Maine Writer

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Saturday, October 31, 2020

Republicans mandatory reading- Flu and COVID medical science supports prevention to stop infectious disease co-mobidity

Co-infection reported in California: Flu and Covid

JAMA- Medical News and Perspectives by Rita Rubin MA:

Do your part! Wear a mask!

At a February 26, press conference, Donald J. Trump said of the novel coronavirus, “This is like a flu,” and expressed surprise that as many as 69 000 people in the US die of influenza every year.

However, the ensuing 5½ months have shown that coronavirus disease 2019 (COVID-19) is far deadlier and less predictable than seasonal influenza. Unlike influenza, COVID-19 does not appear to be seasonal, given the ever-increasing numbers of US cases this summer.

So,beginning this fall, the US for the first time will have to deal with a flu season wrapped in a global pandemic. 

Or, as the headline on a recent editorial by Edward Belongia, MD, and Michael Osterholm, PhD, MPH, described it, “a perfect storm.”

Many questions remain about how flu season might affect the pandemic, and vice versa. For example, would coinfection with influenza worsen the course of COVID-19? Experts also aren’t certain whether influenza vaccination could help protect against COVID-19 or whether steps taken to mitigate COVID-19 will reduce the burden of the coming flu season.

Some hints have come from preliminary research conducted in China, where influenza was still widely circulating when the first novel coronavirus infections emerged, and in the southern hemisphere, which is currently in the midst of its flu season.

At least 2 things are clear: Quicker and more widely available testing is needed to distinguish between COVID-19 and influenza, which have similar symptoms, at least at first, but require different treatments. On top of that, a severe influenza season—the result of more virulent strains, inadequate vaccination rates, or a combination of both—coupled with a COVID-19 pandemic that shows no signs of abating, could overwhelm already taxed emergency departments and intensive care units.

As pulmonary and critical care specialist Benjamin Singer, MD, wrote in a recent editorial, influenza and other causes of pneumonia represent the eighth leading cause of US deaths in nonpandemic years.

“We can expect that the new reality of COVID-19 will only complicate the next influenza season,” Singer, of the Northwestern University Feinberg School of Medicine, concluded in his editorial.

Flu-Like but Not Alike


Distinguishing between influenza and COVID-19 “has important prognostic implications,” Singer said in an interview. “In many ways it matters that you find out quickly.”

While the course of influenza is rapid, COVID-19 “kind of limps along a little bit,” he said. Knowing the reason for a patient’s respiratory symptoms “helps inform what you can expect.”

Identifying the cause, of course, helps determine how best to treat respiratory symptoms, Singer noted. Although supportive care for influenza and COVID-19 is similar, drug treatments don’t overlap, he said.

“We have things that we can do for COVID if we know someone’s infected,” he said. “If they have influenza, we can give antivirals targeted against influenza.”

But mistakenly treating patients with influenza as though they have COVID-19, is wasteful and potentially harmful, Singer said.

For example, he noted, randomized controlled trials have found that intravenous remdesivir, a broad-spectrum 
antiviral that is not approved anywhere in the world for any use, was more effective than a placebo in treating severe and moderate COVID-19. 

Remdesivir has received Emergency Use Authorization to treat COVID-19 from the US Food and Drug Administration and regulatory agencies in a few other countries, but, as an unapproved drug, it has been in short supply. (Maine Writer update: Remdesivir has subsequently been approved, but supplies continue to be less than the need and, therefore, access to treatment is difficult for many, especially in medically underserved areas.)

Meanwhile, although earlier studies found that remdesivir had antiviral activity against influenza A, the drug has not been tested in patients with the flu, so there’s no evidence it’s effective in treating that disease.

Another drug, the corticosteroid dexamethasone, appears to be effective in some patients hospitalized with COVID-19, but it could harm those who instead have influenza. A recent preliminary report found that dexamethasone resulted in a lower 28-day mortality rate among patients hospitalized with COVID-19, who were receiving respiratory support. However, in 2019, clinical practice guidelines, the Infectious Diseases Society of 
America (IDSA) specifically advised against using corticosteroids to treat seasonal influenza unless clinically indicated for other reasons, such as asthma. 

Data from randomized controlled trials of corticosteroid treatment of influenza aren’t available, but 2 meta-analyses of observational studies suggested that corticosteroid treatment of patients hospitalized with influenza was associated with increased mortality, according to IDSA.

A retrospective study from Wuhan, China, suggested that lopinavir-ritonavir combination therapy led to faster resolution of pneumonia than standard care alone among patients with both COVID-19 and influenza. However, the World Health Organization (WHO) on July 4, discontinued the lopinavir-ritonavir arm of its Solidarity trial because interim results found the treatment, which is approved for HIV, produced little or no mortality reduction in patients hospitalized with COVID-19.

“Although we need more data to confirm the conclusion, we prefer to use the lopinavir-ritonavir to treat all 
COVID-19 patients with influenza,” coauthor Rui Zeng, MD, PhD, a kidney specialist on the faculty of Wuhan’s Tongji Medical College at Huazhong University of Science and Technology, said in an email.

Another reason it’s important to determine whether respiratory symptoms are due to influenza or to COVID-19 (or both) is that mitigation efforts for the former aren’t as strict as for the latter. “We’ve never told people with influenza to isolate themselves from everyone else,” Osterholm, founder and director of the Center for Infectious Disease Research and Policy at the University of 
Minnesota, said in an interview.

Without quickly learning which virus they have, some people with COVID-19, during flu season, might mistakenly attribute their symptoms to influenza and not take the necessary precautions to prevent spreading severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is more easily transmitted, he said.

In addition, distinguishing between COVID-19, and influenza will be vital for disease surveillance, the authors of a recently published letter noted. Given the overlap of symptoms, systematic testing for SARS-CoV-2 and influenza will be needed during the upcoming flu season to determine the contributions of each viral illness to the burden of respiratory disease, the authors wrote.


“The chances are more likely that they have one or the other,” Osterholm said, noting that only 3% or 4% of the population have SARS-CoV-2 infection, while 10% to 20% might become infected with influenza virus, so the odds of being infected with both are small.

Early reports from China suggested that coinfection with other respiratory diseases was extremely rare in patients with COVID-19. For example, in a study of 99 patients with COVID-19 admitted to Wuhan Jinyintan Hospital from January 1 to January 20, none tested positive for any of 9 other respiratory pathogens, including influenza A and influenza B.

However, Zeng’s study, conducted at Wuhan’s Tongji Hospital, which the government had designated for treating patients with severe COVID-19, produced a much different finding. Of 544 patients with polymerase chain reaction–confirmed COVID-19 who were admitted from January 28 to February 18, 11.8% were coinfected with influenza A or influenza B. Zeng noted that the influenza infection rate in his study was similar to that reported in the US during the 2018-2019 influenza season.

“Coinfection was a significant risk factor for prolonged hospital stay,” Zeng said. In addition, his study found that 
COVID-19 patients who were coinfected with influenza shed SARS-CoV-2 longer than other COVID-19 patients (17 days vs 12 days on average). “We don’t know the reason.”

Studies about coinfection in the US have found rates more in line with those at Jinyintan Hospital than at Tongji Hospital.

A recent study in JAMA found that out of 1996, patients hospitalized with COVID-19, in metropolitan New York City, who were tested for other respiratory viruses, only 42 (2.1%) were coinfected, and only 1 was coinfected with influenza. The patients were hospitalized between March 1 and April 4.

Considering Coinfection

Physicians in several countries have reported patients who tested positive for both COVID-19 and seasonal influenza. “We have seen patients with both viruses,” Singer said. “It was early on, in March.”

But such patients have represented a small minority.


In Northern California, laboratories that simultaneously tested for SARS-CoV-2, and other respiratory pathogens, found a 10-fold higher coinfection rate (20.7%) than the New York study, but only 0.9% of specimens were coinfected with influenza. Moreover, the authors, who reported their findings in a JAMA research letter, studied 1217 specimens, 116 of which had tested positive for SARS-CoV-2 and 318 for other respiratory pathogens. 

Of the 116 that were positive for SARS-CoV-2, 24 were positive for at least 1 other respiratory pathogen. However, only 1 of the 116 was positive for influenza.

During the pandemic, “the possibility of COVID-19 should be considered regardless of positive findings for other pathogens,” Japanese researchers recommended in a recent case report about a 57-year-old restaurant worker.

COVID-19 Protection From Flu Shots?

A study conducted at Ohio’s Wright-Patterson Air Force Base during the 2017-2018,flu season recently caught the attention of Luigi Marchionni, MD, PhD, an oncologist and computational biologist at Johns Hopkins University. The study compared the influenza vaccination status of approximately 6000 Department of Defense personnel with their respiratory virus status.

“That paper didn’t find vaccination was making people more likely or less likely to get another infection from another virus,” Marchionni explained. However, it did find that influenza vaccination was associated with a higher risk of non-SARS coronavirus infection, offset by a lower risk of influenza, parainfluenza, respiratory syncytial virus, and some other respiratory infections.

Marchionni wondered whether the finding of an association between flu shots and coronavirus infections might bode ill for influenza vaccination in the middle of a coronavirus pandemic. 

So he and his coauthors explored a possible county-level association between influenza vaccination coverage in people aged 65 years or older and the number of COVID-19 deaths.

Their findings, which have not yet been peer-reviewed, suggest that influenza vaccination in that age group is negatively associated with COVID-19 mortality. Marchionni said he and his coauthors have submitted an expanded version of their paper to a peer-reviewed journal.

“I’m quite confident in the fact that influenza vaccination in the population is associated with less [COVID-19] mortality,” Marchionni said. “There are many plausible biological explanations.”

Another study that has not yet undergone peer review also found that patients with COVID-19, who were immunized against influenza, fared better than those who had not. The authors analyzed data from 92 664 
confirmed COVID-19 cases in Brazil and found that recently vaccinated patients had, on average, an 8% lower chance of needing intensive care, an 18% lower chance of requiring invasive respiratory support, and a 17% lower chance of dying.

Can We Curb Flu Along With COVID-19? 

Intuitively, it makes sense that wearing masks, social distancing, working from home, closing schools, and other strategies to minimize the spread of COVID-19 would lessen transmission of other respiratory infectious diseases as well.  That appeared to be the case in Taiwan, researchers concluded in a recent brief report.  They compared 25 weeks of case data for severe influenza, invasive Streptococcus pneumoniae disease, and pneumonia deaths from 2016 to 2020. All 3 trended downward in 2020, compared with the same weeks in previous years, especially after Taiwan implemented COVID-19, prevention strategies. The downward trend does not appear to be a result of negligence in reporting cases, the authors noted, because there were still substantial cases of severe influenza-like illness reported. However, they tested negative for influenza. 
Japanese researchers also observed less influenza activity week by week in 2020, compared with the previous 5 seasons. They speculated that high awareness among the Japanese public of measures to reduce COVID-19 transmission early in the year might explain their finding, according to a recent research letter in JAMA. 


And, researchers in Qatar recently reported a “dramatic decrease” of laboratory-confirmed influenza A, after the state closed schools on March 10, although laboratory-confirmed cases of other respiratory pathogens, including influenza B, barely budged. Seasonal variations likely do not explain the 30-fold drop in laboratory-confirmed influenza A cases between February 13 to March 14 and March 15 to April 11, because a similar decline was not seen between the same periods in 2019, the authors wrote.

In the southern hemisphere,, the situation might provide more clues as to what the northern hemisphere can expect in the upcoming flu season. Or, as Osterholm cautioned, it might not. “We’re seeing an incredibly mild flu season in the southern hemisphere,” he said. “To date, we’ve seen virtually little, little activity…We don’t know what’s going on right now.” And that’s throughout the southern hemisphere, including COVID-19, hotspots such as Brazil, Osterholm noted. “We have to be careful not to assume that’s what’s going to happen in the northern hemisphere.” 

The best-case explanation for the southern hemisphere’s mild flu season is that COVID-19, mitigation strategies are tamping down the spread of other respiratory viruses, said Brendan Flannery, PhD, coauthor of the letter calling for systematic testing for both influenza and COVID-19.  But the worst-case scenario is that COVID-19 has overwhelmed health care systems, so people with the flu are staying home and not being counted; or, they are seeking care but getting lost in the crowd of COVID-19 patients, said Flannery, lead investigator from the US Centers for Disease Control and for the US Flu Vaccine Effectiveness Network. 


“We’re all going to learn a lot,” Osterholm said of the upcoming flu season. “We can speculate until we’re blue in the face, and I don’t think we know yet what’s going to happen.”

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Saturday, May 30, 2020

A historian grades Donald Trump's failed coronavirus pandemic leadership: Republican alert!

Pandemic data examined under a history lens:
Over 100,000 coroavirus deaths while Donald Trump played golf at his own club.

America's response to the coronavirus pandemic and especially the failed leadership exhibited by Donald Trump is incomprehensible! John M. Barry, 73, is a historian and author of several books, including "The Great Influenza: The Story of the Deadliest Pandemic in History," about the 1918 flu pandemic. He lives in New Orleans.
(MaineWriter- I have read and reported about Barry's excellent historic reporting about the 1918 influenza pandemic because my father-in-law was at Camp Devens in 1918, when the outbreak prevented his World War I Infantry Unit from deploying to fight in France.)

Interview with Barry published in the History News Network and the Washington Post: 
As you’ve watched the coronavirus pandemic unfold, what’s been going through your mind?
Barrry: Well, I mean, it’s predictable. In the middle of January you could see pretty much what was going to happen. Anybody who understood anything about virology and pandemics, you know, it was obvious. You did not need an intelligence briefing to figure it out.

How would you characterize the United States’s response to the pandemic?
In a local paper I gave Trump a 3.5 a couple of days ago, but I was being overly generous.

3.5 out of what?
Ten. The first few months it was hugely disappointing to see him trivialize this outbreak. A few weeks ago he suddenly took it seriously and said we were at war. That was important. Since then, he’s up and down. The positive is, he does seem to take it seriously. He still is telling people to keep apart, and that’s important. But obviously, he gives out inaccurate information on a daily basis. I was part of the groups that did preparedness planning for pandemics in the [George W.] Bush administration, and in those groups we discussed the importance of who the spokesperson should be. Because getting compliance from the public obviously is crucial if you’re going to get social distancing and compliance with your recommendations. And we were unanimous that it should not be any politician, not the president, not secretary of Health and Human Services (HHS), not even the Center for Diseases Control and Prevention (CDC). But the reason was that any politician would start out with a significant chunk of the public not trusting him, not believing him.

Additionally, the following interview with Barry was published by the University of Minnesota's Center for Infectious Disease Research and Policy:
When the coronavirus pandemic first began in this country, the president said it was no worse than seasonal flu. Did leaders in 1918 say anything similar during the first spring wave of that pandemic?
Yes. National public health leaders were saying things like, "This is an ordinary influenza by another name," and, "You have nothing to fear if proper precautions are taken."
We know the pandemic in 1918 was caused by an influenza virus, and a coronavirus is a different animal. But what are some similarities and differences in terms of the actual illnesses people experienced?
You know, it's not clear how many people died from ARDS [acute respiratory distress syndrome] in 1918 or bacterial pneumonia. Some say the vast, overwhelming majority of deaths in 1918 were due to bacterial pneumonia, but I don't share that view. There were very rapid deaths in a few days from symptom onset. That clearly wasn’t bacterial.

A difference is obvious in terms of spread. As your readers know, influenza has a shorter incubation period. The length of time COVID-19 takes to work its way into the body is considerably longer. The longer incubation period stretches everything out.

Influenza in 1918 to 1920 would burn through a community in 6 to 10 weeks, and then you forget about it. That's not going to be the case with this. Whether COVID-19 results in a flatter, more continuous line or undulates is not clear.

The 1918 pandemic started with a mild wave of illnesses in the spring, and then 6 months later a fall wave that was more deadly. How did cities respond to the different curves?

No city closed in the spring; that was a mild wave, it was very hit or miss and was really only recognized in retrospect, except in military camps. Even medical journal articles at the times said it looks and smells like influenza, but not enough people died [for it] to be influenza. The virulence was so different in the fall wave.

New York City didn't close anything at all, a decision that was highly political. Chicago didn't close schools or much of anything else, either.

Coincidentally, both Chicago and New York had more pronounced spring outbreaks—they were in the minority. But the spring outbreaks provided significant immune protection naturally.

What about other cities? How did they decide when to shut down?
There were no general lockdowns, the way we have today. Most cities closed saloons, theaters, places of public gathering, but no general closing. However, fear was pretty effective in keeping people home. There was tremendous absenteeism from work, whether out of fear or because workers were taking care of sick people.

The ship-building industry had good data. Workers were told they were important as soldiers, they had to work out of patriotism, and there was no sick leave. In addition, there was medical care available in the ship yards that was unavailable in civilian communities.

Even with those factors, they saw 40% to 60% absenteeism. My guess is the absenteeism was significantly higher in other industries.

Metropolitan Life concluded that more than 3% of all industrial workers died because of the flu, and remember how compressed the time frame was—6 to 10 weeks to pass through any community. So when 3.25% of entire population in a working age-group die in a matter of a few weeks, that's a pretty good reason not to go to work.

What about opening up? How did cities make that decision?

It was a back-of-the-envelope calculation by public health leaders, usually pressured by the business community. The question was whether the local public health commissioner was strong enough to stand up to pressure.

After a few weeks, all businesses were insistent on coming out. And there was no radio or TV or Internet, so most people weren't too thrilled with being at home, anyway.
As you watch the current pandemic, do you see any leaders, local or national, who are doing a good job? A bad job?

The governor of Georgia stands out as a liar or fool or both (Governor Brian Kemp). Probably 70% of citizens know that COVID-19 transmits when you're asymptomatic. The governor of Florida also stands out on the downside (Governor Ron DeSantis).
Governor Andrew Cuomo in New York certainly stands out in a good way in terms of communication. John Bel Edwards, here in Louisiana, has done a good job.
Speaking of Louisiana, New Orleans was one of the first cities in the current pandemic to sound the alarm that black Americans were dying more than whites. What sort of disparities were seen in the 1918 flu?
There were epidemiological studies at the time that showed the amount of space that people had was a factor in how many people died in a family—the poorer you are the more crowded you are. Clearly, there was a socioeconomic factor related directly to living space.
Each day, it seems, governors extend stay-at-home mandates. As a historian who has studied people in past pandemics, how long do you think can people maintain this?
As a historian, I don't like to predict. You have to wait and see what the data is. There's been better compliance with social distancing than I expected, and perhaps more compliance then some of the models expected.

On the other hand, certain pockets of people are paying no attention at all. Again, we wait and see what the data says.

(Maine Writer- what the data says and also how history will report the failed Trump leadership response!)

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