A very good write up for sure – covering an important topic of viral load and spreading of the virus – https://erinbromage.wixsite.com/covid19/post/the-risks-know-them-avoid-them

“There are very few states that have demonstrated a sustained decline in numbers of new infections. Indeed, the majority are still increasing and reopening. As a simple example of the USA trend, when you take out the data from New York and just look at the rest of the USA, daily case numbers are increasing. Bottom line: the only reason the total USA new case numbers look flat right now is because the New York City epidemic was so large and now it is being contained.”

Not necessarily sold on that statement because the big issue is the states connected to NY through rail and commuters. If we exclude NJ, CT, MA, and PA (growing/plateau states) then we do see a flattening of the increase of DEATHS in fact a decline in the trend. I know her focus is on spread mitigation hence confirmation – but I am not sold on viewing confirmation. Confirmation is important to mitigate – but our economic closure was driven because of deaths and the overwhelming of the ICU leading to doctors choosing who lives or dies. It is reasonable to say that we will accept confirmation of the virus as long as it does not lead to death/ICU visits. Therefore death becomes the ultimate metric. Also viewing death vs. confirmation will take into account new ways of treatments and the overall health of the nation as asymptomatic carriers should not be a concern – as we wish we all could be that.

Death Chart – excluding NY, CT, MA, and PA.

If we look at the states announcing openings – the only 1 with real concern is IL.

Removing IL you can see an actual decline trend – certainly not necessarily sustained as Erin alludes to.

Viral load has always been a key focus for me and she does a great job highlighting various cases – however no studies have yet confirmed the level of viral load for covid-19 that would lead to infection. Hypothesis would be it is less than SARS. In her example she notes SARS infection level of 1000. Ideally you want to get covid-19 but at a level the body can defend and keep up with to build the antibody.

“A Toilet flush: Without a seat to close, a single flush releases ~8000 droplets into the air.”

Do you want to know what else is bad in the bathrooms – those environmentally no paper waste air dryers! They stir up the room immediately spreading all the gunk all around in the facility. They have huge intake air and spray it out. I always hate using them….

“The biggest outbreaks are in prisons, religious ceremonies, and workplaces, such a meat packing facilities and call centers.”

Once again focused on containment and spreading of disease not the end issue of death as each of those examples above death numbers are really low. Interesting on the meat packing stats – (obviously I am against this type of trade) – but the numbers are interesting. There are 248K meat plant workers in the industry. 45 deaths – average of meat plant worker 40 yr old. 80% of deaths are over age 60! https://datausa.io/profile/soc/butchers-other-meat-poultry-fish-processing-workers

Over 10K confirmed…..so we have a fatality rate of 0.5% ….not older than 60 fatality rate of 0.1%. Currently an infection rate of 4% within just the worker community – clearly family members are being impacted – https://www.usatoday.com/story/news/investigations/2020/05/06/meatpacking-industry-hits-grim-milestone-10-000-coronavirus-cases/5176342002/

She did note my two favorite studies so far the Chinese restaurant and the Korean building – both highlight the virus is contagious but at the same time focused (reviewed in previous morning notes). Not so contagious that you can get it from an elevator ride or just because you are in a room with a person – because if you are seated on the other side with no ventilation crossing – you will be fine.

However her whole focus is not getting it – which might be a noble cause – but similar to the cold and flu the odds of never getting it will likely be small.

The next big press was the release of the secret Manhattan group report focus on solving this crisis – https://www.wsj.com/articles/the-secret-group-of-scientists-and-billionaires-pushing-trump-on-a-covid-19-plan-11587998993?mod=e2fb

You can download the report from there https://s.wsj.net/public/resources/documents/Scientists_to_Stop_COVID19_2020_04_23_FINAL.pdf . One big takeaway they discuss WAVES in terms of implementation plan – but at the same time they do allude to the wave of infection. It would seem they also agree there will be a second wave of infection. AS noted before IF you believe that your plan of action is different vs. if there is only 1 wave.

Their first wave is repurposing existing drugs – they do note even though they note Remdesivir the process they talk about applies to any drug.

“Many of our suggestions, while presented for remdesivir, are also applicable to other drug candidates.”

Nonetheless it is the highlighted drug they are expecting to be the first wave implemented. Once again they do note what I have been saying remdesivir is an IV administered drug not a pill and has note been tested on a coronavirus – most of the efficacy came from Ebola.

“The drug is given intravenously, and the initial dose is 200 mg followed by 100 mg for 5-10 days. We believe this dose may be too low and treatment should be administered earlier in symptomatic patients.”

Does this mean double the cost? Already at $1000 a dose. They also note this drug is used for early stages not late stage.

“Remdesivir has already been shown to be safe in humans. In a trial of Ebola patients described in 2019, remdesivir did not show any noted toxicity.”

I bet this is not millions of people we are talking about in terms of sampling of safety. I know they call called phase 1 repurposed drug – remdesivir in my mind is not really officially a drug that treated anything yet – it was still in trials for Ebola.

The second wave was focused on antibody therapies. In this section they pinpoint regulations that need to be removed in order to get this therapy to market faster. Their timeline notes a release in August-Sept 2020 time period.

The third wavy they focus on vaccine development.

The last section they talk about opening up society – with their recommendation of daily app one must use each morning and submit your symptoms – eerie I think there is a movie like this?

“All employees and students must certify (via smartphone app), before leaving home, that they are not experiencing enough of the following COVID-19 symptoms”

All my concerns are quickly at ease once they note no individual judgement will be made – a centralized algorithm will take care of it all.

“These data emphasize the importance of respondents giving accurate answers to survey questions and using centralized algorithms, rather than individual judgment, to make decisions about who can engage in work and school activities.”

PCR testing values they note are quite bad –

“case of tests performed on close-contact cohorts, throat-swab PCR was found to have a false-negative rate of 28.7% after one sample, reduced to 7.8% with a second sample at a later time. Another study found that China’s national PCR test had a false-negative rate of 34%.”

For sure agree with this statement:

“Nasopharyngeal or throat-swab PCR sampling is too invasive and demanding for regular mass testing.”

Also support the following statement:

“Current protocol in many states allows only symptomatic individuals to be tested, requires that orders for testing come from a physician or healthcare worker, and requires that tests are administered by a healthcare professional. Such policies are incompatible with large-scale testing, and have contributed to our inability to estimate asymptomatic individuals, those with mild symptoms, or those who do not seek care—all of whom are capable of transmitting the virus. To reopen our society and to keep it open, virus testing must be dramatically expanded to include these critical segments of the population. Because healthcare systems have limited capacity to provide expanded testing while also caring for ill people, requirements for ordering and administering virus tests must be substantially relaxed so that testing of asymptomatic citizens can be greatly expanded and decentralized.”

“…Business or school officials can be trained and certified at qualified institutions and laboratories to administer nasal, throat, or saliva sample collection.”

This one will be tricky to implement – even for those already recovered?

“We recommend that wearing PPE throughout the work or school day become a requirement. Multiple studies have shown that the single most effective piece of PPE is a face mask or respirator. For the general public, we recommend surgical-style masks, with simple training on their use.”

After a discussion with antibody test – they end the letter with

“Finally, we note the danger of strongly associating a positive antibody test with the right to return to school or to work. Plans to reopen our workplaces and schools must avoid the moral hazard of creating a perverse incentive to purposefully increase one’s risk of exposure to the SARS-CoV-2 virus in order to increase the chance of being able to return to studies or professional work.”

I guess the whole write up and theme in their big quest is this virus is worse than anything we have seen before. The possibility of getting it is much more deadly even if you are young and healthy. However at some point we will get enough information to conclude if this is the case. IF – which we all should hope – this virus ends up being the most nasty flu virus but no more particular to the young – perhaps some of their strategy changes? I wish they started off with what their premise was in terms of what this virus is expected to do.

The next read I would recommend is the latest study on HCQ – https://www.nejm.org/doi/full/10.1056/NEJMoa2012410?query=main_nav_lg

This is once again not direct study but a data collection and sampling study similar to the VA – no interviews were made – they did have dosage data here and covered 1446 patients. Unlike the VA study they did not conclude more deaths because of HCQ.

“In this analysis involving a large sample of consecutive patients who had been hospitalized with Covid-19, the risk of intubation or death was not significantly higher or lower among patients who received hydroxychloroquine than among those who did not”

It was very neutral conclusion – they did not do what most of the doctors that are observing positive results which is a zinc supplement on top of the HCQ dosage. I think perspective of this drug not doing any harm is the key – whether it can help for certain it is not scientifically confirmed. Perhaps it is a long shot – but it is a very cheap long shot and you get anti-malarial benefits with the benefit knowing millions of people have taken HCQ without much issue.

Another data request would be to get the deaths by age on a national basis – currently one can only find the age breakout by visiting state sites and or specific studies – https://www.courant.com/coronavirus/hc-news-coronavirus-80percent-deaths-20200506-fuhlhtusajb7dd7p6sf5xekl54-story.html

“Nearly 90% of the COVID-related deaths recorded by the state last week occurred in nursing homes as COVID-19 continues to attack residents of long-term care facilities and the state prepares to partially reopen later this month. Between April 22 and April 29, the state’s death total rose from 1,544 to 2,089, or 545 new deaths, according to data released by the state Department of Public Health. In that same seven-day period nursing home deaths rose from 768 to 1,249, meaning 481 among the 545 new deaths — about 88% — were nursing home patients.”

Today we are back below 2K deaths in US. Brazil has moved up to 2nd place in terms of new confirmation – not a good thing. Their death change 827.

Usually on these low US death reporting days NY is not leading the pack – as is the case today – very spread among the east states with NJ leading the pack (153)

Brazil is not getting better they are testing more and they are just accumulating more confirmation and deaths. Just like Mexico expect their situation to look worse as they catch up to testing.

Brazil is re-accelerating daily deaths. Mexico continues to ramp. AZ deaths rising.