The testing, and the testing only, is the thing

To paraphrase Oscar Wilde’s “The play, and the play only, is the thing” may not be entirely appropriate, but diagnostic testing is the most important thing in fighting this most infectious and vicious coronavirus plague, no doubt about it.

We are learning as we are fighting a novel virus, the learning curve is steep, the price paid is high. This is why I constantly look for exemplary “models” among the countries fighting along with us, or better yet, took the fight before we did.

Widespreading testing is the common denominator of the success
If the low death rate is selected as a measure of success, then Germany, South Korea, New Zealand and Taiwan emerge as the models. There is a common denominator for the success of these countries：wide spread testing.

Mortality rate as of 4/17/2020 according to Johns Hopkins University coronavirus resource center:

United Kingdom    15,498/115,314 (13.4%）
Italy                       23,227/175,925 (13.2%)
USA                       38,664/732,197 (5.28%)

Germany               4,459/143,342 (3.1%)

South Korea          232/10,653 (2.17%)
Taiwan                  6/398 (1.5%)
New Zealand        11/1,422 (0.7%)

Across the globe the success of the curb of coronavirus spread and the relatively low mortality rate are corresponding to the level of widespread testing.

The initial flawed test developed by CDC cost US several precious weeks
WHO delivered 250,000 diagnostic tests (designed and manufactured by German Lab, later proved to be dependable) to 70 laboratories around the world, US health officials decided to go on their own way. Unfortunately the initial test developed was flawed due to contamination; it took several weeks to correct it. CDC also didn’t send virus samples to private labs and university research centers to develop the tests until late February.

U.S. lost several precious weeks in rolling out testing at the crucial moment—at the beginning of this scourge, even Dr. Anthony Fauci so admitted in yesterday’s (4/17/2020) White House press conference.

Without testing capability the U.S. can only play mitigation, not containment

This led to all the “hot spots” to lose the chances of containment, viruses are ahead every step of the way. All they can do is chasing the viruses through mitigation. America is now poised to gradually enter the three-phased economy re-opening, containment is all the more important. Widespread testing capacity is the prerequisite of entering the Phase 1.

Whether we have testing capacity to enter Phase 1 to “open America”, it is all depends on what you read or watch. CDC messed up early on, no doubt. But it has since been ramped up tremendously and the capacity is growing everyday.

Dr Anthony Fauci

Dr. Fauci is hopeful that we have testing capacity to fight the next stage of containment

Dr. Anthony Fauci seemed to be confident that we do have testing capacity to enter Phase I, although he also admitted that his colleagues on the front lines telling him otherwise. He explained that it is most likely due to the logistics, the gap or disruption between the supply and demand. Testing can be more complicated than you thought, supply of swabs and testing reagents can be the issue.

Nobody knows what is considered the adequate testings per capita, but one thing for sure is the more the better, as testing is the only way to “see” this invisible enemy.

Wide spread testing capacity is the indispensable tool for containment, which is achieved by quickly identifying the infected, followed by isolation and contact tracing and this cannot be done without testing in a timely fashion.

The level of testing separates the countries with success and otherwise
The U.S. is not alone running into testing problems. The countries shared the mishap of testing with the U.S. are also the countries most ravaged in this horrendous pandemic, such as Italy, Spain, France and United Kingdom.

Countries (Germany, South Korea and Taiwan) are in stark contrast with the U.S. United Kingdom has medical technology know-how, but lack the scale to mass produce. The healthcare system reform over the past 10-20 years enables Germany to have nearly100 private laboratories that can be mobilized quickly. I read “drive through” test in German newspaper almost one week before I first heard in the U.S. Being a role model though Germany may be, a recent study commissioned by the government said Germany has to speed up the testing capacity in order to gain an upper hand on virus. Lothar Wieler, the head of the Robert Koch Institute (RKI)—equivalent to our CDC—shared the same view.

Dr. Christian Drosten, Jens Spahn, Dr Lothar Wieler

German Minister of Health declared worldwide pandemic on March 4, a week before WHO did on March 11.  Dr. Christian Droston (a noted virologist) is German's answer to our Dr. Fauci, but not his experience.

There was an article on March 3, 2020 the Journal of American Medical Association (JAMA), chronicling the success story of fighting coronavirus in Taiwan: proactive testing is one of the most important tools.

President Tsai of Taiwan on Time

The article in Time President Tsai of Taiwan reporting the success story.

https://time.com/collection/finding-hope-coronavirus-pandemic/5820596/taiwan-coronavirus-lessons/

Some technology issues and concern on testing

Many pharmaceutical giants and biotech companies (Roche, Abbott, Hologic, Labcorp, Cepheid, etc.) rose to the occasions in developing various testing kits. Abbott's NOW COVID-19 takes 5 minutes for positive results, 13 minutes for negative results.  Abbott has had three testing kits so far and is working on the fourth.

This New England Journal of Medicine showing how to do a nasopharyngeal swab, which is more complicated than you thought, one may have false negative result if the specimen is not obtained deep enough into the nose.

https://www.nejm.org/doi/full/10.1056/NEJMvcm2010260?query=featured_coronavirus

The standard way is doing throat and nose swab, it can be labor-intensive and the healthcare worker needs PPE. Germans are trying to do it on sputum, but it requires good sputum coughing up from deep chest and that is not an easy task.

FDA approves a test done on saliva, but a negative saliva test has to be double checked by standard throat or nose swab.

A Q-tip type test kit is being developed and it is funded by Gates Foundation and UnitedHealth. Gates Foundation is also funding 8 of the vaccines being developed, thank you, Bill and Melinda.

All of these diagnostic tests are “approved” through FDA Emergency Use Authorization (EUA), the approval process was expedited at the expense of stringent evaluation. Two days ago a UPMC pathologist reported the Abbott's rapid test can have false negative result when the virus load is low.

The right attitude to look at the projection models

I always look at the various projection models with mixed emotions; it is a love and hate affair.  I am a true believer in science, and modeling is a scientific work, yet the numbers from some of the models are so outrageously astonishing or even astronomical borders on being sensational.

all models are as good as the assumptions that you put into the model

The indispensable Dr. Anthony Fauci

While talking about not to read too much into these models, Dr. Anthony Fauci said the models should be treated with precaution, “all models are as good as the assumptions that you put into the model,”  he then said, “my colleagues [model creators] are not going to be happy with me.”

Models are essential tools
Projection models are essential tools for the governing bodies and policy makers, not for general public consumption.  White House Coronavirus Task Force, of which Dr. Fauci is a member, used 12 models.  CDC convened national experts making the model, although one will not see it on its website.

Bill Gates shares the same view on models with Dr, Anthony Fauci
In response to a question about the grim figures in the Imperial College model, Bill Gates

The incomparable Bill Gates

said the Imperial model does not match the experience in China, the parameters used are too negative, “models are only as good as the assumptions put into them.”

Not that Bill Gates doesn’t believe in models.  In 2017 the Gates Foundation gave $279 million to Institute for Health Metrics and Evaluation of Washington University (IHME or known as the Chris Murray Model, who was on CNN with Anderson Cooper yesterday), upon which the White House Coronavirus Task Force depends heavily.

White House Coronavirus Task Force press conference

Various models have different approaches
IHME is designed to be a planning tool for hospital administrators, projecting the future needs of hospital beds, ICU beds and ventilators (see graph below)

Some models depends heavily on the level of social distancing, which is a good tool to motivate people for strict adherence to avoid the worst-case scenarios.

The models are not static
It is updated every so often, even daily, based on the real world data.  A few days ago the White House Coronavirus Task Office revised downwards the possible American deaths from 80,000 to 60,000. This apparently went by IHME model, which revised downwards from 80,000 deaths to 60,415 by 8/4/2020 (see graph below).  Of note, the projected deaths is 60,067 by 5/23/2020, that is to say few deaths will occur after the end of May.

Study the models or ignore them
Models making is a scientific endeavor and complex.  Unless you have some basic understanding of a given model, knowing it’s approach, function, and purpose, and follow its update, you might as well ignore it, lest you may have unnecessary anxiety or even fear.

(You may stop reading here, the following story is to demonstrate the inherent controversy of the models and the subtle way of “fake news”.)

On March 16 a friend from Taiwan sent me a panel discussion which claimed coming from UCSF and BioHub (which was founded with Zuckerbergs’ $600 million). The panel predicted (on March 13) 40-70% of American population will be infected with COVID-19 in next 12-18 months and 1,600,000 Americans will die.

A panel discussion by credible scientists was disclaimed by UCSF
UCSF put out a statement stating the panel discussion was not sponsored by UCSF even though the expert speakers were from UCSF and BioHub.  It referred to CDC for the information on the scope of the COVID-19 pandemic.  But this kind of projection model is no where to be found on CDC online site.

UCSF was apparently trying to avoid the controversy.  However the grim figures are in line with those reported in a NY Times article (3/13/2020）based on the CDC model which has four scenarios. The CDC models predicted between 160 million and 214 million Americans could be infected over the course of the pandemic lasting months to over a year.  As many as 200,000 to 1.7 million Americans could die.  CDC refused the interview request by NY Times.

This is the inner working of CDC, serving as the guidance, calling for the all-out efforts to avoid the worst-case scenario.  這是 CDC 的內部作業 （沒有對外公開，但紐約時報拿到了那四個 scenarios of the model, CDC 拒絕 NYTimes 的 interview), 所以 CDC 知道若不採取嚴厲的行動，後果會如此。

Let's work harder and longer to prove the projection model numbers are wrong
Of course the figures don’t account for the interventions (containments and mitigations）that have been undergoing in earnest.  Dr. Fauci said the ultimate number “will be how you respond to it with containment and mitigation.” Let’s work harder and longer (social distancing) to prove those projection models are wrong, then their purposes are served.

My letter-to-the-editor exhorting everyone to wear face coverings in public

I have a letter-to-the-editor published in The Observer-Reporter today. I actually explained it better in the post in my blog as the letter writing has to be concise and to the point at the expense of more detailed explanations.

Stay home, save lives. Wear face coverings, stop the spread

https://doctorjytsai.blogspot.com/2020/04/stay-home-save-lives-wear-face.html

Not having the talent of our daughter, Jo, of making cloth face masks for others, to spread the useful messages of “stay home, save lives, wear face coverings and stop the spread” is the least I can do. This war can only be won when everyone participates in the fight. There is no better way to get the messages out in the newspaper.

The following is what a daughter of our family friend wrote in response to my post. It made me all the more happy as I did not send the email to her; people must have passed along my blog posts.

Her writings represents the love and concern of our adult children to us, and from one who truly understands the ferocity and viciousness of this horrendous virus, which I never observed in my entire professional career, simply put how easy one can get it.

(The following is her response)

Hi Dr. Tsai, 

Thanks for writing the post to your peers reminding them of the critical importance of STAYING HOME and if you absolutely must go to a place where there are other people, please wear a face mask. On behalf of all of your adult children and grandchildren, please make these changes in your daily lives. I know it is difficult because we are creatures of habit. We take joy in the simple pleasures in life. However, for just a short time (1-2 months, or even just the next 2 weeks), we're asking you to simply stay at home. This is the safest place to be.

This means:

- NO GROCERY STORES. If you *must* go, go during early morning hours for elderly folks, or try to space these visits out to 2+ wks, and WEAR A MASK (and gloves, wipe the handle of the cart down). Best is to have your kids setup online grocery delivery to your house for a few weeks.

- No bakeries, you don't need that pastry.

- No bank, depositing checks can wait.

- No drive through McDonald's coffee

- No Sam's Club or Costco or Target or Walmart

- If you need to get some fresh air, go for a walk around your block. Sunshine and fresh air are still good. Or call your kids if you're bored.

As you can see, my friends and I have had to call our parents every 1-2 days and YELL AT THEM FOR NON COMPLIANCE. The above are all the things we have collectively argued with parents about. The reason why we are all so adamant that you protect yourself and reduce exposure is because we know that if you get sick, 1) we don't get to stay with you at the hospital, 2) we don't get to visit you on the med floors, 3) we don't get to be with you in ICU. The absolute worst thing about covid19 is that patients are dying alone in ICU. The consequences for the elderly, immunocompromised, or those w underlying co-morbidities is simply too high to make it worth any of the above activities. Plus your grandchildren would like to have their grandparents around for a few more years if possible.

So please stay home! Wear a mask. It's just a few weeks, or few months. You can do it!

Thanks. XXXXX

Stay home, save lives. Wear face coverings, stop the spread

To wear the face covering or not to wear the face covering in public. It is no longer a question. Let me say a few words about the rationale of wearing face coverings in public.

It is regrettable that President Trump said, in the White House press conference, he chose not to wear mask while CDC urges everyone to wear “non-medical cloth” face coverings in public to curb the spread of coronavirus.

It is true that some sort of facial covering is effective at keeping someone from spreading the virus to others, but not the other way around. That is to say that wearing a face covering is not an effective protection to oneself, unless it is an N95.

It is also well known that symptom-free transmission is what drives this horrible pandemic. This is why CDC reversed its previous recommendation since it is no longer possible to tell who can spread the virus based on the symptoms. Any one is a potential virus spreader in a “hot spot”.

There is convincing evidence from some Asian countries that the spread of the virus declines when a majority of population wears masks. This collective benefit can only be achieved by asking most, if not all, population to wear masks.

Do not have the false sense of security just because you wear a mask, the protection comes from only everyone around you wearing a mask, thus decreasing the potential virus spreading. In other words, you wear face covering to protect others while others wear face coverings to protect you; it is a mutual protection and benefit. It is only through this practice that the benefit of wearing masks can be realized.

We are all in this unprecedented and vicious virus crisis, we are all in the same boat. With the grace and mercy of God, we'll pull through together, let us wear face coverings to protect each other.

Stay home, save lives. Wear face coverings, stop the spread.

It is admirable that our daughter, Jo, has turned her home into the cloth face coverings making factory. They are intended for the use of receptionists of doctors' office or those who are still working, or like healthcare workers, working even harder, to keep the “essential” business going.

Talented Jo even made high-fashion cloth face masks to make it more attractive to young ladies. The other day CNN Dr. Sanjay Gupta showed off a cloth face mask that his daughter made for him, I am proud to say it is no match for Jo's product, and I said it unabashedly.

Frankenmuth (MI) had online (or in the phone) Town Hall meeting organizing and coordinating the efforts to fight this vicious virus. Jo said the products (cloth face coverings) are picked up in the porch. Frankenmuth is a microcosm of America. America will prevail in this fight.

Stay home, stop the spread and save lives

Katy went to two grocery stores (Walmart and ALDI）the day before yesterday, our daughter (Joy）admonished us severely （教訓我們一頓）asking what are the “essential” reasons that Katy had to go out at this time, we couldn’t give any convincing reason. Our daughter urged us not to venture out again until at least a month later.

Joy has very good reason to ask us to take it very seriously in following “stay home, stop the spread, save lives” order, because she has insider information and data of MGH.  TV cameras normally do not go to hospital wards because of privacy issue. Ordinary folks may not have a realistic perception of what coronavirus can do to you and how easily you can get it.

Grocery shopping is not as safe as it seems
We are fighting an invisible enemy. We are aware the risks of those working in the front lines (hospitals, nursing homes, clinics or medical offices), but they actually “see” the enemy and know how to protect themselves. The grocery shoppers thought everyone is OK, as nobody was coughing or sneezing and felt very safe. To them the coronaviruses are truly invisible.

Symptom-free transmission is the key
This is why this virus so scary and so deadly. Georgia Governor has resisted making “stay home” order until April 2, at the time of announcement he said he heard of the “symptom free” transmission within the past 24 hours. CNN Dr. Sanjay Gupta said this is inexcusable and Anderson Cooper said this is political malpractice.  In fact, a study from Wu Han reported 4 out of 5 (i.e. 80%) got it from those who did not know they had it, and this has been widely reported in the media the past two months or so.

Transmission can occur with simple talking and breathing
It has been widely recognized that the mode of transmission is through the air drops coming from sneezing and coughing. The air drops may land on any surface, upon which one touches and then touches one’s face.

However, on April 2 researchers from the National Academy of Science sent a letter to the White House of Science and Technology Policy stating “SARS-CoV-2 could be spread via bioaerosols generated directly by patients’ exhalation.” That is to say simple conversation (talking and breathing) with an asymptomatic patient is able to pass along the viruses.

Dr. Harvey Fineberg, chairman of a committee with the National Academy of Science, the former dean of the Harvard School of Public Health, wrote in the letter, “While the current [coronavirus] specific research is limited, the results of available studies are consistent with aerosolization if virus from normal breathing.” So far this is not disputed by the White House Coronavirus Task Force.

The letter also cites a research by the University of Nebraska showing the genetic material from the virus was found in patients’ room more than 6 feet away from the patient. Dr. Fauci insisted that 6 feet guideline is still practical as it may take a very “robust” coughing or sneezing to shoot the air drops to go beyond 6 feet.

Dr. Fineberg said it is possible that aerosolized coronavirus droplets can hang in the air and potentially infect someone who walks by later.

How long coronavirus lingers in the air?
Dr. Fineberg said, “If you generate an aerosol of virus with no circulation in a room, it is conceivable that if you walk through later, you could inhale the virus. But if you’re outside, the breeze will likely disperse it.”

This is why grocery shopping in an enclosed room is not as safe as you think. It is also Dr. Fauci, when asked by CNN Dr. Gupta, whether he and his wife (also an excellent clinician) would stop jogging, he said NO.

The pathogenesis of coronavirus is still beyond us
There was no dispute the vulnerable groups (the elderly or those with chronic medical conditions such as chronic lung or heart diseases or diabetes or anything that may compromise the immune system) tend to have severe disease and complications or even death. However, we have seen seemly healthy young people succumbed to this virus, it was initially thought this is just one-off outlier. But it happened every so often that Dr. Fauci began to say there may be some unknown pathogenesis of mysterious coronavirus that escapes us. The unknown and uncertainty is why we need to respect and fear this virus.

Yes, healthcare workers got it, but much much more non-healthcare workers got it, simply because the former “see” the invisible enemy, and to the general public, they are truly invisible, and that is scary.

“I stayed at work for you; you stay at home for us”
Everyone has seen the signs the healthcare workers hold: “We stayed at work for you; you stay at home for us”, staying home is the least we can do to show our appreciation to the healthcare workers.

If you really have to go out for grocery shopping, do strategical planning, PA and many other states or cities may peak in about 2 weeks ( Trump said it will be very very painful 2 weeks) so it may will be less risky to venture out a month from now.

Remember this is war time, and war time calls for “sacrifice”, missing your favorite fruit (such as papaya 木瓜）is not “essential”. Not having fresh vegetables or fruits for a few weeks will not give you scurvy, like the sailors got it in old days when they were at sea for months or even years at a stretch, especially many of you may be taking some sorts of vitamins. Besides there is no need to go to two grocery stores like Katy did, that will double your risk. Every one should re-think “essential”, which means “absolutely necessary and extremely important”, online shopping and home delivery is an option, if available (certain precaution is still warranted.) Restaurant take out is allowed if you are a true epicure.

Stay home, stop the spread, save lives
When you stay home, you will be absolutely safe, not only good for your health, the benefit extends to the people surrounding you. Keep in mind that when you venture out, you will have much more chances to get common cold or flu than get coronavirus, in that case you'll have enormous anxiety and fear.

Since I came to America in June 1971, I have never seen America in such a crisis, 911 is no comparison. America was kind and generous in accepting me as its citizen, I feel compelled to do something for America in crisis. Social distancing is the best tool to fight this vicious virus. I exhort you to stay home as much as you can for your own good as well as the good of America. I am hoping you will pass this message to your friends and loved ones.