Thursday, July 23, 2020

IS THIS THE END OF SANITIZING CHEMICALS?

Images courtesy of www.freshaireuv.com

In 2006, the U.S. Environmental Protection Agency approved a test plan for Biological Inactivation Efficiency by HVAC In-Duct Ultraviolet Light Air Cleaners. (1) The tests were conducted using three organisms, two bacteria (Bacillus atrophaeus and Serratia marcescens) and one bacterial virus (MS2).  These organisms were selected because their sizes, shapes and susceptibility to UV inactivation make them reasonable surrogates for biological warfare agents (BWAs). Generally, vegetative bacteria are readily killed and bacterial spores are more difficult. To model use in a VAC system, RTI used a test duct designed for testing filtration and inactivation efficiencies of aerosol, bioaerosol, and chemical challenges.  The bioaerosol inactivation efficiencies calculated for the three organisms were 9% for B. atrophaeus, 99.96% for S. marcescens and 75% for MS2. The irradiance was measured as 1190 W/cm2 at 161 cm(63 in.) upstream from the lamps with an airflow of 0.93 m3/sec (1970 cfm). The system had four lamps that were burned in for 100 hours prior to measurements.

UV lamps have been used to inactivate airborne microorganisms for many years. Much of the early work was directed at the control of very infectious microorganisms (particularly Mycobacterium tuberculosis, the causative agent of tuberculosis), often in medical facilities. Wavelengths within the short wave, or C band of UV light (UVC), were found to be the most effective germicidal light wavelengths. UVC usually is generated by use of UVC fluorescent lamps. These lamps use electrical discharge through low-pressure mercury vapor enclosed in a glass tube that transmits UVC light (primarily at the mercury wavelength of 253.7 nm). Because this wavelength has been found to be about the optimum for killing microorganisms, UVC from mercury lamps also is referred to as UVG to indicate that it is germicidal. UVG has been shown to inactivate viruses, mycoplasma, bacteria, and fungi when used appropriately.

Due to the recent pandemic, companies developing this technology are (now) on the fast track to advance UVC installations for a wide range of professional and commercial environments.  Specific testing is currently underway as to the efficacy against SARS-CoV-2 (the virus that causes COVID-19) but historically, systems like those developed by Fresh-Aire UV have been tested and proven effective against pathogens that require even greater UVC dosages.  "Every microorganism requires a specific UVC dosage for inactivation including the novel coronavirus. UV disinfection has been employed for decades in water treatment; these microwatt values have been used for reference to gauge UVC efficiency against a large cross-section of microorganisms. UV disinfection systems for room, surface & HVAC are (also) an ideal proactive measure to complement filtration", stated Aaron Engel, VP of Business Development at Fresh-Aire UV.

--------------------------------------------------------------------------------------------------------------------------


"My disease has played a very great role for my whole development… I was of course interested to know what benefit the sun really gave. During my work towards this goal I encountered several effects of light-- I then devised the treatment of small-pox in red light (1893) and further the treatment of lupus (1895)."-  Niels Ryberg Finsen


"VIRAL INACTIVATION": INSIGHTS FROM THE INDUSTRY
From an interview with Skytron technology | Written by: Cheri Ambrose
Introduction by: Dr. Robert L. Bard

In our current health crisis, prevention terms like DISINFECTING, SANITIZING or ANTI-BACTERIAL treatments are part of our common reality. Until recently, noxious "bio-killing" chemicals in atomized /spray form has been the most widely available choice on the market. With proper repeated use, fogging, spraying or ionizing chemistries in our living space are the popular option in contaminant prevention, but public concerns about the many possible physiological side effects of atomizing toxins into our air supply call for new alternatives.

Per-room disinfecting UV-C "Robot" (Skytron)
A sustainable upgrade in sanitizing was developed through the use of UV-C light. The CDC recognizes this innovation as one of the 'best disinfecting practices'. Ultraviolet germicidal irradiation (or UVGI) is the use of ultraviolet (UV) energy (electromagnetic radiation with a wavelength shorter than that of visible light) to kill or inactivate viral, bacterial, and fungal species. The UV spectrum is commonly divided into UV-A (wavelengths of 400 nm to 315 nm), UV-B (315 nm to 280 nm), and UV-C (280 nm to 200 nm). The entire UV spectrum can kill or inactivate many microorganisms, but UV-C energy provides the most germicidal effect, with 265 nm being the optimum wavelength. [1]

The earlier studies on the germicidal efficacy of far UVC light were performed exposing bacteria irradiated on a surface or in suspension. Modern developments have since honed the science of deactivating viruses and their ability to contaminate and transmit diseases with proven success when directly applying 222-254nm of UVC light on airborne viruses and microbes. [4]

On a recent interview, UVC expert Michael Czechowskyj of Skytron, a leading domestic manufacturer of infection prevention technologies presents valuable insight on the effectiveness of light disinfectants and the recent market expansion of UVC devices and installations. He discussed its ease-of-use and integrative friendliness of how a UVC device can take over the age-old spraying solutions.

"Today's UVC lamps are fully automated with complete safety features in place. You literally plug it in, start it up and leave the room to go about your day. Once the machine is done, it's perfectly safe that you can enter immediately. Not all sprayers and foggers can let you do that. And under the wait period, especially with ozone foggers, there's no ongoing chemicals that you're spraying or ongoing chemicals to buy either. Another difference is the coverage; with spray sanitizers, the sprayer can often MISS areas, or not spray enough solution in a specific area that needs it. This manual process of spraying leaves so much room for error and uncertainty. Irradiating a room with a UVC system does it all for you. It calculates the treatment time, intensity and because it's light, it gets into all the nooks and crannies to ensure a complete application."


HOW DOES IT WORK?
UV-C devices and lamps uses light wavelengths of around 254 nanometers, which denatures the DNA of the microbe. It creates a Thymine Dimer Pair, which prevents them from replicating. So it essentially does not kill the virus. It prevents it from reproducing, which means it prevents it from being infectious. Within a century of its existence, UV-C technology has maintained a constant design using the 254nm setup with a low pressure mercury amalgam bulb. The latest technology change was the bulb, where we eliminated ozone production. They have a special covering on them, which means that blocks the certain nanometers of light that produces ozone because ozone can be detrimental to humans as well.

Our devices all have a predetermined endpoint- much like filling a bucket of water.  Based on our research and lab studies, our machines identify when to turn itself off once it hits that mark of disinfecting the room. On a safety aspect, its 'dose' or application cycle is contingent upon the exact size of that room. There will be a faint, minor smell (most likely caused by irradiating the many particulates in the air) after the room and we call it "the new smell of clean".

'C. DIFF' TESTED- TOP MARKS IN "KILLING" AIRBORNE VIRUSES
There’s been very few studies done on the SARS COVID-19 virus. Most studies are done on surrogate pathogens. Corona viruses is recognized as a lipid based envelope virus and is fairly easy to kill. As with washing your hands, soap and water alone does a good job of killing this virus. We've also used a lot of similar studies on other types of CoronaViruses like MERS and SARS 14 COVID. Our devices are also calibrated for C-Diff (a spore producing bacteria known to cause a range if disorders from diarrhea to life-threatening inflammation of the colon- a bacteria that is very hard to kill, inactivate or sterilize). It is this lab standard that fosters the health industry's confidence in UVC technology's ability to inactivate the coronavirus.

Our industry undergoes strict efficacy studies with third party labs (to ensure the validity of the data) which is what are our end points were based on. Because of the nature of disinfecting, it's important to gain the confidence of the end user like a hospital- where we try to find more visualization for our clients. Something like a dosimeter color changing device (a device used to measure an absorbed dose of ionizing radiation) lets the director of a medical facility identify the right end point that they're looking for- and to make sure that they know the treatment is working properly.

RECENT APPLICATIONS
Facilitating health and safety protocols in this pandemic, UV-C disinfecting has been made available in smaller and larger applications. There's a smaller device that will disinfect masks in about six minutes. We defer to a lot of what the CDC has done with decontaminating N-95's. We know that not all UVC is created the same-- different bulbs, UVC output, wattage etc. And so, you know, we're real careful to make sure that we're keeping the clinicians as safe as possible and giving the people the information. When disinfecting an entire room, we use something called "dose assurance technology". This feature constantly reads the UVC field in real time; it reads the UVC that's being put out by the lamps and the UVC that is being reflected. We calibrated to a predetermined dose, that when they get to that end point, the machines then shut off knowing they've done their job well - within a specified time vs. ray intensity.

For additional information on UV-C technology or SKYTRON, visit www.skytron.com or contact Mr. Czechowskyj directly at mczechowskyj@skytron.com.



--------------------------------------------------------------------------------------------------------------------------



HISTORY
Niels Ryberg Finsen (1860-1904) was the first to employ UV rays in treating disease. He was awarded the Nobel Prize for Medicine in 1903 for his invention of the Finsen curative lamp, which was used successfully through the 1950s. [01]  Updates in the technology for commercial use evolved as UV-C germicidal lamps in the 1930's and have been primarily used in healthcare facilities. UVGI is highly recognized for addressing airborne microbial disease prevention (including influenza and tuberculosis). UVC is proven to prevent airborne transmission by deactivating airborne pathogens, but public use has been curtailed due to its potential to cause cancers and cataracts upon direct contact. [02]

The history of UVGI air disinfection has been one of promise, disappointment, and rebirth. Investigations of the bactericidal effect of sunlight in the late 19th century planted the seed of air disinfection by UV radiation. First to nurture this seed was Richard L. Riley and his mentor William F. Wells, who both discovered the spread of airborne infection by droplet nuclei and demonstrated the ability of UVGI to prevent such spread. With the enduring research of Riley and others, and an increase in tuberculosis (TB) during the 1980s, interest in UVGI was revitalized. With modern concerns regarding multi- and extensive drug-resistant TB, bioterrorism, influenza pandemics, and severe acute respiratory syndrome, interest in UVGI continues to grow. Research is ongoing, and there is much evidence on the efficacy of UVGI and the proper way to use it, though the technology has yet to fully mature.  [3]

...................................................................................................................................................................
Epilogue: Straight Answers from the CDC
In our commitment to publish helpful information about innovative solutions, we rely on top health  authorities to provide us with unbiased clarity and technical standards. We inquired about how UV-C Disinfecting technology truly ranked as the future solution to defeating viruses and transmitted diseases. Steve Martin, PhD, an engineer in NIOSH’s Respiratory Health Division provided us with these valuable statements:

Q: Does the CDC see UV-C Disinfecting as the next trend- evolving from chemical spray sanitizing?
A: No.  CDC understands that germicidal UV technologies, including patient room terminal cleaning devices (sometimes called UV robots), can provide enhanced surface disinfection over the use of chemical disinfectants alone. However, UV technologies, as they currently exist, will never replace manual chemical cleaning in healthcare spaces.  While UV can be very efficient at inactivating pathogens on surfaces, UV-C energy cannot substantially penetrate blood and other bodily fluids, or through other simple spills and splashes that occur in the course of patient care, even those that have dried and left residues. Thus, healthcare surfaces need to first be thoroughly cleaned to remove gross contamination before the UV energy can directly impact the surfaces and provide the most disinfection benefit. Then, UV systems that are properly applied can effectively inactivate many of the pathogens that manual cleaning may have left behind.

Q: From an original post on 2016, CDC warned about potential OZONE output from UV.  It has been evident that companies have since been addressing the testing, preventing and validating of ozone output.  Does CDC have enough data on this upgrade?
A: Concerns about UV lamps producing ozone have existed for decades and there have not been any significant “upgrades” since 2016.  There are some UV-C lamps designed specifically to produce ozone.  Ozone-producing lamps generally do not use an internal coating on the glass (or quartz) tube so UV energy at wavelengths below 200 nm (predominantly 185 nm) is emitted from the lamp. These wavelengths are responsible for ozone production.  There is a separate group of UV-C lamps designed specifically not to produce ozone.  This group is the low-pressure mercury vapor lamps used for germicidal ultraviolet (GUV) applications.  GUV lamps have interior coatings to block UV energy at wavelengths below 200 nm from escaping the tube, so ozone is not created. Unfortunately, ozone-producing lamps and GUV lamps of the same type and size can often be powered using the same electrical connectors and electronic drivers (ballasts).  So, it is critical for the end user to choose the proper lamp for their application.  If they choose a typical GUV lamp for a germicidal application, then ozone is not a concern.  If an end user unknowingly chooses an ozone-producing lamp that happens to fit properly into their GUV device, then ozone exposures will happen. CDC always recommends that end users communicate with the UV device manufacturer or a reputable UV system designer when purchasing replacement UV lamps.

...................................................................................................................................................................

CONTRIBUTORS

ROBERT L. BARD, MD, PC, DABR, FASLMS
Advanced Imaging & Diagnostic Specialist
Dr. Bard received the 2020 nationally acclaimed Ellis Island Award for his lifetime achievement in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. 


PIERRE KORY, M.D., M.P.A.
Dr. Kory is Board Certified in Internal Medicine, Critical Care, and Pulmonary Medicine. He served as the Medical Director of the Trauma and Life Support Center at the University of Wisconsin where he was an Associate Professor and the Chief of the Critical Care Service. He is considered a pioneer and national/international expert in the field of Critical Care Ultrasound and is the senior editor of the widely read textbook “Point-of-Care Ultrasound” (winner of the President’s Choice Award for Medical Textbooks from the British Medical Association in 2015).  Most recently, Dr. Kory joined the emergency volunteer team during the early COVID-19 pandemic in NYC at Mount Sinai Beth Israel Medical Center. He is also a founding member of the Front Line COVID-19 Critical Working Group (flccc.net) composed of 5 critical care experts that devised the COVID-19 treatment protocol called MATH+. (www.covid19criticalcare.com/)

AARON ENGEL
Mr Engel is Vice-President of Business Development for Fresh-Aire UV, a global leader in UV disinfection technologies. Aaron has 20 years experience in the design, manufacturing and marketing of UV disinfection systems for domestic and international applications including those for residential, commercial and healthcare. Aaron has worked on projects with various groups & associations including the definitive study on UV inactivation of airborne bioterrorism agents sponsored by RTI, the United States EPA & US National Homeland Security. Aaron is frequent guest speaker and lecturer and contributes to publications on IAQ technologies and UV disinfection. Aaron is a member on various ASHRAE committees including TC2.9 Ultraviolet Air and Surface Treatment and the Programs Chair for TC2.9.  www.freshaireuv.com

MICHAEL CZECHOWSKYJ MSN, RN
Taking care of patients at the bedside is where Mike Czechowskyj started his nursing career.  After caring for patients in the Progressive Care and Burn ICU, he advanced into different leadership positions at Spectrum Health.  There he helped educate new staff, build new programs and advanced nursing practice.  He then joined the Spectrum Health Innovations team where he worked with local businesses, health systems, and universities to create new medical devices that would help patients and healthcare providers.  This led him to one of their partners, Skytron, where Michael now provides leadership for the Infection Prevention team. www.skytron.com


2) Disinfection and Sterilization Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)
3) US National Library of Medicine National Institutes of Health: The History of Ultraviolet Germicidal Irradiation for Air Disinfection  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789813/
4) Far-UVC light: A new tool to control the spread of airborne-mediated microbial diseases

©Copyright Intermedia Worx Inc./Prevention 101. All Rights Reserved.

Wednesday, July 22, 2020

DOES UV-C HOLD THE PROMISE OF SAFE SANITIZING?

"My disease has played a very great role for my whole development… I was of course interested to know what benefit the sun really gave. During my work towards this goal I encountered several effects of light-- I then devised the treatment of small-pox in red light (1893) and further the treatment of lupus (1895)."-  Niels Ryberg Finsen


Written by: Cheri Ambrose  /   Introduction by: Dr. Robert L. Bard

In our current health crisis, prevention terms like DISINFECTING, SANITIZING or ANTI-BACTERIAL treatments are part of our common reality. Until recently, noxious "bio-killing" chemicals in atomized /spray form has been the most widely available choice on the market. With proper repeated use, fogging, spraying or ionizing chemistries in our living space are the popular option in contaminant prevention, but public concerns about the many possible physiological side effects of atomizing toxins into our air supply call for new alternatives.

Per-room disinfecting UV-C "Robot" (Skytron)
A sustainable upgrade in sanitizing was developed through the use of UV-C light. The CDC recognizes this innovation as one of the 'best disinfecting practices'. Ultraviolet germicidal irradiation (or UVGI) is the use of ultraviolet (UV) energy (electromagnetic radiation with a wavelength shorter than that of visible light) to kill or inactivate viral, bacterial, and fungal species. The UV spectrum is commonly divided into UV-A (wavelengths of 400 nm to 315 nm), UV-B (315 nm to 280 nm), and UV-C (280 nm to 200 nm). The entire UV spectrum can kill or inactivate many microorganisms, but UV-C energy provides the most germicidal effect, with 265 nm being the optimum wavelength. [1]

"VIRAL INACTIVATION": INSIGHTS FROM THE INDUSTRY
(From an interview with Skytron technology)
The earlier studies on the germicidal efficacy of far UVC light were performed exposing bacteria irradiated on a surface or in suspension. Modern developments have since honed the science of deactivating viruses and their ability to contaminate and transmit diseases with proven success when directly applying 222-254nm of UVC light on airborne viruses and microbes. [4]

On a recent interview, UVC expert Michael Czechowskyj of Skytron, a leading domestic manufacturer of infection prevention technologies presents valuable insight on the effectiveness of light disinfectants and the recent market expansion of UVC devices and installations. He discussed its ease-of-use and integrative friendliness of how a UVC device can take over the age-old spraying solutions.

"Today's UVC lamps are fully automated with complete safety features in place. You literally plug it in, start it up and leave the room to go about your day. Once the machine is done, it's perfectly safe that you can enter immediately. Not all sprayers and foggers can let you do that. And under the wait period, especially with ozone foggers, there's no ongoing chemicals that you're spraying or ongoing chemicals to buy either. Another difference is the coverage; with spray sanitizers, the sprayer can often MISS areas, or not spray enough solution in a specific area that needs it. This manual process of spraying leaves so much room for error and uncertainty. Irradiating a room with a UVC system does it all for you. It calculates the treatment time, intensity and because it's light, it gets into all the nooks and crannies to ensure a complete application."


HOW DOES IT WORK?
UV-C devices and lamps uses light wavelengths of around 254 nanometers, which denatures the DNA of the microbe. It creates a Thymine Dimer Pair, which prevents them from replicating. So it essentially does not kill the virus. It prevents it from reproducing, which means it prevents it from being infectious. Within a century of its existence, UV-C technology has maintained a constant design using the 254nm setup with a low pressure mercury amalgam bulb. The latest technology change was the bulb, where we eliminated ozone production. They have a special covering on them, which means that blocks the certain nanometers of light that produces ozone because ozone can be detrimental to humans as well.

Our devices all have a predetermined endpoint- much like filling a bucket of water.  Based on our research and lab studies, our machines identify when to turn itself off once it hits that mark of disinfecting the room. On a safety aspect, its 'dose' or application cycle is contingent upon the exact size of that room. There will be a faint, minor smell (most likely caused by irradiating the many particulates in the air) after the room and we call it "the new smell of clean".

'C. DIFF' TESTED- TOP MARKS IN "KILLING" AIRBORNE VIRUSES
There’s been very few studies done on the SARS COVID-19 virus. Most studies are done on surrogate pathogens. Corona viruses is recognized as a lipid based envelope virus and is fairly easy to kill. As with washing your hands, soap and water alone does a good job of killing this virus. We've also used a lot of similar studies on other types of CoronaViruses like MERS and SARS 14 COVID. Our devices are also calibrated for C-Diff (a spore producing bacteria known to cause a range if disorders from diarrhea to life-threatening inflammation of the colon- a bacteria that is very hard to kill, inactivate or sterilize). It is this lab standard that fosters the health industry's confidence in UVC technology's ability to inactivate the coronavirus.

Our industry undergoes strict efficacy studies with third party labs (to ensure the validity of the data) which is what are our end points were based on. Because of the nature of disinfecting, it's important to gain the confidence of the end user like a hospital- where we try to find more visualization for our clients. Something like a dosimeter color changing device (a device used to measure an absorbed dose of ionizing radiation) lets the director of a medical facility identify the right end point that they're looking for- and to make sure that they know the treatment is working properly.

RECENT APPLICATIONS
Facilitating health and safety protocols in this pandemic, UV-C disinfecting has been made available in smaller and larger applications. There's a smaller device that will disinfect masks in about six minutes. We defer to a lot of what the CDC has done with decontaminating N-95's. We know that not all UVC is created the same-- different bulbs, UVC output, wattage etc. And so, you know, we're real careful to make sure that we're keeping the clinicians as safe as possible and giving the people the information. When disinfecting an entire room, we use something called "dose assurance technology". This feature constantly reads the UVC field in real time; it reads the UVC that's being put out by the lamps and the UVC that is being reflected. We calibrated to a predetermined dose, that when they get to that end point, the machines then shut off knowing they've done their job well - within a specified time vs. ray intensity.

For additional information on UV-C technology or SKYTRON, visit www.skytron.com or contact Mr. Czechowskyj directly at mczechowskyj@skytron.com.



--------------------------------------------------------------------------------------------------------------------------


Images courtesy of www.freshaireuv.com

In 2006, the U.S. Environmental Protection Agency approved a test plan for Biological Inactivation Efficiency by HVAC In-Duct Ultraviolet Light Air Cleaners. (1) The tests were conducted using three organisms, two bacteria (Bacillus atrophaeus and Serratia marcescens) and one bacterial virus (MS2).  These organisms were selected because their sizes, shapes and susceptibility to UV inactivation make them reasonable surrogates for biological warfare agents (BWAs). Generally, vegetative bacteria are readily killed and bacterial spores are more difficult. To model use in a VAC system, RTI used a test duct designed for testing filtration and inactivation efficiencies of aerosol, bioaerosol, and chemical challenges.  The bioaerosol inactivation efficiencies calculated for the three organisms were 9% for B. atrophaeus, 99.96% for S. marcescens and 75% for MS2. The irradiance was measured as 1190 W/cm2 at 161 cm(63 in.) upstream from the lamps with an airflow of 0.93 m3/sec (1970 cfm). The system had four lamps that were burned in for 100 hours prior to measurements.

UV lamps have been used to inactivate airborne microorganisms for many years. Much of the early work was directed at the control of very infectious microorganisms (particularly Mycobacterium tuberculosis, the causative agent of tuberculosis), often in medical facilities. Wavelengths within the short wave, or C band of UV light (UVC), were found to be the most effective germicidal light wavelengths. UVC usually is generated by use of UVC fluorescent lamps. These lamps use electrical discharge through low-pressure mercury vapor enclosed in a glass tube that transmits UVC light (primarily at the mercury wavelength of 253.7 nm). Because this wavelength has been found to be about the optimum for killing microorganisms, UVC from mercury lamps also is referred to as UVG to indicate that it is germicidal. UVG has been shown to inactivate viruses, mycoplasma, bacteria, and fungi when used appropriately.

Due to the recent pandemic, companies developing this technology are (now) on the fast track to advance UVC installations for a wide range of professional and commercial environments.  Specific testing is currently underway as to the efficacy against SARS-CoV-2 (the virus that causes COVID-19) but historically, systems like those developed by Fresh-Aire UV have been tested and proven effective against pathogens that require even greater UVC dosages.  "Every microorganism requires a specific UVC dosage for inactivation including the novel coronavirus. UV disinfection has been employed for decades in water treatment; these microwatt values have been used for reference to gauge UVC efficiency against a large cross-section of microorganisms. UV disinfection systems for room, surface & HVAC are (also) an ideal proactive measure to complement filtration", stated Aaron Engel, VP of Business Development at Fresh-Aire UV. 
--------------------------------------------------------------------------------------------------------------------------


HISTORY
Niels Ryberg Finsen (1860-1904) was the first to employ UV rays in treating disease. He was awarded the Nobel Prize for Medicine in 1903 for his invention of the Finsen curative lamp, which was used successfully through the 1950s. [01]  Updates in the technology for commercial use evolved as UV-C germicidal lamps in the 1930's and have been primarily used in healthcare facilities. UVGI is highly recognized for addressing airborne microbial disease prevention (including influenza and tuberculosis). UVC is proven to prevent airborne transmission by deactivating airborne pathogens, but public use has been curtailed due to its potential to cause cancers and cataracts upon direct contact. [02]

The history of UVGI air disinfection has been one of promise, disappointment, and rebirth. Investigations of the bactericidal effect of sunlight in the late 19th century planted the seed of air disinfection by UV radiation. First to nurture this seed was Richard L. Riley and his mentor William F. Wells, who both discovered the spread of airborne infection by droplet nuclei and demonstrated the ability of UVGI to prevent such spread. With the enduring research of Riley and others, and an increase in tuberculosis (TB) during the 1980s, interest in UVGI was revitalized. With modern concerns regarding multi- and extensive drug-resistant TB, bioterrorism, influenza pandemics, and severe acute respiratory syndrome, interest in UVGI continues to grow. Research is ongoing, and there is much evidence on the efficacy of UVGI and the proper way to use it, though the technology has yet to fully mature.  [3]

...................................................................................................................................................................
Epilogue: Straight Answers from the CDC
In our commitment to publish helpful information about innovative solutions, we rely on top health  authorities to provide us with unbiased clarity and technical standards. We inquired about how UV-C Disinfecting technology truly ranked as the future solution to defeating viruses and transmitted diseases. Steve Martin, PhD, an engineer in NIOSH’s Respiratory Health Division provided us with these valuable statements:

Q: Does the CDC see UV-C Disinfecting as the next trend- evolving from chemical spray sanitizing?
A: No.  CDC understands that germicidal UV technologies, including patient room terminal cleaning devices (sometimes called UV robots), can provide enhanced surface disinfection over the use of chemical disinfectants alone. However, UV technologies, as they currently exist, will never replace manual chemical cleaning in healthcare spaces.  While UV can be very efficient at inactivating pathogens on surfaces, UV-C energy cannot substantially penetrate blood and other bodily fluids, or through other simple spills and splashes that occur in the course of patient care, even those that have dried and left residues. Thus, healthcare surfaces need to first be thoroughly cleaned to remove gross contamination before the UV energy can directly impact the surfaces and provide the most disinfection benefit. Then, UV systems that are properly applied can effectively inactivate many of the pathogens that manual cleaning may have left behind.

Q: From an original post on 2016, CDC warned about potential OZONE output from UV.  It has been evident that companies have since been addressing the testing, preventing and validating of ozone output.  Does CDC have enough data on this upgrade?
A: Concerns about UV lamps producing ozone have existed for decades and there have not been any significant “upgrades” since 2016.  There are some UV-C lamps designed specifically to produce ozone.  Ozone-producing lamps generally do not use an internal coating on the glass (or quartz) tube so UV energy at wavelengths below 200 nm (predominantly 185 nm) is emitted from the lamp. These wavelengths are responsible for ozone production.  There is a separate group of UV-C lamps designed specifically not to produce ozone.  This group is the low-pressure mercury vapor lamps used for germicidal ultraviolet (GUV) applications.  GUV lamps have interior coatings to block UV energy at wavelengths below 200 nm from escaping the tube, so ozone is not created. Unfortunately, ozone-producing lamps and GUV lamps of the same type and size can often be powered using the same electrical connectors and electronic drivers (ballasts).  So, it is critical for the end user to choose the proper lamp for their application.  If they choose a typical GUV lamp for a germicidal application, then ozone is not a concern.  If an end user unknowingly chooses an ozone-producing lamp that happens to fit properly into their GUV device, then ozone exposures will happen. CDC always recommends that end users communicate with the UV device manufacturer or a reputable UV system designer when purchasing replacement UV lamps.


...................................................................................................................................................................


CONTRIBUTORS

ROBERT L. BARD, MD, PC, DABR, FASLMS
Advanced Imaging & Diagnostic Specialist
Dr. Bard received the 2020 nationally acclaimed Ellis Island Award for his lifetime achievement in advanced cancer diagnostic imaging. He co-founded the 9/11 CancerScan program to bring additional diagnostic support to all first responders from Ground Zero. His main practice in midtown, NYC (Bard Diagnostic Imaging- www.CancerScan.com) uses the latest in digital imaging technology and has been also used to help guide biopsies and in many cases, even replicate much of the same reports of a clinical invasive biopsy. Imaging solutions such as high-powered sonograms, Power Doppler Histogram, sonofluoroscopy, 3D/4D image reconstruction and the Power Doppler Histogram  are safe, noninvasive, and do not use ionizing radiation. 

PIERRE KORY, M.D., M.P.A.
Dr. Kory is Board Certified in Internal Medicine, Critical Care, and Pulmonary Medicine. He served as the Medical Director of the Trauma and Life Support Center at the University of Wisconsin where he was an Associate Professor and the Chief of the Critical Care Service. He is considered a pioneer and national/international expert in the field of Critical Care Ultrasound and is the senior editor of the widely read textbook “Point-of-Care Ultrasound” (winner of the President’s Choice Award for Medical Textbooks from the British Medical Association in 2015).  Most recently, Dr. Kory joined the emergency volunteer team during the early COVID-19 pandemic in NYC at Mount Sinai Beth Israel Medical Center. He is also a founding member of the Front Line COVID-19 Critical Working Group (flccc.net) composed of 5 critical care experts that devised the COVID-19 treatment protocol called MATH+. (www.covid19criticalcare.com/)



MICHAEL CZECHOWSKYJ MSN, RN
Taking care of patients at the bedside is where Mike Czechowskyj started his nursing career.  After caring for patients in the Progressive Care and Burn ICU, he advanced into different leadership positions at Spectrum Health.  There he helped educate new staff, build new programs and advanced nursing practice.  He then joined the Spectrum Health Innovations team where he worked with local businesses, health systems, and universities to create new medical devices that would help patients and healthcare providers.  This led him to one of their partners, Skytron, where Michael now provides leadership for the Infection Prevention team. www.skytron.com


AARON ENGEL
Mr Engel is Vice-President of Business Development for Fresh-Aire UV, a global leader in UV disinfection technologies. Aaron has 20 years experience in the design, manufacturing and marketing of UV disinfection systems for domestic and international applications including those for residential, commercial and healthcare. Aaron has worked on projects with various groups & associations including the definitive study on UV inactivation of airborne bioterrorism agents sponsored by RTI, the United States EPA & US National Homeland Security. Aaron is frequent guest speaker and lecturer and contributes to publications on IAQ technologies and UV disinfection. Aaron is a member on various ASHRAE committees including TC2.9 Ultraviolet Air and Surface Treatment and the Programs Chair for TC2.9.  www.freshaireuv.com


2) Disinfection and Sterilization Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)
3) US National Library of Medicine National Institutes of Health: The History of Ultraviolet Germicidal Irradiation for Air Disinfection  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789813/
4) Far-UVC light: A new tool to control the spread of airborne-mediated microbial diseases

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Monday, July 20, 2020

Sonographic signs and patterns of COVID-19 pneumonia

by: Giovanni Volpicelli & Luna Gargani  / Published: 21 April 2020





Abstract
The pandemic of COVID-19 is seriously challenging the medical organization in many parts of the world. This novel corona virus SARS-CoV-2 has a specific tropism for the low respiratory airways, but causes severe pneumonia in a low percentage of patients. However, the rapid spread of the infection during this pandemic is causing the need to hospitalize a high number of patients. Pneumonia in COVID-19 has peculiar features and can be studied by lung ultrasound in the early approach to suspected patients. The sonographic signs are non-specific when considered alone, but observation of some aspects of vertical artifacts can enhance the diagnostic power of the ultrasound examination. Also, the combination of sonographic signs in patterns and their correlation with blood exams in different phenotypes of the disease may allow for a reliable characterization and be of help in triaging and admitting patients.

Chest imaging is in the front door in the diagnostic approach to any patient with respiratory and infective symptoms during this COVID-19 outbreak. The novel corona virus has a specific tropism for the low respiratory airways and the main complication of the disease is pneumonia. Analysis of chest CT scans from patients with COVID-19 allowed important conclusions about the main aspects of the disease [1,2,3]. The characteristic feature visible in all patients with pneumonia is the Ground Glass Opacification (GGO), a descriptive term indicating interstitial alteration of the lung parenchyma. This was variably associated with peripheral consolidations and crazy paving, a more advanced interstitial alteration where the GGO is combined with interlobular thickening. COVID-19 typically induces an interstitial diffuse bilateral pneumonia with lesions in asymmetric and patchy distribution involving mainly the lung periphery, which makes it particularly suitable for an ultrasound investigation. Alternation of GGO with crazy paving and consolidations can be well depicted by lung ultrasound (LUS). Finally, LUS imaging is also useful to observe the regional distribution of these patterns and describe the patchy bilateral spread of lesions.

Main signs at lung ultrasound
The sonographic signs of interest in COVID-19 include all those which are well known in ARDS. These are the B-lines in various forms, both separate and coalescent, irregular or fragmented aspect of the pleural line, and small peripheral consolidations. Explanations and demonstrations of all these signs can be easily found in the vast existing literature on the topic [4]. However, in the diagnosis of COVID-19 some specificities need to be considered.

B-lines B-lines in COVID-19 pneumonia are visualized in all their possible forms. We may describe COVID-19 pneumonia as a storm of clusters of B-lines, both in separate and coalescent forms, sometimes giving the appearance of a shining white lung. They can arise from one point of the pleural line and from small peripheral consolidations and spread down like rays maintaining their brightness until the edge of the screen without fading. These artifacts represent the typical signs of the disease, but can be also observed in other interstitial diseases of various etiologies [4]. However, we are observing that one peculiar aspect of these artifacts is invariably visualized in the early phases of COVID-19 pneumonia (unpublished data). It is a shining band-form artifact spreading down from a large portion of a regular pleural line, often appearing and disappearing with an on–off effect in the context of a normal A-lines lung pattern visible on the background

In our opinion, this sign is demonstrative of a very acute phase of GGO lesions during the early spread of the active disease, when limited areas of lesions alternate with preserved lung parenchyma. Other Chinese authors called this sign “waterfall”, without further characterizing it [5]. They did not differentiate this vertical artifact from other less specific signs, like coalescent B-lines arising from peripheral consolidations or from a very irregular pleural line. We think that the name “light beam” can well describe this artifact, as a large beam of light sometimes appearing and disappearing during respiration. Identifying this band-form sign as the one arising from a large portion of a regular pleural line helps characterizing the LUS pattern. As a technical note, it is crucial to use a convex probe with a large emission surface and low frequency to visualize the light beam more reliably. It is also important to position the focus at the level of the pleural line to prevent misinterpretations of the vertical artifacts.

TO SEE COMPLETE ARTICLE, VISIT: THE ULTRASOUND JOURNAL/SPRINGER

References
1. Wu J, Wu X, Zeng W et al (2019) Chest CT findings in patients with corona virus disease 2019 and its relationship with clinical features. Invest Radiol. https://doi.org/10.1097/rli.0000000000000670

2. Zhao W, Zhong Z, Xie X et al (2020) Relation between chest CT findings and clinical conditions of coronavirus disease (COVID-19) pneumonia: a multicenter study. Am J Roentgenol 3:1–6. https://doi.org/10.2214/AJR.20.22976

3. Zhou S, Wang Y, Zhu T et al (2020) CT features of coronavirus disease 2019 (COVID-19) pneumonia in 62 patients in Wuhan, China. Am J Roentgenol 5:1–8. https://doi.org/10.2214/AJR.20.22975

4. Volpicelli G, Elbarbary M, Blaivas M et al (2012) International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 38(4):577–591. https://doi.org/10.1007/s00134-012-2513-4

5. Huang Y, Wang S, Liu Y et al (2020) A preliminary study on the ultrasonic manifestations of peripulmonary lesions of non-critical novel coronavirus pneumonia (COVID-19). SSRN. https://doi.org/10.2139/ssrn.3544750

6. Nazerian P, Cerini G, Vanni S et al (2016) Diagnostic accuracy of lung ultrasonography combined with procalcitonin for the diagnosis of pneumonia: a pilot study. Crit Ultrasound J 8(1):17. https://doi.org/10.1186/s13089-016-0054-8


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Sunday, July 19, 2020

Chest Ultrasound- Smart Uses in identifying Respiratory Issues







“When conducting lung ultrasound scanning, you look for signs of B-LINES. The more B lines you have equals a bad lung ultrasound score – indicating a high risk of deterioration. For any treatment protocol, if a patient whose lung ultrasound scan was getting worse, I might want to start escalating my therapy.” – Dr. Philippe Kory, MATH+

Monday, July 6, 2020

COALITION OF GLOBAL SCIENTISTS IN SOLIDARITY TO SAVE LIVES






By: Cheri Ambrose & Adrian Barrios

June 24, 2020- Months into the CoronaVirus pandemic, the tally of efforts expended by government health agencies and professionals worldwide has been noted to significantly exceed any global campaign in history.  Economists tend to use war terms to help put the pandemic's containment efforts and collateral damage in perspective.  IMF's chief economist Gita Gopinath,  (in an April 15 news conference) stated that "the best case scenario, the world is likely to lose a cumulative $9 trillion in output over two years"- making this a global war 3x the fiscal size of World War II.

As with past wars, alliances were formed, industries were committed to task and scientists worldwide have united by sharing information toward this single directive. The Department of Global Communications (U.N.) announced their drive to mobilize global cooperation in science-based COVID-19 responses, "The United Nations is mobilizing international cooperation to harness the power of science to tackle the coronavirus pandemic, while also working with partners to explore innovative crisis response tools."

Epidemiology
Unlike the early months of the year, the second quarter showed the front lines to finally "catching up to the war efforts" with installments of these comprehensive containment measures:
  • a dedicated testing strategy & global data tracking
  • ample access to Covid tests and antibody testing
  • policy enforced education about preventive and safety guidelines
  • ample manufacturing of medical equipment and medicines
  • consistent PPE supply & distribution chains
  • trained critical care response personnel
  • lab research for therapeutics and vaccines

GLOBAL SOLIDARITY AGAINST THE PANDEMIC
"The COVID-19 pandemic has demonstrated the interconnected nature of our world – and that no one is safe until everyone is safe.  Only by acting in solidarity can communities save lives and overcome the devastating socio-economic impacts of the virus.  In partnership with the United Nations, people around the world are showing acts of humanity, inspiring hope for a better future." - United Nations

World medical conferences and international forums unite
multidisciplinary experts to continue global info-sharing
This pandemic has clearly illustrated that "Scientists by nature do not see borders or politics - only solutions", states Dr. Robert Bard, cancer diagnostics expert (NYC). "The spirit of teamwork is alive and well with this community- especially in a crisis. Historically, medical and scientific people have always raced to the front lines - always at the ready to pool resources and collaborate.  Like the domestic and international health associations, we continue to see some of the sharpest clinical minds in the world- including American teams that are now coming out with promising protocols to help end this pandemic.  To contain and eliminate this human threat means UNITING WITH SCIENCE AND WORKING TOGETHER ON A COORDINATED GOAL."

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IS MATH+ THE LIFE-SAVING PROTOCOL TO SAVE US FROM THE CORONAVIRUS?  



With a confirmed global count of 9.27+ Million cases and 470,000+ deaths,  the world continues its desperate search for a treatment that will save the lives of COVID-19 patients who come into the ER or hospital with low oxygen levels or struggling to breathe.  Where the more popular treatment for patients in ICU is the use of ventilators, a reported 80-85% of Covid-19 patients on ventilators in New York end up dying (Associated Press and state and city officials).

A founding union of experts discuss the MATH+
protocol in this widely shared video: SEE LINK
M.A.T.H.+ ESSENTIALS:
Recently, a group of scholars specializing in critical care developed what appears to be an effective treatment protocol using a combination of medicines that is having remarkable success in hospitals that have adopted its use. According to the critical care physicians applying this formula, MATH+ manages multiple facets of the illness, such as sepsis, inflammation, severe clotting, and acute respiratory distress syndrome (ARDS), all complications known to arise from CoronaVirus infection. This protocol is designed to counter the body’s overwhelming inflammatory response to the virus as it is this hyper‐inflammation, not the virus itself, that damages the lungs and other organs, and ultimately leads to multi-organ failure and death. (To view the complete video of the founding union of experts discuss the MATH+ protocol, visit: www.covid19criticalcare.com)

The corticosteroid Methylprednisolone is a key component, based on large studies that have proven its effectiveness in prior viral pandemics‐ and whose potency is significantly increased when administered intravenously with high doses of the antioxidant Ascorbic acid (Vitamin C)Thiamine (Vitamin B1) is given to optimize cellular oxygen utilization and energy consumption, protecting the heart, brain, and immune system and the anticoagulant Heparin prevents (or breaks up) blood clots that increasingly appear as illness worsens. The + represents other supportive treatments by the administering doctor for patients who present other pre‐existing conditions (as needed). The group also plans to add or change components and dosing as published  medical  literature evolves.


PROVEN SUCCESS FROM THE FRONT LINES
This segment is based on a recent interview with Dr. Joseph Varon, Chief of Clinical Care at the United Memorial Medical Center in Houston, TX.  Dr. Varon introduces the MATH+ treatment solution from the Covid Unit of one of America's latest CoronaVirus epicenters.




THE JUNE SPIKE OF HOUSTON
According to the Texas Medical Center data, COVID-19 cases escalated from 267 in week 10 (5/31) to 962 in week 13 (6/21). "I've had the worst 48 hours of the last 84 days. I have received more patients over the last two weeks than in the last 10 weeks [totalled]. As the state opened up, people get crazy‐‐ this includes Memorial day weekend and last week's protest and mass gatherings. Out of all this, my ward is getting a flood of patients. I have tested more than 55,000 people for Covid in the Houston metropolitan area‐‐ and out of those 55,000, 10.5% are Covid positive. And these numbers in Texas are still going up."

Dr. Varon attributes the current increase in case numbers to the lack of social distancing among the general public as the state's lock‐down is released. "I'm seeing more cases now than I have ever seen. So I have to trust our data based on all that work that we have done as a group. The problem is that (at least) in Texas, when people got told that they can go out to restaurants, they act as if CoronaVirus is over! There is no social distancing, no masks... nothing. The virus is very unique and what we're seeing now, the severity of illness for us is increasing from all these mass gatherings... but also the people‐‐ they don't give too much attention to the virus. By the time they come to us, it's often too late. MATH+ works beautifully when you start early. So the sooner I can start you off, the better off you are!"

REPLACING THE VENTILATOR
Medical data from UMMC Covid Patients
Treated with MATH+: Click to Enlarge
Countless news reports and researchers are now showing a significant percentage (75‐85%) of ventilated patients are ending in death. Interviews with medical experts state that patients who are ventilated typically have critical or dire conditions‐ whereby ventilators are not the cause of death.

According to the Journal of American Medical Assoc., "In (a) case series that included 5700 patients hospitalized with COVID‐19 in the New York City area, the most common comorbidities were hypertension, obesity, and diabetes. Among patients who were discharged or died (n = 2634), 14.2% were treated in the intensive care unit, 12.2% received invasive mechanical ventilation, 3.2% were treated with kidney replacement therapy, and 21% died."

"When the pandemic started, my partner who owns a hospital was going crazy, trying to get ventilators. When we started working with MATH+, we actually changed the whole concept of treatment. Out of the last 70 patients that I've had with severe Covid, only two have required ventilators.  Why? Because I can manage most of the patients with high flow nasal cannula (HFNC), which are special devices that can provide large amount of oxygen comfortably to patients without having to put them on it on a respirator. Now this is not what's happening across the U.S. a lot of people are still using ventilators. A lot of people don't believe that when we tell them, once you put a patient on a mechanical ventilator, we're pretty much giving them more than 80% chance of dying. Information changes every day. In early March, I was probably thinking about ventilating a lot of people, but when I saw that MATH+ was working fabulously, that changed everything. And when we started to give them all these corticosteroids, ascorbic acid and the Heperin... they get well!"


"MATH+ Saved My Life" - In March, 2020, Jeffrey Boney of Houston, TX had fallen critically ill from the CoronaVirus and checked into critical care at United Memorial Medical Center.  Dr. Joseph Varon, frontline physician saved Mr. Boney through the use of FLCCC’s MATH+ protocol. (see Mr. Boney's video)





PAVING THE WAY TO GLOBAL ACCEPTANCE- ONE PATIENT AT A TIME
By: Dr. Joseph Varon

Dr. Paul Marik and I have been working together for close to 30 years. Since the middle of 2017, we've been working very closely on the H.A.T. protocol, (Hydrocortisone, Ascorbic Acid and Thiamine) and we enrolled more than 1500 patients together. By the time the pandemic came around, that's when I met with Dr. Umberto Meduri (the world's Guru on corticosteroids) and educated us all on Methylprednisone as a better choice. Then other specialists and researchers came aboard like Dr. Jose Iglesias and Dr. Pierre Kory‐‐ the group just came together, all from video conferencing.

Like anything else in life, every time a new therapeutic intervention comes in, it's usually met with a lot of resistance. Oddly enough, I'm getting a lot of international acceptance. Domestically, acceptance is not there yet. We are still having issues of people here who are just afraid‐ of giving steroids because they think that patients are going to get worse. They're stuck on the idea of intubating everybody. Now, in all fairness, when I am in my regular ICU, if you sneeze, I will intubate you. I'll put you on a respirator. But if I am on the Covid unit, I will do whatever it takes to prevent you from getting ventilated.

Covid‐19 is a very liquid illness because of its ability to keep changing. What I'm doing today is not what I was doing 10 weeks ago. We're in June now, and we are in the process of (still) learning more about the disease... and (with concepts like MATH+), we are trying to implement things that are easy to adopt by everybody. As of today, in my hospital, we have a 96.7 percent success rate with MATH+ . When you look at the data from Dr. Marik’s hospital and some of the other members of FLCCC, we're talking about a 95%, success rate among everybody. That's by far the best therapeutic intervention that is out there for coronavirus.


(End of Part 1)
For complete information about the MATH+ treatment protocol, visit: www.covid19criticalcare.com


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Other articles recently published in Prevention101.org

"The Power of Prevention of Covid-19 is in YOUR HANDS"
Source: MD Anderson Cancer Center
Watch how a blacklight reveals what improper hand washing can leave behind. According to Dr. Christina Le-Short of MD Anderson Cancer Center, "Cancer patients are at greater risk of developing complications from respiratory viruses... Effective hand-washing is your best defense against germs that cause the flu or Covid-19". 
Possible Health Hazards Behind the Mask
Source: NIOSH SCIENCE BLOG
Reports about Prolonged PPE Use by healthcare workers are aligned with health issues from abnormally elevated carbon dioxide (CO2) levels in the blood causing increased pressure inside the skull, nervous system changes, cardiovascular effects and reduced tolerance to lighter workloads that may lead to possible dizziness, hyperventilation and dehydration. View the report by the CDC about the many physiological effects of breathing increased concentrations of CO2 and the effects of failing overused respirator masks: See complete article
Suggested Safety Measures for Covid Prevention in Medical Offices  From respirators to hand sanitizers to regular use of hospital-grade disinfectants, the medical community is trusted to apply and set standards when it comes to safety measures, risk prevention strategies and sanitizing efforts. This new article offers a collective set of smart and sensible safety ideas from a group of doctors in your area. Promoting SAFETY GUIDELINES in any health practice is everyone's duty in our community.  See complete article




References:
1) Some doctors moving away from ventilators for virus patients: https://apnews.com/8ccd325c2be9bf454c2128dcb7bd616d

2) Global economy to be worst hit since Great Depression: Gita Gopinath, Chief Economist, IMF

https://www.youtube.com/watch?v=rpiZ0DkHeGE

3) W.H.O. CASE COUNT: https://covid19.who.int/?gclid=CjwKCAjw88v3BRBFEiwApwLevVNWB8VzRXQYzS6KGVe1QkdIdQ7P5G4SoXNIeYnTSKcIooGXKqbIzBoCnIkQAvD_BwE


4) UChicago Medicine doctors see 'truly remarkable' success using ventilator alternatives to treat COVID-19 https://www.uchicagomedicine.org/forefront/coronavirus-disease-covid-19/uchicago-medicine-doctors-see-truly-remarkable-success-using-ventilator-alternatives-to-treat-covid19


5) Ventilators: Helping or Harming COVID-19 Patients https://www.webmd.com/lung/news/20200415/ventilators-helping-or-harming-covid-19-patients#1


6) Study: 88% of coronavirus patients on ventilators died in NY

https://www.syracuse.com/coronavirus/2020/04/study-88-of-coronavirus-patients-on-ventilators-died-in-ny.html

7) Coronavirus patients on ventilators are unusually likely to die, causing some doctors to change strategy

https://www.independent.co.uk/news/coronavirus-ventilators-nhs-death-rates-china-wuhan-us-cases-a9458541.html

8) Texas Medical Center Data: https://www.tmc.edu/

9) Nearly 9 in 10 COVID-19 patients who are put on a ventilator die, New York hospital data suggests
https://www.livescience.com/coronavirus-ventilator-deaths-new-york.html

10) Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area
https://jamanetwork.com/journals/jama/fullarticle/2765184

11) Center for American Progress: Removing Barriers for Immigrant Medical Professionals Is Critical To Help Fight Coronavirus  https://www.americanprogress.org/issues/immigration/news/2020/04/02/482574/removing-barriers-immigrant-medical-professionals-critical-help-fight-coronavirus/

12) UN Foundation: HOW THE WORLD’S SCIENTISTS, DOCTORS, AND NURSES ARE UNITING TO FIGHT COVID-19  https://unfoundation.org/blog/post/how-worlds-scientists-doctors-and-nurses-uniting-fight-covid-19/



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