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Tuesday, April 28, 2020

We are ALL GOING TO DIE!!!


A LONG RANT

I have been around Infectious Diseases, Microbiology, Eldercare, Infection Control and “pandemics” and other crises for near 50 years.  So maybe that allows me to have my own perspective.

I was not born in time for the Spanish Flu pandemic of 1918 which killed millions and millions.  My first influenza pandemic was in 1957-8 followed in 1968 with  the “Asian Flu (H2N2).  I don’t remember much about getting sick with either and obviously I didn’t die, so it is fair to say I survived my first pandemics without any problems.  

In 1976, when I first became a trainee (resident) to become an Infectious Diseases physician was a special year.  First there was the H3N2 pandemic and then suddenly there was a second outbreak in an army camp in New Jersey (Fort Dix) that spread quickly.  This second one (the Swine Flu) scared everyone because it was an (H1N1) just the Spanish Flu.    

Everyone (well almost everyone) agreed.  This is it!!  I was TOTALLY convinced.

The US President at the time (Gerald Ford) created a “gold medal advisory panel” which some real superstars, like Jonas Salk, and Albert Sabin, the creators of the  polio vaccines.  The politicians decided that the only solution was to create a new vaccine and immunize everyone immediately.  Have to be seen to be leading.  Sabin, both brilliant and bold (he tested his oral polio vaccine on himself) was never happy with the hurry up vaccine.  In a New York Times editorial, he said that while he agreed with the decision to create the vaccine and thought preparedness for an outbreak was good, he criticized the "scare tactics" used by Washington to promote mass vaccination (“scare tactics”… sounding familiar?). He suggested stockpiling and waiting to see what might happen.  

Sabin lost the battle and the mass immunization started, but he turned out to be right and the charge-aheads were wrong.  Some 450 people were paralyzed with a vaccine related syndrome called Guillain-BarrĂ© syndrome.  The government relented and stopped the ill fated hurry-up  vaccine program.   

Despite the absence of vaccination, the outbreak burned itself out, and the sun rose.  Despite the absence of vaccine, (and no “social distancing”) the world survived. 

Over the next bunch of decades leaders have repeated this same exercise.  Most times it was influenza, other times HIV or West Nile Virus, or St. Louis Encephalitis, or other coronaviruses (SARS, MERS).   Occasionally they decided to go extreme because of bacteria - C. difficile diarrhea or antibiotic resistance (MRSA).  The message was always  the same.  We are all unsafe… the world is coming to an end… we are all going to DIE!!!!!

Today is just the latest version; “experts” who know exactly what to do,  and politicians and the media all prepared to run with them.  They run their SCARE TACTICS, and spout stuff that sounds like science instead of opinion.   

This time has had its own twist: Shelter-in-place, snitch on your neighbours, hide in your basement. “socially distance”, keeping count of “cases” on an hourly basis.    If Hippocrates was around, he would remind us "First, Do NO Harm"

We will forever remember this as the great panic-demic of 2020.

This time it will be just like the Spanish Flu of 1918.   But think about it…  1918 was the last year of World War 1.  Europe was a mess.  Food was not plentiful.  Most homes did not have running water or indoor plumbing.  There was no refrigeration, no food storage.  Intravenous rehydration was in its infancy (no disposable needles).   There were no antibiotics.  Therapeutic oxygen was only being experimented with for poison gas in 1916-17  (Modern use of oxygen didn’t start until 1962).  The “modern medical and nursing care” of the time in NO way resembled the care we have available today.  There were NO laboratories to help diagnose diabetes, infection, sepsis, kidney failure, or strands of viral RNA.  
 So how exactly is this “just like 1918”? 

This panic-demic speaks more about the nature of us as a species.  We have these great brains, but we seem to prefer to use them to experience horror movies like Rosemary’s Baby and The Exorcist and The Night of the Living Dead.  We love virus movies like Andromeda Strain and Outbreak and Contagion.  We construct fear stories and convince ourselves of the dangers solar eclipse and the boogeyman under the bed, and witchcraft and devil worship and changing clocks (remember Y2K).  Each time it is the same: “… well sure before it was shameless hype and hysteria, but this time, THIS TIME, IT’S REAL!

 “Fool me once, shame on you; fool me twice, shame on me.”

Wednesday, April 15, 2020

They’re NOT lying… they’re just jargonizing?





What is a test?
Up until now there has been only one type of test which is intended to tell us if the person is carrying the virus.  Actually,  the test does  not look for the virus, it looks for a piece of the virus, and to be more accurate, it looks for a piece of what is thought to be the specific virus.    
The virus we are looking at is a part of a large family called coronavirus, which is very wide spread and is the second most common cause of common colds. 
 The test looks for genes that some think is specific to the SARS-C0V-2 virus, but since not all coronaviruses have been studied, it is not certain that the test is detecting is the gene that is specifically from the SARS CoV-2 virus .
We cannot say that the test is as specific as we would like.  
That may be why there is a lot of concerns about FALSELY POSITIVE tests.

Importantly, we assume that when the test is done, it is done correctly; that when the swab was put in someone’s nose or throat that was done correctly, that the swab was labelled correctly, that it was transported correctly, that it was put in the machine correctly, that the machine was working properly, that the result was read correctly and recorded correctly and sent back to the right person.  LOTS of opportunity for error.  There is a lot of evidence that when tests are done in high stress the risk of error rises. 
So we have lots of reasons to be careful (suspect?) of all test results, positive and negative.

What is a case?
The test as developed has a big problem because the laboratory cannot confirm the test result is right because patients can have symptoms, or may not, may be sick or may not.  If there is no marker, can you say for certain that the test result is correct?

To reduce some of the confusion, public health excludes testing people without symptoms.  You cannot get a positive test in a person without symptoms if you don’t test them.   So we know very little about people with a positive test when they have little or no symptoms.  Maybe this is what a CARRIER STATE, or maybe it is a FALSE POSITIVE laboratory error.

If you only test people with symptoms, and you get a positive test, does that mean the symptoms are associated with SARS CoV-2?  Maybe, but maybe not.  False positives are just as possible in people with symptoms as in people without symptoms.

Also, when people with symptoms of cough and sore throat and fever are tested, only about 4 percent are positive.  That seems VERY LOW.  Does that mean when 96 percent of people with fever and cough and a sore throat in the presence of this epidemic have a negative test?  

Either there are many other viruses around, or this is an example of  FALSE NEGATIVE laboratory error.

All this says that at this point we know very little about what test results means, about its sensitivity or specificity or its accuracy.   Should questionable test results decide what is or what is not a case?

What is a "new death count"?

When many people hear the term “new death count” they may understand that to mean a person who recently acquired the virus, got sick and then very sick and then died. 
But the single group that makes up the majority of the “new deaths count” are elder people, the majority over 80 years, mostly frail and living in nursing homes.  They became sick weeks ago, were admitted to hospital, maybe ended up in intensive care with a breathing tube.  They have been kept alive through mechanical support until their body finally gave up and passed away.  So yes, their death occurred today, but in reality it was expected for days or weeks.  Calling this a "new death" is a tad disingenuous, and needs a different classification.
When you hear a public health official say they expect the number of "new deaths" to rise, they are saying there are lots of these folks lying in beds, and one day, their day will come.

So as you listen to the nightly review of COVID-19 statistics, listen carefully and understand what you are being told.  Maybe it is just language confusion,
But maybe not.