells are programmed to secrete antibodies that are primed to target a viral invader.
- These antibodies can circulate for a long time and make a person immune to reinfection. Whether people infected with C19 develop lasting immunity hasn’t been established with certainty.
- But it’s clear that infection triggers a strong immune response and the production of neutralizing antibodies. There’s still a lot to learn. But if this virus behaves like others, including other coronaviruses, there’s reason to believe that these antibodies are protective at least for a year or so.
- Evidence suggests that even asymptomatic people infected with C19 mount a robust antibody response. In most parts of the country, exposure may be low, perhaps 5% of the population nationally. But in hot spots like New York, New Orleans and Detroit, the odds of being exposed are much higher. Antibody surveys conducted in New York City in April showed that about 21% of New Yorkers may already have antibodies to C19. By the time the city’s epidemic runs its course through June that number could reach as much as one-third. But how to use evidence of immunity has been a subject of debate.
- First, on whether patients can trust the tests: Determining whether you’ve been exposed to C19 and developed some immunity involves serology tests that screen for the neutralizing antibodies that the body produces in response to the infection. Initially, the FDA allowed these serology tests to enter the U.S. without review because they weren’t classified as diagnostic. Dozens of tests from China flooded the market, many of questionable quality and accuracy.
- Recently, reputable manufacturers entered the market with good tests that they asked the FDA to evaluate. The National Cancer Institute has been reviewing these tests to confirm accuracy, and sharing the results. Because there are now reliable tests authorized by FDA, such as the blood test from Quest or the panels from Roche and Abbott, last week the agency gave other tests 10 days to submit data proving their accuracy or face removal from the market.
- While all of these tests can still generate false positives—a finding that you have the antibodies when you don’t—that risk can be sharply reduced by repeating the test if it comes back positive. The predictive value of two consecutive positive tests is high enough that you can be confident antibodies are present.
- There are concerns about privacy. In Chile, Germany and the U.K., researchers and politicians have floated the concept of giving residents “immunity passports” that would allow people who have recovered from C19, and have antibodies, to be exempt from restrictive measures or deployed to jobs. It’s hard to imagine immunity being used to segregate people in America.
- There may be ways to incorporate evidence of immunity into a person’s overall health that can be used to guide what precautions should be taken on the job and in personal lives. As states start to relax restrictions on economic and social activity, antibody test results can be helpful in assessing the risk of certain activities.
- Health-assessment software such as CareEvolution’s “Safer Covid” tool can combine multiple health factors to evaluate a person’s total risk of contracting C19 or suffering a bad outcome. Such a “risk score” could at some point soon include antibody results and help inform decisions about behavior. How much information fed into these tools is up to the person using them. Americans can decide their own comfort level with offering personal health data. Similar tools already assess the risk of, say, stroke or diabetes.
- There’s instinctual discomfort about using evidence of past immunity as a factor for decisions about health, work or even questions like whether it’s safe to visit someone in a nursing home. But there are ways to deploy immunity information to help us understand our own health status and keep us safer from C19, without surrendering privacy.
1. Dangers of Ventilators Causing Doctors to Change Treatment of Low Blood Oxygen Levels
- It is another medical mystery of the coronavirus pandemic: Large numbers of C19 patients arrive at hospitals with blood-oxygen levels so low they should be unconscious or on the verge of organ failure. Instead they are awake, talking—not struggling to breathe.
- Although nobody is quite sure what about the coronavirus causes these patients to react this way, they are rapidly changing how many doctors are treating the disease. Instead of rushing to put such patients on mechanical ventilators for fear of them suddenly getting worse and dying, some doctors are now holding off on the invasive treatment, believing that many of these patients will do just fine without them.
- Pre-C19, doctors looking to boost a patient’s blood-oxygen levels would often turn first to less invasive methods of support such as CPAP or BiPAP machines that push air into a patient’s airway through a face mask, or high-flow nasal cannulas—prongs that blow heated, humidified oxygen into a patient’s nostrils. If that didn’t work, physicians would use mechanical ventilators.
- But people with C19 began showing up at the hospital with rarely seen, ultra-low blood-oxygen levels. Even for those who weren’t struggling to breathe, doctors were concerned that patients’ conditions could suddenly worsen, which with C19 could swiftly turn deadly. So they often intubated sooner.
- “In the past, you’d see these kinds of oxygen levels, and your brain would intuit all these other things,” said Scott Weingart, chief of emergency critical care in the department of emergency medicine at Stony Brook Hospital in Stony Brook, N.Y. “For instance, you’d assume the patient’s lungs must be so bad that if we don’t intubate now, they might crap out.”
- Doctors have dubbed these patients “happy hypoxemics,” a reference to the paradox of abnormally low levels of oxygen found in their blood combined with an ability to breathe relatively easily. In recent weeks, doctors at Stony Brook Hospital have used ventilators less on these patients, turning instead to the CPAP or BiPAP machines or high-flow nasal cannulas.
- Dr. Weingart remembers one of his first such patients in March—a 42-year-old man with blood-oxygen levels so low he should have been unconscious. Instead, he was sitting up, smiling and talking. He was breathing quickly, but seemed fine otherwise.
- Dr. Weingart and his team used a high-flow nasal cannula to boost the patient’s oxygen levels. They also turned him on his front, a method known as “prone positioning” that doctors have found can also help boost oxygen levels partly by reducing the pressure of the heart and diaphragm on the lungs. The patient was never put on a ventilator and was discharged in a week, Dr. Weingart said.
- Several other doctors said they are having success with such simpler approaches. That, in turn, is reducing demand for ventilators—a critical concern early in the crisis—and easing strain on hospital staff, they say.
- Abdul Khan, medical director for Ochsner Medical Center’s West Bank intensive care unit in Gretna, La., has also encountered these so-called “happy hypoxemic” C19 patients.
- “We’ve learned that they are able to tolerate these lower levels of oxygen for a significant period of time,” he said. Dr. Khan and his colleagues now use ventilators as a last resort for such patients.
- Mechanical ventilators help people breathe when they can’t on their own. A tube is inserted through the nose or mouth into their trachea. The tube is connected to the ventilator, which pushes a mix of air and oxygen into patients’ lungs. The ventilator can also apply a constant amount of low pressure that helps keep air sacs in the lung from collapsing.
- Ventilators play an important part in care, but there are serious risks to being on one for too long. Patients can get secondary infections like bacterial pneumonia. They can get urinary tract infections from being bed-bound and are at higher risk of kidney failure and getting blood clots. If the ventilator isn’t set properly, patients can sustain lung injury.
- Recently published data also suggest ventilators may not be as effective at keeping seriously ill C19 patients alive as they are with other patients with severe respiratory problems.
- In the U.K., 58.8% of C19 patients on invasive breathing support had died as of May 7, according to data from the country’s National Health Service. That compares with a 34.5% death rate among patients with other types of viral pneumonia who receive invasive breathing support, according to historic data. Of the C19 patients placed on basic breathing support, 17.8% died.
- In New York, 88% of 320 C19 patients placed on mechanical ventilation in the state’s Northwell Health System died, according to a study in the Journal of the American Medical Association. Of the 2,314 who didn’t receive mechanical ventilation, 11.7% died.
- Experts note that the studies may at least partly reflect that C19 patients who start ventilation tend to be the sickest, and therefore the least likely to survive.
[NOTE: We’ve highlighted the dangers arising from C19 related hypoxia in prior Updates. As people can reach dangerously low blood oxygen levels without knowing that they are in danger, we continue to recommend buying a pulse oximeter (found on Amazon here). A pulse ox (it’s the little device that doctors put on your finger) measures your blood-oxygen levels and can provide an early warning of decreases in your blood oxygen, which can lead to earlier medical intervention and a better health outcome (including a reduction in the risk of being put on a ventilator).]
G. Lockdown vs. Reopening
1. Take the Shutdown Skeptics Seriously
- Should states ease pandemic restrictions or extend lockdowns and shelter-in-place orders into the summer? That question confronts leaders across the United States. President Trump says that “we have to get our country open.” And many governors are moving quickly in that direction.
- Critics are dismayed. Citing forecasts that C19 deaths could rise to 3,000 per day in June, they say that reopening without better defenses against infections is reckless. That assessment may well be correct. Many insist it is immoral, too. The columnist Amy Z. Quinn says the Trump administration is “choosing money over lives.” In a CNN news analysis, Daniel Burke offers this characterization of America’s choice: “Should we reopen the economy to help the majority or protect the lives of the vulnerable?”
- Denunciations of that sort cast the lockdown debate as a straightforward battle between a pro-human and a pro-economy camp. But the actual trade-offs are not straightforward. Set aside “flattening the curve,” which will continue to make sense. Are ongoing, onerous shutdowns warranted beyond what is necessary to avoid overwhelming ambulances, hospitals, and morgues?
- The answer depends in part on an unknown: How close the country is to containing the virus.
- “The public, the media, the business community, and policymakers are largely unprepared for a pessimistic scenario,” the Foundation for Research on Equal Opportunity argued in a recent white paper. That is, the U.S. may have no treatment, no vaccine, and no ability to scale up testing and quarantining, due to technical hurdles or incompetence or a lack of public buy-in.
- If we knew that a broadly effective C19 treatment was imminent, or that a working vaccine was months away, minimizing infections through social distancing until that moment would be the right course. At the other extreme, if we will never have an effective treatment or vaccine and most everyone will get infected eventually, then the costs of social distancing are untenable. We don’t know where we sit on that spectrum. So we cannot know what the best way forward is even if we place the highest possible value on preserving life and protecting the vulnerable.
- That uncertainty means, at the very least, that Americans should carefully consider the potential costs of prolonged shutdowns lest they cause more deaths or harm to the vulnerable than they spare.
- Ongoing closures and supply-chain interruptions in wealthier countries could have catastrophic ripple effects, Michael T. Klare warns in The Nation, highlighting the possibility that global starvation could soar. “Even where supply chains remain intact, many poor countries lack the funds to pay for imported food,” he explained. “This has long been a problem for the least-developed countries, which often depend on international food aid … It is becoming even more severe as the number of people without jobs multiplies and donor countries balk at higher aid expenditures.” His article wasn’t a brief for reopening the economy, but it implied a need to guard against shutdowns that cause more deaths via starvation than are saved by slowing infections.
- “A prolonged depression will stunt lives as surely as any viral epidemic, and its toll will not be confined to the elderly,” Heather Mac Donald argues at Spectator USA. “The shuttering of auto manufacturing plants led to an 85% increase in opioid overdose deaths in the surrounding counties over seven years, according to a recent study.” Deficit spending may be necessary to keep people afloat, she continued, but the wealth that permits it could quickly evaporate. “The enormously complex web of trade, once killed, cannot be brought back to life by government stimulus. And who is going to pay for all that deficit spending as businesses close and tax revenues disappear?”
- At Arc Digital, Esther O’Reilly asks, “Why should we assume that a crashing economy would leave the healthcare system standing?” Fleshing out the matter, she writes, “You can’t keep the hospital lights on without keeping on the lights of the economic sectors undergirding it. Yes, our doctors and nurses are running out of masks and gloves, which is a serious problem. It would also be a serious problem if we lost the means and the manpower to make more, or if the hospitals ran out of cash on hand to buy more beds, ventilators, etc. And there’s the rub. We are being told we can’t fight the virus without pausing the economy, yet we can’t fight the virus without the economy.”
- School closures may do long-term damage, as well. A recent study in The Lancet concluded that “the evidence for the effectiveness of school closures and other school social distancing measures comes almost entirely from influenza outbreaks,” and that the effectiveness of school measures in a coronavirus outbreak is uncertain. Another article in The Lancet noted that “education is one of the strongest predictors of the health and the wealth of a country’s future workers, and the impact of long-term school closure on educational outcomes, future earnings, the health of young people, and future national productivity has not been quantified.” A given closure could add months to the lives of some and subtract from the lives of others.
- The general point is that minimizing the number of C19 deaths today or a month from now or six months from now may or may not minimize the human costs of the pandemic when the full spectrum of human consequences is considered. The last global depression created conditions for a catastrophic world war that killed roughly 75 to 80 million people. Is that a possibility? The downside risks and costs of every approach are real, frightening, and depressing, no matter how little one thinks of reopening now.
- These facts may not be evident from the least thoughtful proponents of reopening, many of whom advance arguments that are uninformed, dismissive of experts, or callous. But the warnings of thoughtful shutdown skeptics warrant careful study, not stigma rooted in the false pretense that they don’t have any plausible concerns or value human life.
2. Is Relockdown in Germany’s Future?
[NOTE: Germany is using the reproduction or transmission rate of the coronavirus (commonly referred to as “R0” or “R-naught”) as the benchmark by which to measure whether a lockdown should be reimposed on the country. Chancellor Merkel has previously stated that a lockdown would have to be reimposed if R0 exceeds 1.2.]
- Germany’s coronavirus infection quota has jumped beyond one, just days after federal and regional authorities eased restraints. Keeping the patient ‘reproduction rate’ down is decisive, say epidemiologists
- The coronavirus reproduction rate in Germany rose to 1.1, scientists announced on Saturday after Germany loosened many of its restrictions.
- That rate, which assumes statistical lag in data delivered, is the key measure used by Germany’s pandemic overseer, the Robert Koch Institute (RKI) based in Berlin.
- On Wednesday, as Chancellor Angela Merkel and state premiers announced the easing of social distancing coupled with wearing masks, the rate was 0.65.
- Saturday’s figure meant that one patient infects at least one other. The rise made it necessary to “watch the development very carefully in the next days,” said the RKI.
- Its overall figures for Saturday documented 169,551 confirmed cases of infection (1,251 more than Friday), 7,369 deaths since early March, and 143,300 persons declared recovered.
- Again topping infection data were Germany’s southern states Baden-Württemberg and Bavaria and the northern city-state of Hamburg.
- Warning that C19 remained a potentially fatal infection, the RKI said patients occupied 19,732 beds — 1,650 in intensive care — with another 12,096 beds ready in reserve at 1,226 clinics across the nation.
H. Spring Forward or Lag Behind?
1. U.S. cities best and worst positioned to bounce back
- Moody’s Analytics analyzed U.S. metro areas capabilities for a strong recovery post-coronavirus using two primary factors: population density and educational attainment.
- “The most dynamic recoveries may well bypass traditional powerhouses and take place instead in areas that [weren’t] poised to lead the way in 2020 before everything changed,” wrote Adam Kamins, senior regional economist at Moody’s Analytics.
- The report examined the top 100 metro areas in the U.S. The metros poised to recover quickly based on the analysis included San Jose, California; Durham, North Carolina; Austin, Texas; Seattle; and Minneapolis.
Recovery will depend on population density
- Kamins believed that the twin factors of low population density and educational attainment were going to boost these metro areas.
- “A key difference between this recovery and the last recovery is the population density,” he explained. “It’s going to have a different effect this time than it did last time.”
- During the Global Financial Crisis, “the first places out of the recession were big densely populated global cities,” he explained. But this time, depending on the duration and the eventual outcome of the COVID-19 outbreak, Kamins believed that “big densely populated cities … are going to be viewed as inherently risky.”
- So “some of the places that we’re really looking at now would be places that have high degrees of educational attainment but are lower density … [that] have grown very, very well over the last five or six years in particular, are pretty well positioned coming out of this whenever we do,” he said.
Cities best positioned for a recovery
- Economies built around a major university, such as Durham, North Carolina, and Madison, Wisconsin, “could enjoy a surge in growth in the years to come,” Kamins wrote in his report.
- At the same time, with the coronavirus pandemic putting pressure on colleges’ finances and with enrollment dropping, could that reliable ingredient to the recovery recipe be in peril?
- “You could see possibly where we get in a situation four or five years down the road where the pool of available first year workers that have recently graduated colleges is less than usual,” Kamins said. But “there’s just hope at that point you’re in a recovery or expansion anyway, and it just creates more labor market tightness, especially at the entry level.”
- Denver, Salt Lake City, and Washington D.C. were also noted as positioned for a relatively quick recovery. D.C. in particular was an interesting case, Kamins explained: “That’s one where I think that was more a function of just as population density being a lot lower than other kind of Northeastern cities.”
- Two cities that surprised him were Des Moines, Iowa, and Omaha, Nebraska.
- “They’re not places that you think of as sort of prestigious economies — they’re somewhat isolated in terms of where they are relative to the rest of the U.S.,” Kamins said. “But both of those actually have a pretty strong financial services sector, a fairly well educated population, especially compared to the kind of surrounding regions at lots of opportunity to kind of spread out.”
- And especially if the trade war with China “recedes from memory under a new administration,” the farm sectors in those cities could be poised to benefit well.
Most vulnerable cities
- On the flip side, cities facing headwinds on the road to recovery are the names we are most familiar with, Kamins wrote.
- For instance, “New York City’s greatest asset is a large, skilled workforce that is drawn to the fast-paced and highly interactive nature of life in the Big Apple,” he explained. “But activities such as riding the subway, dining in crowded restaurants, and attending Broadway shows may be viewed as inherently risky for some time, consistent with the city’s status as the single-most economically exposed metro area or division.”
- Boston, Miami, Las Vegas, and San Francisco could also see some tough challenges ahead. These cities generally appear below the line and lean towards the bottom right in the map above.
- “Places like San Francisco, Miami, are very high on the list,” Kamins said, adding that tourist hotspots like Las Vegas were also in this group because its economy “is almost completely shuttered right now and will be for some time as both leisure travel and business travel dry out.”
- And while big cities are likely to be able to eventually recover, out-migration may pick up, Kamins added, “the generation that is growing up today could remember the impact of the COVID-19 pandemic … [and eventually] opt for less densely packed pastures in the decades to come.”
- Would this sort of financial pressure lead some states or cities to opt for a bankruptcy route? Kamins said that it was too soon to tell, but there were signs to watch.
- “What we would be looking for would be states where the impact is going to be very severe,” he explained.
- For instance, “a state like Illinois … has above average exposure, because Chicago [has] … densely populated urban characteristics,” Kamins said. “And the fiscal situation for that state [will be] extremely problematic.”
I. Play Ball!?
1. Major League Baseball Antibody Test Results Are Surprising
- Major League Baseball is on the verge of finalizing a plan to begin the 2020 regular season during the coronavirus pandemic, but well before that was a possibility, the league delved further into the spread of the disease. Last month, to figure out exactly how widespread the coronavirus had already become in their community, the league agreed to participate in a nationwide COVID-19 antibody test, run by Dr. Jay Bhattacharya, a professor of medicine at the University of Stanford.
- The results came in on Sunday, and it revealed that only 39 of the 5,603 participants in the study tested positive for coronavirus antibodies, which accounts for only 0.7% of the league. Additionally, the MLB mortality rate sits as 0%.
- “I was expecting a larger number,” said Dr. Bhattacharya, via ESPN. “It shows the value of doing the science as opposed to guessing.”
- These results are surprising, because Bhattacharya and other medical experts believed that they would receive similar numbers as California’s antibody tests in Los Angeles and Santa Clara Counties, proving that the disease had been more widespread across a random sample of citizens, both at Spring Training sites and in MLB host cities.
- One of the possible reasons for the low numbers is the prevalence of white-collar individuals who took part in the study, as opposed to those in poorer parts of the United States. Additionally, those in MLB who participated in the test can work from home, which obviously reduces their chances of contracting COVID-19. [NOTE: We would add highly motivated, high-paid athletes who were in the middle of spring training when the shutdown occurred. MLP players have been anticipating a return to baseball during the summer and may have been more motivated to maintain strict social distancing.]
- This is good news, in some aspects (a low infection rate is, of course, preferred), but it’s worrisome that this random sample of employees is nowhere close to a semblance of herd immunity.
- Regardless, the league is prepared to begin their negotiations with the players union about a possible start date for the 2020 season. Ideally, that vital next step goes smoothly.