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Absolute lymphocyte count is a prognostic marker in Covid‐19: A retrospective cohort review

Introduction

Prognostic factors are needed to aid clinicians in managing Covid‐19, a respiratory illness. Lymphocytopenia has emerged as a simply obtained laboratory value that may correlate with prognosis.

Methods

In this article, we perform a retrospective cohort review study on patients admitted to one academic hospital for Covid‐19 illness. We analyzed basic demographic, clinical, and laboratory data to understand the relationship between lymphocytopenia at the time of hospital admission and clinical outcomes.

Results

We discovered that lymphocyte count is lower (P = .01) and lymphocytopenia more frequent by an odds ratio of 3.40 (95% CI: 1.06‐10.96; P = .04) in patients admitted to the Intensive Care Unit (ICU), a marker of disease severity, relative to those who were not. We additionally find that patients with lymphocytopenia were more likely to develop an acute kidney injury (AKI), a marker of organ failure, during admission by an odds ratio of 4.29 (95% CI: 1.35‐13.57; P = .01).

Conclusion

This evidence supports the hypothesis that lymphocytopenia can be an early, useful, and easily obtained, prognostic factor in determining the clinical course and disease severity of a patient admitted to the hospital for Covid‐19.

1 INTRODUCTION

Coronavirus disease 2019 (Covid‐19) is a predominantly respiratory illness caused by the SARS‐CoV‐2 virus. Data regarding prognostic factors are currently scarce given the novelty of the disease. Prognostic information would aid clinicians in managing patients, who are often left without data‐driven guidelines to make important clinical decisions. It is known that lymphocytopenia, defined as an absolute lymphocyte count (ALC) < 1000 cells/µL, occurs in Covid‐19 and may correlate with increased disease severity1–5; indeed, lymphocytopenia is a common systemic manifestation of many viral illnesses6; in particular, other coronaviruses like Severe Acute Respiratory Syndrome coronavirus (SARS‐CoV) and Middle Eastern Respiratory Syndrome coronavirus (MERS‐CoV) have been demonstrated to cause lymphocytopenia.2 However, few studies have examined whether lymphocytopenia found at the time of admission to the hospital is helpful in understanding the disease course. Here, we set out to study a cohort of patients admitted to the hospital diagnosed with Covid‐19 to determine whether lymphocytopenia, found at the time of admission to the hospital, was associated with disease severity and other clinical outcomes.

2 MATERIALS AND METHODS

Data were obtained for patients admitted to one local, academic, community‐based hospital in Houston, TX, USA. IRB approval was granted by the University of Texas Health Science Center at Houston, Houston, TX, USA. Patients were included if they had a positive diagnosis of Covid‐19 based on a polymerase chain reaction‐based assay to detect the SARS‐CoV‐2 virus or had been diagnosed in the community, were over the age of 18, and were admitted and discharged from the hospital between 03/01/2020 and 05/07/2020. Data were collected and extracted from an electronic medical record system and included many variables, such as demographic, clinical outcomes, and laboratory data. We define severe disease as those patients who required admission to the ICU; non‐severe disease is classified as those admitted to the hospital, but did not require ICU admission. Admission to the ICU was determined by clinical factors, namely respiratory failure and hemodynamic instability. Lymphocytopenia was not part of these criteria. Acute Kidney Injury (AKI) is defined as a rise in serum creatinine > 0.3 mg/dL from baseline within 48 hours at any time during admission (if baseline data were unavailable, the lowest value during admission was presumed to be the baseline; if only one value was available, the patient was not presumed to have an AKI).

2.1 Laboratory data

All laboratory data were collected within 24 hours of admission. Laboratory data were analyzed by our hospital’s hematology laboratory. All laboratory samples are typically processed within hour of receipt. Complete blood counts (CBCs) were measured on automated CBC and differential analyzer (X‐N 3000), if the XN3000 could not classify a WBC an attached module (SP10) automatically made the blood smear slides. This blood smear side was manually loaded onto a cell locator imaging (DM96). Technician classified WBC with differential, if technician had difficulty in interpreting results; the pathologist reviewed the slide. Quality control materials were run every 8 hours. Lymphocytopenia is defined as an absolute lymphocyte count (ALC) < 1.0 × 103 cells/µL. Anemia is defined as hemoglobin < 14 gm/dL for men or < 12 gm/dL for women. Thrombocytopenia is defined as platelet count < 150.0 × 103 cells/µL. Leukopenia is defined as leukocyte count < 4.4 × 103 cells/µL. Leukocytosis is defined as a leukocyte count > 11.0 × 103 cells/µL.

2.2 Data analysis

For statistical analyses, the computer program R and accompanying R studio (version 1.2.5033, Orange Blossom) were used to perform analyses.7, 8 R is an open source statistical software program widely used in the academic research community. For continuous variables, a Welch’s two‐sided t test was performed, assuming variances were unequal between samples. To correct for multiple comparisons, a Bonferroni test was performed to adjust P‐values. For categorical data, a Fisher Exact test was used to make comparisons. For all analyses, a P‐value < .05 was used to reject the null hypothesis that either there was no difference between two samples tested or that samples were independent. Odds ratios and confidence intervals were calculated using the package epiR9 in the R‐studio software. Code is available upon request. Figures were prepared using the ggplot210 software in the R software platform.

3 RESULTS

3.1 Basic population demographics

We obtained a cohort of 57 patients who were admitted to and discharged from the hospital between 03/01/2020 and 05/01/2020. The cohort was predominantly male (59%), obese (average BMI of 32.3 ± 1.19 kg/m2) with an average age of 58.2 ± 2.08 years. Our cohort consisted mostly of patients with minority backgrounds (86%). Thirty‐one percent of patients (N = 18) were admitted to the ICU and mortality was 16% (N = 9). Of note, two patients had a diagnosis of Human Immunodeficiency Virus (HIV) infection. The median Charlson comorbidity index was 4 (1.5‐6), indicating an median 10‐year survival rate of 53%.11 In our study, we found that 50% (9/18) of patients admitted to the ICU required intubation and 38% (7/18) required vasopressors (Table 3). Thus, patients admitted to the ICU were classified as having severe disease given the relatively common occurrence of hemodynamic instability and respiratory failure in this population.

 

3.2 Lymphocytopenia at the time of admission is related to disease severity in Covid‐19

The average ALC count obtained at the time of admission to the hospital in patients requiring ICU admission was lower (0.8 ± 0.11 × 103 cells/µL) relative to those not needing ICU admission (1.4 ± 0.15 × 103 cells/µL; P = .01; Table 1, Figure 1). Additionally, more patients admitted to the ICU had lymphocytopenia (62%) at the time of admission to the hospital compared to those not admitted to the ICU (32%; P = .04; Table 2). Interestingly, the presence of lymphocytopenia conferred an odds ratio of 3.40 (95% CI: 1.06‐10.96) for admission to the ICU.

TABLE 1. Basic hematological laboratory values collected at the time of admission to the hospital of patients based on the need for ICU admission at any time during hospitalization
Non‐ICU ICU Significance
Sample size, N 39 18 —
ALC 1.4 ± 0.15 0.8 ± 0.11 *P = .01
Hemoglobin 12.9 ± 0.37 11.3 ± 0.54 P = .08
Hematocrit 38.5 ± 1.38 35.4 ± 1.30 P = .55
Platelet count 202.8 ± 11.84 274.7 ± 20.22 *P = .02
WBC 8.8 ± 0.73 10.4 ± 1.13 P = 1.0

Note

  • Data are expressed as mean ± SEM. Welch’s two‐sample t test with a Bonferroni post hoc correction for multiple comparisons was used to compare groups. An asterisk indicates a statistically significant result.
  • Abbreviations: ALC, Absolute Lymphocyte Count; ICU, Intensive Care Unit; WBC, White Blood Cell count.
image

FIGURE 1

Open in figure viewerPowerPoint
Scatter plot for Absolute Lymphocyte Count (ALC)‐based ICU admission status (patient outcome). Red bars represent standard deviation, and red dot represents the mean. Data points are represented by black dots. Abbreviations: ICU, patients admitted to the Intensive Care Unit; IP, patients admitted to the In‐Patient unit, not the ICU
TABLE 2. Frequency of laboratory results and corresponding odds ratios based on ICU admission status
Non‐ICU

No (%)

 ICU

No (%)

 Odds ratio, OR (95% CI) Significance
Sample Size 39 18 —
Lymphocytopenia Frequency 12 (32), N = 38 11 (61) 3.40 (1.06‐10.96) *P = .04
Anemia Frequency 19 (49) 14 (78) 3.68 (1.03‐13.20) *P = .04
Thrombocytopenia Frequency 6 (15) 1 (5) 0.32 (0.04‐2.91) P = .41
Leukopenia Frequency 5 (13) 0 — —
Leukocytosis Frequency 9 (23) 6 (33) 1.67 (0.49‐5.71) P = .5

Note

  • Raw count data are presented as the count (% of total sample size). Anemia, thrombocytopenia, lymphocytopenia, and leukopenia are defined in the methods. Fisher’s Exact test was performed to compare groups above. Odds ratio is reported as OR (95% CI). Sample sizes are listed as above, unless otherwise stated, with the value N adjacent to the data point. An asterisk indicates a statistically significant result.
  • Abbreviation: ICU, Intensive Care Unit.
3.3 Anemia and platelet count at the time of admission are related to disease severity in Covid‐19

Nick Note: Your LYM% is key to covid19 survival here is a link to a blood test scoring service. just plug in your test results to the link below:

https://bloodtesteasy.com/eval/

 

Continue reading “Absolute lymphocyte count is a prognostic marker in Covid‐19: A retrospective cohort review”

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The FDA says Pfizer’s Covid vaccine is safe and effective. But trial participants warn of intense symptoms after second shot

  • The FDA said data from Pfizer’s Covid vaccine trials show that side effects are common, though there are “no specific safety concerns identified that would preclude issuance of an” emergency use authorization.
  • Trial participants in the Moderna and Pfizer studies told CNBC they developed more significant symptoms following the second dose.

The Pfizer–BioNTech coronavirus vaccine is both safe and effective, according to the U.S. Food and Drug Administration. In a report released Tuesday morning, the FDA indicated that it could greenlight the country’s first Covid-19 inoculation within days. If Pfizer’s shot is granted an emergency use authorization, or EUA, the immunizations — which are administered in two doses about three weeks apart — could start as soon as next week. One Pfizer trial participant told CNBC that after the second shot, he woke up with chills, shaking so hard he cracked a tooth. “It hurt to even just lay in my bed sheet,” he said. Others experienced headaches and fatigue. The FDA said that while side effects of the Pfizer vaccine are common, there are “no specific safety concerns identified that would preclude issuance of an EUA.” The Pfizer vaccine is one of four U.S.-backed candidates in phase three trials. Next up is one from U.S. biotech firm Moderna, which has also submitted its EUA application. Both companies have said that taking their vaccines could result in side effects similar to mild Covid symptoms. Think muscle pain, chills and a headache. When trial participant Yasir Batalvi first read Moderna’s 22-page consent form warning of side effects ranging from nothing at all to death, he felt pretty worried, he told CNBC. “You have to keep in mind, I joined the trial when we didn’t know it was going to be a safe vaccine,” said Batalvi, a recent college graduate living in Boston. The 24-year-old said that when he got the first injection in mid-October, it felt just like a flu shot. “I experienced stiffness and pain in my left arm where I had gotten the shot, but it was mild,” he explained. “By that evening, I didn’t want to move my arm above my shoulder, but it was localized, and it disappeared by the next day.” “After the injection, I had the same side effects as the first: localized pain and stiffness, but it was a little bit worse. My arm got sore faster, and by the time I got home, I started feeling fatigued and like anyone would feel if they were coming down with the flu,” said Batalvi. More significant symptoms presented that evening. “I developed a low-grade fever and had chills,” he said. “That evening was rough.” After a restless night, he called the study doctors, who reassured him it was a normal reaction and no cause for concern. By that afternoon, Batalvi said, he felt like himself again. Moderna stopped testing the highest dose of its vaccine during the trial because of the number of reports of severe adverse reactions. As for any long-term effects, Batalvi isn’t giving it much thought. “I’m not too concerned,” he said. “We know from vaccination trials that any adverse events mostly show up in the first couple of months.”Front-runners Pfizer and Moderna built their candidates with a new kind of technology that’s never before been licensed in the U.S. Messenger RNA vaccines, called mRNA for short, aren’t like your normal flu vaccine. Typically, a vaccine puts a weakened or inactivated virus into our bodies to trigger an immune response, which then produces antibodies. Those antibodies are what ultimately protect us from getting infected if we ever encounter the real thing. An mRNA vaccine, on the other hand, is essentially just a piece of genetic code that contains instructions for our body. The mRNA tells our cells to make a protein — the same protein that is the spike on top of the actual coronavirus. This is what triggers the immune response in these types of vaccines. So even though some trial participants reported Covid-like symptoms, it is impossible to contract the coronavirus from the vaccine, because the mRNA vaccines that Pfizer and Moderna are making don’t use the live virus. Dr. Hana El Sahly, who oversees a clinical trial for Moderna’s vaccine candidate, said one major benefit of the mRNA technology is how fast it is to make. “The attractiveness of it is the speed with which it can be manufactured once we know the sequence of the virus,” said El Sahly. With the traditional flu vaccine, you have to first grow the virus in an egg, then deactivate the virus, and finally, put it into vaccine vials with either mRNA or recombinant DNA technology, explained El Sahly. The Covid vaccine’s faster manufacturing timeline is key, as distributors look to expedite distribution to the U.S. population. Also key to widespread vaccination is making sure governments around the world have enough money to buy the vaccines. Moderna said in August it is charging between $32 and $37 per dose for its vaccine and would perhaps offer a discount if it is bought in bulk. Pfizer’s, on the other hand, is more affordable. It is reportedly $20 per dose. The U.S. has secured 100 million doses of the Pfizer vaccine, which is enough to vaccinate 50 million people. But to achieve herd immunity, experts say, roughly 70% of the population needs to be vaccinated or have natural antibodies. That’s about 462 million doses for herd immunity and an estimated 660 million doses for everyone in the country. Pfizer board member Dr. Scott Gottlieb told CNBC on Tuesday that President Donald Trump declined the company’s offer to buy additional doses. Both Pfizer and Moderna are conducting double-blind trials, which means that half the participants receive a placebo and the other half receive the actual vaccine. Because the trials are ongoing, it also means that patients don’t know which group they are in. There is a debate raging among experts about whether to give the control group the vaccine. The FDA isn’t too keen on the idea of dosing the placebo group, while some scientists are making the case that they should be moved higher on the prioritization list as a thanks for their service. But this kind of break in trial protocol would interfere with the integrity of the trial, so for now, participants such as Batalvi remain in the dark as to whether they’re actually protected against the virus. A person can still present symptoms, as Batalvi did, even if they are in the control group. It’s the “placebo effect.” But either way, Batalvi said he’s glad he had the opportunity to participate in an effort to protect the world against the pandemic.

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Dow, S&P turn positive on vaccine optimism

The Dow Jones Industrial Average and the S&P 500 turned to gains on Tuesday after positive news related to coronavirus vaccines. The United States Food and Drug Administration (FDA) said in a report that there was no reason not to approve Pfizer’s COVID-19 vaccine while AstraZeneca confirmed its earlier findings on the efficacy of its coronavirus vaccine. After opening in the red, the Dow was 0.23% higher at 11:23 am ET as it was led by Johnson & Johnson which increased by 1.62% at 11:09 am ET. The S&P was 0.07% up at 11:24 am ET as Equifax jumped 10.76%. Meanwhile, the tech-heavy Nasdaq 100 fell 0.30% at 11:26 am ET.

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Coronavirus stimulus: $908 billion stimulus plan likely to be backed by Trump and McConnell

  • Some of the senators working on a $908 billion coronavirus relief plan say their bipartisan proposal could be finalized early this week.
  • GOP Sen. Bill Cassidy told Fox News that President Donald Trump had “indicated” he would support it, and he expressed optimism that Senate Majority Leader Mitch McConnell would too.
  • Sen. Mark Warner, a Democrat, told CNN the final wording of the plan could be ready as early as Monday.
  • Both Republican and Democratic senators have started to line up behind the package, with Warner saying he thinks it has the numbers to pass.

Senators are inching closer to an agreement on the final wording of a bipartisan $908 billion coronavirus relief plan, with some expressing confidence that both Senate Majority Leader Mitch McConnell and President Donald Trump would back it. Democratic Sen. Mark Warner, who is part of the 10-person cross-party group crafting the plan, told CNN’s “State of the Union” on Sunday that the wording could be finalized as early as Monday. “I think we have got the top-line numbers done,” he said. “We are working right now on language so that we can have – as early as tomorrow – a piece of legislation.” He added that he had “pretty high assurance” the final proposal would have enough votes to pass the Senate. The $908 billion package appears to have the most bipartisan support of the multiple proposed options for federal spending to address the coronavirus pandemic. Leading Democratic figures such as House Speaker Nancy Pelosi and Senate Minority Leader Chuck Schumer have embraced it, as have some Republicans. Though McConnell has called for bipartisanship in stimulus negotiations, he is sticking to his own package, which is based on a much smaller bill that has twice failed to pass this fall. Sen. Bill Cassidy, a Republican senator in the bipartisan group behind the package, expressed optimism that support from figures like McConnell and Trump would be forthcoming. He told “Fox News Sunday” that Trump had signaled willingness. “President Trump has indicated that he would sign a $908 billion package,” he said. “There’s only one $908 billion package out there – that’s ours.” Cassidy added that he was “optimistic” about McConnell’s support. Cassidy did not say where he had learned of Trump’s indication of support. At a Thursday press conference, the president had said he would support a bill, but when asked for clarification the White House said he had meant a much slimmer one promoted by McConnell. “Now, neither have said: ‘Oh, we’ll sign your bill,'” Cassidy told Fox News. “That’s fair, we have final language” to agree on, he said, adding that the urgency of the situation would be clear to Trump and McConnell. That wording is likely to come out “early this week,” Cassidy said. Two main points remain a source of disagreement in the negotiations, CNN reported, citing unnamed sources. According to the outlet, the first is liability protections for businesses in the pandemic, which the GOP supports. The second is funding demanded by the Democratic Party for state and local governments. Both measures were included in some form in a draft that circulated last week. It also included a $288 billion small-business-loan program, $180 billion added to unemployment insurance, and $16 billion for distribution of coronavirus vaccines. The bipartisan package does not include $1,200 direct payments to Americans. Numerous members of Congress have noted the pressure in the situation, as they rush to agree a separate spending plan by Friday to avoid a government shutdown. “We don’t have a choice now. It’s one of those things that has to be done,” CNN reported Democratic Sen. Joe Manchin telling NBC.

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Vaccines won’t end Covid – immunity may only be 6 monthd Vaccine immunity

CNN)Coronavirus vaccines will provide some light at the end of the tunnel, but they alone won’t mean an end to Covid-19, one leading health official said Friday. “I would like to say vaccines do not equal zero Covid,” said Dr. Michael Ryan, the executive director of the World Health Organization’s Health Emergencies Program.

“Vaccines and vaccination will add a major, major, powerful tool to the toolkit that we have.”But by themselves they will not do the job.”

The US is seeing the worst days of the pandemic and had its highest day of new cases — 217,664 — and deaths — 2,879 — on Thursday, according to Johns Hopkins.On Friday, there were 101,276 people hospitalized with Covid-19, breaking the previous record set on Thursday, according to the Covid Tracking Project. This is the third consecutive day that the US has remained above 100,000 current hospitalizations.More than 14.3 million cases and more than 278,000 deaths have been recorded in the US, according to Johns Hopkins University. For months, health experts have said that to prevent spread of the virus, people should keep their distance from others, wash their hands and wear their masks. As they learned more about this coronavirus and the disease it causes — Covid-19 — officials have amended their recommendations.
The US Centers for Disease Control and Prevention on Friday strengthened its guidance for face coverings, saying that wearing a mask is critical and sometimes people should wear them even in their homes. “Because the highest risk for transmission has been documented among household contacts of Covid-19 patients, keeping the household safe requires physical distancing, using the other public health strategies summarized here, and, in particular, consistent and correct use of face masks (outside the household and in some circumstances within the household) to prevent introduction and transmission of (the virus),” the CDC said. The CDC also said that while face coverings should be worn to cut down on possible transmission of the virus, they also can provide some protection to the person wearing one.
Officials have cautioned that coronavirus cases will rise during the winter as more people stay inside, and as people gather for holidays. Cases, hospitalizations and deaths are at an all-time high, but vaccines will help once they are authorized.
States are now preparing to roll out the vaccines to frontline health care workers and people at long-term care facilities. Ohio was one of the states that on Friday released its plan.”During Phase 1, vaccine supply will be limited, and Ohio will focus on vaccinating those who wish to be vaccinated in the critical Phase 1A groups,” according to a news release from the office of Ohio Gov. Mike DeWine.

Ohio expects to receive 660,000 doses in before the end of December. In New Jersey, where hospitals are preparing to receive 76,000 doses of the vaccine in the first shipment, Gov. Phil Murphy called vaccine distribution a “game changer.” But he warned New Jerseyans not to expect restrictions to be lifted soon. “Covid isn’t going to simply vanish just because there are vaccine doses in a freezer waiting for distribution,” Murphy told reporters. Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said full immunity to the virus develops a week to 10 days after people get the second of two doses of a vaccine. “OK, so both of the vaccines that we’re talking about — the Moderna vaccine and the Pfizer vaccine — are what’s called a prime boost, one injection followed in (three to four) weeks by another injection,” Fauci told CNN’s Dr. Sanjay Gupta and Anderson Cooper on Friday during CNN’s Coronavirus Town Hall. People start to develop immunity after the first dose of the vaccine, Fauci said, but it’s not optimal. “After the second dose, you get optimal immunity anywhere from seven to 10 days after the second dose,” he said.

The vaccines appear to provide protection that is at least as strong, if not stronger than, the immunity that you find in a person who has had Covid-19.
“If you look at the vaccine, the level and quality of neutralizing antibodies was comparable to and even better than what you see in the convalescent plasma of people who actually were infected and developed an immune response,” he said. “It’s at least as good as the response associated with natural infection.”
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How Doctors Can Predict Who Dies From COVID

There are a number of studies that have come out about COVID 19 prognosis. We now have a powerful way to predict which patients with COVID 19 pneumonia are more likely to die, and more likely to require longer stays in the hospital. We already know that less than 15% of people who get COVID 19 have severe disease to the point of requiring hospitalization. Less than 5% of people who get coronavirus require ICU. For those with COVID 19 pneumonia who require ICU, and for some of the other patients in the hospital who might not necessarily need ICU, these are the patients who have the cytokine storm that we keep hearing about, meaning the immune system is going haywire, and there is a ton of inflammation taking place in the body….especially the lungs. But now, we have a more specific way of predicting who is more likely to develop cytokine storm, and therefore more likely to die, and who is more likely to require a longer stay in the hospital….and it’s based on the bloodwork we get when patients are hospitalized. When we get bloodwork, we’re doing various lab tests. Most commonly a complete blood count, or CBC, and a complete metabolic panel, or CMP. We often check other things as well, like troponin, d-dimer, LDH, ferritin, and CRP. A complete blood count is specifically looking at 3 things: levels of hemoglobin, platelets, and white blood cells. We can see not only the total number of WBC, but also the breakdown of the percentages of the types of white blood cells, meaning, what percentage are neutrophils, monocytes, lymphocytes, eosinophils, and basophils. Lymphocytes generally make up about 15-45% of WBC. This is very important as it pertains to COVID-19, and you’ll see why in a little bit. The CMP stands for the complete metabolic panel, and that is looking at levels of sodium, potassium, chloride, bicarbonate, blood urea nitrogen, creatinine, glucose, calcium, bilirubin, albumin, and liver enzymes like AST, ALT, and alkaline phosphatase. Some of these also have important implications when it comes to COVID 19 disease severity. Because In the recent study done at Temple University, they analyzed over 500 hospitalized COVID-19 patients, all of which had inflammation in their lungs seen on CT scan of the chest (show). They determined the criteria for COVID 19 cytokine storm. For patients who met these criteria, their length of stay in the hospital was on average 15 days, compared to 6 days if they did not meet the criteria. Mortality was 28.8% in the group that met criteria, vs 6.6% in those who did not meet criteria. So if they met cytokine storm criteria, their likelihood of dying was 4 times higher. And how accurate was this prediction model? Pretty accurate, as this study had a specificity of 79% and a sensitivity of 85%, which is a lot of predictive power. Most of the patients who met the criteria for CS did so at the time of admission or shortly after. This suggests that there is an early and rapid progression in these patients, and also suggests that there is a low likelihood of developing cytokine storm after 10 days of hospitalization. So based on these specific lab parameters, this is how doctors can predict which patients are more likely to die of COVID-19. And I do find that this study correlates with what I’ve seen in my personal experience with hospitalized covid patients. And yes, the man whose CT scan I showed you earlier in this video, met all of these criteria for cytokine storm, and he did so as soon as 24 hours of being admitted to the hospital.
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COVID-19 vaccine rollout relies heavily on pharmacy giants CVS and Walgreens

Plans to begin administering COVID-19 vaccines this month to millions of vulnerable Americans will depend not on public health departments but largely on the nation’s two largest for-profit pharmacy chains. CVS Health and Walgreens Boots Alliance were tapped by the Trump administration to vaccinate more than 3 million residents of nursing homes and other long-term care facilities, which are expected to get the first wave of vaccines perhaps as soon as next week.

The leading role highlights the power and reach of the two companies, which together have some 20,000 pharmacy locations nationwide. It also underscores how, after years of underinvestment in public health, the U.S. is highly dependent on for-profit companies for critical public services such as immunizations.

“We’re in a situation where we don’t have a public sector that’s able to do something like this,” said Jeffrey Levi, former director of the nonprofit Trust for America’s Health. “We have to work with the system we have.” Federal officials say the partnership with the pharmacy companies is a model that will rapidly get vaccines to needy patients. “I’m incredibly confident that these public-private partnerships are ready to execute,” U.S. Army Gen. Gus Perna told reporters this week. Perna is chief operating officer of Operation Warp Speed, the federal initiative set up by the Trump administration to support development and distribution of COVID-19 vaccines and medicines. Some public health leaders nevertheless remain leery of the heavy reliance on multibillion-dollar corporations whose primary duty is to their shareholders, especially as the full scope of the companies’ vaccine distribution work remains secret. Neither CVS and Walgreens nor the U.S. Department of Health and Human Services would provide copies of the agreements signed between the companies and the federal government. “At the end of the day, these are businesses,” said Lori Tremmel Freeman, who directs the National Assn. of County and City Health Officials. “They are not the same as a health department, whose business is keeping people safe. Health departments have no other motive. They don’t care about the bottom line.” Other healthcare experts warned that while CVS and Walgreens may have the logistical capability to get vaccine to thousands of nursing homes and assisted living facilities across the country, they may not be the best option to help other vulnerable populations, including the low-income and minority communities hit hardest by the pandemic. “We’ve learned over the years that the private sector, in general, does a really poor job of reaching out to at-risk populations,” said Christopher Koller, the former state insurance commissioner in Rhode Island who heads the Milbank Memorial Fund, a nonprofit supporting research on the healthcare system.

Walgreens, though it bills itself as a “health and wellness enterprise,” continues to sell cigarettes and other tobacco products, despite repeated pleas from public health officials to end the practice. (CVS stopped selling tobacco products in 2014.)Senior CVS and Walgreens officials insist they’re dedicated to the public health effort.

Rick Gates, Walgreens’ senior vice president for pharmacy, noted that vaccination clinics “are pretty core to what we do.” The initiative has been welcomed by the long-term care industry, which complained for months that the federal government failed to get vital protective equipment to its facilities. There is little dispute about the importance of the immunization effort. The pandemic has devastated long-term care facilities since the first major outbreak at a nursing home was recorded in February in Kirkland, Wash. More than 100,000 long-term care residents and staff have died, accounting for some 40% of the nation’s COVID-19 fatalities, according to a tally by the nonprofit Kaiser Family Foundation. The vulnerability of these institutions prompted the Centers for Disease Control and Prevention to advise states to give first priority to residents of nursing homes and healthcare workers when vaccines become available. Federal health officials said they selected CVS and Walgreens to lead the effort for nursing homes because of the companies’ vast network and experience serving long-term care facilities, many of which already work with them to get annual flu vaccines for residents. “We solicited input and had discussions with many different potential partners, the vast majority of whom told us they simply could not deliver on these capabilities,” said Paul Mango, deputy chief of staff at the federal Department of Health and Human Services. Under the CDC’s Pharmacy Partnership for Long-Term Care Program, nursing homes and other long-term care facilities were invited in October to select one of the pharmacy chains to deliver and administer vaccine to their residents and staff. More than 25,000 facilities selected CVS, according to the company. About 23,000 chose Walgreens, said Gates. The vaccines, which the federal government has purchased, will be administered at no cost to patients or to long-term care facilities. But CVS and Walgreens can bill for administering the shots. The Medicare payment rate is $16.94 for the first shot and $28.39 for the second, according to the fee schedule from the federal Centers for Medicare and Medicaid Services. Both Pfizer and Moderna, whose COVID-19 vaccines are expected to win approval first, require two shots. Importantly, the companies will have to report vaccination data to local, state and federal public health officials, a key component of any vaccination initiative. With Pfizer’s vaccine scheduled to be reviewed by an FDA panel next Thursday, the first shipments of vaccine could be headed out by next weekend, according to federal health officials. Moderna’s vaccine is scheduled for review the following week. Dr. Moncef Slaoui, the chief science advisor to Operation Warp Speed, told reporters this week that means there should be ample vaccine to reach all 3 million residents of long-term care facilities by the end of the year.

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Employment growth slows sharply in November amid coronavirus surge

  • Nonfarm payrolls increased by 245,000 in November, down from 610,000 in October.
  • The total was below the Wall Street estimate of 440,000.
  • Unemployment decreased to 6.7%, meeting expectations.
  • Job gains were concentrated in warehousing as well as professional and business services. Retail jobs fell ahead of the holiday shopping season.

Nonfarm payrolls increased by just 245,000 in November, well below Wall Street estimates as rising coronavirus cases coincided with a considerable slowdown in hiring.

Economists surveyed by Dow Jones had been looking for 440,000 and the jobless rate to decrease to 6.7% from 6.9% in October. The unemployment rate met expectations, though it fell along with a drop in the labor force participation rate to 61.5%. A more encompassing measure of joblessness edged lower to 12% while the number of Americans outside the labor force remains just above 100 million.

The November gain represented a pronounced slowdown from the 610,000 positions added in November. In all, the economy has brought back 12.3 million of the 22 million jobs lost in the first two months of the crisis. There are still 10.7 million Americans considered unemployed, compared to 5.8 million in February. The total of permanent job losers remained at 3.7 million in November, but is up 2.5 million from February. At the pace added in November, the economy would not be back to pre-pandemic employment levels until 2024, according to Daniel Zhao, senior economist at job placement site Glassdoor. “Today’s report is a firm reminder that we’re not out of the woods yet,” Zhao said. “Even with a vaccine on the horizon, many are bracing for a long winter ahead.” The November job gains would be considered strong under normal circumstances, but the pandemic has left millions of Americans out of work from jobs lost in the early stages of the crisis. The total represents the slowest job growth since the employment recovery began in May as the number of workers unemployed for at least 25 weeks surged 11% to nearly 4 million.

“Overall, it is a disappointing report,” economists at Jefferies said in a note. “With COVID cases surging again and policies being put in place to try and slow the spread, hiring has slowed down. Also, worker availability is a significant limiting factor as well, with many unable to go to work due to COVID concerns or family care obligations.” Despite the disappointing number, markets showed little reaction, with Wall Street expecting a higher open Job gains came from transportation and warehousing, which rose by 145,000 thanks to a jump in couriers and messengers as well as warehousing and storage. Professional and business services added 60,000 and health care was up 46,000. The battered hospitality industry, which has taken the worst of the job losses during the pandemic, increased just 31,000, while retail lost 35,000 jobs, a potentially troubling sign heading into the holiday shopping season. General merchandising stores dropped 21,000, while sporting goods, hobby, book and music stores declined by 12,000. Electronics and appliance stores were down by 11,000 while health and personal care stores cut 8,000. Overall, retail is down 550,000 employees from February, the month before the pandemic restrictions went into place. Construction and manufacturing each added 27,000 jobs for the month, while financial activities rose 15,000. Government hiring fell for the third straight month, down 99,000 primarily due to the loss of Census workers hired for the 2020 count.

The numbers come amid a new wave of coronavirus cases that threatens to push the U.S. healthcare system to the brink. More than 100,000 people are hospitalized across the U.S. due to the accelerated outbreak, which saw 210,161 new cases Thursday, according to the Covid Tracking Project overseen by journalists at The Atlantic.

Though the U.S. is coming off its fastest growth quarter ever, economists worry that the next quarter or two could see flat or even negative growth before rebounding strongly in the latter part of 2021.