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Increasing the odds that my very-productive 82-year-old colleague can keep thriving for another twenty years? If there is no vaccine, or if the vaccine isn't v

by ISL 7y ago

Increasing the odds that my very-productive 82-year-old colleague can keep thriving for another twenty years? If there is no vaccine, or if the vaccine isn't very good, social-distancing and contact-tracing is the only way to win. One fifth of the global population doesn't yet have it. Like many people around the world are undoubtedly experiencing, an elderly relative died yesterday from Covid-19 in New York. I doubt she will be the last.

SlowRobotAhead 7y ago
>If there is no vaccine, or if the vaccine isn't very good, social-distancing and contact-tracing is the only way to win. Why is herd immunity not a "way we win"? edit: Ah, yes, concern about the time to get there. Well, let's hope that happens quicker than expected (has any study not shown this?) because from where I'm sitting it looks like lock down is ending.
- pacificmint 7y ago
  Because a lot of people will be dead by the time we get to ~70% immunity.
  - mrfusion 7y ago
    As I understand it, the healthy majority would get the immunity while continuing to isolate the at risk groups.
    - james_s_tayler 7y ago
      Which is not very realistic as a possibility given the number of people that fall into the at risk groups. It sounds simple in theory but seems very unlikely to be something workable in practice.
    - AaronFriel 7y ago
      The "at risk" groups include a sizable percent of the US population, and isolating all of their first degree daily contacts alone is likely impossible. Hospice patients, and the hospice workers. People already in treatment, and the healthcare professionals providing them with care. People who smoke, have diabetes, a heart condition, or are immune compromised, and so on, and everyone they know. This has got to be millions and millions of people, and this isolation will be extraordinarily porous. Those folks have friends and family too, they will slip up, exposing their contacts and then the virus is on the other side of a firewall. And we've seen how quickly the virus spreads in isolated groups!
    - adrianN 7y ago
      It's impossible to isolate only the at risk group. That's like 30% of the population. Also, there is growing evidence that even mild cases can leave more or less permanent damage.
  - sjwright 7y ago
    And the huge number of severe cases will overwhelm health care systems by an order of magnitude, risking the lives of other people who will need medical care to survive.
  - coretx 7y ago
    Big IF we ever reach those numbers at all. (!)
- edmundsauto 7y ago
  The path to herd immunity includes a lot of death.
  - mrfusion 7y ago
    What’s you’re source on that? As I understand it, Sweden is almost there.
    - joshuamorton 7y ago
      Almost to herd immunity? No. They're at less than 1% infected (like most places), with more deaths per capita than the us despite a younger healthier population.
      - mrfusion 7y ago
        https://www.npr.org/2020/04/26/845211085/stockholm-expected-to-reach-herd-immunity-in-may-swedish-ambassador-says https://www.npr.org/2020/04/26/845211085/stockholm-expected-...
        acdha 7y ago
        That’s a political answer to a question they’ve staked their political future on. Let’s wait for actual scientific evidence before accepting it.
    - newacct583 7y ago
      Uh... from what do you understand that? Sweden isn't even close. Their deaths/case ratio isn't too far off from New York. We have reasonably good evidence now that New York is maybe 30-50% of the way to herd immunity (plus or minus a factor of two or so). New York has six times the per capita deaths that Sweden does. Just extrapolating and multiplying their current number by 3x6==18, that's about 35000 dead swedes until they get to herd immunity. I genuinely don't understand the alternative world some people live in where Sweden has already beaten this. They're current curve is about 3 weeks behind most of Europe, largely due to the lack of lockdown that allowed the early outbreak to spread for longer.
- maxerickson 7y ago
  They'd rather not (and I agree) have the accompanying death toll that comes with getting to herd immunity by having lots of people get infected. (we also get the benefits of herd immunity if enough people get an effective vaccine)
lbeltrame 7y ago
> If there is no vaccine, or if the vaccine isn't very good, social-distancing and contact-tracing is the only way to win. I know I sound like a broken record every time I say this on HN... but why no one thinks of pharmacological treatment? The first wave of (small) trials will end this June.
- adrianN 7y ago
  I'm moderately optimistic that plasma transfusions will help reduce the death toll, but evidence is mounting that even "mild" cases can leave the patients with severe lung damage. Having the contact data ready to start treatment earlier might help with that too.
  - lbeltrame 7y ago
    I meant something far more aggressive towards disease treatment, from the repurposed drugs (which a few here say don't work, but I'm waiting for the results of the trials), then the specific ones like antibodies, soluble ACE2 receptors, and others. Plus I'm confident that the anti-inflammation drugs being tested can help with lung tissue damage.
    - adrianN 7y ago
      I'm no pharmacologist but I think we would be extremely lucky if one of existing antivirals also works here. I don't think that antibody drugs will be an important tool. They're extremely hard to manufacture (and hence very expensive). I don't think we could satisfy demand. It would be great though if one of those studies found an effective drug!
      - lbeltrame 7y ago
        > I'm no pharmacologist but I think we would be extremely lucky if one of existing antivirals also works here. Even if the results are bad, it also depends on what they were used for, since the little evidence we have tells us that the sooner we act, the better. Example: ritonavir was a letdown, but even in the NEJM paper the limitations of the study mention that the trial was done on people with rather severe sympthoms. At this point it was probably too late to make a dent in the infection. The data on remedisivir (which came from two suspended trials due to lack of enrollment, so no statistical power) showed an almost-identical mortality between the two groups, but I'd argue that those (at least one of them was) were done on patients in severe conditions, so once again late. Later trials which are ongoing are hopefully better designed (NIH's for remedisivir at least, Gilead's don't use a placebo IIRC) and will get us answers. IMO, even a small improvement on hospitalization rate would be a huge win for the ICUs. That said, remedisivir is i.v. so this limits applicability to hospitals.

by ISL 7y ago

SlowRobotAhead 7y ago

>If there is no vaccine, or if the vaccine isn't very good, social-distancing and contact-tracing is the only way to win. Why is herd immunity not a "way we win"? edit: Ah, yes, concern about the time to get there. Well, let's hope that happens quicker than expected (has any study not shown this?) because from where I'm sitting it looks like lock down is ending.

pacificmint 7y ago
Because a lot of people will be dead by the time we get to ~70% immunity.
- mrfusion 7y ago
  As I understand it, the healthy majority would get the immunity while continuing to isolate the at risk groups.
  - james_s_tayler 7y ago
    Which is not very realistic as a possibility given the number of people that fall into the at risk groups. It sounds simple in theory but seems very unlikely to be something workable in practice.
  - AaronFriel 7y ago
    The "at risk" groups include a sizable percent of the US population, and isolating all of their first degree daily contacts alone is likely impossible. Hospice patients, and the hospice workers. People already in treatment, and the healthcare professionals providing them with care. People who smoke, have diabetes, a heart condition, or are immune compromised, and so on, and everyone they know. This has got to be millions and millions of people, and this isolation will be extraordinarily porous. Those folks have friends and family too, they will slip up, exposing their contacts and then the virus is on the other side of a firewall. And we've seen how quickly the virus spreads in isolated groups!
  - adrianN 7y ago
    It's impossible to isolate only the at risk group. That's like 30% of the population. Also, there is growing evidence that even mild cases can leave more or less permanent damage.
- sjwright 7y ago
  And the huge number of severe cases will overwhelm health care systems by an order of magnitude, risking the lives of other people who will need medical care to survive.
- coretx 7y ago
  Big IF we ever reach those numbers at all. (!)
edmundsauto 7y ago
The path to herd immunity includes a lot of death.
- mrfusion 7y ago
  What’s you’re source on that? As I understand it, Sweden is almost there.
  - joshuamorton 7y ago
    Almost to herd immunity? No. They're at less than 1% infected (like most places), with more deaths per capita than the us despite a younger healthier population.
    - mrfusion 7y ago
      https://www.npr.org/2020/04/26/845211085/stockholm-expected-to-reach-herd-immunity-in-may-swedish-ambassador-says https://www.npr.org/2020/04/26/845211085/stockholm-expected-...
      - acdha 7y ago
        That’s a political answer to a question they’ve staked their political future on. Let’s wait for actual scientific evidence before accepting it.
  - newacct583 7y ago
    Uh... from what do you understand that? Sweden isn't even close. Their deaths/case ratio isn't too far off from New York. We have reasonably good evidence now that New York is maybe 30-50% of the way to herd immunity (plus or minus a factor of two or so). New York has six times the per capita deaths that Sweden does. Just extrapolating and multiplying their current number by 3x6==18, that's about 35000 dead swedes until they get to herd immunity. I genuinely don't understand the alternative world some people live in where Sweden has already beaten this. They're current curve is about 3 weeks behind most of Europe, largely due to the lack of lockdown that allowed the early outbreak to spread for longer.
maxerickson 7y ago
They'd rather not (and I agree) have the accompanying death toll that comes with getting to herd immunity by having lots of people get infected. (we also get the benefits of herd immunity if enough people get an effective vaccine)

lbeltrame 7y ago

> If there is no vaccine, or if the vaccine isn't very good, social-distancing and contact-tracing is the only way to win. I know I sound like a broken record every time I say this on HN... but why no one thinks of pharmacological treatment? The first wave of (small) trials will end this June.

adrianN 7y ago
I'm moderately optimistic that plasma transfusions will help reduce the death toll, but evidence is mounting that even "mild" cases can leave the patients with severe lung damage. Having the contact data ready to start treatment earlier might help with that too.
- lbeltrame 7y ago
  I meant something far more aggressive towards disease treatment, from the repurposed drugs (which a few here say don't work, but I'm waiting for the results of the trials), then the specific ones like antibodies, soluble ACE2 receptors, and others. Plus I'm confident that the anti-inflammation drugs being tested can help with lung tissue damage.
  - adrianN 7y ago
    I'm no pharmacologist but I think we would be extremely lucky if one of existing antivirals also works here. I don't think that antibody drugs will be an important tool. They're extremely hard to manufacture (and hence very expensive). I don't think we could satisfy demand. It would be great though if one of those studies found an effective drug!
    - lbeltrame 7y ago
      > I'm no pharmacologist but I think we would be extremely lucky if one of existing antivirals also works here. Even if the results are bad, it also depends on what they were used for, since the little evidence we have tells us that the sooner we act, the better. Example: ritonavir was a letdown, but even in the NEJM paper the limitations of the study mention that the trial was done on people with rather severe sympthoms. At this point it was probably too late to make a dent in the infection. The data on remedisivir (which came from two suspended trials due to lack of enrollment, so no statistical power) showed an almost-identical mortality between the two groups, but I'd argue that those (at least one of them was) were done on patients in severe conditions, so once again late. Later trials which are ongoing are hopefully better designed (NIH's for remedisivir at least, Gilead's don't use a placebo IIRC) and will get us answers. IMO, even a small improvement on hospitalization rate would be a huge win for the ICUs. That said, remedisivir is i.v. so this limits applicability to hospitals.