Coronavirus: why so few deaths among Singapore’s 14,000 infections?

[Leongsam]

As I have been saying repeatedly all those below 50 should be allowed to carry on with their lives normally and keep the economy going.

The old should play it safe.

What is happening right now is that the whole country is being shut down for the sake of those who are already about ready to hand in their ICs. It's a ridiculous situation.

All it takes to keep this virus from killing Singapore residents is to ensure that the old are protected.

scmp.com

Coronavirus: why so few deaths among Singapore’s 14,000 infections?


Published: 7:00pm, 27 Apr, 2020
Updated: 10:01am, 28 Apr, 2020

5-7 minutes


Firstly, most of Singapore’s new cases are younger people, comprising mostly of migrant workers living in mega dormitories. Secondly, elderly people with chronic conditions who are most vulnerable have listened to the government’s advice to stay at home to reduce their chances of infection.

More than 90 per cent of Singapore’s recent cases are low-wage foreign workers living in dormitories. While the health ministry this month stopped providing a breakdown of patients’ ages, authorities have stressed that most are young and many have either mild symptoms or none at all. Leong Hoe Nam, an infectious disease specialist, said such cases had “diluted” the country’s death rate.

There are about 323,000 migrant workers living in specially dedicated dorms in Singapore. These workers are involved in jobs shunned by Singaporeans in industries such as construction, estate maintenance and manufacturing. On April 1, these dorms accounted for just 19 infections. By Sunday, April 26, they accounted for 11,419.

Because most of the infected people in these dormitories are exhibiting only mild symptoms, they are being treated in community isolation facilities instead of hospitals, freeing up beds for more severe cases.

Meanwhile, the more vulnerable elderly population has been staying in. “Our old folks have been sheltered at home,” Leong said.

Singapore Prime Minister Lee Hsien Loong has personally appealed to the elderly to stay home. Photo: EPA

In addition to frequent advertisements on national television, Prime Minister Lee Hsien Loong this month made a personal, televised appeal to the elderly to stay home.
Among those heeding the leader’s advice is Soh Lai Hoe, 94, who lives with her children and has not stepped out of her house since March, when the island’s partial lockdown came into force. Before the coronavirus outbreak, she usually exercised outside twice a week. Now, she is exercising at home.

Paul Tambyah, President of the Asia Pacific Society of Clinical Microbiology and Infection, said it would be problematic if there were more cases from nursing homes or among senior citizens as these people would require more medical care.

Five nursing homes in Singapore now have 20 Covid-19 infections among staff and residents. This compares to the 11,000 deaths in nursing homes across 36 states in the US, according to NBC News.

“Fortunately, we have a much smaller proportion of elderly people than Italy or Spain,” Tambyah said.

In Italy, almost a quarter of the population is over 65 and more than a third of the infections have been in people older than 70. Many Italian patients have needed critical care and 26,644 have died – a mortality rate of 12.9 per cent. For Singapore, the average age of the 12 deaths is 78.


Many experts believe the reason Belgium has such a high death rate – its rate of 55 fatalities per 100,000 inhabitants is more than four times that of the US – is that unlike many other countries it has been including deaths at nursing homes in its statistics, even in cases where an infection wasn’t confirmed. Essentially, if a person dies in a nursing home and was showing coronavirus symptoms and had been in contact with an infected person, then they are included in the statistics.

Another reason for Singapore’s success was that it had ensured there was enough equipment to deal with more severe cases, said Leong, pointing out that milder cases were now being cared for in community facilities, which put less on a strain on hospitals.

Medical teams in Singapore had also learned from the experiences of other countries and adapted treatment methods, he said. For example, local media recently reported how the National Centre of Infectious Diseases, which houses most of the severe cases, was placing more patients in the prone position after a study found that patients lying face down on their stomach needed less oxygen support than those on their back.

“We learn from experience. We get better,” said Leong.

“The government [has also] proactively decanted patients in anticipation of this surge [in cases], freeing resources for those who need them,” he said, citing how elective – or non-urgent – surgeries that would usually require ventilators, such as heart valve repairs or brain surgeries, had been postponed where possible.

Associate professor Jeremy Lim of the National University of Singapore’s Saw Swee Hock School of Public Health said the key thing was that the health care system had not been overwhelmed by patients needing critical care. The number of patients in intensive care across the nation rose to 32 on April 10, but has since dropped to 22.
Lim said Singapore clearly had “a very strong and credible health care system” but he added that the low number of critical cases was not because it was doing anything differently from other countries.

“Our clinical teams do what they always do – providing holistic care to patients, addressing not just the disease-related factors but also being proactive in optimising other aspects of health like nutrition and activity,” he said.
Additional reporting by Bloomberg

 

[zhihau]

Simply because our Sinkiestan health system is of GOLD standards.

Just make sure Khaw don’t jinx this.

 

[syed putra]

Banglas are tough.

 

[glockman]

Banglas are tough.

Indians are tougher. I can vouch for that.

 

[jw5]

This means that we have at least 2 tough guys in the forum - glockman and syed putra.

Indians are tougher. I can vouch for that.

 

[glockman]

This means that we have at least 2 tough guys in the forum - glockman and syed putra.

Yes sir! Present and ready to serve sir!

 

[syed putra]

Indians and banglas beat the hell out of the pakis.

 

[CharKuayTeow]

As I have been saying repeatedly all those below 50 should be allowed to carry on with their lives normally and keep the economy going.

The old should play it safe.

What is happening right now is that the whole country is being shut down for the sake of those who are already about ready to hand in their ICs. It's a ridiculous situation.

I think part of the problem is that there is no clarity about the severity of the virus. Might be more than one strain, maybe the strain running around in Singapore is the less virulent one. More analysis seems to be prudent. If there is more than one strain, how do you keep out the more virulent strain?

Look at this article from yesterday's WSJ:

Coronavirus Hijacks the Body From Head to Toe, Perplexing Doctors
More than a respiratory infection, Covid-19 wreaks havoc on many organs; inflammation and abnormal blood clotting are likely culprits
By Betsy McKay and Daniela Hernandez
May 7, 2020 11:10 am ET
Garvon Russell was having trouble breathing when he arrived sick with Covid-19 at a New York City emergency room. By the time he left the hospital two weeks later, he had battled the new coronavirus all over his body.

His lungs were inflamed, their tiny air sacs filled with fluid that made it hard for oxygen to get into his bloodstream. His kidneys failed with Mr. Russell in septic shock from his infection.

Then, when it looked like he had turned the corner, his bedside nurse noticed his left leg was swollen. Doctors found a blood clot in a deep vein.
Mr. Russell, a 67-year-old retiree, said he feels lucky to have survived: “It’s nothing to play with.”
As the number of Covid-19 patients grows, doctors are learning its damage can extend well beyond the lungs, where infection can lead to pneumonia and acute respiratory distress syndrome, the sometimes fatal condition Mr. Russell had. The disease can also affect the brain, kidneys, heart, vascular and digestive system. Some patients have sudden strokes, pulmonary embolisms or heart-attack symptoms. Others have kidney failure or inflammation of the gut.
Infection can affect the nervous system, causing seizures, hallucinations or a loss of smell and taste. It may affect pregnancies, though the science is nascent: The placenta of a patient who miscarried during her second trimester tested positive for the virus and showed signs of inflammation, according to a paper published April 30 in the Journal of the American Medical Association.
Lungs
SARS-CoV-2 replicates rapidly in lungs, damaging tiny air sacs. Immune cells set off an inflammatory response against the infection, but too much inflammation can damage lung cells and blood vessels. In blood vessels, inflammation can activate proteins that form blood clots.

Cardiovascular system
Clots in large blood vessels can lead to stroke or pulmonary embolisms. Microclots can make it hard for lungs to oxygenate blood; less oxygen can lead to multi-organ-system failure.
Heart
Some patients suffer heart-lining inflammation, heart attacks or abnormal heart rhythms.
‘Covid toe’
Clots can cause painful, purplish swelling in the toes.
Nervous system
Some studies have found SARS-CoV-2 in cerebrospinal fluid. Patients have lost smell and taste. Some patients experience seizures, which are caused by abnormal brain activity, and hallucinations. Even young patients have suffered strokes, caused by clots reaching the brain.
Musculoskeletal system
Some patients report mild muscle and joint aches; others' pain is severe. The CDC recently added muscle pain to its symptoms list.
Digestive system
Some patients report gastrointestinal issues, including diarrhea. Stool samples have tested positive for SARS-CoV-2.
Throat, nose, eyes
The CDC recently added sore throat to its symptoms list. Some patients report runny noses. Reports suggest conjunctivitis is a symptom; eye-fluid samples have tested positive for viral RNA.
Kidneys
Blood clots in capillaries may prevent blood from getting to kidneys, leading to acute kidney injury. Shock or a direct attack by the virus can also cause kidney injury.
Multi-Front Attack
How Covid-19 affects the body

Source: Health-care professionals
Graphic: Merrill Sherman, Josh Ulick and Alberto Cervantes
The virus’s strange effects go beyond anything doctors say they usually see with other viral infections. “It seems to strike so many systems,” said Maya Rao, a nephrologist at New York-Presbyterian/Columbia University Irving Medical Center in New York who is treating Covid-19 patients with acute kidney failure. “We don’t understand who gets it.”
Doctors are trying to understand what about the infection predisposes patients to so many complications. The number of confirmed Covid-19 cases world-wide topped 3.7 million as of Thursday morning with roughly 260,000 deaths, according to data compiled by Johns Hopkins University. The U.S. accounted for more than 1.2 million cases and over 73,000 deaths.
“Sometimes with very severe infections you can see things similar to this,” said Magdy Selim, a neurologist at Beth Israel Deaconess Medical Center in Boston, who is treating Covid-19 patients who have had strokes. “But not all this combination of things in one patient. These are really sick patients.”
Some patients are young and otherwise healthy. Some children, who generally don’t get very sick with Covid-19, have been hospitalized with symptoms similar to Kawasaki disease—an inflammatory condition typically affecting young children—with acute inflammation in their hearts and intestines.
The extreme inflammation that is a hallmark of the most severe Covid-19 cases is likely at play, doctors said. Inflammation can also cause blood clots, which doctors believe may be a common denominator spanning several complications. Physicians describe stunningly extensive and swift clotting leading to the strokes and pulmonary embolisms seen in even otherwise young, healthy patients.
The complications add to the mysteries of a virus that makes an estimated 10% to 20% of those who are infected severely ill, though more population-wide testing and studies are needed to know the true percentage. Most people who develop Covid-19 experience relatively mild symptoms—fevers, coughs, chills, fatigue, nausea, diarrhea, pinkeye—but for a minority, ailments can quickly escalate to a more serious stage.
Share Your Thoughts
If you or someone you know has had Covid-19, did you observe any unusual symptoms? Join the conversation below.
Figuring out how to treat patients with Covid-19 is difficult because the virus is new, identified just at the beginning of this year, and its effects differ from those of other coronaviruses that infect humans. Patients are often admitted to the hospital when already very sick, significantly narrowing the window to save them, and there aren’t any medications approved to specifically treat infection with the new coronavirus. Some of these complications ultimately will be considered rare but appear more common now because so many people have gotten sick at once, doctors say.
Scientists are combing through piles of studies, and doctors are sharing experiences in real-time on Facebook and WhatsApp groups.
The inflammation at play in many complications is starting to come into focus. Immune-system cells rush in to kill infected cells. They also release molecules known as cytokines and chemokines that promote inflammation. The inflammation’s goal is to cordon off infected tissue, but too much can promote extra damage and create a “cytokine storm.”
Inflammation in the lungs can starve the blood of oxygen, depriving other organs, as it did with Mr. Russell, who spent eight days on a ventilator. Inflammation of the heart muscle, called myocarditis, can cause chest pain, shortness of breath and heart-rhythm disorders and scar the heart tissue.

Doctors examine images of a Covid-19 patient’s lungs at Sharp Grossmont Hospital in La Mesa, Calif., in April.
Photo: etienne laurent/epa/Shutterstock
Mark Gorelik, a pediatric rheumatologist and immunologist at New York-Presbyterian/Columbia University Irving Medical Center, has treated children and young adults with a condition resembling Kawasaki disease. While that condition involves artery inflammation, Dr. Gorelik said, these young patients have fevers, “a lot of cardiac inflammation” and sometimes a condition in their guts resembling colitis.
Genetic sequencing showed some patients have gene variants associated with a hyperactive immune response to viral infections, he said, yielding one possible clue into why some people develop serious complications, though such evidence is preliminary.
Researchers are also studying complications possibly caused by a direct attack by the virus. A recent study in the journal The Lancet found evidence the virus attacks endothelial cells, which form a layer lining blood vessels and the heart. That makes Covid-19 a vascular disease as well as a lung disease, said Mandeep Mehra, executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital in Boston, an author of the study.
“It might be that this is a disease that requires a combination of therapy that attacks the virus and that also stabilizes the vasculature,” he said.
Strange complication
Among the strangest and most worrisome complications is how prone to clotting the blood of some Covid-19 patients seems to be. “Every time you have hyper-inflammation, you’re more prone to clotting,” said Andre Goy, a hematology oncologist and chair of the John Theurer Cancer Center at Hackensack University Medical Center. “This is not new…but what’s amazing is the extent of it.”
A study in the Netherlands found 49% of patients in intensive-care units developed clotting complications, mostly pulmonary embolisms but also some strokes. The risk of death for these patients with these complications was 5.4 times the risk for those without those complications, according to the study, published in the journal Thrombosis Research. “We were very much surprised by what we saw,” said Erik Klok, an internist and vascular-medicine specialist at Leiden University Medical Center, and lead author of the study. “We’re not used to this in patients with the normal flu.”
Why Fully Recovering From Coronavirus Might Take Longer Than Expected

0:00 / 8:21

Why Fully Recovering From Coronavirus Might Take Longer Than Expected
Understanding how the body clears the new coronavirus is becoming more important as the U.S. begins to reopen. WSJ’s Daniela Hernandez explains how the body fights infection and why feeling better doesn’t equal being virus-free. Photo illustration: Laura Kammermann
Doctors have seen some patients’ blood clot during dialysis, or while circulating in life-support machines, clogging the circuits. “They’re clotting off things that don’t usually clot,” said Lee Schwamm, executive vice chairman of neurology at Massachusetts General Hospital in Boston. “It’s as if you had sludge in your garden hose.”
At Mount Sinai Hospital in New York, a 44-year-old stroke patient’s blood started visibly clotting while surgeons were trying to remove a clot from his brain despite infusion with clot-busting drugs, according to Thomas Oxley, the interventional neurologist who treated the patient. The patient can’t speak or move his right side, he said.
Strokes happen when large clots in large blood vessels make their way to the brain, cutting off vital oxygen. About 5% of Covid-19 patients develop them, according to a study of 221 patients in China.
Patients are presenting not just with the more-common large clots that can lead to strokes and pulmonary embolisms, but also a constellation of small clots that block blood flow through the tiny blood vessels, known as capillaries, that deliver blood to all organs throughout the body. Some suffer from “Covid toe,” a painful, purplish swelling caused by clots in small blood vessels.
The International Society on Thrombosis and Haemostasis now recommends that any patient admitted to the hospital be evaluated for the risk of clotting and be given anticoagulants like heparin, according to Jeffrey Weitz, the organization’s president-elect. Thrombosis is the medical term for blood clots that form in blood vessels.
How Covid-19 infection makes blood more clot-prone isn’t entirely understood. But a growing body of studies suggests some patients have elevated levels of d-dimer, a protein produced when the body breaks down clots. D-dimer levels are a reliable indicator of Covid-19 severity, several doctors said. A study published by Chinese researchers in March in The Lancet found patients who died had higher d-dimer levels than survivors.
Clinicians think clots may be forming along walls of tiny and major blood vessels due to damage caused by inflammation or the virus itself. When the SARS-CoV-2 virus, as the new coronavirus is officially called, reaches the lung, it replicates rapidly, damaging cells of tiny air sacs called alveoli. That damage triggers inflammation, which leads the blood to coagulate, clinicians say. The damaged cells also release substances that activate coagulation.

A cerebral angiography shows carotid-artery blockage typical for large vessel stroke, left, and after the blockage was removed—from a case Dr. Thomas Oxley did last year.
Photo: Mount Sinai Health System
A study of three patients who died from Covid-19 published in The Lancet showed evidence the virus can infect walls of capillaries that feed several organs, including the kidneys and small intestine. Pro-clotting proteins flood in to patch up the damage in a process similar to what happens when a scab forms—except the wounding persists internally, promoting more clotting.
“The high levels of d-dimer indicate the body is trying its darndest to break down the clot,” said Dr. Weitz. But “the forces to generate clots are overwhelming the capacity of the body to get rid of them.”
This runaway process wreaks havoc on the entire body. When micro-clots form in tiny blood vessels, they create a traffic jam. Blood can’t flow through the lungs’ alveoli, where blood picks up oxygen.
Clots can lead to heart problems, including reduced blood flow in coronary arteries. Some patients show signs of heart problems a week or so after developing blood clots that start in the lung, said Gian Paolo Rossi, chair of internal medicine at the University of Padua in Italy. The heart damage develops slowly, he said. “They do very badly.”
Clots are also one suspect in acute kidney failure, which is caused by inadequate blood flow and oxygen. Blood clots in capillaries may prevent blood from getting to the kidneys, said Dr. Rao, of Columbia. Other possible causes of acute kidney injury are shock or a direct attack by the virus, because the kidneys have the ACE2 receptor to which the SARS-CoV-2 virus binds to enter cells, she said. Patients include people who had healthy kidneys, she said.

A worker prepares a dialysis machine to be used for Covid-19 at the Joseph Imbert Hospital Center in Arles, France, in April.
Photo: Daniel Cole/Associated Press
As many as 30% of Covid-19 patients in the intensive-care unit at her hospital have required dialysis or consultation from a nephrologist, Dr. Rao said. That doesn’t include patients with kidney injuries that aren’t severe, she said. “We have seen an enormous amount of this in patients who are in the ICU with Covid-19,” she said.
Some people will fully recover. Others will need dialysis the rest of their lives, she said. “We’re not seeing a lot of recovery in the kidneys,” she said, “but we hope in the longer term people will get better.”
Mr. Russell’s clot
Other patients develop deep vein thrombosis, a life-threatening condition usually occurring deep in a leg vein. Mr. Russell, who has diabetes and high blood pressure, was improving in late March when doctors found the blood clot in his left leg. He had been on a prophylactic dose of a blood thinner, but it wasn’t enough, said Neha Dangayach, a neurocritical care specialist at Mount Sinai Hospital, where Mr. Russell was cared for.

A Mount Sinai nurse practitioner and colleagues celebrate Garvon Russell's release from the ICU.
Photo: Ruth Levy
He was put on a stronger dose of anticoagulants, Dr. Dangayach said. Given Mr. Russell’s health and the number of complications he suffered, she said, “he could have died.”
He is now at home in the Bronx. His kidneys recovered, but he is on blood thinners to prevent more clots.
A study published Wednesday by Mount Sinai researchers in the Journal of the American College of Cardiology found that treating hospitalized patients with blood-thinning drugs improved their chances of survival.

Sagine Alexandre, 33, was diagnosed with a stroke and tested positive for Covid-19.
Photo: Sagine Alexandre
In a span of two weeks, Mount Sinai treated five Covid-19 patients under age 50 who had experienced a major stroke. None had clotting disorders, though one had a previous history of stroke. Normally, the hospital sees less than one such patient on average during that same period, according to a paper published in the New England Journal of Medicine in April.
Patients are often unsure when to call for help when they start experiencing symptoms such as numbness on one side of the body and trouble speaking, neurologists said. Some are waiting more than a day to call. The reason: Patients are being advised to call for help only if fevers or shortness of breath worsen.
Sagine Alexandre, 33, one of the patients described in the paper, had no history of stroke. She said she is slowly regaining movement in her left arm and learning how to walk again. She hasn’t seen her family in person since she went into the hospital on April 1.
“It’s hard to be going through something like this and not have any family or friends around,” she said. “I thank God for FaceTime. That’s all I have.”
Write to Betsy McKay at [email protected] and Daniela Hernandez at [email protected]

 

[Leongsam]

I think part of the problem is that there is no clarity about the severity of the virus. Might be more than one strain, maybe the strain running around in Singapore is the less virulent one. More analysis seems to be prudent. If there is more than one strain, how do you keep out the more virulent strain?

Look at this article from yesterday's WSJ:

Coronavirus Hijacks the Body From Head to Toe, Perplexing Doctors
More than a respiratory infection, Covid-19 wreaks havoc on many organs; inflammation and abnormal blood clotting are likely culprits
By Betsy McKay and Daniela Hernandez
May 7, 2020 11:10 am ET
Garvon Russell was having trouble breathing when he arrived sick with Covid-19 at a New York City emergency room. By the time he left the hospital two weeks later, he had battled the new coronavirus all over his body.

His lungs were inflamed, their tiny air sacs filled with fluid that made it hard for oxygen to get into his bloodstream. His kidneys failed with Mr. Russell in septic shock from his infection.

Then, when it looked like he had turned the corner, his bedside nurse noticed his left leg was swollen. Doctors found a blood clot in a deep vein.
Mr. Russell, a 67-year-old retiree, said he feels lucky to have survived: “It’s nothing to play with.”
As the number of Covid-19 patients grows, doctors are learning its damage can extend well beyond the lungs, where infection can lead to pneumonia and acute respiratory distress syndrome, the sometimes fatal condition Mr. Russell had. The disease can also affect the brain, kidneys, heart, vascular and digestive system. Some patients have sudden strokes, pulmonary embolisms or heart-attack symptoms. Others have kidney failure or inflammation of the gut.
Infection can affect the nervous system, causing seizures, hallucinations or a loss of smell and taste. It may affect pregnancies, though the science is nascent: The placenta of a patient who miscarried during her second trimester tested positive for the virus and showed signs of inflammation, according to a paper published April 30 in the Journal of the American Medical Association.
Lungs
SARS-CoV-2 replicates rapidly in lungs, damaging tiny air sacs. Immune cells set off an inflammatory response against the infection, but too much inflammation can damage lung cells and blood vessels. In blood vessels, inflammation can activate proteins that form blood clots.

Cardiovascular system
Clots in large blood vessels can lead to stroke or pulmonary embolisms. Microclots can make it hard for lungs to oxygenate blood; less oxygen can lead to multi-organ-system failure.
Heart
Some patients suffer heart-lining inflammation, heart attacks or abnormal heart rhythms.
‘Covid toe’
Clots can cause painful, purplish swelling in the toes.
Nervous system
Some studies have found SARS-CoV-2 in cerebrospinal fluid. Patients have lost smell and taste. Some patients experience seizures, which are caused by abnormal brain activity, and hallucinations. Even young patients have suffered strokes, caused by clots reaching the brain.
Musculoskeletal system
Some patients report mild muscle and joint aches; others' pain is severe. The CDC recently added muscle pain to its symptoms list.
Digestive system
Some patients report gastrointestinal issues, including diarrhea. Stool samples have tested positive for SARS-CoV-2.
Throat, nose, eyes
The CDC recently added sore throat to its symptoms list. Some patients report runny noses. Reports suggest conjunctivitis is a symptom; eye-fluid samples have tested positive for viral RNA.
Kidneys
Blood clots in capillaries may prevent blood from getting to kidneys, leading to acute kidney injury. Shock or a direct attack by the virus can also cause kidney injury.
Multi-Front Attack
How Covid-19 affects the body

Source: Health-care professionals
Graphic: Merrill Sherman, Josh Ulick and Alberto Cervantes
The virus’s strange effects go beyond anything doctors say they usually see with other viral infections. “It seems to strike so many systems,” said Maya Rao, a nephrologist at New York-Presbyterian/Columbia University Irving Medical Center in New York who is treating Covid-19 patients with acute kidney failure. “We don’t understand who gets it.”
Doctors are trying to understand what about the infection predisposes patients to so many complications. The number of confirmed Covid-19 cases world-wide topped 3.7 million as of Thursday morning with roughly 260,000 deaths, according to data compiled by Johns Hopkins University. The U.S. accounted for more than 1.2 million cases and over 73,000 deaths.
“Sometimes with very severe infections you can see things similar to this,” said Magdy Selim, a neurologist at Beth Israel Deaconess Medical Center in Boston, who is treating Covid-19 patients who have had strokes. “But not all this combination of things in one patient. These are really sick patients.”
Some patients are young and otherwise healthy. Some children, who generally don’t get very sick with Covid-19, have been hospitalized with symptoms similar to Kawasaki disease—an inflammatory condition typically affecting young children—with acute inflammation in their hearts and intestines.
The extreme inflammation that is a hallmark of the most severe Covid-19 cases is likely at play, doctors said. Inflammation can also cause blood clots, which doctors believe may be a common denominator spanning several complications. Physicians describe stunningly extensive and swift clotting leading to the strokes and pulmonary embolisms seen in even otherwise young, healthy patients.
The complications add to the mysteries of a virus that makes an estimated 10% to 20% of those who are infected severely ill, though more population-wide testing and studies are needed to know the true percentage. Most people who develop Covid-19 experience relatively mild symptoms—fevers, coughs, chills, fatigue, nausea, diarrhea, pinkeye—but for a minority, ailments can quickly escalate to a more serious stage.
Share Your Thoughts
If you or someone you know has had Covid-19, did you observe any unusual symptoms? Join the conversation below.
Figuring out how to treat patients with Covid-19 is difficult because the virus is new, identified just at the beginning of this year, and its effects differ from those of other coronaviruses that infect humans. Patients are often admitted to the hospital when already very sick, significantly narrowing the window to save them, and there aren’t any medications approved to specifically treat infection with the new coronavirus. Some of these complications ultimately will be considered rare but appear more common now because so many people have gotten sick at once, doctors say.
Scientists are combing through piles of studies, and doctors are sharing experiences in real-time on Facebook and WhatsApp groups.
The inflammation at play in many complications is starting to come into focus. Immune-system cells rush in to kill infected cells. They also release molecules known as cytokines and chemokines that promote inflammation. The inflammation’s goal is to cordon off infected tissue, but too much can promote extra damage and create a “cytokine storm.”
Inflammation in the lungs can starve the blood of oxygen, depriving other organs, as it did with Mr. Russell, who spent eight days on a ventilator. Inflammation of the heart muscle, called myocarditis, can cause chest pain, shortness of breath and heart-rhythm disorders and scar the heart tissue.

Doctors examine images of a Covid-19 patient’s lungs at Sharp Grossmont Hospital in La Mesa, Calif., in April.
Photo: etienne laurent/epa/Shutterstock
Mark Gorelik, a pediatric rheumatologist and immunologist at New York-Presbyterian/Columbia University Irving Medical Center, has treated children and young adults with a condition resembling Kawasaki disease. While that condition involves artery inflammation, Dr. Gorelik said, these young patients have fevers, “a lot of cardiac inflammation” and sometimes a condition in their guts resembling colitis.
Genetic sequencing showed some patients have gene variants associated with a hyperactive immune response to viral infections, he said, yielding one possible clue into why some people develop serious complications, though such evidence is preliminary.
Researchers are also studying complications possibly caused by a direct attack by the virus. A recent study in the journal The Lancet found evidence the virus attacks endothelial cells, which form a layer lining blood vessels and the heart. That makes Covid-19 a vascular disease as well as a lung disease, said Mandeep Mehra, executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital in Boston, an author of the study.
“It might be that this is a disease that requires a combination of therapy that attacks the virus and that also stabilizes the vasculature,” he said.
Strange complication
Among the strangest and most worrisome complications is how prone to clotting the blood of some Covid-19 patients seems to be. “Every time you have hyper-inflammation, you’re more prone to clotting,” said Andre Goy, a hematology oncologist and chair of the John Theurer Cancer Center at Hackensack University Medical Center. “This is not new…but what’s amazing is the extent of it.”
A study in the Netherlands found 49% of patients in intensive-care units developed clotting complications, mostly pulmonary embolisms but also some strokes. The risk of death for these patients with these complications was 5.4 times the risk for those without those complications, according to the study, published in the journal Thrombosis Research. “We were very much surprised by what we saw,” said Erik Klok, an internist and vascular-medicine specialist at Leiden University Medical Center, and lead author of the study. “We’re not used to this in patients with the normal flu.”
Why Fully Recovering From Coronavirus Might Take Longer Than Expected

0:00 / 8:21

Why Fully Recovering From Coronavirus Might Take Longer Than Expected
Understanding how the body clears the new coronavirus is becoming more important as the U.S. begins to reopen. WSJ’s Daniela Hernandez explains how the body fights infection and why feeling better doesn’t equal being virus-free. Photo illustration: Laura Kammermann
Doctors have seen some patients’ blood clot during dialysis, or while circulating in life-support machines, clogging the circuits. “They’re clotting off things that don’t usually clot,” said Lee Schwamm, executive vice chairman of neurology at Massachusetts General Hospital in Boston. “It’s as if you had sludge in your garden hose.”
At Mount Sinai Hospital in New York, a 44-year-old stroke patient’s blood started visibly clotting while surgeons were trying to remove a clot from his brain despite infusion with clot-busting drugs, according to Thomas Oxley, the interventional neurologist who treated the patient. The patient can’t speak or move his right side, he said.
Strokes happen when large clots in large blood vessels make their way to the brain, cutting off vital oxygen. About 5% of Covid-19 patients develop them, according to a study of 221 patients in China.
Patients are presenting not just with the more-common large clots that can lead to strokes and pulmonary embolisms, but also a constellation of small clots that block blood flow through the tiny blood vessels, known as capillaries, that deliver blood to all organs throughout the body. Some suffer from “Covid toe,” a painful, purplish swelling caused by clots in small blood vessels.
The International Society on Thrombosis and Haemostasis now recommends that any patient admitted to the hospital be evaluated for the risk of clotting and be given anticoagulants like heparin, according to Jeffrey Weitz, the organization’s president-elect. Thrombosis is the medical term for blood clots that form in blood vessels.
How Covid-19 infection makes blood more clot-prone isn’t entirely understood. But a growing body of studies suggests some patients have elevated levels of d-dimer, a protein produced when the body breaks down clots. D-dimer levels are a reliable indicator of Covid-19 severity, several doctors said. A study published by Chinese researchers in March in The Lancet found patients who died had higher d-dimer levels than survivors.
Clinicians think clots may be forming along walls of tiny and major blood vessels due to damage caused by inflammation or the virus itself. When the SARS-CoV-2 virus, as the new coronavirus is officially called, reaches the lung, it replicates rapidly, damaging cells of tiny air sacs called alveoli. That damage triggers inflammation, which leads the blood to coagulate, clinicians say. The damaged cells also release substances that activate coagulation.

A cerebral angiography shows carotid-artery blockage typical for large vessel stroke, left, and after the blockage was removed—from a case Dr. Thomas Oxley did last year.
Photo: Mount Sinai Health System
A study of three patients who died from Covid-19 published in The Lancet showed evidence the virus can infect walls of capillaries that feed several organs, including the kidneys and small intestine. Pro-clotting proteins flood in to patch up the damage in a process similar to what happens when a scab forms—except the wounding persists internally, promoting more clotting.
“The high levels of d-dimer indicate the body is trying its darndest to break down the clot,” said Dr. Weitz. But “the forces to generate clots are overwhelming the capacity of the body to get rid of them.”
This runaway process wreaks havoc on the entire body. When micro-clots form in tiny blood vessels, they create a traffic jam. Blood can’t flow through the lungs’ alveoli, where blood picks up oxygen.
Clots can lead to heart problems, including reduced blood flow in coronary arteries. Some patients show signs of heart problems a week or so after developing blood clots that start in the lung, said Gian Paolo Rossi, chair of internal medicine at the University of Padua in Italy. The heart damage develops slowly, he said. “They do very badly.”
Clots are also one suspect in acute kidney failure, which is caused by inadequate blood flow and oxygen. Blood clots in capillaries may prevent blood from getting to the kidneys, said Dr. Rao, of Columbia. Other possible causes of acute kidney injury are shock or a direct attack by the virus, because the kidneys have the ACE2 receptor to which the SARS-CoV-2 virus binds to enter cells, she said. Patients include people who had healthy kidneys, she said.

A worker prepares a dialysis machine to be used for Covid-19 at the Joseph Imbert Hospital Center in Arles, France, in April.
Photo: Daniel Cole/Associated Press
As many as 30% of Covid-19 patients in the intensive-care unit at her hospital have required dialysis or consultation from a nephrologist, Dr. Rao said. That doesn’t include patients with kidney injuries that aren’t severe, she said. “We have seen an enormous amount of this in patients who are in the ICU with Covid-19,” she said.
Some people will fully recover. Others will need dialysis the rest of their lives, she said. “We’re not seeing a lot of recovery in the kidneys,” she said, “but we hope in the longer term people will get better.”
Mr. Russell’s clot
Other patients develop deep vein thrombosis, a life-threatening condition usually occurring deep in a leg vein. Mr. Russell, who has diabetes and high blood pressure, was improving in late March when doctors found the blood clot in his left leg. He had been on a prophylactic dose of a blood thinner, but it wasn’t enough, said Neha Dangayach, a neurocritical care specialist at Mount Sinai Hospital, where Mr. Russell was cared for.

A Mount Sinai nurse practitioner and colleagues celebrate Garvon Russell's release from the ICU.
Photo: Ruth Levy
He was put on a stronger dose of anticoagulants, Dr. Dangayach said. Given Mr. Russell’s health and the number of complications he suffered, she said, “he could have died.”
He is now at home in the Bronx. His kidneys recovered, but he is on blood thinners to prevent more clots.
A study published Wednesday by Mount Sinai researchers in the Journal of the American College of Cardiology found that treating hospitalized patients with blood-thinning drugs improved their chances of survival.

Sagine Alexandre, 33, was diagnosed with a stroke and tested positive for Covid-19.
Photo: Sagine Alexandre
In a span of two weeks, Mount Sinai treated five Covid-19 patients under age 50 who had experienced a major stroke. None had clotting disorders, though one had a previous history of stroke. Normally, the hospital sees less than one such patient on average during that same period, according to a paper published in the New England Journal of Medicine in April.
Patients are often unsure when to call for help when they start experiencing symptoms such as numbness on one side of the body and trouble speaking, neurologists said. Some are waiting more than a day to call. The reason: Patients are being advised to call for help only if fevers or shortness of breath worsen.
Sagine Alexandre, 33, one of the patients described in the paper, had no history of stroke. She said she is slowly regaining movement in her left arm and learning how to walk again. She hasn’t seen her family in person since she went into the hospital on April 1.
“It’s hard to be going through something like this and not have any family or friends around,” she said. “I thank God for FaceTime. That’s all I have.”
Write to Betsy McKay at [email protected] and Daniela Hernandez at [email protected]

There are horror stories for every disease. The issue boils down to the probability of all this happening and it is very low based on the stats.

 

[Leongsam]

smh.com.au

How the flu kills: What happens when a person dies with influenza
Kate Aubusson

5-6 minutes

An electron microscopy image of the flu virus.Credit:Rob Ruigrok/ UVHCI
In Victoria, 121 influenza-related deaths have been recorded so far this year.
A suboptimal flu vaccine that offered as little as 15 to 20 per cent protection hampered efforts to stem the spread of the viral infection.
While the vast majority of flu deaths every year are among the elderly with pre-existing conditions, the young and healthy are not immune.
Three children, including three-year-old Sydney girl Vanika Idnani, died with flu in NSW this flu season. In Victoria, an eight-year-old girl died of flu in September. A handful of young, fit adults die flu-related deaths each year in Australia.
But what exactly are people dying from?
Death by influenza is complicated, said Dominic Dwyer, medical virologist and infectious diseases physician at Westmead Hospital, and clinical professor at the University of Sydney.
The frail and elderly are not the only patients at risk of dying from influenza. The viral infection itself can be fatal to a small proportion of otherwise healthy people or can trigger a fatal secondary infection.
Cytokine storm syndrome
Every flu season intensive care units treat a small number of people who have an over-exuberant, uncontrolled immune response to influenza, Professor Dwyer said.
"They have this overwhelming reaction to the infection and their lungs fill up with fluid, and otherwise healthy people can die," he said.
It is unclear why these patients have this terrible response, though it may be a genetic predisposition.
Patients are drowning in their own secretions, Professor Dwyer said.
Their lungs fill up with fluids containing proteins that fight infection, immune cells and some with antiviral and anti-inflammatory properties.
"The body produces these proteins to fight the infection. Normally these things naturally operate with a feedback mechanism; when the infection goes down they also drop back, but for some reason in these over-exuberant cases it just keeps building up," he said.
The syndrome not only attacks the lungs but can cause kidneys to shut down and affects the heart.
On chest X-rays the lungs of these patients look like a complete "white-out", Professor Dwyer said.
"It's a terrible disease, and fortunately it's not common," he said.
The secondary infections
Most people who die flu-related deaths are not killed by an influenza infection itself, but by secondary infections, most commonly pneumonia.
Staphylococcus and pneumococcus bacteria colonised harmlessly in the throat and nose can break through damaged mucosal lining of the respiratory tract caused by influenza, Professor Dwyer said.
This flu damage provides a "portal of entry" for the bacteria to get into the lungs or bloodstream, becoming harmful infections.
Damaged lungs caused by flu also leave patients vulnerable to staphylococcal or pneumococcal infections.
"The bacteria grows and replicates in the lungs, clogging them up," Professor Dwyer said.
Pneumonia usually affects part, or a lobe, of a lung or both lungs. On an X-ray the white cloud is usually localised to the affected area.
Pre-existing conditions under strain
Secondary infections are most likely to be fatal in patients with underlying respiratory conditions whose lungs are already under strain.
"Add a secondary infection over the top and they can get dramatically worse," Professor Dwyer said.
People with asthma, cystic fibrosis, chronic obstructive pulmonary disease as well as former smokers were at higher risk of contracting pneumonia.
Even other diseases that don't affect the lungs, including diabetes and kidney failure can get worse and potentially fatal with the added strain of flu.
"Every winter we see heart attacks and strokes increase during the flu season and we know flu increases the risk of both," Professor Dwyer said.

Flu deaths in children
Children die of flu from the same conditions that affect adults, and children with underlying respiratory conditions – like asthma – or heart problems were at increased risk, Professor Dwyer said.
Roughly half of the children who died from with influenza had no known underlying condition, said infectious diseases paediatrician Professor Robert Booy.
"The majority of flu deaths in children are before they get to school age," said Professor Booy, head of clinical research at the National Centre for Immunisation Research and Surveillance in Australia.
Flu and other viral respiratory infections are known risk factors for meningococcal disease, Professor Booy said.
Like staphylococcus and pneumococcus bacteria almost everyone will carry harmless meningococcus bacteria in their nose and throat at some stage in their lives.

 

[nirvarq]

Associate professor Jeremy Lim of the National University of Singapore said the key thing was that the low number of critical cases was not because we were doing anything differently from other countries.


WRONG !!!


1. Singapore is one of the cleanest cuntry in the world.

2. Singapore is one of the few cuntry that has no homeless and beggars.

3. Singapore is the only cuntry that the whole world knows is kiasi kiasu hence the Merdeka Generations the older folks that build up Singapore from slum with Ah Kong cannot be compared to the recent younger folks who are glutton pigs and live in very unhealthy ways. We're the 'fighter' generation stronger and smarter that takes care of their health better than any other similar folks of the same age across the entire world.

4. Singapore health system is one of the bestest in the World.

5. Last but not least something that ya'll totally missed out is that our Specialists and A&E wards Doctors are brilliant and of world class standard. The already half dead bangala with COVID was saved. Surgeon charges the Brunei Queen's sister for 40 million in 4 years.

6. Despite the conditions of our Dorms it is still the best and within livable standard though not ideal because it is not suitable in a pandemic which is Government's fault as they have 17 years to prepare and millions dollars incentive in terms of salaries yet failed very very badly to accommodate 300,000 workers ASAP into separate locations in our many empty blocks of flats, hotels total 63,000 rooms, holiday resorts chalets, thousands of empty cruise ships in the world.

We have the money and thousands of young Army boys, volunteers and reservists only just if they would have just asked instead of leaving them jobless and in high anxiety fapping everyday to release stress.........

They could house at least 3/4 of them into those areas mentioned above and leave only 1/4 staying in the Dorms that would have eased the congestions easily hence solved our Dorm proximity spread problem from early early.....

Congestions or close proximity is the bane of any pandemic it's a no brainer, is it not ?!

 

[sweetiepie]

KNN why Britain having the 2nd highest death rate still can have Britain got talent 2020 ? KNN

 

[laksaboy]

Certainly there are a few officially dead, but how many are officially dying?

Also, if you look at per capita, Sinkieland is the champion of (SE?) Asia. No contest. Gold standard.