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COVID intensive care admissions are on the rise, 6-8 times slower than the first wave.

The 29 July saw the lowest number of occupations of Italian intensive care COVID: 38 Patients. Since then there has been a slow but inexorable increase and today we have come to 133 critical COVID patients.
The severity of the patients seems to be comparable to that of March and April, as dichairato by the president of the Association of Anesthesiologists RiaItalian Hospital Nimatori, Dr Vergallo https://www.repubblica.it/cronaca/2020/09/06/news/l_associazione_anestesisti_i_casi_di_covid_gravi_come_a_marzo_il_virus_non_e_meno_aggressivo_-266395144/

COVID, New: Those infected are hospitalized?

SARSCOV2 infection has a very wide and disparate spectrum of clinical manifestations ranging from completely asymptomatic subjects to subjects with ARDS (acute respiratory distress syndrome) that require intensive treatments and with poor prognosis.

The severity of clinical manifestations is primarily related to the age of the subject and, secondly, with its conhorbidity.

We're seeing an increase in cases. How many of these cases will need hospitalization?
Easy question but whose exact answer is extremely difficult.

To try to respond we can try to look at the situation of European countries that declare the daily number of new COVID hospitalizations.
Italy unfortunately declares only the number of patients total hospitalized.
The number of new daily admissions is available for:

New cases diagnosed are all asymptomatic? What are the real numbers?

As containment measures gradually loosen, in the last period, we're seeing an increase in cases and, to a lesser extent, of the hospitalizations.
Many, unfortunately also listed doctors, claim and claim that the new cases are all or almost asymptomatic, alluding to a non-relevance of the problem. There are those who launch themselves and in interviews with national newspapers say that the 90% of the new cases is asymptomatic.
The problem is that so many citizens who are furious to hear these statements made by doctors and politicians are convinced that they are true.
Let's see what the real numbers are, those declared by the Istituto Superiore di Sanità, if they are consistent and what conclusions can be made.

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Distance and hygiene standards work and not just for COVID!

From March 2020 much of the world is fighting against SARSCOV2.
The economically stronger and more technological countries have put their full potential into the field by carrying out massive tests of the population, methodical contact tracking and case isolation.
In addition to these measures specifically aimed at blocking SARSCOV2, non-specific measures have been applied, with the aim of hindering the spread of respiratory infections: social distancing, intensification of hygiene standards, flanked by the use of masks.
These measures precisely because they are apparently simple have often been underestimated. Many have denied their effectiveness, preferring to call into question other more or less scientific justifications.
After months of pandemic, one may wonder what happened to other infectious diseases.
Unfortunately, there are not many states that publish data on the surveillance of infectious diseases and, especially, many respiratory diseases are more frequent in the cold period.
Thankfully Australia offers the solution to both problems: publishes a lot of data on the health surveillance of infectious diseases (http://www9.health.gov.au/cda/source/cda-index.cfm) and now there it's full winter.

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ISTAT serum survey: some considerations about the lethality of SARS-COV2

One of the parameters for understanding the severity of an infection #8217 is its lethality, i.e. the ratio of the deceased to people infected, read in another way lethality is the probability of dying that has a person infected.
It seems like a fairly easy calculation and yet it gets very complex, during a’epidemic, have the’exact death count and, especially, l’exact number of people infected.
The 3 August l’ISTAT [1] published the first results of SARSCOV2's ’&Seroprevalence Survey in Italy. They've been tested 64660 People, choosing a representative sample of the Italian population.
The initial goal was #8217 to test a much larger population but many citizens did not join the ’ initiative. The reduced sample may affect the quality of the data, however, l’ISTAT declares the #8217;confidence interval that turns out to be quite narrow, index of the good reliability of their results.
The estimate of the infected subjects reported by the #8217;ISTAT may also be affected by the fact that some infected subjects, especially asymptomatic and paucysynthetic, may not develop antibodies or lose them after a few months.
According to this consideration, cases estimated by serologicals may be lower than the real cases, It is also true that such an #8217 investigation is affected by the false positives of the #8217;examination that would lead to overestimating real cases.
Aware of all these limits we have a denominator to use in the calculation of lethality (lethality - deaths / Infected). As a numerator we can use either the number of confirmed deaths or the #8217;excess mortality [2].

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COVID19: when you are contagious?

This is a very important question whose answer would allow efficient isolation of asymptomatic cases and subjects with mild symptoms and an easier approach to symptomatic subjects.
Unfortunately we don't have a certain answer, to try to clarify our ideas a little bit let's try to retrace the knowledge that we have acquired since the beginning of the epidemic.
A positive swab is an indication of contagiousness?
At the beginning of the epidemic we had a certainty: a positive swab corresponds to the presence of viruses and therefore the patient should be considered as contagious potential.
It is a reasonable and partly correct assumption but as often happens in Medicine certainties are few and the first doubts came when we saw people with positive swab for a few weeks even in the absence of symptoms.
Many patients continued to have viruses on the mucous membranes and so we feared in a very long contagious phase, even after the symptoms have been resolved.

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The second wave will arrive in the autumn? We can avoid it?

We're learning about this infection and the way it spreads, now we have so many experiences from other countries in the world to think about.
In some states it's all pretty quiet for months despite the virus entering their borders (South Korea, Taiwan, Greece, New Zealand).
Others do not appear to be able to contain the first wave (Mexico, for example).
Other countries are facing a second wave (Iran, Serbia, Israel).
In the US in some states it's all under control, others are in trouble.
Sweden applied soft measures early on, avoiding a lockdown, had far more deaths than “Neighbors” but less than other European countries.

There are very different scenarios in the world.

What we can learn from these situations:
-should not underestimate an increase in cases. An increase in cases is followed by, late, necessarily the increase #8217 in admissions and deaths. The ratio of curves depends on the testing capabilities, average age #8217 of infected individuals and the capacity of health systems (see USA).
-test, "It's not just about the #8217, it's about the same way," he said. (Korea).
-lockdown is the most extreme measure, very effective in bringing down the contagio>e-contaminas but harmful to the #8217;economy (Italy).
-lifestyle has a lot of influence on infections. The pre-epidemic Italian lifestyle led to R0 3-3,5. The lockdown at 0,3-0,5.
Between these two extremes there are so many nuances and the current lifestyle allows an R0 close to ’1.
-Spain, climatically and culturally close to us, is facing a new increase in cases these days and some areas have been put in lockdown.

We can say that a second wave will not necessarily wait for the cold weather.
September will be an extremely critical moment, in my opinion: we will see at the same time the repopulation of cities, the reopening of many businesses/activities and the reopening of schools.
There will be a gradual reduction in activities and life to the ’open.

What can we do?

We must work today to make people understand that it is essential to continue to keep all the attention, social distance, masks indoors or when you can't keep your distance, hygiene standards.
We need to install and incentivize the #8217 use of immune to facilitate tracking.
We must always pay close attention to hospitals and RSA (almost the 40-50% of the infections come from here).
We need to train citizens to understand what is going on and to self-exate at the first symptoms.
We need to encourage flu vaccination both to reduce flu mortality and to reduce cases that could be confused with COVID.
Insist that smart working continue.
Public Health will need to work hard to ensure testing, contact tracking and isolation and to filter cases from ’foreign.

The Italians have been better than many others in both the lockdown and the later stages, we must continue on this path and avoid new waves.

SARSCoV2 and viral load, let's make it clear.

For a month it is very fashionable to talk about viral charge of SARSCoV2, often associating it with concepts that are not quite correct.
Let's try to make some clarity by analyzing the various works published by the Scientific Literature.
First of all, what is viral upload? How to measure?
Viral load refers to the concentration of virus present or in the blood or, as in the case of SARSCoV2, on mucous.
In clinical practice, through the now famous tampons, you go to look for some fragments of genetic material of the virus and the examination can give us 3 Results: Negative, weakly positive, Positive.
To calculate the viral load, you have to use more complex methods that, For now, are reserved exclusively for research.
The genetic material is amplified until the machine can detect certain viral genes, more amplification cycles are needed to detect them and fewer viruses were present at the start.
From a scientific point of view it is very important to study the viral load present on mucous, also to get an idea of the contagiousness of the subjects: the more viruses there is on the mucous it's more easily you are contagious

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Clinical course of COVID-19 patients: share of asymptomatic patients, mild shapes, severe, incubation time, duration of the contagious phase.

Clinical course of COVID-19 patients: share of asymptomatic patients, mild shapes, severe, incubation time, duration of the contagious phase.

SARS-COV-2 is a virus that we've been getting to know these months, extremely contagious that can occur with very different forms from subject to subject, going from completely asymptomatic forms to fatal forms in a few days.
The duration of the incubation period, the contagious phase and symptomatic phase are extremely variable.
I did a Literature review to try to do some’ and summarized the MEDI data in the attached chart.
This graph is useful for having an epidemiological’epidemiological idea of the behavior of the virus but of course it should not be interpreted as a means of predicting the #8217;performance of the individual patient.
We often see patients with extremely prolonged hospitalizations and positive swab even after 3 weeks from the resolution of the symptoms.

 

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