A negative coronavirus test doesn't always mean you are not infected/ WaPo

Various interviewees estimated the that the coronavirus tests they are familiar with are 75%, 85% or 100% accurate:

Demetre Daskalakis, deputy commissioner for the division of disease control of the New York City Department of Health and Mental Hygiene, said he recently told a patient with mild symptoms who sought a test and received a negative result to act like he had it.
“The pretest probability if you have fever or cough in a pandemic — if you have a fever, cough and shortness of breath, it’s covid-19. Even if the test is negative,” Daskalakis said.

How dependent is the U.S. on China for its drugs? The fact is, the FDA doesn’t know/ FiercePharma

Janet Woodcock has spent most of the last 20 years as the head of FDA's Center for Drugs.  Most of that time, while China and India took over the manufacturing of most of the world's drugs, her head has been buried in the sand.  From FiercePharma:

"As the spread of COVID-19 threatens to disrupt pharma supply chains and create drug shortages, the Trump administration is reportedly looking for ways to reduce U.S. dependence on APIs and drugs from China. So, how dependent is the U.S. on China for its drugs? The fact is, the FDA doesn’t know. 
Janet Woodcock, FDA’s director of the Center for Drug Evaluation and Research, in congressional testimony in October said while it is clear drug production, particularly of APIs, has moved out of the U.S., the FDA doesn’t know a lot more than that. FDA info show the number of Chinese facilities licensed to produce APIs for U.S. drugs is smaller than in the U.S., 13% versus 28%, but those statistics don’t mean much. 

 
“The FDA doesn’t know whether Chinese facilities are actually producing APIs, how much they are producing, or where the APIs they are producing are being distributed worldwide, including in the United States,” Woodcock reported. “… Similarly, we do not have information that would enable us to assess the resilience of the U.S. manufacturing base, should it be tested by China’s withdrawal from supplying the U.S. market.”

CDC considering recommending general public wear face coverings in public/ WaPo

This WaPo piece provides further evidence that the government is well aware this virus transmits via the airborne route.  As a result, indoor air that is shared with those infected (who may be asymptomatic or presymptomatic) carries risk of infection.  You don't need to have someone cough on you.  Breathing infected air is enough to catch coronavirus.

Of 60 members of a choir who came together for a rehearsal, practiced social distancing, used hand sanitizer and did not hug each other, 45 developed COVID and 2 have died.

Dr. David Price, a new pulmonology graduate at Weill Cornell Medical Center, is spreading a terribly dangerous rumor that 99% of infections are spread through touching a contaminated object.  It isn't true.  Airborne spread is a terribly important mode of transmission.  Please don't let your guard down.

Battelle has had an (unused) method to decontaminate N95 masks aka respirators for years!

Unbelievable.  4 years ago, the FDA gave contractor Battelle half a million dollars to study the use of commercial decontamination equipment, using hydrogen peroxide gas, on N95 masks.  Battelle said the method worked in 2016.  But we are only just hearing about it, as thousands of healthcare workers get infected due, in part, to lack of these masks. WTF??!!

Politico reports that FDA did not want to approve the technology, until Ohio governor Mike Dewine asked President Trump to lean on FDA. Battelle is in Ohio.  

Either it works reliably or it doesn't, FDA.  Which is it? The healthcare workforce is waiting with bated breath for the answer.

From FiercePharma:

Battelle received an emergency go-ahead from the FDA over the weekend to deploy its decontamination system for personal protective equipment (PPE), allowing healthcare workers to clean and reuse scarce N95 respirator masks.
The system is currently operating at Battelle’s Ohio facility—capable of processing up to 80,000 masks per machine, per day, within what looks like a large metal shipping container—and has been working to help stretch supplies for the OhioHealth system based in Columbus.

Using concentrated hydrogen peroxide vapor, the filters are gassed for two and a half hours to destroy bacteria, viruses and other contaminants, including the novel coronavirus SARS-CoV-2. According to the company, the system can clean the same N95 mask up to 20 times without degrading its performance. 

The FDA had first OK’d the use of the system on Saturday but initially limited its use to 10,000 masks per day, according to Republican Ohio Gov. Mike DeWine, who called on the agency to unlock the system’s full decontamination capacity. DeWine also said this would have limited Battelle’s plans to deploy machines to the hard-hit New York metro area as well as Washington state and Washington, D.C.
Within hours, and after President Donald Trump also urged the FDA to approve the equipment on Twitter, FDA Commissioner Stephen Hahn tweeted late Sunday evening that the agency had issued an amended authorization. 

Donald J. Trump

✔@realDonaldTrump

Thank you Dr. Hahn & the FDA for your fast approval of this respected Ohio company recommended by Governor @MikeDeWine. Great potential! https://twitter.com/stevefda/status/1244472087831552004 …Dr. Stephen M. Hahn

✔@SteveFDA
We issued a new authorization this evening to @Battelle for their decontamination system. @US_FDA staff have been working nonstop across gov and with the private sector to deliver solutions to the American public.

45K7:07 AM - Mar 30, 2020Twitter Ads info and privacy

In the near term, Battelle’s facility plans to begin decontaminating respirator masks for three other central Ohio health systems this week.

Battelle previously engaged with the FDA from 2014 to 2016 to study the use of its decontamination machine in the midst of a potential pandemic and PPE shortage. Currently, the company is exploring its use outside of N95 masks to other equipment such as ventilator components.

Update April 2:  Duke is using this method to sterilize and reuse its N95 masks.

Why is the World's Richest Country Short of Medical Masks?/ NYT

Here, the WaPo goes into the tawdry story of how DHHS' Preparedness group and BARDA got prototypes for a machine to produce reusable N95 masks, then dropped the ball despite their $1.5B yearly funding for 'preparedness.'

From  the NY Times:

Few in the protective equipment industry are surprised by the shortages, because they’ve been predicted for years. In 2005, the George W. Bush administration called for the coordination of domestic production and stockpiling of protective gear in preparation for pandemic influenza. In 2006, Congress approved funds to add protective gear to a national strategic stockpile — among other things, the stockpile collected 52 million surgical face masks and 104 million N95 respirator masks.

But about 100 million masks in the stockpile were deployed in 2009 in the fight against the H1N1 flu pandemic, and the government never bothered to replace them. This month, Alex Azar, secretary of health and human services, testified that there are only about 40 million masks in the stockpile — around 1 percent of the projected national need.

As the coronavirus began to spread in China early this year, a global shortage of protective equipment began to look inevitable. But by then it was too late for the American government to do much about the problem. Two decades ago, most hospital protective gear was made domestically. But like much of the rest of the apparel and consumer products business, face mask manufacturing has since shifted nearly entirely overseas. “China is a producer of 80 percent of masks worldwide,” Laverdure said.

Hospitals began to run out of masks for the same reason that supermarkets ran out of toilet paper — because their “just-in-time” supply chains, which call for holding as little inventory as possible to meet demand, are built to optimize efficiency, not resiliency.

“You’re talking about a commodity item,” said Michael J. Alkire, president of Premier, a company that purchases medical supplies for hospitals and health systems. In the supply chain, he said, “by definition, there’s not going to be a lot of redundancy, because everyone wants the low cost.”

In January, the brittle supply chain began to crack under pressure. To deal with its own outbreak, China began to restrict exports of protective equipment. Then other countries did as well — Taiwan, Germany, France and India took steps to stop exports of medical equipment. That left American hospitals to seek more and more masks from fewer and fewer producers...

There are many ways the novel coronavirus may have come about/ Nass

Nature Medicine ran a 3 page article that claimed to explain why the novel coronavirus is not a lab construct.  USA Today wrote a summary piece explaining it:

“If someone were seeking to engineer a new coronavirus as a pathogen, they would have constructed it from the backbone of a virus known to cause illness,” the report said. “But the scientists found that the SARS-CoV-2 backbone differed substantially from those of already known coronaviruses and mostly resembled related viruses found in bats and pangolins.”—USAT

Yet it turns out to be a specious argument, relying on the fact that the novel coronavirus backbone sequence was not already known in the open virology literature.

1.  While starting from a known RNA sequence is one easy way to create a pathogen, it is certainly not necessary to do so. 

2.  Nor is it likely that biodefense/biowarfare programs share knowledge of all their creations.  They never have before.  

3.  a)  Finally, it is relatively easy to detect the human hand when a chimera of known virulence factors is strung together.

      b)  But because plausible deniability is a critical component of a bioweapons attack, I doubt that a chimera using known sequences is the path that would have been followed by a modern biowarrior.

I will briefly mention some of the old techniques for creating bioweapons, none of which require that a known, published RNA backbone would be required to build a novel, virulent coronavirus:

1.  China has unique bats.  So do other countries. Unique bats likely harbor unique viruses.  Bits of these viruses can be strung together, while no outside parties are aware that these particular RNA threads exist in nature.

2.  You take an already virulent RNA virus, subject it to high rates of mutation via chemical or radiological exposure, and test the viruses that survive for the acquisition of new virulence characteristics.

3.  You simply passage the virus through tens, hundreds or thousands of lab animals or cell cultures and test the results for acquisition of new virulence characteristics.

4.  You mix different viruses together with different virulence characteristics, allow them to grow together, and seek recombinants that have obtained the desired new mix of virulence factors.

All these possibilities result in viruses that are hard to pin on lab production.  I dare the Nature Medicine scientists to dismiss these scenarios.

Still, I doubt that any national program would deliberately release this coronavirus onto the people of the earth, because it is so hard to control. 

Historically, bio-weaponeers have required their creations to be controlled at all costs. In one well-documented example of biowarfare, unleashing African swine fever on a Caribbean island was associated with no spread beyond the island. In another, anthrax spores were used because they stay put-- their use did not cause anthrax cases beyond the borders of Rhodesia (now Zimbabwe).

So why do we have a coronavirus epidemic now?

An accidental biowarfare laboratory release is the best current hypothesis, in my opinion.  Such accidental releases have been documented for many decades, throughout the world.  But I could certainly be wrong.

Update April 29:  Newsweek has been delving into "gain of function" (which means increasing the virulence of a pathogen) coronavirus research in Wuhan, China which might have contributed to the formation of SARS-CoV-2... and the interesting fact (which I posted about here) that the US government provided financial support for this research.  Newsweek's pieces were posted April 27, and 29.  My other pieces questioning the origin of SARS-CoV-2 are here and here.

An important proposal that ameliorates our lack of protective equipment and spares both patients and healthcare workers

There is a huge disconnect between the personal protective equipment (PPE) healthcare workers (HCWs) should be wearing to protect themselves from coronavirus, and what actually exists right now for them to use.  The White House has told the governors to find their own supplies.  The equipment market is in chaos.  CDC is now telling HCWs to make their own equipment.  But Kaiser Permanente threatened to fire nurses for wearing their own N95 respirators.  The WHO says the "shortage of personal protective equipment is endangering health workers worldwide."

What many people don't know is that HCWs change in and out of protective gear, which is almost entirely single use, every time they enter a room to see a patient who may be contagious via the airborne route. One contagious patient may lead to the use of 20 changes of PPE in a single day.

Nurses and doctors deserve congratulations for their bravery and commitment to continue working, even without adequate protective equipment.  Though UK doctors have threatened to quit, and Bulgarian doctors have quit.

Having doctors and nurses work under these conditions is extremely shortsighted.  Given the tremendous propensity of the virus to spread--US deaths are doubling every 3 days, and are believed to lag infection by a month--healthcare workers will be infected disproportionately, as in Wuhan and northern Italy.  But worst of all, HCWs may become viral spreaders, transmitting infection to patients who are in their healthcare facility for other reasons.  Doctors in Italy have warned that hospitals might be “the main” source of Covid-19 transmission. 

This situation should not be tolerated by the doctors and nurses, who know better, nor by their non-COVID patients, nor by their healthcare administrators and government.

There is only one solution:  keeping patients with COVID-19 in facilities that treat only COVID-19.  And treating other patients in separate facilities.  This requires government to take control of a very messy situation:  hospitals and clinics are about to become, if they are not already, the locations that put their patients at highest risk of infection. But hospitals will not suddenly create separate COVID facilities by themselves.  Government needs to step in to make this happen.

Creating designated COVID-19 facilities would allow healthcare workers to put on a complete set of protective garments: masks, goggles, face shields and head to toe gowns and shoe covers, at the beginning of their shift.  They would then not change out of the garments between patients, since all the patients are already infected.  It would save tremendous amounts of equipment and time, since HCWs would not have to change up their gowns, gloves, etc. between each patient, and would have enough protective equipment to work in safety.

How do you identify the COVID patients, when PCR tests have again slowed due to lack of reagents and swabs?

In Italy and China, ultrasound exams of the lungs, or CT scans, have been used to differentiate the specific lung pattern caused by this coronavirus (a bilateral ground glass appearance, especially in the lung periphery) from other infections.  This can provide a faster diagnosis than a lab test, with almost as much accuracy, at the point of patient contact. Ultrasound machines may be portable and inexpensive.

Hopefully new rapid laboratory tests will also be available to aid in immediate diagnosis.

Patients would be triaged and separated into those who: 

1.  definitely have COVID-19 based on their history, symptoms and a scan
2.  definitely have a different disorder, or
3.  maybe have COVID-19 

The 'maybe' patients must be situated in separate rooms to avoid cross-contamination, and would require HCWs to change their gowns, masks, etc. between patients. The HCWs caring for non-COVID patients would not require protective gear, except perhaps a mask in case they are asymptomatic spreaders.  Those caring for COVID patients would use only one set of gear for each shift.

By so doing, we keep HCWs and patients safe, and sensibly use the limited personal protective equipment currently available.  We avoid reliance on expensive but untested tech solutions for monitoring patients from a distance.  And it saves patient lives.

By keeping HCWs suited up, they can safely work at the bedside, and, when critical patients need urgent intubation, which is required all too often with COVID-19, our doctors and nurses will avoid the several minute delay of getting dressed in gear before they can take care of the patients' immediate needs.

We need strong leadership to immediately enable healthcare facilities to implement this type of system, the same way we needed strong leadership to impose quarantines to 'flatten the curve.'

Desperate for Covid-19 answers, U.S. doctors turn to colleagues in China/ Stat

From STAT, a report of an online meeting between Johns Hopkins infectious disease doctors and doctors from Zhejiang, one of China's top medical schools, who had responded to the COVID-19 epidemic: 

...We want to work together with you to help fight Covid-19, Wang told the Americans as the hourlong meeting began. Their first question: If you were in our position, at the very beginning of the outbreak, what are the most important things to know?

The Zhejiang contingent took over one makeshift ICU in Wuhan on Feb. 14, plus one ward for Covid-19 patients in an existing hospital. They had 72 ICU patients, 55% older than 65, yet only nine of the ICU patients died; 17% required intubation in order to breathe, a procedure that risks making virus particles not only airborne but also aerosolized — meaning they can remain suspended in the air for some time.

The Hopkins doctors were keen to hear how their counterparts cured 35 intensive-care patients completely and brought the status of another 28 to only mild disease. With no surefire Covid-19 therapy and a blizzard of conflicting information on what existing drugs might work, Antar said, “one of our main questions was about their experience with off-label use” — repurposing existing drugs approved for other illnesses to use in the fight against Covid-19.

That experience has involved everything but the kitchen sink, though informed as much as possible by science. Several antivirals, including the HIV drugs lopinavir and ritonavir, did not accelerate recovery or reduce mortality, ICU physician Xiao Lu said. Some immune system regulators — including alpha interferon, anti-IL-6 monoclonal antibodies such as tocilizumab, and immunoglobulin — showed hints of efficacy in some critical cases.

Some patients received the malaria drug chloroquine, which President Trump has touted and which is being tested in a World Health Organization-supported clinical trial, but the Zhejiang team did not have rigorous data on its effects. They tried tocilizumab, too, a drug that has enough potential that on Monday, Genentech announced that it had received U.S. Food and Drug Administration approval for a clinical trial in Covid-19 patients with severe pneumonia; the rheumatoid arthritis drug, which goes by the brand name Actemra, might quell the out-of-control immune reaction that has killed many Covid-19 patients.
“All of us want to practice evidence-based medicine,” Antar said. “But the timeline for this might not allow us to wait for that.”

The right equipment helped. The Zhejiang team brought oxygen supply systems, monitors, ultrasounds, ventilators, and protective equipment from Hangzhou.

Who should be hospitalized, the Hopkins physicians asked? Suspected cases can be isolated and observed in their homes, they were told, as doctors in overwhelmed Italy are also telling U.S. doctors. Mild and moderate cases can be treated in mobile units, away from other patients; coronavirus spread within hospitals has been disastrous in Italy. Severe and critical cases in China get hospitalized, but at a dedicated facility, to reduce spread from Covid-19 patient to hospital worker to non-Covid-19 patient.

How do we know when a patient can be discharged, Antar and her colleagues asked? After a normal body temperature lasting three days, minimal respiratory symptoms, two negative tests for the virus more than 24 hours apart, improvements seen in lung imaging, and no serious underlying conditions, especially for older patients.
The Hopkins teams was impressed with China’s scrupulous measures to minimize viral transmission, “especially among health care workers,” Auwaerter said. “Such measures have successfully slowed the epidemic in China.” In contrast, failing to do so has fueled the disastrous spread of Covid-19 in Italy, physicians at a hospital in the country’s hard-hit north warned over the weekend.

What other drugs might be useful?

FiercePharma on other drugs being considered for Covid-19:

Other than remdesivir and chloroquine, researchers and physicians are also looking at other existing drugs to treat COVID-19. These include AbbVie’s HIV combo therapy Kaletra (Aluvia), which just failed a clinical study in China in critically ill patients. Chinese authorities, which have been dealing with the virus longer, are also recommending an influenza med called Arbidol (umifenovir) that’s not approved in Western countries, old antiviral ribavirin and interferon-alpha. And Fujifilm’s flu drug Avigan (favipiravir) has also shown promise in the clinic, according to Chinese officials.

Roche is testing its arthritis drug Actemra’s ability to rein in the potentially deadly inflammatory response called cytokine storm observed in severe COVID-19 patients, just as Sanofi and Regeneron are running clinical trials of their rival IL-6 inhibitor Kevzara in the same setting.  See more about this drug here.

Update NY Post, March 24:

Seriously sick coronavirus patients in New York state’s largest hospital system are being given massive doses of vitamin C — based on promising reports that it’s helped people in hard-hit China, The Post has learned.
Dr. Andrew G. Weber, a pulmonologist and critical-care specialist affiliated with two Northwell Health facilities on Long Island, said his intensive-care patients with the coronavirus immediately receive 1,500 milligrams of intravenous vitamin C.
Identical amounts of the powerful antioxidant are then readministered three or four times a day, he said.

Update FiercePharma, March 26:

News recently came out that hydroxychloroquine—an anti-malaria drug highlighted by President Donald Trump as a promising coronavirus therapy—disappointed in a China clinical trial on mild COVID-19 patients. But a careful examination of the study reveals a more complicated situation.

According to investigators, adding hydroxychloroquine (HCQ), a more tolerable form of chloroquine, on top of conventional therapy didn’t shorten the time to SARS-CoV-2 clearance in a 30-patient trial. No significant differences were observed across the two arms in terms of the time it took to bring body temperature to normal or the number of patients with disease progression as shown in CT scans.

However, most patients in the study's control group were actually treated with other antiviral therapies at the same time, including AbbVie’s HIV combo med Kaletra and flu drug Arbidol. Most, but not all, patients in the hydroxychloroquine group were also treated with Arbidol. All patients got interferon-alpha.

Those meds had already been added to China National Health Commission’s COVID-19 treatment guidelines after showing some promise against the novel coronavirus. As a FiercePharma reader pointed out, “If that is the case, and even one of them has some effect on the virus, then one cannot tell if hydroxychloroquine worked or not.”

The study, published in the Journal of Zhejiang University (Chinese), found that the median time from hospitalization to conversion to virus-negative status was four days in the HCQ group, “comparable to” the two days observed in the control group. After one week of treatment, 13 patients (86.7%) had turned negative in a throat swab test, while 14 (93.3%) in the control group could say that. Again, no significant difference.

Then the question comes down to, do Kaletra or Arbidol work? At least Kaletra has stumbled in a 199-patient clinical trial in serious Chinese patients. But industry watchers also have expressed different opinions on ruling Kaletra a complete dud in the fight against COVID-19.

In a separate, retrospective study published in the Chinese Journal of Infectious Diseases on 134 patients conducted by several members of the same team, researchers reported that both Kaletra patients and Arbidol patients restored normal temperature after a median of six days, while those who got no antiviral med saw their temperatures drop after four days.

All three groups’ median time to viral clearance was seven days, and the disease progression rate on CT scans at day seven also showed no statistically significant difference.

Separately, in another clinical trial on 44 mild-to-moderate COVID-19 patients, neither Kaletra nor Arbidol demonstrated benefits in viral clearance or symptom relief compared with no antiviral treatment.

Nevertheless, the majority of patients in the new study had restored normal temperature after just one day or turned viral negative after two days, the authors noted. Cross-trial comparison of these two important endpoints revealed that fever clearance as a major difference.

It’s possible that the virus itself has changed, reducing COVID-19 severity, the researchers speculated. The new study enrolled patients from Feb. 6 to 25, while the old one looked at those accepted between Jan. 20 and Feb. 6.

Perhaps more importantly, the viral clearance and temperature-lowering data in the HCQ study's control arm were already quite impressive, reaching a “ceiling effect” that makes finding a better treatment more difficult, they wrote.

Let’s not forget the small sample size of just 30 patients. The new study’s authors argue that to reach a conclusion of whether HCQ works, a study needs to enroll around 900 patients, taking potential drop-out into consideration. That would be a major challenge during an ongoing pandemic, so they suggest testing whether the med can lower mortality rate in serious or critically-ill COVID-19 patients.

The World Health Organization is already planning a large-scale global trial, dubbed Solidarity, to test promising antivirals in thousands of patients around the globe. The treatments to be examined include chloroquine and hydroxychloroquine; Kaletra alone; a cocktail of Kaletra plus interferon-beta; and Gilead Sciences’ remdesivir...

Update March 26:  Science magazine describes a wide variety of planned drug trials

Here is what you do before you run out of medical equipment

A view of gloves and boots used by medical staff, drying in the sun, at a center for victims of the Ebola virus in Guekedou.

1.   Nitrile or latex gloves can be rewashed and reused.  Soap and water.  Hang to dry.
2.   Face shields and goggles can be rewashed and reused--avoid bleach solutions which cloud them.
3.    Ventilators can be replaced by humans squeezing a bag attached to an endotracheal tube to fill the lungs with a desired concentration of oxygen ("bagging the patient"), just like in surgery. or resuscitation.  I saw this in Vietnam, where the US embargo prohibited companies selling Vietnam parts for ventilators made in the US.  This kept patients with tetanus alive who would have died otherwise.  Do we have enough bags?
4.    QUESTIONS:  Has anyone discovered how to disinfect N95 masks?  Apparently Battelle has, using exposure for several hours to hydrogen peroxide gas.
5. How to make shoe covers out of plastic bags?  What fabric can be used for gowns that are breathable yet an effective barrier for coronaviruses, and can be worn for prolonged periods?  Those see-through overgowns don't look trustworthy to me.

On use/reuse of N95 "respirator" masks, CDC notes that over 99% of virus remains on the mask and remains viable for a period of time.  So you can contaminate yourself when you touch the mask.  They must be removed carefully and hands washed after.  Unless you can safely use a mask, you are much better off just staying away from people indoors, unless you live with them.  Don't give yourself a false sense of security because you have a mask.

"Respiratory pathogens on the respirator surface can potentially be transferred by touch to the wearer’s hands and thus risk causing infection through subsequent touching of the mucous membranes of the face (i.e., self-inoculation). While studies have shown that some respiratory pathogens (22-24) remain infectious on respirator surfaces for extended periods of time, in microbial transfer (25-27) and reaerosolization studies (28-32) more than ~99.8% have remained trapped on the respirator after handling or following simulated cough or sneeze."

Early report: ARB and ACE inhibitor blood pressure drugs, which target receptor used by Coronavirus, may increase virus' mortality rate

This is a preliminary report from a Scottish doctor, and may turn out to be wrong later.  He has analyzed data from Italy on deaths, and concluded that those patients on ACE inhibitors or ARBs (which target ACE receptors, which are also used by coronavirus) had significantly higher death rates.

Because coronavirus disease is currently causing mortality rates upwards of 10% in Italy, I personally would switch to another BP medication if I were taking an ACE inhibitor (lisinopril, enalopril, captopril) or an ARB (losartan, valsartan, olmesartan, etc.)

'They could work’: Coronavirus drug trials to begin in N.Y. state, Cuomo says/ NY Daily News

Newest on a chloroquine drug trial, to start 3/24: 

New York State is about to begin testing drugs for treatment of coronavirus, Gov. Cuomo said Sunday. 

The feds have given the state 70,000 doses of hydroxychloroquine, 10,000 doses of zithromax and 750,000 doses of chloroquine. Testing will kick off Tuesday, Cuomo said. 

“The president is optimistic about these drugs and we are all optimistic that it could work,” the governor said at a press conference. “I’ve spoken with a number of health officials and there is a good basis to believe that they could work.”

WHO launches global megatrial of the four most promising coronavirus treatments/ Science mag

Here's the story.

Oddly, the WHO was initially going to omit studying the cheapest drugs, chloroquine and hydroxychloroquine, despite support for them by Chinese doctors here and here and French doctors.  But now both have been added to WHO's mega COVID-19 trial.

Here is the Chinese guidebook for clinical care of COVID-19

Handbook of COVID-19 Prevention and Treatment--a 68 page guide
Zhejiang University School of Medicine

Thanks to Jack Ma/ Alibaba for the web creation and English translation of the Chinese guidelines found to be most useful in clinical care of COVID-19!

FDA authorizes first rapid ‘point-of-care’ test for coronavirus/ WaPo

"The Food and Drug Administration late Friday approved the first coronavirus test that can be conducted entirely at the point of care for a patient — and deliver results in 45 minutes.

The FDA granted “emergency use authorization” to Cepheid, a California company that makes a rapid molecular test for the coronavirus. The turnaround time for Cepheid’s product is far shorter than for the tests being used, which are typically sent to centralized labs that may not return results for days..."

Doctors are being censored/ Medscape

A Medscape Commentary by John Medrola, MD

"I have to remind the American doctor that life is changing.… It's not a normal life. It's a #COVID19 life. It's a pandemic life."

With these words, spoken March 18, during a joint webinar of the Chinese Cardiac Society and the American College of Cardiology, Professor Bin Cao, MD, from China, jolted healthcare workers across the world. And while China reported good news this week, with its first day of no new local infections in Wuhan province, the United States and other countries face the beginning of the surge.

I've heard and sensed that many nurses and docs are ready for the challenge. But the new fear is the shortage of personal protective equipment (PPE).

The analogy of a coming storm is apt. It's as if we can now feel the winds and see the dark clouds. But even as we begin to see patients with COVID-19, and some hospitals in hot spots feel the surge, we won't be fully protected against the contagious virus.

Numerous colleagues have direct messaged (DM) me on Twitter that their hospital is rationing PPE and supplies are running short. C. Michael Gibson, MD, tweeted that he has received 10 DMs about shortages of masks. In a Twitter poll with more than 300 votes, a third of respondents said their hospital had no masks, and nearly half said they were allowed only one mask.

Another chilling message received through the privacy of direct messaging: many doctors have been expressly told by their administration not to speak publicly about conditions. And few will go against their employer out of fear of being fired. That means the stories about PPE shortages likely underestimate the problem.

Adding to the shortages of PPE and the muzzling of frontline clinicians is the lack of testing. We simply don't know who is infected. And if you don't know that, you don't know who to isolate.

If we were to follow Cao's advice—that it's a pandemic life—we would use masks and PPE routinely, and we would test patients immediately so that those infected can be put on isolation wards. These seemingly simple actions would protect caregivers. But we can't do that because we don't have access to rapid testing or PPE.Perhaps the most dire message came when Gibson tweeted a screenshot from the Centers for Disease Control and Prevention with recommendations for use of homemade masks if a facility runs out of masks: "HCP [health care provider] might use homemade masks, such as a bandana or scarf, for the care of patients with COVID19. However homemade masks are not considered PPE."

Bandanas? Are they serious? In the richest country in the world?

To be clear, hospital administrators did not cause PPE shortages. Leadership at my hospital has not told me to shut up. I see them working hard to help us. While administrators are less likely to be exposed, they have a huge role to play in getting us PPE, changing policies on the move, and keeping the hospital financially solvent. Indeed, we want administrators to succeed.

On an e-group with colleagues, most of whom are young and healthy, a friend wrote, "Every time I read about a person with no comorbidities on a ventilator, my heart sinks."

I remember these sensations from the 1990s, when we placed lines in patients with HIV. But at least then we could identify infected patients; we can't do that with COVID-19. And this week, the New England Journal of Medicine reports the virus can be passed through the air.

It's weird: the feeling that your job could take your life.

A month ago, we were providers tapping on our electronic health records and marching to the whims of administrators. Now, nurses and doctors report to work knowing that we will likely become infected.

While we don't know the exact virulence of this disease, the evidence is clear that some of us will become ill and die. It's a numbers game.

Be safe and be lucky, colleagues. Respect to you all.