Happy Mother’s Day!

Lots of news to discuss – where to start….

The more the data comes out the more it shows this problem cannot be tackled on a macro scale. The virus is quite focused but still virulent. I can’t highlight enough the Korean study of the building which by far is the MOST informative and MOST to the point study of what we are dealing with. https://wwwnc.cdc.gov/eid/article/26/8/20-1274_article

In fact they should have mapped out the Diamond Princess just like this study to understand where exactly the virus was at – or was it just random. With the Chinese restaurant study and this it shows this is not random.

The more I think of this study the more takeaways I develop.

Lets think of the building being a country. We can lock up the entire building – every floor forced to quarantine. We would have literally locked away 91% of the population that was innocent bystanders and would have not done anything to solve the issue at hand. Finding the right group to quarantine was not hard – the virus was very focused – 97% all on the 11th floor AND not only that 95% of the 97% was on the HALF of the 11th floor.

The mitigation problem was VERY solvable on a local basis. A floor by floor management could have easily isolated and solved the problem. A “federal” solution – ONLY SEEING TOTAL numbers would not have the knowledge or wits to realize the fact the entire building did not need to be closed down. WE HAVE THE TECHNOLOGY – to solve this problem. This is about getting data and organizing it so you can see what is going on. You give someone experienced in managing and building a database and person familiar with analyzing data or even a program to review data – they would have come to the conclusion to closed the 11th floor. Then analyze what makes the 11th floor unique.

We need to focus on the data – not macro level but we need to pinpoint the problem as S. Korea has done. They know this that’s why they are ahead of everyone. My years spent in technology – it so unfortunate the bottleneck is people – change management is key. It is a cliché consulting term but it is so on the point.

Another nuance I want to highlight the above was a discussion on mitigation – not a reduction of death. They are not necessarily connected. Obviously in the extreme they are – no spread – mitigation solved = 0 deaths. However in the non -extreme case – we can have spreading with limited deaths. Lets mitigate but where there are holes in mitigation lets have the second prong strategy of reducing death. “SMART” testing is mitigation strategy. “SMART” quarantining is focused on reducing death statistics.

Lets get more macro – Arizona has a new covid dashboard which is very informative. https://www.azdhs.gov/preparedness/epidemiology-disease-control/infectious-disease-epidemiology/covid-19/dashboards/index.php

They are also now tracking their serology tests. They are doing a test blitz and so far the data indicates mitigation to zero is not likely. Large quarantining is not going to be effective – there will be holes and given how virulent in nature the virus is you will get pockets of spreads. We need to find the pockets (not LARGE segments) and isolate them – its like the Whac-A-Mole game – but we have the technology it can be done. The acceptance of the disease spread allows the second phase of the strategy to evolve – “SMART” quarantine.

They have to dig deeper than even county level – its too high of a level but you now know which county needs to focus Maricopa. Note the amount of confirmed cases in the age group 20-44 = 4145 65+=2521

So the 20-44 yr death is 19….19/4145 = 0.5% 65+=16.8%

I know you will see the headlines of kids getting sick and the young and they will stress to you this isn’t an age disease – but it is statistically. 37X more likely to die if you get covid-19 and you are 65+ vs. 20-44. Now I am sure in general 65+ is more likely to die from even a broken leg than 20-44 – but the data suggest IF you want to reduce death FROM covid-19 focus not getting the elderly to get the virus. Spending your time isolating the youth is a poor allocation of time and resource when the key is isolating the elderly – you get 37X bang for your effort.

Tesla is in the headlines – https://www.tesla.com/blog/getting-back-work

So many people want to bash Elon that he is money grabbing. The DATA shows its pinpoint issue – if it shows up in your factory you got to deal with it – IF its not in your factory its going to be okay. HOW do you get it not in your factory and not have it spread – do things about it….WE NEED GUIDELINES to make buildings and workplace environments SAFER – we don’t need massive isolation protocols. They are taking their experiences from Shanghai and applying it – that’s what you should do. NOT ALL PLACES ARE EQUAL! Those places that do things to make their place safer SHOULD BENEFIT. They should be able to retain more talent they should be able to be more productive – they invested in making their place a better place WHY cant they get a return on it. We have data perhaps not SPECIFC to covid-19 – but we do know UV light mitigates viruses and closed recirculated air increase viral load – places installing UVC lighting and fresh air HVAC system SHOULD benefit from their capital investment – WHY are we so fixated to make everyone suffer and not have competition to make better safer places to go and visit? WHY do we not cultivate innovation to make grocery stores and essential places safer places? WE HAVE THE TECHNOLOGY. Yes Covid-19 is a unique virus but it is still a virus. WE know how to destroy viruses in terms of sanitary measures. WE know how to help mitigate spread of viruses. Educate people what would make a very safe environment to go to – then storeowners would make their places better else people will go to other places….allow competition to make us better. Policy to reduce death can coincide with guidelines – we can still focus quarantine on metrics causing death and overwhelming the healthcare system. DATA shows its not 20-44yrs overwhelming the system.

Politics…ugh – but I figure you should know its out there – looks like there COULD be some collusion with WHO and China – https://www.dailymail.co.uk/news/article-8304471/Chinas-president-Xi-Jinping-personally-requested-delay-COVID-19-pandemic-warning.html

“China’s president Xi Jinping ‘personally asked WHO to hold back information about human-to-human transmission and delayed the global response by four to six WEEKS’ at the start of the COVID-19 outbreak, bombshell report claims”

“Der Spiegel published bombshell claims from its Federal Intelligence Service “

Reiteration on what concerns me in the future as I noted before – the kids of Covid-19 – living a life of early sterility – https://science.sciencemag.org/content/368/6491/598.full

Also notes the IMPORTANCE and DEMONSTRATES the immunity system is different when young and needs to be fostered.

“Evidence is also mounting that immune system programming that starts in early life may influence the risk of developing conditions such as allergic, autoimmune, reproductive, and neuropsychiatric disorders in later life, further underscoring the translational implications of this kind of research.”

Divorce lawyers are going to be banking another article supporting the trend – https://www.scmp.com/news/hong-kong/health-environment/article/3083681/covid-19-toll-marriage-divorce-inquiries-rise

Another day under 2K for the US – but it’s the weekend. Brazil still showing strong numbers with an increase of 639

Once again NY is back on top of the additional deaths (369)

Sweden is not looking too good as their deaths and confirmations are increasing relative to the testing. They are the highest now among the European countries. HOWEVER as I noted before they could be playing the long game in mitigating the flu season coming up. Only time will tell on this – but some data indicate they may be right. Riddle me why flu season happens every year? Did you know in the US 50% of the death of flu occur in the 1st quarter –(https://data.cdc.gov/NCHS/NCHS-VSRR-Quarterly-provisional-estimates-for-sele/489q-934x)

Rhode Island should have some interesting data they are at 8.3% testing of total population.

Mexico and Brazil continue to rise. AZ is rising to but perhaps more testing results in more confirmation and more allocation to deaths?

There is an indication opening up is leading to some increase in daily deaths….but not back to previous peaks yet.

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.

Interesting to see CA gov claim that 1st community spread Covid happened in nail salon – https://theweek.com/speedreads/913304/california-governor-says-states-1st-community-spread-covid19-case-happened-nail-salon

At the same time TX Governor releases nail salon owner from jail and today hair salons are opening in TX – https://www.usatoday.com/story/news/nation/2020/05/07/texas-gov-greg-abbott-jailing-salon-owner-shelley-luther-too-far/3087849001/

I do believe just like not all types of stores are the same – also not all stores within a type of stores are the same. For example lets say a nail salon installed an advance UVC HVAC fresh air system and implemented social distancing with barriers, mask wearing employees and patrons, approved cleaning chemicals sanitize after every patron, and had testing for employees and patrons even if it was only temp reading and only took those who sign off on waiver that did not have health issues such as diabetes and obesity etc…I suspect that store would be way safer and also not cause a significant burden to the healthcare system than any grocery store or home appliance store that is currently allowed to open. Clearly NY data shows its not just these stores that’s causing the issue as they have been close all this time and all we have are “essential” stores in NY operating. The mitigation requires more than a “type” of store is the point – sure it could be worse if those stores open – BUT if mitigation efforts were to be put in place at these types of stores they could potentially not have a material impact.

Perhaps instead of sledgehammer policy of closure – guidelines to the public to watch for stores that have social distancing in place, mask wearing, and advance UVC HVAC system with fresh air system non circulated negative pressure zones – should be visited over those that do not. I think guidelines not edicts should allow consumers to come back and have confidence to visit certain stores that have implemented those guidelines. Many places that have open are still not getting any customers. Fear is still there and without some guidelines and checklist to know what store is safe or even for a store owner to make their store “safer” then the fear will likely continue. Also a reinforcement of quarantine for those that have health issues and particularly those that the covid-19 has shown to hurt the most diabetes, obesity, upper respiratory issues – and free testing for those health issues will help mitigate overwhelming the health system.

We can mitigate with technology and it doesn’t depend on the type of store you have – obviously a more contact store more mitigations would be needed to reduce viral load.

With more data and much more testing and the conclusion that in many places the virus is out and likely no way of putting it away – its now important to figure out what is going on in terms of reducing fatality. The below chart shows countries/states who have tested over 1% of their per capita and have at least 25K confirmed cases. Can we learn from those that have low fatality rates (death/confirmed). Data is so fascinating – I never realized how densely populated Netherland is. Of course population density for a country is not the best metric as perhaps population density for the most populated city in the country e.g. Russia pop density looks extremely low. Is the strain in Russia the Chinese strain thereby limiting deaths or are we going to accuse the country of misreporting the numbers? If it is a real number certainly this needs to be investigated to figure out some lessons learn – likewise with Saudi Arabia – if the two are right then its not the vodka. Saudi Arabia does by its culture ~50% population wear a face mask in public settings. Interesting comparison is TX vs. LA – over 50% better in TX than LA – all metrics similar BMI is higher in LA but both high relatively speaking.

Because of that train of thought lets dive into the county data – in New Orleans they are 3X more likely to take public transport than in Harris County TX . There is a race component 3X African American rate. There is likely more sunshine in Harris County – whether Harris County goes outside relative to Orleans folks that’s not known in this data.

Daily update another US 2k plus day of deaths (2231). Russia confirmed cases rises but their death numbers barely rise (88).

NY still lead the way in the US rise 23% (521) – then the same group of states – all intertwined with NYC. This does support the claim that NYC was ground zero for the spread. Travel from Europe was the culprit not China. China travel infection in Washington but that strain was way “better”.

Open state watch – so far nothing significant to report from the states opening up – but wont really know much for another 2 weeks.

Mexico testing data is flat lining for some reason even though confirmed cases and death rising – https://ourworldindata.org/grapher/full-list-total-tests-for-covid-19?year=2020-04-18&country=MEX

Sweden surpassed Spain in Deaths/Confirmed – now at 12.35%

Several US states haven’t turn the corner in terms of daily death changes 7 day MA – AZ,PA,CA,FL,CT. AZ in fact is peaking not flat lining. Mexico,Brazil, India continue to rise.

Interesting read with lots of twist and turns to question – https://www.dailymail.co.uk/news/article-8293417/amp/66-New-York-coronavirus-hospitalizations-people-staying-HOME.html

“A study of hospitals last week found that of 1,000 patients, 66 percent were people staying at home

73% of the new hospitalizations were people aged 51 and over and 96% had underlying health conditions

Most were in Manhattan – 21% – but 18% of the new hospitalizations were in Long Island

In New York City, 90% of those who answered said they had not been taking public transport

Cuomo said it showed that the new infections were down to ‘personal behavior’ like not wearing masks or not hand washing enough

It prompts the question of whether lockdown even works or is necessary

Deaths, hospitalizations and intubations are all down but the state remains in lockdown until May 15

Cuomo said he is ‘vindicated’ by the states that are seeing numbers continue to rise throughout reopening

There are now 19,877 deaths in New York state and more than 321,000 cases of the virus

Across America, there have been more than 1million cases and 72,000 deaths

Recent data shows that while New York’s numbers are decreasing, the rest of America’s are on the rise “

The 66% from home is a weird stat – most people do have homes or a place called home? So it would seem reasonable that would be the highest. I think the better question was the transportation question where the response indicated they are generally staying at home – Over 84% stay at home- NYC 90%. In order for them to get sick it must be either they already had it in system all the time or their little trips they are getting it – or its in their living spaces perhaps coming through ventilation?

Staying at home still meant going grocery shopping? Do they wear mask? Where do they go outside their house and how often? How are these homes ventilated? Do you live in multiplex units?

Cuomo push the blame to personal behavior interesting move….

Vindicated – interesting use of words – is he pleased that states opening up are seeing rising numbers (not confirmed)? Would it be better that they weren’t so then we can all open up and forget the parade of who was better and move on with our lives? Looking at the data which I suspect is a little too soon to really know – there is no indication that this is the case. Probably need to wait 2 weeks to really say opening up INCREASE deaths. Remember its not about confirmed cases – cases will rise but as long as no one is overwhelming the hospitals we should be fine. Vindicated by an inevitable rise in confirm cases is misalign as we know covid seems highly contagious in closed surroundings. Cases will rise be prepared for that – smart quarantine is to limit – not stop- cases and reduce/eliminate those likely to go to ICU. Comparing NY to total US numbers is also unreasonably as the rises are now in NJ, PA, and MA – all related to NY – not the states opening up.

To clarify the last bullet – NY numbers are decreasing in their growth – the absolute amount of deaths and confirmations are still rising. In fact today NY is back as the leader of daily deaths (499 increase).

To mask or not to mask – another awful reporting – https://fee.org/articles/stop-forcing-people-to-wear-masks-over-covid-19-fears/

Is it a strategy to link to studies and claim something else or even to link to studies expecting no one to read them?

“A 2011 randomized clinical trial found that medical masks offered no protection at all. A 2015 study concluded rates of infection were especially high in cloth masks, finding particle penetration in nearly 97 percent of them. A 2016 paper that analyzed six clinical studies found that N95 respirator masks fared no better than medical masks in preventing respiratory infection.”

The first two links to the study point to the same study but one should be a 2011 study and the other a 2015 study. The study https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1750-2659.2011.00198.x?fbclid=IwAR3kRYVYDKb0aR-su9_me9_vY6a8KVR4HZ17J2A_80f_fXUABRQdhQlc8Wo is not answering the question to mask or not to mask – they are focused on whether fit-tested vs. non-fit-tested N95 have any material difference. In the study assessment they don’t….this is not answering to mask or not to mask?

The next study https://www.cmaj.ca/content/cmaj/188/8/567.full.pdf?fbclid=IwAR1pzMCjQNUnUCUrXAeOMjcurr5WFpWur5t_JjhDEKnIcHc3h2Jj4gJCHIU Once again is not to mask or not to mask – but a study comparing N95 with surgical mask – no conclusion insufficient data.

What is going on here? Paper goes on to state:

“As recently as April 7, a paper analyzing data from 15 randomized trials concluded that “compared to no masks there was no reduction of influenza-like illness cases for influenza for masks in the general population, nor in healthcare workers.” Despite the lack of hard empirical evidence, however, the study’s authors recommended the use of masks based on “observational evidence from the previous SARS epidemic.””

This study link goes https://www.medrxiv.org/content/10.1101/2020.03.30.20047217v2.full.pdf and states

“All trials were conducted in nonpandemic settings…. Five trials compared surgical masks with N95/P2 respirators.”

Probably a worthy disclaimer to bring up first point – but then look at the comparison – its not comparing No mask vs. mask!

I don’t know what to say about reporting like this – anyway lets use common sense – mask likely stops macro air drops – doesn’t not stop completely everything. However if one sneezed or cough the spread is likely limited. Could a mask upon inhale perhaps screen out some – it would seem like a virus on a droplet would at some level stop on the fiber. I am sure many will pass through – but once again as I have been noting its about VIRAL LOAD – so if at some level you reduce the volume it will likely not impact you significantly. The better argument to not wear a mask is because you want to boost your immunity strength – then that’s a personal choice based on your risk/reward – but to say mask doesn’t do anything not sure about that…. I wear a mask grocery shopping now not biking or in my backyard or in an environment I know but everywhere else why not – risk/reward.

I do agree with this reporting – we must confront the elephant in the room that is overwhelming our healthcare system – it’s directly not covid – https://life.spectator.co.uk/articles/its-time-we-were-honest-about-obesity-and-covid-19/

“First do no harm” is the first principle of medicine. Fifty years ago, cigarettes were designated harmless, their use defended by the medical profession, despite the health concerns, and patients paid the price; today, processed food is “part of a balanced lifestyle”. Why do people have to be harmed while we wait for the medical profession to catch up with the science? There are those who wish to suppress legitimate discussion, by calculated faux outrage. Facts, I’m afraid, don’t care about your feelings.”

Back to more than 2K deaths reported in the US. This time NY is back on top (499). UK and Brazil are 649 and 650 respectively. For NY to be so high for so long compared to all these countries – either others are not testing enough and/or we just have the super strain and/or over reporting and/or have a heath issue in NY relative to other parts of the world. We have found a source of weekly total deaths by state so we will start analyzing that as soon as we get the data aligned to see if there is any insights into that data.

Still in the East coast all the big changes

Incremental deaths per tested is rising for Sweden – not a good sign for there open policy.

Japan has ticked back down below peak daily death 7 day MA. NY still way higher than any other state or country at death/capita 0.13% and rising.

Interesting news from our night/morning reads….

This report perhaps explain why its worse in Europe and East Coast vs. China – Also highlights the difficulties in developing a vaccine or cure but also highlights our computer powers to track this virus which we didn’t have in 1918 – https://www.biorxiv.org/content/10.1101/2020.04.29.069054v1.full

“…revealed that viruses bearing the mutation Spike D614G are replacing the original Wuhan form of the virus rapidly and repeatedly across the globe (Fig. 2-3). We do not know what is driving this selective sweep, nor for that matter if it is indeed due the modified Spike and not one of the other two accompanying mutations that share the GISAID “G-clade” haplotype.”

“Increased infectivity would be consistent with rapid spread, and also the association of higher viral load with G614 that we observed in the clinical data from Sheffield, England (Fig. 5)”

“To date, mutations are extremely rare in the Spike RBD, but the mutation G476S is directly in an ACE2 contact residue. The mutation L5F occurs in many geographic regions in many distinct clades, suggesting it repeatedly arose independently, and was selected to the extent that was frequent enough to be resampled. Finally, the mutation S943P seems to have been transferred by recombination into diverse viral backbones that are co-circulating in Belgium (Fig. 6); we also found strong evidence of recombination in other regional sample sets (Fig. S8). Recombination among pandemic SARS-CoV-2 strains is not surprising, given that it is also found among more distant coronaviruses with higher diversity levels (Graham and Baric, 2010; Li et al., 2020; Rehman et al., 2020).”

“recombination provides an opportunity for the virus to bring together, into a single recombinant virus, multiple mutations that independently confer distinct fitness advantages but that were carried separately in the two parental strains.”

Positive news – patients infected do develop some form of immunity – also the residual positive confirmation are not likely reinfections – https://www.medrxiv.org/content/10.1101/2020.04.30.20085613v1

“the vast majority of confirmed COVID19 patients seroconvert, potentially providing immunity to reinfection. We also report that in a large proportion of individuals, viral genome can be detected via PCR in the upper respiratory tract for weeks post symptom resolution, but it is unclear if this signal represents infectious virus.”

“our findings suggest that IgG antibodies develop over a period of 7 to 50 days from symptom onset and 5 to 49 from symptom resolution, with a medianof 24 days from symptom onset to higher antibody titers, and a median of 15 days from symptom resolution to higher antibody titers. This suggests that the optimal time frame for widespread antibody testing is at least three to four weeks after symptom onset and at least two weeks after symptom resolution. In our survey, we did not find evidence for a decrease in IgG antibody titer levels on repeat sampling.”

Patience is needed to test for the antibody!

“Although we do not yet know what, if any, immunity is conferred by IgG or the duration of the IgG response, at this time it seems likely that IgG to SARS-CoV-2 may confer some level of immunity based on what is known about viral immunity to other pathogens. In prior studies of SARS-CoV-1 and Middle East Respiratory Syndrome patients, IgG peaked within months of primary infection and waned over time. Similar observations have been made with human coronaviruses were immunity can confer at least limited protection.”

Some of vanity fair pieces have somewhat been balanced – this is not – https://www.vanityfair.com/news/2020/05/whistleblower-complaint-rick-bright-blasts-team-trumps-pandemic-response

“..which had been cobbled together by a cryptocurrency investor and a New York City lawyer…” Missing from story he is an MD from Columbia University – perhaps limited on the amount of words they can put into a story? The google doc does point to studies done way before Covid

2005 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232869/

Therefore show HCQ is not an out of the box crazy idea to look into

“Chloroquine is effective in preventing the spread of SARS CoV in cell culture. Favorable inhibition of virus spread was observed when the cells were either treated with chloroquine prior to or after SARS CoV infection. In addition, the indirect immunofluorescence assay described herein represents a simple and rapid method for screening SARS-CoV antiviral compounds.”

2010 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2973827/

Paper shows that Zinc does something to viruses is the point of paper and perhaps HCQ ability to help absorption of zinc leads to a positive outcome.

“In summary, the combination of zinc ions and the zinc-ionophore PT efficiently inhibits nidovirus replication in cell culture.”

Vanity Fair failed to highlight some issues with the study they conclude caused the scale back of cheerleading – “Only after a study of veterans with COVID-19 found that patients treated with chloroquine died at twice the rate of those who didn’t get the drug did Trump scale back his cheerleading.”

Number 1 not a study – but a math exercise of putting past data into a matrix to draw a conclusion. No discussion of dosage or timing or interview conducted with doctors on their decisions. Authors had ties to Gilead Science. Many cited were ophthalmologist – nothing against them but its not really their specialty.

To characterized HCQ as a lethal drug would not make sense in terms of how many millions have taken the drug for malaria and lupus. At least there is data on the side effects and which patients should not take it vs. drugs who have not been taken by millions around the world? Is it the cure all – not likely but several test are sure indicating it to be a good tool to have in your war against Covid – it would be a shame if politics got in the way of using a tool that when administered right – even if not directly effective to eliminating Covid – has showned to have limited to no side effects per millions of documented cases.

US back to above 2K death reporting. Russia reports more confirmation but their deaths are amazing low vs. how many confirmed.

This time NY is not a even a top 3 state in terms of death. PA(341), NJ(334), and IL(175) top3.

PA is similar to NY – in that the issue is focused to a particular part of the state – Philadelphia.

Mexico likely the next hotspot. They have quite a high death/confirmed and they have still quite a bit of testing that needs to be done. Note Russia under 1% death/confirmed.

Japan has surpassed their previous peak in daily death change so it looks like they are in a second wave – however their confirmation numbers are still way low compared to the peak so it should still be manageable.

Pakistan and India are both rising.

Some good reports to read. I will start highlighting the reference text (red) so there is no misunderstanding what I say vs. paper.

This paper notes the spread of Covid-19 for France occurred in Dec 2019 – this causes a lot more questions than answers as many good papers do. https://www.sciencedirect.com/science/article/pii/S0924857920301643

“Covid-19 was already spreading in France in late December 2019, a month before the official first cases in the country.

Early community spreading changes our knowledge of covid-19 epidemic.”

The one patient found through all the testing of culture was:

“42 years old manborn in Algeria, who lived in France for many years, and worked as a fishmonger. His last trip was in Algeria during August 2019. One of his child presented with ILI prior to the onset of his symptoms. His medical history consisted in asthma, type II diabetes mellitus. He presented to the emergency ward on December 27 2019 with hemoptysis, cough, headache and fever, evolving for 4 days. Initial examination was unremarkable and the performed CT scan revealed bilateral ground glass opacity in inferior lobes (Figure 3). at admission he had a lymphopenia, an elevated C-Reactive Protein and fibrinogen while Pro Calcitonin was in normal range value. No pathogen was identified on sputum sample collected in the emergency ward. The patient was admitted to the ICU with antibiotic therapy, and evolution was favorable until discharge on December 29,2019”

The impact on this is the theory I have been hypothesizing is that the cat is out of the bag and the virus has already spread by the time it finally hits a patient that would warrant an investigation.

“Two recent studies suggested that around 18 to 23% infected with SARS-COV-2 were asymptomatic16 and that around 55% of infected were caused by unidentified infected persons.17 Our results strongly support these two assumptions, suggesting that many asymptomatic patients were not diagnosed during January 2020 and contributed to the spread of this epidemic”

The stat that ALL was asymptomatic is interesting – be interested to get the demographics of all the workers – also note the contagious figure similar to cruise ship 17% – https://edition.cnn.com/2020/05/04/us/triumph-foods-outbreak-missouri/

“More than 370 workers at a pork plant in Missouri tested positive for coronavirus. All were asymptomatic”

This paper supports the theory that immunity is built once you have the virus. However there sample size is small (14) but they do demonstrate both antigen and Tcell immunity https://www.cell.com/action/showPdf?pii=S1074-7613%2820%2930181-3

“In all 14 patients tested, 13 displayed serum neutralizing activities in a pseudotype entry assay. Notably, there was a strong correlation between neutralization antibody titers and the numbers of virus-specific T cells. Our work provides a basis for further analysis of protective immunity to SARS-CoV-2, and

understanding the pathogenesis of COVID-19, especially in the severe cases. It has also implications in developing an effective vaccine to SARS-CoV-2 infection.”

Positive news on the antibody front – https://www.dailymail.co.uk/sciencetech/article-8285333/Antibody-prevents-COVID-19-virus-infecting-human-cells.html?

“Antibody found to block infection by the novel coronavirus SARS-CoV-2 in cells

The ’47D11′ antibody targets the ‘spike protein’ of the destructive coronavirus

It could alter the ‘course of infection’ or protect an uninfected person exposed”

Looks like everyone converging on antibody – https://www.malaymail.com/news/world/2020/05/05/israel-isolates-coronavirus-antibody-in-significant-breakthrough-says-minis/1863150

“Israel has isolated a key coronavirus antibody at its main biological research laboratory, the Israeli defence minister said yesterday, calling the step a “significant breakthrough” toward a possible treatment for the Covid-19 pandemic.”

Iceland notes SMART testing – via Test and Trace – https://time.com/5831580/iceland-coronavirus-tests/?

Iceland has done quite well and are ahead in terms of testing per capita – but they are very small relative to even cities in the US. They did not just test symptomatic they took a more statistical approach and moved around to sample the population and found hot spots.

“The company used its facilities to test a cross-section of the population, and identified scores of new cases, including people with mild or no symptoms.”

Last but not least a PSA – https://amp.lbc.co.uk/radio/presenters/iain-dale/quitting-junk-food-risk-dying-of-coronavirus/?

“A cardiologist has insisted that reducing the amount of junk food you eat will significantly reduce your chance of dying from coronavirus.”

“Dr Malhotra told Iain that people who are obese and are suffering with diseases related to obesity have a "tenfold increase in death" from coronavirus. Because of the health issues associated with obesity, the cardiologist told LBC that obese people have a "significantly higher chance of hospitalisation and death" from the virus.

He noted that "poor diet is the biggest factor of putting stress on our healthcare system" but assured the public that they "can reverse these risk factors very quickly". "30 minutes of exercise is the best thing you can do for you health" and taking action such as this will greatly reduce your risk of succumbing to coronavirus.”

“Dr Malhotra went further to predict a possible change in coronavirus strategy in the coming months if the UK was to adopt a healthier diet, stating that "if our population is healthier we may not need to lockdown next time we have an outbreak."

Good update day – but could be weekend lull – low deaths reported with US still leading at 1240 new deaths – almost 70K total for the US with over 50% in NY,NJ, MA.

NY still lead the way in increased death but now is less than 25% of the total – only 291.

The UK has dropped below 10% of those tested are being confirmed.

Japan is observing a resurgence in the 7 Day MA daily death – still not surpassing the initial peak but getting very close at 21.6 daily deaths. Still in the grand scheme of countries that is extremely low compared to other countries particularly given the density. I would be shocked if this level would overwhelm their health system. The state of Illinois is at 96.6 daily deaths.

We have 19 states opening up. We should expect confirmations to rise – the virus is not eliminated. What we need to track is deaths and hospitalization. If people manage their risk/reward and we somewhat smart quarantined we can keep the health system form overwhelming – therefore deaths at some level should not rise obsessively. The message should be focused on telling people who /what type of people are at risk and have those testing metrics available (e.g. obesity, diabetes, etc…).

Once again I would not want to focus on daily death reporting as it seems too volatile. A 7 day moving average smooths out the operations of reporting.

So far the 7 Day MA deaths for those states nothing sticks out.

I don’t have hospitalization for all the states – of the 19 only 11 states. Only states with potential spike is Idaho and Tennessee. Utah has been climbing since Mid April.

Sunday updates are generally the lowest numbers – 1313 incremental death for the US – New York leading the way with 510.

Deaths are still very East centric.

Testing in the US is way up there – its not about just testing now- now have to smart test. Mexico is likely going to start showing some very bad numbers. The orange line spike was Ecuador – and they recently showed a large spike in deaths.

Brazil looks to be on a plateau now. Ecuador and Peru still rising. India continues to rise in death. Japan is seeing a small rise bit not past their previous peak daily death changes.

Interesting stats….on a county basis

90% of covid deaths in the US represent:

7% of total counties in the US (223 counties vs. 3255)

49% of total population of the US

8% of the total land mass of the US

Clearly population density means something – perhaps this promotes suburbia and telecommuting. A good proportion of the country is not impacted.

500 death is the max red in order to even show anything on the figure below – slight pink is essentially 100 deaths – in some parts we underwhelmed the healthsystem – hard to find the right balance for sure but with technology we should be able to do better. Given the paper from Korea yesterday it would suggest the hot spots within the county are probably even more focused. We should be taking the test data and building a more pinpoint mapping of the virus. Certainly testing is behind in several states so this may be quite an incomplete picture but you really don’t have to test that much to get a good view of what is going on.

You can see once you test around 0.5% to 1% you can build an equation to calculate the amount of confirmed case as you test more and it has been generally accurate. NY is prime example now NJ – for a lower level of infection – TX continued testing but it is not changing the trajectory.

Lower death day typical for Sunday reporting

NJ CT PA show death uptick on 7day MA

US has now tested almost 2% per capita. I suspect something is off in Mexico.

World view to see that Sweden does stick out from their neighbors – but not significantly – just slightly higher than the US on death per capita (0.026%)

Leading with a most informative paper – particularly as we decide to go back to work – https://wwwnc.cdc.gov/eid/article/26/8/20-1274_article

As with many good papers it leaves you with some good questions. In reality the problem really cannot be seen from a country, state, city, or even county – the real point of transmission is happening at a workplace or store or place of gathering. Here the S. Korean once again show their tech savviness and ability to tackle this problem – we should be smart about testing and quarantine learn from S. Korea. This paper focuses on a workplace building and deciphers what happened.

Lets start with the interesting observations from the paper – once again its viral load that matters. They essentially tested everyone in the building which was combination of offices and residential. Even in their microcosm of a building this really did not explain everything as the infections only occurred on a few floors. Total infection rate was 8.5% – but 91.7% on floor 11 – and most on a side off that floor – even more precision. As they pointed out if looking at ONLY 11th floor the infection/attack rate 43.5%.

“This outbreak shows alarmingly that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can be exceptionally contagious in crowded office settings such as a call center. The magnitude of the outbreak illustrates how a high-density work environment can become a high-risk site for the spread of COVID-19 and potentially a source of further transmission. Nearly all the case-patients were on one side of the building on 11th floor. Severe acute respiratory syndrome coronavirus, the predecessor of SARS-CoV-2, exhibited multiple superspreading events in 2002 and 2003, in which a few persons infected others, resulting in many secondary cases. Despite considerable interaction between workers on different floors of building X in the elevators and lobby, spread of COVID-19 was limited almost exclusively to the 11th floor, which indicates that the duration of interaction (or contact) was likely the main facilitator for further spreading of SARS-CoV-2.”

Viral load is key – the odds of a passerby transmitting an infectious level to you is not likely per this study.

The study also reduces a little bit the fear of the asymptomatic spreader – the note 16.5% – so those who were asymptomatic what was their likelihood of spread among their close contacts. Among their 97 confirmed only 4.1% remained asymptomatic.

First question it started on the 10th floor Feb 22 but it was the 11th floor where everything played out . I wish there was more description on what differentiated the 10th floor and the 11th floor.

Nonetheless the drama starts on the 11th floor. Based on the facts the 10th floor and 11th floor are unrelated. One could perhaps jump to the conclusion that it was transferred in the elevator – but IF that was prevalent than we would see it beyond 3 floors. The more likely scenario at this time these are individual infections brought into the workplace.

11th floor is a call center with seating arrangements as described below along with the infections locations highlighted. As noted all on the one side. I would be very interested to see the airflow for the ventilation system. A deeper understanding on the 11th floor work engagement – does the 11th floor not interact across the floor. They all do share a common bathroom – how often is that used? Of the 5 that got infected on the other side – did they interact with ones on the otherside. Is the non-infected side have different work hours – or different ventilation that prevented the spreading on that side? This knowledge could help layout the work setup for future office design. As of right now a complete contiguous open floor does not seem wise. Breaking up with meeting rooms looks to the right approach. Last question – no mention of any deaths – what treatment was done? All survived and recovered?

Another praise for Sweden – https://www.intellectualtakeout.org/who-declares-swedens-covid-response-a-model-for-the-world/

I do agree with several key points. At some level in order to learn we do need to see various approaches for the next time. It is funny they note the “American model” – individual responsibility – which in general we didn’t follow. It is clear the author and this site is probably a conservative slanted – I never been to their site before. The article on Sweden intrigued me hence ended up at the site.

I won’t conclude the Swedes showed us the better way as the article did – as it is too early – but hopefully they do succeed to show us a better way – as why wouldn’t we want to have a better way for next time? I am still keen on crowning S. Korea over Sweden. S. Korea a lot more population density and their approach is more technology married – their numbers are better so far – but will the approach be good enough for the second wave if it comes?

Those that think something will come in time for the flu season in the winter – better read Gates notes on vaccine – https://www.gatesnotes.com/Health/What-you-need-to-know-about-the-COVID-19-vaccine?WT.mc_id=20200430100000_COVID-19-vaccine_BG-EM_&WT.tsrc=BGEM

Interesting pic on how the compress 5 years into 18 months.

Since this is Austin – does that mean Foxnews is more balanced there – https://www.fox7austin.com/news/fox-26-gets-unprecedented-access-to-texas-1st-nursing-home-to-treat-covid-19-with-hydroxychloroquine.amp?

The numbers are the numbers typically – so far their mortality rate is MUCH better than any nursing home who has gotten the virus.

“only one of the nursing homes COVID-19 patients has died.”

“99 percent of the staff stayed we had 34 employees that contracted Coronavirus all lived and 98% are back at work right now,”

Want a thought piece to ponder – https://foreignpolicy.com/2020/03/27/coronavirus-pandemic-shows-why-no-global-progress-on-climate-change/

The massive amounts of destruction in order to reduce CO2 – and the collectivism needed to do that – can we do it for a problem that is not very immediate?

Lastly go out and get some sun and vitamin D – https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3585561

Once again US almost at 2K deaths with NY (452) and then NJ (310)

Even with NJ and NY leading they are dropping in the key metrics of confirmed/test

Surprised not more discussion on Mexico – perhaps the data feed of testing is not too good but deaths are now at 1972 – confirmed at 20739 and they barely tested 0.06% of per capita.

We are nearing 100 days since first confirmation for many countries.

It is May – lets see if we can look at the data differently to get a better perspective on where we came from in April.

In theory if one kept on testing (which in general everyone did) eventually at some point you move away from the obvious infected people to the less obvious and your testing confirmation and deaths should naturally fall.

The good thing we see this across most major states. The below chart represents the 7 day moving average of the daily difference in the categories noted. Using a 7 day in theory help gets rid of the social behavior of not reporting consistently over weekdays vs. weekend and any data blip that occur that eventually get corrected but perhaps not back corrected in time. The 7 Day Average view does make you lose sight of anything that might occur this week but I don’t think we should necessarily respond per daily change given the errors noted above. At the same time this view is just the change so its not bias to the history – so it represents the recent testing batch.

The top blue line NJ and the top red line before crashing into the see of other states is NY. 7 day MA change of confirmed / 7 day MA change of tested is the first plot. This gives an indication of when you test how many have Covid-19 in their system. This gives you a clue on how pervasive the virus is in society. Obviously this metric is dependent on the method of testing. If you only test symptomatic patients it will be high odds its positive. In the beginning of April NY testing was coming out at 50% then by the end of the month 20%. The average of the timeline is coincidently near the weighted average on April 30th based on test by state of 13%. Studies have indicated that general population likely infected 4-8% already. This does support that number. Washington who was ground zero for US is testing still at 10%. Strategy should change as a function of how many you believe are already infected.

The second graph gives an indication of death/tested. In theory on a long enough timeline everyone gets tested and you obtain the crude death rate so this gives a clue to that figure. NY started at 4.8% and now is 1.4%. The average weighted on April 30th is 0.9%.

The third graph is the most common metric discuss when talking about death (crude death rate likely more accurate for historical comparisons). As noted in other discussion the death/confirmation is tied to the confirmation which in the beginning is changing so much as you start testing the sick and expand. NY mortality rate started the month at 9.5% and is now at 6.95%. So in the beginning IF you were confirmed with covid-19 in NY you would have a 9.5% chance of dying vs. now its 6.95%. This number will continue to fall as more and more are confirmed as more testing is done as indicated by the first metric.

Looking at this on the same global view ex US – we see a lot more volatile data as different countries are at different stages and also the data inconsistency is apparent. Testing data from various countries seemed to be delayed.

The UK was testing confirming 42% in the beginning now only 13%. UK death per tested dropped from 6.4% to 1.9% with mortality rate staying the same at around 16%. Italy dropped from 12% to 4%. Italy death per tested dropped from 1.9% to 0.6%. The mortality rate for Italy unfortunately has been staying around 15.5%.

A lot of the countries are bunching up around 3-5% confirmed per test . Death per test all point to sub 1% on a long enough timeline. Mortality rate more of a function of the countries issues and doesn’t seem to trend to bunch down overtime.

The craziness in the UK disappeared. The US is back on top in daily deaths. This time NJ is in the lead with 457 deaths. Very concern given how much an outlier NY is now whether some of those deaths are over reported whereas other places are more epidemiology reported so we can actually learn and understand the impact. IF reporting any death infected from covid this will not give a very good representation of what is actually going on. However one should be able to see this if you graphed deaths from other diseases on a timeline with last yr, 5 yr avg, vs this year by different major cause of death buckets. I don’t have the data to do this.

NJ is a concern as noted several times.

Mexico is somewhat a data issue but there are underlying concerns. Belgium looks to be creating a mini – second wave.

Looks like Brazil might be hitting a plateau. Todays chart looks good overall with many countries showing declines the daily death change and several pausing their climb in deaths.