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  • Josh Schiffer

March 17, 2020

Hi everyone! Thank you all for sharing the blog with people in your life. Today there were over 1200 views of my post from yesterday. This is pretty cool but makes me realize that I probably need to be really careful with my words going forward, which will be difficult because I anticipate becoming more and more stretched, and tired. I’ll re-emphasize that I will get things wrong when making predictions about the pandemic, but just reporting the news without my opinions and perspective would be no fun. I’ll do my best.


I hope that you are all keeping strong and finding a bit of time to enjoy this new version of life. Today, my low-level sense of dread was unrelenting. Indeed, I am going to report on some pretty tough news below. However, the stronger feeling was that of gratitude.


I do not wish to brag, but the people in my life are shining right now. Kids across the planet are in a tough situation, but mine have handled it really well. It is fun to listen from upstairs as they actually participate in class. They are keeping in shape, not yet killing each other, and have not complained once. I am very proud. Chihana is just a force right now. She is supporting us in every way possible while continuing to work and has not lost her spirit even a little. She is on a streak of new and creative meals, and we are eating like royalty.


My research group is on fire. Two members developed a hypothesis about HIV infection this week that I cannot yet share, but it is somewhat paradigm shifting, controversial and ever so possibly a real thing. Two scientists are working feverishly on putting together a useful COVID model. Another submitted a modeling paper that is a true technical achievement. Ours is typically the least urgent science imaginable. However, my group has responded to 130 AM emails and bizarre unexpected requests (from me) without blinking. I am submitting a herpes grant with 2 of my favorite people in the world and am on the phone constantly with different scientists at the Hutch and UW, trying to come up with the best way to help in this constantly shifting environment. We have an idea for a clinical trial but making this happen is a whole different story. We are countering the dread with a lot of positive energy.


Because of COVID-19, I have heard from so many old friends by text and phone, and have not laughed this hard, and this many times per day, in years. I honestly have no idea how I got so lucky to have this many superb people in my life. I am humbled and again just so grateful.


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Today’s reads:

What will happen next? The big news today is the report from Imperial College in London. This is the leading infectious diseases epi modeling group in the world. They have an incredible intensive 3-week course each year: I was there in 2007 and it shaped my future.


Here the Imperial group prognosticates what will happen in the case of different interventions in the US or the UK. The mitigation strategies in Figure 2 are a detailed version of flatten the curve and worth a look.


However, what is really sobering and important is Figure 4. Our fundamental issue right now is that we are stuck between a rock and another rock: physical distancing is necessary to put out the massive acute fires in our cities; however, it is not sustainable. I am not an economist, but it is pretty clear that the economy will collapse if this policy is maintained for too long. Eventually after we survive the first terrible wave, we must relax a bit to let businesses survive, maintain the supply chain and keep our children sane. However, when distancing is relaxed, cases and deaths will pop back up pretty quickly. We will be more prepared but ultimately will likely be forced back into a period of physical separation to avoid a second or a third catastrophic wave.


Therefore, a tight walk pattern of periodic physical distancing and relaxing seems like potentially the best way forward until a vaccine is developed, approved and widely implemented. The time for this to occur could be 12 months (a miracle), 18 months or god forbid, never. In summary, our lives have fundamentally changed for a long time:

https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf


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SARS-CoV-2 testing. Last week I included an article from the NY Times about my friend and colleague Helen Chu, and her experience diagnosing a healthy teenager with SARS-CoV-2 through the seatleflu study, before SARS-CoV-2 PCR tests were available in our city. This provided the clue of widespread cryptic transmission in Snohomish county. I was privy to that story immediately after it went public and hearing it firsthand was jolting.


This is another infuriating story from Seattle about 2 friends and collaborators at UW (Alex Greninger and Keith Jerome) whose PCR assay was held up due to red tape. I also remember talking with Alex as this was happening. When he told me that he had to physically mail his application to the FDA, I just laughed. At that point we knew that the US was going to take a hit from SARS CoV-2: it seemed inconceivable to me that the capabilities of UW Virology would be stymied by the system. As these articles describe, I was wrong.

https://www.newyorker.com/news/news-desk/what-went-wrong-with-coronavirus-testing-in-the-us

https://www.gq.com/story/inside-americas-coronavirus-testing-crisis

On a lighter note, it is no surprise to me that Keith and Alex are in the New Yorker. They deserve it on the merits of their pre-COVID work. GQ I did not see coming.


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Ethics of critical care: Mark Tonelli from UW Pulmonary talks about prepping the medical center for a surge of critically ill patients and the ethics of rationing ventilators in the event of demand exceeding supply. While this scenario is unthinkable, I am worried that it could happen here next week. It is reassuring that a plan is in place as spontaneous decisions on the ground would be impossible. There also should be a push to manufacture 1000s of new ventilators but this is apparently not happening.


https://twitter.com/T_Inglesby/status/1239675564199481347


https://www.washingtonpost.com/video/national/at-the-center-of-the-coronavirus-outbreak-a-hospital-prepares-for-the-worst/2020/03/17/66ef889f-8c27-432d-8d02-5cbbed4094f7_video.html?fbclid=IwAR3TaoXmBdxN5-QikDGcAHnUXA2BvdFQCJS-BrgecZxIjz3eAc8qyeCbOfs


At minute 4:05, notice that the person gets both nostrils swabbed instead of just one side. I was definitely not in the room when this decision was made (I never am) but I think that it was based on some vintage 2017 data from the deep vault of the Schiffer group.


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How Korea succeeded and whether it is sustainable. Korea now has walk through negative pressure testing sites in which there is no human contact with the person getting swabbed. When this is all over, I am going to Korea to eat and to congratulate people on their general awesomeness fighting SARS. https://www.sciencemag.org/news/2020/03/coronavirus-cases-have-dropped-sharply-south-korea-whats-secret-its-success?fbclid=IwAR35rYpoj1GX8FajwwyD8PcUyxfsUq9Owsog88w85OmkcwJ00H1gVCJRvPQ


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Pollution. A virus from pangolin infects a human in a market in Wuhan leading to a dramatic decrease in pollution in Northern Italy several months later: https://www.nytimes.com/interactive/2020/climate/coronavirus-pollution.html


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Younger cases in France than Italy. This seems odd and I’d like to see the real data. Perhaps this reflects earlier quarantine of the elderly after witnessing the events in Italy. Not sure: https://www.businessinsider.com/half-of-french-coronavirus-intensive-care-patients-are-under-60-2020-3

In Italy, the risk of bad outcomes in the elderly vs the young is staggering:

https://jamanetwork.com/journals/jama/fullarticle/2763401?guestAccessKey=72f61225-c3fd-4fb1-81fd-09b6a1666aaa&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=031720


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Kids. The news from China is that severe illness really does appear to be pretty rare which is what we thought: https://pediatrics.aappublications.org/content/pediatrics/early/2020/03/16/peds.2020-0702.full.pdf


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Virus as fomites. I saw this study and had to laugh. I have wanted to do something similar for the human herpes viruses for over a decade but nobody who can do it has the time or desire to help me. This study of SARS-CoV-2 half-life on different surfaces was probably done in an afternoon but provides really useful info. The bottom line is that the virus has fomite potential with a pretty long half-life on steel & plastic. So it might stick around for several days if it starts at a high level. I doubt that this is the most common mode of transmission, though I do wonder if it plays a role in mass transmission events like the Biogen conference. Practical advice is to wash your hands: https://www.nejm.org/doi/10.1056/NEJMc2004973?fbclid=IwAR2JV_9UQ-2l-LDN4NiSxs7PlAJ565C88Fk6145uHKPbKeki0zgqdkRmM10


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There is some new data about a Japanese antiviral that is promising from China but publication in a newspaper before even a pre-print scientific journal dose not inspire 100% confidence. I can’t wait to see the actual data: https://www3.nhk.or.jp/nhkworld/en/news/20200317_48/


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Finally, a great editorial from the NY Times. Think now about what you will do to help when help is needed. If you get infected and heal, then you may be a particular asset in health care settings: https://www.nytimes.com/2020/03/17/opinion/war-crononavirus-trump-production.html

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