Saturday, April 4, 2020

A Strategy To Get Past The Shutdown?

We don't have that strategy yet--or, at least, not one that's been publicly promulgated. However, two articles today may point the way. Nothing in the articles is exactly new, but taken together the elements of a workable strategy to combat the disease and take some pressure off the economy--and working people--may be close to falling in place.

For now, we're still concentrating on keep the Attack Rate (Rate of Infection) as low as possible. That's what social distancing is all about. If that rate isn't constrained the then inevitably the Case Fatality Rate will begin to climb. All that and much more is discussed in Why the Shutdown Is Necessary: This is not just a bad flu. The article is heavy on statistics, but without that knowledge you'll be left thinking the recent upward trend in the Case Fatality Rate in supposedly model countries like South Korea and Germany are somehow inexplicable. Those trends are not inexplicable and were entirely predictable. It's not that South Korea and Germany are doing something wrong--they're doing it right, but this virus is really that dangerous if allowed to rampage through the general population. Pretending this is just the flu, or something very like it, isn't an option and is simply a denial of basic science.

Having said that, there is hope, and the hope lies in testing. But not the testing we're all familiar with from standard scorecard type stats: Total case, New cases, Total deaths, New deaths. If you read through the article linked above, slowly digesting it, you'll understand why those stats are deceptive unless they've been carefully sifted.

The second article--A better way to handle the coronavirus?--gets into the testing more deeply. We've mostly all heard about the usual testing for the virus. But other types of testing are coming online, and these types provide hope that we may soon be able to distinguish between those who are truly at risk and those who are not or are no longer at risk. (Other genetic factors may also play a role in this, but are too speculative for any practical application at this point.) We're talking about antibody tests:

We now have the ability to conduct antibody tests that are quick and inexpensive.  These tests will identify patients who have immunity (IgG antibodies) versus current infection (IgM antibodies).  An immune person can likely safely return to work and be out in public, as would also be the case with an immune customer.  A five-minute test prior to entering a store or restaurant would allow both a worker and a customer to safely return.  A person who has neither antibodies (not yet exposed) would be stratified into a risk category to determine activity.  

Of course, the real question is not whether we "have the capability"--it's a question of logistics, deploying that capability, making it widely available. However, once that can be accomplished, the stratification of the general population into risk categories becomes more feasible.

The author of this blog provides a breakdown that, admittedly, can't be ironclad. Once you start listing "risk factors" you may be surprised at how much of the population are included. For example, in the "high risk" category are "older Americans, 60 and above, and those who are immuno-compromised." Wow! That's a lot of people. Smokers, fat people, diabetics, those with heart conditions of all sorts, male homosexuals, and on and on the list goes. Nevertheless, this stratification suggests a way to come up with a more flexible social distancing strategy.

Here are the authors' tentative categories:

1. High Risk (with no antibody protection) 
Taking guidance from the CDC, those who are at the highest risk are defined as older Americans, 60 and above, and those who are immuno-compromised.
2. Medium Risk 
If you are experiencing flu-like symptoms, you should self-quarantine and be tested and retested to confirm COVID-19 or to rule it out. 
If you live in an urban population center in New York, New Jersey, Michigan, Louisiana, or California, you are at higher risk of contracting the coronavirus and should take precautions to protect yourself and your neighbors.
If you are healthy but live with someone in a high-risk category, you should take precautions to protect your loved ones and consider testing to know the status of immunity. 
3. Low Risk or confirmed antibody protection 
If you are young and healthy and live in a more suburban or rural setting, your risk of contracting COVID is low.  While you should continue to practice "social distancing" measures and wash your hands regularly, you should be permitted to go back to work and begin to socialize in small group settings.

The third factor in the strategy is actually closer to becoming widely available. That is the availability of specific medical treatments of various sorts. When combined with flexible social distancing based on risk categories as well as prudent precautionary measures--gloves and masks--we may be nearer than we think to a strategy that would address both medical and economic concerns. However, it is key that we not jump the gun--not attempt this comprehensive strategy before all the parts are in place.


  1. Not a statistician but the 1st article says false-positives artificially suppress the case-fatality-rate:
    "So if we have 200,000 positive tests with 4,000 dead, what’s the CFR? [ 2% ? ]
    Well, if only 100,000 of the 200,000 actually have the virus, then our “real” CFR is 4 percent."

    NO!. 4000 died, but FROM WHAT? The false-positives are false "cases" and should be ignored.
    OK, I'm done. Like I say, no mathematician, so I'm probably wrong.
    Why did I eve write this? This is what COVID19 does to my brain.

  2. I wonder about those who have been diagnosed HIV positive at some time and have been taking significant doses of both antiviral meds to fend of the virus and antibiotics like azithromycin to prevent pneumonia? It would be interesting to see what effect that treatment regimen would have in the current pandemic.

    1. I read somewhere recently that people who have had the flu recently may have a sort of general viral immunity for a while. This was supposed to have benefited people on the West Coast who were said to have had an early and severe flu season. Speculation, but there are weird things about this virus. I did also write about this virus piggybacking on the flu a while back.

  3. The strategy is do what we are doing now, but not much longer, at worst 3-4 more week (that's max), and then open up allowing states to do what is best for them.

    No, I am not plugged in, have no juice, do not associate with the powerful and influential, but I can read between the lines and know that we cannot sustain this.

    Just as the virus is exponential, the effects of the shut down is the same affecting people along vectors that are not considered.

  4. I worry that the "over 60" label will be used to discriminate against me. I am in great health; probably as good as most 50 yr olds. I can see where this may become an excuse for companies to push healthy oldsters into early retirement.

    1. The "old people at risk" label is simplistic.

  5. The 2nd article was OK, but not great.

    Somehow today the US did 216,000 tests, a record. Yesterday was 140,000, and the day before that 117,00. So huge increases. I'm not sure who is going gangbusters on testing. It's not California, NY, Louisiana, or MI.

    Deaths don't seem to be increasing as fast as they were (30% to 50%). Still not good at around 15% per day in hte US. My guess is use of Quinine is having an impact.

    NY is about 50% of all deaths in the US.

    The biggest challenge, is how fast are tests done. I have been reading in CA it's currently 5 days to in a hospital, to 2 weeks for the significant other of a nurse. This is way to slow, since Quinine is more effective the earlier in the infection it is given. The good news is huge room for improvement. Bad news is the current situation is not good. Use of masks may help drop the rate of infection, I am seeing a lot more masks today in So CA, and not just Asians. San Diego County is now requiring wearing of masks to by employees.

    I'm very worried about the economy.

  6. I missed this earlier. Somehow CA recorded 76,100 tests today. They were doing about 2,000. This made a huge dent in the backlog of 60,000 test, 10 days old, which is now down to 13,500. I hope they can keep up this through put.

  7. Another blogger has been doing some great digging on the testing debacle in her comments:

    And found this link (free registration required):

    Snippets they pulled out:

    This week, Quest Diagnostics filed a form 8-K in which it noted that during the last two weeks of March the company's test volumes, inclusive of COVID-19 tests, declined by more than 40 percent.


    Kyle Fetter, executive vice president and general manager of diagnostic services at revenue cycle management and lab informatics firm Xifin, said that thus far, most industry layoffs and furloughs were occurring on the administrative side of the business as labs tried to maintain their clinical staff.

    Fetter said his firm has seen volumes drop substantially not only for routine lab testing but also for tests that might not typically be considered elective, such as genetic tumor testing to determine patient cancer therapy, which he said had dropped around 30 percent to 35 percent since the start of the outbreak in the US.


    Raich said that some labs are trying to move into SARS-CoV-2 testing to help address the broader shortfall but noted that "you can't make up that [lost] volume with just COVID-19 testing."

    Additionally, it can be difficult for labs to get ahold of the instrumentation and supplies they need to start SARS-CoV-2 testing, he said.


    Birenbaum similarly said that many NILA member labs were exploring SARS-CoV-2 testing but that they were running into a number of challenges.

    "We have different size laboratories with different capabilities," he said. "If they are decent sized and have some of the [RT-PCR] equipment in-house already, the challenge has been, do they have equipment that is compatible with the [CDC test]?

    More recently, he noted, several vendors have received FDA Emergency Use Approval for tests on their platforms. For labs with these platforms, a major challenge has been getting test kits, with some labs being told by vendors that they won't be able to get shipments of kits for two months. [Swabs, too.]


    "Labs [without the equipment] are saying, well, we would [start SARS-CoV-2 testing], but we don't have the necessary capital and we're not willing to take loans out if we don't know whether we can get kits," Birenbaum said....

    There are also questions about whether making capital investments makes sense given the relatively low reimbursement for the test. Pricing put out by local Medicare Administrative Contractors last month put reimbursement for the CDC test at around $36 and reimbursement for non-CDC versions at around $51.

    According to some NILA member labs, "if you factor in all the capital investment and everything, the [Medicare rates] don't cover their costs," Birenbaum said.

    Fetter agreed. "At the price [CMS] is going to pay for COVID-19 testing, if a lab is super efficient, they will potentially break even," he said.

    1. There is a YouTube video from NYC doctor. He looks wiped out, but has a hopeful message. What I found interesting, though, is the fact he stated the entire 12k hospital is not doing heart transplants or any orher kinds of medical intervention because they are "elective" and only Covid is being handled.

      Think about that.

      Need a cancerous tumor removed early before it spreads?

      Not here.

      Need a new kidney?

      Not here, keep on dialysis.

      On and on it goes.

    2. I saw that video a week or so ago. That situation may be slowly changing. They've got like 4K patients on HCQ and Cuomo is asking Trump to get them more. Apparently it may be making a difference. But it's not just at hospitals. Many doctors offices are closed for the time being for safety reasons. I was planning on having some dental work done--what better situation for transmitting a virus?