Hawaii, opening up to tourism with testing may not be the best idea.
Islands like Aruba, French Polynesia, and Iceland had seen terrific control of COVID until tourists, fully tested tourists, arrived and then COVID rates exploded.
Aruba opened to tourism in July 1. All tourists were tested immediately before or after arrival. By August, Aruba saw the highest rate per capita in the world. travelpulse.com/news/destinati…
French Polynesia opened to tourism July 15th. All visitors over the age of 6 had to have negative PCR testing. COVID cases stayed low until they didn't. Cases shot up over the last month and now French Polynesia has the highest per capita COVID rate in the world.
Iceland was the COVID control exemplar. Tourists from EU/Schengen + 'safe' countries could visit w/testing or quarantine (or mix of both). A strain likely from tourists spread and now travelers from Iceland must quarantine. schengenvisainfo.com/news/iceland-t…
The test-and-then-consider-safe policy works until it doesn't. When it doesn't work, it's a set up for superspreading, as the world saw after the White House began reporting cases.
Test-then-consider-safe policies work until they don't. When they don't, they fail spectacularly

They select for superspreaders

Viral shedding goes from 0 to full throttle fast.
The most dangerous spreader is the person who just turned positive and was negative hours ago.
Most who test negative won't be on the cusp of explosive viral shedding, but sometimes there's that person who tests negative will be on that cusp. The time between a negative test and a positive test may be the duration of a long haul flight or a short holiday break.
Those who know they have COVID often aren't as infectious. If symptoms prompted testing, they likely had the illness for days before being tested as early symptoms are very mild. They may ahve waited days for results. Shedding drops off quickly and by day 10 most arent infectious
Most who test negative won't be on the cusp of explosive viral shedding, but sometimes there's that person who tests negative on that cusp. The time between a negative test and a positive test may be hours. It can be the duration of a long haul flight or a short holiday break.
Most testing negative wont be on the cusp of explosive viral shedding, but sometimes there's that person on that cusp. The time between a negative test and a positive test can be the time between take off and landing on a long haul flight or arrival and departure on a short break

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More from @InfectiousDz

5 Oct
Infection Prevention and Control 101.
1. Do not rely on one tool. Do not build a Maginot Line
2. Work from broadest communal protection down to personal protection. Reduce entry, design environments with reduced contacts, ensure rules allow for compliance.
3. The slices of Swiss cheese, each line of defense, have to line up for the pathogen to pass through the holes. Line up so many slices that probability makes this an impossibility.
4. Don't allow for work arounds and honor codes. We're all in denial about having an infection.
5. Design is a tool for health. Layout can permit communication (or observation) without contact/exposure. Flows of traffic can be designed to reduce mixing. Natural ventilation and outdoor spaces can be maximized.
Read 10 tweets
4 Oct
Nurses of Filipino descent comprise just 4% of the US workforce, but nearly a third of registered nurse deaths due to COVID-19, according to National Nurses United union
Nurses of Filipino descent make up of the staff in many hospitals hit hard by COVID.
There are about 150,000 Filipino nurses working in the United States — and 20% of the nursing force in California.
Vulnerability to infectious diseases though is not always due to increased exposure. There may be increased genetic vulnerabilities as well, as we have seen certain immune differences that can be genetic, such as seen with Interferon genes.
Read 4 tweets
4 Oct
Dr Conley, White House doctor: "we are trying to maximize everything that we could do for him and we debated whether we'd even start it - the dexamethasone, and we decided that, in this case, the potential benefits early on the course, probably outweighed any risks at this time."
Two things
1. Maximizing everything we do is not the goal. Less is often more.
2. If indeed has not had persistent low oxygen levels, the concern is this drug, whose side effects are well known, could cause more harm than good, especially 'early on the course'
VIP medicine is more prone trying to do everything. Patients often want to do everything. Everything is not always best. In this case, the med can affect the patient's ability to do his job, which the patient may not have fully understood.
Read 4 tweets
4 Oct
Walter Reed
- 2 incidents of drop in O2, last to 93%. This alone is not that worrisome
- First dose of dexamethasone. This is the only treatment shown to improve survival, but only in those who have needed oxygen (and these oxygen levels are higher than most given steroids)
Radiology findings of changes due to COVID are quite common. Without specifics, could certainly have findings without these being signs of severe disease.

O2 drop was yesterday morning. Press conference yesterday would have been at about the same time, apparently
None of these reported oxygen levels are worrisome but it's still early in the course, and early days are usually mild, though the start date of symptoms has not been fully clarified. The findings relative to the day of symptoms help determine severity of course.
Read 14 tweets
3 Oct
If a patient becomes severely ill with COVID, the course is long and the outcome uncertain for weeks. COVID is cruel. We have no crystal ball for a patient with early signs of severe COVID where they will be come November. They may be intubated. They may be fine. They may not be.
Care progresses from needing oxygen to high flow oxygen to non-invasive ventilation to intubation/mechanical ventilation to sometimes ECMO.
Many patients do quite well with oxygen alone. Those who need intubation do much more poorly.
Progression through the stages of oxygen support can be slow and steady. Some patients though can change quickly. They may look quite well medically, until they don't, and rapidly decline. Outcomes though are usually not quickly determined.
Read 4 tweets
27 Sep
Back in February, a Champions League football match between teams from Valencia and Lombardy appeared to act as a super-spreading event, seeding COVID in Europe, with spread soon to NYC.
There's no reason to repeat any of this.
Atalanta, the football team from Lombardy, Italy, in this apparent superspreading event earned 50 million euros in prize money from this ill-fated match news.fenomeno.app/2020/03/how-at… football-italia.net/151062/atalant…€50m?fbclid=IwAR317iExsxwmLpolizaPMMbJtdn2WTFP36OhatWBbW0yyD-jQAFiATwuK00
It takes tremendous political will to stand in front of the power of football, but it's crucial that the love of the game - and the prize money waiting - do not let us backtrack into seeing more COVID cases.
Read 5 tweets

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