Sunday, April 5, 2020

COVID-19 update April 5 2020

The main advice about COVID-19 is just the same as before:  very strict social distancing (stay at least 2 metres, or 6 feet away from other people at all times), stay at home as much as possible,  wash your hands very thoroughly after touching anything that someone else might have touched, and do not touch your face unless your hands have been very carefully washed.

Please keep in mind that the 2 metre or 6 foot social distancing guideline is an arbitrary recommendation.  It would clearly be more effective to have 4 metres of social distancing!  The 2 metre recommendation is a starting point, but it would be best of all to avoid all crowds entirely, and even to avoid places which have been crowded in the previous hours (especially indoor places). 

These measures alone are helping to contain the spread of the disease, but we need to keep this up for many more weeks or months.

It has become clear (unsurprisingly) that disease spread can be significantly reduced if as many people as possible are wearing masks, especially in crowded places such as grocery stores or public transit.  Masks probably are most effective to prevent a person with COVID, including the many people without active symptoms, from spreading it.  Therefore, mask usage, if it is to be optimally effective, has to be used on a massive scale.

However, we have a terrible shortage of medical masks.  So it will be necessary to make home-made masks, or use scarves, until we have an abundant supply for the public of medical masks.  Medical masks need to be prioritized for medical workers, community workers, transit drivers, and grocery store staff.

It is valuable to look closely at what China, South Korea, and Taiwan have done to get their COVID-19 infections under good control.  We should be well-informed about their strategies, and copy.  Generally, my impression is that their strategies are similar to what we are doing here, but much more strict and enforced.

One of the issues of the week has to do with hydroxychloroquine and azithromycin as possible treatments for COVID.  The only evidence for these comes from so-called "in vitro" experiments; there is not yet any supportive evidence for their use in people with COVID.  But it is still important to study the question, which has to be done in a randomized controlled fashion.  Results of this research will take weeks.   I am neutral on this question, as we have no good evidence to guide us one way or the other on it, except for a recent negative study showing that it is not useful in severely ill patients.  It remains to be studied whether they could be effective if given early in the disease process, or prophylactically.   It is very clear that these drugs should not be endorsed, as they have potentially dangerous side effects.  And the public focus on this issue in the U.S. may distract people from focusing on what actually IS proven to help, which is social distancing, staying home, hand washing, and mask use.

I have thought of a modification of my "COVID hotel" idea, (see which is much less controversial.  It would seek participants for the hotel from a cohort of people working in high-risk zones, such as hospital staff, emergency response workers, and grocery clerks.  A cohort of several thousand such people would be followed closely, with a COVID test being given daily.  There would be no inoculation--each person who ended up with COVID would have acquired it in the course of their work.  Every person with a positive test would be promptly enrolled in the COVID-hotel study.  The advantage of this technique compared to present research studies, is that we could be guaranteed that every participant had become positive within the previous 24 hours, therefore would all be in an equivalently early stage of infection.  I hypothesize that any treatment intervention (such as an antiviral drug) would have the best chance of working if given as early as possible in the infection process.  Since everyone in the study would begin treatment at the exact same stage of infection, it would greatly reduce variability in outcome simply due to giving the drug at a different stage.

Friday, April 3, 2020

Mental Health care during COVID-19

With COVID-19, we are all likely to experience great hardships:  social isolation, cramped living quarters, severe financial problems, daily anxiety about going outside, difficulties with simple activities such as getting groceries or basic supplies, and of course the awful horror when we learn about what is going on elsewhere.  "Elsewhere" for now may be an abstraction about some city far away, but at some point "elsewhere" will get closer to home, to our families, to our loved ones. 

Symptoms of all mental illnesses have a high chance of becoming more severe.  

What can we do?  

I don't have the answers.  I'm scared myself.  

But here are some reminders about the basics: 

1) to the best of your ability, eat well, sleep well, and get some exercise, every day.  Try to have a schedule about doing these things.  It may not be possible to get these things done.  Normal sleep may be impossible due to anxiety.  But try.  Have a schedule.  Do your best.  Avoid things that make you worse emotionally, such as too much caffeine, too much junk food, etc.  

2) Try to focus on something else other than COVID news.  Read.  Study.  Clean.  Play video games.  

3) Have social contact.  This would have to be on the phone, by email, by Skype or FaceTime.  Or you could talk or sing to people who live nearby, as they are doing in Italy.  

4) Plan for what you'd like to do when this is all over.  It could be brief, over months, but maybe this could drag on for a year or more.  Think of the great celebration we will have then.  

COVID update April 3, 2020

As the pandemic progresses, we see more and more abundant evidence that very strict social distancing is effective.

2 metres (or 6 feet) of social distancing means that if both you and a person next to you have your arms extended, stretched out as far as you can reach, you should not be able to touch the other person's fingertips.

As expected, mask use is gaining more clear evidence.  Probably the greatest benefit of wearing a mask is to prevent the mask-wearing COVID-positive person (including the many people who are carrying the virus but not yet showing obvious symptoms) from spreading the virus to others.  Therefore, to be most useful, everybody should be wearing masks, particularly in crowded places such as grocery stores.

I have updated my idea about a voluntary inoculation technique:
The risk of this technique would be that some of the volunteers would face a risk of death or permanent injury.  But the benefit of the technique would be that a cohort of people would leave the technique in a proven immune state; and the technique would allow much more rapid research (done in the most perfectly rigorous blinded randomized-controlled manner) to establish clearly and in the quickest possible way whether proposed antiviral treatments work or not.  I suspect most antiviral treatments would be much more effective if given in the earliest stages of infection, rather than after severe symptoms have developed.  This is true of other antiviral treatments, such as acyclovir for HSV.  This technique would allow a guaranteed method of testing whether such antivirals would make a difference for people guaranteed to be infected but who are in the earliest pre-symptomatic stage.  In getting these answers quickly (saving weeks to months of time), tens of thousands of lives could be saved as we determine much more quickly which treatments actually work and which do not.  Not only could it identify effect sizes of effective treatments rapidly, it could also give us the information which would lead us to stop  offering putative treatments that may actually be harmful.

Meanwhile, I continue my advice to keep up social distancing.  Wash your hands very thoroughly and frequently, with an extra time whenever you have touched anything that anyone else might have touched.  Learn about good hand-washing technique.

Mask use has strong evidence.  But there is a shortage of masks for those who need them most.  So people will have to improvise their own home-made masks.

I encourage keeping some disinfecting cloths with you.  Clorox wipes are in short supply, but you can make your own by cutting up some old clothes into rags, and storing them in a glass jar containing a strong antiseptic such as Mr. Clean.

Avoid going out unless it is absolutely necessary.  I do consider daily exercise necessary, but if you do this, choose a time when fewest people are around, and a place where there is the least crowding.  I suggest sunrise or midnight.  Of course, be mindful about other safety risks.