COVID-19 in Suffolk County

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Patch.com just published the latest local figures for Suffolk County as of yesterday and they were obtained from the official  county site here:

conf. cases deaths population 2017 cases per 1000 people *
Islip: 395 333700 1.183697932
Huntington: 358 203276 1.761152325
Brookhaven: 281 486170 0.577987124
Babylon: 271 213,603 1.268708773
Smithtown: 120 117390 1.02223358
Southold: 107 22284 4.801651409
Riverhead: 39 33781 1.15449513
Southampton: 33 58439 0.564691388
East Hampton: 13 32000 0.40625
Shelter Island: 2 2421 0.826104915
other towns 261
total County 1880 18 1503064 1.25077841
at Peconic Landing 6

* some have proposed multiplying this number by 100 because most people are not getting tested (even those with symptoms).

Suffolk County Executive Steve Bellone reported 1,880 confirmed cases countywide which is a jump of 422 from the day before. Of that number, 163 are hospitalized, with 50 in intensive care.

Southold is particularly hard hit.  The Peconic Landing retirement community in Greenport has reported a sixth death related to coronavirus.

Ventilators in Suffolk County

With the desperate need for ventilators , Bellone said 25 are headed to Suffolk County. While numbers were not known for how many are available countywide, Bellone said that number is “woefully inadequate for what that need will be.”

Personal Note (regarding testing)

Contrary to the incredible efficiency of the South Koreans in testing everyone and containing the virus, see this NYT article,  we are still struggling.  For instance, after a few attempts, costing me hours on the phone to get thru to the county health officials, I finally got them to agree to test me (I have a bad cough and fever). This was finally done 2 days ago, but the test result (Quest Labs) is not expected for one week.  There are also no plans to have the 6 others staying in our house tested even though one of them also has symptoms!  We have been under self-quarantine for weeks now.  But some kind of public enforcement should occur. Even if it is just phone calls to follow up on our progress, from the health department.  I highly recommend reading about how South Korea has flattened the curve.

Considering that this is the richest nation on earth, with supposedly the most advanced healthcare, we deserve an ‘F’. It is too late to change the course of COVID-19 in the US I fear.  But in the meantime, we should all consider volunteering.  There are many opportunities and there will be more.

I called the county to volunteer as a retired MD.  I may perhaps be Corona virus-positive right now, but when I recover and come out of self-quarantine, I could not be safer, knowing that I will have acquired disease-fighting antibodies.  Those of us that have recovered and those that test positive for the presence of antibodies will be ideally suited to help care for the sick and critical patients.

Gov. Cuomo has announced that he wants retired health care professionals to be recruited. Suffolk county is just starting an effort along these lines.  I contacted Suffolk County Medical Reserve Corp.  Here is their response:

Thank you for contacting us. Volunteer opportunities exist within the Suffolk County Medical Reserve Corp.   Please visit this site for more information and to join through the NYS HCS:

https://suffolkcountyny.gov/Departments/FRES/Office-of-Emergency-Management/Medical-Reserve-Corps

From that point you will be contacted for an assignment.

Jennie Nedell , Volunteer Programs Coordinator 

Jennie.Nedell@suffolkcountyny.gov

631-852-4853

I will warn you about the sign-up process which puts you into NY.gov.  It is cumbersome but I will gladly help you with it!

I urge you to sign up now.  Jennie is very friendly and willing to help.  They have possible jobs for all of us and much can be done from home (where you might be under self-isolation), electronically or by phone, etc.  If you are elderly, or no longer registered as a health care professional or can’t travel around the county, don’t worry, they have jobs for you!

It will get crazy in 1-3 weeks when the system is overrun.  Now is the time to sign up to volunteer.

David

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Immune Response in COVID-19 Leading to Disease Resolution

This is a fascinating little paper in the medical journal Nature Medicine.  It is written by an Australian group arguably the top leaders in the field of antiviral immune responses.

It describes a 47-year-old woman from Wuhan, Hubei province, China. She presented to an emergency department in Melbourne, Australia. Her symptoms commenced 4d earlier with lethargy, sore throat, dry cough, pleuritic chest pain, mild dyspnea and fevers. She had traveled from Wuhan to Australia 11 days earlier. She had no known contacts with COVID-19 cases and was otherwise healthy.

She had a fever of 38.5 °C, and pneumonia by clinical exam and chest XR. PCR tests for SARS-CoV-2 were first positive at 4d (4 d after symptoms onset). But PCR tests were no longer positiive after d7. She recovered and was discharged on d11.

There follows a detailed description of her immune response.  It involved all components of the immune system known to partake in responses to other viruses like the flu.

Why is this important?

  1. It defines a normal immune response leading to disease resolution
  2. it will be compared with the immune response of patients that don’t do well or succumb to COVID-19.  This will lead to insights about why they do poorly.
  3. antibodies and various types of T cells all seem to be important
  4. unlike H7N9 influenza disease, where inflammatory cytokines are elevated, minimal pro-inflammatory cytokines and chemokines were found in this patient
  5. robust and broad immune responses can be elicited to the newly emerged virus SARS-CoV-2, similar to the avian H7N9 disease and suggest that early immune responses might correlate with better clinical outcomes.
  6. NB in this patient testing by PCR was negative after D7 (many patients are not tested that early and results would therefore be falsely negative)
  7. I think patients doing poorly on ventilators in the ICU, should  get trials of plasma from recovered patients as this would provide antibodies.  This is an old type of therapy first used for Spanish Flu patients with some success.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781783/
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Magic Wand Needed!

If it were possible to wave a magic wand and make all Americans freeze in place for 14 days while sitting six feet apart, epidemiologists say, the whole epidemic would sputter to a halt!

Here is another coronavirus curve (from March 22nd).  The Germans claim it shows flattening of the curve for their country.  I’ not so sure (yellow curve)!  The more dramatic finding is the black curve (USA) which has the steepest incline showing that COVID-19 is spreading most aggressively here in the US than anywhere else.

My friend James, is vacationing in Mexico.  Guess what, he is going to stay there for now! Good decision.

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Why is this worrisome? The NYT ran his piece:  “The Virus can be Stopped, but only with Harsh Steps” By

…coronavirus more often infects clusters of family members, friends and work colleagues, said Dr. David L. Heymann,

“You need to identify and stop discrete outbreaks, and then do rigorous contact tracing.”

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But doing so takes intelligent, rapidly adaptive work by health officials, and near-total cooperation from the populace.   My thoughts: Right.  Is that going to happen?

Americans must be persuaded to stay home, the experts said, and a system put in place to isolate the infected and care for them outside the home. Travel restrictions should be extended, they said; productions of masks and ventilators must be accelerated, and testing problems must be resolved.

It is not the “American way”.  “The American way is to look for better outcomes through a voluntary system,” said Dr. Luciana Borio, who was director of medical and biodefense preparedness for the National Security Council before it was disbanded in 2018.

Many experts, some of whom are international civil servants, declined to speak on the record for fear of offending the president. But they were united in the opinion that politicians must step aside and let scientists both lead the effort to contain the virus and explain to Americans what must be done.  My thoughts: is that going to happen? No.  Americans distrust science.

The next priority, experts said, is extreme social distancing. If it were possible to wave a magic wand and make all Americans freeze in place for 14 days while sitting six feet apart, epidemiologists say, the whole epidemic would sputter to a halt.

…the police may be needed to enforce stay-at-home orders, as they were in China and Italy.

People in lockdown adapt. In Wuhan, apartment complexes submit group orders for food, medicine, diapers and other essentials. Shipments are assembled at grocery warehouses or government pantries and dropped off. In Italy, trapped neighbors serenade one another!  Watch this Youtube video on life in Wuhan.

It’s an intimidating picture. But the weaker the freeze, the more people die in overburdened hospitals — and the longer it ultimately takes for the economy to restart.

So, here is the Trump response delivered by tweet last night”

“Mr. Trump has become frustrated with Dr. Fauci’s blunt approach at the briefing lectern, which often contradicts things the president has just said, according to two people familiar with the dynamic.”

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“WE CANNOT LET THE CURE BE WORSE THAN THE PROBLEM ITSELF,” Mr. Trump tweeted in all capital letters shortly before midnight. “AT THE END OF THE 15 DAY PERIOD, WE WILL MAKE A DECISION AS TO WHICH WAY WE WANT TO GO!”

It seems clear, Donald is taking charge as the ultimate expert for anything.  Some think Dr. Fauci will be sidelined.

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But doing so takes intelligent, rapidly adaptive work by health officials, and near-total cooperation from the populace.

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 But doing so takes intelligent, rapidly adaptive work by health officials, and near-total cooperation from the populace.

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Dire Report from Epicenter Bergamo

Screen Shot 2020-03-22 at 5.19.47 PMClick and watch this disturbing video from a Bergamo hospital

A new report published by the New England Journal of Medicine (NEJM; arguably the top medical journal in the world) makes the point that hospitals are major sites of corona-virus transmission and home care (community-centered care) would be a better model.  It is also a dramatic plea for help.

At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation.

March 21, 2020.

Mirco Nacoti, MD,, Andrea Ciocca, MEng, Angelo Giupponi, MD, Pietro Brambillasca, MD, Federico Lussana, MD, Michele Pisano, MD, Giuseppe Goisis, PhD, Daniele Bonacina, MD, Francesco Fazzi, MD, Richard Naspro, MD, et al.

In a Bergamo hospital deeply strained by the Covid-19 pandemic, exhausted clinicians reflect on how to prepare for the next outbreak.

Summary

In a pandemic, patient-centered care is inadequate and must be replaced by community-centered care. Solutions for Covid-19 are required for the entire population, not only for hospitals. The catastrophe unfolding in wealthy Lombardy could happen anywhere. Clinicians at a hospital at the epicenter call for a long-term plan for the next pandemic.

We work at the Papa Giovanni XXIII Hospital in Bergamo, a brand-new state-of-the-art facility with 48 intensive-care beds. Despite being a relatively small city, this is the epicenter of the Italian epidemic, listing 4,305 cases at this moment — more than Milan or anywhere else in the country (Figure 1). Lombardy is one of the richest and most densely populated regions in Europe and is now the most severely affected one. The World Health Organization (WHO) reported 74,346 laboratory-confirmed cases in Europe on March 18 — 35,713 of them in Italy.

Figure 1 .

Figure 1

Our own hospital is highly contaminated, and we are far beyond the tipping point: 300 beds out of 900 are occupied by Covid-19 patients. Fully 70% of ICU beds in our hospital are reserved for critically ill Covid-19 patients with a reasonable chance to survive. The situation here is dismal as we operate well below our normal standard of care. Wait times for an intensive care bed are hours long. Older patients are not being resuscitated and die alone without appropriate palliative care, while the family is notified over the phone, often by a well-intentioned, exhausted, and emotionally depleted physician with no prior contact.

But the situation in the surrounding area is even worse. Most hospitals are overcrowded, nearing collapse while medications, mechanical ventilators, oxygen, and personal protective equipment are not available. Patients lay on floor mattresses. The health care system struggles to deliver regular services — even pregnancy care and child delivery — while cemeteries are overwhelmed, which will create another public health problem. In hospitals, health care workers and ancillary staff are alone, trying to keep the system operational. Outside the hospitals, communities are neglected, vaccination programs are on standby, and the situation in prisons is becoming explosive with no social distancing. We have been in quarantine since March 10. Unfortunately, the outside world seems unaware that in Bergamo, this outbreak is out of control.

Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care. What we are painfully learning is that we need experts in public health and epidemics, yet this has not been the focus of decision makers at the national, regional, and hospital levels. We lack expertise on epidemic conditions, guiding us to adopt special measures to reduce epidemiologically negative behaviors.

For example, we are learning that hospitals might be the main Covid-19 carriers, as they are rapidly populated by infected patients, facilitating transmission to uninfected patients. Patients are transported by our regional system,1 which also contributes to spreading the disease as its ambulances and personnel rapidly become vectors. Health workers are asymptomatic carriers or sick without surveillance; some might die, including young people, which increases the stress of those on the front line.

This disaster could be averted only by massive deployment of outreach services. Pandemic solutionsare required for the entire population, not only for hospitals. Home care and mobile clinics avoid unnecessary movements and release pressure from hospitals.2 Early oxygen therapy, pulse oximeters, and nutrition can be delivered to the homes of mildly ill and convalescent patients, setting up a broad surveillance system with adequate isolation and leveraging innovative telemedicine instruments. This approach would limit hospitalization to a focused target of disease severity, thereby decreasing contagion, protecting patients and health care workers, and minimizing consumption of protective equipment. In hospitals, protection of medical personnel should be prioritized. No compromise should be made on protocols; equipment must be available. Measures to prevent infection must be implemented massively, in all locations and including vehicles. We need dedicated Covid-19 hospital pavilions and operators, separated from virus-free areas.

This outbreak is more than an intensive care phenomenon, rather it is a public health and humanitarian crisis.3 It requires social scientists, epidemiologists, experts in logistics, psychologists, and social workers. We urgently need humanitarian agencies who recognize the importance of local engagement. WHO has declared deep concern about the spread and severity of the pandemic and about the alarming levels of inaction. However, bold measures are needed to slow down the infection. Lockdown is paramount: social distancing reduced transmission by about 60% in China. But a further peak will likely occur when restrictive measures are relaxed to avoid major economic impact.4 We strongly need a shared point of reference to understand and fight this outbreak. We need a long-term plan for the next pandemic.

Coronavirus is the Ebola of the rich and requires a coordinated transnational effort. It is not particularly lethal, but it is very contagious. The more medicalized and centralized the society, the more widespread the virus. This catastrophe unfolding in wealthy Lombardy could happen anywhere.

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South Korea: Aggressive COVID-19 Strategies

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S. Korea is one of the few countries that have “flattened the curve”.  How did they do it?

 

South Korea learned its successful Covid-19 strategy from a previous coronavirus outbreak: MERS

By HyunJung Kim, March 20, 2020

This is a fascinating story.  Here is an excerpt:

Korea’s response to Covid-19 is highlighting a strong public health approach to reigning in the outbreak, one that provides a lesson for the rest of the world. For the country’s health officials, however, it’s a lesson they learned the hard way. Korea’s traumatic experience with a 2015 outbreak of Middle East Respiratory Syndrome, or MERS, paved the way for many of the successful strategies the government is deploying this time around.  Read more about the MERS experience here.

 

After news of the coronavirus outbreak began to emerge from Wuhan, China, earlier this year, the Korean government activated a 24/7 emergency response system to screen all travelers entering the country from that city. A woman was stopped at Incheon Airport en route for Japan at a fever monitoring station and transferred to a hospital where she was quarantined for 14 days. The Covid-19 diagnosis was confirmed on January 20. As it happens, that’s the same day the first US case was reported.

Since the first cases were confirmed, Korean public health authorities and local governments collaborated to precisely document the movement of infected people down to the minute. Authorities sought testimony, watched closed-circuit television, investigated smartphone GPS data and more, publicizing the so-called moving histories of Covid-19 patients. All local governments share information through websites, text messages, and media. Companies have developed apps that allow users to visualize the information. Koreans can now learn where infected people went, when they were there, and how they got there. If someone learns they might have been exposed, they can quickly visit a doctor and begin self-quarantine if they have similar symptoms.

On February 4, the Korea Centers for Disease Control and Prevention took advantage of the post-MERS reform and authorized an unlicensed Covid-19 test; the government went on to test an extraordinary number of people. By February 26, Korea had tested 46,127 cases, while by that point, Japan had tested just 1,846 cases and the United States only 426.

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Doctors Feeling Outrage

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Coronavirus tragedy: Chinese doctor who postponed wedding to treat patients dies of infection.  Feb 21,2020.

 

From Norbert Goldfield (Ask Nurses and Doctors LLC, AND)

Three updates from AND

  1. From Andrew Goldstein. If you read anything today – read this.

I’m watching my hospital, my city, and my world be hit by surges of people sick with COVID19. I know people who have lost loved ones already, and I know health workers who are sick.

But this is actually the tense silence before the storm. The real tidal wave is yet to come and it is still somewhat preventable, if only we intensify our public health approach immediately and ensure it is equitable and humane. With that in mind, my colleague Akash Goel MD and I wrote this plea in The Hill today:

A plea from NYC physicians: Our window of opportunity is closing to avoid Italy’s fate

We know there are challenges and concerns about such measures but I think we can solve them. I hope you will share this message. We must follow the lead of countries that have taken these massively life-saving steps earlier, or we’ll likely join the ones that regretted not doing so.

Spread the word NOW.

2.  It was a matter of time. One of my colleagues, is a retired non practicing physician on life support with Covid-19. One friend has been hospitalized. Despite this challenge, the administrator of our practice emotionally said to me yesterday how each and every physician has volunteered to do more. 200 health professionals in the Baystate system that I am part of are under quarantine. Conditions for which I would ordinarily see the patient – were all managed by phone yesterday.

3. For those interested in more details on our emerging understanding of covid 19 and its antecedents pls sign up for regular updates and the latest research from NIH. https://www.nih.gov/health-information/coronavirus

4. We need to keep in mind who is responsible for the Covid-19 debacle in this country; who is responsible for cutting back just passed legislation on paid leave (any number of the medical assistants I work with are at home with their kids instead of at work); who is blithely stating falsehoods time and time again; who could have taken action but didn’t  – it is the executive branch (with help from the U.S. Senate).  See these links:

https://www.nytimes.com/2020/03/15/opinion/trump-coronavirus.html?searchResultPosition=8

https://www.nytimes.com/2020/03/20/us/coronavirus-poverty-school-lunch.html/

https://www.politico.com/news/2020/03/19/trump-slash-red-tape-to-find-coronavirus-drugs/

https://www.nytimes.com/2020/03/20/us/politics/trump-coronavirus-supplies.html?action=click&module=Spotlight&pgtype=Homepage;

Please act on your outrage via letters to the editor; op-eds; uploads on you-tube videos or any other form of communication  We are happy to help review any communication you choose to write.   Norbert Goldfield MD  and David Posnett MD

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Trump Shirks Responsibility

Letter to the Editor, The East Hampton Star, March 19 edition

An Inspiration
East Hampton
March 16, 2020

To the Editor:

When asked at a press conference last Friday if he takes responsibility for the lack of coronavirus test kits, the president said, “No, I don’t take any responsibility for it at all.”

Enough. Since January it was clear this emerging virus was going to be a problem. Trump could have used the past three months to involve every federal agency in preparing for and dealing with the impending crisis. Instead, we got finger pointing and tweets ranging from “we have it totally under control” (Jan. 22) to “the coronavirus is very much under control.” (Feb. 24) Not.

The president’s disdain for experts has led him to ignore them at every turn. He has repeatedly insisted that a coronavirus vaccine is weeks or months away, only to be corrected by his own officials that it will take at least a year for one to be developed.

When asked at the same conference why the White House pandemic response team was disbanded and never replaced in 2018, Trump snapped, “That’s just a nasty question. I don’t know anything about it.” Nope. Not taking responsibility for that, either.

When it was Pence’s turn at the mic, he declared, “This day should be an inspiration to every American.” Yes. An inspiration to every American to vote in November and elect a president who is intelligent, thoughtful, empathetic, and able to shoulder the responsibility of leading the country during a national emergency.

Sincerely,

CAROL DEISTLER

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