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A modest proposal for COVID-19 response (Or, I’m not King, but)

JAMA table 1, comparing efficacy of masks

(This isn’t medical advice, since it would be unethical to treat people I can’t examine and follow. But this may be a good list of recommendations for discussion.)

If I were in charge of the public health response to COVID-19, I would implement the following:

1. Let physicians practice medicine!

Stop the political, weaponised threats censorship, and cancelling!

Pharmacy Boards should never get between a doctor and patient except in matters of life and death or illegal practice. Politicians, State Medical Boards and our House of Medicine professional organizations should defend our legal practice of medicine rather than threatening physicians and changing the rules during a pandemic.

2. Encourage shared information & fact-checking among physicians as part of our missions of education & transparency.

3. Suggest voluntary use of masks in public places or self-isolation for those worried about their vulnerability. Traditionally, we quarantine the sick and at-risk and new-comers, not the healthy or people in place with a low risk of exposure.

JAMA review of masks, August 2020

4. Where a high percentage of the local population tests positive, local authorities should consider – and have the ethical responsibility to – impose higher isolation measures like masks and public distancing. The threshold for mandates must be locally determined with public input, and explained – clearly, frequently.

This means you, anti-maskers!

5. Stress that surgical procedure masks are nearly as effective as N95 masks, blocking nearly as much aerosols and viral particles for both wearer and those around us. Medical providers and those with a high risk of prolonged close contact need fitted N95 masks, the rest of us don’t.

Single layer cut-up T-shirts and homemade masks, balaclavas or bandannas, aren’t very effective protection at all, either for the wearer or the people around us. N95 Masks with single valves are a money-maker, but not nearly as effective as surgical masks, even with an added filter layer.

5. Educate the elderly & vulnerable about extra infection-avoiding and -control precautions, advising self-imposed near-quarantine for the most vulnerable of them.
6. Recommend Vitamin D & zinc over the counter supplements, possibly Vitamin C – which are harmless to virtually everyone, if not beneficial, to everyone.
7. Make Rapid tests for in-home testing available at nominal, sliding scale cost, on demand and at first symptoms or exposure. (This may be a place for donations by crowd funding.) Back up positives with the PCR tests, quarantine all rapid positives until cleared by PCR.

8. Begin early prophylaxis with hydroxychloroquine/zinc and/or inhaled steroids for the willing & likely exposed.

10. Open the schools, let the kids be kids on the playground. Utilize younger teachers and aides in the classroom. Supervision & protection for vulnerable teachers & students can be achieved as necessary with distance learning measures.
11. Make sure we have lots of Hydroxychloroquine/ azythromycin/ zinc/ vitamin D to begin at the first symptoms (I know the literature is mixed, but every article or study that I’ve seen it’s all flawed, see below**).
12. For both of my homes, in Texas, USA and in the British Virgin Islands, we should open the borders to anyone willing to quarantine in a government-secured location for 14 days & planning to stay at least 30 days (maintaining strict isolation & infection control precautions).
And, the most risky proposal of all...
10. I’d sanction the Chinese government-connected businesses and confiscate their assets to pay for it.

REFERENCES

** I follow the literature as best as I can: every single peer-reviewed study is flawed. However the anecdotal evidence for some protocols is very strong. If necessary to avoid politics, let the controlled trials continue but let willing physicians continue our ethical off-label prescription. We could just pretend we’re giving malaria prophylaxis, if it makes you feel better.
Prophylaxis dosing:
Hydroxychloroquine: 400 mg. twice on day one 200 mg twice on day two, then 200 mg. Twice a day every 4 days

Treatment dosing (always allowing treating physicians who prescribe determine need & frequency of alternate doses & monitoring)

This isn’t a prescription!

Hydroxychloroquine: 400 mg. twice on day one then 200 mg. twice a day for either 5 or 10 days;

Azithromycin: 250 mg. tablet, 2 on day one, 1 on day 2 to 5;

Budesonide: unit dose via hand held inhaler or nebulizer twice a day. (I’m looking for references for this one. )

Zinc 150 mg. to 250 mg. a day indefinitely. (Best evidence for lozenges or syrup multiple times a day. See references.)

Vitamin D, 1000 IU a day, up to 4000 IU is safe

Vitamin C, No set dose, but extra will be excreted in the urine or feces, can cause diarrhea.

References

Journal of the American Medical Association review. Published August 11, 2020. (Free, with Tables)

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2769443?guestAccessKey=53b2b8ec-df1a-4ca4-88ce-abf6c4fa470c&utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=081120

CDC recommendation on cloth masks:

https://wwwnc.cdc.gov/eid/article/26/10/20-0948_article

John’s Hopkins recommendation:

https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-face-masks-what-you-need-to-know

Zinc:

https://www.uchealth.org/today/zinc-could-help-diminish-extent-of-covid-19/

Journal article on treatment for the common cold: https://www.acpjournals.org/doi/10.7326/0003-4819-125-2-199607150-00001

Unpublished, non-peer reviewed: https://www.researchgate.net/publication/47794995_Zn_Inhibits_Coronavirus_and_Arterivirus_RNA_Polymerase_Activity_In_Vitro_and_Zinc_Ionophores_Block_the_Replication_of_These_Viruses_in_Cell_Culture

Hydroxychloroquine/azithromycin protocols

International Journal of Infectious Diseases (Henry Ford or Ashad report):

https://www.ijidonline.com/article/S1201-9712(20)30534-8/fulltext

https://www.ijidonline.com/article/S1201-9712(20)30600-7/fulltext

On synergistic effect of hydroxychloroquine plus steroids:

https://www.ijidonline.com/article/S1201-9712(20)30613-5/fulltext

Budesonide

Description of study in progress on treatment for loss of smell in patients without severe symptoms:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370627/

Vitamin C safety:

https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/expert-answers/vitamin-c/faq-20058030#:~:text=For%20adults%2C%20the%20recommended%20daily,Nausea

Note: comments are off. Please comment on my Facebook page, Beverly Nuckols.

Edited 31/08/20 12:30 for mis-spellchecked word. BBN

#BVILove, #Coronavirus Delayed, not “beaten.” (One small country’s COVID-19 story)

Here in the small Nation of the British Virgin Islands, we’ve delayed, but we haven’t “beaten,” or completely avoided, the disease caused by the novel, or new, Coronavirus, COVID-19. Everyone who hasn’t yet been infected is still at risk. A lot of us will eventually catch the virus if and when we once again interact with the world at all.

If you want to learn about the current state of the science, this video is excellent by a fantastic teacher.

The Nation has done an excellent job of blunting the effect of the disease, beginning with closing all ports of entry to everyone except residents, back in March, followed by a 6 day “lockdown” with an in-home curfew at night and limitedbusiness and shopping.

Beginning about April 2, Government began enforcing a 24 hour in-home curfew, shutting business and forbidding residents from leaving our homes.

There have been 5 people with positive tests. 4 of them caught the disease in other countries and one person may have caught the disease from the last of those 4. The first 3 had mild cases and appear to be recovering.

Unfortunately, that last case was a woman whose disease was only discovered when she became very sick and had to be admitted to the hospital. She died the next day. One of her contacts has tested positive, but has mild symptoms. Unfortunately, not all of the people she might have interacted with have been identified and tested.

Hopefully, over the last 6 weeks, the BVI health department has had time to plan and prepare for multiple sick patients.

Even more: I hope that researchers around the world will come up with good treatments and discover why some patients get so sick so fast.

If there’s ever a vaccine, it’s years away There haven’t been any successful vaccines for other human strains of coronavirus.

It appears from some recent random testing in the US, that about 25% – 30% of an exposed population contracts the disease. Most either have no symptoms or mild symptoms. A small minority gets sick enough to be hospitalized, and a fraction of those end up in the ICU.

You may have heard about the high “case fatality rate,” reported anywhere from 0.01 to 10. Remember that this statistic only counts those who have been tested, predominantly those sick enough to be admitted to the hospital.

There is good news in addition to the fact that most infected people have mild or no symptoms: evidence that we have immunity after recovery comes from one of the treatments undergoing research: serum containing antibodies from the blood of recovered patients helps other people get well.

The scary part of the story is that the virus is very contagious, largely because people without symptoms can spread the disease. Medical personnel have been surprised by what appears to be the unprecedented, rapidity of the onset of Acute Respiratory Distress Syndrome (ARDS) in some patients, usually about day 12 to 14 of the symptoms. In a matter of a few hours, patients become very short of breath, requiring intubation. 80%- 90% of those intubated have died in the ICU.

The virus can also cause the body to produce proteins causing increased coagulation (the tendency for blood to clot). It also can directly infect the heart muscle and brain.

As our country opens up, and goes back to (relatively) more normal interaction, it’s important to remember that infected people may not have symptoms, but are still able to share the virus and spread the disease. They don’t know they have it and you certainly can’t tell by looking at them.

We will probably see our neighbors continue “social distancing” and wearing face masks when we leave our homes. And yes, inevitably, some of us will get sick.

Disappointed by BVI Immigration 

A month ago, one week after Irma I came into Beef Island as volunteer doctor with a small medical relief group on a charter plane.   I was only given a visa for 30 days, even though I explained that I have a Non-Belonger Land Holder License (NBLHL), but didn’t have it with me when I canceled the rest of our vacation in Europe. 

Today I went to the government offices in Spanish Town with my NBLHL and was refused a visa extension until I could produce a return ticket. The officer informed me that the NBLHL only allowed me 6 months “per annum” and proceeded to examine my passport, as though to check how long I had been present in the Country this year. 

(I had to go up to Flow to get a good signal in order to buy the ticket online. I returned to find the officer leaving for lunch 15 minutes before noon.)

When I came in on September 14, there was no demand for a return ticket. At the timethere was a perceived shortage of doctors and we believed I would need to be self-sufficient for food and water as I wouldn’t have access to power or running water. The prisoners and looters were still at large. 

Thank goodness, nothing was quite as bad as we feared:  The British military had arrived by then; the wonderful people at Nanny Cay took great care of me and the rest of the group and we arrived the first day that Nanny Cay was able to turn on their desalination plant /water maker for a few hours.  


The medical need on Tortola was already improving enough that I was able to come to Virgin Gorda just 4 days later. Although they don’t need me either, I’ve been working at the clinic in Spanish Town at least two days a week ever since. I don’t want a job and don’t need the experience, but feel that I made a contract that I must keep. I also want the docs, nurses, and staff to know me if one of the feared medical crises does arise. 


BTW, That NBLHL I mentioned “authorizes”  immigration “to grant leave to land for a period not exceeding six months…” Not “per annum,” and there is no mention of a return ticket six months in advance. 


Larry and I have also applied for a “permit to reside”  which required the same documentation that we submitted –  and resubmitted after it was lost – for our NBLHL:  letters from law enforcement and character references, and financial statements. We were required to leave the Country while it was processed, but have been informed that it  languished in the Immigration department without action from 5 July to September 4 –  2 months before Hurricane Irma – and that it is most likely lost and will need to be resubmitted. 


If you saw my post last week, you’ll recall that when Larry was finally able to come to the BVI 3 weeks after I did, he was required to pay duty or produce receipts at Beef Island Customs on the 

(I had to go up to Flow to get a good signal in order to buy the ticket online. I returned to find Ms. Smith leaving for lunch 15 minutes before noon.)

When I came in on September 14, there was no demand for a return ticket. At the time, there was a perceived shortage of doctors and we believed I would need to be self-sufficient for food and water as I wouldn’t have access to power or running water. The prisoners and looters were still at large.

Thank goodness, nothing was quite as bad as we feared: The British military had arrived by then; the wonderful people at Nanny Cay took great care of me and the rest of the group and we arrived the first day that Nanny Cay was able to turn on their desalination plant /water maker for a few hours.

The medical need on Tortola was already improving enough that I was able to come to Virgin Gorda just 4 days later. Although they don’t need me either, I’ve been working at the clinic in Spanish Town at least two days a week ever since. I don’t want a job and don’t need the experience, but feel that I made a contract that I must keep. I also want the docs, nurses, and staff to know me if one of the feared medical crises does arise.

BTW, That NBLHL I mentioned “authorizes” immigration “to grant leave to land for a period not exceeding six months…” Not “per annum,” and there is no mention of a return ticket six months in advance.

Larry and I have also applied for a “permit to reside” which required the same documentation that we submitted – and resubmitted after it was lost – for our NBLHL: letters from law enforcement and character references, and financial statements. We were required to leave the Country while it was processed, but have been informed that it languished in the Immigration department without action from 5 July to September 4 – 2 months before Hurricane Irma – and that it is most likely lost and will need to be resubmitted.

If you saw my post last week, you’ll recall that when Larry was finally able to come to the BVI 3 weeks after I did, he was required to pay duty or produce receipts at Beef Island Customs on the items (water filters, etc.) he brought, in spite of the moratorium.

Beyond investing in our home at Nail Bay on Virgin Gorda, Larry and I have done what we could to assist physically and financially in the BVI recovery after Irma. I’m not as enthusiastic about residency as I was in June or even a month ago, and do not feel at all welcomed by the BVI.

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