A brief flurry of interest last week as the UK seemed to be trying a different strategy from everyone else – isolating their oldest and most vulnerable citizens, but letting everyone else get the virus to build herd immunity. They’ve since backtracked after people did the math and found that an epidemic even among healthy young people only would overwhelm their medical system. Here’s another critique of herd immunity, appropriately enough on UnHerd.com.
But the UK’s original point – that without herd immunity, all we can do is continue the lockdown until something happens – remains sound and worrying. Everyone is hoping for a quick vaccine or antiviral, but this is a field where “quick” sometimes means months or years instead of decades. If we don’t get a deus ex machina, eventually somebody will need to implement some long-term strategy.
Last week I predicted that this might look like titrating quarantine levels – locking everything down, then trying to unlock it just enough to use available medical capacity, then locking things down more again if it looked like the number of cases was starting to get out of hand. This would eventually develop herd immunity without overwhelming the medical system. A paper yesterday out of Imperial College London (discussed here) said the same thing, arguing for alternating periods of higher and lower quarantine levels based on how the medical system was doing:
The orange line is projected ICU cases. The blue line is government-mandated social distancing levels. Relax social distancing levels, then after ICU cases cross some threshold, reinstate them again. That way at least we can have a few weeks of normal economic activity and seeing friends in between each lockdown. Control systems are the solution to everything!
Problem: it would take forever to develop herd immunity under this system, and we might just have to keep turning quarantine on and off for a year or two until a vaccine gets developed. Does anyone have any better ideas?
The closest thing I’ve heard is “what China and South Korea are doing”, which seems to be having so many tests available, and such good health services, that it’s easy to detect cases, track down their contacts, and manage the epidemic even while life goes on mostly as usual. So maybe the end date isn’t “have a vaccine available”, it’s “have millions of test kits available”, which I think looks more like a few months than like years and years.
Flatten the curve
Is flattening the curve just another name for the “have a control system to titrate lockdown levels so that only the right number of people get it at a time” strategy? Maybe everyone just assumes that we’re never going to get the cases down to too low a level, so we should try to get them as low as possible and maybe hit the right amount? And overshooting and reducing it so far that you’re not using the medical capacity you have, and wasting an opportunity to have a normal life and/or build herd immunity, is just really unlikely without China-level resources?
An article called Flattening The Curve Is A Deadly Delusion has been going around this part of the Internet, saying that there’s basically no way to match a curve of any flatness with our current hospital capacity. Nostalgebraist says the math is wrong, mostly because it uses a normal distribution when it should use an exponential one. But I’ve seen some other people making this basic point now, so it could just a be a question of how bad things get, rather than whether they’ll be bad at all. (...)
Don’t use aspirin
Doctors in Germany and France are saying that a suspicious number of young coronavirus patients who end up in the ICU took aspirin or other anti-inflammatory drugs (Advil, Motrin, Aleve, ibuprofen, diclofenac, etc, yes I know several of these are the same drug, I’m trying to inform readers) before getting worse. There’s a plausible biological mechanism; anti-inflammatories dial down the immune system. BMJ agrees: Ibuprofen should not be used for managing symptoms, say doctors and scientists. Tylenol, acetaminophen, or paracetamol (YES, I KNOW) is still okay, so use that for coronavirus-induced fever.
[EDIT: WHO is skeptical, but French and German doctors stick to their guns. It seems like there’s a longstanding debate on this with the French and German medical establishment thinking it’s bad for lots of diseases, and most of the rest of the world not believing them. I have no strong beliefs about whether France/Germany or everyone else is better, but switching from Motrin to Tylenol in this case seems pretty low cost] (...)
Ventilation, part 2
Right now the biggest bottleneck to treating coronavirus is likely shortage of ventilators and oxygen concentrators. Many people are trying to come up with ideas for solving the shortage. EndCoronavirus.Org is trying to get a team together, and is looking for doctors, engineers – and of course lawyers, to jump over the inevitable regulatory hurdles.
Meanwhile, at least according to Breitbart, existing ventilator manufacturers are just…not bothering to ramp up production yet? Does this make sense to anyone else? According to Forbes, ventilator manufacturers could quintuple capacity over the next few months, but…nobody has asked them to?…and they don’t want to take the initiative until somebody asks? Economists are begging the US government to ask, and maybe to ensure that every ventilator they make will get bought no matter what the circumstances are a few months from now – if they can’t, maybe private philanthropists should step in? Kudos to the UK government, which has just sent ventilator blueprints to a bunch of manufacturers and told them to get to work. But even if this comes through, how are we going to get enough skilled labor to ventilate this many people? [EDIT: As per WSJ, ventilator manufacturers are now ramping up production].
Also in medical supply news – when a hospital runs out of a critical $11,000 part and the manufacturer can’t supply more, a local guy with a 3D printer prints one up for $1. Now he’s being threatened with a lawsuit by the manufacturer. [EDIT: possibly not true or exaggerated, see here] This whole epidemic has been a fun adventure in “newspapers finally paying attention to what everything in health care is like all the time.”
Ventilation, part 3
When doctors need to ventilate someone in an emergency and don’t have time to hook them up to a real ventilator, they use manual ventilation, ie “bag and mask ventilation”, a really simple technique using a $30 piece of equipment which is literally just a bag attached to a face mask. Somebody squeezes the bag in a breathing-like rhythm, sending air into the person’s lungs until they’re able to get on a real ventilator. It’s not perfect but it saves lives.
In a New York Times article on the expected upcoming ventilator shortage, they say:
[EDIT: some discussion of why this may not work here and here.]
But the UK’s original point – that without herd immunity, all we can do is continue the lockdown until something happens – remains sound and worrying. Everyone is hoping for a quick vaccine or antiviral, but this is a field where “quick” sometimes means months or years instead of decades. If we don’t get a deus ex machina, eventually somebody will need to implement some long-term strategy.
Last week I predicted that this might look like titrating quarantine levels – locking everything down, then trying to unlock it just enough to use available medical capacity, then locking things down more again if it looked like the number of cases was starting to get out of hand. This would eventually develop herd immunity without overwhelming the medical system. A paper yesterday out of Imperial College London (discussed here) said the same thing, arguing for alternating periods of higher and lower quarantine levels based on how the medical system was doing:
Problem: it would take forever to develop herd immunity under this system, and we might just have to keep turning quarantine on and off for a year or two until a vaccine gets developed. Does anyone have any better ideas?
The closest thing I’ve heard is “what China and South Korea are doing”, which seems to be having so many tests available, and such good health services, that it’s easy to detect cases, track down their contacts, and manage the epidemic even while life goes on mostly as usual. So maybe the end date isn’t “have a vaccine available”, it’s “have millions of test kits available”, which I think looks more like a few months than like years and years.
Flatten the curve
Is flattening the curve just another name for the “have a control system to titrate lockdown levels so that only the right number of people get it at a time” strategy? Maybe everyone just assumes that we’re never going to get the cases down to too low a level, so we should try to get them as low as possible and maybe hit the right amount? And overshooting and reducing it so far that you’re not using the medical capacity you have, and wasting an opportunity to have a normal life and/or build herd immunity, is just really unlikely without China-level resources?
An article called Flattening The Curve Is A Deadly Delusion has been going around this part of the Internet, saying that there’s basically no way to match a curve of any flatness with our current hospital capacity. Nostalgebraist says the math is wrong, mostly because it uses a normal distribution when it should use an exponential one. But I’ve seen some other people making this basic point now, so it could just a be a question of how bad things get, rather than whether they’ll be bad at all. (...)
Don’t use aspirin
Doctors in Germany and France are saying that a suspicious number of young coronavirus patients who end up in the ICU took aspirin or other anti-inflammatory drugs (Advil, Motrin, Aleve, ibuprofen, diclofenac, etc, yes I know several of these are the same drug, I’m trying to inform readers) before getting worse. There’s a plausible biological mechanism; anti-inflammatories dial down the immune system. BMJ agrees: Ibuprofen should not be used for managing symptoms, say doctors and scientists. Tylenol, acetaminophen, or paracetamol (YES, I KNOW) is still okay, so use that for coronavirus-induced fever.
[EDIT: WHO is skeptical, but French and German doctors stick to their guns. It seems like there’s a longstanding debate on this with the French and German medical establishment thinking it’s bad for lots of diseases, and most of the rest of the world not believing them. I have no strong beliefs about whether France/Germany or everyone else is better, but switching from Motrin to Tylenol in this case seems pretty low cost] (...)
Ventilation, part 2
Right now the biggest bottleneck to treating coronavirus is likely shortage of ventilators and oxygen concentrators. Many people are trying to come up with ideas for solving the shortage. EndCoronavirus.Org is trying to get a team together, and is looking for doctors, engineers – and of course lawyers, to jump over the inevitable regulatory hurdles.
Meanwhile, at least according to Breitbart, existing ventilator manufacturers are just…not bothering to ramp up production yet? Does this make sense to anyone else? According to Forbes, ventilator manufacturers could quintuple capacity over the next few months, but…nobody has asked them to?…and they don’t want to take the initiative until somebody asks? Economists are begging the US government to ask, and maybe to ensure that every ventilator they make will get bought no matter what the circumstances are a few months from now – if they can’t, maybe private philanthropists should step in? Kudos to the UK government, which has just sent ventilator blueprints to a bunch of manufacturers and told them to get to work. But even if this comes through, how are we going to get enough skilled labor to ventilate this many people? [EDIT: As per WSJ, ventilator manufacturers are now ramping up production].
Also in medical supply news – when a hospital runs out of a critical $11,000 part and the manufacturer can’t supply more, a local guy with a 3D printer prints one up for $1. Now he’s being threatened with a lawsuit by the manufacturer. [EDIT: possibly not true or exaggerated, see here] This whole epidemic has been a fun adventure in “newspapers finally paying attention to what everything in health care is like all the time.”
Ventilation, part 3
When doctors need to ventilate someone in an emergency and don’t have time to hook them up to a real ventilator, they use manual ventilation, ie “bag and mask ventilation”, a really simple technique using a $30 piece of equipment which is literally just a bag attached to a face mask. Somebody squeezes the bag in a breathing-like rhythm, sending air into the person’s lungs until they’re able to get on a real ventilator. It’s not perfect but it saves lives.
In a New York Times article on the expected upcoming ventilator shortage, they say:
One doctor wondered if they could recruit enough volunteers to manually ventilate patients — which involves squeezing a small inflatable device by hand — indefinitely.I know nothing about respiratory medicine, and I guess I always assumed that there were issues with bag-mask ventilation which made it unsuitable for longer than the few-minute-period it usually gets used for. If that’s not true, and the limiting factor is just getting enough people to keep squeezing the little bag, then surely our civilization can come up with some sort of automatic squeezing machine, right?
[EDIT: some discussion of why this may not work here and here.]
Come summer
The smart people seem to be going back and forth on whether the coronavirus might die down in summer like a seasonal flu. The good news is that this has sparked more interest in the absolutely fascinating field of disease seasonality:
by Scott Alexander, Slate Star Codex | Read more:
Image: uncredited
The smart people seem to be going back and forth on whether the coronavirus might die down in summer like a seasonal flu. The good news is that this has sparked more interest in the absolutely fascinating field of disease seasonality:
Except in the equatorial regions, respiratory syncytial virus (RSV) is a winter disease, Martinez wrote, but chickenpox favors the spring. Rotavirus peaks in December or January in the U.S. Southwest, but in April and May in the Northeast. Genital herpes surges all over the country in the spring and summer, whereas tetanus favors midsummer; gonorrhea takes off in the summer and fall, and pertussis has a higher incidence from June through October. Syphilis does well in winter in China, but typhoid fever spikes there in July. Hepatitis C peaks in winter in India but in spring or summer in Egypt, China, and Mexico. Dry seasons are linked to Guinea worm disease and Lassa fever in Nigeria and hepatitis A in Brazil.Their explanation for why we don’t know more about this:
“It’s an absolute swine of a field,” says Andrew Loudon, a chronobiologist at the University of Manchester. Investigating a hypothesis over several seasons can take 2 or 3 years. “Postdocs can only get one experiment done and it can be a career killer,”As for the coronavirus itself? Unclear. The latest study says it might be seasonal, but a lot of comments on it point out continuing epidemics in tropical countries like Malaysia (currently 900 official cases). If your hometown isn’t going to get warmer this summer than Kuala Lumpur is right now (95 degrees at time of writing), you may not quite be off the hook.
by Scott Alexander, Slate Star Codex | Read more:
Image: uncredited
