Multiple prestigious journals have weighed in on the U.S. pandemic response.
From The Lancet:
“If logic and justice prevail in the next presidential administration, universal health coverage, a fairer society, stronger health institutions, more energetic global engagement, and a robust research agenda will be the foundations for America’s renewal. We all have a stake in America’s success.”
Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it.
The better question is: “How will we know when to reopen the country?”…
A recent report by Scott Gottlieb, Caitlin Rivers, Mark B. McClellan, Lauren Silvis and Crystal Watson staked out some goal posts.
Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care.
A state needs to be able to test at least everyone who has symptoms.
The state is able to conduct monitoring of confirmed cases and contacts.
There must be a sustained reduction in cases for at least 14 days…
These four criteria are a baseline…Until we get a vaccine or effective drug treatments, focusing on these major criteria, and directing efforts toward them, should help us determine how we are progressing locally, and how we might achieve each goal.
Related blog posts/links:
COVID-19 Projections -IHME DataIHME Link:IHME Website for COVID-19 This post details the projected needs (ventilators, ICU beds) and projected mortality. The site allows one to look at specific states; while NY is expected to peak this week, Georgia is expected to peak in about 18 days.
COVID-19 Posts: At bottom of post is a NEJM link to video demonstrating need for PPE during intubation – Fluorescent Spray During Intubation and information on how hydroxychloroquine and azithromycin could increase risk for life-threatening arrhythmias
My wife has been receiving a lot of compliments for her daily jokes which she decided to post for all of the neighborhood walkers. “A lot of people cry when they cut an onion. The trick is not to form an emotional bond.”
This coronavirus disease has caused incredible upheaval & misery throughout the world. In addition, it has created an “infodemic.” This blog post is intended to collate my previous related posts/& many of the referenced links into one location, to provide GI society guidelines for PPE/endoscopy as well as to place a good image at the bottom:
New: NEJM link to video demonstrating need for PPE during intubation -see picture at bottom of post. Fluorescent Spray During Intubation and at the bottom -there is an image showing how hydroxychloroquine and azithromycin could increase risk for life-threatening arrhythmias
Aslo, recommendations from GI societies -AGA, ACG, ASGE and AASLD
Use of Personal Protective Equipment in GI Endoscopy
Endoscopic Procedure Guidance
JOINT GASTROENTEROLOGY SOCIETY MESSAGE: COVID-19
Use of Personal Protective Equipment in GI Endoscopy
General measures of physical distancing and adequate hand hygiene are of critical importance and need to be practiced diligently, independent of other protective measures.
All elective, non-urgent procedures should be postponed until ample supplies of PPE, hospital beds and other resources are available after the COVID-19 surge.
All members of the endoscopy team should wear a full set of PPE, predicated on resource availabilities.
The correct sequence of putting on and taking off PPE (“donning” and “doffing”) is critical and needs to be understood and practiced .
All members of the endoscopy team should wear N95 respirators (or devices with equivalent or higher filtration rates) for all GI procedures performed on patients with known SARS-CoV-2 infection and those with high risk of exposure. Given the high rate of infection transmission from pre-symptomatic individuals, all patients undergoing GI endoscopy in an area of community spread need to be considered ‘high risk’.
All healthcare workers should have their N95 respirators fitted by an occupational health specialist prior to the first usage.
Staffing of endoscopy rooms should be reduced to the minimum number of individuals necessary, in order to conserve PPE and other resources.
In some cases, shortages may require extended and limited reuse of N95 respirators. Guidance is available on how to wear, remove and store respirators to minimize contamination . Decontamination of N95 respirators with hydrogen peroxide vapor has been approved by the FDA as a means of reuse in times of limited supply .
GASTROENTEROLOGY PROFESSIONAL SOCIETY
GUIDANCE ON ENDOSCOPIC PROCEDURES
DURING THE COVID-19 PANDEMIC
Below is guidance regarding how to manage the clinical procedural needs of patients during the COVID-19 pandemic. Any decisions should be informed by the local situation and available resources. There may be state, local and institutional rules in place that must be considered as well. This guidance is offered until more definitive data-driven information becomes available.
For those patients for whom a procedure or appointment is not deemed immediately necessary, each practice should implement mechanisms to assure appropriate follow-up once the immediate impact of the COVID-19 pandemic has eased or passed.
All Elective Procedures Should Be Delayed
Screening and surveillance colonoscopy in asymptomatic patients
Screening and surveillance for upper GI diseases in asymptomatic patients, including surveillance for esophageal varices in patients with cirrhosis
For patients needing interval endoscopy for obliteration of esophageal varices post-acute bleeding, the individual circumstances of the patient need to be taken into account to determine safety of delay (i.e., size of varices, red wale markings, CTP status of the patient, acute bleed characteristics).
Evaluation of non-urgent symptoms or disease states where procedure results will not imminently (within 4-6 weeks) change clinical management (e.g., EGD for non-alarm symptoms, EUS for intermediate risk pancreatic cysts)
Nationwide stay-at-home. Given mobility in country, having some states policies lessens the effectiveness of individual state mandates. “Because people can travel freely across state lines, so can the virus. The country’s leaders need to be clear: Shutdown anywhere means shutdown everywhere. Until the case numbers start to go down across America — which could take 10 weeks or more — no one can continue business as usual or relax the shutdown. Any confusion about this point will only extend the economic pain, raise the odds that the virus will return, and cause more deaths.”
Much more testing and quicker turnaround. This would allow more effective isolation policies and help determine if/when we are truly making progress.
Nationwide coordination for ventilators/supplies. Competition between states is counterproductive
Preparation for making billions of doses of vaccine (when available)
Current coronavirus tests may have a particularly high rate of missing infections. The good news is that the tests appear to be highly specific: If your test comes back positive, it is almost certain you have the infection… From a technical standpoint, under ideal conditions, these tests can detect small amounts of viral RNA. In the real world, though, the experience can be quite different, and the virus can be missed.
A terrific commentary (Bill Gates, NEJM 2018; 378: 2057-60) explains how we are NOT preparing for the next pandemic and what we should be doing and why.
There has been incredible progress in many areas of global health and infectious diseases. In fact, “child mortality has decreased by more than 50% since 1990.” HIV is no longer “a certain death sentence” and there has been progress with malaria.
Yet, “there is a significant probability that a large and lethal modern-day pandemic will occur in our lifetime.” Some recent events have alerted us to this risk, including swine flu in 2009, Ebola in 2014 as well as recent MERS (Middle East respiratory syndrome) and SARS (severe acute respiratory syndrome).
“We need better tools, an early detection system, and a global response system.”
“A simulation by the Institute for Disease Modeling shows what would happen if a highly contagious and lethal airborne pathogen, like the 1918 influenza, were to appear today. Nearly 33 million people worldwide would die in just 6 months.” (see below)
Vaccine development holds some promise to protect against many pathogens. One step to help with vaccines has been a public-private venture, Coalition for Epidemic Preparedness Innovations (CEPI).
Vaccines alone are not enough as they take time to stimulate immunity and often not enough people receive them. “So we need to invest in other approaches, such as antiviral drugs and antibody therapies that can be stockpiled.”
My take (borrowed): “”If it were a military weapon [threat], the response would be to de everything possible to develop countermeasures. In the case of biologic threats, that sense of urgency is lacking. But the world needs to prepare for pandemics in the same serious way.”
An excellent commentary (JE Marrison et al. NEJM 2016; 375: 1817-20) throws a bunch of cold water on the idea that there is a massive vitamin D deficiency pandemic. The main contention of the authors is that physicians, and by extension patients, focus too closely at specific thresholds which are poorly understood.
They explain the term “Estimated Average Requirement” (EAR) which is the median of the distribution of human requirements. Whereas, the RDA or recommended daily allowance “reflects the estimated requirement for people at the highest end of the distribution.” So, at least 97.5% of people will have a requirement below the RDA. However, due to Vitamin D’s importance, particularly with bone health, “the EAR is set at 400 IU per day for persons 1 to 70 years of age and 600 IU per day for persons older than 70.”
Other key points:
The EAR and RDA assume minimal to no sun exposure.
The RDAs of 600 IU/day and 800 IU/day correspond to 25(OH)D level of 16 ng/mlL and 20 ng/mL.
“A common misconception is that the RDA functions as a ‘cut point’ and that the entire population must have a serum 25(OH)D level above 20 ng per millimeter to achieve good bone health.”
“Approximately half the population has a requirement of 16 ng per milliliter (the EAR) or less.”
“Many studes establish ‘inadequacy’ using the RDA, though it is actually at the upper end of the spectrum of human need.” Thus, most people who are labelled as deficient are misclassified.
Using correct methodology, the authors assert that 13% of Americans 1-70 years are ‘at risk’ and <6% are deficient (with 25(OH)D < 12.5 ng/mL.
The problem with excessive Vitamin D testing and excessive treatment:
If 97.5% of the population has levels of Vitamin D exceeding 20 ng/mL, there are likely to be adverse effects in addition to increased costs of testing/treating.
Who to screen?
Those with risk factors for vitamin D deficiency: osteoporosis, osteomalacia, malabsorption, medications that can affect vitamin D metabolism (eg. anticonvulsants), or institutionalization
“For healthy patients, routine screening is not recommended by most medical organizations.” Though, the authors do recommend that “the RDA will nearly always meet the needs of generally healthy people.”
My take: This article makes a good argument for less testing along with avoidance of overprescribing vitamin D. Nevertheless, for healthy people taking the RDA for vitamin D is quite sensible.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Victoria Chimes -Maine’s Ship on their state quarter