Must read – at least in terms of very well written and its Gates – https://www.gatesnotes.com/Health/Pandemic-Innovation?WT.mc_id=20200423090000_Pandemic-Innovation_BG-FB_&WT.tsrc=BGFB

Certainly some scary issues for third world places – “If you live in an urban slum and do informal work to earn enough to feed your family every day, you won’t find it easy to avoid contact with other people. Also, the health systems in these countries have far less capacity, so even providing oxygen treatment to everyone who needs it will be difficult.

Tragically, it is possible that the total deaths in developing countries will be far higher than in developed countries.”

He acknowledges there are SOME seasonal aspects given – “Almost all respiratory viruses (a group that includes COVID-19) are seasonal… we already know the virus is not as seasonal as influenza is.”

He leads with the Gilead drug – “For the novel coronavirus, the leading drug candidate in this category is Remdesivir from Gilead, which is in trials now. It was created for Ebola. If it proves to have benefits, then the manufacturing will have to be scaled up dramatically.”

His notes on HCQ – “Another class of drugs works by changing how the human body reacts to the virus. Hydroxychloroquine is in this group. The foundation is funding a trial that will give an indication of whether it works on COVID-19 by the end of May. It appears the benefits will be modest at best.”

I am thankful he did not mention the VA study that was released and noted in over 6+ reports I have read since last night. For clarity that was not a clinical study – but a MATH study matching past historical data to create various groups. Think about this you pull from a set of data not knowing any conversations with patients and you want a group that took NO drugs – what do you think the chances that group was doing relatively better than the rest of the group? There were no list of symptoms for each patient in the table they presented. A little journalistic dig would find this hole and not perpetuate that study.

Sad fact –“the typical development time for a vaccine against a new disease is over five years. This is broken down into: a) making the candidate vaccine; b) testing it in animals; c) safety testing in small numbers of people (this is known as phase 1); d) safety and efficacy testing in medium numbers (phase 2); e) safety and efficacy testing in large numbers (phase 3); and f) final regulatory approval and building manufacturing while registering the vaccine in every country.”

“I am often asked when large-scale vaccination will start. Like America’s top public health officials, I say that it is likely to be 18 months, even though it could be as short as nine months or closer to two years. A key piece will be the length of the phase 3 trial, which is where the full safety and efficacy are determined.”

He agrees with me but did not market it to get approval by regulators – we need “SMART” testing – not just testing!– “…South Korea, did a great job of ramping up the testing capacity. But the number of tests alone doesn’t show whether they are being used effectively. You also have to make sure you are prioritizing the testing on the right people. For example, health care workers should be able to get an immediate indication of whether they are infected so they know whether to keep working. People without symptoms should not be tested until we have enough tests for everyone with symptoms. Additionally, the results from the test should come back in less than 24 hours so you quickly know whether to continue isolating yourself and quarantining the people who live with you. In the United States, it was taking over seven days in some locations to get test results, which reduces their value dramatically. This kind of delay is unacceptable.”

“You want to have so much testing going on that you see hot spots and are able to intervene by changing policy before the numbers get large. You don’t want to wait until the hospitals start to fill up and the number of deaths goes up.”

Go talk to S. Korea and lets do this….

“China and South Korea, required patients to turn over information about where they have been in the last 14 days by looking at GPS information on their phone or their spending records. It is unlikely that Western countries will require this. There are applications you can download that will help you remember where you have been; if you ever test positive, then you can voluntarily review the history or choose to share it with whoever interviews you about your contacts.”

I know for a fact the data is there to do this in the US. IF this not worthy of homeland work I don’t know what is….Also can obtain this data from all those “free” apps.

Agree there is no going back to normal for awhile as there will always be a group that will be permanently effected by this and will change their behavior for a very long time. “Some people will be naturally reluctant to go out even once the government says it is okay. Others will take the opposite view—they will assume that the government is being overly cautious and start bucking the rules.”

Remember the big attack on Santa Clara study showing the virus is 4X more than reported number – and then the LA county study – KY county study – no we have Miami Dade county study also showing similar result – https://www.miamidade.gov/releases/2020-04-24-sample-testing-results.asp

“Using statistical methods that account for the limitations of the test (sensitivity and specificity), we are 95% certain that the true amount of infection lies between 4.4% and 7.9% of the population, or between 123,000 and 221,000 residents. These results are similar but not identical to other recent, non-randomized testing programs that have been conducted throughout the United States.”

The cat is out of the bag. Test more only to test what is out there not necessarily spreading is one potential outcome. In terms of public panic we shouldn’t be over alarmed the confirmation continues to rise. The focus probably should be on deaths. Can we keep those who are vulnerable safe?

Another study from Washington nursing shows even more alarming figures – https://www.nejm.org/doi/full/10.1056/NEJMoa2008457?query=featured_coronavirus

“More than half of residents with positive test results were asymptomatic at the time of testing and most likely contributed to transmission. Infection-control strategies focused solely on symptomatic residents were not sufficient to prevent transmission after SARS-CoV-2 introduction into this facility.”

“57 of 89 residents (64%) tested positive for SARS-CoV-2. Among 76 residents who participated in point-prevalence surveys, 48 (63%) tested positive. Of these 48 residents, 27 (56%) were asymptomatic at the time of testing; 24 subsequently developed symptoms (median time to onset, 4 days). Samples from these 24 presymptomatic residents had a median rRT-PCR cycle threshold value of 23.1, and viable virus was recovered from 17 residents. As of April 3, of the 57 residents with SARS-CoV-2 infection, 11 had been hospitalized (3 in the intensive care unit) and 15 had died (mortality, 26%).

They did note some caution not to extrapolate this data to the general population which I suspect the media might not translate given it lessens the fear – “because this analysis was conducted among residents of a skilled nursing facility, it is not known whether the findings apply to the general population, including younger persons, those without underlying medical conditions, or similarly aged populations in the general community or in other long-term care settings.”

They politely said that the facility could have been run much better “We estimated that the doubling time in this facility was 3.4 days, which is faster than that of the surrounding community, 5.5 days. The accelerated doubling time was likely to have been due to inadequately controlled intrafacility transmission, which sequencing and spatiotemporal data suggest was the primary driver of new infections”

Nursing facilities for sure should follow the recommendation – “Our data suggest that symptom-based strategies for identifying residents with SARS-CoV-2 are insufficient for preventing transmission in skilled nursing facilities. Once SARS-CoV-2 has been introduced, additional strategies should be implemented to prevent further transmission, including use of recommended personal protective equipment, when available, during all resident care activities regardless of symptoms.5 Consideration should be given to test-based strategies for identifying residents and staff with SARS-CoV-2 infection for the purpose of excluding infected staff and cohorting residents, either in designated units within a facility or in a separate facility designated for residents with Covid-19.”

Last topic before delving into the numbers and tying the concept the virus is prevalent – what is interesting is to go back in time and note that history doesn’t necessarily repeat itself but many times show similarity. Below is the graph of the 1918 flu in several places. Note the humps – 3. Note the timeline – summer to winter lull.

If our focus was to flatten the curve AND we have somewhat resemblance of the above – we flatten the easy curve. I have been a skeptic of Sweden approach https://www.bbc.com/news/world-europe-52395866?

But they could be right as they could be playing the LONG game and the rest of us are focus on the SHORT game. In terms of business strategy this is about seeing the bigger picture and not dealing with the day to day issues. One of the best focused on the LONG game is Elon Musk – https://twitter.com/thirdrowtesla/status/1253548213144965120

Amazing how he traversed all the naysayers and revolutionized something that was not possible by almost ALL – but it’s the focus on the LONG game.

Could Sweden approach look poorly in the beginning but only be the right approach when viewed on a long enough timeline. Fill up the hospital now keep it at a constant rate so the 2nd and 3rd hump are manageable?

Resource planning requires a LONG game approach knowing you could look like a fool for a decade only to be right the next 2-4 decades as you are dealing with 40-60 year assets. With this historical context I can appreciate their approach. I still think the “SMART”quarantine is the right approach given the risk/reward. Could I be wrong and that we “sacrifice” too many in the beginning WHEN it seemed it could be prevented easily for the next few months IF we just isolate —- OR if we can appreciate a historical movement that could cause an extreme spike this winter because we weren’t able to find a cure/vaccine and that the quarantine had wholes and people were able to keep it hosted and it came back this winter. I guess this no different when a commander makes a bet to attack and sacrifice his men for the greater good. I am not in that position but God help those who have to make that decision. This decision of how we quarantine could be the big war time decision.

If Sweden could apply SMART quarantine they should see a drop a drop in mortality rate. It is unfortunate they are under 1% per capita tested so their mortality rate is tough to understand. IF Europe countries had county data then the 1% could be right as it could be focused on the hot spots which could perhaps be over 2% in that county. As a country level they are still showing similar numbers from Spain, Italy, UK, France.

SMART quarantine is a compromise approach where we take the data we know on what causes covid-19 patients to be hospitalized go to ICU then eventually death. Play the probability game and find those issues – and test for those given the testing for those are easy and well known (Diabetes, Heart Issues, Obesity, Immune issues). Quarantine that subset. Slowly phase in by age group not in those categories. Just like any flu – if you show symptoms stay home – this reduces viral load. Managing the viral load in areas is the key. Take advantage of the virus ability to spread – but spread in small quantity which then allows many to build defenses in managed level.

Obviously continue to wash hands wear mask etc… all these things reduce viral load and help you body not have other agents to deal with so when you do get the virus your body is ready for it. A more controversial but the data shows during this period we should revamp the food availability and reduce process food – reduce inflammation food from the system. We need our strength to fight this virus.

US numbers came back down under 2000 new deaths. The rest of the world new deaths has been quite tamed. UK 776

NY confirmation bounced back likely fixing the 0 reported yesterday. NY positive/tested still coming down. At some point I can get an estimate of death similar to the Italy exercise done.

Sad this is a nice chart given the historical charts – NJ and MA 2nd and 3rd

Ecuador is in the early stage of testing – hence big spike in confirmation/tested

Good news NY big drop and NJ seems to be stabilizing. France, Italy, Spain, Belgium, Austria, UK, all trending down. Brazil, IL,MA, even Sweden are somewhat concerning. Ireland looks to just have spiked up so that’s a country to watch.