H5N1

Factbox: Latest on the worldwide spread of COVID-19

Via Reuters: Factbox: Latest on the worldwide spread of coronavirus. Excerpt:

A divided world has failed to rise to the challenge of fighting the pandemic, U.N. Secretary-General Antonio Guterres said on Saturday and warned concerted action was needed to prevent millions of people being pushed into poverty and hunger.  

EUROPE 

** Europe surpassed 150,000 daily coronavirus cases on Friday just a week after reporting 100,000 cases for the first time, according to Reuters tally, with countries such as France, Germany reporting record daily numbers of infections this week. 

** The foreign ministers of Austria and Belgium have tested positive for coronavirus after attending a meeting with EU colleagues earlier this week, raising concerns the gathering may have been a so-called “super-spreader” event. 

** Italian Prime Minister Giuseppe Conte will announce on Sunday another set of measures to counter the new wave of COVID-19 cases, his office said, after the country registered a new daily record in infections on Saturday. 

 AMERICAS 

** President Donald Trump called for a big economic stimulus as U.S. infections surpassed eight million, with record spikes in several states.  

** Mexico’s health ministry on Friday reported 6,751 new confirmed cases of coronavirus infection and 419 additional fatalities, bringing the country’s total to 841,661 cases and 85,704 deaths.  

ASIA-PACIFIC 

** Prime Minister Jacinda Ardern delivered the biggest election victory for her centre-left Labour Party in half a century as voters rewarded her for a decisive response to COVID-19. Her “go hard, go early” approach has eliminated locally spread coronavirus in the nation.  

** India’s infections rose by another 62,212 cases over the previous day and a local media report said on Saturday the government had begun identifying about 300 million people who would be given a vaccine first when it is ready.  

** Australia’s coronavirus hotspot of Victoria recorded a single case on Saturday - the lowest daily number since early June - and no deaths, with the state’s top health official calling the figures “one-der-ful”.

MIDDLE EAST AND AFRICA

* Iran, the hardest hit Middle Eastern country, extended coronavirus restrictions and closures in Tehran into a third week on Saturday as its death toll rose above 30,000.

COVID-19 and excess all-cause mortality in the US and 18 comparison countries

Via JAMA Network, a horrifying report: COVID-19 and Excess All-Cause Mortality in the US and 18 Comparison Countries. Excerpt, with my bolding:

On September 19, 2020, the US reported a total of 198 589 COVID-19 deaths (60.3/100 000), higher than countries with low and moderate COVID-19 mortality but comparable with high-mortality countries (Table 1). For instance, Australia (low mortality) had 3.3 deaths per 100 000 and Canada (moderate mortality) had 24.6 per 100 000. Conversely, Italy had 59.1 COVID-19 deaths per 100 000; Belgium had 86.8 per 100 000. If the US death rates were comparable to Australia, the US would have had 187 661 fewer COVID-19 deaths (94% of reported deaths), and if comparable with Canada, 117 622 fewer deaths (59%).  

While the US had a lower COVID-19 mortality rate than high-mortality countries during the early spring, after May 10, all 6 high-mortality countries had fewer deaths per 100 000 than the US. For instance, between May 10 and September 19, 2020, Italy’s death rate was 9.1/100 000 while the US’s rate was 36.9/100 000. If the US had comparable death rates with most high-mortality countries beginning May 10, it would have had 44 210 to 104 177 fewer deaths (22%-52%) (Table 1). If the US had comparable death rates beginning June 7, it would have had 28% to 43% fewer reported deaths (as a percentage overall).  

In the 14 countries with all-cause mortality data, the patterns found for COVID-19–specific deaths were similar for excess all-cause mortality (Table 2). In countries with moderate COVID-19 mortality, excess all-cause mortality remained negligible throughout the pandemic. In countries with high COVID-19 mortality, excess all-cause mortality reached as high as 102.1/100 000 in Spain, while in the US it was 71.6/100 000. However, since May 10 and June 7, excess all-cause mortality was higher in the US than in all high-mortality countries (Table 2).  

Discussion 

Compared with other countries, the US experienced high COVID-19–associated mortality and excess all-cause mortality into September 2020. After the first peak in early spring, US death rates from COVID-19 and from all causes remained higher than even countries with high COVID-19 mortality. This may have been a result of several factors, including weak public health infrastructure and a decentralized, inconsistent US response to the pandemic.

The key lesson from SARS that Canada failed to heed when COVID-19 hit

Via CBC News Second Opinion: The key lesson from SARS that Canada failed to heed when COVID-19 hit. Excerpt:

In the years that followed the 2003 SARS outbreak that infected over 400 Canadians and killed 44, an independent inquiry was launched in Ontario to investigate the response to the outbreak and learn from the mistakes made. 

Some of the experts involved in that inquiry say there was one key lesson learned at the time — which Canada failed to apply when the coronavirus pandemic hit.  

At the helm of the 2007 SARS Commission was Justice Archie Campbell, a superior court judge with an "insatiable curiosity," who colleagues say was determined to ensure the lessons from the outbreak were never forgotten.    

As Campbell met with advisers in the library of a federal building in downtown Toronto, he noted how decades of previous royal commission reports were there just collecting dust on the shelves. 

"We would look around the room and he'd point out a royal commission and he'd say, 'As far as I know, that is as far as the recommendations of that royal commission got. They're sitting on the library shelf,'" remembers lawyer Doug Hunt, chief counsel for the commission. "And he said, 'I do not want ours to end up that way.'"  

That was the driving force behind the inquiry, which aimed to thoroughly investigate the outbreak and make clear recommendations that governments would want to follow in the face of future infectious disease outbreaks.  

"We had great hope at the time," said Hunt. "But I think in the end, from a government standpoint, it did end up just on the shelves of that library."    

Canada didn't 'err on the side of caution' early in pandemic  

Canada has faced a much more dire situation in the coronavirus pandemic, with more than 190,000 COVID-19 cases and 9,700 deaths in the eight months since it began.  

But experts who worked on the SARS Commission say if the lessons from SARS had been better applied early on, the country could have fared much better.    

"Canada, China, Hong Kong and Taiwan had more than 90 per cent of all SARS cases and deaths, so they're the ones who we should be comparing ourselves to," said Mario Possamai, a senior adviser to Campbell on the SARS Commission. "Canada now has more COVID-19 deaths and cases than China, Taiwan and Hong Kong combined." 

He said the most important lesson from the SARS Commission was a concept called the "precautionary principle," a strategy that future governments could apply to ensure the situation didn't get out of control.  

The basic tenet of that principle is to always take the safest approach in an outbreak and not wait for all of the scientific evidence before acting.   

"What Justice Campbell said was that when there is scientific uncertainty, err on the side of caution and protect health care workers and protect Canadians," said Possamai. "And we didn't do that."  

Possamai said early hesitation on closing borders to international travellers, the resistance to recommending the use of masks for the general public and the impact of a depleted national stockpile of PPE had devastating consequences on Canada's ability to control COVID-19.  

"In case after case, a precautionary approach would have made a difference," said Possamai. "We were not only late in moving in that direction, but there was a real lack of transparency."   

Time and time again the Public Health Agency of Canada assured Canadians it was using the best guidance available, but declined to cite the specific scientific evidence behind its decisions, like its reluctance to acknowledge asymptomatic transmission and the possibility of airborne spread of the virus — something Possamai said caused confusion. 

"What were the studies? What was the science?" he asked. "It's completely opaque."   

Hunt said the lack of personal protective equipment available to frontline health-care workers at the beginning of the pandemic was "inexcusable," and called the decision to destroy millions of expired N95 masks last year "mind-boggling." 

The federal government was widely criticized early in the pandemic for failing to maintain an adequate supply of personal protective equipment in the National Emergency Strategic Stockpile (NESS), and for sending 16 tons of PPE to China, leading to a scramble to procure supplies. Canada has since become almost entirely self-sufficient in producing its own PPE, and China has repaid the donation. 

Canada's Chief Public Health Officer Dr. Theresa Tam finally conceded this week that the science is "evolving" on whether COVID-19 can be transmitted via aerosols — or microscopic airborne particles — yet PHAC's guidelines still make no mention of it. 

"In key areas, we just didn't take a precautionary approach," Possamai said. "The kinds of arguments that the federal government made at the time didn't make sense then, and make even less sense now."

Canada 'must do a lot better' at protecting elderly in 2nd wave

Prime Minister Justin Trudeau responded to questions last week about whether Canada's lessons from SARS had been followed, after the release of a report Possamai authored that alleged Canada put health-care workers at undue risk of COVID-19.

"As we look back on those first months, there are a lot of things we could have done differently, we should have done differently, and things we're learning from," Trudeau said during a news conference on Oct. 5.

"At the same time, many of the things that we were able to do successfully in those first months of the COVID-19 pandemic were based on lessons learned from SARS."

 

COVID-19 in Spain: A predictable storm?

Via The Lancet Public Health, an editorial: COVID-19 in Spain: a predictable storm?

As of Oct 12, there have been 861 112 confirmed cases and 32 929 deaths due to COVID-19 in Spain. More than 63 000 health-care workers have been infected. Spain was one of the most affected countries during the first wave of COVID-19 (March to June), and it has now been hit hard again by a second wave of COVID-19 infections. While the reasons behind this poor outcome are still to be fully understood, Spain's COVID-19 crisis has magnified weaknesses in some parts of the health system and revealed complexities in the politics that shape the country. 

The COVID-19 pandemic tested health system resilience and pandemic preparedness. Despite the creation in 2004 of a Centre for Coordination of Health Alerts and Emergency, the pandemic laid bare the country's “weak surveillance systems, low capacity for PCR tests, and scarcity of personal protective equipment and critical care equipment, a delayed reaction by central and regional authorities, slow decision-making processes, high levels of population mobility and migration, poor coordination among central and regional authorities, low reliance on scientific advice, an ageing population, vulnerable groups experiencing health and social inequalities, and a lack of preparedness in nursing homes”, according to 20 Spanish public health leaders writing in August in The Lancet. 

The Spanish health system's four pillars—governance, financing, delivery, and workforce—were already fragile when they were overwhelmed by COVID-19 in March. A decade of austerity that followed the 2008 financial crisis had reduced the health workforce and public health and health system capacities. Health services are understaffed, under-resourced, and under strain. With 5·9 nurses per 1000 inhabitants, Spain has one of the lowest ratios in the EU (where the average is 9·3 per 1000), and too often relies on temporary contracts that can run for just a few days or weeks. 

Granular data surveillance is key for understanding and responding to an outbreak. For Sergi Trias-Llimós and colleagues, writing in The Lancet Public Health, the data currently published at the country and regional levels are insufficient to understand the dynamics of the epidemic. They call on authorities to provide comprehensive data updates on tests, cases, hospitalisations, intensive care unit admissions, recoveries, and deaths, all disaggregated by age, sex, and geography. 

The test-trace-isolate tryptic, which is the cornerstone of the response to the pandemic, remains weak—COVID-19 cases are increasing alarmingly, and authorities are again looking at lockdowns to contain the spread of the virus. When the national lockdown was lifted in June, some regional authorities were probably too fast at reopening and too slow at implementing an efficient track and trace system. In some regions, the local epidemiological control infrastructure was insufficient to control future outbreaks and limit community transmission. Spain's political polarisation and decentralised governance might also have hampered the rapidity and efficiency of the public health response. Whereas the first wave might have been unpredictable, the second wave in some parts of Spain was quite predictable, Rafael Bengoa (Institute for Health and Strategy, Bilbao, and former Minister of Health Basque Country) told The Lancet Public Health. 

In an attempt to identify areas where public health and the health and social care system need to be improved, Alberto García-Basteiro and colleagues, in their Letter in The Lancet Public Health, urged the Spanish central and regional governments to set up an independent evaluation of their COVID-19 responses, and lay down the requirements and principles for such an evaluation. 

The evaluation should start immediately, should build consensus among society, and requires firm commitment from the central and regional governments; the evaluation committee should be independent, diverse and multidisciplinary, the evaluation should be broad in scope (health, economic, and social effects) and providing recommendations. Such an independent evaluation will be key to reassure the population and rebuild trust in the Government's approach to public health. 

And there are reasons for hope. In the latest Global Burden of Disease analysis, published in The Lancet, health indicators (such as life expectancy and healthy life expectancy) suggest that Spain overperforms, with indicators better than would be predicted according to the country's socio-demographic index. If Spain's political leaders can draw the lessons from their sub-optimal response to COVID-19, the country is very well placed to give its population a bright and healthy future.

Cytokine elevation in severe and critical COVID-19

Via The Lancet Respiratory Medicine: Cytokine elevation in severe and critical COVID-19: a rapid systematic review, meta-analysis, and comparison with other inflammatory syndromes. The summary:

The description of a so-called cytokine storm in patients with COVID-19 has prompted consideration of anti-cytokine therapies, particularly interleukin-6 antagonists. However, direct systematic comparisons of COVID-19 with other critical illnesses associated with elevated cytokine concentrations have not been reported. 

In this Rapid Review, we report the results of a systematic review and meta-analysis of COVID-19 studies published or posted as preprints between Nov 1, 2019, and April 14, 2020, in which interleukin-6 concentrations in patients with severe or critical disease were recorded. 25 COVID-19 studies (n=1245 patients) were ultimately included. 

Comparator groups included four trials each in sepsis (n=5320), cytokine release syndrome (n=72), and acute respiratory distress syndrome unrelated to COVID-19 (n=2767). In patients with severe or critical COVID-19, the pooled mean serum interleukin-6 concentration was 36·7 pg/mL (95% CI 21·6–62·3 pg/mL; I2=57·7%). Mean interleukin-6 concentrations were nearly 100 times higher in patients with cytokine release syndrome (3110·5 pg/mL, 632·3–15 302·9 pg/mL; p<0·0001), 27 times higher in patients with sepsis (983·6 pg/mL, 550·1–1758·4 pg/mL; p<0·0001), and 12 times higher in patients with acute respiratory distress syndrome unrelated to COVID-19 (460 pg/mL, 216·3–978·7 pg/mL; p<0·0001). 

Our findings question the role of a cytokine storm in COVID-19-induced organ dysfunction. Many questions remain about the immune features of COVID-19 and the potential role of anti-cytokine and immune-modulating treatments in patients with the disease.

COVID-19 on Friday night as seen by Reuters

I find a lot of stories on the Health News Headlines | Reuters website. Tonight it's just a barrage of bad news, from Germany's 7,830 new cases today to Mexico's total of 841,661 cases and 85,704 deaths, to the surge of cases in Wisconsin where Trump plans to take his superspreader tour.

The stories will doubtless change by the time you visit the site, but the underlying story will remain: the pandemic is bad and getting worse.

COVID-19 in British Columbia and Washington state

Here's a screenshot from today's British Columbia COVID-19 Dashboard. We are what looks like a second wave, higher and longer-lasting than the first. We really don't like the series of triple-digit case numbers we've been racking up.

And here's today's Washington state COVID-19 dashboard:

Washington has a population of 7.6 million. BC has a population of 5 million, most of it concentrated in the southwest corner of the province literally within sight of our neighbour. Seattle is maybe 4 hours' leisurely drive south of Vancouver (when the border is open, which is unlikely for the foreseeable future). 

 

I really don't understand why Washington's case numbers and deaths are almost an order of magnitude higher than ours. Perhaps something in the initial responses must have set the pattern. We both suffered early cases and fatalities in long-term care facilities, but somehow COVID-19 spread far faster in Washington than it did here. If anyone is aware of a comparative study of COVID-19 in the two jurisdictions, I would be grateful to know about it.

'On the brink of disaster': Europe's Covid-19 fight takes a turn for the worse

Via The Guardian: 'On the brink of disaster': Europe's Covid fight takes a turn for the worse. Excerpt:

"It’s not a word I’ve heard in a long, long time,” an elderly Paris resident said, leaving her apartment in mask and gloves for an early expedition to the shops. “A curfew. That’s for wartime, isn’t it? But in a way I suppose that’s what this is.”  

Europe’s second coronavirus wave took a dramatic turn for the worse this week, forcing governments across the continent to make tough choices as more than a dozen countries reported their highest ever number of new infections. 

In France, 18 million people in nine big cities risk a fine from Saturday if they are not at home by 9pm. In the Czech Republic, schools have closed and medical students are being enlisted to help doctors. All Dutch bars and restaurants are shut.  

Austria, Belgium, the Czech Republic, France, Germany, Italy, the Netherlands and Poland are among countries to have broken daily case records, prompting the World Health Organization to call for an “uncompromising” effort to stem the spread.  

Unfortunately, that requires making all but impossible compromises. 

Most European governments relaxed strict lockdowns over the summer to revive economies shattered by the pandemic’s first wave. The return of normal activity, from packed bars to new academic terms, has fuelled an exponential increase in infections. 

With infections across the continent breaking the barrier of 120,000 a day, authorities must now tighten restrictions once more to slow the spread of the disease – while doing all they can to avoid destroying already-jeopardised jobs and livelihoods. 

They are also facing legal challenges: the Dutch government must work out how it can make masks mandatory while complying with the law, and a Berlin court suspended a city order requiring bars to close at 11pm, for lack of evidence it would prove effective.  

In France, which reported more than 30,000 new infections on Thursday, President Emmanuel Macron said a curfew was needed to halt “the parties, the moments of conviviality, the festive evenings … They accelerate the disease. We have to act.”

COVID-19 on Friday morning: 39,002,007 cases, 1,099,469 deaths

A screenshot from the Johns Hopkins Coronavirus COVID-19 (2019-nCoV) dashboard:

China's Qingdao city says COVID-19 cluster traced to two dock workers

Via CBC News, a Thomson Reuters report: China's Qingdao city says coronavirus cluster traced to two dock workers. 

The cause of an outbreak of the novel coronavirus at a hospital in the Chinese coastal city of Qingdao was traced to two infected dock workers, authorities said on Friday. 

The workers had check-ups in an examination room at the Qingdao Chest Hospital, and the room was contaminated due to insufficient disinfection and protection measures, a Qingdao health official told a media briefing.  

One of the workers had tested positive for the virus in late September, but only developed symptoms after 20 days, on Oct. 14, the Qingdao Municipal Health Commission said in a statement.  

No details were given on the second worker. Both of them were asymptomatic, the official said. 

In September, Qingdao health authorities found coronavirus contamination on some packages stored by a seafood importer after two of its handlers tested positive for the virus but displayed no symptoms. 

It was unclear whether or not the two handlers were the two infected dock workers. 

In response to the outbreak, Qingdao launched a city-wide test for the virus on Oct. 12, and expects to complete testing all of its 9 million residents by Friday.  

It reported 13 new infections this week, most linked to the Qingdao Chest Hospital, where infected travelers arriving from overseas had been treated in an isolation area.