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COVID-19

COVID-19 Update (5/8/20)

By our way of counting, this is Day 130 of the COVID-19 pandemic. Our first USA case was identified in Washington State on Day 21 of the pandemic. In those next 109 days (15.5 weeks) the United States, as of 5/08/20, had 1,292,623 known COVID-19 PCR positive infected patients and 76,928 deaths, giving us a still rising death rate of 5.95%. We have 1,035,768 more COVID-19 positive infected patients than any other country in the world. The total number of COVID-19 positive infected patients in Spain, Italy, France, Germany and the United Kingdom is 1,023,649 or 268,974 fewer infected patients than in the United States.  Two new rapidly expanding “hot spot” countries are Russia with 177,160 infections and 11,231 new infections on 5/8/20 and Brazil with 135,693 infections and 9,082 new infections on 5/8/20.

As of 4/28/20:

      USA                                  WORLD

57,812 deaths                      215,461 deaths

1,004,908 infections        3,094,829 infections   

Death rate: 5.75%             Death Rate: 6.96%

As of 5/08/20:

USA                                     WORLD

76,928 deaths                     270,426 deaths

1,292,623 infections        3,913,644 infections   

Death Rate: 5.95%         Death Rate: 6.91%

The University of Washington’s Institute of Health Metrics (IHME) said on 4/28/20 that we would have a total of 74,000 deaths in the USA by August 5, 2020. In contrast to this, we analyzed the case and death data using our two methods again on 5/08/20.  We now estimate that we will reach 2,000,000 infected patients in 25 days (601 hours or 3.5 weeks) and have between 42,088 and 45,200 new daily deaths for a total number of deaths between 119,017 and 122,128.

Our predictions from 4/28/20, 5/03/20 and 5/08/20 for time to reach 2,000,000 infections and the estimate of the number of deaths are listed in the following chart:

Recently the University of Washington re-projected the number of deaths by August 4, 2020 to be 134,475.

We don’t usually project out 3 months for total infections and deaths, but if we did, using our methodology, we would predict that by August 4, 2020 in the United States we will have 3,807,104 COVID-19 infected patients and a total of between 207,895 and 231,101 deaths. If the death rate (now 5.95%) continues to increase, these estimates of the number of deaths will be too low.

The FDA finally approved Gilead’s Remdesivir for intravenous treatment of COVID-19 infected patients (5/01/20). Since we initially recommended approval of this drug, another 66,500 Americans have died. Gilead is donating a large amount of drug for free. Unfortunately, it now appears that the government will be involved in the distribution of the drug, which means that rural counties and clinics like ours will probably not have the opportunity to treat our patients with Remdesivir. If it were up to us, this drug would be sold through normal drug distribution channels. Hopefully use of Remdesivir and/or plasma therapy will alter reported deaths in the next four months. I’m not optimistic based on the United States government’s performance during the first 130 days of the COVID-19 pandemic.  

Please think globally and act locally.

COVID-19

COVID-19 Update (5/3/20)

By our way of counting, this is Day 125 of the COVID-19 pandemic. Our first USA case was identified in Washington State on Day 21 of the pandemic. In those next 104 days (15 weeks) the United States as of  9:32 A.M. on 5/03/20 had 1,138,690 known COVID-19 PCR positive infected patients and 66,570 deaths giving us a still rising death rate of 5.84%. We have 922,108 more COVID-19 positive infected patients than any other country in the world. The total number of COVID-19 positive infected patients in Spain, Italy, France, Germany and the United Kingdom is 944,501 or 194,184 fewer infected patients then the United States. By our modeling method, in the United States we should now reach 2,000,000 COVID-19 positive infected patients in 29.7 days (714 hours or approximately 4.25 weeks). 

As of 4/28/20:

      USA                                  World

57,812 deaths                     215,461 deaths

1,004,908 infections        3,094,829 infections   

Death rate: 5.75%            Death Rate: 6.96%

As of 5/03/20:

USA                                  World

66,570 deaths                     244,911 deaths

1,138,690 infections        3,462,682 infections   

Death rate: 5.84%            Death Rate: 6.43%

The University of Washington’s Institute of Health Metrics said on 4/28/20 that we would a total of 74,000 deaths in the USA by August 5, 2020.

For our prediction on 4/28/20, we used two simple methods to predict the number of deaths and came up with two numbers: in 34.5 days (828 hours or 5 weeks) we should have either  56,166 additional deaths or 57,004 additional deaths from COVID-19. Therefore we predicted  that 5 weeks from  (April 28, 2020), the total number of deaths in the United States would be either 112,641 deaths or 113,479 deaths and we would have 2,000,000 PCR positive COVID-19 infected patients.

We’ve looked at our two methods again 5 days later (5/03/20).  We would now estimate we will now reach 2,000,000 infected patients in 29.7 days (714 hours) and have either 48,400 or 50,587 new deaths, for a total  number of deaths between 114,970 and 117,157.

Other news of interest is that the FDA has finally approved Gilead’s Remdesivir for intravenous treatment of COVID-19 infected patients (5/01/20). Gilead is also donating a large amount of drug for free. Hopefully use of Remdesivir and/or plasma therapy may alter reported deaths in the next month. We recommended that the FDA approve Remdesivir back on March 14.

Please think globally and act locally.

Recommended Reading:

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-potential-covid-19-treatment

https://www.cnbc.com/2020/05/03/gilead-ceo-says-remdesivir-available-to-coronavirus-patients-this-week-weve-donated-the-entire-supply.html

COVID-19

COVID-19 Update (4/28/20)

By our way of counting, this is Day 120 of the COVID-19 pandemic. Our first USA case was identified in Washington State on Day 21 of the pandemic. In those next 99 days (14 weeks) the United States as of 2:05 P.M. on 4/28/20 had 1,004,908 known COVID-19 PCR positive infected patients and 57,812 deaths giving us a still rising death rate of 5.75%. We have 772,780 more COVID-19 positive infected patients than any other country in the world. The total number of COVID-19 positive infected patients in Spain, Italy, France, Germany and the United Kingdom is 921,450 or 83,458 fewer infected patients then the United States.  By our modeling, we should reach 2,000,000 COVID-19 positive infected patients in 34.5 days (828 hours or 5 weeks). 

As of 4/28/20:

      USA                                  World

57,812 deaths                     215,461 deaths

1,004,908 infections        3,094,829 infections   

Death rate: 5.75%            Death Rate: 6.96%

One thing that concerns us is that the University of Washington’s Institute of Health Metrics said last week that we would have 67,641 deaths from COVID-19. This was updated today to a nice round number of 74,000 deaths by August. Their prediction is that we will have this number of total deaths in 93 days.

We think we have a more accurate prediction. We used two simple methods to predict the number of deaths and came up with two numbers:  in 34.5 days (828 hours or 5 weeks) we should have either 56,166 additional deaths or 57,004 additional deaths from COVID-19. Therefore, I would predict that 5 weeks from today (April 28, 2020), the total number of deaths in the United States will be either 112,641 deaths or 113,479 deaths. Let’s review this in 5 weeks.

Again I’m going to leave it up to each of you to decide whether we’ve done a good job in this pandemic.  Please think globally and act locally.

COVID-19

This Week’s COVID-19 Update (4/25/20)

By our way of counting, this is Day 116 of the COVID-19 pandemic. Our first USA case was identified in Washington State on Day 21 of the pandemic. In those next 95 days (13 weeks), the United States as of 10:30 A.M. on 4/24/20 had 883,826 known COVID-19 PCR positive infected patients and 50,373 deaths giving us a still rising death rate of 5.69%. We have 664,062 more COVID-19 positive infected patients than any other country in the world. The total number of COVID-19 positive infected patients in Spain, Italy, France, Germany and the United Kingdom is 870,996 or 12,830 fewer infected patients than the United States.  At our current rate of testing and rate of positive PCR tests, I would predict in the United States that we will have 1,000,000 infected patients in 103 hours (4.3 days).  We could reach 2,000,000 COVID-19 positive infected patients in 41.3 days (6 weeks).  Again, I’m going to leave it up to each of you to decide whether we’ve done a good job in this pandemic.

As of 4/24/20:

New York City            New York State              USA                            World

11,544 deaths              16,388 deaths            50,373 deaths             194,456 deaths

150,473 infections      271,590 infections    883,826 infections    2,766,611 infections   

Death rate:7.67%      Death rate: 6.03%      Death rate: 5.69%       Death Rate: 7.02%

In New York State, 695,920 PCR assays have been performed, and 271,590 tests were positive (39.02%). Only 4 countries have more infections than New York City. No other country has more infections than New York State.

As previously stated, every state, to include New York and Georgia, needs to perform more tests. Homeless shelters need to be screened and positive folks quarantined. Nursing homes and extended care facilities need to have all staff and patients screened. All hospitals should test every one of their employees. Additionally, it would be nice to give everyone an antibody test for COVID-19. 

In our county we should screen and sample at least our nursing homes, extended care facilities, hospital employees, first responders (police, fire and ambulance staff), jails and prisons to identify problems before it’s too late. We should also screen our agricultural employees to include folks in our agricultural processing plants. 

COVID-19 is a disease of hot spots with lots of asymptomatic transmission. A study of infections in Italy in April 2020 showed that 41% of their infections occurred in nursing homes (staff and patients), 24.7% from spread within families, 10.8% from hospitals, and 4.2% at work.

Speaking of hot spots and asymptomatic transmission of COVID-19, California Public Health officials released the following data on California skilled nursing facilities for the last two weeks:

The first week of reporting, 258 of 1224 skilled nursing facilities had one or more staff and patients with COVID-19 infections, 1290 staff were infected, and 1740 patients were infected. A little simple math shows that 33 of the 258 sites had 716 of the infected workers (average 21 workers per facility). The other 225 facilities only had 574 infected workers (average of 2 per facility). Data a week later revealed 2,099 infected staff (62% increase in one week) and 3141 infected patients (80% increase in one week). 486 infected patients have died (15.4%). No data on deaths of staff has been provided. Either incomplete data was provided by facilities the first week, or in the second week of reporting there has been a remarkable increase of infected staff and patients in skilled nursing facilities in California. The state has agreed to attempt to update the report weekly.

The scope of our problem locally is that skilled nursing facilities in our region include 52 in Santa Clara County, 16 in Monterey County, 8 in Santa Cruz County and 1 in San Benito County. Only one skilled nursing facility in Monterey County reported any infections in the first weekly report. Data is incomplete or not entered in the state report from this week.

A new hot spot of interest is one of the nuclear power plants in Georgia. The Vogtle and Hatch Nuclear Power plants in southeastern Georgia provide approximately 20% of the electrical power in Georgia. The Vogtle power plant has two functioning reactors and two new reactors under construction. 9,000 workers were on the site until April 17th when 2,000 workers were laid off due a COVID-19 outbreak. The Vogtle plant is in Burke County, Georgia on the banks of the Savannah River. Adjacent counties on the Georgia side of the river are Richmond and Columbia Counties. Across the river in South Carolina are Aiken and Edgefield Counties. Georgia has 22,147 COVID-19 positive patients and 892 deaths. South Carolina has 4,917 COVID-19 infected patients with 150 deaths. The five counties listed above have a total of 642 COVID-19 infected patients and 24 deaths. Burke County has only reported 64 COVID-19 infections and three deaths. There are at least 130 infections listed just at the Vogtle plant in Burke County below:

At the Vogtle plant, 28.0% of the tested workers are COVID-19 PCR positive. To date only 5.1% of the work force has been tested. The Vogtle nuclear power plant in Burke County appears to be an epicenter of an outbreak in five counties in two states.

Georgia already opened up their economy on 4/24/20 in an uncoordinated regional manner and has multiple other hot spots including this potentially dangerous outbreak.

Power plants and our power grid are key components of our infrastructure, and protecting their workers should also be a priority in each state, county and city. Has anyone offered testing to the workers at the power plant in Moss Landing, California?

Locally, are we squandering an opportunity to get ahead of an approaching storm? 

Please think globally and act locally. As usual, please feel free to share this post.

PubMed, Support Group

[November] Articles of Interest

Dr. Wright discussed the following articles with the members of the Borrelia (Tick-borne Relapsing Fever and Lyme disease) patient support group in their November meeting:

1. Autoimmunoreactive IgGs from patients with postural orthostatic tachycardia syndrome. (link to abstract)
Cardiologists at the Mayo Clinic in the Department of Internal Medicine looked at people with postural orthostatic tachycardia syndrome (POTS) to see whether they had autoimmune antibodies. The study revealed 40 unique proteins, many of which are associated with cardiac problems. The study concluded that patients with POTS do have autoantibodies, and these autoantibodies cross-react with cardiac proteins, possibly causing changes in cardiac function.

Dr. Wright commented that many patients with tick-borne illnesses have postural tachycardia, so in the case of damage to the cardiac muscle, it is unclear whether damage is caused by the infection or by the autoimmune issues associated with POTS.

2. Investigation of Borrelia burgdorferi genotypes in Australia obtained from erythema migrans tissue (link to full text)
A dermatologist in Australia conducted a study on four patients with erythema chronicum migrans (EM) (the bull’s-eye rash) to see which species of Borrelia patients were infected. PCR of central tissue biopsy revealed two strains similar to Borrelia burgdorferi (strain 64b), one isolate similar to Borrelia bissettii, and one similar to Borrelia valaisiana. Dr. Wright commented that it would be a good idea to do both a central lesion biopsy and a leading edge biopsy. This study suggests the presence of both Borrelia burgdorferi and Relapsing Fever Borrelia isolates in Australia.

3. A hard tick relapsing fever group spirochete in a Brazilian Rhipicephalus (Boophilus) microplus. (link to abstract)
One of Dr. Wright’s patients was planning a trip to Brazil, and he was reminded of this article from 2007, the first documented isolation of Borrelia from ticks in Brazil. The researchers found a species similar to the Relapsing Fever isolate Borrelia lonestari and labeled it Borrelia sp-BR. This species of Borrelia was found in the Rhipicephalus (Boophilus) microplus tick, a hard-bodied tick that feeds on cattle (it is also known as the southern cattle tick). This tick can be found in South and Central America, as well as in Africa, Asia, and Australia.

4. A novel relapsing fever Borrelia sp. infects the salivary glands of the molted hard tick, Amblyomma geoemydae. (link to abstract)
Japanese researchers have found a new, yet unnamed, species of Borrelia. It is phylogenetically related to B. miyamotoi and B. lonestari (both of which cause tick-borne relapsing fever). The new species was found in Amblyomma geoemydae ticks, which feed on cows and other large animals. Also found in 5% of the ticks studied was Borrelia sp. tAG, a species associated with reptiles.

5. Associations of passerine birds, rabbits, and ticks with Borrelia miyamotoi and Borrelia andersonii in Michigan, U.S.A. (link to full text)
A four-year study from Michigan, published in October 2012, examined ticks found on wild birds and rabbits to see what isolates of Borrelia they were carrying. Two strains of B. miyamotoi were found, and this was the first time B. miyamotoi was documented in ticks removed from wild birds. Most of the birds carrying ticks positive for B. miyamotoi were Northern Cardinals. Ticks found on birds and rabbits also tested positive for B. andersonii. The authors of the study conclude, “Given the current invasion of I. scapularis, a human biting species that serves as a bridge vector for Borrelia spirochetes, human exposure to B. miyamotoi and B. andersonii in this region may increase.”

Dr. Wright reminded patients that there are currently no commercially-available tests (in the U.S.) for B. miyamotoi and B. andersonii. He also recommended that people limit exposure to wild birds and bird feeders.

PubMed, Support Group

[August] Articles of Interest

Dr. Wright discussed the following articles with the members of the Borrelia (Tick-borne Relapsing Fever and Lyme disease) patient support group in their August meeting:

1. Humans Infected with Relapsing Fever Spirochete Borrelia miyamotoi, Russia (link) (PDF)

Dr. Wright drew attention to two figures from this article.

Figure 2

Examples of relapsing fever episodes in 2 patients with Borrelia miyamotoi infection.

Interesting Points:

  • This figure illustrates that an antibody test can be negative at anywhere between 15 and 37 days post-tick bite, even though a PCR may be positive. Each graph above represents episodes of relapsing fever in one patient from the study.
  • During the time that both patients were hospitalized with high-spiking fevers, antibody tests for Borrelia miyamotoi were negative.
  • Antibiotic therapy was not initiated until 30 days after the tick bite. If the patients had been infected with Rocky Mountain spotted fever instead of Borrelia miyamotoi, some would likely have died waiting to get treatment.
  • In cases where doctors are not sure which tick-borne infection a patient has–because symptoms of fever and myalgia come with many infections–it is important to start antibiotic treatment right away.
  • Dr. Wright reminded the group that, according to Israeli studies on Borrelia persica, prophylaxis does not work at 72 or 96 hours. If treating a patient with antibiotics later than 48 hours after a tick bite, doxycycline should be given for at least two weeks.

Figure 3 (Click image to enlarge)

Phylogenetic tree of Borrelia spp. detected in persons and ticks, based on flagellin gene fragment (A) and16S rRNA gene fragment (B).
Phylogenetic tree of Borrelia spp. detected in persons and ticks, based on flagellin gene fragment (A) and16S rRNA gene fragment (B). Sequences were aligned and analyzed by using MEGA4.1 software (www.megasoftware.net). Genetic trees were constructed from the partial nucleotide sequences of the flagellin gene and the 16S rRNA gene by using the Kimura 2-parameter model and the unweighted pair group method with arithmetic mean. Arrow indicates the 16 Borrelia spp. from Yekaterinburg in 2009 that had the same nucleotide sequence. Circles indicate sequences that we listed in GenBank (accession nos. GU797331–GU797346 and JF951378–JF951392). Sequences for B. burgdorferi sensu lato and relapsing fever borreliae are shown for comparison. Scale bars indicate genetic distance.

Interesting Points:

  • There appear to be three main types of Borrelia miyamotoi: 1) Russian/Asian, 2) European, and 3) U.S. and Japanese.
  • It’s possible that we have an undiagnosed Borrelia miyamotoi epidemic. It’s already been detected in wild turkeys in the U.S. If we had commercially-available tests for it, we’d likely be detecting it in people, too.
  • People who test positive for Borrelia hermsii with a low antibody titer could have Borrelia miyamotoi.
  • Researchers say that species like Borrelia hermsii that cause Tick-borne Relapsing Fever are only carried by soft-bodied ticks, but Borrelia miyamotoi is carried in two different U.S. species of hard-bodied ticks. If there is one exception, there are likely others.

2. Signs and significance of a tick-bite: psychiatric disorders associated with Lyme disease (link to abstract)

This is a study from the Netherlands in which a researcher reviewed the literature on psychiatric disorders and Lyme disease. The disorders most often associated with Lyme disease were:

  • depressive disorders
  • psychotic disorders
  • cognitive impairment
  • memory and concentration disorders

Dr. Wright mentioned a case of a child with “atypical psychosis” who turned out to have a Borrelia hermsii infection, and recommended that patients with psychiatric disorders of an unknown origin be screened for Borrelia infections.

3. Bell palsy in Lyme disease-endemic regions of Canada: a cautionary case of occult bilateral peripheral facial nerve palsy due to Lyme disease. (link to abstract)

  • About 25% of cases of Bell palsy in Canada are due to Lyme disease.
  • A facial palsy is a neurologic presentation of the infection, which means doctors missed the infection in its acute stage. For this reason, Dr. Wright believes it is more effective to treat patients with Bell palsy with IV ceftriaxone (as opposed to oral doxycycline).
  • In this study, researchers only looked for one isolate of Borrelia burgdorferi. It’s possible that if they had looked for multiple isolates, greater than 25% of Bell palsy cases would have been due to Borrelia infections.

4. Aseptic meningitis and adult respiratory distress syndrome caused by Borrelia persica. (link to abstract)

  • Borrelia persica is a relapsing fever species commonly found in the middle east and has been studied extensively by Israeli scientists.
  • In this study, they find that adult respiratory distress syndrome (ARDS) can be a complication of Borrelia persica infection.
  • ARDS is a known complication of Borrelia hermsii infection as well.
  • When a patient has ARDS, fluid accumulates in the lungs, and the patient has to be put on a ventilator. Dr. Wright suggests that perhaps we should be screening patients on ventilators for Borrelia infections.

5. Solitary erythema migrans in children: comparison of treatment with clarithromycin and amoxicillin. (link to abstract)

  • Clarithromycin and amoxicillin differ from ceftriaxone and doxycycline in that they cannot cross the blood-brain barrier. In advanced infections with neurological symptoms, it is important to be treated with an antibiotic that can cross this barrier.
  • To date, Dr. Wright knows of no study of prophylaxis in children; this would be helpful to have.

Disease prevention reminders:

Dr. Wright discourages patients from letting their pets sleep with them in their beds, as this is how many zoonotic infections can be spread. He also stresses the importance of keeping one’s house free of rodents (which carry ticks). “We still haven’t learned the Middle Ages lesson about rodents living with humans,” Dr. Wright said in reference to the bubonic plague.