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COVID19

SOME REFLECTIONS ON HOME THERAPY OF COVID

Covid is a balorda disease. It does everything and the opposite of everything and we are not completely able to understand why and predict its course.

It goes from absolutely asymptomatic forms or very similar to a mild cold, to cases that go into severe respiratory failure after 1-2 days of cough and fever, going from muscle aches, nasal drip, diarrhea, cough, fever, fatigue, absence of #8217;smell, instability …
Older and frail people are more at risk of developing severe forms, this does not change the fact that there are also very slight forms in ninety years, just as you rarely see very ugly forms in your twenties.

 

The whole world is working and is trying and testing both specific therapies, i.e. directed against the virus, that support, i.e. aimed at improving the survival of the patient while waiting for the response of his immune system.

 

The only specific therapies currently known are monoclonal antibodies, more effective when administered in combination (cocktail). https://www.nejm.org/doi/full/10.1056/nejme2034495
However, these drugs are very expensive, they must necessarily be administered in the hospital (on an outpatient basis) And they work very well only shortly after #8217 the onset of symptoms. Factors that make it impossible to use it extensively.

 

Regarding supportive therapies, the greatest progress has been made at the hospital level.
Respiratory care techniques have improved, the importance #8217 of cortisone #8217 and heparin has been clarified. https://www.nejm.org/doi/full/10.1056/NEJMoa2021436 https://www.nejm.org/doi/full/10.1056/NEJMe2111151

The experiments go on and small steps forward continue every day.

 

As far as home therapies are concerned, unfortunately, there has been little progress.
There are interesting works on a type of inhaled cortisone (not in tablets), The budesonide, and a promising study on the colchicine.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01744-X/fulltext https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00160-0/fulltext https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00222-8/fulltext Interesting but not conclusive works that present encouraging results but not able to overturn #8217 the outcome of the #8217 infection.
These poor results are partly related to the fact that it is more difficult to set up studies outside hospitals and partly to the fact that many studies, Unfortunately, have clarified the non-effectiveness of some drugs at home or in the early stages of the disease.

 

L’hydroxychloroquine has been shown to be ineffective both in prevention and at an early stage
https://academic.oup.com/cid/article/72/11/e835/5929230
https://www.nejm.org/doi/full/10.1056/nejmoa2016638
https://www.acpjournals.org/doi/10.7326/m20-4207

 

The steroids (Cortisone) could aggravate the disease if taken in forms without desaturation (type of patients who, except for hospital congestion, would deserve hospitalization).
https://www.nejm.org/doi/full/10.1056/NEJMoa2021436
https://www.medrxiv.org/con…/10.1101/2021.07.06.21259982v1

 

L’recruitment of Anti-inflammatory nonsteroidal before hospitalization does not seem to upset the course of the disease.
https://www.thelancet.com/…/PIIS2665-9913(21…/fulltext
https://www.nature.com/articles/s41598-021-84539-5
(Unless you make forced comparisons with patients of the first wave when the diagnosis was reserved for the most severe patients https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(21)00104-1/fulltext )

 

The antibiotics they are of little use. Bacterial overinfections are seen in less than the 10% of patients at the time of admission (the most serious and most at risk) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101968 and severe patients are about the 7% of the infected. So it's not very useful to give antibiotics to everyone if then the bacterial infections are in the 0,7% and only in the most compromised patients.

In particular, the’azithromycin (which also has an anti-inflammatory effect) proved not to be useful. https://jamanetwork.com/journals/jama/fullarticle/2782166
https://www.thelancet.com/article/S0140-6736(21)00461-X/fulltext

There are still many open questions and a lot of studies are underway to try to give other answers.

 

Pending the results it seems that the best attitude is to stratify the risk of patients.
On the younger and healthy ones, low risk, you can limit yourself to symptomatic drugs (paracetamol or anti-inflammatories) and close monitoring. This type of patients heals spontaneously in over the 98% of cases, their immune system independently manages to defeat the disease.

However, we must be careful of a possible worsening of that 2% which could go wrong despite age and health.
On older patients and / or with comorbidities must keep the level of attention high, make sure that their underlying diseases do not go down and carefully evaluate other drugs, always weighing the risk-benefit.

Be wary of those who promise miracle cures, of those who describe zero hospitalizations, zero deaths and remember that the audience of facebook groups is very different from the average of Italian citizens. Hardly on facebook you will find the’80 year old with health problems. Having a group of patients on average young and healthy automatically means having better results, regardless of therapy.

DEATHS IN ENGLAND FROM DELTA VARIANT BETWEEN VACCINATED AND UNVACCINATED: WE READ THE DATA CORRECTLY.

The UK is providing a #8217-enormity of data on the #8217 trend of #8217 the epidemic, among the many documents we find the “SARS-CoV-2 variants of concern and variants under investigation in England – Technical briefing 16” https://www.gov.uk/government/publications/investigation-of-novel-sars-cov-2-variant-variant-of-concern-20201201 which shows an interesting table on the spread of cases, emergency room access and deaths attributed to the Delta variant, dividing them on the basis of vaccination status (attached image).
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The data reported by this table have been completely distorted and are used superficially by many conspiracy theorists for “support” l’uselessness or ineffectiveness of vaccines.
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Their theses are:
-the number of deaths among the vaccinated (26 Deaths) is very similar to that among the unvaccinated (34 Deaths), so vaccines are useless
-the ratio of cases to deaths is greater among the vaccinated (4087 cases, 26 Deaths, deaths/cases = 0,63%), compared to the unvaccinated (35521 cases, 34 Deaths, deaths/cases = 0,096%) so the vaccinated have a higher risk of dying.
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No, dear conspiracy theo player, this is not the case, just for nothing.
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There are 2 Important things to consider:
-COVID leads to death only in very rare cases at a young age
-to estimate a risk you must always take into account the denominator, i.e. the number of vaccinated and unvaccinated people who are potentially exposed.
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In the latest https report://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1001354/Variants_of_Concern_VOC_Technical_Briefing_17.pdf, the number of deaths from delta variant has been defined both on the basis of vaccination status #8217 and on the basis of age (above or below 50 years), since it helps a lot to clarify the situation. We see that among the unvaccinated have been registered 38 deaths above 50 years and 6 deaths under 50, while among the vaccinated to 2 doses we had zero deaths below 50 years and 50 deaths above 50 years.
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Now let's see the number of people vaccinated.
Among the amount of data officially published by the United Kingdom we find the vaccination coverage by #8217 age group of the #8217 England updated to the 23/5 https://www.ons.gov.uk/visualizations/dvc1434/ageovertimewrapper/datadownload.xlsx , which I reported in the attached histograms, both in percentage and in total number.
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Per 23 May in England we had:
<50 aa: 18.687.910 unvaccinated; 6.320.104 vaccinated with 2 Doses
>50 aa: 4.883.757 unvaccinated; 14.502.087 vaccinated with 2 Doses
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The very first deaths from delta variant were recorded at the end of May, so we can consider the coverage of the 23/5 as the minimum number of vaccinated subjects on the basis of which to calculate the risk.
If vaccines do not serve as ever on over 14 millions vaccinated above 50 years have been recorded 50 deaths and on less than 5 millions of unvaccinated 38?
Among the unvaccinated over50 there was one death every 128.520 while among the vaccinated one every 290.042. So the risk of death is at least halved.
In fact the risk is even lower, the data provided divide the deaths between over and under 50 but in the band 50-59 the risk of death is much lower than in the range 60-69 (about 1/4) and between the 4.883.757 unvaccinated in England over 50 years well 3.257.092 were in the band 50-59. If we had the data by single age group #8217 of deaths attributed to Delta, almost certainly an even greater efficac #8217 y of vaccines would emerge. In addition, in the weeks following the 23 May the vaccination coverage has further increased especially above the 50 years, further lowering the risk.
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The usefulness #8217 of vaccines is even more evident if we look at the data of access to the emergency room: among the unvaccinated there were 2035 accesses under 50 years and 213 above i 50 years, while among the vaccinated to 2 Doses 94 under i 50 years and 254 above i 50 years.
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Considering the denominator we have:
-one access in PS every 9.183 unvaccinated under the 50 years and one access each 22.928 unvaccinated above 50 years.
-one access in PS every 67.235 vaccinated to 2 doses below 50 years and one access each 57.095 vaccinated to 2 doses above 50 years. So a much lower risk for the vaccinated.
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If we read the data correctly we see that even with the delta variant the vaccinated get sick less (fewer cases), they go less to the emergency room and die less!
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PS to further clarification: when you look at the cases / hospitalizations / deaths between vaccinated and unvaccinated remember that among the unvaccinated there are very few subjects with more than 60 years, so you are comparing 2 two populations absolutely not homogeneous by age.
I added a ’image in which you can see the different age distribution of vaccinated and unvaccinated above the 50 years to 23/5. In the following weeks the vaccination continued increasing the discrepancy.
Among the unvaccinated we have very few subjects with more than 65 years that have almost all been vaccinated.
If we have 1000 infected over50 vaccinated, we will also have many large elderly people with significant risk of death even if vaccinated. Among the unvaccinated I will have almost exclusively subjects among the 50-59 years.

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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