Shutdowns prevented 60 million coronavirus infections in the U.S., study finds

https://www.washingtonpost.com/health/2020/06/08/shutdowns-prevented-60-million-coronavirus-infections-us-study-finds/?fbclid=IwAR3J402h_abt63p-JDNEEBrNwrZ_nRjQza8OKxtV9xmtt4n5Oky-droY_-c&utm_campaign=wp_main&utm_medium=social&utm_source=facebook

Shutdowns prevented 60 million coronavirus infections in the U.S. ...

Shutdown orders prevented about 60 million novel coronavirus infections in the United States and 285 million in China, according to a research study published Monday that examined how stay-at-home orders and other restrictions limited the spread of the contagion.

A separate study from epidemiologists at Imperial College London estimated the shutdowns saved about 3.1 million lives in 11 European countries, including 500,000 in the United Kingdom, and dropped infection rates by an average of 82 percent, sufficient to drive the contagion well below epidemic levels.

The two reports, published simultaneously Monday in the journal Nature, used completely different methods to reach similar conclusions. They suggest that the aggressive and unprecedented shutdowns, which caused massive economic disruptions and job losses, were effective at halting the exponential spread of the novel coronavirus.

“Without these policies employed, we would have lived through a very different April and May,” said Solomon Hsiang, director of the Global Policy Laboratory at the University of California at Berkeley, and the leader of the research team that surveyed how six countries — China, the United States, France, Italy, Iran and South Korea — responded to the pandemic.

He called the global response to covid-19, the disease caused by the virus, “an extraordinary moment in human history when the world had to come together,” and said the shutdowns and other mitigation measures resulted in “saving more lives in a shorter period of time than ever before.”

The two reports on the effectiveness of the shutdowns come with a clear warning that the pandemic, even if in retreat in some of the places hardest hit, is far from over. The overwhelming majority of people remain susceptible to the virus. Only about 3 percent to 4 percent of people in the countries being studied have been infected to date, said Samir Bhatt, senior author of the Imperial College London study.

“This is just the beginning of the epidemic: we’re very far from herd immunity,” Bhatt said Monday in an email. “The risk of a second wave happening if all interventions and precautions are abandoned is very real.”

In a teleconference with reporters later, Bhatt said economic activity could return to some degree so long as some interventions to limit viral spread remain in place: “We’re not saying the country needs to stay locked down forever.”

The Berkeley study used an “econometric” model to estimate how 1,717 interventions, such as stay-at-home orders, business closings and travel bans, altered the spread of the virus. The researchers looked at infection rates before and after the interventions were imposed. Some of these interventions were local, and some regional or national. The researchers concluded that the six countries collectively managed to avert 62 million test-confirmed infections.

Because most people who are infected never get tested, the actual number of infections that were averted is much higher — about 530 million in the six countries, the Berkeley researchers estimated.

Timing is crucial, the Berkeley study found. Small delays in implementing shutdowns can lead to “dramatically different health outcomes.” The report, while reviewing what worked and what made little difference, is clearly aimed at the many countries still early in their battle against the coronavirus.

“Societies around the world are weighing whether the health benefits of anti-contagion policies are worth their social and economic costs,” the Berkeley team wrote. The economic costs of shutdowns are highly visible — closed stores, huge job losses, empty streets, food lines. The health benefits of the shutdowns, however, are invisible, because they involve “infections that never occurred and deaths that did not happen,” Hsiang said.

That spurred the researchers to come up with their estimates of infections prevented. The Berkeley team did not produce an estimate of lives saved.

One striking finding: School closures did not show a significant effect, although the authors cautioned that their research on this was not conclusive and the effectiveness of school closures requires further study. Banning large gatherings had more of an effect in Iran and Italy than in the other countries.

In discussing their findings Monday with reporters in the teleconference, leaders of the two research teams said challenges exist in crafting their models and thus there are uncertainties in the final estimates.

Bhatt, for example, said the model used by his team is highly sensitive to assumptions about the infection fatality rate, estimates for which have varied among researchers and from one country to another. He said his team was heartened to see that its estimates for the number of people infected so far is generally consistent with antibody surveys that attempt to calculate the attack rate of the virus.

Ian Bolliger, one of the Berkeley researchers, acknowledged the difficulty in obtaining reliable numbers for coronavirus infections given the haphazard pattern of testing for the virus. Both research teams said the peer review process had made their findings more robust.

 

 

 

 

How the CDC “missed its moment”

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

CDC releases new guidance for colleges on reducing coronavirus spread

If, like us, you’ve been wondering exactly why the CDC always seems to be a step behind in responding to the pandemic, a new, in-depth New York Times piece helps elucidate the myriad challenges—structural, cultural and political—that led to the agency’s flawed response.

Given the CDC’s history, it should have been the world’s “undisputed leader” in the pandemic response. But its early reticence to absorb lessons from other countries, combined with flawed testing, slowed down responses across the nation. While much has been made of political machinations within the Trump administration, a deep-rooted bureaucratic and exacting culture left the CDC ill-suited to respond to a crisis of this scale, requiring improvisation and rapid adaptation.

Career scientists and epidemiologists clashed with CDC leader Dr. Robert Redfield, who was eclipsed by Drs. Tony Fauci and Deborah Birx in public communication. But even if it were firing on all cylinders, the CDC is only one of the many parts of government at the table for what should have been a coordinated, all-government response.

Whether led by the CDC or another entity, the pandemic response has highlighted the need for a massive overhaul of the nation’s public health system, so that future challenges—both COVID-related and beyond—are met with a rapid and coordinated response.

 

 

 

 

The patients stayed away—will they come back?

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

Emergency Department Patient Resources

new analysis from the CDC this week confirmed what we have been hearing anecdotally from health systems for several weeks—as the coronavirus lockdown took hold, there was a precipitous drop in visits to hospital emergency departments. According to the study, visits were down by 42 percent in the month of April compared to the previous year, and despite a rebound in May, were still 26 percent lower than a year ago. Visits in the Northeast dropped the most, as did those among women, and children under 14.

Although visits for minor ailments and symptoms declined the most, even more disconcerting was the drop in visits for chest pain, echoing the concern we’ve heard in many parts of the country that many patients may have suffered minor heart attacks without being treated, or may have waited to be seen until significant damage had been done.

As non-emergent visits have begun to return to many facilities, we continue to hear that emergency department and urgent care volume remains relatively low.

Survey data indicate that patients are fearful of becoming infected with coronavirus if they visit healthcare facilities—especially, it seems, ones where they’ll be forced to wait.

While many providers are investing in messaging campaigns to assure patients it’s safe to return, this nightmarish first-person account by one healthcare insider provides a useful cautionary tale.

Visiting a surgeon for a pre-op consult, she found the experience of visiting a COVID-era hospital downright dystopian. Simply touting safety precautions by itself won’t make patients more comfortable—they’ll need to see and feel that measures are in place to make time spent in a care setting as efficient and reassuring as possible. Otherwise, like the insider in question, they’ll take their business elsewhere. There’s work to be done.

 

Hospitals Emptied Out by Pandemic Push for Patients to Return

https://www.bloomberg.com/news/articles/2020-06-04/dear-patient-we-want-you-back-for-that-knee-replacement

Empty Emergency Rooms Worry Doctors as Heart Attack, Stroke ...

After months of lock down, hospitals are eager to get patients back for routine care and elective procedures.

An executive at a Palm Beach hospital stands between a box of surgical masks and a Purell dispenser.

“We understand you haven’t been inside our hospitals for some time,” she says to the camera. The executive is delivering her line for a promotional video intended to get people back to hospitals after almost three months of avoiding the place at all costs. 

Moments later, the film crew records her chatting with a vascular surgeon in an idled operating room, who soothingly reassures that  a hospital is the cleanest place to be outside your home. “The hospital is safer than the grocery store,” the doctor says.

The video published on YouTube in mid-May is part of a marketing campaign by Tenet Healthcare, which operates 65 hospitals and about 250 ambulatory surgery centers. It’s one attempt to solve a problem the entire health-care industry faces: Most patients vanished when Covid-19 swept the country.

Billions in Losses

Much of routine health care came to a halt in March as hospitals cleared space for an expected wave of Covid-19 patients and authorities ordered a halt to surgeries and other procedures that could be postponed. The decline in volume has clobbered hospital finances, with the industry estimating it is losing $50 billion a month.

Emergency visits dropped by 42% in four weeks in April compared to the same period last year, the Centers for Disease Control reported June 3. The number of U.S. patients getting hospital care dropped by more than half in late March and early April compared to 2019, according to data from Strata Decision Technology, which provides software to hospitals.

Some of that rebounded modestly in May as distancing rules eased, but hospital volume is nowhere near pre-Covid levels. With the pandemic ongoing and many states still confirming hundreds of new cases daily, patients are hesitating to rush back to hospitals.

“The main thing that really is a gating factor at this point is patient comfort,” Tenet President and Chief Operating Officer Saumya Sutaria said at a recent virtual conference with investors. Tenet declined interview requests.

Free Masks

To counter the public’s fears, hospitals publicize what they’re doing to keep patients safe. They’re handing out masks at the door and spacing out chairs in waiting rooms. They’re steering Covid-19 patients to dedicated sites and testing staff regularly.

Hospitals need to show patients that their facilities are safe. At Catholic hospital chain Trinity Health, that includes moving patients through “Covid-free” zones with separate doors, elevators and waiting areas.

“We can put all of the outreach and marketing in place, but it’s only as effective as the people who execute those strategies,” said Julie Spencer Washington, Trinity’s chief marketing and communications officer.

The question for the entire industry is how quickly patients come back. The answer will depend on a constellation of related variables, including how reluctant people are to resume care, and the course of the pandemic. Future surges could force hospitals to shut down regular care again — and spook patients further.

Hospitals and doctors are going to have to do as much as they can as fast as they can until they can’t anymore,” said Lisa Bielamowicz, co-founder of consultancy Gist Healthcare.

Many patients, on the other hand, are in no rush. “They’re waiting and watching rather than pulling the trigger and going to see the doctor like they would have in the past,” Bielamowicz said.

The calculation for the health-care industry is different than for many other service businesses resuming operations. A hospital procedure or even a check-up is more intimate than a meal out.

For procedures that require in-patient rehab stints for recovery, the havoc Covid-19 has brought to nursing homes adds another layer of concern. “Those places seem like deathtraps now, so it’s much harder to bring back those patients because you need to find an alternative way for them to rehab,” Bielamowicz said.

And the biggest consumers of health care are the elderly and the chronically ill, the very people Covid-19 most threatens. “From personal discussions with my patients, the older and more co-morbidities that any individual has, the more nervous they are about returning,” said Shauna Gulley, chief clinical officer at Centura Health, which has hospitals in Colorado and Kansas.

Patients with serious ongoing needs like cancer treatment or emergencies like heart attacks and strokes have continued to get care. And many medical problems resolve on their own. The decline in those visits – for a migraine headache, for example – reduces providers’ revenue but may not harm patients in the long-term.

While people often go to the emergency room for needs better treated in other settings, now the concern is the opposite: That true medical emergencies will be neglected.

Ascension, the nation’s largest Catholic hospital chain, has purchased billboards that say “Don’t delay ER care.” On hospital websites and social media posts, Tenet facilities reminded patients that “Emergencies Can’t wait. We’re Open & Safe.”

Deferred Care

Doctors fear that some patients will defer needed care too long, allowing progressive conditions to deteriorate. Clinicians at Maimonides Medical Center in Brooklyn, New York, have seen patients arrive sicker because they didn’t come earlier, said Ken Gibbs, the hospital’s CEO.

“There are unmet needs, I think that’s clear,” he said. “And I think the data on that will emerge, but it will take time.”

Maimonides treated 471 Covid patients at the peak on April 9, Gibbs said, and still had about 100 in late May. The hospital has applied for a waiver from New York State to resume elective surgeries, which are still on hold in New York City.

Some hospitals are preparing for a lasting dent in their revenue. For years, health economists have pointed to waste in the health-care system, with the estimated cost of unnecessary treatments in the hundreds of billions of dollars. Covid-19 may demonstrate that patients are willing to forego some of that care or opt for more conservative treatment.

People who had delayed back surgeries, for example, may now decide that doing physical therapy at home is good enough, said Marvin O’Quinn, president and chief operating officer at CommonSpirit Health, a large Catholic hospital system.

“We’ve all talked about too much intervention in health care in the past,” he said. “I think we’ll see a new normal in terms of what patients want to do and what doctors want to do, and we will have to adjust to that.”

 

 

 

 

Identifying “triple-threat” counties at higher risk of COVID outbreaks

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

“Superspreader facilities”—nursing homes, correctional facilities, and meatpacking plants—have become major COVID hotspots across the US. Many counties are dealing with a large outbreak in one type of tightly-packed facility or another.

Case in point: the outbreak at Cook County Jail in Chicago, which now accounts for a whopping 15.7 percent of all COVID cases in the state of Illinois. Some places, like Colorado’s Weld County, are managing outbreaks across all three types of superspreader facilities.

The graphic above highlights the nearly 260 counties that we’ve termed “triple-threat counties”: those which have all three types of superspreader facilities. The counties are mapped using our Gist Healthcare COVID-19 Risk Factor Index, which identifies particularly vulnerable populations using chronic disease, demographic, and acute care access variables.

The top 10 “triple-threat counties” by risk index score are all in more rural areas of the country with limited acute care access and more vulnerable populations—places where a COVID outbreak is likely to be particularly devastating. Seven of the 10 have a high percentage of African-American or Hispanic/Latino residents, groups with a an outsized burden of COVID-19 illness and death. These risk factors are intersectional; for example, food processing plants employ twice as many Hispanic workers as the national average, and a disproportionate share of long-term care workers are black.

[Click here for more information and interactive data from our analysis of the risk impact of these superspreader facilities.]

 

 

 

 

66% of counties with most COVID-19 cases lack infectious disease physician

https://www.beckershospitalreview.com/infection-control/66-of-counties-with-most-covid-19-cases-lack-infectious-disease-physician.html?utm_medium=email

About 208 million Americans are living in counties with no or very few infectious disease physicians, and many of these areas have been hit hardest by COVID-19, according to a study published in Annals of Internal Medicine.

Researchers determined the density of infectious disease physicians in every U.S. county using 2017 Medicare Provider Utilization and Payment Data. They also used aggregated data from the CDC and local public health agencies to plot the rate of confirmed COVID-19 cases in each county as of May 12.

Four study findings:

1. Of the 3,142 total counties in the U.S., 79.5 percent did not have a single infectious disease physician.

2. Among 785 counties with the highest burden of COVID-19 cases, 66 percent did not have an infectious disease physician working in the county.

3. About 9.9 percent of counties had an infectious disease physician density below the national average of 1.76 physicians per 100,000 population.

4. Only 10.5 percent of counties had an infectious disease physician density above the national average.

“The deficits in our [infectious disease] physician workforce today have left us poorly prepared for the unprecedented demand ahead,” study authors said, highlighting telemedicine as a key strategy for expanding access to this speciality.

To view the full study, click here.

 

 

 

 

CDC director: US needs up to 100,000 contact tracers by September to fight coronavirus

https://thehill.com/policy/healthcare/501157-cdc-director-us-needs-30-to-100-thousand-contact-tracers-by-september-to?utm_source=ActiveCampaign&utm_medium=email&utm_content=Does+the+US+Spend+Too+Much+on+Police%3F&utm_campaign=TFT+Newsletter+06042020

CDC director: US needs up to 100,000 contact tracers by September to fight coronavirus

Centers for Disease Control and Prevention (CDC) Director Robert Redfield told Congress on Thursday that the country needs between 30,000 and 100,000 people working on contact tracing in order to help contain the next wave of the coronavirus.

The estimate shows the daunting challenge of hiring an army of people to interview those infected with coronavirus to identify who they have been in contact with so that those people can quarantine and help prevent the spread of the virus.

“I’ve estimated between 30 and 100,000” contact tracers are needed,” Redfield told the House Appropriations Committee during a hearing Thursday. He acknowledged the figure is “sizable,” though it is actually less than the 300,000 people former CDC director Tom Frieden has estimated the U.S. will need.

He said it is crucial to get the contact tracing system in place by September to try to keep the virus in check ahead of an expected surge in the fall and winter. That could help prevent the type of blunt stay-at-home orders that the U.S. had to implement this spring after missing the window to contain the virus earlier this year.

“We really have to get this built and we have to get it built between now and September,” Redfield said.

Redfield said his agency has met with all 50 states to discuss hiring contact tracers and is pleased that some states have already started to do so. New York City, for example, has hired 1,700 contact tracers. 

He said the CDC Foundation is working to hire personnel to augment state efforts and the CDC has distributed funding to states provided by Congress for the purpose. He added he hopes AmeriCorps is a source of additional staff.

“It is fundamental that we have a fully operational contact tracing workforce that every single case, every single cluster, can do comprehensive contact tracing within 24 to 36 hours, 48 hours at the latest, get it completed, get it isolated, so that we can stay in containment mode as we get into the fall and winter of 2020,” he said.

 

 

 

 

Open (Your Wallet) Wide: Dentists Charge Extra For Infection Control

https://khn.org/news/open-your-wallet-wide-dentists-charge-extra-for-infection-control/

Open (Your Wallet) Wide: Dentists Charge Extra For Infection ...

After nearly two months at home due to the COVID-19 pandemic, Erica Schoenradt was making plans in May to see her dentist for a checkup.

Then she received a notice from Swish Dental that the cost of her next visit would include a new $20 “infection control fee” that would likely not be covered by her insurer.

“I was surprised and then annoyed,” said Schoenradt, 28, of Austin, Texas. She thought it made no sense for her dentist to charge her for keeping the office clean since the practice should be doing that anyway. She canceled the appointment for now.

Swish Dental is just one of a growing number of dental practices nationwide that in the past month have begun charging patients an infection control fee between $10 and $20.

Swish and others say they need the extra money to cover the cost of masks, face shields, gowns and air purifiers to help keep their offices free of the coronavirus. The price of equipment has risen dramatically because of unprecedented demand from health workers.

Dentists say they struggle to pay these extra costs particularly after most states shut down dental offices in March and April for all but emergency care to reserve personal protective equipment for hospital use. They are also seeing fewer patients than before the pandemic because some fear going back to the dentist and at the same time dentists need to space out appointments to keep the waiting room uncrowded.

Nearly two-thirds of dental offices across the country have reopened for routine care, according to the American Dental Association.

The association, which sets industry standards, says dentists who opt to charge the extra infection control fee should disclose it to patients ahead of each visit, a spokesperson said.

The infection control fee is helping us mitigate the costs of the extra expenses,” said Michael Scialabba, a dentist and vice president of 42 North Dental, whose 75 dental offices in New England are charging an extra $10.

Why don’t dentists just raise prices instead? Dentists said they have little or no leverage with large insurance companies to force them to raise their reimbursement rates. The ADA asked insurers to take into account additional COVID costs dentists face and many insurers responded by agreeing to pay extra fees.

For example, Harrisburg, Pennyslvania-based United Concordia Dental agreed to pay dentists $10 per patient per visit in May and June to offset their PPE expenses for all fully insured clients. The company has more than 9 million members nationwide.

The new infection control fee upsets some patients, although most understand that the cost of dentistry has increased, said Rishi Desai, director of operations and finance at Swish Dental, which has eight locations in the Austin area. “We are just as frustrated with all of these, too, but as a small business we had to reassess things.”

Desai, whose wife, Viraj, is a dentist and the founder of the dental chain, said the extra money will help the practice survive. “We are not making money off this,” he said. “This is just to sustain us so we are not bleeding out cash.”

He noted that last year Swish was paying about $6 for a box of 20 face masks. Today, $6 buys a single mask. The dental office has installed sneeze guards, staffers are wearing face shields over their masks, and the offices have added air filtration systems and hired additional sanitation staff members to clean their offices every day.

He estimates the offices are working at only about half capacity since reopening in mid-May. In weighing how to handle the extra costs, Swish was reluctant to cut employee wages, he said. “Everyone is trying to figure this out,” he added.

Kim Hartlage, office manager of Klein Dental Group in Louisville, Kentucky, said insurers recommended the office add an infection control fee. The insurers balked at raising their reimbursement rates.

She said the small office has had to buy many more disposable masks and gloves. “We’ve had to step up our game,” she said. So far, she hasn’t heard any feedback on the $10 fee. “We have very understanding clients,” she said.

Tamar Lasky, an epidemiologist, said she likes her Owings Mills, Maryland, dentist and was glad the office was communicating the many precautions it was taking to prevent the spread of COVID-19. But she was stunned when informed by email that a $15 “infection control charge” would be added to her bill.

“I can readily imagine there are a range of additional expenses, as well as a loss of revenue associated with the pandemic, but infection control is not an extra service. It is part of the practice of dentistry,” Lasky said.

“I’m not sure what is the best solution to the increased costs of tighter infection control, but this new charge may not be covered by insurance, and that passes all the burden to the patient.”

 

 

 

ICUs become a ‘delirium factory’ for Covid-19 patients

https://www.cnn.com/2020/06/01/health/brain-coronavirus-delirium-kaiser/index.html

ICUs Become A 'Delirium Factory' For COVID-19 Patients | Health ...

Doctors are fighting not only to save lives from Covid-19, but also to protect patients’ brains.

Although Covid-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, and it can starve the brain of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.
Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.
And while Covid-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.
When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with Covid-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.
Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.
“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.
In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.
“We may not know if they’ve had a stroke,” Sheth said.
study from Wuhan, China — where the first Covid-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.
“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.
In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.
“We may not know if they’ve had a stroke,” Sheth said.
smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.
Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.
New York’s Northwell Health is using a mobile MRI machine for Covid patients, said Dr. Richard Temes, the health system’s director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.
Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain’s electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.
“Right now, we actually don’t know enough to say definitely how Covid-19 affects the brain and nervous system,” said Chou, who is leading an international study of neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”
To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.

The brain under attack

Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.
But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.
That’s because performing autopsies on patients who died of Covid-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.
Some of the best-known symptoms of Covid-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.
Authors of a recent study from Germany found the novel coronavirus in patients’ brains.
Research shows that the coronavirus may enter a cell through a molecular gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also other organs, including many parts of the brain.
In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.
Some of the most surprising symptoms of Covid-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.
A study from Europe published in May found that 87% of patients with mild or moderate Covid-19 lost their sense of smell. Patients’ loss of smell couldn’t be explained by inflammation or nasal congestion, the researchers said. Stevens said it’s possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.
new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a Covid-19 patient who lost her sense of smell.
Many coronavirus patients also develop “silent hypoxia,” in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.
When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with Covid-19 could indicate the brain stem is impaired.
Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.

Collateral damage

Well-intentioned efforts to save lives can also cause serious complications.
Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.
Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.
Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.
Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often “don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”
In the French study in the New England Journal of Medicine, one-third of discharged Covid-19 patients suffered from “dysexecutive syndrome,” characterized by inattention, disorientation or poorly organized movements in response to commands.
Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.
Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.
Simply allowing a family member to hold a patient’s hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they’re in the hospital.
“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said.
These and certain innovative practices — such as helping patients to move around and get off a ventilator as soon as possible — can reduce the rate of delirium to 50%.
Hospitals have banned visitors, however, to avoid spreading the virus. That leaves Covid-19 patients to suffer alone, even though it’s well known that isolation increases the risk of delirium, Fleisher said.
Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.
Doctors are also positioning patients with Covid-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.
But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.
All of these factors make coronavirus patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a “delirium factory.”
“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”

Americans’ deepening financial stress will make the coronavirus a lot harder to contain

https://theconversation.com/americans-deepening-financial-stress-will-make-the-coronavirus-a-lot-harder-to-contain-139741

Americans' deepening financial stress will make the coronavirus a ...

Preventing deaths from COVID-19 depends on people who get it seeking treatment – which also allows authorities to track down whom they came in contact with to reduce spread.

But, as the economic pain and joblessness caused by the statewide lockdowns continue to grow, more Americans are experiencing severe strains on their personal finances. This threatens our ability to contain the pandemic because those feeling the most financial stress are much less likely to seek medical care if they experience coronavirus symptoms, according to my analysis of a recent Federal Reserve survey.

As an economist who studies how individuals make health care choices, I worry that in the coming months even more people will consider forgoing vital treatment to pay rent or some other bill – especially as the extended unemployment benefits, rent moratoriums and other relief are set to expire soon.

‘Just getting by’

The Fed conducts a survey of the economic health of U.S. households every quarter, most recently near the end of 2019. In April, it conducted a supplementary but similar survey to quickly gauge how people were handling the coronavirus crisis. Results of both surveys were released on May 14.

The Fed tries to measure financial stress in three key ways. Its surveys ask respondents if they are unable to pay all their monthly bills, couldn’t cover a US$400 emergency expense, or are “just getting by” or worse.

Even before the pandemic hit, the picture wasn’t pretty. In October, when the fourth-quarter survey was conducted, 42% of employed respondents reported fitting at least one of these descriptions, while over 8% said they fit all three. Those figures jumped to 72% and 20% for low-income workers.

But by April, tens of millions of people who had jobs in October lost them as most nonessential businesses across the U.S. either closed or reduced their services. The unemployment rate shot up to 14.7% that month – the highest since the Great Depression – and is expected to climb further when the May data are released on June 5.

The Fed’s April survey, however, paints an even broader picture of the economic impact of the pandemic. In that survey, about 28% of the previously employed respondents said they either lost their job, were being furloughed, had their hours cut or were taking unpaid leave. This has been financially devastating to many, with 68% of this group reporting one of the stresses listed above and 28% saying they were experiencing all three, regardless of income level.

Forgoing medical care

Separate questions in the surveys demonstrate just how strong the link is between financial and physical health.

The October survey also asks those respondents if they had skipped a doctor’s visit during the previous 12 months because of the cost. More than 20% of those who reported one of these financial stresses said they had, while almost 46% of those with all three said so.

In April, the Fed asked a more timely question: “If you got sick with symptoms of the coronavirus, would you try to contact a doctor?”

A third of those respondents who also said they’re experiencing all three financial stresses said “no.” This is especially significant because, unlike the October question, it describes a current, known threat, rather than referring to a previous medical issue of unknown severity. And the widely reported urgency and seriousness of the coronavirus suggests someone wouldn’t treat the decision to seek a doctor’s care or advice lightly.

Relieving the stress

That was back in April, less than a month into the coronavirus lockdowns. If the same questions were asked today, I believe the numbers would look a lot worse.

In the middle of a serious pandemic, we don’t want sick people avoiding treatment because they’re worried they won’t be able to put food on the table. This would likely worsen the spread of the coronavirus and make it a whole lot harder to contain.

As Congress debates additional measures to mitigate the economic and financial effects of the pandemic, it would be wise to keep in mind the connection between financial stress and individual decisions to seek medical care.