Chinese warns against 'trade war,' appeals for cooperation

Feb 26: China’s massive travel restrictions, house-to-house checks, huge isolation wards and lockdowns of entire cities bought the world valuable time to prepare for the global spread of the new virus.

But with troubling outbreaks now emerging in Italy, South Korea and Iran, and U.S. health officials warning Tuesday it’s inevitable it will spread more widely in America, the question is: Did the world use that time wisely and is it ready for a potential pandemic?

“It’s not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen — and how many people in this country will have severe illness,” said Dr. Nancy Messonnier of the U.S. Centers for Disease Control and Prevention.

Some countries are putting price caps on face masks to combat price gouging, while others are using loudspeakers on trucks to keep residents informed. In the United States and many other nations, public health officials are turning to guidelines written for pandemic flu and discussing the possibility of school closures, telecommuting and canceling events.

Countries could be doing even more: training hundreds of workers to trace the virus’ spread from person to person and planning to commandeer entire hospital wards or even entire hospitals, said Dr. Bruce Aylward, the World Health Organization’s envoy to China, briefing reporters Tuesday about lessons learned by the recently returned team of international scientists he led.

“Time is everything in this disease,” Aylward said. “Days make a difference with a disease like this.”

The U.S. National Institutes of Health’s infectious disease chief, Dr. Anthony Fauci, said the world is “teetering very, very close” to a pandemic. He credits China’s response for giving other nations some breathing room.

China locked down tens of millions of its citizens and other nations imposed travel restrictions, reducing the number of people who needed health checks or quarantines outside the Asian country.

It “gave us time to really brush off our pandemic preparedness plans and get ready for the kinds of things we have to do,” Fauci said. “And we’ve actually been quite successful because the travel-related cases, we’ve been able to identify, to isolate” and to track down those they came in contact with.

With no vaccine or medicine available yet, preparations are focused on what’s called “social distancing” — limiting opportunities for people to gather and spread the virus.

That played out in Italy this week. With cases climbing, authorities cut short the popular Venice Carnival and closed down Milan’s La Scala opera house. In Japan, Prime Minister Shinzo Abe called on companies to allow employees to work from home, while the Tokyo Marathon has been restricted to elite runners and other public events have been canceled.

Is the rest of the world ready?

In Africa, three-quarters of countries have a flu pandemic plan, but most are outdated, according to authors of a modeling study published last week in The Lancet medical journal. The slightly better news is that the African nations most connected to China by air travel — Egypt, Algeria and South Africa — also have the most prepared health systems on the continent.

Elsewhere, Thailand said it would establish special clinics to examine people with flu-like symptoms to detect infections early. Sri Lanka and Laos imposed price ceilings for face masks, while India restricted the export of personal protective equipment.

India’s health ministry has been framing step-by-step instructions to deal with sustained transmissions that will be circulated to the 250,000 village councils that are the most basic unit of the country’s sprawling administration.

Vietnam is using music videos on social media to reach the public. In Malaysia, loudspeakers on trucks blare information through the streets.

In Europe, portable pods set up at United Kingdom hospitals will be used to assess people suspected of infection while keeping them apart from others. France developed a quick test for the virus and has shared it with poorer nations. German authorities are stressing “sneezing etiquette” and Russia is screening people at airports, railway stations and those riding public transportation.

In the U.S., hospitals and emergency workers for years have practiced for a possible deadly, fast-spreading flu. Those drills helped the first hospitals to treat U.S. patients suffering from COVID-19, the disease caused by the virus.

Other hospitals are paying attention. The CDC has been talking to the American Hospital Association, which in turn communicates coronavirus news daily to its nearly 5,000 member hospitals. Hospitals are reviewing infection control measures, considering using telemedicine to keep potentially infectious patients from making unnecessary trips to the hospital and conserving dwindling supplies of masks and gloves.

What’s more, the CDC has held 17 different calls reaching more than 11,000 companies and organizations, including stadiums, universities, faith leaders, retailers and large corporations. U.S. health authorities are talking to city, county and state health departments about being ready to cancel mass gathering events, close schools and take other steps.

The CDC’s Messonnier said Tuesday she had contacted her children’s school district to ask about plans for using internet-based education should schools need to close temporarily, as some did in 2009 during an outbreak of H1N1 flu. She encouraged American parents to do the same, and to ask their employers whether they’ll be able to work from home.

“We want to make sure the American public is prepared,” Messonnier said.

How prepared are U.S. hospitals?

“It depends on caseload and location. I would suspect most hospitals are prepared to handle one to two cases, but if there is ongoing local transmission with many cases, most are likely not prepared just yet for a surge of patients and the ‘worried well,’” Dr. Jennifer Lighter, a pediatric infectious diseases specialist at NYU Langone in New York, said in an email.

In the U.S., a vaccine candidate is inching closer to first-step safety studies in people, as Moderna Inc. has delivered test doses to Fauci’s NIH institute. Some other companies say they have candidates that could begin testing in a few months. Still, even if those first safety studies show no red flags, specialists believe it would take at least a year to have something ready for widespread use. That’s longer than it took in 2009, during the H1N1 flu pandemic — because that time around, scientists only had to adjust regular flu vaccines, not start from scratch.

The head of the World Health Organization, Tedros Adhanom Ghebreyesus, said the U.N. health agency’s team in China found the fatality rate between 2% and 4% in the hard-hit city of Wuhan, the virus’ epicenter, and 0.7% elsewhere.

The world is “simply not ready,” said the WHO’s Aylward. “It can get ready very fast, but the big shift has to be in the mindset.”

Aylward advised other countries to do “really practical things” now to get ready.

Among them: Do you have hundreds of workers lined up and trained to trace the contacts of infected patients, or will you be training them after a cluster pops up?

Can you take over entire hospital wards, or even entire hospitals, to isolate patients?

Are hospitals buying ventilators and checking oxygen supplies?

Countries must improve testing capacity — and instructions so health workers know which travelers should be tested as the number of affected countries rises, said Johns Hopkins University emergency response specialist Lauren Sauer. She pointed to how Canada diagnosed the first traveler from Iran arriving there with COVID-19, before many other countries even considered adding Iran to the at-risk list.

If the disease does spread globally, everyone is likely to feel it, said Nancy Foster, a vice president of the American Hospital Association. Even those who aren’t ill may need to help friends and family in isolation or have their own health appointments delayed.

“There will be a lot of people affected even if they never become ill themselves,” she said.

Washington, Apr 28: After nearly three weeks in an intensive care unit in Los Angeles, doctors treating 41-year-old Broadway actor Nick Cordero for COVID-19 were forced to amputate his right leg.

The flow of blood had been impeded by a blood clot: yet another dangerous complication of the disease that has been bubbling up in frontline reports from China, Europe and the United States.

To be sure, so-called "thrombotic events" occur for a variety of reasons among intensive care patients, but the rates among COVID-19 patients are far higher than would be otherwise expected.

"I have had 40-year-olds in my ICU who have clots in their fingers that look like they'll lose the finger, but there's no other reason to lose the finger than the virus," Shari Brosnahan, a critical care doctor at NYU Langone said.

One of these patients is suffering from a lack of blood flow to both feet and both hands, and she predicts an amputation may be necessary, or the blood vessels may get so damaged that an extremity could drop off by itself.

Blood clots aren't just dangerous for our limbs, but can make their way to the lungs, heart or brain, where they may cause lethal pulmonary embolisms, heart attacks, and strokes.

A recent paper from the Netherlands in the journal Thrombosis Research found that 31 percent of 184 patients suffered thrombotic complications, a figure that the researchers called "remarkably high" -- even if extreme consequences like amputation are rare.

Behnood Bikdeli, a doctor at New York-Presbyterian Hospital, assembled an international consortium of experts to study the issue. Their findings were published in the Journal of The American College of Cardiology.

The experts found the risks were so great that COVID-19 patients "may need to receive blood thinners, preventively, prophylactically," even before imaging tests are ordered, said Bikdeli.

What exactly is causing it? The reasons aren't fully understood, but he offered several possible explanations.

People with severe forms of COVID-19 often have underlying medical conditions like heart or lung disease -- which are themselves linked to higher rates of clotting.

Next, being in intensive care makes a person likelier to develop a clot because they are staying still for so long. That's why for example people are encouraged to stretch and move around on long haul flights.

It's also now clear the COVID-19 illness is associated with an abnormal immune reaction called "cytokine storm" -- and some research has indicated this too is linked to higher rates of clotting.

There could also be something about the virus itself that is causing coagulation, which has some precedent in other viral illnesses.

A paper in the journal The Lancet last week showed that the virus can infect the inner cell layer of organs and of blood vessels, called the endothelium. This, in theory, could interfere with the clotting process.

According to Brosnahan, while thinners like Heparin are effective in some patients, they don't work for all patients because the clots are at times too small.

"There are too many microclots," she said. "We're not sure exactly where they are."

Autopsies have in fact shown some people's lungs filled with hundreds of microclots.

The arrival of a new mystery however helps solve a slightly older one.

Cecilia Mirant-Borde, an intensive care doctor at a military veterans hospital in Manhattan, told AFP that lungs filled with microclots helped explain why ventilators work poorly for patients with low blood oxygen.

Earlier in the pandemic doctors were treating these patients according to protocols developed for acute respiratory distress syndrome, sometimes known as "wet lung."

But in some cases, "it's not because the lungs are occupied with water" -- rather, it's that the microclotting is blocking circulation and blood is leaving the lungs with less oxygen than it should.

It has just been a little under five months since the virus emerged in Wuhan, China, and researchers are learning more about its impact every day.

"While we react surprised, we shouldn't be as surprised as we were. Viruses tend to do weird things," said Brosnahan.

While the dizzying array of complications may seem daunting, "it's possible there'll be one or a couple of unifying mechanisms that describe how this damage happens," she said.

"It's possible it's all the same thing, and that there'll be the same solution."