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[IPn] Covid 19 information

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This article was just published by a colleague of my scientest 
daughter, Dr. Daisy. The post contains a WEALTH of information and 
links to the science that backs up the comments in the article. 

Hey Dad, here is the latest update from my doc friend Jordan, helpful
with most up-to-date science and credible resources. 

Daisy Robinton, PhD Molecular Biologist o 
Science Storyteller o StrategistLinkedIn o YouTube 
Tweet @DaisyRobinton o IG @daisy_robinton 

Begin forwarded message:
From: "Dr. Jordan Shlain" 
Subject: Dispatch #9 - Remember The Future
Date: June 1, 2020 at 3:51:50 PM GMT-6
To: Daisy 

Dispatch #9 - Remember The Future
The best prophet, naturally, is the best guesser - Thomas Hobbs
If one thing is predictable, it´s tomorrow.

It is near the end of May. We have over 100,000 deaths from COVID-19 
in the past two months and we just witnessed the largest human 
experiment the planet has ever seen: huge, non-mask wearing crowds on 

Memorial Day weekend. Within the next ten days to two weeks we will 
learn some very important lessons. Will there be a spike? Will people
die? Will nothing happen? People made clear decisions that their 
immediate gratification was likely more important than their long 
term consequences. Edward Schoedinger eloquently stated, "In an 
honest search for knowledge, you quite often have to abide by 
ignorance for an indefinite period." It´s okay not to know. Even 
Socrates said, "I know one thing: that I know nothing."

This undated photo provided by Georgia Tech alumnus Andy McNeil shows
a Georgia Tech home game during the 1918 college football season. The
photo was taken by Georgia Tech student Thomas Carter, who would 
receive a degree in Mechanical Engineering. (AP)
It´s also worth reading remarks from Exeter´s headmaster, Principle 
Rawson in 1918
as he laments his school closure during the Spanish flu in his 
virtual assembly remarks.

A week ago today the grip epidemic struck the Academy with full 
force. Since then many things have happened. One boy has succumbed to 
the disease, two others have been threatened with the same fate, over 
75 other students have been taken ill. ... Church and chapel services 
and all other such meetings have been entirely suspended for the 
present. The old gymnasium has been turned into a hospital for 
students. Over 25 beds are occupied by patients at present....Avoid 
all unnecessary crowds, such as in theatres, movies, crowded street 
and railroad cars, also all private and semi-public gatherings. Keep 
out of doors, walk to work if possible and sleep with the windows 
open. Make use of all available sunshine.  

These are not unprecedented times, they are precedented times! We are
smarter and more scientifically sophisticated than the days of 
headmaster Rawson; yet in 2020, like 1918, this will likely be a long
haul until we are out of the woods. I hope the following dispatch 
provides actionable information that makes sense and the decisions 
you need to make a little easier.

Let´s get to it.

We don´t yet know the true case fatality rate

We don´t yet know all the way *exactly* how it´s transmitted we know 
that droplets definitely spread the virus, but ordinary surfaces?

We don´t fully understand why & how it causes the spectrum of 
clinical syndromes it does and what role genetics, environment, 
medical predispositions play.

We don´t really know what works to treat it, aside from some early 
evidence of plasma and remdesivir for the critically ill. But what 
about the moderately ill?

We cannot represent the efficacy of homemade masks.
To what degree do we develop immunity, ie:can we get it twice? Will 
we be immune for a month? Will this be like the common cold in which 
we get temporary immunity and need a coronavirus vaccine every year 
like a flu vaccine, or like smallpox in which one vaccine and your 
immune for life?

We don´t truly know how long people are infectious.

We don´t know when we will have a safe and effective vaccine. Best 
case scenario end of 2021 with everyone immunized end of 2022 - worst
case scenario and this evolves from a pandemic to an endemic 
situation like HIV.

If you´re looking to see common myths, the WHO has published 
their mythbusters page.	https://tinyurl.com/IP-covid19-6-1b

As we lurch headlong into our third month, we are learning quickly 
and developing a better understanding of what information can assist 
us in making everyday decisions about our lives.

According to a recent JAMA 
viewpoint, the existing data on our ability to mount a durable immune 

response is not clear. It does appear that we develop temporary 
immunity, yet the big questions on everyone´s mind is whether once 
we´ve had it, we´re free to roam about the cabin of life. There are 
many large scale studies underway to get clarity on post-infection 
immunity. This information will be critical to develop personal and 
public health strategies.

The Moderna vaccine, for which there was quite a bit of excitement 
earlier in the week, developed in partnership with the NIH, will be 
the first to enter large-scale testing in July, and may be joined by 
the vaccine from Oxford University and AstraZeneca developed in 
partnership with the NIH. The main challenge if we get a vaccine will
be scaling up production and nailing distribution. The logistics will
need to be highly coordinated...and if you know your healthcare 
system, it´s just messy.

Warp Speed

The White house has launched Operation Warp Speed, a massive testing 
effort involving more than 100,000 volunteers and a half dozen or so 
of the most promising vaccine candidates in an effort to deliver a 
safe and effective vaccine by the end of 2020.

Vaccine makers will share data and their clinical trial networks to 
competitors should their own candidates fail. #cool. Vaccine 
candidates that demonstrate safety in small early studies will be 
tested in huge trials of 20,000 to 30,000 subjects for each vaccine, 
slated to start in July.

Side Effects

An ironic side effect of waiting for a COVID-19 vaccine is 
that everyone else 		https://tinyurl.com/IP-covid19-6-1c
is skipping out on their routine vaccines. On the list of important 
adult vaccines include the pneumonia vaccine, shingles vaccine, 
tetanus, measles boosters and more. Furthermore, parents are 
postponing their children´s checkups, including shots, putting 
millions of children at risk of exposure to known, preventable deadly
diseases. Ugh.

My advice is to get current on your vaccines - the healthcare system 
is open and safe.

Here comes summer and most of us are kicking in the stall. We want to
get out and find some sense of normalcy. Well, it turns out that 
everything we do must be viewed through the lens of risk-scoring.

NPR put out a great risk assessment
of common summer activities. I´ll summarize:

High Risk:

Attending a religious service indoors: high risk
Going to a nightclub: high risk
Getting a haircut: medium to high risk
An outdoor celebration such as a wedding with more than 10 guests: 
medium to high risk
Eating indoors at a restaurant: medium to high risk
Going shopping at a mall: risk varies

Medium Risk:

Using a public restroom: medium to low risk
A BYOB backyard gathering with one other household:
   medium to low risk
Staying at a hotel: medium to low risk

Low Risk:

Spending the day at a popular beach or pool: low risk
Letting a friend use your bathroom: low risk
Going camping: low risk
Exercising outdoors: low risk
Is it OK to have revolving people visit if the house is cleaned in 
between? Most people say yes.

Gyms are closed and some are reopening. What are the options for 
getting your cardiovascular system humming again?

To put a fine point on walking: it matters how many people you´re 
walking by, the size of the sidewalk and what type of mask you´re 

Yes, masks really matter.

A Cough:		https://www.ncbi.nlm.nih.gov/books/NBK143281/
A single cough releases about 3,000 droplets and droplets travels at 
50 miles per hour. Most droplets are large, and fall quickly 
(gravity), but many do stay in the air and can travel across a room 
in a few seconds.

A Sneeze: 
A single sneeze releases about 30,000 droplets, with droplets 
traveling at up to 200 miles per hour. Most droplets are small and 
travel great distances (easily across a room).

A breath:			https://tinyurl.com/IP-covid19-6-1f
A single breath releases 50-5,000 droplets. Most of these droplets 
are low velocity and fall to the ground quickly. There are even fewer 
droplets released through nose-breathing.

Speaking:		https://pubmed.ncbi.nlm.nih.gov/30787335/
increases the release of respiratory droplets about 10-fold, 
approximately 200 virus particles per minute. Again, assuming every 
virus is inhaled, it would take about five minutes of speaking face-
to-face to receive the required dose.

When you´re hanging out, socially distanced, it matters how many 
people you´re with and how long you spend with them.

Here is a great		
risks of exposure and the math that supports them.


Scientists are honing in on the little red spike or the `loop´ 
pictured below to the right. It is believed that the location of this 
loop could help explain why SARS-CoV-2 is so wicked, enabling it to 
easily infect the lungs. Given our new understanding of this 
mechanism of action, biologic agents in the form of protease 
inhibitors are being developed.

The modern family has more kids living with their parents and likely 
even higher during this pandemic. This is important. Spreading 
happens in families and the older people are at higher risk.

Babysitters, Daycare, Summer Camps

There are some bright spots for parents. Given proper precautions and
monitoring in place, most experts believe parents can safely rely 
on caregivers, daycare centers, and perhaps even counselors at sleep-
away camp.		https://tinyurl.com/IP-covid19-6-1g

Despite some of the recent alarming headlines of kids getting ill 
from a severe inflammatory syndrome, they are in the rare minority. 
We can confidently say that kids just do not get sick like adults. 
This has been proven in study
after study
death from COVID-19 in children is extremely rare.

In a population study
in Iceland of 13,080 residents, 100 people (or 0.8 percent) tested 
positive for an active infection. None of the 848 children under age 
10 tested positive.

Daycare and overnight camps might be safe if they rigorously 
follow CDC recommendations for Youth and Summer Camps

The bottom line: check the community infection rates and avoid 
sending your kids out if you have susceptible family members living 
in the same house.

More Research, Please
Boston Children´s 		
is leading a nationwide study in more than 35 hospitals to study why 
kids don´t get as sick as adults.

Reimagining Education - Back to School
There is near universal agreement that long-lasting school closures 
harm kids. They fall behind in learning and social isolation has 
effects on mental health. The big question is, does the harm outweigh
the risks?It is critical to society that we understand this question. 

There is a recent paper in  Acta Paediatrica
that concludes that children are `unlikely to be the main drivers´ of 

COVID-19 spread.

If you want a quick read on the pro school-opening argument, my 
friend Rajiv Bhatia contributed to this piece in the Daily Beast.
The summary, according to their investigation is that a) kids may not
get the virus due to their young, underdeveloped mucus lining cells, 
b) they have enhanced immune systems 
from being exposed to so many viruses, c) experiences in France, 
Austria, and China showed minimal spread to school contacts initiated
by a child. In essence, we have some hard trade-offs ahead of us and 
we must weigh our own risk tolerance against the evidence that 
continues to accumulate in front of us.

Here is a detailed report by Johns Hopkins Center for Health 
Security 		https://tinyurl.com/IP-covid19-6-1l
on how the science community should think about reopening schools.

Children account for less than 2 percent of identified cases of 
COVID-19.		https://tinyurl.com/IP-covid19-6-1e1
	(revised)	https://tinyurl.com/IP-covid19-6-1e2
It is hypothesized that the lower risk among children is due to 
differential expression of angiotensin-converting enzyme 
in the nasal epithelium of children and adults. Some kids have 
different expressions of this gene and understanding why could help 
with future treatments.

Large supermarkets are about 100 times riskier than the local corner 
shop - and the risk is mostly due to people-to-people contact, not 
touching surfaces. You should wear gloves when you walk in and 
properly take them off when you exit. Most grocery store workers have
implemented strategies where all workers are wearing gloves which 
means you likely don´t need to wash down all your goods when you 
arrive home. We are still learning more about surface to human spread
but it appears it is not nearly as significant as breathing, talking,
coughing without a mask.

Many of us have opted to defer our routine screening medical visits. 
I, on the other hand, just had a colonoscopy that was originally 
slated for March. The endoscopy suite had a full screening protocol 
and only used two out of the five suites in their office. For the 
most part, the medical system has pivoted to safely accommodate 
routine medical procedures.

People are not going to the doctors office....and it shows.

As some medical centers		https://tinyurl.com/IP-covid19-6-1m
and sub-specialists open up again, the risks of exposure to COVID-19 
may be lower right now than they will be in the months ahead. The 
risk is lowest now and will slowly increase over time, so I suggest 
making your appointments sooner than later. Please consider whether 
now is the right time for any important deferred medical 
care - screening tests, radiology studies, doctor appointments and 
important procedures. For example, screening for cancer is important 
and updating your vaccines is important. If you have high blood 
pressure, perhaps it is time to buy a home blood pressure cuff. Being
healthy and staying on top of your existing medical problems will 
confer benefit should you become infected with COVID-19.

U.S. Healthcare Capacity

ICU bed utilization rates in NY and NJ have finally fallen below 75 
percent; the median ICU utilization level for the rest of the states 
is just seven percent. Combined with a median hospital bed 
utilization rate of 50 percent (with none above 70 percent), U.S. 
states appear to have sufficient excess healthcare capacity to handle
a second wave, if or when it occurs - more on the second wave later.
This means that aside from ER´s and ICU´s all medical care is being 
deferred. This bodes poorly for countries and businesses whose 
business model is transactional. It may finally highlight the need to 

rethink how we value health and how we generate revenue off illness. 
Is this a sign of things to come?

The COVID-19 pandemic has us heading full steam into an epidemic of 
anxiety and depression. One third of all Americans, and likely all 
global citizens, now suffer from anxiety, depression or both. Aside 
from the inherent problem this entails, there is a far more nefarious
consequence: a rise in suicide, substance abuse, and overdose deaths.
Sadness negatively impacts our ability to predict our future. This is
called inter-temporal discounting, or delayed discounting. According 
to this concept, sadness increases impatience and creates a myopic 
focus on our decision-making processes. Specifically, this speaks to 
how the choices we make today will have consequences in our future 
and this does not bode well when we all need to be making concurrent 
short and long term decisions.

Furthermore, anxiety has been shown to attenuate our otherwise robust
cognitive biases, including having overly optimistic views of one´s 
importance, reputation and abilities.

Digital Empathy?

Will a new generation of apps or telehealth bridge the human empathy 
gap. We all thought that in person visits would never succumb to Zoom
visits. I´m hopeful a digital empathy platform will emerge to provide
counseling that honors each person´s individual circumstances while 
accounting for the scale of the problem at hand.

Hydroxychloroquine - The scientific jury is weighing inand leans 
heavily against the use in hospitalized patients. For non-
hospitalized patients, Yale 		https://tinyurl.com/IP-covid19-6-1n
believes that we´ll have to wait until September for a verdict. The 
Lancet 			https://tinyurl.com/IP-covid19-6-1o
recently published a study of 96,000 patients with 15,000 in the 
treatment group. There was no benefit found in hospitalized patients 
taking Hydroxychloroquine or chloroquine and they found worse 
outcomes due to cardiac arrhythmia. Furthermore, a May 11th JAMA 
study 		https://jamanetwork.com/journals/jama/fullarticle/2766117
showed that among patients hospitalized with COVID-19, treatment with
hydroxychloroquine, azithromycin, or both was not associated with 
significantly lower in-hospital mortality.

Of course, there is more confusion than clarity as the NY Times 
published			https://tinyurl.com/IP-covid19-6-1p
an open letter to the authors of the Lancet study asking for 
clarification and demanding a transparent review of their peer review

"Scientists who wrote and signed the letter criticizing the study 
included clinicians, researchers, statisticians and ethicists from 
academic medical centers, including Harvard´s T.H. Chan School of 
Public Health, the University of Pennsylvania, Vanderbilt University 
and Duke University."

The University of Minnesota may have some results next week. It is 
testing whether hydroxychloroquine prevents infection in people 
exposed to the coronavirus and whether it alleviates COVID-19 
symptoms. Other placebo-controlled trial results are expected 
starting this summer.

The New England Journal of Medicine
recently published the results of a double-blind, randomized, placebo-
controlled trial of intravenous remdesivir in adults hospitalized 
with COVID-19 with evidence of lower respiratory tract involvement. 
Patients receiving remdesivir recovered four days sooner than those 
not on the drug. The trial was unblinded for ethical reasons.

A new trial ACTT-2 is underway. 	https://tinyurl.com/IP-covid19-6-1q
It looks at remdesivir, Baricitinib vs Placebo.

First China, then Italy, then the United States had to learn the 
painful lesson of viral math. Now Brazil, Russia and India are re-
learning algebra through this reality. Brazil could overtake the US 
in the number of new cases in the coming days.

The novel coronavirus has sickened 6,600,000 and killed 350,000 
people worldwide. In the US, it is currently the second leading cause
of death with 1,700,00 people (30 percent of global burden) infected 
and over 100,000 have died as of May 28th. Wake up call: The 
infection rate has doubled past two weeks. They are nature´s 

Over here in California, we´re doing OK, yet Los Angeles county is 

Check out your state scorecard 
based on shelter in place restrictions on case trajectories, testing 
efficiency and ICU availability. These are guide rails to help states
determine when to instate shelter in place regulations.

Sewage SARS-CoV-2 RNA concentrations were a seven day leading 
indicator 			https://tinyurl.com/IP-covid19-6-1r
ahead of Covid-19 testing data and lead hospital admissions data by 
three days. Wow. Shit really matters.

Wastewater offers a promising way to track the virus.
The EPA, which regulates wastewater treatment plants, said it is 
coordinating with the CDC to kick off scientifically-sound monitoring
in areas hit hard by the virus. Australia is leading 
the way in these efforts.

False-Positive, Negative.

If your active infection (PCR) test is positive, that´s bad news 
(maybe). That is, for some people who get infected, they don´t get 
sick yet they are at risk of spreading it without knowing. This means 
fourteen day quarantine time for you

If your antibody test is positive, that´s good news (we think). We 
are currently in the process of understanding immunity. If you do 
test positive for antibodies, it likely means you have immunity. The 
question is: for how long? We still need time to guide our 
understanding on this.

Welcome to my world.

Home tests are here. While it is still early days, you can 
order LabCorp´s Pixel test and the Vault saliva tests online to check
for active infection. Quest has antibody testing you can order 

The sensitivity, or the accuracy of these tests if they are negative 
is still wanting. There are more than a few experts that suggest that
if you get a negative test, you should test twice. This improves the 
likelihood of diminishing the error. This whole concept speaks to 
the sensitivity of the test.

If your test is positive, you definitely have it - this represents 
the specificity of the test.

After allowing over 180 antibody tests to get emergency approval 
since March, the FDA just named 28 antibody tests
that are being taken off the market for their extremely poor ability 
to accurately measure antibodies. The big testing bake-off continues.

Below is the best graph 		https://tinyurl.com/IP-covid19-6-1ff
to help you understand when tests are likely to show you are positive
for the virus or positive for the antibody.

Some Positive News

Mammoth Biosciences is working to develop a CRISPR-based, over-the-
counter test. 		https://tinyurl.com/IP-covid19-6-1u
This could be a big deal.

In New York, the governor has allowed pharmacists
to order COVID tests.

Denmark is working on Robot Swabs	https://tinyurl.com/IP-covid19-6-1w
which could come in very handy for borders, airports, or any place 
that requires large-scale testing.

CONTACT TRACING: Human vs. Digital

Contact tracing is a critical component of taming a pandemic. 
Traditional tracing begins with reporting to the health department, 
which then assesses risk, asks diagnosed patients for their known 
contacts, and notifies contacts of potential exposure, all by 
telephone call or in-person. Although patients are not usually 
obligated to disclose their contacts, and health officials do not 
inform contacts of the patient´s name, in some instances those 
informed can infer who the index patient is.

By contrast, digital tracing rapidly notifies users if they have been
in close proximity with a person medically diagnosed with COVID-19. 
By design, these systems will have layers of privacy protection. 
Digital tracing will detect proximity, not geographic location, 
avoiding centralized databases of where smartphone users have 
traveled. Moreover, downloading and using one of the many smartphone 
applications is voluntary.

It is clear from PEW research		https://tinyurl.com/IP-covid19-6-1x
that Americans are just not ready to accept civil liberty 
encroachment in the context of digital contract tracing for the 
purposes of public health. A head scratcher and I kinda get it.

A May 27th JAMA Viewpoint
does a nice job of articulating all of this and concludes there is an
optimal design that balances health and privacy.

In a must read for the geeks, this article really lays bare
the importance of epidemiology.

"Epidemiology should be of two minds. It must combine theory with 
evidence and make use of diverse data while demanding data of 
increasingly higher quality. It must be liberal in its reasoning but 
conservative in its conclusions, pragmatic in its decision making 
while remaining skeptical of its own science. It must be split-
brained, acting with one hand while collecting more information with 
the other. Only by borrowing from both ways of thinking will we have 
the right mind for a pandemic"

Whichever scenario the pandemic follows (assuming at least some level
of ongoing mitigation measures), we must be prepared for at least 
another 18 to 24 months of significant COVID-19 activity, with hot 
spots popping up periodically in diverse geographic areas. As the 
pandemic wanes, it is likely that SARS-CoV-2 will continue to 
circulate in the human population and will synchronize to a seasonal 
pattern with diminished severity over time, as with other less 
pathogenic coronaviruses, such as the common cold (betacoronaviruses)
. . . and past pandemic influenza viruses have done.

Politico 		https://tinyurl.com/IP-covid19-6-1z
ranks countries with varying degrees of restrictions and public 
health outcomes.

Johns Hopkins has published a tool-kit
for how to reopen the workplace. Until testing becomes widely 
available, please consider all the ways 
that you can make your work environment safer. Engineering controls, 
barriers, monitoring for symptoms and fever, open windows, physical 
distancing and masking, hand hygiene, air purification, and limiting 
the use of common areas are just some ways to encourage and engineer 
safety. Collected wisdom will develop over time about `best 
practices´, but within any scheme that involves testing, work shifts
or other strategies, you can make choices to further reduce the risk 
of exposure.

Atul Gawande writes in the Atlantic 
what business and reopening can learn from healthcare.

Restaurant Servers
Given the rapidly changing nature of work, Glassdoor
has begun to analyze the pandemic impact on where work exists. An 
excerpt below.

It also appears the long running trend of open office architecture 
may be coming to an end? Back to your cubicle!

Nature´s Algebra

We are fighting an algorithm, a biological, natural algorithm. This 
is nature talking to us. Actually, it´s nature yelling at us. To 
compete with a viral algorithm, we need our own, human and social 
algorithm. Ours will need to be a combination of testing, tracing, 
isolation and treatment until we can disable the Covidian algorithm 
with a vaccine. If we think we can just swashbuckle our way through 
this, we will succumb to the same fate as the dread Pirate Roberts.

Throughout this epidemic, we have been inspired by the collective 
power of a global scientific movement to `solve´ COVID-19. The human 
and financial resources being applied to this problem are staggering. 

Those of us watching the sheer speed of science are optimistic that 
these efforts will ultimately yield effective approaches to treatment
and prevention. While it´s important to have an open mind to new 
developments, it is critical that we remain disciplined in our 
evaluation of any new information or models. We are all impatient for
progress, yet small misteps can be catastrophic.

Neil Ferguson, one of the leading epidemiologists behind the Imperial
College models, describes epidemic modeling as "building simplified 
representations of reality." In an outbreak, models without evidence 
are blind, while evidence without models is inert.

Science alone will not suffice, we also need the political will to 
design a societal algorithm, one that adheres to a set of rules in 
the spirit of problem solving. I believe pandemics can be manageable; 
they require that we make smart decisions in the short term that will
impact the long-term. Intelligent iteration is how we augment our 

A post-COVID future doesn´t exist in reality, only in our minds. We 
must remember the future we want and acknowledge that we do not yet 
have the collective scientific knowledge to make the wisest 
decisions. However, we are endowed with common sense - and this 
should be our existential guide. We are not on a power walk into the 
future, rather a syncopated stroll into the fog of humility, science,
imagination and deliberate action.

Until next time,


And people stayed home
A poem by Kathleen O´Meara (1839-1888)

And people stayed home 
and read books and listened 
and rested and exercised 
and made art and played 
and learned new ways of being 
and stopped 
and listened deeper 
someone meditated 
someone prayed 
someone danced 
someone met their shadow 
and people began to think differently 
and people healed 
and in the absence of people who lived in ignorant ways, 
dangerous, meaningless and heartless, 
even the earth began to heal 
and when the danger ended 
and people found each other 
grieved for the dead people 
and they made new choices 
and dreamed of new visions 
and created new ways of life 
and healed the earth completely 
just as they were healed themselves.

Dispatch #9 - Remember The Future was originally published 
in Tinctureon Medium, where people are continuing the conversation by
highlighting and responding to this story.


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