First, Do No Harm – Open Letter to Doctors

27 03 2020

Primum non nocere is “one of the principal precepts of bioethics that all medical students are taught in school and is a fundamental principle throughout the world. Another way to state it is that, “given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good.” It reminds physicians to consider the possible harm that any intervention might do. It is invoked when debating the use of an intervention that carries an obvious risk of harm but a less certain chance of benefit.”  Prescribing medications with a less certain chance of benefit would be in that category.  Prescribing medications that creates a shortage for people who need this medication for serious illnesses would be causing harm. 

It is now news that doctors are now sending in prescriptions for hydroxychloroquine and Z-Paks, even though THERE IS NO CLINICAL STUDY THAT SAYS THIS WORKS against COVID-19, not only for THEMSELVES, but their families, their friends, and their office staff and God knows who else.  You think you aren’t doing any harm, BUT YOU ARE.  You are taking away a valid treatment option for people with lupus and rheumatoid arthritis.  At a press conference, Dr. Fauci even stood up to say, “The information that you’re referring to is anecdotal. It wasn’t done in a controlled clinical trial, so you can’t make a definitive statement about it.”  But there was President Trump is constantly spreading the name of the medication; it even caused a tragedy that didn’t need to happen to a couple in Arizona who decide to ingest chloroquine phosphate that they thought was the compound Trump kept saying over and over and over again.  The man died; the woman said she specifically tried it because it was the name the president said.  But it wasn’t the exact one he was spouting.

According to a report by BuzzFeed who saw this woman’s note, Kaiser Permanente thanked her for her sacrifice since the medication would be used for COVID-19 patients.  See this link for the full story.  Below is the picture.  It came from kp.org so it is a valid text message. 

Lupus and rheumatoid arthritis patients who rely on this medication now cannot access it because of your unethical (at best and perhaps criminal at worst) behavior.  I hope when this is all over they do an accounting with the pharmacies to figure out who called in an unusually high number of prescriptions (comparing all local pharmacy’s data just in case you covered your tracks knowing that it may be scrutinized) to see just how many prescriptions of this drug you prescribed in March 2020 and going forward and compare it to your prescribing habits of this medication for the year prior.  There needs to be an ethics inquiry with loss of licensure to any doctor who did.    

I tend to have lots of side effects.  Kaiser Permanente alludes to the fact that there are “other medications” lupus and rheumatoid arthritis patients can use instead to free up the hydroxychloroquine. Are they telling people receiving this for off-label use hydroxychloroquine may cause macular degeneration because I have to get eye exams every 6 months?  I have been on this medication now for 10 years.  When I called my pharmacy, they said that yes, it was happening in our area (the doctors’ behavior) and yes, they were having great difficulty getting more.  I then, in a heap of tears, fell apart.  I told them the two medications I was given a choice of was hydroxychloroquine or methotrexate to try at the beginning of this process. 

So let’s review:  Doctors, who are scared and are human, but took an ethical oath not to do harm, are now causing harm and I have to choose between not getting hydroxychloroquine which I know works for me and I have zero side effects, to move to a drug used for chemotherapy for breast cancer and all the side effects that would come with since it would be a new drug in my system.  I let my pharmacy know that I would have to call my rheumatologist to come up with a plan. 

The plan would be I could take 1 pill a day to try to stretch my supply for 2 additional weeks, but if by 4/20 my pharmacy is not able to procure it to fill my prescription, then he wants to put me on a drug called Benlysta versus going to methotrexate. 

I looked up that medication.  Once again, I burst out into tears that I am being forced to make difficult choices to make YOU FEEL SAFE.  This is bullshit.  Is this drug benign?  Oh hell no. 


And

You watch….If I am forced onto this medication, I will find out that my insurance won’t cover it and I’ll have to get some sort of “deal” with the pharmaceutical company.  I’ll be the one that gets PML that requires hospitalization.

But let’s talk about the medical industry as a whole. There is what I call the “BRO-CODE.” I worked for a cardiology group a long time ago.  I remember the doctors in the group talking about other doctors and would tell us this one was addicted to drugs or that one was doing XYZ.  I remember asking them, “Why don’t you report them then?”  It was then I learned about the BRO-CODE.  No doctor rats out another doctor even if that other doctor may be putting their patients under that doctor’s care at risk.  It was so wrong.  But I was young and kept my mouth shut.  When doctors would have affairs with their office staff, I kept my mouth shut. When staff took medication samples from the closet (including drugs like Ativan), I kept my mouth shut. I was part of that BRO-CODE….until I started being blamed for things I had not done. I left.

Later when I worked for a medical transcription company, I would hear stories about some of the doctors.  One was Dr. Eric Scheffey of Houston, Texas.  He became a notorious workman’s compensation doctor who performed way too many unnecessary procedures and killed many of his patients and maimed too many more.  He had a $6M mansion, had a private jet, multiple Ferrari’s and a horrible cocaine habit.  Of the ones he didn’t kill, he maimed others and left them in chronic pain forever.  At least four of them committed suicide from their chronic pain they didn’t have until he operated on them. His license was suspended in 2003.  In 2005 it was finally revoked and he was fined $845,000.  Despite reports from colleagues and nurses (one described that he had slurred speech) during surgery, no one actually stopped him or refused to scrub in. He was named “Eric the Red” because of the large blood loss volumes of his patients.  But he continued to be allowed to practice.  Police arrested him after he was higher than a kite on cocaine at a Montgomery Ward store; they found 30 grams of cocaine in his car.   But after a whole bunch of this stuff, he only lost privileges at three of the hospitals.  I often heard stories from the people in the medical records’ department about this man.  I could not believe he was still allowed to perform surgeries at their facility (and another hospital).  This is the BRO-CODE.  When a judge ultimately tried to revoke his medical license, the Medical Board reversed it and gave him a 5-year probation.  But then a district court overturned their decision and let him go back to practice without ANY restrictions.  An appeals court overturned the district court.  But his probation was almost over.  He continued to work and went right back to what he was doing.  Scheffey’s practice had never operated quite so efficiently, relying upon an elaborate network of enablers that included fellow surgeons, nurses, radiologists, anesthesiologists, and a system of insurance and workers’ comp approvals that was easily gamed. The TWCC (Texas Workman’s Compensation Commission), which, in effect, controlled 90 percent of his revenue, not only allowed him to continue but failed to challenge him when he was asking for approval (in one case, for the fifteenth surgery on one patient). Once the TWCC approved it, there was little anyone could do.  He continued to maim and kill people without any checks on him.  This is the BRO-CODE.  His license was FINALLY suspended in 2005.  But he found a way around that with another enabler.  In its 2004 complaint, the state medical board also charged Scheffey with practicing medicine with a suspended license, a third-degree felony punishable by up to ten years in prison. According to the complaint, Scheffey continued to practice medicine even after his 2003 suspension, using his partner Dr. Floyd Hardimon as a front. When the board temporarily suspended Hardimon’s license later in 2003, it did so in part because it found that Hardimon “associated with and aided and abetted [Scheffey] in the practice of medicine after [Scheffey’s] medical license had been suspended.”  In 2005, he was arrested in Aspen, Colorado for practicing medicine without a license.  In 2007, his trial started.  Prosecutors decided to dismiss the charges after three days of testimony.  He never suffered any consequences outside of settlements with the victims or his victim’s families if they had died.

If I find out you are among one of my doctors who have done this, you will have no place in my care team.  I will always wonder if you were putting your interests above what is best for my health and that you were so willing to toss aside your oath to your patients in order to take care of yourself, your family, your friends and your office staff first.  And I will report you to the Medical Board.  Count on that.





Coronavirus (COVID-19) Update: The totals March 11, 2020

11 03 2020

The Maps and Charts March 11, 2020

Fantastic news from China!  Only 25 new cases from March 10 to March 11.  Today marked the point where the United States went over 1000 cases (1015 confirmed cases).  I am sure this number is going to grow exponentially in the coming weeks.  Thirty-one people have died from this virus (deepest sympathies to the family and friends of all those individuals).  The COVID-19 virus is affecting 104 countries now.  New countries to the list are Panama and Turkey.  There are new graphics below as well.   In the graphics below you can see that Japan has 1277 cases (but 696 of those cases came from a cruise ship quarantined in Yokohama).   Lebanon has experienced their first casualty.  Countries that have no new confirmed cases to report in 24 hours (doesn’t mean they don’t have more—their numbers will go up) are:   Algeria, Andorra, Armenia, Bangladesh, Bhutan, Brunei, Bulgaria, Cambodia, Cameroon, Costa Rica, Ecuador, Estonia, Faroe Islands, Georgia, Gibraltar, Hungary, Jordan, Liechtenstein, Macau, Mexico, Monaco, Mongolia, Nepal, New Zealand, Nigeria, Senegal, Serbia, Sri Lanka, Togo, Ukraine, Vatican City.  These totals are from 2:03 a.m. ET on March 11, 2020. 





Coronavirus (COVID-19) Update: New info about the virus

11 03 2020

NEW STUDY BY NEW ENGLAND JOURNAL OF MEDICINE

This warrants its own blog post.  Here is a warning.  This is going to flip everything you have heard about this COVID-19 virus.  This was a study that was published by the New England Journal of Medicine on February 28.  These are the take-aways from that report.

The WHO has updated the death rate on Wednesday to 3.4%. 

The study from the NEJOM looked at 1,099 COVID-19 patients.  The majority of non-severe cases (60%) are teens and adults between 15 to 49 years old which could suggest this group is spared the worst.  In the public, this is what we have been told up until I read this today.  The truth is severe cases were slightly more prevalent in the younger demographic.  Of the 163 severe cases reported in the study, 41% were young adults ages 15-49; 31% were ages 50-64; and 27% were ages 65 and up. 

According to the Chinese CDC, after looking at 72,000 patients, millennials and Gen Z are also just as likely as the older groups to contract the virus.  Risk should be factored by underlying medical conditions.  So, what are the risks?

This is where it gets a little graphic.  “The novel coronavirus tears apart the lungs” but, according to the American College of Cardiology, they state the condition that is most connected with the worst outcomes are heart issues.  Examples would be high blood pressure, acute cardiac injury, arrhythmias, hypotension, and tachycardia as well as atherosclerosis.  They are not sure exactly why other than the heart and lungs are interconnected.   One study in China of 150 patients from Wuhan, China, they found that patients with cardiovascular disease had a significantly increased risk of death when they are infected.  Dr. Erin Michos, cardiologist of Women’s Cardiovascular Health at Johns Hopkins Medicine in Baltimore said a lot of people are walking around unaware of plaques in their arteries or that they have hypertension.  The CDC said 108 million Americans have hypertension but at least 11 million have no idea they have it.   Diabetes is often associated with cardiovascular problems and it is in the high-risk category.     

Next issue is chronic respiratory illness (like cystic fibrosis, COPD, asthma or reactive airway disease or allergies and people with lung damage linked to smoking).  There is a long incubation period which ranges from 2 to 14 days. 

A new study in the Lancet has found that coronavirus patients SHED THE VIRUS (which means they are still contagious) FOR (sit down for this) BETWEEN 8 TO 37 DAYS.  Thirty-seven days!!!!!!!??????  Oh, I’m screwed.  I take immunosuppressants and I can’t be around anyone who has gotten a vaccine with live virus because they shed the virus, too.  Back in 1997 when they were giving the oral polio solution, I had to get my son the inactivated polio injection so that I didn’t have to go away until he was done shedding polio virus.  There were cases with my disease where people got polio by being around people who got the live virus.  Now that is the standard of care (the IPV versus OPV). 

So why is this a problem.  Here is what I envision:  Person A is exposed to someone with COVID-19 or maybe they think they are coming down with symptoms and their doctor asks them to stay in their home for 2 weeks.  Let’s say they get the very mildest form of this.  They call their doctor and say, “I got a scratchy throat but that was it.”  Doctor says, “Well, if you didn’t have any other symptoms than that then maybe it was just allergies but stay in your home for the 14 days just to be on the safe side.”  Person A goes out in public on day 15.  From day 15 until possibly 37 days they are shedding virus wherever they go and people start getting sick. 

Dr. Enid Neptune, a pulmonologist at Johns Hopkins Medicine, said that with any chronic respiratory illness, she would advise her patients to come up with a plan of protection with their doctors which might include knowing which nearby hospitals employ respiratory specialists. 

Cancer patients and immunocompromised individuals are also at risk.  Dr. J. Leonard Lichtenfeld, deputy chief medical officer for the American Cancer Society in Atlanta said this in an interview: “Patients who have had cancer treatment in the past may also remain immunologically compromised even though they appear to have recovered.” 

The Chinese CDC recorded 44,600 confirmed cases with children involved, but only 400 involved kids under 9 years old and none died.  The question is postulated are children less likely to be infected or that they just didn’t get sick?  Dr. John Williams, Chief of the Division of Pediatric Infectious Disease at the University of Pittsburgh Medical Center thinks the latter is true.  Once testing begins to include more mildly symptomatic patients, outpatients in clinics, and doctors’ offices, they’ll find a lot more kids who are positive (as well as the adults). 

China also has suggested that the virus can spread BEFORE symptoms present, but there is no evidence for these claims so far although Raina MacIntyre, a professor of global biosecurity at University of New South Wales, Australia, said that young people could have the virus without displaying any symptoms. 

HOW LONG CAN THE VIRUS LAST ON SURFACES

Dr. Robert Redfield, director of the CDC said this:  On copper and steel, it’s about 2 hours.  On other surfaces like cardboard and plastic it is longer and so we are looking into this.  The Journal of Hospital Infection found that coronaviruses may persist on surfaces for up to 9 days.  Best thing you can do after handling a package would be to wash your hands. 

WHAT ARE THE SYMPTOMS

According to the Lancet’s January 24th edition:

COMMON SYMPTOMS

Fever

Dry cough

Fatigue or muscle pain

Breathing difficulties

LESS COMMON SYMPTOMS

Coughing up mucus or blood

Headaches

Diarrhea

Kidney failure





Coronavirus (COVID-19) Update: March 9, 2020

10 03 2020

The Proposed Payroll Tax Relief – This is NOT a Good Idea

Trump is proposing a payroll tax relief to help people.  Right now, your payroll tax is 6.2%, which means for every $100 you make, you are paying $6.20.   Barclay’s economist Michael Gapen said that it would likely be something that Obama did by reducing the payroll tax to 4.2%, which means for every $100 you make, you would only pay $4.20, which only gives you $2.00 extra per $100 you make.  If you only make $1000 a month, you would get $20.00 a month extra.  If milk cost $5.00 a gallon (it’s cheaper usually but just to give you an idea), you could buy 4 extra gallon of milk a month, or maybe one prescription medication if your copay is $20.00.  Breadcrumbs for the poor if they are still employed when this happens. 

But here is the kicker-in-your-ass:  “A temporary cut in the payroll tax can help workers who are still drawing a paycheck, but if you’re idled due to the virus and don’t have paid leave, it doesn’t help you,” he said. 

If you start hearing THIS is the plan they are going to choose to offer to the masses, you get on the phone and call your senators and representatives immediately.  Other economists are recommending that Congress that for the short-term to aid those affected by the virus, they could help defray the health care costs of those infected and also reducing the Social Security payroll tax for all workers.  That might have been a good idea though before they decided to allow corporations to pay zero taxes and now the GOP are back on their policy of cutting Social Security, Medicare and Medicaid benefits.  But once again, if they decide to reduce the Social Security payroll tax for all workers, it assumes you are working which you might not be if you lose your job because 1) the business had to cut back or went under because people were too scared to go out in public and spend money and 2) you haven’t been asked to self-quarantine you and/or your family.  If you are a gig worker, like an Uber or Lyft driver you wouldn’t qualify for this program either.  If you are retired, this won’t help you either because you don’t get a paycheck anymore. 

But let’s also remember that through the GOP tax bill, in 2019 anyone making $30,000 or under will have had your wages taxed at a higher rate, which might be a big surprise to you when you file your tax return and your amount was less than last year.  Don’t worry people making $40,000 or under in 2021, you’ll have to pay more taxes on your income in 2021 which you’ll discover when you file those taxes April 2022.  And remember how many corporations who supposedly got a tax break that said they would pay 15% of their profits only paid….ZERO.

CONCEALED INFORMATION

The Center for Disease Control and Prevention submitted a plan that they wanted to recommend that the elderly and physically fragile Americans be advised not to fly on commercial airlines because of COVID-19.   White House officials ordered the air travel recommendation be removed.  An official with direct knowledge of the plan who then spoke to the news.  This is the reason why they wanted all statements to go through them so they could decide what is told to the public and what is not.  Instead, they suggested that certain people should consider not traveling, but have stopped short of the guidance sought by the CDC.  And they wonder why they are having a crisis in credibility which spills over to the stock market.  It makes you wonder what else they are not telling us. 

UPDATED TOTALS

As of 1:13 a.m. ET on March 10, 2020, 114,100 people were confirmed positive worldwide with 4020 people having died; all but 884 people died from the mainland China totals.  It is affecting 102 countries now. 

Some excellent news from China, though.  For the third day in a row their number of newly positive testing has diminished.  Between March 9 and March 10, there were only 19 new cases.  Italy has now taken the number 2 spot which had been held by South Korea. 

In sad news, Germany is reporting their first 2 deaths and Canada their first death.

New countries on our list today are Albania, Brunei, Burkina Faso, Cyprus, and Mongolia. 

All countries are still reporting new positive testing (but these countries have remained the same in the last 24 hours, which again, does not necessarily mean that they have hit their peak but rather they either don’t have enough kits or are waiting for results or have logistical issues that is not allowing them to test:   Afghanistan, Andorra, Argentina, Armenia, Bangladesh, Belarus, Bhutan, Bosnia & Herzegovina, Bulgaria, Cambodia, Cameroon, Chile, Colombia, Czech Republic, Dominican Republic, Estonia, Faroe Islands, Gibraltar, Greece, Iraq, Ireland, Israel, Jordan, Kuwait, Lebanon, Liechtenstein, Lithuania, Luxembourg, Macau, Maldives, Malta, Mexico, Moldova, Monaco, Morocco, Nepal, New Zealand, Nigeria, North Macedonia, Oman, Pakistan, Paraguay, Portugal, Romania, San Marino, Senegal, Serbia, Singapore, Slovakia, Slovenia, South Africa, Sri Lanka, Taiwan, Thailand, Togo, Tunisia, U.A.E., Ukraine, Vatican City, Vietnam, West Bank & Gaza. 

The United States, as of 1:13 a.m. on March 10, 2020, had 729 confirmed cases with sadly 26 deaths.





Coronavirus (COVID-19) Myths and Facts Part One

9 03 2020

Facts and Myths Part One

Myth/Comment:  On a mayor’s Facebook page: “My friend tested positive for coronavirus but was told it was not the China one.”  Then the comment went sideways with the individual accused the local government as a conspiracy or that it was because of the color of their skin. 

Truth:  You can test positive for coronavirus without having COVID-19.  The common cold and the flu are all under the category of coronaviruses.  Those are the relatively harmless ones.  The more lethal coronaviruses are the rare ones like SARS and MERS and now COVID-19.  Within the SARS and MERS categories, there are even more specific names for certain types of SARS and MERS.  COVID-19 was 2019-nCoV originally (2019 the date, “n” for novel meaning “new”, and CoV for Coronavirus.  It’s new name is SARS-CoV-2 (for severe acute respiratory syndrome coronavirus number 2—there was a SARS-CoV back in 2003.  The coronaviruses HCoV-229E, -NL63, -OC43, and -HKU1 continually circulate in the human population and cause respiratory infections in adults and children world-wide.

Myth:  The coronavirus came from Corona beer.

Truth:  It did not.  But 38% of people believe this. 

Myth:  Dogs and cats can give you this disease (or conversely you can give them the disease).

Truth:  A company that produces breathing masks for dogs told Fox Business that customers have been buying its products in droves in places where the coronavirus has been confirmed in recent weeks. There are even pictures of dogs wearing the masks in public.   Dr. Gregory Poland, a virus expert and head of the Vaccine Research Group at the Mayo Clinic says you are not going to get a dangerous human coronavirus from your furry friends.  It’s true that dogs, cats and most species carry their own kinds of coronavirus, but those are not human pathogens. 

Myth:  Drinking “Miracle Mineral Solution” will protect you from COVID-19.  (This dangerous myth came from the group QAnon).

Truth:  Miracle Mineral Solution has been touted as a remedy for everything from autism to HIV, claims that the FDA has already dismissed this.  Dr. Andres Romero, an infectious disease specialist at Providence Saint John’s Health Center in Santa Monica, CA, said, “Drinking a strange beverage will not prevent you from acquiring the infection.  In fact, Miracle Mineral Solution (and similar products) contain sodium chlorite (not chloride-chlorite was not a typo) which turns into bleach when mixed with citric acid as per the instruction.  Dr. Gregory Poland, a virus expert and head of Vaccine Research Group at the Mayo Clinic, said “You will end up with esophageal pathology if you drink diluted bleach.  The way this virus infects you is in your respiratory cells, not your gastrointestinal system. 

Myth:   Antibiotics can prevent or treat COVID-19. 

Truth:  Perhaps you’ve been typed if you still have some antibiotics hanging around your medicine cabinet as a preventive measure or after you seem to get respiratory symptoms.  According to the CDC, antibiotics only treat bacterial infections, not viruses like the coronavirus.  As for prevention, antibiotics won’t help with that either. 

Myth:  Cold weather and snow can kill the virus. (OR that a hot bath will prevent you from getting it). 

Truth:  Regardless of what the temperature is outside your body, your body temperature relatively stays the same.  The best way to prevent this is using alcohol-based hand sanitizer or washing with soap and water.   (Source:  W.H.O.)

Myth:   You can catch COVID-19 by buying goods coming from China (or any other country).

Truth:  The virus can last on surfaces for a few hours or several days depending on the type of surface.  If you think it may be contaminated, wipe it down with a disinfectant wipe.  After you are finished cleaning the surfaces, wash your hands for 20-30 seconds with soap and water or an alcohol-based hand sanitizer.  (Source:  W.H.O.)

Myth:  You can get COVID-19 via an insect bite.

Truth:  People are thinking that this is like the Zika issue that was transmitted by mosquito bites.  COVID-19 is a respiratory virus which is spread through droplets that are generated by an infected person when they cough or sneeze, through droplets of saliva, or discharge from the nose.  Besides hand washing with hand sanitizer or hand soap and water, avoid close contact with anyone who is coughing or sneezing.  (Source W.H.O.)





Coronavirus COVID-19 Update: March 8, 2020

9 03 2020

Updated Totals

I am short on time today.  Maybe I will do a double blog on Monday because there is a lot of ground to cover. 

COVID-19 is now being reported in 97 countries.  In the US, at 12:10 a.m. ET on March 9, 2020, there are 545 confirmed cases in the United States with sadly 22 deaths.  Don’t be surprised in the weeks to come that the numbers will go up, but that doesn’t mean that all of it are new people getting infected; as testing occurs, and only the sickest people are going to be tested until more tests can be made, it is going to appear that there is a high mortality rate.  You can’t extrapolate real percentages when real numbers are not known.  You have to get a large enough sample size of how many people were tested, how many were negative, and how many were positive to get any clear idea of percentages.  For example, there have been 109,900 cases confirmed worldwide at this time but as China is beginning to stabilize some (only 83 new confirmed cases between the 3/8 and 3/9 totals), things are going up in most of all the other 96 countries.  There have been 3825 deaths and all but 706 of them were in mainland China.  In China, there have been 80,734 confirmed cases with 3119 deaths.  That leads to a 0.038% mortality rate.  But in smaller populated countries, the mortality rate could be much lower when this is all over.    

US map:

All countries who have confirmed cases increased their number of confirmed cases with the exception of these countries who have had no new confirmed cases in 24 hours (which does not mean the virus is finished):  Andorra, Belarus, Bhutan, Bosnia and Herzegovina, Colombia, Croatia, Estonia, Gibraltar, Iceland, Jordan, Latvia, Liechtenstein, Lithuania, Macau, Monaco, Morocco, Nepal, Nigeria, North Macedonia, Oman, Pakistan, Paraguay, Peru, Senegal, Serbia, Sri Lanka, Taiwan, Thailand, Togo, Tunisia. U.A.E., Ukraine, West Bank and Gaza. 

Egypt and Argentina have reported their first deaths respectively. 

Countries reporting confirmed cases and who were not previously on the list are:   Bangladesh, Bulgaria, Faroe Islands, Maldives, Moldova, and Vatican City.





Coronavirus (COVID-19) Update: March 7, 2020

7 03 2020

I meant to get this blog out last evening but I found myself falling asleep before I had finished.  Now it is just going to be a March 7 blog. 

Houston Area Update First

New totals released as of 7:56 p.m. on Friday, March 6, show that we have 8 confirmed cases in the Houston area.  There are three confirmed cases and five presumptive positive (which means the tests here were positive, but they still require the final result to be approved by the CDC).  All the cases are related to travel abroad.  In Montgomery County (which is my county), there is one case of possible COVID-19 which is under investigation.  Eight additional people in Harris County are under investigation as possible cases.  Officials are saying that they do not believe the virus has spread into the community at large.  Local news’ source said that just over 100 people who may have come into contact with the patients are being monitored.  Three presumptive cases in Fort Bend County; 2 confirmed cases in Harris County (one of these people was the Rice University professor); 1 confirmed case and 1 presumptive positive case within Houston; and 1 possible case ‘under investigation in Montgomery County.  The map below shows 19 (these people plus 11 people who were confirmed to have COVID-19 from the cruise ship (not the one currently out there) but when it was going from Japan to the United States. 

National level

The administration still does not understand that having a mixed message, one badly enough that people are beginning not to trust what they are saying, is what upsets the stock market.  Between that and the bungled efforts by CDC (who STILL does not have accurate totals on their web site), it leads the world and most of the United States to bestow a “no confidence” vote on their response.  Example:  VP Pence promised that by the end of the week (which was Friday) there would be 1.5M test kits ready to send out; there are only 75,000.  So far only 1900 people have been tested.  If Trump cannot state the scientific facts as commanded by the task force underneath VP Pence, then he needs to just go play golf somewhere and let people do the real work and get the real information out.  Also, someone needs to tell Trump that every death is a human being, not a number that he fears will weigh him down on Election Day. 


Trump said of the cruise ship (my comments in bold italics): “They would like to have the people come off.  I’d like to have the people stay, but I’ll go with them.  I told them to make the final decision.  I would rather because I like the numbers being where they are.  (Has no one explained to him that the number of infected is going to go up as more kits can start diagnosing more people??) He goes on: “I don’t need to have the numbers double because of one ship.  That wasn’t our fault.  I like the numbers…I would rather have the numbers stay where they are but if they want to take them off, they’ll take them off.  But if that happens all of a sudden you are 240 (meaning the number of infected people); it’s an obviously going to be a much higher number and probably 11 will be a higher number.  (Unsure where he is getting 11 from because the total is 352 cases in the US and 17 deaths.  Also, these people on the ship are American citizens.

Trump went on: “Anybody who needs a test gets a test.  They’re there.  Okay?  We have the tests.  And the tests are beautiful.  Anybody that needs a test gets a test.  If there’s a doctor that wants to test; if there’s somebody coming off the ship like they did that monster ship out there, which again is a big decision.  I want to bring all the people on.  If they’d like me to do that.  I don’t like the idea of doing that.  But anybody that needs a test can have a test.  They’re all set.  They have enough.  In addition to that, they are making millions more as we speak as of right now and yesterday, anybody that needs a test—and that’s the important thing.  And the tests are perfect.  Like the letter was perfect.  Like the transcription was perfect.” 

THIS IS A BOLD-FACE LIE.  75,000 tests were just sent out, and only 1900 people have been tested as of Friday morning.  There are very critically ill patients who are suspected as having COVID-19 that can’t get tested because the tests are not available because the administration really fell on their face with regards to this disaster response (they had 6-8 weeks to get ready for this pandemic).  And what the hell?  The “letter”?  I can only assume he meant to say “phone call.”  And like the transcription (please note a word-for-word transcription of the call was never released just a Trump-approved summary, but when the people who also listened to the call were asked if it looked complete, including someone who worked for VP Pence, they both said it was not complete.    

Trump had made 16,241 false or misleading claims in his first three years in office by the end of 2019. A few days ago, I admonished Trump for saying the coronavirus was a Democrat hoax.  A friend said that isn’t what he MEANT.  I disagreed.  Now I have proof.  A reporter asked for comments from someone waiting in line to see Trump.  She said to the woman: “What are you doing to prepare for the coronavirus?”  The woman said, “That is not real; it’s a story made up by the Democrats.”  I rest my case.  Cult followers are going to believe whatever he says even if it is not reality.  The very horrible truth is that they need to take personal responsibility, even if it just involves their person hygiene habits, to not spread this virus. 

Then Trump was supposed to go to the CDC.  A statement then went out that said: “[T]he President does not want to interfere with the CDC’s mission to protect the health and welfare of their people and the agency.’  But when Trump had some press in the oval office to witness his signature on a bill (a bill that he wanted 8x less money than what Congress decided he needed and Congress upped that to $8.3M because they knew he wasn’t asking for a good number), he said it was because they thought someone at the CDC had the virus.   Azar spoke up that he had sent him so he was going to go see.. but Trump interrupts him and changes his mind on the spot, “We may go….” And explains about the person.  Do I believe him?  No.   

Then there was this segment on another show: Host:  “There seems to be a big disconnect on this testing issue.”  


Guest: “What do we hear from doctors in emergency rooms?  That they don’t have the test.  When NY State complained to the federal government, they can’t get the test.  Obviously, the number of people with the coronavirus is going to explode once they do get tests because we’ll find out all these people who don’t know that they have the virus have it.  So, why does the President say at a time when we know that in his briefings he’s not been told that.  Vice President Pence has acknowledged they haven’t had enough test kits, and they are trying to work on it which is the appropriate health response and also the appropriate political response.” 

Host:  “Then again, I think he fails to realize that people look at this through their own lives.  Here he was last night at the town hall [on Fox News] when he was asked about it because it sort of epitomizes his reaction.”

My comments below for the Town Hall question are in bold italics. 

Town Hall:  A woman asks: “Mr. President.  At the onset of the coronavirus, your administration’s response seemed to some as being confusing or minimizing.  What plans are being considered on a federal level for the possibility of a long-term disruption from the novel coronavirus?  (THIS IS A GREAT QUESTION).  Trump’s response: “Well actually we’re given, I think really given tremendous marks.  You look at Gallup poll, you look at other polls, the way we’ve handled it. One of the things I did was I closed down the borders to China and other areas that are very badly affected and really having a lot of trouble.  I closed them down very early against the advice of almost everybody and we’ve been given rave reviews.    (He talked about closing entry off from China into the US which is in the PAST, not what the woman’s question was pertaining to—what are the plans on the federal level for long-term disruption from this virus.  Also, again, he brings it back to himself – the “me, me, me syndrome” what are HIS poll results about how he is handling this.  All politicians are narcissists but this is where it jumps into a narcissistic sociopath category). 

The Iran hostage crisis wasn’t President Jimmy Carter’s fault, but Americans didn’t think he handled it in a competent way and he was punished for it by not being re-elected.   And Jimmy Carter was facing a nominee that people thought was too old and wasn’t up to the job.  Life surely does repeat patterns, doesn’t it? 

During the Task Force Briefing, an official (didn’t catch his name) said that as of yesterday (Friday), CDC tests shipped out 900,000 tests.  They expected to 200,000 today (Saturday).  They have gone through the quality assurance process.  Another 1M tests will be quality-assessed this weekend; they expect those to go out early next week.   They expect further surge in test capacity beyond that by the end of next week (meaning March 13). 

Also, to correct another comment the task force has made about the states making their own tests.  On another news program, a guest, Robinson Meyer, writer for “The Atlantic” said: “They are not at a place where they could rapidly scale up to a million tests either.  Instead of being able to test 10,000 people or 100,000 people a day, right now, the total national capacity across all these state public health labs that the Trump administration says are going to be testing for this virus is about a couple-thousand tests.  It’s not even 10,000 tests.   The host asks:  Why does the US lag behind other countries?   Guest: “It’s a complicated question.  I don’t think we fully know the answer.  Basically, other countries have accepted the test made by the World Health Organization and has accepted it.  The US through the FDA and the CDC tried to make its own test.  They distributed that test a few weeks ago.  It realized about two weeks before COVID had came up in the news in the US that those tests were faulty.  It then withdrew them and now it has redistributed these new tests, but it started doing that the tail end of last week and so only through this week they started reaching these state public health labs which are now in charge of testing.  The host asks, “Do you recommend, do you find that the experts that you talk to, say that if people feel anything, they should stay home from work, they should go get tested?”  Mr. Meyer: “I should say I’m not a public health expert, but I have to say that right now the issue is that if you go to your doctor, they probably can’t test you for the virus.  Doctors do not have it in their repertoire; there are not enough tests out there to do it right now.  They can’t even test all front-line health workers who are reporting symptoms, but yes, right now the CDC is saying that if you have symptoms and you think you might have been in contact, a dry cough, a fever, then you should start to self-isolate. 

MAPS AND CHARTS UPDATES

These were accurate as of 1:33 p.m. on March 7, 2020.  Ninety-two countries are now involved.  More than 105,400 people have been sick with COVID-19 by official counts only.  Of these, 3557 people have died, all of those were in China except for 487 deaths that have happened in other countries.  In the United States, 352 tests have been confirmed by the laboratory as being positive and sadly there have been 17 deaths (our hearts go out to the family, friends and caregivers of those individuals).  New countries to the list include Bosnia and Herzegovina, Colombia, Malta, Serbia, and Slovenia. 

Since my Thursday posting, all countries have seen increases with the exception of these countries who are still at their same levels (which just means their labs don’t have any new positives, not that there aren’t more infected people in their midst).  A lot of countries who are reporting just 1 case thus far will change in the coming days; sadly, they always do.   Afghanistan, Algeria, Andorra, Armenia, Belarus, Cambodia, Cameroon, Chile, Costa Rica, Ecuador, Georgia, Gibraltar, Hungary, Indonesia, Jordan, Latvia, Liechtenstein, Lithuania, Macau, Mexico, Monaco, Morocco, Nepal, Nigeria, North Macedonia, Oman, Peru, Qatar, Saudi Arabia, Senegal, Slovakia, South Africa, Sri Lanka, Togo, Tunisia, Ukraine. 





Coronavirus (COVID-19) Update: March 5, 2020

6 03 2020

COVID-19 NOW TESTING POSITIVE IN THE HOUSTON AREA

My thoughts for a blog post in the morning always change by the evening.  Today I learned that three individuals who traveled to Egypt together, that the two in Harris County [Houston] who live in an unincorporated northwest area of Harris County, have had positive tests for COVID-19 and the one in Fort Bend County (which is southwest of downtown Houston in a suburb called Stafford) was presumptively positive.  One of the Harris County travelers was a professor from Rice University.  She had come into limited contact with an employee on February 24-25.  Fourteen Rice doctoral students, faculty and staff have been in self-quarantine away from campus.  None of those individuals have reported symptoms.  Potential contacts of the man from Stafford are being notified and being asked to self-quarantine for 14 days.   The only callers coming into the screening line in Stafford being referred for testing were those who were sick enough to go to a hospital and who had either come into contact with someone confirmed to have coronavirus or who had also traveled to China, Iran, Italy, Japan or South Korea.   People in area didn’t seem rattled by the news. 

The University of Houston announced that it requires students or staff returning from travel to countries under a CDC Level 2 or Level 3 travel warning related to coronavirus to self-quarantine for a period of 14 days away from campus.  Two faculty members and four students from the University of Houston are under a 14-day self-quarantine after returning from Italy and South Korea.

The Houston Health Department laboratory is now conducting COVID-19 testing for specimens collected by medical providers from patients who meet CDC COVID-19 testing criteria.

As a follow-up to my post about how companies planned to profit off Americans to come up with the test kits (and in the future a vaccine), companies we already pay upfront to subsidize their research with our tax dollars, a bright light came from sunny California from Governor Gavin Newsom:  BREAKING: we have ordered health insurance companies to waive ALL out-of-pocket costs for preventive coronavirus testing. Let’s hope other states will follow suit.

On Monday, March 2, 2020, San Antonio Mayor Ron Nirenberg declared a public health emergency Monday after the federal government released a woman from quarantine who tested positive for COVID-19.  The woman was among the 91 Americans evacuated from Wuhan and was placed in federal 14-day quarantine at Joint Base San Antonio-Lackland.  She tested negative twice for COVID-19 and was released on Saturday under the guidance from the CDC.  After the woman’s release, the CDC received the results of another test that showed a weakly positive confirmation of the virus that causes COVID-19.  Nirenberg said, “As mayor of this city, I find it totally unacceptable that CDC would release a patient prior to receiving all test results and potentially expose the public to this harm.”  According to the press release, the woman arrived at the Holiday Inn Express Airport at 3 p.m.  The woman also visited North Star Mall, where she browsed stores including Dillard’s, Talbot’s and Swarovski and ate at the food court.  They transported her to Texas Center for Infectious Disease at 2 a.m.  Local officials are tracking 16 people from the mall and three at the hotel who they believe had contact with her.  The city health department has recommended deep cleanings “with disinfectants” to both the hotel and mall.  Nirenberg said, “We simply cannot have a screw-up like this from our federal partners.  While the CDC is encouraging everyone to wash their hands and prevent the spread of the virus, as we would during the season, I would encourage the federal administration to not wash its hands of the responsibility to protect the public.” 

Bexar County Judge Nelson Wolff said that 235 people were still under quarantine at Lackland. They came from the Diamond Princess cruise ship which was quarantined last month off the coast of Japan.  Those evacuees were scheduled to be released Monday but local officials have requested a third round of testing before giving them the all clear. 

Eleven of those individuals had tested positive prior to this gross error and were still being monitored at Lackland. 

I caught some video of a news correspondent who was in Seattle.  It looks like a ghost town; it is creepy.  My husband said that when he went to the gym today (and he goes at the same time every night after work) he noticed more people had dropped off.  On Monday it wasn’t as crowded (like one-third of the people were not there) but he didn’t give it much thought, but as the week went on, it became less and less. 

Meanwhile, China has discovered that the coronavirus has mutated at least once into two strains.  One type, called type L, accounted for about 70% of the cases in China and is much more aggressive than the other strain, called type S, which is milder and is the source of about 30% of cases.  Type L was more common in the early stages of the outbreak in Wuhan, but began to decrease after early January 2020.  They believe human intervention may have placed more severe selective pressure on the type L, which might be more aggressive and spread more quickly.  But type S, which is evolutionally older and less aggressive, might have increased in relative frequency due to the relatively weaker selective pressure per the scientists.   “The researchers said the S type is thought to be the ancestral strain and that the findings ‘strongly support an urgent need for further immediate, comprehensive studies that combine genomic data, epidemiological data, and chart records of the clinical symptoms of patients with coronavirus disease 2019.”   It goes on to say “the genomes studied were only sourced from China, so it is unclear what strains are most common in other countries or if there have been further mutations.” 

The Trump administration said today they will not have the number of kits available as VP Pence stated in his press conference yesterday (stop promising things until you know that this is true).  The stock market does not like uncertainty as one could see by the drop after the gains yesterday.

The CDC still does not have its correct number of cases.  Even though it says their numbers are updated at noon every day (and these were the noon March 5, 2020 totals), they don’t even say these numbers on air.  These numbers aren’t even the ones they publicly said on Monday and it was now Thursday.  Heavy sigh.  They say the numbers that are accurate (which is more than double their number on their web site).   

This is incorrect information — BTW

And here are the stats I post at the end of every blog:  

In the United States there are now 215 cases confirmed by lab tests and sadly 14 deaths.   Deepest sympathies to the family and friends of these individuals. This is as of 12:30 a.m. March 6, 2020.

Of hopeful note, Mainland China only saw an increase of 143 cases between yesterday and today, perhaps a sign that things are getting under control there.  Switzerland has reported its first death from the virus as did the United Kingdom. 

All the countries on the chart below had increases from the day before with the exception of these countries who did not have tests showing positive results (doesn’t mean there aren’t more people infected):  Afghanistan, Andorra, Argentina, Armenia, Belarus, Brazil, Cambodia, Croatia, Denmark, Dominican Republic, Egypt, Estonia, French Guiana, Gibraltar, Hong Kong, Indonesia, Iraq, Ireland, Japan, Jordan, Latvia, Liechtenstein, Lithuania, Luxembourg, Macau, Malaysia, Mexico, Monaco, Morocco, Nepal, Nigeria, Pakistan, Poland, Qatar, Republic of Macedonia, Senegal, Sri Lanka, Tunisia, Ukraine, Vietnam.

The only new country on the list tonight is the West Bank and Gaza. 





Coronavirus (COVID-19) Update: March 4, 2020

5 03 2020

How US Companies Will Profit Off this Public Health Crisis

Today I had to run down to the Texas Medical Center to see my rheumatologist.  For those of you who don’t know me or don’t know my history, I am on immunosuppressants.  I was curious to see what was going on in the heartbeat of Houston’s best and finest.  Not a damn thing different.  No one was pushing the elevator buttons with their Kleenex; no visitors were washing their hands any better in the restroom.  It was reassuring. 

Before I left to go down there (which is like a 4-hour commitment for me), I saw a segment on my favorite local TV station, Fox 26 Houston, about myths people were writing about COVID-19 and the facts.  I thought that might make a great blog for today.   The mayor’s FB page is RICH with misunderstandings (the one I found the other day, in fact, how a coronavirus test can be positive without it being the China version).  Then when I got home, I saw a post from a friend Michael, from another local news station about a 70-year-old man in Fort Bend County (which is southwest of downtown Houston) who they are certain is positive for COVID-19 (just got back from an extensive overseas trip), and they were awaiting confirmation. 

But then I saw why the stock market was rallying today:  Greedy bastards with their tongues hanging out who plan to profit off this horrible public health crisis.  Read below about the involvement of private companies like Quest Laboratories.  Don’t be surprised if you get the $3000 bill that your insurance won’t cover should you need a test.  Osmel Martinez Azcue had returned from China to Miami.  He was worried about the coronavirus.  Jackson Memorial Hospital told him he needed a “CT scan” to see if he had this.  He said he would have to pay out of pocket for this so asked for a flu test first, which they did, which was positive.  He later received a bill for a test for the flu for $3200 plus the small amount of time someone was saw him in the ER.  I’m glad he didn’t have a CT scan because that could have been $20,000 or more.  Mine was $30,000 for a different thing.  Once you send this out to for-profit companies, you are going to see the internet light up with people taking pictures of what they were billed for the test.  And Quest is an outpatient facility.  Do you really want to sit next to someone coming in to get tested for COVID-19 and you don’t know it?  They obviously haven’t really thought this through.  Hospitals have their own laboratories. 

Later I saw a news conference. I will have to say that Dr. Deborah Birx, the Obama appointee who VP Pence put in charge of the virus effort, after Trump put him in charge of it, was making VP Pence look pretty competent.  As he is talking, you see her in the background nodding her head (as if she herself wrote most of those talking points…up to a point…then her nodding stopped…until he said, “whole of America approach.). 

All my comments will be in bold italics.  

VP Pence:  “All state laboratories and all university laboratories at the state level can conduct coronavirus tests without any additional assets or resources from the federal government.  They have the FDA approved test; they can conduct the test all across the country in all the states.”  (Hmmm.. Does he mean that FDA/CDC flawed test or have they fixed the flawed test? He doesn’t say).  VP Pence continues: “Beyond that, as we announced, through the efforts of HHS, 2500 kits of tests are going out this week… (then he corrects himself) …2500 kits including tests has gone out this week, that’s roughly 1.5 million (WHICH IS ABOUT THE POPULATION SIZE OF PHILADELPHIA).  VP Pence continues: “A test that will available this week, we will continue to build on that number.  But perhaps most significantly, thanks to Dr. Birx’s effort and leadership, we brought together today at the White House the leaders of all of the largest commercial laboratories in this country, companies like Quest who have vast capabilities, logistic and testing capabilities, and we were pleased to report today that they have created a consortium to share information and to share resources and literally have told us that as they go through what is called the validation process on testing that by next week individual companies will be able to do, as they said to me, thousands of tests of coronavirus if they are needed and are required and many many multiples more of that in the not-distant future.  Our objective here is Dr. Birx raised with the task force is we’ve got hospitals in affected areas and those are requesting they have kits.  We’ve got universities and state labs that now can perform the test on a requested basis.  But our objective ultimately, and as quickly as possible, is to have tests made through these commercial laboratories (cough, cough – for profit – your dime), and commercial providers that your local doctor, your CVS (okay so Minute Clinic might have COVID-19 patients now, or will pharmacists be doing that along with vaccines—unless they are thinking of drive-through like South Korea has with hazmat suits??), your Med-Check is able to have coronavirus tests.  That isn’t there yet.  We are working to make that a reality but again it is one more example—its not just a whole of government approach—it’s a whole of America approach (until you get the bill & their profit in a big way or bankrupt a whole family who has to get tested especially if they have no insurance).   Whether it be our nursing home industry or it be our airline industry or whether it be our commercial laboratories, I can (he stutters for a minute) on behalf of President Trump and our entire task force when I say we are profoundly grateful for the spirit—this being reflected by the companies all across the United States of America, grateful for the leadership at the state level, and the American people should be confident (in your pending bankruptcy) that that spirit of partnership is going to continue to drive this at every level as we work our way through dealing with the coronavirus in the United States.   End of VP Pence’s speech. 

Then they were going to let Dr. Birx speak but the segment was interrupted. 

So, there we are—how America will be profiting off this public health crisis. 

The CDC is still showing their incompetence.  This is what their website shows today.  The correct amount is 152 confirmed cases.  Even if they were just going by YESTERDAY’S (March 3) TOTAL, that one was 118 confirmed cases.  ARGGHHHHHHHHHHHHHHHHHHHHH!!!!

And the tally updates: 

There are now 80 countries with some level of confirmed cases.  There are now 152 cases confirmed in the United States (remember, not that there were more infected, but more are just testing positive).  This information was valid as of 10:43 p.m. Eastern Time on March 4. 

All countries on the list have still seen a rise in confirmed cases, the most still being China.  Today, countries not having new confirmed cases (that doesn’t mean there aren’t people infected, just that they don’t have updates in their confirmations) were:  Afghanistan, Armenia, Argentina, Azerbaijan, Cambodia, Canada, Chile, Denmark, Dominic Republic, Egypt, Finland, Georgia, Gibraltar, Indonesia, Jordan, Kuwait, Latvia,  Lebanon, Liechtenstein, Lithuania, Luxembourg, Macau, Mexico, Monaco, Morocco, Nigeria, Nepal, Pakistan, Philippines, Qatar, Republic of Macedonia, Romania, Russia, Saint-Barthelemy, Saudi Arabia, Singapore, Sri Lanka, Taiwan, Tunisia, United Arab Emirates, Ukraine, and Vietnam. 

New to the list are:  Estonia, Faroe Islands, French Guiana, Hungary and Poland.





Coronavirus (COVID-19) Pandemic March 4, 2020

4 03 2020

Super Tuesday sucked the oxygen out of the COVID-19 talk which I think is really a good thing for us.   Today Dr. Irwin Redlener, Director of National Center for Disaster Preparedness said, when someone said the word ‘epidemic:” “Actually we have been in a pandemic for some period of time.  This is a pandemic, so pussyfooting around that is not helping anymore.” 

What are you doing (or not) to get ready for possible self-quarantined states? Are you changing your travel plans at all? Has your employer given you a plan yet? I’m interested so let me know in the comments.

Today another case popped up in New York and it appears to be the first “community spread” case in the state.  The man in his 50’s was hospitalized in severe condition.  Nothing in his travel history suggested any direct connection to China or any countries on the watch list.  He had no travel during the [supposed] 2-week incubation period.  His severe symptoms became noticeable at the end of last week, but he had respiratory issues for the last month [which makes me think they may need to rethink their incubation period time as he had been in Israel where 12 people are now testing positive and to Miami, Florida].  He has two sons with a NYC connection.  Both sons are now isolated at their home.  Four schools the one son is associated with are all now closed.  The other is an undergraduate student; he has not been on campus since Feb 27.  Both boys are now isolated at home.  The place of worship of the ill man has been notified.  They have suspended services for the foreseeable future.  Some of the members have been ordered to self-quarantine due to possible exposure. 

Five additional COVID-19 cases are still under investigation.  The state of New York is also testing two families in Buffalo who recently returned from Italy.  They are being tested and are quarantined.  SUNY schools plan to send home students who are studying abroad in countries with high prevalence of the virus.  The state public health laboratory is teaming up with hospitals with a goal of ensuring the state can handle up to 1,000 tests per day.  Governor Cuomo said that New York will institute a new cleaning protocol at schools and in the public transportation system. 

There are now 76 countries who are dealing with COVID-19.  There are now 118 identified cases in the United States; 9 people in the United States have died.  The charts were updated 11:50 p.m.  Most of the countries on the list have increased both in numbers of confirmed cases and deaths, although for some their death totals have not changed.  San Marino and Spain both had their first casualties of the virus. 

Several countries have no new confirmed cases to report (but that usually changes as they get their testing processes straightened out):  Afghanistan, Algeria, Armenia, Azerbaijan, Belarus, Brazil, Cambodia, Dominican Republic, Egypt, Finland, Georgia, Greece, India, Indonesia, Jordan, Lebanon, Lithuania, Luxembourg, Macau, Mexico, Monaco, Nepal, New Zealand, Nigeria, Philippines, Russia, and Vietnam.

New countries who have had people test positive for the disease are Argentina, Chile, Gibraltar, Latvia, Liechtenstein, Morocco, Saint Barthelemy, Sri Lanka, North Macedonia, Saudi Arabia, Tunisia, and Ukraine.