Thread by @friedberg

love @UCSF and @UCSFMedicine grand rounds video,

here are my tl;dw notes if you don't have the time to watch:

epidemiology:
- asian response to pandemic was informed by their experience with SARS. already common practice to wear masks in public, knew how to rapidly test & trace, isolation protocol planned & ready; thus, better curve flattening over US

- outbreak now much worse in Europe and US than it ever was in China
- key metric to watch is daily new cases per 1M pop
- china peaked at 10, spain steady over past week at 173, italy steady over past week at 100, US now at 90 rising every day (these are my calcs)

- net mortality rate 10-20x seasonal flu, likely closer to 10x due to lack of testing and undercounting cases
- definitely NOT seeing deaths in younger age groups
- US seeing more deaths in middle age groups likely due to sig higher prevalence of pre-existing conditions in US pop

- IHME model currently predicting ~80k net deaths in US with peak daily death rate in mid-April
- genetic analysis of virus in Bay Area patients indicates 3-4 unique strains.. Bay Area NOT just community spread but seems to have acquired virus from multiple land/sea/air vectors

- jingle from Riverside county "Stay in place, maintain space, cover your face"
- each action reduces transmission rates and R drops
- success in singapore,hongkong from combo isolation, testing, tracing, strategic antibody detection

testing:
- considers abbott and cepheid systems helpful in creating point-of-care <1 hr PCR detection (still hard to scale or address volume issues but helps in small hospital setting)
- sensitivity of PCR tests now measured based on swab type: oral 56%, nasal 76%, oral+nasal 84%

- viral load highest during early stage of disease
- sputum from lungs has highest viral content but hard to produce/isolate, thus double oral/nasal swab
- best case still 16% false negative w PCR

clinical:
- taste and smell disorders in 34% of patients in a small study, mostly younger women and study was done later in disease course
- not clear how widespread smell/taste issues are at this point, mechanism not clearly understood
- anecdotally, smell/taste recovery likely

- c19 causes systemic inflammation, not just in lungs, seeing gut and ocular manifestations too
- ocular issues manifesting as conjunctivitis, WITHOUT co-infection typically, seen in about 32% of patients

- 25-30% mortality in cancer patients infected and admitted, however 58% of those patients had lung cancer and 42% on active chemo (immune suppression); so not all cancer patients equally at risk

- not seeing a lot of co-infection generally; studies range 5-14%, one study (not peer reviewed came in at 22%)
- ICU mortality study comparison data interesting: china ~70%, US 48% -- better care, treatment, or ICU admission bias? is survival improving with learnings about care?

treatment:
- can't draw any conclusions from published data on remdesivir at this point; 5 clinical trials underway -expecting readouts any day
- compassionate use program closed as expanded access program underway now for intubated patients w/o multi-organ failure

- hydroxychloroquine is an antiviral and antiinflammatory
- most patients gets better and most patients see decline in viral load without treatment... the HCL series from France did not account for NO HCL as a treatment course

- HCL trial on mild patients from china saw 13/15 on HCL get to no viral load on day 7, 14/15 on NO HCL got to no viral load on day 7.. negligible effect on safety or clinical outcome
- 62 patient study showed 1-day reduction in fever/cough but generally this was not clear study

- may need high dose 800mg/day of HCL
- hard to make any clear statement at this point on HCL -- good safety signals but no real data to draw conclusions at this point
- french study was people EXPECTED to do well so hard to say if HCL+zpak was useful

- encouraging recovered patients to donate blood to use plasma (with antibodies) to help ill patients ... "convalescent plasma" seems to be useful, FDA indication allows it be used now in limited way
- big driver of COVID is immune-modulated inflammation - "cytokine storm"

- several anti-inflammatory/immune modulating drugs are showing efficacy but jury is still out on whether single pathway (i.e. IL-6 or IL-1b) or multi (i.e. steroids) is better, helping, or hurting patients
- COVID-19 vaccine already being trialed

- 8 different vaccine approaches with 47 candidate compounds ... expect a vaccine at least 12 months from now
other q&a:
- yes, the general public should wear masks
- when do we stop isolation? need more testing - pcr and sero - to confirm de-isolation is viable

- need to loosen restrictions gradually with masks, given high asymptomatic transmission rate
- if you have antibodies, it's not FULLY ANSWERED that you are immune, but some papers show that you can't be re-infected, w some anecdotal data of reinfection (unproven)

- new data indicates asymptomatic transmission increases need for gen pop wearing masks
- virus itself not airborne, virus transmitted in droplet particles in the air and on surfaces
- treatment not needed with mild symptoms
- high-risk patients should consider HCL w tracking

- intubated patients good candidates for clinical trials and case-by-case with other drugs
course of disease:
- seeing cohort of patients do well in first week then rapidly progress in second week, dyspnea / breathing difficulties a good predictor here

- only 4% of tested symptomatic patients C19 are PCR+ ... (interesting stat, indicates lots of other respiratory disease issues right now)
- consistent observations with china, kirkland, italy.. older patients, not younger, co-morbities, not healthy; long ICU stay if admitted

- ARDS course is long and requires venitllation
- explains high ICU/ward ratio - high threshold for admission, longer time in bed vs ward not needing ICU simply leaving much quicker and not needing long care
- not seeing ventillator trade-off issues at UCSF today

- "the greatest medical benefit for the greatest number of patients" is the mantra that helps frame these trade-off decisions. hard moral issue
- masking could lead to false sense of security (go outside more often than you should)