Monday, March 30, 2020

The unpredictable yet predictable targets of SARS-CoV-2

I've tried to help myself and others discern SARS-CoV-2.

The best analogy I have come up with is as follows.

Imagine you have a less-than-mentally-stable-gun-carrying person passing through your town and possibly into your neighborhood. Let's call her Martha.

Imagine that Martha might walk down your street in the days that she was passing through your town.  Martha's presence would be unpredictable, she may be in your town for a few days or a few weeks, and she may be on your street 1x or 10x or 20x.  When Martha is present, with no pattern of frequency, with no predictable timeline, Martha shoots bullets in any direction, at random intervals.  And, Martha likes to remain in neighborhoods where people come out.

Let's imagine, for whatever reason, no one could stop Martha - though, for the sake of this imaginary exercise, let's imagine that if you never open your door to Martha, nor approach her, she could not fire at you (her ammunition would not, for example, go through your walls/windows.)  And, let's imagine that if Martha sees no person, she moves on to the next town.

In such an imaginary scenario, you would reasonably and practically never go anywhere in sight of nor in any proximate distance to Martha.  Ever. 

You would counsel everyone you know to stay away from Martha, too.  You would stay home until you had the "all clear" that Martha had left town.  And, if you went out for any reason, and saw Martha, you would steer clear of her on any street.

Martha doesn't intend to be mean or villainous, though, she does injure people.

Not all of her bullets hit live targets. 

Many of her bullets injure people. 

Some of her bullets kill people.

She shoots. She injures.  She kills.

SARS-CoV-2 is kind of like Martha.  It injures.  It kills.  It is unpredictable - while also being predictable. 

The only way to stay safe from SARS-CoV-2 is for you, and everyone you know, to stay away from "Martha"/SARS-CoV-2.

Of course, the problem with SARS-CoV-2 is that we don't know who "has it" and therefore, who, like Martha, is firing random penetrating "shots" at people.

And, of course, the greater problem with SARS-CoV-2 - and it is remarkably greater, is that in my imaginary scenario there is just Martha.  In the reality of SARS-CoV-2, every person that is infected, becomes a "new Martha" "shooting" at random intervals, at random frequency, in random directions, to anyone in their vicinity.

The only way to stop Martha from injuring or killing anyone, thereby, is to act, for a reasonable period of time over a few weeks - as if *every* person you meet is Martha - possibly, randomly, shooting you or anyone near her to injure or kill.

If left alone, Martha will go away.

If approached, Martha will maim, injure or kill more people.

More eery than Martha, SARS-CoV-2 multiples and replicates.

If left alone, Martha will go away.

If left alone, SARS-CoV-2 will go away. 

If we could get people to understand that SARS-CoV-2 is an "invisible" and nearly imperceptible "Martha" firing to injure some and kill others, perhaps we could better discern the need to be Safer At Home and to radically social distance - from anyone - as anyone could be "firing" lethal doses of SARS-CoV-2 into your body - injuring or killing you - or those that you love.

Be safe.

Wednesday, March 25, 2020

What lessons will we learn?

While the future is always unknown, it seems particularly true right now with major fractures from SARS-CoV-2 and COVID-19 to our sense of well being, work, eating, travel, social-distancing - that now, more than ever, we feel disrupted.

My hope  -  my genuine and true and real hope  -  is that human persons will emerge better from this.  Better able to discern our mutuality, our basic human needs, our willingness to help one another. 

I'm optimistic on many days that we can be better.

I'm fearful on some days that we will learn no lessons and only repeat our persistent cycles of desire, greed, rivalry, displacement and "othering" that make us less human, one with another, and which distort our relationship to all of Creation.

Sunday, March 22, 2020

Sharing from CNN - on SARS-CoV-2 and COVID-19

Former CDC director: There's a long war ahead and our Covid-19 response must adapt

(CNN)  Different times call for different measures. When Covid-19 hit China, I was concerned, as were many public health professionals, about what could happen and urged rapid action to understand more and prepare. But few of us anticipated the catastrophic impact the new virus has had in Wuhan, in Italy and may soon have in many other places.

For most people, there is simply no frame of reference for this pandemic. Never in our lifetime has there been an infectious disease threat as devastating to society. Never in our lifetime have we seen a rich country like Italy face the need to ration respirators. And never have we seen the fear that millions of health care workers around the world feel about being infected by the virus -- justified fear we must address.

What we're learning about the novel coronavirus

    We learn more about this virus by the day, often by the hour and most of the news is bad. Here are five things we've learned in the past week:
    • The virus is much more infectious than influenza or the SARS virus, which it closely resembles. This week, new data showed that SARS-CoV-2, the virus that causes Covid-19, can live on contaminated surfaces as the SARS virus can, so it may spread, sometimes explosively, from doorknobs, elevator buttons and contaminated surfaces in hospitals and elsewhere. But we also learned that, unlike SARS, patients become highly infectious before they become seriously ill, explaining at least in part why Covid-19 acts like a super-SARS, far more infectious than its vanquished cousin.
    • It's not just older people with underlying conditions who become very ill and can die. Younger adults, previously healthy people and some children develop viral pneumonia. Although prior reports suggested that 80% of people got only mild disease, it now appears that about half of these people, despite not needing hospital admission, have moderately severe pneumonia, which can take weeks or longer to recover from.
    • Explosive spread will almost certainly overwhelm health care capacity in New York City and elsewhere, and lead to the inability to save patients who could otherwise have been saved. Today's severe cases are in people infected 10 to 14 days ago who got sick five to six days ago and have steadily progressed to severe illness. That means cases will continue to skyrocket for weeks after spread stops. Not only won't there be enough ventilators, there won't be enough supplies for the ventilators, hospital beds to support patients -- or health care workers to help patients.
    • Health care workers are in peril. Thousands were infected in China, more than 3,000 have been infected in Italy, protective equipment is in short supply in the United States, and as health care becomes overwhelmed, it becomes harder to provide care safely.
    • It's going to get a lot worse. Not only is the global economy in free-fall but supply chains for essentials, including medicines, are disrupted. Even China, which has successfully tamped down spread, is only now reopening its economy -- which produces components of many medicines people rely on -- and very slowly.
    This is a war. And in war, strategy is important. The leading concept, now remarkably widely understood, is flattening the curve. This is an important tactic to protect patients and health care workers from a surge that can overwhelm our hospitals, increase death rates and put health care workers' lives at risk. But it is not a strategy. A month ago today, my organization, which focuses on preventing epidemics, published a concept of operations showing the shading of containment into mitigation, and the need to pause contact tracing when it became impractical and scale up social distancing interventions (see link for details.)
    Today, learning from another month of experience from around the world, particularly China and South Korea, we recognize a third phase of the response: suppression of episodic outbreaks. In this new third phase, extensive testing and alert clinical systems can identify cases and clusters promptly, intervene extensively and suppress spread before widespread societal harms occur.
    The revised approach also recognizes that this is going to be a long war, and that we need to address the extensive risks to societal continuity, including health care for people with ongoing medical needs such as hypertension and diabetes, and the vulnerability of the supply chain for medicines and supplies.
    China has outlined an analogous approach, based in part on their experience with cases re-imported from other parts of the world. In China, Hubei province faced a peak that overwhelmed health care services, but other provinces were able to avoid this through aggressive containment (the purple curve below). China remains largely locked down, with only gradual reopening, and is urgently expanding health care capacity, preparing for possible clusters or larger outbreaks in the future.
    There are five priorities essential for successful implementation of the third phase of this strategy.
    Extensive testing and contact tracing. China has tested millions of people and traced more than 685,000 contacts. Contact tracing requires skilled public health professionals -- and sophisticated data management. Testing is required in multiple venues:
    • Health care facilities. Every patient with fever or cough and every patient requiring mechanical ventilation or with signs or symptoms of pneumonia.
    • Contact tracing. An army of skilled public health workers, potentially empowered by new data streams such as cell phone location trails, are needed to identify exposed people, who must be isolated for 14 days after exposure. How widely a circle of contacts to track, and how and how often to test contacts will depend on emerging information about who spreads the infection and when in the course of their illness.
    • Drive-through. Quick, safe, convenient drive-through testing facilities, as pioneered by South Korea, reduce the burden on health care facilities, reduce the risk to health care workers and others who patients may come into contact with, and identify infections among contacts and others.
    • Surveillance. We need tracking systems, including the Influenza-Like Illness system, to find spread and monitor trends. Syndromic surveillance systems will need to be tuned to detect possible clusters, and signals investigated immediately.
    Prepare for health care to surge safely. Every community in the country needs to ramp up the ability to safely care for large number of patients with minimal risk to health care staff. This means not only flexing up the number of beds and availability of oxygen and ventilators, but every aspect of health care including staffing, equipment, supplies and overall management.
    Preserve health and routine health care functions. We need to increase the resilience of both our people and our health care facilities, as rapidly as possible.
    • Increase personal health resilience. Underlying conditions greatly increase the risk of severe illness. This isn't just bad for patients who get infected, it will take up scarce health care facilities. There has never been a better time to quit smoking, get your blood pressure under control, make sure that if you have diabetes it's well controlled, and -- yes -- get regular physical activity. (Being active outside for at least 15 minutes a day also helps with vitamin D levels. Of all of the various proposed measures to increase your resistance to infection, regular physical activity and adequate vitamin D levels probably have the most scientific evidence to support them -- and can be done safely.)
    • Massively scale up telemedicine. We need to reduce the number of people attending health care facilities while at the same time preserving and improving health. The Administration issued flexible and constructive guidelines for Medicaid, but much more is needed. Patients -- especially those who are uninsured or who don't have a regular source of care -- need to be able to refill prescriptions, get medical advice and find a clinician readily.
    • Fix supply chain weaknesses. This is crucial for masks and other personal protective equipment, ventilators and supplies for ventilators, and laboratory materials. This is a good time to look at a core list of medications and ensure that the safest and most effective ones are available. For example, in another area where my group works globally, we've discovered that instead of 30 or 50 medications for high blood pressure, three would do for nearly all patients. Let's make sure we have life-saving medicines and worry less about which companies are making them.
    Learn intensively. If there is one key lesson from past epidemics, it's that getting real-time data is essential for a great epidemic response.
    • Most urgently, we must learn how best to protect health care workers from infection.
    • We need to know who is most at risk for spreading the infection, and at what point in their illness -- so that we can target contact tracing most effectively. This will help determine how wide a circle of contacts to track, and how and how often to test.
    • Who is at the highest risk for severe illness and death.
    • What works to reduce infection? What public health advice is being followed, and what is the impact? Some countries require that all patients, even those with mild illness, are isolated in facilities. (This could be done, for example, in college dormitories). Is this necessary and effective? Should it be extended to close contacts to prevent them from spreading the infection? The answer to these questions will depend in part on answers to other questions, such as how often people who never have symptoms, or people who are just beginning to get sick, spread infection.
    • Are there rapid point-of-care tests and how accurate and timely are blood tests for coronavirus infection?
    • Is immunity protective? Even if antibodies are reliably produced, this doesn't necessarily mean that recovered patients are immune from a future infection.
    For these questions, the US Centers for Disease Control and Prevention and state and local health departments, as well as public health agencies around the world, are crucial. They are the intelligence officers needed to guide our strategy and tactics, and they need to be both at the table when decisions are made and at the podium when policies are explained.
    And these are just the epidemiological questions. We also urgently need to know whether treatments work. The preliminary report on the value of chloroquine and azithromycin needs to be rigorously addressed. The disappointing finding that two anti-viral medications didn't improve survival in severely ill patients is a sobering reminder that until there are rigorous studies, we won't know how best to treat patients. Even if we can't dramatically improve outcomes, a treatment that reduces the need for intubation could save many lives.
    A safe and effective vaccine is of greatest importance. The world must do everything possible to develop a vaccine, while also recognizing that this may or may not be possible.
    Adapt to a new normal. The Covid-19 pandemic will change our world forever. Until it is controlled, we will all need to change how we wash our hands, cover our coughs, greet others and how close we come to others. We will rethink the need for meetings and conferences. We will need broadband for all as a public utility like mail or water. We will need to support the vulnerable, even if only because their illness can risk our health.
      Our strategy to mitigate the impact of Covid-19 will necessarily evolve as we learn more about the virus and the effectiveness of different interventions.

      In a fourth phase, a vaccine, if one can be found, or global elimination efforts, if they can succeed, would either end the pandemic or, if not, force us to adapt to the continuing threat for the indefinite future. We face weeks and months of fear and tragedy. Leaders at every level must be frank that this is frightening, unprecedented and irrevocably changes how we provide care and prepare for the future. But it is also a time to recognize that we are all in this together -- not only all in the United States, but all of us globally. Spread anywhere in the world increases risk everywhere. We have a common enemy, and, working together with a common strategy, we can build a new normal that minimizes risk, maximizes collaboration and commits to shared progress.

      Monday, March 09, 2020

      Kiss more & touch nothing! ;-)

      Quoted from Bill Bryson:
      For years, Britain operated a research facility called the Common Cold Unit, but it closed in 1989 without ever finding a cure. It did, however, conduct some interesting experiments. In one, a volunteer was fitted with a device that leaked a thin fluid at his nostrils at the same rate that a runny nose would. 
      The volunteer then socialized with other volunteers, as if at a cocktail party. Unknown to any of them, the fluid contained a dye visible only under ultraviolet light. When that was switched on after they had been mingling for a while, the participants were astounded to discover that the dye was everywhere—on the hands, head, and upper body of every participant and on glasses, doorknobs, sofa cushions, bowls of nuts, you name it. 
      The average adult touches his face sixteen times an hour, and each of those touches transferred the pretend pathogen from nose to snack bowl to innocent third party to doorknob to innocent fourth party and so on until pretty much everyone and everything bore a festive glow of imaginary snot. In a similar study at the University of Arizona, researchers infected the metal door handle to an office building and found it took only about four hours for the “virus” to spread through the entire building, infecting over half of employees and turning up on virtually every shared device like photocopiers and coffee machines. 
      In the real world, such infestations can stay active for up to three days. Surprisingly, the least effective way to spread germs (according to yet another study) is kissing. It proved almost wholly ineffective among volunteers at the University of Wisconsin who had been successfully infected with cold virus. Sneezes and coughs weren’t much better. The only really reliable way to transfer cold germs [viruses] is physically by touch.
      Bryson, Bill. The Body: A Guide for Occupants (p. 34).

      Saturday, March 07, 2020

      COVID-19 ( Coronavirus) & Global Climate Change

      Virus and disease are natural parts of the living order.

      It is sad to recognize that in the same decades that we have "mastered" vaccinations and thousands of people working in teams with Rotary or the Carter Foundation have eliminated Polio and the Guinea Worm, that "we" have given rise to a new virus in COVID-19.

      While the science is not yet settled on *precisely* how and where the Cornavirus emerged, it seems clear it was from "wet" markets, where unclean animals were caged/sold in Wuhan, China.

      It seems to me, no "single" person is to blame and instead, "we" as humans are to blame.  And in a few weeks, the spread of a "single" virus - microscopic - has killed thousands, infected hundreds of thousands, and  . . . if my sense is correct, will "live with us" "forever" and will kill millions.  (I predict over 150 million will die in the next few years.  It will spread to "everywhere" humans live.)

      What will kill tens of thousands, at minimum - will do so quickly.  It's tragic.

      On the not-so-quick side of the time-scale is the anthropogenic (human created) change in our climate over decades.   The scale of Global Climate change is BOTH microscopic and macroscopic - and the links I share to microplastics and the loss of the ice sheets are just two of thousands of examples!

      It seems to me human hubris and human "growth" and human practices of exploitation continue nearly unabated - certainly across human species.

      While human persons might give priority to our own sense of self - we are still inhabitants in Creation with all other living things.

      I'm a realist by-in-large - already shared with my family that each of us, will, in due time, be infected with COVID-19 - though perhaps human ingenuity will find remediation methods or cures quickly, perhaps.

      Even still, human ingenuity MUST turn to find ways to live more wholistically, carefully, attentively, and with kindness toward the lives of all living things.