
Covid-19’s stop-gap solution until vaccines and antivirals are ready - rsfern
https://www.globalhealthnow.org/2020-03/covid-19s-stop-gap-solution-until-vaccines-and-antivirals-are-ready
======
_bxg1
This crisis is the first event in my lifetime that's given me any optimism
about our ability, as a global civilization, to solve problems and get things
done. I don't feel like we've seen humanity at its best in several decades.
Shame it always takes a catastrophe (and an immediate one at that; see climate
change) to bring it out.

~~~
nikofeyn
> This crisis is the first event in my lifetime that's given me any optimism
> about our ability, as a global civilization, to solve problems and get
> things done.

would you mind elaborating? because i find it extremely difficult how one
could hold such an optimistic and apparent naive opinion.

from where i sit, this crisis is showing the exact opposite. there is very
little international communication and cooperation, and even internal to
countries, like in the u.s., there is very little communication and
cooperation. aside from a few outliers, the while thing has just been wave
after wave of delayed and reactive actions that were underprepared to begin
with.

people keep thinking we'll solve this with technology (the typical human way),
but what would have been better is if everyone simply communicated, listened,
and cooperated.

the human race could not face a _dumber_ enemy. think about it. if everyone on
earth just sat still for a couple of weeks, this thing would just vanish. can
you imagine a more simple foe? and yet, this thing is crippling econmies,
healthcare, and more.

~~~
matwood
I think you're paying too much attention to Trump and politics. The people
actually getting work done are cooperating and moving at a pace that has
really never been done. The articles I've read and podcasts I've heard with
scientist all echo the same sentiment. Ignore Trump and the politics, the
science is happening at a pace unseen before.

> the while thing has just been wave after wave of delayed and reactive
> actions that were underprepared to begin with.

I do agree the US has been slow to ramp up, but that is quickly changing.
Although, I would once again offer up to ignore Trump and watch the governors.
They have been acting quickly and decisively.

Underprepared with respect to supplies is always easy to say in hindsight
because now we know the war we are fighting. There is a saying that armies are
always tooled to fight the _last_ war. Until you know what the next war will
be, it's impossible to fully prepare.

> if everyone on earth just sat still for a couple of weeks, this thing would
> just vanish.

IMO, that is naive and optimistic. The problem, for lack of a better word, is
that the large majority of cases (80-90%?) are mild. For many, it's mild
enough that they would have not deviated from their normal routine. Once this
thing escaped China, and definitely once it got out of SEA, it was going to be
incredibly hard to stomp out without herd immunity either through infection or
vaccine.

~~~
JackeJR
I too share a dim view of the world's ability to work together. Even now when
faced with such a disease that is essentially everyone's problem, countries
first and foremost chose to safeguard their own interests at the expense of
others. It is a situation where if we survive, we did so because we worked
together and if we die, it is because we only cared for ourselves and nobody
else. If course this is oversimplifying a very complex interplay of things but
my drift is that no country seems to be able to look beyond their borders and
see that if we were to win this, we have to work together.

Even more dismaying is the refusal to lift sanctions on Iran. Even a narrowly
crafted exception to the sanctions for supplies needed to combat the onslaught
of the virus would be good but so far nothing. This is according to what I
have read this far and if this is in error, I would be happy to be shown that.

~~~
matwood
I view a pandemic like what happens in an airline emergency. The first thing
you do is put on your own oxygen mask to make sure you are stabilized before
helping others. It sounds selfish, but if the most powerful options lose
control because they are busy helping others then they can cause everyone to
lose.

Also, let me say that I'm not saying it's all rainbows and butterflies out
there. I just think about all the things that were going to end humankind in
my lifetime alone, yet here we are arguably in the best position we have ever
been to fight something like this. As a kid we were genuinely afraid of
nuclear war. Then there was the HIV epidemic. Y2K, tech bubble busting, 2008
financial crisis, and all the smaller things in between I'm forgetting about.

I look out and see the people on ground sharing information, being incredibly
cooperative, and trying to stabilize their situation so then they can
effectively help others. That is why I'm optimistic we'll work through this.

------
tcbawo
Some emerging theories of pathology suggest that lung function can be
increased by reinflating collapsed alveoli with constant pressure:
[https://emcrit.org/pulmcrit/cpap-covid/](https://emcrit.org/pulmcrit/cpap-
covid/). It describes cases where oxygen supplementation could be reduced or
eliminated.

This development ([https://www.isinnova.it/easy-
covid19-eng/](https://www.isinnova.it/easy-covid19-eng/)) looks very promising
for 'sub-intensive' cases -- adapting decathlon mask/snorkel with a 3D printed
valve to provide positive air pressure (to help reinflate lungs) without
intubation or leaking contaminated exhaust. If the closed mask method could be
used successfully to prevent serious cases from progressing to ICU (or more
importantly, keep people in their homes a little longer), it could have a huge
impact on reducing load in the hospital system.

~~~
agumonkey
I don't know where to ask.. is vaporized cbd helpful ? it's said to be a
potent anti inflammatory compounds and also help cleansing cells through
apoptosis.

~~~
jeltz
I am not a doctor but if it is indeed anti-inflammatory and causes apoptosis
it sounds more likely to be harmful than to be helpful. I suspect apoptosis
(or rather what happens is that cells get hijacked by the virus and then the
immune systems kills the hijacked cells) is what causes most of the lung
damage and inflammation is an important part of the response from the immune
system so I would not mess with that more than necessary.

~~~
agumonkey
good point, although reduce inflammation would clearly help respiratory
distress.. I'll dig further

------
rsfern
Formal writeup here:
[https://www.jci.org/articles/view/138003](https://www.jci.org/articles/view/138003)

Edit: lots of interesting details. a couple takeaways:

1\. “Depending on the antibody amount and composition, the protection
conferred by the transferred immunoglobulin can last from weeks to months.”

2\. One of the proposed deployments is to protect frontline health care
workers from infection (and remove their need to quarantine) until a vaccine
can be developed

3\. This treatment was apparently used for quite a few other outbreaks,
including the 1918 flu epidemic, MERS, and there is a report of it being used
against the novel Coronavirus in China

~~~
koheripbal
It's really only a solution for healthcare workers due to the amount of work
required to harvest and transfer immunoglobulin.

I think a far more scalable solution for the general public is the use of
existing anti-viral drugs.

------
DarmokJalad1701
This may be a stupid question. But can the antibodies be synthesized based on
samples from recovered patients? If not, why?

~~~
ars
That's basically what a
[https://en.wikipedia.org/wiki/Monoclonal_antibody](https://en.wikipedia.org/wiki/Monoclonal_antibody)
is - and those are by far the most expensive drugs there are, with costs in
the $100,000/person range.

~~~
freepor
What would the costs look like if the market scaled up by 1000 or 10000x?

~~~
acqq
The cost comes from the nonscalability of both the production and the use.

~~~
jlokier
What are the main obstacles to scalability of production and of use?

Could the former be amenable to treatment as an engineering problem? There are
a lot of motivated engineering minds right now.

~~~
acqq
I'm not a professional in that area, just based on what I've read, so in case
of doubt, check better sources:

If you use human donors, you need trained doctors spending time and equipment
to select the donors, handle the donors, take care of them during the donation
which takes hours (the needle is stuck in their vein during that time),
trained professionals using expensive equipment to process the donation, and
then trained doctors to perform the infusion on the patient, an hour or two,
but you still want keep the patient in the hospital overnight in case of
complications, which do happen often enough that it was practice to do so: as
in, once in thousand. At the end all that work, it is relatively sure that the
described work could result in protection of exactly one patient more than
before you started. The percentage of known complications and the potential
for failure in every step is what makes it non scalable.

With non human donors you can avoid some work, but the second part remains:
it's not "just a shot" like when you do a vaccination which is scalable.

And while vaccination is scalable, if you're going to vaccinate billions, you
also want to be very sure you aren't harming them, that's why speeding up
vaccine production is not scalable. Even producing the vaccines is not easy at
all to scale.

It's not that nobody has attempted hard to achieve this up to now.

~~~
jlokier
Thanks, that's quite informative.

In a critical situation such as the pandemic, it seems to me, from a project
management and engineering perspective, that it might be worth ramping up
production of a vaccine (or several) even before it has passed later stage
trials, and maybe even pre-distribute it a bit to national storage facilities.
So if the trials look great and the side effects are sufficiently minimal, the
delay for manufacture and distribution will be reduced after the trials.

But I guess I see all sorts of political problems with that, if the trials are
good but the side effects are a problem, or say it causes a horrible desease
for 0.1% of people down the line. The pressure to use the product would be
immense, despite the trial saying no this is not safe.

~~~
acqq
Long term, THE major problem is the expectation to _profit_ _every time_ ,
stupidly, nobody with the money cares if one of that times the whole world
gets infected:

[https://www.newyorker.com/news/news-desk/how-long-will-it-
ta...](https://www.newyorker.com/news/news-desk/how-long-will-it-take-to-
develop-a-coronavirus-vaccine)

"There may never be a market for a vaccine at the end of the development
process, because the epidemic is contained, or never comes to pass. Then,
traditionally, if there is an epidemic, it may take hold in a developing
country where _the costs of research and development cannot be recouped_. “The
resources and expertise sit in biotech and pharma, and they’ve got their
business model,” Grant said. “ _They’re not charities. They can’t do this
stuff for free._ ”"

The "investors" just want the _growth_ of their money, even the money they
make would become meaningless after the pandemics that's efficient enough. The
nature is indeed capable to set its own growth not caring about the "interests
of investors."

Obviously the whole structure as well as the priorities just have to be set
differently. The next time could be even much worse than now.

Which must be a political decision for change, not a technological
"invention". The technology is not a "deux ex machina" \-- the natural
limitations are real. Some solutions exist but simply can't be expected to
"make profit every time." So how can it be done? Taxes. What was too dangerous
selling point for generations of politicians? "Less taxes."

[https://en.wikipedia.org/wiki/Deus_ex_machina](https://en.wikipedia.org/wiki/Deus_ex_machina)

But the taxes are even now used, and spent in mind boggling amount, just for
other priorities, year after year:

[https://www.nytimes.com/2019/08/21/magazine/f35-joint-
strike...](https://www.nytimes.com/2019/08/21/magazine/f35-joint-strike-
fighter-program.html)

------
samsonradu
My knowledge about industrial manufacturing is slim to none so can someone
explain please why is it not possible to (globally) ramp up production of face
masks and ventilators to a virtually unlimited quantity?

What exactly is the bottleneck? Are we lacking materials, labour or the
technical know-how? Are the factories currently producing them so advanced and
hard to reproduce?

~~~
fulafel
Same as many other problems (eg global warming) - the market economy can't
deliver a solution because it's not short teem profitable for the relevant
actors.

~~~
lotsofpulp
It could be priced to be short term profitable, but then the sellers would get
accused of price gouging.

~~~
TeMPOraL
If manufacturers sold direct-to-consumers, they wouldn't. Problem with price
gouging happens because of _resellers_ , and that money does not work as a
signal for manufacturers.

The solution for undersupply in times of emergency is, IMO, to ban resale.
Some countries, including mine, went that route now.

------
fernly
Could somebody with medical knowledge speak to the lifetime of exogenous
antibodies in another person's blood?

And, does their presence in any way "train" the host immune system to make
more? Or is the benefit solely from the introduced antibodies?

~~~
ghufran_syed
The half-life of exogenous antibodies is around one month:

[https://pubmed.ncbi.nlm.nih.gov/3183495/](https://pubmed.ncbi.nlm.nih.gov/3183495/)

The benefit is solely from the antibodies attacking and reducing the level of
virus in the body, it does NOT induce an immune response from the body (though
that will happen anyway as the body mounts it's normal immune response to the
virus)

~~~
rootusrootus
So it does not interfere with the body's own immune response, and in the end
the patient should be immune in their own right (for however long that lasts)?

Almost sounds too good to be true. I wonder what the real downside risks are.

~~~
zaroth
IVIG is an extremely common treatment, used for immunocompromised patients, or
sometimes after a stem cell transplant to bolster the immune system while it
recovers.

It’s not typically used in healthy adults as a way to treat a specific known
pathogen because, well, we usually have much better options. Aside from being
somewhat pricey, side effects are mild and it should be fairly effective.

~~~
gus_massa
How similar is this to the antibodies that are injected to a RH- mother just
after the delivery of a RH+ baby to prevent the formation of their own
antibodies that would attack the next baby?
[https://en.wikipedia.org/wiki/Rho(D)_immune_globulin](https://en.wikipedia.org/wiki/Rho\(D\)_immune_globulin)

------
snehapa
21 days lock down the best prevention. However, In India, the train and other
transport and the PM said to make a 21 days lockdown. I think its the best
preventive measure. Look at the report what will be the situation if the
public transport works under this condition.
[https://quintdaily.com/2020/03/train-services-stopped-due-
to...](https://quintdaily.com/2020/03/train-services-stopped-due-to-corona-
outbreak/)

Even though, not only the government can only prevent this issue. Self-
protection by taking care of their business for some days, until this issue
get into a stable position is also the right choice.

My suggestion as my thought by checking with my doctor's circle is that:
Preventive medicines for Ebola, Polio Vaccines that gives under age of 10 can
be a better solution to stop far away virus issue.

------
tyingq
_" Yes. In fact, the Chinese sent 90 tons of plasma to Italy."_

That's impressive. I wonder how many individual donations that maps to. And
how many people that could treat.

Edit: Trying to answer my own question. Typical blood donation is 470ml. That
weighs about 0.5 kilograms. Plasma is roughly half of what's in your blood, so
half that again... 0.25 kilograms. So assuming they meant metric ton (1000Kg),
4000 individual donations per ton. 90 tons is then 360,000 donations. Did I
miss some math? That's, um...wow. Maybe the 90 tons includes bags, boxes,
pallets, etc?

No idea how many that treats though.

~~~
funcDropShadow
There don't exist 360.000 recovered humans at the moment. At least officially.

~~~
tyingq
Yeah, that's why I keep looking at my math, though it seems straightforward.
That 90 tons must be off somehow.

~~~
DigitalSea
Presumably, they also have to keep the plasma cool, I am guessing some of that
90-tonne wait could be attributed to cooling gels/liquids of some kind to keep
it stable for transport. Admittedly, I don't know how they would even
transport this over long distances like that.

------
Retric
While viable and potentially lifesaving, the risks associated with this type
of treatment are significant and should not be downplayed.

Edit: This is the line I am objecting to: “ _it can be used for prevention of
infection for people who are being exposed_ or it could be used for therapy
for those who are sick.” This is not something to generally be handing out to
people after simple exposure. For one thing the benifit is short term.

~~~
atwebb
Can you please explain? On the surface this all sounds great, then again, on
the surface a lot of things sound great.

Especially looking for clarity around this part:

Are there side-effects to using this?

Plasma is very safe. It is screened for bloodborne pathogens and blood typed
so you don't have a transfusion reaction. Blood transfusion is one of the most
regulated industries in the United States. It's one of the safest things
available.

~~~
1996
> Plasma is very safe. It is screened for bloodborne pathogens

For those we know. In some countries with centralized organizations handling
transfusions, both HIV and hepatis were spread before they knew to test them
-- then even after they learned. People sued for willful poisoning in Europe,
as there was documented evidence the persons taking the decision were told
about the risks yet decided to ignore them against experts advice. To the best
of my knowledge, nobody was convicted, ever.

> Blood transfusion is one of the most regulated industries

Now, given that background, do you think regulations will protect you from
unknown pathogens? Or from known ones if someone decides not to bother with
the testing?

~~~
14
That was a huge failure on [1] the Canadian Red Cross. They knew the blood was
tainted but wanted to use up existing supply. They were buying blood from
prisoner populations, didn't bother to do testing that would have detected
most of the Hepatitis C cases, and infected more then 2000 Canadians with HIV.
This was a giant screw up I have heard many times because back just before it
went public the doctors wanted to give my dad a transfusion for a massive cut
he sustained at work. He refused saying no way he trusts the blood. It was
just a gut feeling. The doctor said he was making a foolish decision. Two
weeks later it was all over the paper. So of course my dad took the paper to
his next doctors appointment to get his stitches out and asked the doctor what
he thought of his decision now. [1]: [https://www.cbc.ca/strombo/news/canadas-
tainted-blood-scanda...](https://www.cbc.ca/strombo/news/canadas-tainted-
blood-scandal)

~~~
1996
Or maybe it was Canada, I can't say for sure. I just wouldn't call that a
screw up, but deliberate risk taking by managers ignoring experts.

Tell us, what was the doctor reply? That your dad was lucky?

But luck favors the prepared mind - or something like that.

------
znpy
Dumb question: infusing someone with antibodies-containing plasma from a
recovered patient will help the receiver develop their own antibodies ?

~~~
ssijak
No

~~~
znpy
Thanks.

------
ltbarcly3
Why do they keep saying 'until vaccines are ready' as though it's a foregone
conclusion that we can make a vaccine for this? Is this type of virus always a
good one to make vaccines for?

There are tons of viruses we have failed to vaccinate for, despite trying for
30 or 40 years. People seem to be universally saying a vaccine is '12-18
months away'. Is this just misinformation?

I would love to hear from an expert about this.

~~~
funcDropShadow
Because, there are multiple teams of companies and scientists around the
globe, that all report that they'll have candidates ready in the very near
future, i.e. 3-4 weeks. Which means they are convinced the vaccines work. But
since vaccines are given to a large number of people, you have to make sure
that there is a very low number of adverse effects. And that takes most of the
time. But the vaccine candidates are almost ready.

------
tmalsburg2
China sent 90 tons of plasma to Italy? I don't understand. A ton is 1000
liters. A single blood donation is usually 500ml , not sure how much plasma
that would produce. But this means that they had at least 180K donations which
seem implausible. Could someone please explain?

~~~
Guidii
Perhaps the plasma is packaged? I'd expect there'd be a fair amount (20-50%?)
of non-plasma in those 90 tons.

------
tomohawk
> clinical trials could begin in 3–4 weeks provided that they clear all the
> regulatory steps. If that happens ...

Can someone break this down day by day as to why 3-4 weeks are necessary and
proper to get through the very first regulatory hurdle?

------
koolba
>> You're making sure that there are antibodies in there and that they would
be effective?

> Exactly. Exactly—that we have a potent unit. We think that one person can
> treat two people.

Does this work in an ongoing chain? For example if person A’s plasma is used
to treat B, can we take from B and treat C as well?

Or does the quality of the anti-bodies depend purely on the immune system of
the hose?

~~~
zaroth
Once someone has been exposed and recovered, they should have the antibody
concentration required to be become a donor themselves.

The required number of cells we’re taking about is high enough that you’re not
transfusing A->B and then recovering A from B’s plasma and going on to give
A->C.

But while B is infected they will make their own antibodies and after they
recover they could then be a donor as in B->C.

As TFA mentions, China doesn’t even bother testing the level of antibodies,
they just collect the plasma from anyone recovered. 90 tons to Italy... is a
lot of plasma.

At least for IVIG the plasma is pooled from a large number of donors for each
transfusion ultimately given to a patient. So it’s more a question of the
average antibody load than needing to gauge each individual donor’s levels.

> _Each IVIG preparation is made from the pooled plasma of 3,000-10,000 blood
> donors, which is then purified to contain more than 90% antibodies._ [1]

I think we need to start collecting plasma from recovered positive cases
today. I get that for a trial you do want to have a measured baseline of
antibodies. But we can start stockpiling and pooling COVID antibody plasma
even without the antibody testing.

[1] - [https://www.rheumaderm-society.org/ivig/](https://www.rheumaderm-
society.org/ivig/)

------
arjunvr54
Vaccines should be the better idea rather go behind launching tons of
ventilators. Even there were people not educated and still not care about the
issues. For those people antivirals don't be the right choice, looks like
vaccines are the best prevention - Early vaccines. How about trying the Ebola
vaccines - I think that can be a preventive measure right.?

------
cleeus
China now has a lot of donors for plasma with antibodies. That's why they can
stop the shutdown and start tracing outbreaks and treating patients.

------
alok-g
Does someone know how much of this needs to be injected to be effective?

~~~
tyingq
Not a real answer, but the article says one person can treat two people. So
somewhere around 0.25 to 0.35 liters is a rough guess, assuming "one person"
means "one typical blood product donation".

~~~
alok-g
Got you. Thanks.

------
stjohnswarts
I don't see why people think we will hold out 18 months for a vaccine to be
developed and tested, society would fall apart by then. I don't see it lasting
longer than 2-3 months quarantine and then the common people will just go out
anyway, especially in the USA where there's not much of a safety net.

~~~
ltbarcly3
There won't be a safety net anywhere if they require everyone to be
quarantined for 18 months. The government can print money by changing a number
in a computer, but they can't print sandwiches that way. Eventually dumping
money into the economy where very little is being produced just leads to
runaway inflation.

------
ekianjo
Why this article does not mention chloroquine at all, though?

------
Jemm
Problem with vaccines is that there is as yet no evidence that humans develop
immunity to COVID-19. No immunity, no vaccine.

Hopefully that changes soon.

~~~
AntonStratiev
[https://twitter.com/NAChristakis/status/1240689935557865472](https://twitter.com/NAChristakis/status/1240689935557865472)

Details a study on a different Coronavirus in 1990. There is definitely some
immunity, but its complicated.

------
rurban
Antivirals are ready. HCQ was mass produced for decades, and ramping it up is
trivial, and already done.

The first vaccines, BGM, will be ready in summer. This was already applied en
masse in the UK in the 60ies, and is in stage 3 testing.

What else: Vitamin C is ready.

Self made masks are better than no masks.

Ramping up tests kits are the most important part until summer. There's a new
faster one in testing, which needs 20min, and will cost €15.

Contact-less thermometers can be imported en masse from China.

Creating antibodies from plasma is not really viable for billions. The rest
is.

