“States, not the Federal Government, should be doing the Testing — But we will work with the Governors and get it done.”
— President Trump
“The president is right, testing is up to the States, which will implement the tests and logistically coordinate the tests.”
— NY Governor Cuomo
“Unless we get the virus under control, the real recovery economically is not going to happen. So what you do if you jump the gun and go into a situation where you have a big spike, you’re going to set yourself back.“ — Dr. Fauci
- Recent Developments and Headlines
- Numbers and Trends
- Sneak Preview: The First Immunity Passport
- How Many People Have Been Infected by the Coronavirus? And Why Any Plan to Reopen Our Economy Hinges on the Answer
- New Scientific Findings
- Technology Takes on the Coronavirus
- The Road Back?
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Note: As there is a lot of inaccurate information circulating, we only include information that we can confirm from a credible source or that is based on data that we can verify. To the extent that we derive information from an online source, we provide a link to the source, which typically provides more detail that is included in our update. If you have any questions about any information included in an update, or if you have a different view, please let us know and we will supplement or correct as needed.
A. Recent Developments and Headlines
Note: All changes noted in this Update are since the 4/20 Update
Sources: New York Times Coronavirus Updates, New York Post Coronavirus Updates, Zero Hedge Coronavirus Updates, Drudge, Breitbart, Wall Street Journal, Coronavirus White House Task Force Briefing, NY Governor Daily Briefing, and Worldometers
- The coronavirus is affecting 210 countries and territories (+0)
- Worldwide Total Cases = 2,482,577 (+3.2%) (+76,002)
- US Total Cases = 792,759 (+3.7%) (+28,123)
- Worldwide deaths = 170,397 (+3.3%) (+5,366)
- US deaths = 42,514 (+4.8%) (+1,939)
- WHO head warns worst of virus is still ahead
- There are many hurdles to developing and widely distributing a vaccine, a W.H.O. official warned
- 1/5th of world is taking first steps toward reopening economies
- Second night of riots erupt in Paris as residents accuse ‘racist’ police of attacking minorities during coronavirus lockdown
- Dr. Fauci warns US needs to triple coronavirus testing and says ending lockdowns too soon could backfire
- Former FDA Commissioner Warns Waiting For “Optimal” Testing Capacity Before Reopening Simply “Not Possible”
- Georgia Will Become First State In The US To Reopen
- Model shows New York could begin lifting coronavirus restrictions in June
- Kudlow says Trump’s May 1 reopening goal is “aspirational”
- US sees 20% drop in cases
- NY Gov. Cuomo: Data Shows N.Y. May Be Past High Point
- NJ achieves “stability” in new cases
- Demonstrators demand economies reopen now in Denver, Austin
- Indiana Gov. Eric Holcomb: Lockdown Protests ‘Not Helping,’ ‘Petri Dish’ for Virus
- Germany, Denmark, Czech Republic, Norway, India among countries reopening right now
- Bolsonaro joins crowds of protesters demanding reopening in Brazil
- Japanese hospitals turn away non-COVID-19 patients
- Russia outbreak continues to accelerate
- Australia, New Zealand begin easing lockdowns
- Iran and Iraq ease restrictions, allowing some workers to return
- Turkey passes China in total ‘confirmed’ cases
- Istanbul deaths suggest a wider outbreak than Turkey admits
- Turkey Overtakes China & Iran In Total COVID-19 Cases But Still Resists Lockdown
- India Reports Record Spike In Coronavirus Cases Just As It Starts Reopening Economy
- Hong Kong extends its social distancing rules, even after local infections slow to zero
- Saudi Arabia, Qatar see alarming rise in new cases
- In Old Cairo, a subdued Ramadan looms as the virus shutters the city
- Indonesia bans travel during Muslims’ most important holiday
- 9th Vatican employee tests positive
- Italy reports slight rise in deaths, drop in cases
- UK reports 450 new deaths
- NYC reports another drop in hospitalizations
- Merkel urges more ‘caution’ as Germany begins to reopen
- Belgium reports 1,487 new cases
- German newspaper slams Beijing for “exporting” virus
- Facebook Bans Civil Disobedience, Removes Posts Organizing Anti-Lockdown Protests
- ‘We’re Completely Overwhelmed’ – Mexico City Hospitals Turn Away Patients As Serious COVID-19 Cases Surge
- Fears Of Nationwide 9MM Ammo Shortage Sparks Panic Hoarding
- Berlin Cops Aggressively Breakup Protest Against Nation’s “Authoritarian” Lockdown
- California researchers test everybody in one town for coronavirus
- South Korea reports clusters as reopening continues
- Small Marin County town hopes to test every resident
- National Restaurant Association says 2/3rds restaurant workers in US have lost their jobs
- Amazon warehouse workers plan nationwide protest this week to demand coronavirus protections
- Coronavirus likely to transform world far more than 1918 flu pandemic
- A billionaires’ compound with its own coronavirus testing center stokes anger on the French Riviera
- Luxury Moscow clinic becomes coronavirus ‘battleground’
- Deserted Thai beaches lure rare turtles to build most nests in 20 years
- Sisters die 102 years apart — one from the Spanish flu, the other from coronavirus
- Stirrings of unrest could portend turmoil as economies collapse
- Italy’s current virus cases fall for first time
- Indonesia Punishes Quarantine Violators by Sending Them to Haunted House
- U.S. citizens living in Baja California make tough decisions amid coronavirus crisis
- Empty resorts spell long crisis for Caribbean as coronavirus hits
- “The Hit Is Huge”: Colleges Brace For ‘Fatal’ Blow Of Next Fall As Face-To-Face Instruction Uncertain
- “Tourist Go Home” – Tensions Soar As Hawaiians Urge Non-Residents To “Leave”
- NYPD Confiscates Drone Belonging To Freelance Photojournalist Documenting NYC’s Mass Burials
- Georgia, Tennessee, SC announce plans to reopen some businesses, wind down coronavirus stay-at-home orders
- Sweden sees jump in coronavirus deaths with less restrictive guidelines under scrutiny
- President Trump to suspend immigration to US due to coronavirus
- Mexican president tells cartels to focus on ending crime, not handing out coronavirus aid
- Gov. Andrew Cuomo to meet President Trump at White House
- New Zealand could pull off ambitious goal of wiping out coronavirus
- Lord & Taylor explores bankruptcy as stores remain shut in coronavirus pandemic
- 4/20 blues: Pot industry struggles during coronavirus
- Westchester residents sue WHO for alleged coronavirus cover-up
- Many Georgia businesses may reopen by Friday; Tennessee eyes next week
- Connecticut attorney sues governor over face-mask mandate
- Coronavirus continues to curb most crime in NYC
- Seashells pile up on North Carolina beaches as coronavirus keeps tourists away
- Prescriptions for anti-anxiety meds spike amid coronavirus, new report finds
- High school seniors should take next year off in light of coronavirus, professor says
- Hundreds of protesters defy coronavirus lockdown orders in Pennsylvania
- Stressed mortician describes coronavirus overflow: ‘It is dark right now’
- Oil prices drop below zero for first time ever as COVID-19 kills demand
- Cops at crowded Brooklyn park basically leave people to police themselves
- NY nurses sue state Health Department, hospitals over PPE failures
- Iranian ‘Prophetic Medicine’ Leader: Camel Urine Cures Coronavirus
- Queen Elizabeth to have a virtual birthday party on Zoom
- Oktoberfest, the iconic German beer festival, is canceled
B. Numbers & Trends
Note: All numbers in this update are worldwide unless otherwise indicated. The numbers in this update only include cases that have been (i) confirmed through testing, and (ii) reported. The actual number of cases may be materially higher than confirmed cases, which means that the number of actual deaths from COVID-19 and recoveries may both be materially higher than reported. As testing in US ramps up, confirmed cases may rise rapidly as actual but unidentified cases are confirmed.
1. Confirmed Total Cases and New Cases
- Total Cases = 2,482,577 (+3.2%)
- New Cases = 76,002 (+0.3%) (+193)
- Total Cases = 1,113,096 (+2.2%)
- New Cases = 23,840
- Total Cases = 396,496 (+3.5%)
- New Cases = 13,339
- Total Cases = 792,759 (+3.7%)
- New Cases = 28,123 (+8.6%) (+2,216)
- US States & Territories:
- 42 States > 1,000 cases (+0), plus DC, US Military & Puerto Rico
- 33 States > 2,500 cases (+0), plus DC & US Military
- 21 States > 5,000 cases (+0)
- 16 States > 10,000 cases (+0): NY, NJ, MA, PA, CA, MI, IL, FL, LA, TX, GA, CT, MD, WA, IN & OH
- 9 States > 20,000 cases (+0): NY, NJ, MA, PA, CA, MI, IL, FL & LA
- 5 States With Largest Number of Total Cases:
- NY = 252,294 (+2%) (+4,879)
- NJ = 88,806 (+4.1%) (+3,505)
- MA = 39,643 (+4.1%) (+1,566)
- PA = 33,914 (+3.6%) (+1,180)
- CA = 31,527 (+6.5%) (+2,519)
- Top 5 States = 56.5% of Total Cases in US
- NY & NJ = 43% of Total Cases in US
- For more information on US States and territories, see https://ncov2019.live/data & https://www.worldometers.info/coronavirus/country/us/
2. Serious or Critical Cases
- Worldwide serious or critical cases = 56,763 (+2,538)
- US series or critical cases = 13,951 (+385)
- US serious or critical cases = 2.1% of Active Cases compared with worldwide percentage of 3.4%
- Worldwide deaths = 170,397 (+3.3%) (+5,366)
- Europe deaths = 104,491 (+2.6%) (+2,655)
- US deaths = 42,514 (+4.8%) (+1,939)
- NY deaths = 18,929 (+3.5%) (+631)
- Deaths per 1M population of 5 Countries with Largest Number of Confirmed Cases:
- Italy: 399 (+8)
- Spain: 446 (+9)
- US: 128 (+5)
- France: 310 (+8)
- Germany: 58 (+3)
- US Total Confirmed Case Fatality Rate = 5.4% compared with a Worldwide Confirmed Case Fatality Rate of 6.9% [Note: The number of cases in which infected people recovered without being tested is believed to be a large number, which would substantially reduce the fatality rate. US health officials have estimated that the US actual fatality rate is 1% or less, but we do not have yet have sufficient data to calculate or estimate the actual fatality rate.]
- Worldwide recoveries = 652,520 (+4.4%) (+27,422)
- US recoveries = 72,389 (+1.7%) (+1,202)
C. The First Immunity Passport
- We are pleased to bring you a sneak preview of the first immunity passport! Hard earned, but comes with the right to move freely around the country.
D. How many people have been infected with coronavirus? And Why Any Plan to Reopen Our Economy Hinges on the Answer
- It is important to know the approximate number of people infected with coronavirus, including those that have not been tested for the virus, because it will determine the lethality of COVID-19, which will impact public policy regarding when and how to reopen businesses. If the total number of infected people is much larger than the number of confirmed cases, then the fatality rate will be much smaller, and conversely if the total number of infected people is not much larger than the number of confirmed cases, then the fatality rate will be higher.
- Estimates of the fatality rate of COVID-19 by public health officials and epidemiologists have ranged from less than 1% to 3.4% (by comparison, the fatality rate of the flu is generally estimated at 0.1%). If we can determine that the fatality rate is less than 1%, we can be more aggressive in reopening our businesses. On the other hand, if fatality rate is higher, then it would be prudent to be more cautious.
- So, if the fatality rate is low and States reopen their business too slowly, then they risk devastating their economies for little gain. Alternatively, if the fatality rate is high and States reopen their businesses too quickly, there is a high risk of a new major outbreak that requires lockdowns to be reimposed. The stakes could not be higher – public health, economies and political winners and losers will be determined on a State-by-State basis in accordance with the plans developed and implemented by each State.
- Being overly cautious will have as much risk for States as being too aggressive as voters are (in our opinion) more likely to reward and punish politicians based on what actually happens, not what could have happened, particularly if their missteps are highlighted by the success of other States. In other words, we think it unlikely that politicians will be given an “A” for effort or giving good speeches – actual results will be critical and each State will be graded on a curve based on how other States perform. Accordingly, if any States start to have success in reopening their businesses, look to other States to quickly follow their lead out of fear of being left behind. Also, with States now responsible for when and how their economies will open, it will be harder for them to shift blame to the federal government, which will put even more pressure on States to perform.
- Based on various articles, our understanding is that large scale testing would be the best way to estimate the number of people infected. Until that is possible, various studies are using other methods to estimate the number of unreported cases of the virus.
- A Stanford study recently estimated that the actual number of people infected with COVID-19 is 50 to 85 times more than the number of confirmed cases. This would have profound implications as it would imply that COVID-19 has a fatality rate of approximately 0.1%.
- In the first story below, critics say that the Stanford study was flawed and unreliable. The second story discusses the findings of an antibody test conducted in LA County (which found that actual infections were 50 times reported cases) while the third story discusses the findings of a hospital in NYC that tested every pregnant women that gave birth at the hospital (which found that 15% of the pregnant women have COVID-19, and 88% of them were asymptomatic), each of which provides some insights into the percentage of the population infected by COVID-19.
- The Governor of New York announced that NY would begin a testing program as part of the State’s effort to calculate the number of people in NY that have been infected by the coronavirus.
1. Recent Stanford study concluded that the actual number of coronavirus cases is 50 to 85 times more than the number of confirmed cases, but critics say “the authors owe us all an apology”
- Did you miss a day in Statistics class? The COVID-19 pandemic is here to help.
- In the wake of a startling Stanford report that suggests as many as 81,000 people could already have been infected with coronavirus in Santa Clara County, number nerds are taking to Twitter to debate sampling methods, false positives and Bayesian inferences with a furor reminiscent of the banning of @BabyYodaBaby.
- The heated debate over a few percentage points — has the virus infected 2.5% to 4.2% of county residents, as the study asserts, or is the number closer to 1%? — captures our cultural zeitgeist, sheltering at home in fear of both a virus and an economic meltdown.
- Critics claim the study’s methodology is dangerously flawed and question the political motives of the Stanford-led team. Others have pointed to the study as proof that COVID-19 is merely a partisan-driven flu hoax, as protests broke out this weekend in parts of the country over frustrations with the shutdowns.
- In response, on Sunday, the study’s authors said they are planning to soon release a detailed appendix that addresses many of the criticisms and incorporates many of the suggestions into the paper itself.
- “We have received a vast number of constructive comments and suggestions on our working paper over the past couple of days,” said Dr. Jayanta Bhattacharya, professor of medicine at Stanford University.
- “This is exactly the way peer-review should work in scientific work, and we are looking forward to engaging with other scholars as we proceed in this important work,” he said.
- The estimate, posted on the website medRxiv, comes from a first-in-the-nation community study of newly available antibody tests of 3,300 Santa Clara County residents in early April. Like all other emerging COVID-19 research papers, the work has not been peer reviewed. (Conventional publication can take as long as a year.)
- The authors contend that between 48,000 and 81,000 of the county’s 1.9 million residents had been infected with the virus as of the first week of April.
- That’s 50 to 85 times more than the number of official count of cases at the time.
- If true, it suggests that the large majority of people who contract COVID-19 recover without ever knowing they were infected. If undetected infections are that widespread then the death rate in the county may be less than 0.2%, far less lethal than authorities had assumed.
- It also implies that the virus probably cannot be eradicated at this high level of prevalence and that “contact tracing” — tracking down people who might have been exposed to infected person — could be nearly impossible.
- Whether the true infection rate is higher or lower, Santa Clara County Executive Dr. Jeff Smith remains steadfast in his interpretation of the study’s findings: It suggests that more than 95% of the population remains susceptible to infection, and asymptomatic people spread the virus.
- “That all means that there is more risk than we initially were aware of,” said Smith, lamenting how some are using the study to challenge Bay Area health officials’ unprecedented stay-home orders.
- The study’s authors defend their technique, saying they adjusted for the test kit’s performance and sampling techniques to estimate the prevalence of the virus in Santa Clara County.
- But over the weekend, some of the nation’s top number crunchers took to Twitter to challenge the Stanford research – saying it’s an extrapolation that rests on a flimsy foundation.
- They contended the Stanford analysis is troubled because it draws sweeping conclusions based on statistically rare events, and is rife with sampling and statistical imperfections.
- “I think the authors owe us all an apology… not just to us, but to Stanford,” wrote Andrew Gelman, a professor of statistics and political science and director of the Applied Statistics Center at Columbia University, calling the conclusions “some numbers that were essentially the product of a statistical error.”
- “They need to apologize because these were avoidable screw-ups,” he wrote. “They’re the kind of screw-ups that happen if you want to leap out with an exciting finding and you don’t look too carefully at what you might have done wrong.”
- From the lab of Erik van Nimwegen of the University of Basel came this: “Loud sobbing reported from under Reverend Bayes’ grave stone,” referring to the famed statistician’s technique. “Seriously, I might use this as an example in my class to show how NOT to do statistics.”
- “Do NOT interpret this study as an accurate estimate of the fraction of population exposed,” wrote Marm Kilpatrick, an infectious disease researcher at the University of California Santa Cruz. “Authors have made no efforts to deal with clearly known biases and whole study design is problematic.”
- Others noted that authors had agendas before going into the study. Back in March, Bhattacharya and Dr. Eran Bendavid wrote an editorial in the Wall Street Journal arguing that a universal quarantine may not be worth the costs it imposes on the economy, community and individual mental and physical health. Their colleague John Ioannidis has written that we lack the data to make such drastic economic sacrifices.
- The team’s data scientists made statistical adjustments to account for the sampling problem. Because volunteers were disproportionately white and female, relative to the county’s demographics, the team gave less computational “weight” to those participants. Latino and Asian volunteers, who were underrepresented, got greater “weight.”
- One major problem with the Santa Clara County study relates to test specificity. It used a kit purchased from Premier Biotech, based in Minneapolis with known performance data discrepancies of two “false positives” out of every 371 true negative samples. Although it was the best test at the time of the study, that’s a high “false positive” rate that can skew results, critics say — especially with such a small sample size.
- With that ratio of false positives, a large number of the positive cases reported in the study — 50 out of 3330 tests — could be false positives, critics note. To ensure a test is sensitive enough to pick up only true SARS-CoV-2 infections, it needs to evaluate hundreds of positive cases of COVID-19 among thousands of negative ones.
- This potential error in the test can easily dominate the results, they said.
- Statistician John Cherian of D. E. Shaw Research, a computational biochemistry company, made his own calculations given the test’s sensitivity and specificity — and conservatively estimated the proportion of truly positive people in the Stanford study to range from 0.2% to 2.4%.
- Adjusting for demographics, Cherian’s calculations suggest that county prevalence could plausibly be under 1% and the mortality rate could be over 1%.
- The “confidence intervals” in the paper – that is, the range around a measurement that conveys how precise the measurement is – “are nowhere close to what you’d get with a more careful approach,” he noted.
- Assuming a sensitivity of 72%, this is a histogram of possible true positive rates, according to statistician John Cherian.
- Trevor Bedford, a computational biologist at the Fred Hutchinson Cancer Research Center in Seattle, said “given how sensitive these results are to performance of the assay, I don’t think it’s safe to conclude that infections are ’50-85-fold more than the number of confirmed cases.’ ”
- Even if the test was completely accurate, there would still be sampling problems in the Stanford study, critics said.
- Biostatistician Natalie E. Dean of the University of Florida called it a “consent problem.” Participants weren’t randomly selected — they were recruited using Facebook. This means it might have attracted people who thought they were exposed to the virus and wanted testing. And exposed people may have recruited other exposed people for the study.
- “The prevalence drops off quickly when adjusted for even a small self-selection bias,” wrote Lonnie Chrisman, chief technical officer at the Los Gatos data software company Lumina Decision Systems.
- Addressing the critics, Stanford’s Ioannidis, professor of medicine and biomedical data science at Stanford University, promised an expanded version of their study will be posted soon. “The results remain very robust,” he said.
- In the end, no single study is going to answer the question of how prevalent COVID-19 is in our communities, scientists said. More studies with different technologies and analytic approaches are needed.
- That’s coming. A UC Berkeley project, which will begin in May, will test a large and representative swath of 5,000 East Bay residents. Scientists will take saliva, swab and blood samples from volunteers between the ages of 18 and 60 around the region.
- Starting Monday, UC San Francisco and a privately-funded operation will test all 1,680 residents of rural Bolinas for evidence of the virus. UCSF will launch a similar effort Saturday in San Francisco’s densely populated and largely Latino Mission District, where it hopes to test 5,700 people.
- “This pandemic,” wrote research scientist Ganesh Kadamur, “has been one giant Stats class for everyone.”
[Note: Who knew that statisticians could disagree so vehemently or snarkily over a statistical analysis? Although it is not yet clear whether the actual number of infected people is 50 to 85 times the number of confirmed cases as concluded by the Stanford study (see following stories), the claims of critics that the work is shoddy (and potentially biased) not only undermines the credibility of the Stanford study (which may be deserved), but adds to the rapidly mounting criticisms that other models and projections regarding COVID-19 are materially inaccurate and unreliable.]
2. Antibody study in LA County adds further support for a higher-than-suspected infection rate
- A new study conducted by the University of Southern California along with the LA County Department of Public Health indicates the presence of antibodies for COVID-19 in between 2.8 and 5.6% of the population of LA County, suggesting that between 221,000 and 442,000 individuals had the infection — up to 55 times more people than have been confirmed via testing.
- This is the second antibody study in a short span of time in California that suspects infections are far more widespread than previously thought, and a good justification for continued social distancing measures.
- The LA County study does contain some good news, if the antibody testing proves to be accurate (we aren’t entirely sure what they show for sure at this point, especially in terms of immunity), in that the mortality rate of the infection is actually much lower than the official diagnosed case data would suggest.
- The infection rate found via antibody testing through the USC study is also remarkably close to the rate found in a Stanford study published last week about the number of infections in Santa Clara County, which found that between 48,000 and 81,000 people in that part of California could’ve had and recovered from the infection.
- Whereas the LA study found around 2.8 to 5.6% had antibodies, accounting for the margin of error and extrapolating from results to the entire population, the Stanford research found between 2.5 and 4.2% of residents carry antibodies for the infection. Those numbers are based on the test kits’ performance, as well as the demographic makeup of the sample population tested.
- Neither new research papers have yet been peer-reviewed, so it’s worth taking them with a grain of salt. But the close alignment between the numbers in both, along with early results from similar studies being conducted globally, does seem to suggest that the number of actual cases of COVID-19 far undershoots the published numbers, which typically only include confirmed diagnoses — most of which represent individuals showing moderate to severe symptoms.
- The higher rate of undetected infection definitely should not be taken as a sign that COVID-19 is less serious than it appeared, however; this new info only means that its transmission from people who showed no outward symptoms and subsequently never sought any medical care or were identified for quarantine or contact tracing is probably a lot higher than anyone guessed.
- That means social distancing measures are more important than ever, as it’s likely harder than ever to identify who might be a passive carrier of the virus that leads to COVID-19 without realizing it. Eventually, understanding the nature of the spread should help with refining measures to avoid the greatest potential risks of exposure, but for now, this new info just means that COVID-19 is much more effective at moving through a population without raising early warning signs than we previously understood.
3. We tested all our patients for coronavirus — and found lots of asymptomatic cases.
- As the novel coronavirus spread in New York City, pregnant patients developed severe symptoms of the coronavirus only after they were admitted to our labor and delivery unit, exposing health-care providers to the virus. We rapidly instituted a universal screening policy.
- This week, we published our findings after two weeks of universal screening at New York-Presbyterian/Columbia University Irving Medical Center. In our area, which includes upper Manhattan and the Bronx, about 15 percent of patients who came to us for delivery tested positive for the coronavirus, but around 88 percent of these women had no symptoms of infection. That means 13.5 percent of all our patients during this time were infected with the coronavirus but weren’t exhibiting symptoms.
- Our findings may shed light on the overall rate of infected people in New York City. Our screenings suggest more people are infected with the virus but are not becoming sick. We cannot say for sure how our findings apply to the general population because our group was made up of young, relatively healthy, pregnant women in an area of high virus prevalence. But this is one of the first opportunities to understand covid-19, the disease the virus causes, in a somewhat random sample of the U.S. population. Our findings have huge implications for everyday life on a labor and delivery unit, as well as potential broader implications.
- Far more people in the U.S. have the coronavirus than you think
- For example, patients who test positive for the virus need to be managed with extra precautions to limit exposure and infection risk for other patients, support staff, their newborns and their health-care team members. Proper personal protective equipment must be worn, and patients must be isolated in private rooms, which require specialized cleaning. Pediatricians need to be informed of virus status so they can take proper precautions to limit the exposure of other babies.
- While most of our patients may be less likely to suffer from the severe consequences of covid-19, many of our health-care personnel are not, and we need to keep them healthy. The labor and delivery unit is different from other units in many ways. We routinely have multiple groups of providers in one space: nurses, obstetricians, pediatricians and anesthesiologists. Exposure leading to infection could take providers out of work and away from other areas of the hospital that they routinely cover — and where they are very much needed.
- Our patient population also is unique in that all will require admission to the hospital at some point in their pregnancy. During the pandemic, we are minimizing in-person contact using virtual visits, but some points of contact are unavoidable.
- Patients need to see us for ultrasounds to check on the development of their babies’ organs and overall growth. Some patients will develop complications of pregnancy like preeclampsia, preterm labor or breaking their water early, and they’ll require admission to the hospital. Their babies will need to be examined and cared for by a pediatrician before they can be safely discharged from the hospital, and in most cases, they’ll visit a pediatrician again not long after they return home.
- Understandably, patients are concerned. They worry about their own safety and that of their partners and newborns. Hearing that 1 out of 8 patients admitted to labor and delivery tested positive for the coronavirus and had no symptoms is jarring. We experienced the same emotions. It is why we have remained vigilant in our universal screening policy — so that not only are patients aware of their statuses, but we also can monitor them for symptoms.
- Patients discharged from our service are followed with telehealth visits through the Mothers Center at NewYork-Presbyterian/Columbia University Irving Medical Center for 14 days after their positive test results. Luckily, so far, none of these patients has suffered serious medical problems.
- This pandemic has created an ever-shifting landscape that has forced us to change multiple processes for patient, provider and public safety. With all the unknowns during this time, universal testing has taken at least one of them away. It has allowed us to protect our pregnant patients admitted to the hospital and know all precautions will be taken to minimize risk of exposure and infection. We will monitor them for any emerging symptoms. It also allows us to use personal protective equipment only when necessary.
- To safeguard a woman’s pregnancy is to safeguard the future of our population. For our labor and delivery unit, universal testing is vital. At our hospital, we were fortunate to have executed a universal screening policy for our pregnant patients being admitted to labor and delivery quickly and efficiently, but we recognize the same may not be true across all centers and all patient populations. Broader testing will probably be key in controlling the spread of the coronavirus.
E. New Scientific Findings and Other Advances
1. Antibody Points to Possible Weak Spot on Novel Coronavirus
- Researchers are working hard to produce precise, 3D molecular maps to guide the development of safe, effective ways of combating the coronavirus disease 2019 (COVID-19) pandemic. While there’s been a lot of excitement surrounding the promise of antibody-based tests and treatments, this map highlights another important use of antibodies: to inform efforts to design a vaccine.
- This image shows the crystal structure of a human antibody (heavy chain in orange, light chain in yellow), which is a blood protein our immune systems produce to attack viruses and other foreign invaders. This particular antibody, called CR3022, is bound to a key surface protein of the novel coronavirus (white).
- The CR3022 antibody actually doesn’t come from someone who has recovered from COVID-19. Instead, it was obtained from a person who, nearly two decades ago, survived a bout of severe acute respiratory syndrome (SARS). The SARS virus, which disappeared in 2004 after a brief outbreak in humans, is closely related to the novel coronavirus that causes COVID-19.
- In a recent paper in the journal Science, the NIH-funded lab of Ian Wilson, The Scripps Research Institute, La Jolla, CA, along with colleagues at The University of Hong Kong, sought to understand how the human immune system interacts with and neutralizes this highly infectious virus. The lab did so by employing high-resolution X-ray crystallography tools. They captured the atomic structure of this antibody bound to its target by shooting X-rays through its crystallized form. (An antibody measures about 10 nanometers; a nanometer is 1 billionth of a meter.)
- Other researchers had shown previously that CR3022 cross-reacts with the novel coronavirus, although the antibody doesn’t bind tightly enough to neutralize and stop it from infecting cells. So, Wilson’s team went to work to learn precisely where the antibody attaches to the novel virus. Those sites are of special interest because they highlight spots on a virus that are vulnerable to attack—and, as such, potentially good targets for vaccine designers.
- A key finding in the new paper is that the antibody binds a highly similar site on both the SARS and novel coronaviruses. Those sites differ in each virus by just four amino acids, the building blocks of a protein.
- This is particularly interesting because the antibody pictured above is bound to a spike protein, which is the appendage on both the SARS and novel coronavirus that enables them to bind to a key receptor protein on the surface of human cells, called ACE2. This binding activity marks the first step for these viruses in gaining entry into human cells and infecting them.
- The human antibody shown in this image locks onto the virus’s spike protein at a different location than where the human ACE2 protein binds to the novel coronavirus. Intriguingly, the antibody binds to a spot on the novel coronavirus that is usually hidden, except for when virus shapeshifts its structure in order to infect a cell.
- The findings suggest that a successful vaccine may be one that elicits antibodies that targets this same spot, but binds more tightly than the one seen above, thereby protecting human cells against the virus that causes COVID-19. However, Wilson notes that this study has just uncovered one potential vulnerability of the novel coronavirus, and it is likely the virus likely has many more that could be revealed with further study.
- To continue in this quest to design a safe and effective vaccine, Wilson and his colleagues are now gathering blood samples to collect antibodies from people who’ve recovered from COVID-19. So, we can look forward to seeing some even more revealing images soon.
2. Natural light, fresh air could keep coronavirus out of workplaces
- With millions of people adjusting to work-from-home orders and practicing social distancing, scientists are examining what simple changes could be made to home and office environments in order to reduce the spread of coronavirus.
- Researchers from UC-Davis and the University of Oregon published their report in the journal mSystems and came up with some recommendations for healthier work spaces in the age of COVID-19.
- Two of their suggestions: opening windows for better air circulation and opening blinds or drapes for more natural sunlight.
- Although more research is needed to better understand the impact of natural light on the virus indoors, “daylight exists as a free, widely available resource to building occupants with little downside to its use and many documented positive human health benefits,” the researchers wrote in their paper.
- The paper also urges building operators and office administrators to post signs reminding employees to wash their hands with soap and hot water for at least 20 seconds, to provide access to alcohol-based hand sanitizer and to implement new stringent cleaning protocols — especially for areas that are higher risk, such as near sinks and toilets.
- The scientists also write that more air entering the building from the outside can dilute any virus particles that are already indoors.
- “No filter system is perfect,” the study says. “Recently, it has been found that gaps in the edges of filters in hospitals has been a contributing factor of the failure of filtering systems to eliminate pathogens from the shared air environment.”
3. Engineers Offer DIY Solutions to Coronavirus Equipment Shortages
- The world is in desperate need of protective gear to keep health care workers safe and ventilators to help severely ill COVID-19 patients breathe. In the face of massively increased demand and stalled supply chains, engineers are scrambling to redesign equipment so it can be produced outside of specialized factories.
- Researchers at academic institutions are drawing on the spirit of the independent maker movement, according to Saad Bhamla, a bioengineer at the Georgia Institute of Technology. “We’re tapping into this whole existing community,” he says, noting that many cities have clubs for DIY enthusiasts. Such individuals often volunteer their time at fabrication labs and maker spaces. Now the COVID-19 pandemic is presenting them with a unique problem. “People have a call to arms,” Bhamla says, “and they’re tapping their creative and problem-solving abilities.”
- The do-it-yourself approach is most evident in the case of face masks: hobbyists are sharing designs and instructions that allow amateurs to sew their own washable coverings. Some are donating these masks to hospitals, though in a medical setting, such unofficial gear can only serve as a last resort. Previous research has shown that while homemade facial protections can reduce the spread of microbes, they are less effective than professionally produced surgical masks. This disparity is in part because surgical masks are made from materials that are better at halting the virus-carrying droplets that spray out when humans sneeze and cough than fabrics such as cotton, which is used in many homemade versions. Instead of relying on contributions from individuals, some hospitals are sending medical-grade materials to a variety of clothing manufacturers, from fashion designer Christian Siriano to an Amish community in Ohio, who have begun mass-producing more impermeable masks and gowns.
- But masks are only one element of the personal protective equipment that health care workers need—and they do not require a redesign for sewing machines to manufacture them en masse. Gear such as face shields—transparent plastic sheets that wearers strap to their forehead to provide an additional barrier against droplets—are another story. It is possible to MacGyver such a device from a sheet of plastic and zip ties or rubber bands, but the process and results would be too time-consuming and ill-fitting for mass production. Instead engineers have come up with several ways to make facial shields that 3-D printers and laser cutters can churn out.
- Bhamla is a member of one of the first teams taking a DIY approach to coronavirus equipment, which is coordinated on the business communication platform Slack. When Nicholas Moser first joined the group, called Helpful Engineering, he says it had roughly 300 participants. As its focus shifted to coronavirus-fighting designs, membership ballooned to thousands at the time of this writing. Moser, who has experience as a project manager, became lead of MASKproject, a subgroup that aims to develop protective gear. MASKproject quickly began refining two face shields, eventually focusing on an origami-style design. Any commercial die cutter, laser cutter or water jet can slice the open-source design from a flat sheet of plastic, which is then folded by hand into the appropriate three-dimensional shape.
- Moser says his team’s face shields are already going out to five hospitals, including ones in New Orleans, Massachusetts and California, at a rate of about 10,000 per week. Other organizations have followed: both the Massachusetts Institute of Technology and Duke University Health System have announced that their researchers developed and tested their own face-shield prototypes. Like the MASKproject’s design, M.I.T.’s shield is produced on a die-cutting machine and then folded by hand, whereas Duke Health’s uses a 3-D-printed headband.
- In all these cases, the new shields can be produced on relatively common machines—laser cutters, die cutters and 3-D printers are found in many maker spaces, labs and production facilities that do not typically make medical equipment. Moser’s team wants to work with a variety of partners to produce its devices, he says. “Everything from a small shop that does letterpress—that cuts out pieces of paper in shapes—to large factories that have roller die cutters that can produce hundreds of thousands [of shields] a day,” Moser adds. Devices churned out by this so-called distributed-manufacturing model then flow to a central hub for quality control and sanitization before they are shipped to hospitals. “Part of this project, which is fascinating, is that there’s never been this sort of distributed manufacturing,” he says. “This scale of distributed manufacturing has never been done. And the supply chains are getting worked out amazingly rapidly, with all these people.”
In need of N95s
- Although distributed manufacturing has the advantage of speed, it requires reengineering equipment so that items can be produced with machines such as 3-D printers rather than specialized devices. And not all the new designs meet strict medical standards, which are particularly important for major items that are now seriously scarce: N95 respirators. Surgical masks can halt droplets, but viruses can still squeeze through the material. This possibility is a concern when the air gets filled with viral particles, which happens when doctors ventilate severely ill coronavirus patients. To protect themselves in such situations, medical professionals don N95 respirators. These masks fit snugly to the skin, only admitting air through a dense filter that blocks 95 percent of very small particles while still allowing wearers to breathe without undue effort.
- The filter within an N95 is made of spun polypropylene, a material currently in short supply. So Moser and his colleagues are designing a similar device that can employ other substances. “We have designed and prototyped and are testing a filter-agnostic face shield to be an alternate to N95,” he says. The MASKproject respirator consists of a 3-D-printed base that can fit tightly to the face. The product has a front grate that forces air to enter through a stack of filtering materials, including high-efficiency particulate air filters “that meet the same particle specification as the N95. So they’re not rated for being used like this, but they have a similar classification,” Moser says. His group is currently testing the devices for both filtering and breathability.
- MASKproject’s device is unlikely to jump through all the regulatory hoops that certified N95 respirators must pass, however. “Products like N95 respirators do go through a stringent testing process to be qualified at that level,” says Julie Swann, a professor of industrial and systems engineering at North Carolina State University. But the current pandemic will not wait for testing: the FDA recently announced that in emergency situations, U.S. organizations can turn to substitutes such as KN95s, comparable protectors used in China. Moser sees his team’s alternative to N95 as a similar backup option. “MASKproject, myself and Helpful Engineers—we’re not making medical devices,” he says. “We’re making general-use products that we are testing to the same international standards as the comparable devices that are in short supply. But they’re not certified, and they’re not regulated, and they’re not meant for medical use.” Moser notes that hospitals can request MASKproject’s devices, “but they’re not being marketed for medical use at all.” Despite this disclaimer, he says, his team is pursuing certification from the FDA and the National Institute for Occupational Safety and Health at the U.S. Centers for Disease Control and Prevention.
- Like N95 respirators, ventilators must meet extremely strict standards. When the amount of oxygen in COVID-19 patients’ blood drops to dangerous levels, these machines attempt to breathe for them. But the complex, expensive devices are in limited supply all over the world, even as manufacturers increase their rate of production.
- “In the U.K., the issue is that our ventilator manufacturers are fantastic—but current capacity to manufacture is about 2,000 per year,” says Mark Thompson, an engineer at the University of Oxford. He notes that the country will need many more machines than that in order to support the estimated number of COVID-19 patients who will require them in the coming months. “It’s just not possible to scale the production of any one of our ventilator manufacturers,” he says. “It needs to have a completely different solution.”
- Thompson is one of several researchers spearheading the development of a single-use ventilator substitute inspired by an existing product: the squeeze bag that health workers employ to manually control a patient’s breathing in emergency situations. With an oxygen supply and an apparatus to automate the squeeze-and-release process, such a device could help an infected person breathe for a prolonged period of time in a way similar to a ventilator. In this case, Thompson’s team wanted to achieve that automated process with off-the-shelf parts to make the device easier to manufacture. “Essentially, it revolves around this idea of having lots of single-use items [that] are widely available [and that] are all patient-facing pieces of equipment,” he says. After a breakneck two-week development period, Thompson and his colleagues began testing their ventilator substitute, called OxVent. And they are currently in the second round of testing to secure approval from the Medicines and Healthcare Products Regulatory Agency, a U.K. body akin to the FDA in the U.S. Once the developers get the green light, they plan to have medical device manufacturer Smith+Nephew produce their open-source design.
- OxVent was an early entry in the race to redesign ventilators for faster manufacturing, but it is not the only contender. Three different groups of physicists have developed their own emergency ventilator prototypes. And this month the CoVent-19 Challenge launched an open contest calling for new ventilator designs. The plan is that they will be developed over the course of only two months.
- These designs will not be as sophisticated as regular ventilators. For example, Thompson notes that his team’s product will have to be discarded after it is used on a single patient. It will also lack the monitoring equipment and alarms that full-scale ventilators have. On the other hand, companies will be able to scale up production of emergency ventilator designs much more quickly by using the type of distributed manufacturing that Moser’s work also relies on. “The challenge is to [make] an additional number of about 20,000 ventilators before the peak of the epidemic,” Thompson says. “We think that with that kind of distributed system, we have a chance of managing to do that.”
F. Technology Takes on the Coronavirus
1. Instagram founders launch COVID-19 spread tracker
- Instagram founders Kevin Systrom and Mike Krieger have teamed up to launch their first product together since leaving the Facebook mothership. Rt.live is an up-to-date tracker of how fast COVID-19 is spreading in each state. You can access the website here: (http://rt.live/)
- “Rt” measures the average number of people who become infected by an infectious person. The higher above the number 1, the faster COVID-19 races through a population, while a number below one shows the virus receding. For example, Rt.live displays that Georgia has the highest, most dangerous Rt score of 1.5 while New York is down to 0.54 thanks to aggressive shelter-in-place orders. [NOTE: You can learn more about Rt here: The Metric We Need to Manage COVID-1. We’ll continue to monitor the website and will include a summary analysis in a future Update].
- Krieger tells me that “Kevin has been writing and publishing open-source data analysis notebooks on how to calculate Rt on a daily basis. We wanted to take that work and visualize it so anyone can see how their state is doing at curbing the spread.” Krieger had meanwhile been pitching in by building SaveOurFaves, a directory of local Bay Area restaurants that are selling gift cards so patrons can keep them afloat during quarantine. Built with his wife, the Kriegers open sourced it so people can build similar sites for their communities.
- Rt.live shows that as of yesterday, Texas and California are at or just under 1 and Vermont has the best score at 0.33. The charts over time reveal how Washington and Georgia were successfully fighting COVID-19, dipping beneath 1 until the virus bounced back recently. Data is sourced from the COVID Tracking Project and you can examine Rt.live’s modeling system on GitHub.
- “As states decide whether and how to open back up, they’ll have to manage their infection rate carefully, and we hope dashboards like rt.live will be helpful in doing so” Krieger says. By better illustrating how even small differences in shelter-in-place policy and compliance can exponentially change the severity of the impact of the virus, it could help convince people to stay inside. This kind of tool could also be helpful for determining where it’d be safe to reactivate some businesses, and quickly catch if virality is spiking and strict social distancing needs to be reinstated.
- One fascinating feature of the site is the ability to filter by region so you can see how the Western states are doing better at suppressing COVID-19 than those in the South. You can also view the states with no shelter-in-place orders to see they’re doing worse on average. The charts could help identify how different political orientations and their subsequent policies translate to infection outcomes.
- It might seem out of character for the photo app moguls to be building a medical statistics site. But Systrom has long studied virality as part of his work that helped Instagram grow so fast. He began publishing his own statistical models for tracking coronavirus infections and deaths on March 19th. “We’d been talking about ways of working together and this came out of that — my first job out of school was actually doing data visualizations / analysis at Meebo so a blast from the past in more ways than one” Krieger tells me. While Systrom did the data analysis, Krieger built the site, mirroring their old front-end and back-end Instagram roles.
- “We built Rt.live because we believe Rt — the effective infection rate — is one of the best ways to understand how COVID is spreading” Kreiger explains. “It was great to work together again — we were able to take it from idea to launch in just a few days because of all our history & shared context.”
G. The Road Back?
1. Sweden Vs COVID-19: Why “Herd Immunity” Matters & Why Lockdown Doesn’t Really Work
Professor Johan Giesecke, one of the world’s most senior epidemiologists, advisor to the Swedish Government (he hired Anders Tegnell who is currently directing Swedish strategy), the first Chief Scientist of the European Centre for Disease Prevention and Control, and an advisor to the director general of the WHO, lays out with typically Swedish bluntness why he thinks:
- UK policy on lockdown and other European countries are not evidence-based
- The correct policy is to protect the old and the frail only
- This will eventually lead to herd immunity as a “by-product”
- The initial UK response, before the “180 degree U-turn”, was better
- The Imperial College paper was “not very good” and he has never seen an unpublished paper have so much policy impact
- The paper was very much too pessimistic
- Any such models are a dubious basis for public policy anyway
- The flattening of the curve is due to the most vulnerable dying first as much as the lockdown
- The results will eventually be similar for all countries
- Covid-19 is a “mild disease” and similar to the flu, and it was the novelty of the disease that scared people.
- The actual fatality rate of Covid-19 is the region of 0.1%
- At least 50% of the population of both the UK and Sweden will be shown to have already had the disease when mass antibody testing becomes available