“In a podcast interview with CNN’s Dana Bash, former New Jersey Gov. Chris Christie conceded that there would be deaths if states begin to ease their lockdown restrictions, but that people need to accept these deaths because the economic impact would be more dangerous.
Bash began by asking Christie about New York Times reporting that showed White House modeling projected 3,000 deaths a day from the coronavirus by June 1.
Christie acknowledged that “it’s absolutely true,” but believed the country could not sustain its current economic course.
“If we leave this purely up to the physicians’ and the epidemiologists’ data we will be locked in our houses for another year because they don’t want us to be doing anything other than staying in our homes until there’s a vaccine,” Christie said.
“Of course, everybody wants to save every life they can — but the question is, towards what end, ultimately?” Christie later said. “Are there ways that we can thread the middle here to allow that there are going to be deaths, and there are going to be deaths no matter what?”
Christie said it was important to “let some of these folks get back to work, because if we don’t, we’re going to destroy the American way of life in these families — and it will be years and years before we can recover.” (A)
What is herd immunity?
Exposure to a disease-causing organism triggers the body to produce antibodies, disease-specific proteins that fight off the infection. On first exposure, it can take the body a while to develop the right antibody. However, in many cases, the human immune system retains knowledge of that infectious agent, and if it comes across it again, is able to rapidly deploy these antibodies to fight it off.
When a person develops this sort of antibody-based immunity to a given infectious agent, the likelihood that they will pass it on falls significantly says D’Souza. When 70-80% of a given population develops this antibody protection, herd immunity is achieved, indirectly providing protection to those who are not yet immune.
“It’s enough people being immune that over time the number of infections goes down rather than up,” says David Dowdy, associate professor of epidemiology also at Johns Hopkins University. “There are really only two ways to achieve this level of immunity. One is through development and mass distribution of a vaccine, and the other is through a massive increase in the number of people who get sick.” (B)
“How have we achieved herd immunity for other infectious diseases?
Measles, mumps, polio, and chickenpox are examples of infectious diseases that were once very common but are now rare in the U.S. because vaccines helped to establish herd immunity. We sometimes see outbreaks of vaccine-preventable diseases in communities with lower vaccine coverage because they don’t have herd protection. (The 2019 measles outbreak at Disneyland is an example.)
For infections without a vaccine, even if many adults have developed immunity because of prior infection, the disease can still circulate among children and can still infect those with weakened immune systems. This was seen for many of the aforementioned diseases before vaccines were developed.
Other viruses (like the flu) mutate over time, so antibodies from a previous infection provide protection for only a short period of time. For the flu, this is less than a year. If SARS-CoV-2, the virus that causes COVID-19, is like other coronaviruses that currently infect humans, we can expect that people who get infected will be immune for months to years, but probably not their entire lives.
What will it take to achieve herd immunity with SARS-CoV-2?
As with any other infection, there are two ways to achieve herd immunity: A large proportion of the population either gets infected or gets a protective vaccine. Based on early estimates of this virus’s infectiousness, we will likely need at least 70% of the population to be immune to have herd protection.
In the worst case (for example, if we do not perform physical distancing or enact other measures to slow the spread of SARS-CoV-2), the virus can infect this many people in a matter of a few months. This would overwhelm our hospitals and lead to high death rates.
In the best case, we maintain current levels of infection—or even reduce these levels—until a vaccine becomes available. This will take concerted effort on the part of the entire population, with some level of continued physical distancing for an extended period, likely a year or longer, before a highly effective vaccine can be developed, tested, and mass produced.
The most likely case is somewhere in the middle, where infection rates rise and fall over time; we may relax social distancing measures when numbers of infections fall, and then may need to re-implement these measures as numbers increase again. Prolonged effort will be required to prevent major outbreaks until a vaccine is developed. Even then, SARS-CoV-2 could still infect children before they can be vaccinated or adults after their immunity wanes. But it is unlikely in the long term to have the explosive spread that we are seeing right now because much of the population will be immune in the future.” (C)
“There’s a consensus that the key to ending the coronavirus pandemic is establishing herd immunity. But there are many unknowns. One is whether researchers can develop a safe and effective vaccine. Another is how long people who’ve recovered have immunity; reinfection after months or years is common with other human coronaviruses. Finally, it’s not clear what percentage of people must be immune to protect the “herd.” That depends on the contagiousness of the virus. (D)
“Herd immunity is disease-specific and is influenced by the ease with which the disease spreads from person to person, or the level of contagiousness. The specifics about coronavirus and herd immunity are not yet characterized. Regardless of the specifics, achieving herd immunity by the repeated process of infection of one person, recovery and immunity will take a long time – many, many months or even years.
It will take a long time to achieve worldwide herd immunity. It may take less time in some cities or countries, but it will take time. Those individuals who are immune will be able to get back to work and be protected from reinfection and, probably, not transmit the virus or disease.” (E)
“The point at which we reach herd immunity is mathematically related to the germ’s propensity to spread, expressed as its reproduction number, or R0. The R0 for the coronavirus is between 2 and 2.5, scientists estimate (pdf), meaning each infected person passes it to about two other people, absent measures to contain the contagion.
To imagine how herd immunity works, think of coronavirus cases multiplying in a susceptible population this way: 1, 2, 4, 8, 16, and so on. But if half the people are immune, half of those infections won’t ever happen, and so the spreading speed is effectively cut in two. Then, according to the Science Media Centre, the outbreak simmers along like this instead: 1, 1, 1, 1 … The outbreak is snuffed out once the infection rate is less than 1.
The current germ’s rate of spread is higher than that of the ordinary flu, but similar to that of novel emergent influenzas that have occasionally swept the globe before. “That is similar to pandemic flu of 1918, and it implies that the end of this epidemic is going to require nearly 50% of the population to be immune, either from a vaccine, which is not on the immediate horizon, or from natural infection,” Harvard University epidemiologist Marc Lipsitch told a gathering of experts on a video call this weekend.
The more infectious a virus is, the more people need to be immune for us to achieve herd immunity. Measles, one of the most easily transmitted diseases with an R0 over 12, requires about 90% of people to be resistant for unprotected people to get a free ride from the herd. That’s why new outbreaks can start when even small numbers of people opt out of the measles vaccine.
Similarly, if the coronavirus spreads more easily than the experts think, more people will need to get it before herd immunity is reached. For an R0 of 3, for example, 66% of the population has to be immune before the effect kicks in, according to the simplest model.
Whether it’s 50% or 60% or 80%, those figures imply billions infected and millions killed around the world, although the more slowly the pandemic unfolds, the greater the chance for new treatments or vaccines to help.
The newest epidemiological models developed in the UK now recommend aggressive “suppression” of the virus. The basic tactics being urged would be to isolate sick people, try to reduce social contacts by 75%, and close schools. Those economically costly measures could continue for many months.
“Suppressing transmission means that we won’t build up herd immunity,” says Azra Ghani, the lead epidemiologist on the new model of the outbreak from Imperial College London. The trade-off of success is “that we are driving it down to such a low level that we have to keep those [measures] in place.” “ (F)
“Which brings us to why herd immunity could never be considered a preventative measure.
If 70 percent of your population is infected with a disease, it is by definition not prevention. How can it be? Most of the people in your country are sick! And the hopeful nonsense that you can reach that 70 percent by just infecting young people is simply absurd. If only young people are immune, you’d have clusters of older people with no immunity at all, making it incredibly risky for anyone over a certain age to leave their house lest they get infected, forever.
It’s also worth thinking about the repercussions of this disastrous scenario – the best estimates put COVID-19 infection fatality rate at around 0.5-1 percent. If 70 percent of an entire population gets sick, that means that between 0.35-0.7 percent of everyone in a country could die, which is a catastrophic outcome.
With something like 10 percent of all infections needing to be hospitalised, you’d also see an enormous number of people very sick, which has huge implications for the country as well.
The sad fact is that herd immunity just isn’t a solution to our pandemic woes. Yes, it may eventually happen anyway, but hoping that it will save us all is just not realistic. The time to discuss herd immunity is when we have a vaccine developed, and not one second earlier, because at that point we will be able to really stop the epidemic in its tracks.
Until we have a vaccine, anyone talking about herd immunity as a preventative strategy for COVID-19 is simply wrong. Fortunately, there are other ways of preventing infections from spreading, which all boil down to avoiding people who are sick.
So stay home, stay safe, and practice physical distancing as much as possible.” (G)
“But even assuming that immunity is long-lasting, a very large number of people must be infected to reach the herd immunity threshold required. Given that current estimates suggest roughly 0.5 percent to 1 percent of all infections are fatal, that means a lot of deaths.
Perhaps most important to understand, the virus doesn’t magically disappear when the herd immunity threshold is reached. That’s not when things stop — it’s only when they start to slow down.
Once enough immunity has been built in the population, each person will infect fewer than one other person, so a new epidemic cannot start afresh. But an epidemic that is already underway will continue to spread. If 100,000 people are infectious at the peak and they each infect 0.9 people, that’s still 90,000 new infections, and more after that. A runaway train doesn’t stop the instant the track begins to slope uphill, and a rapidly spreading virus doesn’t stop right when herd immunity is attained.
If the pandemic went uncontrolled in the United States, it could continue for months after herd immunity was reached, infecting many more millions in the process.
By the time the epidemic ended, a very large proportion of the population would have been infected — far above our expected herd immunity threshold of around two-thirds. These additional infections are what epidemiologists refer to as “overshoot.”
Herd immunity doesn’t stop a virus in its tracks. The number of infections continues to climb after herd immunity is reached.
Some countries are attempting strategies intended to “safely” build up population immunity to the coronavirus without a vaccine. Sweden, for instance, is asking older people and those with underlying health issues to self-quarantine but is keeping many schools, restaurants and bars open. Many commentators have suggested that this would also be a good policy for poorer countries like India. But given the fatality rate, there is no way to do this without huge numbers of casualties — and indeed, Sweden has already seen far more deaths than its neighbors.
As we see it, now is far too early to throw up our hands and proceed as if a vast majority of the world’s population will inevitably become infected before a vaccine becomes available.
Moreover, we should not be overconfident about our ability to conduct a “controlled burn” with a pandemic that exploded across the globe in a matter of weeks despite extraordinary efforts to contain it.
Since the early days of the pandemic, we have been using social distancing to flatten its curve. This decreases strain on the health care system. It buys the scientific community time to develop treatments and vaccines, as well as build up capacity for testing and tracing. While this is an extraordinarily difficult virus to manage, countries such as New Zealand and Taiwan have had early success, challenging the narrative that control is impossible. We must learn from their successes.
There would be nothing quick or painless about reaching herd immunity without a vaccine.” (H)
“While much of Europe has gone into lockdown, one country has bucked the trend: Sweden.
Restaurants, schools and playgrounds in the Scandinavian country are open. Sweden’s Foreign Minister Ann Linde has said it’s not following the herd immunity theory, but rather relying on its citizens to voluntarily be responsible to prevent the spread of the coronavirus.
But Sweden’s state epidemiologist, Anders Tegnell, claimed herd immunity could be reached in the nation’s capital, Stockholm, within weeks.
“In major parts of Sweden, around Stockholm, we have reached a plateau (in new cases) and we’re already seein the effect of herd immunity and in a few weeks’ time we’ll see even more of the effects of that,” Tegnell said in an interview with CNBC.
The strategy hasn’t come without costs.
WHO has said it’s “imperative” that Sweden take stronger measures to control the spread of the virus.
Compared to other European nations that haven taken stricter measures, Sweden’s “curve” — the rate of infections and deaths caused by the coronavirus — is steeper. As of Wednesday, Sweden has at least 1,937 reported coronavirus-related deaths, compared to Norway’s 185 and Finland’s 149 deaths, according to data from Johns Hopkins University.” (I)
“Sweden’s ambassador to the U.S. has said the country’s capital Stockholm could reach herd immunity from the coronavirus within a few weeks, despite questions over whether people who have recovered from COVID-19 are actually protected from a second infection.
Herd immunity means the majority of a population have become immune to an infectious disease, either by recovering from it or by being vaccinated.
Karin Ulrika Olofsdotter, Swedish ambassador to the United States, told NPR: “About 30 percent of people in Stockholm have reached a level of immunity. We could reach herd immunity in the capital as early as next month.”
How much of the population needs to have been infected to achieve herd immunity depends on the disease. With COVID-19, the figure is unclear, but it is estimated at least 50 to 60 percent of the population would need to have been infected.
There is no official lockdown in Sweden and schools, restaurants and stores have stayed open during the pandemic. The government has issued social distancing guidelines and told citizens to avoid unnecessary travel. Gatherings of more than 50 people and visits to care homes have been banned.
Officials forced five bars and restaurants in Stockholm to close after they failed to respect social distancing guidelines.
Olofsdotter said that additional research and testing is necessary to understand more about immunity to COVID-19. She said the Swedish government would change its approach to tackling the coronavirus if necessary.” (J)
“Governments everywhere are facing a stark “jobs vs. deaths” Hobbesian choice.
How long will the public tolerate lockdowns that paralyze the economy and limit essential social mobility?
In response, many countries are seemingly lining up behind two unproven strategies based on contradictory hypotheses of virus behavior. This with similar hopes that they can thread the needle by limiting the human toll to “acceptable” levels, keep hospitals from being overwhelmed, and maintain vital economic activity.
The first “elimination hypothesis” has been implemented on physical or virtual islands such as Singapore, Taiwan, South Korea, Iceland, and New Zealand. It is based on the presumption that the virus can be eliminated via a two-pronged strategy: stop importation at borders and ports of entry and reduce domestic outbreaks by stringent containment procedures.
In countries such as the U.K., the U.S., Italy, and Spain, where the virus has long ago escaped containment and mitigation phase, a variant of the elimination model is being deployed. Cycles of suppression lockdowns alternating with the relaxation of social distancing interventions accompanied by aggressive containment measures are anticipated.
Significant second and further resurgent waves of infection are likely if the importation of virus or domestic foci re-emerge. Armies of virus hunter tracking teams would need to be deployed in ongoing containment firefights.
The public messaging accompanying the elimination model is for absolute safety to avoid exposure at all costs. Acquired immunity is thwarted, and an effective vaccine features prominently as the end-game.
The second “herd immunity hypothesis“ is actively or implicitly practiced in Sweden, Mexico, and Belarus. It assumes a virus that cannot be sealed off or contained. It is presumed to be best controlled through managed spread through the population, leading to progressively greater levels of acquired immunity. Since the virus cannot be indefinitely evaded, it is accommodated and gently accepted. It was initially slowing then ultimately halting the spread through herd immunity….
As these grand experiments play out, it would be a tragic missed opportunity not to take full global advantage. Each country should make explicit the assumptions and presumed scientific basis of its strategy clear. To allow valid national comparisons, there should be a cooperative global “Big Data” acquisition and analysis framework set up to measure the impact of each strategy.
This race is more marathon than a sprint. Long-term health winners will be judged on the cumulative “area under the epidemic curve” measured in total infections, severe cases, and deaths. Also, when measures of effective immunity are eventually determined, population immunity rates will be critical. If the herd-immunity hypothesis is correct, the early numerical lead of the elimination countries will dissipate over time.” (K)
“Social distancing and frequent handwashing are currently the only ways to help prevent you and those around you from contracting and potentially spreading SARS-CoV-2, the virus that causes COVID-19.
There are several reasons why herd immunity isn’t the answer to stopping the spread of the new coronavirus:
-There isn’t yet a vaccine for SARS-CoV-2. Vaccinations are the safest way to practice herd immunity in a population.
-The research for antivirals and other medications to treat COVID-19 is ongoing.
-Scientists don’t know if you can contract SARS-CoV-2 and develop COVID-19 more than once.
-People who contract SARS-CoV-2 and develop COVID-19 can experience serious side effects. Severe cases can lead to death.
-Doctors don’t yet know exactly why some people who contract SARS-CoV-2 develop severe COVID-19, while others do not.
-Vulnerable members of society, such as older adults and people with some chronic health conditions, could get very sick if they’re exposed to this virus.
-Otherwise healthy and younger people may become very ill with COVID-19.
-Hospitals and healthcare systems may be overburdened if many people develop COVID-19 at the same time.” (L)
“President Trump on Sunday night said that the government would reassess the recommended period for keeping businesses shut and millions of workers at home after this week, amid millions of job losses caused by the efforts to contain the spread of the novel coronavirus.
“WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF,” Mr. Trump tweeted in all capital letters shortly before midnight. “AT THE END OF THE 15 DAY PERIOD, WE WILL MAKE A DECISION AS TO WHICH WAY WE WANT TO GO!”” (M)
“We won’t get to herd immunity in the near future. A miracle drug is not in sight. The only way to restart the economy, then, is to put a highly effective system in place to test millions of people, trace their movements, and quickly quarantine those who might have been infected.
But even as the past few days have brought bad news about the science of the pandemic, they have brought terrifying news about its politics: It now seems less likely than ever that the United States will do what is necessary to reopen the economy without causing a second wave of deadly infections.
America is still behind on testing for COVID-19. Although Trump promised almost two months ago that anyone who wanted a test could get one, the U.S. has still conducted only about 5.4 million. The country needs to increase its testing rate at least threefold to reopen safely.
America is also behind on test and trace. Some countries, such as South Korea, now have robust systems in place to inform people that they have been exposed to the coronavirus, and need to self-isolate. But implementing such a system requires two things the United States sorely lacks: widespread trust in the government and a coordinated response from the White House.
In the absence of a federal strategy, some states, such as New York and Massachusetts, are trying to develop their own test-and-trace systems. But without help from Washington, they will likely lack both the resources to build a comprehensive system and the ability to persuade a large majority of their residents to sign up for an app that tracks their movements. Even if, against the odds, they should succeed in both these tasks, they face another obvious obstacle: Viruses don’t respect state lines.
If he were truly interested in limiting the damage to America’s economy, and opening up the country, Trump would be laser-focused on remedying these problems. Instead, the president has doubled down on culture wars and quack cures.
Early last week, Trump fanned the flames of the irresponsible protests against stay-at-home orders that are now being staged in cities across the country. A few days later, he vowed to “suspend immigration” to the United States. Then he suggested that scientists look into the possibility of injecting patients with bleach.
For all his blustering demands to get the country back to normal, the president is failing to take the steps that are required to reopen the economy without a horrific death toll. And for all the ingenuity shown by individual governors, the absence of a coordinated federal strategy may prove impossible to overcome.
Ihaven’t written much about the pandemic recently. The reason is, quite simply, that I didn’t feel there was much to say. Though every day brought a ton of news, a lot of it was contradictory; for long, painful weeks, I felt as though my overall understanding of the situation was barely improving.
Now I finally feel on firmer ground. Some of what we have learned over the past few weeks has been positive. The fatality rate from COVID-19 is likely to be significantly lower than early estimates suggested. Americans have followed social-distancing guidelines to an impressive degree. So far, we have succeeded in flattening the curve, and have not had to turn thousands of people in desperate need of medical treatment away from the emergency room. Even in New York City, the American epicenter of the pandemic, the number of new infections and new fatalities is ebbing.
We are not in the worst of all possible timelines. And yet, our hopes for the pandemic’s quick resolution should clearly be shelved. Taken together, the three major developments of the past few days paint a bleak picture of the months that lie ahead: COVID-19 is too deadly to let it rip through the population. An effective cure is not in sight. And the federal government is incapable of formulating a coherent pandemic response.” (N)
“You’re tired of Zoom cocktail hours, the never-ending pile of dishes, Netflix.
You miss your friends. You want to hug your parents. You want to see people’s faces, no masks please.
And if you are among the more than 30 million Americans who filed for unemployment since mid-March, you are probably freaking out about your finances too.
Perhaps you are beginning to wonder if the people protesting stay-at-home orders around the state and across the country have a point: Maybe this extended physical distancing is doing more harm to our collective health than good.
Just how bad would it be to let everyone struggling to pay their bills go back to work? To eat at a restaurant again? To go to the beach on a hot day without being scolded by your governor?
After all, doesn’t this pandemic end with either a vaccine, herd immunity or some combination of the two? If everything reopened and a few more people got sick, might that be a reasonable price to pay?
If only it were that simple….
“The hospitals are really the bottleneck here,” she said.
Shelter-in-place orders have effectively kept many hospital systems across the country from becoming overburdened by COVID-19 patients, but that could change quickly as restrictions are eased.
“Because of confinement, there is an appearance that we can manage this,” Bourouiba said.”
But if those measures were suddenly lifted with nothing to replace them, we would overwhelm the healthcare system and doctors would start having to choose who lives and who dies, she said.
“That’s the ethical question people in our society need to be thinking about,” Bourouiba added.
So, what will it take to ease the stay-at-home measures with minimal risk to society? Public health experts agree on the essentials: the capacity to rapidly test people who may be infected, isolate those who test positive, and track and quarantine their close contacts.
And unfortunately, communities must be willing to go back into lockdown if there is an explosion of cases in their midst….” (O)
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”
POST 23. May 3, 2020. CORONAVIRUS. … what Dr. Fauci really wants,…”is just to go to a baseball game. That will have to wait. The level of testing for the virus is not adequate enough to allow for such mass gatherings.’ (K)
POST 24. May 7, 2020. CORONAVIRUS. Former New Jersey governor Chris Christie said: “there are going to be deaths no matter what”… but that people needed to get back to work.
Abstract from April 28th letter from New Jersey Department of Health on serologic testing for Coronavirus.
“Currently, these tests may be useful to determine the prevalence of COVID 19 in a population or to identify individual patients who may be candidates to donate plasma for therapeutic purposes. There is, of course, also great interest in identifying individuals who may be immune to SARS-CoV-2 due to previous infection. However, due to the lack of current evidence that detection of SARS-CoV-2 antibody on any serologic test is indicative of durable immunity, and that false positives can occur with any of these serologic tests, they should not be used for this purpose at this time. Additionally, serologic tests do not have a role in diagnosing acute infection in symptomatic individuals since antibody responses to infection may take days to weeks to be detectable. A negative serologic test does not rule out active infection and a positive serologic test may reflect prior infection with a human coronavirus other than SARS-CoV-2. A positive test is not indicative of immunity and should not be used for return-to-work decisions.”
to read Posts 1-23 in chronological order, highlight and click on
“Some antibody tests, which check for prior Covid-19 infection, had high rates of false positives in screenings performed by a consortium of California laboratories, according to a recently released report.
A false positive means someone would be told they’d already had coronavirus when they had not – a potential danger as people could then think they were immune to the virus when they’re actually still vulnerable.
Of the 12 antibody tests that were studied by the COVID-19 Testing Project, one of the tests gave false positives more than 15% of the time, or in about one out of seven samples. Three other tests gave false positives more than 10% of the time.
“That’s terrible. That’s really terrible,” said Dr. Caryn Bern, one of the authors of the study that looked at the 12 tests. She said while it’s unrealistic to think all tests will be 100% accurate all the time, their false positive rates should be 5% or lower, or ideally 2% or lower.
“This was a real wake up call for me. We’re not at the point where any of these tests can be used reliably,” added study coauthor Dr. Alexander Marson. “There’s a big danger in relying on them at all, but we hope we get to a point soon where we can rely on these tests.” …
Of the 12 tests in the California review, only one company has this FDA stamp of approval. That’s a test by Mount Sinai Laboratory in New York City, which the California group tweaked to use in their own lab.
That test got only one false positive out of 108 blood samples…
The California researchers obtained as many tests as possible, but so far have been unable to screen antibody tests by large test makers such as Roche and Abbott, because they require proprietary instruments to run the tests, which the California tests did not have.
They hope to continue screening more antibody tests to see if they work but warned that even if a reliable test shows you have antibodies, doctors still don’t know what that means. Having antibodies could indicate you’re immune and won’t get infected a second time or it could indicate you have no immunity at all. It could also mean something in between — for example, that you have some limited immunity for a period of a few months.
“We have this huge knowledge gap,” Bern said. “That’s the most important message.” (A)
“The Food and Drug Administration has allowed about 90 companies, many based in China, to sell tests that have not gotten government vetting, saying the pandemic warrants an urgent response. But the agency has since warned that some of those businesses are making false claims about their products; health officials, like their counterparts overseas, have found others deeply flawed.
Tests of “frankly dubious quality” have flooded the American market, said Scott Becker, executive director of the Association of Public Health Laboratories. Many of them, akin to home pregnancy tests, are easy to take and promise rapid results.
And the federal guidance that does exist is so confusing that health care providers are administering certain tests unaware that they may not be authorized to do so. Some are misusing antibody test results to diagnose the disease, not realizing that they can miss the early stages of infection.
“People don’t understand how dangerous this test is,” said Michael T. Osterholm, an infectious disease expert at the University of Minnesota. “We sacrificed quality for speed, and in the end, when it’s people’s lives that are hanging in the balance, safety has to take precedence over speed.”
Even as government agencies, companies and academic researchers scramble to validate existing tests and create better ones, there are doubts they can deliver as promised. Most tests now available mistakenly flag at least some people as having antibodies when they do not, which could foster a dangerously false belief that those people have immunity.
And even if the tests do improve, their availability could be hampered by the same manufacturing shortages that have prevented the Covid-19 diagnostic tests from scaling up adequately.
As President Trump presses to reopen the country and several states are considering lifting lockdowns in the next few weeks, widespread screening is considered critical. On Friday, Mr. Trump cheered the F.D.A.’s emergency approval of some antibody tests, saying they would support efforts to get Americans back to work “by showing us who might have developed the wonderful, beautiful immunity.”” (B)
“Testing for the coronavirus has been very much in the news. The first and most urgent focus is on increasing access to tests to diagnose people with current infections. But now other tests are appearing as well. Antibody tests, which can identify people with signs of past infection, are starting to be available. And a third type of test is on the way.
Here’s a quick guide to sorting out the pluses and minuses to each type of test.
Diagnostic or PCR test
What it does: Doctors use this test to diagnose people who are currently sick with COVID-19. This is the one we’ve been hearing so much about.
Antibody test
What it does: Antibody tests identify people who have previously been infected with the coronavirus. They do not show whether a person is currently infected. This is primarily a good way to track the spread of the coronavirus through a population.
In general, these tests aren’t reliable enough for individuals to act based on the results. And researchers say, even if you were certain you had antibodies to the coronavirus, it’s still unknown if that protects you from getting sick again. Still, these tests can provide good information about rates of infection in a community, where errors in an individual result have less impact.
Antigen test
What it does: This test identifies people who are currently infected with the coronavirus. It may be used as a quick test to detect active infections. Initially it will not be used to diagnose disease, but it may be used to screen people to identify those who need a more definitive test.” (C)
“Should I get an antibody test right now?
I would recommend it, but only if you’re part of a research study where your results are contributing to an understanding of what results actually mean. Otherwise, it’s generally not advisable to get tests unless we know what to do with the results, and we don’t yet. We don’t even know if most of the tests that have come on the market are accurate. There are now more than 150 tests, most of which have not been approved by the Food and Drug Administration.
Why does FDA approval matter?
The FDA is maybe best known for its role in helping make sure that drugs are safe and effective before they go to market. But the FDA does the same for tests, too. That includes nasal-swab tests to detect the coronavirus during an infection, and blood tests to detect antibodies after an infection. The approval process slows down the availability of tests, but the idea is that patients and doctors should have some assurance that the tests they’re using are at least somewhat accurate. Even the coronavirus antibody tests that are “approved” right now by the FDA are only being used under a special “emergency use authorization,” for which standards are looser than usual. The others could be total scams. You can sell almost anything and call it a coronavirus antibody test right now; the market is operating mostly on an honor system.
What makes one antibody test better than another?
The two key features are sensitivity and specificity. A test has to be sensitive enough not to miss the antibodies if they’re actually present, but specific enough not to accidentally show a positive result…
Why are we putting so much emphasis on antibody testing if the results don’t necessarily mean I’m superhuman?
Right now, the antibody tests are being used to help map out where the coronavirus has spread, like tracking the footprints it has left. Combined with other types of research, this information will eventually help identify who is most susceptible to infection, and why. Even if we can’t tell individuals that they are totally protected, we could theoretically begin to allocate scarce resources away from a city where 50 percent of people have antibodies to one where only 5 percent of people do.” (D)
“The World Health Organization has pushed back against the theory that individuals can only catch the coronavirus once, as well as proposals for reopening society that are based on this supposed immunity.
In a scientific brief dated Friday, the United Nations agency said the idea that one-time infection can lead to immunity remains unproven and is thus unreliable as a foundation for the next phase of the world’s response to the pandemic.
“Some governments have suggested that the detection of antibodies to the SARS-CoV-2, the virus that causes COVID-19, could serve as the basis for an ‘immunity passport’ or ‘risk-free certificate’ that would enable individuals to travel or to return to work assuming that they are protected against re-infection,” the WHO wrote. “There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection.”
The statement comes days after Chile announced it would begin issuing immunity cards that effectively act as passports, allowing travelers to clear security at airports with a document that purportedly shows they have recovered from the virus. Authorities and researchers in other countries — such as France and the United Kingdom — have expressed interest in similar ideas, while some officials in the U.S., such as Los Angeles Mayor Eric Garcetti, have mentioned it as one possible facet of a reopening strategy.
The concept for such a card is largely based on the premise that an individual can only contract the coronavirus once before developing the necessary antibodies to fight it off. That premise undergirds another common theory: the concept, known as herd immunity, that if enough people have been infected with the coronavirus — and are therefore immune — its transmission will slow and the risks of infection will diminish even for those who haven’t caught it yet.
But these ideas depend to a large degree on the supposition that one cannot catch the coronavirus a second time — an idea that world health authorities said leaders should not count on right now. As of Friday, the WHO said, “No study has evaluated whether the presence of antibodies to SARS-CoV-2 confers immunity to subsequent infection by this virus in humans.”
What’s more, data reported from the world’s early COVID-19 hot spots, such as South Korea and China, have shown that a growing number of recovered patients appear to have suffered a relapse of the disease…
“People who assume that they are immune to a second infection because they have received a positive test result may ignore public health advice. The use of such certificates may therefore increase the risks of continued transmission.”” (E)
“Zehnder, who helped coordinate Stanford’s antibody test development, said it’s reasonable to assume the antibodies provide some level of protection, since most other viruses generally confer immunity after exposure. But out of an abundance of caution, we cannot say for sure if these antibodies grant immunity to COVID-19.
“It’s important to not make assumptions of being protected before you actually know because that could lead to dangerous behavior and spreading of a disease,” Zehnder said….
The main use of antibodies tests, at least now, is to help researchers understand the prevalence of COVID-19. We’re quickly learning that many people who were symptom-free, or even tested negative for COVID-19 on a diagnostic test, actually had the infection.
With that information, we can get a clearer read on how infectious the coronavirus is.
“If there are enough tests, it would be important to expand the testing to everyone so we understand the extent of viral spread in populations in the future,” Iwasaki said.
Antibody tests alone can’t open up the economy, but used alongside diagnostic tests, contact tracing, distancing and quarantining, these measures can help health officials get a better handle on the coronavirus. If we want to open up the economy, we need to know exactly what is going on with the infection, Zehnder said.” (F)
“The fact that most antibody tests can’t detect neutralizing antibodies is also relevant because some politicians are pushing the idea that these tests be used to clear those with past COVID-19 infections to interact with others again, a so-called immunity passport. Researchers are trying to determine whether the antibodies detected by current kits can act as a proxy for protective immunity, says Smith.
Another complicating factor for immunity passports is that antibody tests can’t rule out that a person is no longer infectious, says Smith. A study published in Nature this month found that viral RNA declines slowly after antibodies are detected in the blood. The presence of viral RNA could mean that the person is still shedding infectious virus.
Despite the challenges, once reliable antibody tests are available, they could be important to understanding which groups of people have been infected how to stop further spread, says Collignon. They could even be used to diagnose active infections when PCR tests fail, adds Smith.” (G)
“A new type of coronavirus test expected to offer clarity on how and when to reopen the nation has instead sowed confusion.
A blood test that can detect whether a person’s had the virus has been heralded as an important tool for policymakers. Not only would it help answer critical questions such as how widespread it is, the test would inform them when people can safety return to work or school and not worry about becoming ill.
But hopes for quick answers have been dashed as a lack of evidence raises questions about the accuracy and reliability of a wide swath of antibody tests now being marketed to hospitals, doctors and consumers.
Public health experts are questioning the precision of antibody tests now being deployed in communities nationwide. And they warn elected officials, business leaders and consumers should be careful about making decisions based on test results.
Colin West is a Mayo Clinic internal medicine doctor and professor who has tracked the accuracy of COVID-19 tests.
“We need to stop pretending the tests are perfect,” West said. A person who gets tested should not “suddenly stop wearing a mask or stop washing their hands. Or stop physically distancing.”
The problem, West said, is tests don’t have evidence to prove they are good enough to ease policies on social distancing.
“Hopefully we will get there at some point,” he said. “Right now, it feels premature.” (H)
“Experts said the FDA likely felt pressure to quickly allow antibody testing after it took several weeks to authorize commercial labs to perform diagnostic tests during the early weeks of the pandemic…
Because shortages made diagnostic testing hard to get during the early months of the pandemic, many are seeking antibody tests to answer whether they recovered from COVID-19…
Hospital systems such as Cedars-Sinai in Los Angeles are taking a different approach. It is working to validate commercial tests before offering to test to the public, said Dr. Rekha Murthy, an infectious disease specialist and associate chief medical officer.
“We need to allow science to drive our decision-making,” Murthy said…
Baird said such inaccurate testing could misinform decision-makers about critical things like fatality rates of COVID-19. More “false positive” tests could dramatically skew results, Baird said.
“It may cause you to erroneously believe that the fatality rates was much lower because you had many cases but few people died,” said Baird, acting chair and professor at the University of Washington Department of Laboratory Medicine.
West said questions about antibody testing accuracy are not meant to undermine the usefulness of the tests. The key is to balance the speed of testing while ensuring the accuracy science demands to produce useful results.
“We are dealing with a pandemic that demands rapid action,” West said, “but developing a robust evidence base with rigorous methodology is not a rapid process.” (I)
“Meanwhile, a flood of new test kits with varying rates of accuracy is now hitting the market. In the U.K., for example, Prime Minister Boris Johnson touted finger-prick antibody tests as a “game changer,” only for the government to realize that the 3.5 million tests it bought from China were not reliable enough to use. Of particular concern here is the false-positive rate: If the prevalence of COVID-19 is quite low in the population—say, 5 percent—and a test can identify people who are truly negative with 95 percent reliability, half of the “positives” it returns will be false positives. In other words, half of the people the test says have antibodies wouldn’t actually have them. “I wouldn’t want to tell a nurse or physician ‘Go back to work’ based on that,” Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told me.
Moreover, Osterholm said, antibody tests don’t give a snapshot of the present. It can take two weeks for a patient to develop a detectable amount of antibodies in their blood, so antibody surveys are necessarily backward-looking. But when public-health officials are deciding whether schools or businesses are safe to reopen, the key piece of information is the number of people currently infected. “I want to know what is happening now,” Osterholm said, “and antibody testing will not get that to you.”
The key strategies for stopping the disease are still the same ones experts have been promoting from the beginning: testing, contact tracing, isolating for those who test positive for COVID-19, and social distancing for everyone else. “There’s going to have to be some level of new normal for a while,” Dean said. Ongoing antibody surveys will help clarify the true scope of the pandemic and the true proportion of asymptomatic carriers, and those data can indeed help inform public-health decisions. But as far as antibody testing goes, Gronvall said, “it’s not the silver bullet for everything.” “(J)
To relieve the stress, he runs daily. But what he really wants, like so many sports fans, is just to go to a baseball game.
“I don’t think there’s any place that I relax more than sitting in Nats Park and watching my now world champion Nats play a game,” Fauci, 79, who grew up in Brooklyn rooting for the Yankees and is now a Washington Nationals fan, said in an interview this week.
That will have to wait. The level of testing for the virus is not adequate enough to allow for such mass gatherings.’ (K)
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”
POST 23. May 3, 2020. CORONAVIRUS. … what Dr. Fauci really wants,…”is just to go to a baseball game. That will have to wait. The level of testing for the virus is not adequate enough to allow for such mass gatherings.’ (K)
“Mayo Clinic is furloughing or reducing the hours of about 42 percent of its 70,000 employees across all of its campuses in an attempt to mitigate the financial losses from the COVID-19 pandemic…
“Approximately 30,000 staff from across all Mayo locations will receive reduced hours or some type of furlough, though the duration will vary depending on the work unit,” according to a statement on Wednesday from spokeswoman Ginger Plumbo.
As these will be furloughs, not layoffs, Mayo Clinic will continue to pay for the health care benefits for all of its employees while they are off work…
Doctors will not be furloughed, but will have a 10 percent wage reduction. Doctors who are senior managers will see reductions of 15 percent. Top executives are taking 20 percent reductions.
Some of Mayo Clinic’s medical departments are mostly quiet, so some doctors may be “redeployed where needed most,” according to Mayo.
Hospitals on the Rochester campus are operating at 35 to 40 percent capacity, and surgical volume is at 25 to 30 percent of the level that was expected. About 60 percent of Mayo Clinic’s business comes from elective procedures of the kind that are now on hold.
This is latest step in Mayo Clinic’s financial stabilization strategy to address an anticipated $3 billion loss due to the pandemic forcing a temporary halt in all elective procedures and average medical appointments.” (A)
“Elective surgery does not mean optional surgery. It simply means nonurgent, and what is truly nonurgent is not always so obvious. Gerard Doherty, the chair of the surgery department at Brigham and Women’s Hospital in Boston, which began postponing elective surgeries on Friday, says surgical procedures can fall into one of three categories. About 25 percent of the surgeries performed at his hospital can be delayed without much harm. These might include joint replacements and bariatric surgeries for weight loss. Another 25 percent are for life-threatening emergencies that need to be treated right away: perforated bowels, serious heart problems, bones that have broken through the skin…
All over the country, patients are finding their nonemergency surgical appointments canceled as hospitals prepare for a spike in coronavirus cases. Surgeries for early-stage cancer, joint replacements, epilepsy, and cataracts are all getting pushed back—to ration much-needed personal protective equipment, keep hospital beds open, and to shield patients from the virus. On Friday, the American College of Surgeons recommended that hospitals reschedule elective surgeries as needed. Hospitals in outbreak hot spots such as Seattle, New York, and Boston were the first to act, but more are likely to follow suit.
The last 50 percent are the tricky ones. These cases, Doherty says, have “some potential for harm to delay”; they might include cancer and problems in the blood vessels of the arms and legs. Brigham and Women’s is postponing some of these surgeries now on a case-by-case basis…
Canceling surgical appointments is also meant to limit the number of people circulating through hospitals. Surgeries like Kumm’s, which require a long hospital stay, during which visitors might be coming in and out, Ko said, may be particularly risky from the point of view of spreading the coronavirus. Hospitals around the country are also limiting patients to one adult visitor.” (B)
“In the same week that physicians at the University of California-San Francisco medical center were wiping down and reusing protective equipment like masks and gowns to conserve resources amid a surge of COVID-19 patients, 90 miles away teams of doctors at UC Davis Medical Center were fully suited up performing breast augmentations, hip replacements and other elective procedures that likely could have been postponed.
Across the nation, hospitals, nurses and physicians are sending out desperate pleas for donations of personal protective gear as supplies dwindle in the regions that have emerged as hot spots for the fast-spreading new coronavirus. The Centers for Medicare & Medicaid Services, the Surgeon General and the American College of Surgeons (ACS) have urged hospitals to curtail non-urgent elective procedures to preserve equipment. Washington state, Colorado, Massachusetts, Ohio, Kentucky, New York City and San Francisco have gone further, placing moratoriums on elective surgeries.
Still, in pockets of the country, some hospitals have continued to perform a range of elective procedures, spokespeople confirmed. In Pennsylvania, the University of Pittsburgh Medical Center is continuing to offer elective procedures on a case-by-case basis. In Indiana and Illinois, Franciscan Health will continue some elective surgeries, depending on the availability of protective equipment and the concentration of COVID-19 cases in the area. And in California, Nebraska, Nevada and Wyoming, Banner Health will continue to offer elective procedures in communities that haven’t yet reported cases of COVID-19.
The divergent responses underscore not only the disparities in supply stockpiles from hospital to hospital, but also a lack of coordination — even at a regional level — in getting equipment and medical care where it’s needed…
California offers a prime example of the disparate responses. The state has been an early epicenter for the new coronavirus, with more than 1,000 confirmed cases and nearly two dozen deaths. The San Francisco Bay Area has been hit particularly hard, and emergency room doctors at UCSF this week described dire shortages of personal protective equipment, or PPE. Sutter Health has shut down elective surgeries, as have most other University of California hospitals across the state.
At UC Davis, in contrast, procedures have continued.
“I’ll be clear: There is no reason to cancel elective procedures at this time and doing so would be a disservice to our patients who, for many different reasons, require surgery or other scheduled procedures,” UC Davis Chief Medical Officer Dr. J. Douglas Kirk wrote in an email to employees earlier this week. “We currently have capacity and we have an outstanding supply chain and procurement team, so the UC Davis Medical Center is doing well on supplies, PPE and space utilization.” (C)
Some hospitals and surgery centers continue to conduct elective surgeries amid the COVID-19 crisis, defying federal requests and state bans seeking to stop the nonessential procedures even as essential medical supplies dwindle.
Medical staff members said the refusal to comply puts them and their families at risk as they are forced to reuse personal protection gear such as face masks. Some said the outsized influence of revenue-generating surgeons is a driving factor….
USA TODAY reported March 21 that hospitals, including UPMC and Virginia Hospital Center in Arlington, allowed some elective surgery. Surgeon General Jerome Adams wrote an op-ed for USA TODAY that day further urging physicians and hospitals to stop. VHC has apparently halted nonemergency procedures.
“As we are in the midst of a whole-of-government effort to fight COVID-19, we need all our health care workforce and more to meet the demands of this challenge,” Adams wrote. “Every non-urgent case takes precious staff time and energy, straining a workforce already going above and beyond in this fight.”
The American College of Surgeons cited the financial pressure in “ethical guidelines” it released.
“Health systems, and federal and state governments should begin developing comprehensive solutions to address the financial impact on hospitals, physicians, and other health care providers that result from canceled operations, so that these perceived financial risks do not influence some surgeons to continue to perform elective operations,” the guidelines say…
Facilities allowing nonemergency surgeries include Steward Health Care. The more than 30-hospital chain, which operates in states including Texas and Louisiana, said in a statement that it will “continue to support all scheduled surgeries and procedures, and we will leave the decision on whether it is appropriate to proceed now to our physicians and their patients.”
Steward said it is “committed to preserving access to scheduled procedure time for as long as possible.”…
Marty Makary, a Johns Hopkins University hospital surgeon and professor, said, “Any entirely elective procedure that uses valuable supplies at this critical time is short-sighted.”
“It is borderline unethical for any U.S. hospital to perform elective surgery if the operation can be delayed three or more months without any health consequences to the patient,” said Makary, author of “The Price We Pay: What Broke American Health Care – and How to Fix It.” (D)
“This week, ACS released guidelines for triaging elective surgery during the pandemic that include seven overarching principles:
1. Although some of the triaging guidelines include recommendations based on a low level of COVID-19 infections, coronavirus cases are expected to surge in the next few weeks and surgical teams are advised to prepare for much higher infection rates when triaging elective surgeries now.
2. Based on surgical judgment and resource availability, patients should get appropriate and timely surgical care.
3. Nonoperative management is advised when it is clinically appropriate for patients.
4. Surgical teams should consider waiting for COVID-19 test results for patients who may be infected.
5. With anticipated staffing shortages, emergency surgical procedures at night should be avoided.
6. Aerosol generating procedures such as intubation and electrocautery of blood increase healthcare worker risk for patients who test COVID-19 positive or are suspected of infection. If aerosol generating procedures are unavoidable, surgical staff should wear full personal protective equipment including an N95 mask or powered, air-purifying respirator designed for operating room use.
7. Although there is insufficient data to make a recommendation for open surgery vs. laparoscopy, surgical teams should pick an approach that reduces operating room time and increases safety for patients and healthcare workers.” (E)
“The ACS bulletin stated the following specific recommendations [11]:
Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs.
Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19.” (F)
“What Cleveland Clinic says
The Clinic will determine, based on guidelines set by the Ohio Department of Health, which procedures are non-essential and ones where patients should expect delays.
“This change supports statewide efforts to conserve hospital beds, equipment and supplies while protecting healthcare workers in preparation for a potential surge of patients with COVID-19,” Cleveland Clinic spokeswoman Andrea Pacetti said.
The procedures that will move forward must be life-saving, preserve the function of organs or limbs, reduce the risk of metastasis or progression of a disease or reduce the risk of severe symptoms, according to the Clinic’s guidelines as well as MetroHealth and University Hospitals.
Examples of elective surgeries and other related procedures include,” deferrable bronchoscopy, deferrable upper and lower endoscopies, routine dental procedures, symptomatic problems which are stable, management of benign conditions, cosmetics, primary and revision joint therapy (non-infected), bariatric and elective hernia surgery, and urogynecology,” the Clinic says.
“We continue to adapt to this evolving situation, with the primary goal of keeping our patients and caregivers safe,” the Clinic said in a statement.” (G)
“Healthcare facilities should be able to begin performing elective procedures again if they follow certain protocols, according to guidelines released Sunday by the Centers for Medicare & Medicaid Services (CMS)…
“Every state and local official has to assess the situation on the ground,” she said. “They need to be able to screen patients and healthcare workers for the COVID virus, and we need to make sure that patients feel safe when they come in to seek healthcare services by showing they have the appropriate cleaning in place and that they observe social distancing inside the healthcare facilities.” Verma added that this will be a gradual process in which “healthcare systems across the country need to decide what services should be available. We want to make sure systems are reopening so they can stay open, and doing that in a very measured way.”
The new CMS guidelines specify that “non-COVID-19 care should be offered to patients as clinically appropriate and within a state, locality, or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases, if necessary. Decisions should be consistent with public health information and in collaboration with state public health authorities.”
Once the facility has reopened to patients needing elective procedures, “evaluate the necessity of the care based on clinical needs,” the guidelines state. “Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.”
As for getting the practice ready to accept patients, “Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area),” according to the guidelines. “Sufficient resources should be available to the facility across phases of care, including PPE [personal protective equipment], healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.”
The guidelines also address PPE for patients and staff. “CMS recommends that healthcare providers and staff wear surgical facemasks at all times. Procedures on the mucous membranes including the respiratory tract, with a higher risk of aerosol transmission, should be done with great caution, and staff should utilize appropriate respiratory protection such as N95 masks and face shields. Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.” (H)
“Centers for Medicare & Medicaid Services (CMS) Recommendations, Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I
General Considerations
• In coordination with State and local public health officials, evaluate the incidence and trends for COVID-19 in the area where re-starting in-person care is being considered.
• Evaluate the necessity of the care based on clinical needs. Providers should prioritize surgical/procedural care and high-complexity chronic disease management; however, select preventive services may also be highly necessary.
• Consider establishing Non-COVID Care (NCC) zones that would screen all patients for symptoms of COVID-19, including temperature checks. Staff would be routinely screened as would others who will work in the facility (physicians, nurses, housekeeping, delivery and all people who would enter the area).
• Sufficient resources should be available to the facility across phases of care, including PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care, without jeopardizing surge capacity.” (I)
1. KNOW YOUR COMMUNITY’S CORONAVIRUS STATISTICS. The maximum incubation period for the coronavirus is estimated at two weeks. There should be a decrease in incidence of COVID-19 cases for at least two weeks before elective surgery is resumed. Monitor local COVID-19 statistics such incidence of new cases to detect a resurgence of the virus. Consider setting a threshold for new cases of COVID-19 that would trigger putting elective surgeries on hold again.
2. KNOW AVAILABILITY OF COVID-19 TESTING AND CRAFT TESTING POLICIES.
Monitor local COVID-19 testing availability and lab result times.
Craft testing policies for patients such as pre-operative testing of patients scheduled for surgery.
Craft testing policies for healthcare workers such as screening and testing guidance.
With false negative test rates as high as 30%, consider establishing retesting policies for patients and healthcare workers.
With fever and lung complications possible in the postoperative period, consider establishing retesting guidelines for symptomatic patients.
3. PERSONAL PROTECTIVE EQUIPMENT.
Before elective surgery is resumed, there should be a stored inventory of PPE or a reliable supply chain for at least 30 days of operations.
PPE policies should be in place for COVID-19 positive patients, persons under investigation, and non-COVID-19 patients, including for high-risk procedures such as intubation.
Consider having all healthcare workers and staff wear appropriate PPE outside the operating room and having all patients wear cloth masks.
4. KNOW KEY HEALTHCARE FACILITY CAPACITIES.
A hospital’s available resources should include peri-anesthesia units, critical care, diagnostic imaging, and lab services.
Consider new sites for elective surgery such as hospital spaces that were converted for COVID-19 care, including outpatient departments.
OR schedules should be set to accommodate a spike of electives surgeries such as performing procedures at night or on weekends.
Make sure there is sufficient capacity for preoperative, intraoperative, postoperative, and post-acute care.
5. SUPPLIES CAPACITY.
Ensure there are adequate levels of surgical supplies and equipment such as implants and anesthesia-sedation medications.
Ensure a supply chain is in place for traditional or new vendors.
Conduct an inventory of existing supplies and check expiration dates.
There should be adequate cleaning supplies, particularly for areas where care is provided to COVID-19 patients and persons under investigation.
6. HEALTHCARE WORKER STAFFING.
There should be adequate multidisciplinary staffing for routine and expanded hours.
Assess coordination of key staff members, including surgeons, anesthesiologists, nurses, and housekeeping.
Have contingencies in place for staff members who test positive for the coronavirus.
Assess the level of stress and fatigue among healthcare workers who have been providing frontline care during surges of COVID-19 patients.
Consider mitigation efforts for workforce shortages such as enlisting retired surgeons to work as first assistants.
7. CREATE GOVERNANCE COMMITTEE.
A governance committee can make real-time decisions for several pivotal issues, including PPE, pandemic assessment, patient backlog, and safety and quality.
The governance committee should be multidisciplinary, including surgeons, anesthesiologists, and nurses.
At least during the elective surgery ramp-up period, the governance committee should meet daily.
8. PATIENT COMMUNICATION.
Consider creating a multidisciplinary committee to manage patient communication.
There are several crucial patient communication topics, including procedure prioritization, coronavirus testing policies, PPE use, and advance directives.
9. PRIORITIZATION OF SURGERY.
Key stakeholders such as surgeons, anesthesiologists, and nurses should participate in ramp-up planning, including the collaborative formation of principles and frameworks for surgery prioritization.
The prioritization process should be adjustable to local, regional, and national epidemiological trends and changes in COVID-19 care. The prioritization process should also take a facility’s resources, priorities, and patient needs into account.
he prioritization process, principles, and framework should be transparent to hospitals, healthcare workers, and the public. The benefits of transparency include reducing ethical dilemmas.
There are multiple considerations in developing the prioritization process, including a list of canceled and delayed procedures, a strategy for phased opening of ORs, PPE availability, and issues related to increased OR volume.
10. ENSURE SAFETY AND HIGH VALUE IN ALL FIVE PHASES OF SURGICAL CARE.
Optimal care in the preoperative phase includes considering the use of telehealth.
Optimal care in the immediate preoperative phase features reviewing surgery, anesthesia, and nursing checklists for possible revisions related to COVID-19 positive patients and other considerations.
Optimal care in the intraoperative phase includes guidelines for staff during intubation.
Optimal care in the postoperative phase includes adherence to standardized care protocols.
Optimal care in the post discharge phase includes post-acute care facility availability and safety. (J)
“Ohio’s doctors and surgeons have one week to tell the governor what steps they would take to protect patients and conserve personal protective equipment if he were to lift the ban on elective surgeries.
Gov. Mike DeWine said he talked for about two hours Wednesday with medical professionals worried about patients who can’t get help because of the state’s restriction. He told the group to give him a plan that would still minimize the use of personal protective equipment…
Ohio Health Director Dr. Amy Acton halted nonessential surgeries and medical procedures during the coronavirus crisis on March 18. The concern was not that medical personnel and facilities were unsafe, but that regular use might deplete the state’s supply of protective gear, and surgical centers might be needed to house COVID-19 patients.
Neither of those things has happened, said Rep. Nino Vitale, R-Urbana. That’s why he and a growing number of other state legislators want the restrictions on health care providers lifted as soon as possible.
“It is the No. 1 call to our offices — even above ‘I can’t get through to the unemployment number,’” Vitale said.
Dr. Thomas Kramer, a gastroenterologist at the Taylor Station Surgical Center on the Far East Side, said he and many of his colleagues think they should be able to get back to work immediately.
Kramer said he doesn’t doubt the seriousness of the virus but thinks it’s clear that Ohio has avoided a worst-case scenario. The center, he said, has enough personal protective equipment from its usual shipments to operate as normal.
“It’s not making a lot of sense to us as physicians and nurses as things are improving,” Kramer said. “If we’ve got enough equipment, and we’re doing the things they want us to do, and people need the health care … then when are we going to be doing this again?”
Orthopedic surgeon Ian Thompson told the task force that he has patients who probably will need additional surgeries or face worse outcomes because they aren’t getting physical therapy. One female patient got worse because her knee-replacement surgery was put on hold.
“Her knee gave out, and she fell and broke her hip and is now in the hospital,” Thompson said.
A pediatric dentist from Minster in northwestern Ohio said he’s worried about his patients’ teeth shifting because devices such as braces and retainers require frequent checkups.
“The longer that treatment gets delayed, there will be teeth moving in directions unsupervised,” Dr. Phil Slonkosky said. “That’s definitely going to cause some problems.”
DeWine and Acton are the ones with the authority to lift the restriction on nonessential medical care. They’ve been in contact with groups such as the Ohio Hospital Association as well as state legislators.
“I think common sense is going to prevail here,” said Rep. Derek Merrin, R-Monclova. “I expect for there to be a reversal here shortly.”
Merrin acknowledged that short of changing the laws that give Acton the authority to issue such orders, there isn’t a lot that legislators can do to force her hand regarding doctors’ offices and surgical centers. He said hopes that the governor and his team will trust Ohio’s medical professionals to keep their patients and employees safe.
“Health decisions need to be between the physician and the patient … We do not need the state government micromanaging what kind of procedures people will get,” Merrin said. “State government has no role in telling someone if they are going to have a hip replacement or not.”” (K)
“Virginia Governor Ralph Northam is extending several orders he announced earlier in the COVID-19 pandemic, including postponements of elective surgeries and the closure of DMV offices.
Northam announced in a statement on Thursday that the current ban on elective surgeries, which was set to expire on Friday, April 24, is being extended by one week to May 1..
Just a few hours before the governor’s announcement on Thursday, the Virginia Hospital & Healthcare Association sent a public letter to the governor urging his administration to let the elective surgery postponement order expire, saying that hospitals have the capacity to handle both the procedures and COVID-19 cases.
But the governor said the ban on elective surgeries will continue until State Health Commissioner M. Norman Oliver, MD, MA can “evaluate, in conjunction with hospitals and other medical facilities, how to safely ease restrictions on non-essential medical procedures, and the availability of personal protective equipment.”
The VHHA said that Virginia hospitals have already established a framework (which you can review here), for re-opening the health care delivery system in a responsible manner consistent with the Open Up America Again Guidance document recently issued by the White House.
“My top priority is protecting public health, and that includes ensuring that our frontline medical staff have the equipment they need to stay safe as they treat Virginians who are sick,” said Governor Northam. “We have increased our supply of PPE, but before we allow elective surgeries to resume, we must first be assured that the doctors, nurses, and medical staff who are fighting this virus or conducting emergency surgeries have the necessary supplies. We are working with medical facilities on plans to ensure that we can resume elective surgeries safely and responsibly.”
The public health emergency order, Order of Public Health Emergency Two, does not apply to any procedure if the delay would cause harm to a patient. The order also does not apply to outpatient visits in hospital-based clinics, family planning services, or emergency needs.
But the VHHA says the continued postponement of the procedures puts patients with chronic conditions at risk and keeps medical workers furloughed.
Hospitals continue to treat emergency patients and perform essential surgeries, and Northam says “Virginians should feel safe going to hospitals if they are experiencing a medical emergency, such as a heart attack.”” (L)
The American Hospital Association published a road map to resuming elective surgeries on April 17, alongside the American College of Surgeons, American Society of Anesthesiologists and the Association of periOperative Registered Nurses.
The road map details principles and considerations for health care professionals to take into account as they start integrating more elective procedures back into their schedules. Some of the principles include timing for reopening elective surgeries, COVID-19 testing within facilities, adequate Personal Protection Equipment (PPE) supplies, conservation policies for PPE and case prioritization and scheduling…
Resumption of elective surgeries is a part of President Donald Trump’s “Reopening America” plan. “We’re encouraging states around the country to restart elective surgery wherever possible even on a county by county basis,” Vice President Mike Pence said Friday, speaking at Trump’s signing of a $484 billion coronavirus relief package.
As states gauge whether to allow elective surgeries, surgeons and hospitals face the difficult task of balancing patients’ needs with safety and equipment requirements. Postponing elective surgeries has also allowed hospitals to conserve personal protective equipment (PPE) and hospital beds for care involving COVID-19 patients.
“Coronavirus is highly infectious, and if there’s a procedure that would bring people together, just like in a restaurant or an airplane, then avoiding it if it can be avoided is the best practice,” Dr. David Hoyt, executive director of the American College of Surgeons, told NBC News. “You have to balance that with patients that need surgery, but the urgency of it can be triaged, and that’s what was done.”
Some surgeons have also shared concerns about performing elective surgeries on asymptomatic COVID-19 patients, fearful that patient mortality and ICU rates can increase significantly for those with unknown infection at the time of surgery.
Hospitals that resume elective surgeries need to be mindful of maintaining beds and equipment in case there are an uptick of sick patients, Hoyt said. “I think people need to ramp up at some rates, not just do it all overnight.”
Most hospitals have come up with systems to assess the urgency of elective surgeries for their patients…
The University of Chicago hospital published a scoring system this month to aid surgeons in making decisions about elective surgeries. The “Medically Necessary Time-Sensitive (MeNTS) Prioritization” system allows surgeons to assess elective surgeries systematically — evaluating risks for both patients and personnel.
“While these numbers are not meant to be strict cutoffs, as far as if it’s above some number, then you can’t do it and below it, you can, that sort of thing, it at least provides guidance,” Dr. Vivek N. Prachand, professor of surgery and chief quality officer for surgery at University of Chicago, said.
Prachand said that this will provide some guidance and then the threshold of whether to do the surgery can be decided, “not only the score, but the availability of the resources and personnel in the hospital itself, depending on where it’s located, not only geographically but where it’s located along the COVID curve.”.. (M)
“Hospitals are preparing for elective surgeries, which were put on hold because of COVID-19. This comes after Governor Greg Abbott made the announcement Friday to allow the procedures again across Texas.
Doctor Richard Peterson, with the Long School of Medicine at UT Health San Antonio, said the move to allow elective surgeries will be methodically planned.
“Most of the facilities are looking to resume elective surgeries kind of starting next week and it’s going to be a gradual ramp-up,” said Peterson said.
Peterson, who also practices at University Hospital, Foundation Surgical Hospital of San Antonio and CHRISTUS Santa Rosa Health System, said patients undergoing elective surgery are often vulnerable.
“What we don’t want to do is put a patient who isn’t sick, at risk for getting sick, especially with this virus,” Peterson said, “So we are taking extra preventative steps.”
Peterson said because non-emergent surgeries are backed up, there will be a re-introduction process.
“We are going to be careful about how much we are scheduling so we don’t overload and use up all of that protective personal protective equipment,” Peterson told us.
Peterson also said doctors will test every elective surgery patient for COVID-19.
“I think that’s kind of a new change, to ensure that we’re definitely making sure the patients aren’t infected prior to surgery,” Peterson said…
In a statement, Methodist Healthcare’s President and CEO, Allen Harrison, said staff there will follow similar guidelines.
As we continue to monitor the dynamic shifts of the COVID-19 pandemic, Methodist Healthcare has begun to thoughtfully re-introduce elective procedures and surgeries following Governor Abbott’s updated Executive Order on Friday, April 17. Elective procedures are not the equivalent of “optional” procedures that can be delayed indefinitely. Elective procedures are those that can be scheduled. These procedures have been classified within tiers of urgency and acuity, allowing us to prioritize services as we take a measured approach to this transition. While continuing to abide by all state regulations, patients and physicians will see continued, and in some cases enhanced, screening, testing, universal masking and patient cohorting, patient flow procedures, as well as infection prevention protocols in our facilities. As an added precaution, we will conduct universal COVID-19 testing for all elective surgery patients prior to their procedure and will continue with a “no visitor” policy per Health and Human Services guidance.” (N)
“Amid the ongoing COVID-19 pandemic, Governor Andrew M. Cuomo today announced elective outpatient treatments can resume in counties and hospitals without significant risk of COVID-19 surge in the near term. Hospitals will be able to resume performing elective outpatient treatments on April 28, 2020 if the hospital capacity is over 25 percent for the county and if there have been fewer than 10 new hospitalizations of COVID-19 patients in the county over the past 10 days. If a hospital is located in a county eligible to resume elective outpatient treatments, but that hospital has a capacity under 25 percent or has had more than 10 new hospitalizations in the past 10 days, that hospital is not eligible to resume elective surgeries. If a county or hospital that has resumed elective surgery experiences a decrease in hospital capacity below the 25 percent threshold or an increase of 10 or more new hospitalizations of COVID-19 patients, elective surgeries must cease. Further, patients must test negative for COVID-19 prior to any elective outpatient treatment. The State Department of Health will issue guidance on resuming elective surgeries.
Restrictions on elective surgery will remain in place in Bronx, Queens, Rockland, Nassau, Clinton, Yates, Westchester, Albany, Richmond, Schuyler, Kings, Suffolk, New York, Dutchess, Sullivan, Ulster, Erie, Orange and Rensselaer Counties as the state continues to monitor the rate of new COVID-19 infections in the region.
Governor Cuomo also announced the state will take a regional approach to reopening and will make decisions on which counties and regions to open and when to open them based on the facts and data specific to that area. Lieutenant Governor Kathy Hochul will coordinate Western New York’s public health and reopening strategy, and former Lieutenant Governor Robert Duffy will volunteer as a special advisor to coordinate the Finger Lakes’ public health and reopening strategy.
It is essential that we continue to support hospitals and health care workers in all regions to ensure they have both capacity and supplies to treat COVID patients because this virus is by no means defeated.
“As New York continues to flatten the curve of new COVID-19 infections, we are now ready to lift the restrictions on elective surgeries in regions where hospital capacity and the rate of new infections do not present a significant risk of a surge in new positive cases,” Governor Cuomo said. “It is essential that we continue to support hospitals and health care workers in all regions to ensure they have both capacity and supplies to treat COVID patients because this virus is by no means defeated.”” (O)
“Despite a directive from the governor of Pennsylvania, the state’s biggest hospital system is preparing to ramp up elective surgical procedures — the goal being to reach pre-shutdown surgical capacity within six weeks.
The Post-Gazette has obtained documentation showing that UPMC is gearing up for the move that makes it the only health care system in the region to do so.
A letter to UPMC surgeons dated April 15 from hospital leadership offers guidance to surgeons on how to justify doing such procedures, recommending the use of terms such as “urgent,” “cancer,” “unstable” and “relief from suffering” in reports.
“We have NOT said no to a surgery that the surgeon and patient feels should proceed,” according to the April 15 letter, which was obtained by the Post-Gazette.
UPMC employees told the Post-Gazette in March that they were upset over risks to staff and patient health, and the use of resources that might be needed as the virus spread.
The Pittsburgh-based health system’s push to return to pre-COVID-19 levels of elective surgery comes despite a ban on elective medical procedures issued by the Pennsylvania governor in March, a ban that the state health department said is still in effect.
But a spokesman for the health system, which operates 40 hospitals, said Monday that UPMC believes it can do elective procedures safely and noted that new guidance from the Centers for Medicare and Medicaid Services emphasized flexibility to “allow facilities to provide care for patients needing non-emergent health care.”
If successful, UPMC, which reported $20.6 billion in revenue for 2019, would be among the first health systems in Pennsylvania to restore elective operations.
UPMC was behind other Pittsburgh-area health systems in winding down non-emergency procedures after Gov. Wolf’s March 19 directive, continuing to do them after Allegheny Health Network, Excela Health, Heritage Valley Health System, St. Clair and Washington Health System said they had stopped.
At Allegheny Health Network, the surgical shutdown continues for elective procedures.
“At AHN, we continue to closely monitor the progression of the COVID-19 pandemic in western PA while also communicating regularly with local and state health officials about the safest and most responsible approaches to patient care at this time,” spokesman Dan Laurent said in a statement. “We are preparing appropriately for an organized, phased-in return to normal surgical operations in the coming weeks and will strictly follow CDC and CMS guidelines in order to ensure the safety and well-being of our patients and caregivers when we do.”
To return to pre-shutdown surgical capacity, UPMC is counting on technology that received emergency clearance from the Food and Drug Administration on March 29, which allows COVID-19-contaminated face masks to be sterilized for reuse by doctors and nurses up to 20 times.
Typically, the malleable polyester masks are discarded after wearing once or twice, but nationwide shortages of the protective gear have been reported…
More than 1,300 UPMC employees were briefed on the plans Thursday, where the partnership with Battelle was described as key to the restoration of the non-emergency surgery caseload at UPMC.
On Friday, Gov. Wolf provided a broad outline for reopening the state, but without a timeline or benchmarks that would guide his decision. On Monday, the governor went further, easing restrictions on online car sales and allowing the restart of construction projects statewide May 8. But he stopped well short of ending mitigation efforts.
The Wolf administration does “not feel that today is the day that hospitals should resume these services,” state Department of Health spokesman Nate Wardle said Thursday. “We must take a slow, iterative process as we ease back on our mitigation efforts and not move too quickly.”
He declined to elaborate when contacted Monday. Health officials have warned that ending mitigation efforts too soon could bring a rebound of the disease.
Citing CMS guidance that was issued Sunday, UPMC spokesman Paul Wood said on Monday that the time was right to begin doing elective procedures.
“In the current environment, with proper protection and precautions, we believe that we can soon begin to treat patients who postponed needed treatments and procedures,” he said in a statement.
His comments echoed the new CMS guidance.
“At this time, many areas have a low, or relatively low and stable, incidence of COVID-19 and that it is important to be flexible and allow facilities to provide care for patients needing non-emergent, non-COVID-19 health care,” CMS said. “In addition, as states and localities begin to stabilize, it is important to restart care that is currently being postponed.”
In a conference call with more than 1,300 employees Thursday, UPMC officials said non-emergency operations would be ramped by 10% this week after a case-by-case review, which will include COVID-19 testing of the patient two days before the procedure, according to the person who participated in the briefing but was not at liberty to speak publicly about it. Back surgery for chronic pain and hernia repair are examples of the operations that could start to be scheduled.” (P)
“New Hyde Park, N.Y.-based Northwell Health is giving front-line staff responding to the COVID-19 pandemic a $2,500 lump-sum payment and a week of paid time off.
Physicians, nurses, respiratory therapists and others involved in direct patient care are eligible for the bonus and PTO as are housekeepers, environmental services workers and others. The health system said about 45,000 workers are eligible for the payments and supplemental PTO.” (Q)
PART 1. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”
PART 2. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”
PART3. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)
PART 4. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….
PART 5. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”
POST 6. Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””
PART 7. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.
PART 8. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”
PART 9. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”
Part 10. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.
PART 11. CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”
Part 12. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”
Part 13. CORONAVIRUS. March 14, 2020. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”
PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”
PART 15. CORONAVIRUS. March 22, 2020. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.
PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT
PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.” “New York’s private and public hospitals unite to manage patient load and share resources.
PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.
PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”
POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”
“President Trump on Saturday cited “positive signs” in the fight against the coronavirus pandemic, claiming that he inherited “broken junk” from the prior administration but has since turned the U.S. into the “king of ventilators.”” (A)
“Just about a month ago, people stricken with the new coronavirus started to arrive in unending ranks at hospitals in the New York metropolitan area, forming the white-hot center of the pandemic in the United States.
Now, doctors in the region have started sharing on medical grapevines what it has been like to re-engineer, on the fly, their health care systems, their practice of medicine, their personal lives.
Medicine routinely remakes itself, generation by generation. For the disease that drives this pandemic, certain ironclad emergency medical practices have dissolved almost overnight.
The biggest change: Instead of quickly sedating people who had shockingly low levels of oxygen and then putting them on mechanical ventilators, many doctors are now keeping patients conscious, having them roll over in bed, recline in chairs and continue to breathe on their own — with additional oxygen — for as long as possible.
The idea is to get them off their backs and thereby make more lung available. A number of doctors are even trying patients on a special massage mattress designed for pregnant women because it has cutouts that ease the load on the belly and chest.
Other doctors are rejiggering CPAP breathing machines, normally used to help people with sleep apnea, or they have hacked together valves and filters. For some critically ill patients, a ventilator may be the only real hope.” (B)
“Even as hospitals and governors raise the alarm about a shortage of ventilators, some critical care physicians are questioning the widespread use of the breathing machines for Covid-19 patients, saying that large numbers of patients could instead be treated with less intensive respiratory support.
If the iconoclasts are right, putting coronavirus patients on ventilators could be of little benefit to many and even harmful to some.
What’s driving this reassessment is a baffling observation about Covid-19: Many patients have blood oxygen levels so low they should be dead. But they’re not gasping for air, their hearts aren’t racing, and their brains show no signs of blinking off from lack of oxygen.
What is making critical care physicians suspect that blood levels of oxygen, which for decades have driven decisions about breathing support for patients with pneumonia and acute respiratory distress, might be misleading them about how to care for those with Covid-19. In particular, more and more are concerned about the use of intubation and mechanical ventilators. They argue that more patients could receive simpler, noninvasive respiratory support, such as the breathing masks used in sleep apnea, at least to start with and maybe for the duration of the illness.
“I think we may indeed be able to support a subset of these patients” with less invasive breathing support, said Sohan Japa, an internal medicine physician at Boston’s Brigham and Women’s Hospital. “I think we have to be more nuanced about who we intubate.”..
An oxygen saturation rate below 93% (normal is 95% to 100%) has long been taken as a sign of potential hypoxia and impending organ damage. Before Covid-19, when the oxygen level dropped below this threshold, physicians supported their patients’ breathing with noninvasive devices such as continuous positive airway pressure (CPAP, the sleep apnea device) and bilevel positive airway pressure ventilators (BiPAP). Both work via a tube into a face mask.
In severe pneumonia or acute respiratory distress unrelated to Covid-19, or if the noninvasive devices don’t boost oxygen levels enough, critical care doctors turn to mechanical ventilators that push oxygen into the lungs at a preset rate and force: A physician threads a 10-inch plastic tube down a patient’s throat and into the lungs, attaches it to the ventilator, and administers heavy and long-lasting sedation so the patient can’t fight the sensation of being unable to breathe on his own.
But because in some patients with Covid-19, blood-oxygen levels fall to hardly-ever-seen levels, into the 70s and even lower, physicians are intubating them sooner. “Data from China suggested that early intubation would keep Covid-19 patients’ heart, liver, and kidneys from failing due to hypoxia,” said a veteran emergency medicine physician. “This has been the whole thing driving decisions about breathing support: Knock them out and put them on a ventilator.”..
The question is whether ICU physicians are moving patients to mechanical ventilators too quickly. “Almost the entire decision tree is driven by oxygen saturation levels,” said the emergency medicine physician, who asked not to be named so as not to appear to be criticizing colleagues…
“We need to ask, are we using ventilators in a way that makes sense for other diseases but not for this one?” Gillick said. “Instead of asking how do we ration a scarce resource, we should be asking how do we best treat this disease?”… (C)
“Some doctors are also concerned that ventilators could be further harming certain coronavirus patients, as the treatment is hard on the lungs, the AP reported.
Dr. Tiffany Osborn, a critical-care specialist at the Washington University School of Medicine, told NPR on April 1 that ventilators could actually damage a patient’s lungs.
“The ventilator itself can do damage to the lung tissue based on how much pressure is required to help oxygen get processed by the lungs,” she said.
Dr. Negin Hajizadeh, a pulmonary critical-care doctor at New York’s Hofstra/Northwell School of Medicine, also told NPR that while ventilators worked well for people with diseases like pneumonia, they don’t necessarily also work for coronavirus patients.
She said that most coronavirus patients in her hospital system who were put on a ventilator had not recovered.
She added that the coronavirus does a lot more damage to the lungs than illnesses like the flu, as “there is fluid and other toxic chemical cytokines, we call them, raging throughout the lung tissue.”
“We know that mechanical ventilation is not benign,” Dr. Eddy Fan, an expert on respiratory treatment at Toronto General Hospital, told the AP.
“One of the most important findings in the last few decades is that medical ventilation can worsen lung injury — so we have to be careful how we use it.”
Doctors are trying to find other solutions and reduce their reliance on ventilators
The lack of treatment options for coronavirus patients has caused much of the world to turn to ventilators for the worst-affected patients.
But the high death rates reported among patients on ventilators have prompted some doctors to seek alternatives and reduce their reliance on ventilators, the AP reported.
Dr. Joseph Habboushe, an emergency-medicine doctor in Manhattan, told the AP that until a few weeks ago, it was routine in the city to place particularly ill coronavirus patients on ventilators. Now doctors are increasingly trying other treatments.
“If we’re able to make them better without intubating them,” Habboushe said, “they are more likely to have a better outcome — we think.”
According to the AP, doctors are putting patients in different positions to try to get oxygen into different parts of their lungs, giving patients oxygen through nose tubes, and adding nitric oxide to oxygen treatments to try to increase blood flow.
Dr. Howard Zucker, the New York state health commissioner, said on Wednesday that officials were examining other treatments to use before ventilation but that it was “all experimental,” the AP reported.” (D)
“Only a few weeks ago in New York City, coronavirus patients who came in quite sick were routinely placed on ventilators to keep them breathing, said Dr. Joseph Habboushe, an emergency medicine doctor who works in Manhattan hospitals…
There are widespread reports that coronavirus patients tend to be on ventilators much longer than other kinds of patients, said Dr. William Schaffner, an infectious diseases expert at Vanderbilt University.
Experts say that patients with bacterial pneumonia, for example, may be on a ventilator for no more than a day or two. But it’s been common for coronavirus patients to have been on a ventilator “seven days, 10 days, 15 days, and they’re passing away,” said New York Gov. Andrew Cuomo, when asked about ventilator death rates during a news briefing on Wednesday…
Experts think most people who are infected suffer nothing worse than unpleasant but mild illnesses that may include fever and coughing.
But roughly 20% — many of them older adults or people weakened by chronic conditions — can grow much sicker. They can have trouble breathing and suffer chest pain. Their lungs can become inflamed, causing a dangerous condition called acute respiratory distress syndrome. An estimated 3% to 4% may need ventilators.
“The ventilator is not therapeutic. It’s a supportive measure while we wait for the patient’s body to recover,” said Dr. Roger Alvarez, a lung specialist with the University of Miami Health System in Florida…
“Needing to be ventilated might mean never getting off the ventilator,” he said.” (E)
“Acute respiratory distress syndrome, or ARDS, is the endgame for the unluckiest COVID-19 patients. By that point, the virus has begun to destroy the tiny compartments in the lungs where blood normally collects oxygen. Roaring inflammation, a response to infection, further deteriorates the lung’s ability to draw in air. Without help, these patients could drown.
More than a dozen medications that were developed to treat other diseases are now being tested on COVID-19 patients. Ideally, several of them would allow patients with mild to moderate symptoms recover before their illnesses reach the severe or critical stage.
But researchers are not stopping there.
They are also using artificial intelligence to identify patients who are most likely to develop ARDS and need the gold standard treatment to survive. They’re devising ways to provide breathing assistance with techniques short of mechanical ventilation. If the ventilator shortage becomes desperate, as it has already in some New York City hospitals, doctors will likely try some of these alternatives to rescue dying patients.
Patients who are older, male and have underlying conditions such as heart disease, diabetes or asthma tend to have worse outcomes. But there are exceptions to that pattern. As they assess incoming COVID-19 patients, doctors need better ways to predict the courses their charges will likely take.
A team of researchers in China and at New York University turned to machine learning to see whether useful clues could be found through a massive scouring of symptoms, blood test results and patient characteristics.
Aided by artificial intelligence techniques, the researchers performed an exhaustive scrub of data from 53 patients who were treated in a hospital in Wenzhou, China. Their work identified the three top signs of a patient likely to develop critical illness, as well as their order of importance.
The resulting list amounts to a step-by-step “decision tree” to help doctors triage patients early and set aside scarce ventilators for the right ones.
At the top of the list: a slightly elevated level of the liver enzyme alanine aminotransferase, or ALT. It is one of 20 measures of metabolic and organ function, blood oxygenation and inflammation that’s routinely tested in all hospitalized patients.
In those who would go on to develop ARDS, ALT levels were so slightly above normal that “it would not necessarily set off alarm bells,” said Dr. Megan Coffee of NYU, who has been working on the research while treating COVID-19 patients. But in winnowing out patients most likely to need a respirator, it offers a powerful first clue.
Once that liver enzyme reading has tripped the alarm, a patient’s report of overall achiness appears to hold important information. After that, there’s a high likelihood of trouble ahead if sign No. 3 is present — an elevated hemoglobin level that looks like the opposite of anemia.
A patient’s male gender, higher temperature and abnormal sodium levels were measures 4, 5 and 6 on the list of predictors…
Coffee and her colleague Anasse Bari of NYU’s Courant Institute plan to refine their prediction tool by adding in the disease histories of more than 14,000 COVID-19 patients that have been admitted to New York City hospitals. Bari hopes a reliable decision tree will help guide healthcare workers in countries such as his native Morocco, where hospitals are expected to be overwhelmed in the pandemic.
Another approach is to find existing medical equipment that can function like a ventilator in certain circumstances.
A leading contender is the bilevel positive airway pressure device that is ordinarily used to help patients with breathing problems that have not progressed to the critical stage. BiPap machines could be used to wean some improving patients from the invasive mechanical ventilators, freeing them up for incoming patients, said Dr. Atul Malhotra, a lung specialist at UC San Diego. Already used widely in New York City, where COVID-19 patients are outstripping ventilators, BiPap machines deliver oxygen under pressure through a mask. Patients can readily pull them off to cough or because they are uncomfortable, so they pose extra infection risks to healthcare workers…” (F)
“For weeks, U.S. government officials and hospital executives have warned of a looming shortage of ventilators as the coronavirus pandemic descended.
But now, doctors are sounding an alarm about an unexpected and perhaps overlooked crisis: a surge in Covid-19 patients with kidney failure that is leading to shortages of machines, supplies and staff required for emergency dialysis.
In recent weeks, doctors on the front lines in intensive care units in New York and other hard-hit cities have learned that the coronavirus isn’t only a respiratory disease that has led to a crushing demand for ventilators.
The disease is also shutting down some patients’ kidneys, posing yet another series of life-and-death calculations for doctors who must ferry a limited supply of specialized dialysis machines from one patient in kidney failure to the next. All the while fearing they may not be able to hook up everyone in time to save them.
It is not yet known whether the kidneys are a major target of the virus, or whether they’re just one more organ falling victim as a patient’s ravaged body surrenders. Dialysis fills the vital roles the kidneys play, cleaning the blood of toxins, balancing essential components including electrolytes, keeping blood pressure in check and removing excess fluids. It can be a temporary measure while the kidneys recover, or it can be used long-term if they do not. Another unknown is whether the kidney damage caused by the virus is permanent…
Kidney specialists now estimate that 20 percent to 40 percent of I.C.U. patients with the coronavirus suffered kidney failure and needed emergency dialysis, according to Dr. Alan Kliger, a nephrologist at Yale University School of Medicine who is co-chairman of a Covid-19 response team for the American Society of Nephrology…
As the coronavirus spread rapidly in New York and in other cities, governors and mayors clamored for thousands more ventilators. But doctors have been surprised by the scarcity of dialysis machines and supplies, especially specialized equipment for continuous dialysis. That treatment is often used to replace the work of injured kidneys in critically ill patients.
The shortages involved not only the machines, but also fluids and other supplies needed for the dialysis regimen. Having enough trained nurses to provide the treatment has also been a bottleneck. Hospitals said they have called on the federal government to help prioritize equipment, supplies and personnel for the areas of the country that most need it, adding that manufacturers had not been fully responsive to the higher demand.
The fluids needed to run the dialysis machines are not on the Food and Drug Administration’s watch list of potential drug shortages, although the agency said it was closely monitoring the supply. The Federal Emergency Management Agency described the shortage of supplies and equipment as “unprecedented,” and said it was working with manufacturers and hospitals to identify additional supplies, both in the United States and overseas.
“Everybody thought about this as a respiratory illness,” said Dr. David Charytan, the chief of nephrology at N.Y.U. Langone Medical Center. “I don’t think this has been on people’s radar screen.”” (G)
“By using ventilators more sparingly on Covid-19 patients, physicians could reduce the more-than-50% death rate for those put on the machines, according to an analysis published Tuesday in the American Journal of Tropical Medicine and Hygiene.
The authors argue that physicians need a new playbook for when to use ventilators for Covid-19 patients — a message consistent with new treatment guidelines issued Tuesday by the National Institutes of Health, which advocates a phased approach to breathing support that would defer the use of ventilators if possible.
As the pandemic has flooded hospitals with a disease that physicians had never before seen, health care workers have had to figure out treatment protocols on the fly. Starting this month, a few physicians have voiced concern that some hospitals have been too quick to put Covid-19 patients on mechanical ventilators, that elderly patients in particular may have been harmed more than helped, and that less invasive breathing support, including simple oxygen-delivering nose prongs, might be safer and more effective.
The new analysis, from an international team of physician-researchers, supports what had until now been mainly two hunches: that some of the Covid-19 patients put on ventilators didn’t need to be, and that unusual features of the disease can make mechanical ventilation harmful to the lungs.
“This is one of the first coherent, comprehensive, and reasonably clear discussions of the pathophysiology of Covid-19 in the lungs that I’ve seen,” said palliative care physician Muriel Gillick of Harvard Medical School, who was one of the first to ask if ventilators were harming some Covid-19 patients, especially elderly ones. “There is mounting evidence that lots of patients are tolerating fairly extreme” low levels of oxygen in the blood, suggesting that such hypoxemia should not be equated with the need for a ventilator….
It’s important to highlight “aspects of Covid-19 that differ from other diseases that require respiratory support,” said Phil Rosenthal of the University of California, San Francisco, editor of the journal. Patients with Covid-19 pneumonia are often less breathless “compared to other patients with similar [blood oxygen] levels,” he said, adding that this difference “may allow physicians to avoid intubation/ventilator support in some patients.”
There is a growing recognition that some Covid-19 patients, even those with severe disease as shown by the extent of lung infection, can be safely treated with simple nose prongs or face masks that deliver oxygen.The latter include CPAP (continuous positive airway pressure) masks used for sleep apnea, or BiPAP (bi-phasic positive airway pressure) masks used for congestive heart failure and other serious conditions. CPAP can also be delivered via hoods or helmets, reducing the risk that patients will expel large quantities of virus into the air and endanger health care workers…
The Covid-19 treatment guidelines released by the NIH do not specifically address what criteria physicians should use for putting patients on a ventilator. But in a recognition of the damage that the ventilators can do, they recommend a phased approach to breathing support: oxygen delivered by simple nose prongs, escalating if necessary to one of the positive-pressure devices, and intubation only if the patient’s respiratory status deteriorates. If mechanical ventilation becomes necessary, the NIH said, it should be used to deliver only low volumes of oxygen, reflecting the risk of damaging healthy lung tissue” (H)
