Note: This Special Edition is a limited update that includes stories of interest from last week that were not included an update during the week.
- Potential Treatments
- New Scientific Findings
- Lessons From Abroad
- Evidence of a Cover-up
- The Road Back?
- Easier Said Than Done – Is Isolation From Loved Ones Practical or Tolerable?
- Georgia Reopening
- Projections and Our (Possible) Future
- Practical Tips – Should You Wear A Mask When Exercising Outdoors?
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A. Possible Treatments
1. Everything we know about Remdesivir, potential new coronavirus treatment drug
- Remdesivir offered a glimmer of hope in the fight against the coronavirus this week when results of a promising clinical trial were released.
- After the trial revealed it could speed up recovery in some patients, Dr. Anthony Fauci called it a “very important first step” in the treatment of the bug, and said the FDA will likely approve the medication for use against the virus “really quickly.”
- Creator Gilead Sciences vowed to create “create enough supply for people all over the world.”
- Here’s what else you need to know:
What is Remdesivir and what was it developed for?
- An experimental antiviral medication developed by the US pharmaceutical firm Gilead Sciences initially to treat Ebola.
- Developed in 2015, the medication showed early promise in a primate study and was later released in the Democratic Republic of Congo — but it ultimately flopped as an effective treatment for Ebola.
- “It never really showed promise; it more or less failed against Ebola,” Peter Pitts, a former associate commissioner of the Food and Drug Administration, told The Post. “So doctors said, ‘Let’s see if this works against C19.’”
How effective is Remdesivir against the coronavirus?
- The results of a clinical trial of more than 1,000 people found that hospitalized C19 patients with respiratory problems got better 31 percent faster than those who took a placebo, according to the National Institute of Allergy and Infectious Diseases.
- But Pitts warned that the drug has shown to a benefit for only the sickest of the sick — hospitalized patients who are elderly, have respiratory problems or preexisting health trouble.
- “It’s saving lives but it’s not a game-changer,” he said. “Clinical trials have shown it has led to recovery in 4 to 10 percent of this desperately ill population.”
- He added, “85 percent of people with the virus will ride it out at home with fluids in bed; it’s not for them. This is not a drug for everyone.”
How does Remdesivir work?
- To get the job done, the drug mimics adenosine, one of the four building blocks of ribonucleic acid — also known as RNA.
- When the virus incorporates Remdesivir into its genome instead of adenosine, it is unable to replicate, according to AFP.
- “It inserts itself into the viral ribonucleic acid, and causes the virus to terminate prematurely,” Pitt explained.
What are the side effects of Remdesivir?
- According to the results of the latest study released by Gilead Sciences, the most common adverse reactions were nausea and acute respiratory failure. Around 7 percent of patients had elevated liver enzymes.
How much will Remdesivir cost?
- That remains unclear, though Gilead Sciences CEO Daniel O’Day told Stat News this week that it is donating 1.5 million doses of the drug — around 140,000 treatment courses — to hospitals and vowed to “work very closely with the government and with health care systems to make sure that it’s accessible, that it’s affordable to governments” in the future.
- “This is a global pandemic. There should be no question about our ability to get medicine in the hands of patients, and that’s how we’re going to approach the period of time after the donation,” he told the outlet.
Are doctors in New York already using Remdesivir?
- Yes. There are at least 700 patients enrolled in multiple trials across the Northwell healthcare system, according to Dr. Marcia Epstein, a lead investigator working on the trials at the Feinstein Institutes for Medical Research at Northwell Health.
- She declined to comment on the outcome of the trials, which began last month.
How excited should we be about Remdesivir?
- It’s a treatment not a miracle cure, and doctors say they need to know more. Some experts consider it a “proof of concept” that could pave the way for better treatments.
- “Clinical trials have shown a very positive impact on those hospitalized,” Pitts said. “But right now, it is still an experimental medicine.”
2. Is a treatment for C19 already sitting on a shelf somewhere? Scientists are trying to find out.
- Arthritis, leukemia and schizophrenia don’t have much in common with each other — or with C19. But drugs used to treat those diseases are being considered as candidates to treat the new coronavirus.
- In fact, scientists in many countries are examining thousands of drugs, developed for a dizzying array of other ailments, to see if they can also help with the current pandemic. Some are specifically antiviral drugs, but most are not; some are new, but many are decades old.
- Researchers can make only rough guesses about which medicines are potential coronavirus treatments. An overwhelming majority will prove to be useless, but a handful are already showing promise.
- “We don’t know a lot about why drugs do what they do,” said Matthew Frieman, a virologist at the University of Maryland School of Medicine.
- After another deadly coronavirus disease, MERS, emerged in 2012, Dr. Frieman and others started testing established drugs against the new contagion. That work has given them a head start on finding contenders for C19 treatments.
B. New Scientific Findings and Theories
1. Coronavirus Pandemic Likely to Last Two Years
- The coronavirus pandemic is likely to last as long as two years and won’t be controlled until about two-thirds of the world’s population is immune, a group of experts said in a report. [The report can be viewed at The CIDRAP Viewpoint]
- Because of its ability to spread from people who don’t appear to be ill, the virus may be harder to control than influenza, the cause of most pandemics in recent history, according to the report from the Center for Infectious Disease Research and Policy at the University of Minnesota. People may actually be at their most infectious before symptoms appear, according to the report.
- After locking down billions of people around the world to minimize its spread through countries, governments are now cautiously allowing businesses and public places to reopen. Yet the coronavirus pandemic is likely to continue in waves that could last beyond 2022, the authors said.
- “Risk communication messaging from government officials should incorporate the concept that this pandemic will not be over soon,” they said, “and that people need to be prepared for possible periodic resurgences of disease over the next two years.”
- Developers are rushing to make vaccines that may be available in small quantities as early as this year. While large amounts of vaccine against the 2009-2010 flu pandemic didn’t become available until after the outbreak peaked in the U.S., one study has estimated that the shots prevented as many as 1.5 million cases and 500 deaths in that country alone, the report said.
- The report was written by CIDRAP director Michael Osterholm and medical director Kristen Moore, Tulane University public health historian John Barry, and Marc Lipsitch, an epidemiologist at the Harvard School of Public Health.
2. Airplanes are not designed to prevent infectious-disease transmission
- Although airlines have touted the safety of flying and their steps against the coronavirus, passenger cabins still pose a danger for the spread of infectious diseases, experts said.
- It is a problem of biology, physics and pure proximity, with airflow, dirty surfaces and close contact with other travelers all at play.
- Breakthroughs are possible, researchers said. Ultraviolet lights that promise to destroy viruses without hurting humans are being tested by Columbia University scientists, who say the lights would be effective in airplanecabins, airports, hospitals and schools.
- “As we speak, there are 100 hairless mice being exposed for 15 months,” said David J. Brenner, director of Columbia’s Center for Radiological Research. The mice live under the lights eight hours a day and get eye and skin tests every couple of weeks, and after eight months the researchers have found no damage, “which is encouraging.”
- The FAA and major manufacturers have long been aware of the risk of diseases spreading on flights and have sponsored research seeking improvements.
- Boeing is experimenting with lavatories that can sanitize themselves in less than three seconds. Engineers at the U.S. manufacturer and its top competitor, Airbus, have explored changing the way air moves around passengers to reduce infections.
- The FAA regulates airplane design and production, down to the requirements for fire-retardant seat cushions, and oversees airline operations. But while the agency sets some air-quality standards, such as acceptable carbon dioxide levels, the FAA has not set rules for preventing the spread of infectious diseases in airplane cabins.
- “The risk to the public is no higher than it would be in any area where you have folks gathered,” Dickson told Rep. David E. Price (D-N.C.), saying the air on planes is “on par” with that in homes and buildings.
- As the coronavirus spread globally, the message from the airline industry to would-be customers was that planes were safe and that extra precautions were being taken. But the science behind cabin air quality has been lost in some of the messaging.
- “To be honest, airplanes are not designed to prevent infectious-disease transmission,” said Chen, who was co-director of the FAA-funded Airliner Cabin Environment Research center from 2004 to 2010. “They’re not designed to do the job.”
- Researchers say tiny droplets containing viruses can be carried along in the wake of someone walking down an aisle.
- Working with two Boeing engineers and a team of researchers from Purdue, Chen wanted to know how changing an airplane’s ventilation system would affect the risk of contracting SARS, as a stand-in for other dangerous viruses that might emerge.
- Their results, published last year, were startling. They found that passengers sitting with a SARS patient in a seven-row section of a Boeing 767 would have a 1-in-3 chance of getting sick from a five-hour flight. On a shorter 737 flight, the risk was 1 in 5.
- But they found that changing the existing ventilation system — essentially by having air flow into the cabin from near the floor rather than from above — would make a big difference, cutting the risk by half or more.
- Chen said droplets were swept away from passengers more efficiently using alternative systems, one tested by Airbus engineers and another developed by Chen and his team.
- One reason: The warmth of the passengers’ bodies helped the flow of air coming up from underneath, since warm air rises, he said. Going with that flow, rather than fighting against it, lessened the turbulence that could keep germs on top of passengers.
- “We try to not mix your air with your neighbors’, ” Chen said.
- The study assumed the virus that caused SARS could stay airborne for long periods, which is different from what the CDC says is typically occurring with the novel coronavirus.
- Scientists and public health officials said C19 is largely spread from one person to another through droplets, such as when people cough or sneeze.
- Such relatively large droplets, brimming with viruses, generally travel only a limited distance before being pulled down by gravity, sort of like ping-pong balls falling back to the table after being whacked.
- That is why social distancing guidelines have emphasized the six-foot distance and call for incessant hand-washing, to avoid picking up fallen droplets and bringing them to your face.
- Fortunately, experts said, the coronavirus does not behave like the fearsomely infectious measles virus, which can stay aloft for up to two hours, more like the balls bobbing and floating around an old-school lottery machine.
- But Chen — whose background is in mechanical engineering and fluid dynamics, not medicine — said the uncertainties around C19 remain a cause for caution.
- The World Health Organization said droplets are the main path for infection, but noted research showing that the coronavirus has become airborne in some hospital settings, including during intubation to help breathing.
- Chen also noted research showing that the coronavirus can be found in feces and wonders if the violent flush of airplane toilets could cause the virus to become airborne. The outbreak on the Diamond Princess cruise ship provides added concern. Though researchers found evidence the virus spread via contacts and droplets, Chen wonders if air systems may also have contributed.
- What he has established through years of research is that droplets less than a certain size — about 20 microns, or millionths of a meter — can easily be swept through the air. Following a cough, they disperse widely, and it takes about four minutes on average for such particles to be filtered out of the cabin.
- Slightly larger droplets can still float for 10 seconds in the cabin’s blowing air, or be carried in the wake of someone walking.
- Larger, heavier droplets that settle quickly remain the most serious risk with C19.
- But any person deciding whether to fly, now or in the future, should be vigilant, and wear a mask.
- On Monday, JetBlue said it would require all passengers to wear masks starting May 4, and American Airlines said it would start handing out face coverings on some flights. “This is the new flying etiquette,” said JetBlue President Joanna Geraghty. [NOTE: Delta (May 4) and Southwest (May 11) are now requiring passengers wear masks as well. American will also require masks starting May 11.]
[Note: As repeatedly noted by public health officials, masks will not protect you from becoming infected. At best, masks will prevent an infected person from spreading the virus. Accordingly, wearing a mask on plane may not protect you from becoming infected.]
1. Your Spit Could Be the Best Coronavirus Test
- Swabs or spit?
- That was the question Anne Wyllie and a team of Yale University scientists set out to answer when they dropped everything they were doing last month and shifted their research focus to studying the new coronavirus.
- They soon made an important finding: spitting into a cup appears to be as effective at detecting this virus as sticking a swab into your nose.
- And that could have even more important implications for the U.S.’s ability to test large numbers of people for the virus.
- Nasopharyngeal swabs are currently the gold standard of specimen collection for the virus. But they’re also in short supply, require health-care professionals wearing protective equipment to administer them and feel like they poke the patient’s brain. All of that contributes to a testing bottleneck that stands in the way of restarting the American economy.
- “We know the hurdles of collecting nasopharyngeal swabs and said there’s got to be a better way,” said Andrew Brooks, chief operating officer and director of technology development at Rutgers University’s RUCDR Infinite Biologics, who is leading the charge on saliva testing across the country.
- Collecting and analyzing a patient’s spit was one such possibility. But a big, unanswered question was if there would be enough virus in the saliva to easily detect. The sensitivity of the test with nasopharyngeal swabs is sometimes lacking, partially because it can be difficult to take a good sample, and less-invasive nasal swabs taken from a person’s nose tend to have fewer copies of the virus.
- When Dr. Wyllie and the Yale team compared samples of saliva with nasopharyngeal swabs, however, the simpler, painless method proved to be successful, according to the report that the 50 researchers posted last week on the preprint server medRxiv.
- “It doesn’t have to be ‘better than,’” Dr. Wyllie said. “As long as it’s ‘as good as.’”
- But the samples of saliva were not merely as good as the swabs in their small study. They were apparently better. The diagnostic test for both was the same—aside from scouring a different type of patient sample for chunks of the virus’s genetic code.
- While their work is preliminary and still awaits peer review and publication, the idea of sampling spit is already spreading across the country, and at least two states are using saliva in addition to swabs.
- The U.S. Food and Drug Administration granted the first emergency use authorization for saliva collection to Dr. Brooks’s team at Rutgers on April 13—before the Yale report went up online.
- To secure that authorization, the team and their collaborators collected both saliva and either a nasopharyngeal or oropharyngeal swab from 60 patients. The results from the saliva and swab samples matched for all 60.
- This proof of concept about the power of saliva comes at a time when testing has never been so essential.
- A non-invasive, self-administered, highly effective spit test could help mass testing become a closer reality. It cuts the demand for supplies such as swabs, preserves the labor of health-care workers, reduces the need for personal protective equipment, alleviates some pressure on global supply chains and makes the test more appealing than your average root canal surgery.
- A saliva-based test could be “game-changing” for those reasons, said Rochelle Walensky, the chief of infectious diseases at Massachusetts General Hospital.
- Now the labs capable of analyzing those saliva tests are moving quickly to adapt. The lab at Rutgers was accustomed to processing DNA genetic tests—people spitting into tubes. “I had never done a viral test in my life maybe six weeks ago,” said Jay Tischfield, a distinguished professor of genetics at Rutgers.
- But the lab was repurposed almost overnight to handle 10,000 coronavirus saliva tests per day, including samples from drive-through sites, and Dr. Tischfield said they recently paid $2 million to clone their equipment and double the lab’s output. The Rutgers test also includes a preservative that helps keep the sample stable between collection and analysis.
- The Yale paper helps support that approach. To determine whether spit tests could detect the coronavirus with the same accuracy as the uncomfortable but historically reliable nasopharyngeal swabs, Dr. Wyllie and her team collected samples from 44 patients at Yale New Haven Hospital who had already tested positive and 98 asymptomatic health-care workers. The size of their study has since increased to 89 and 178, respectively.
- They found the spit tests to be more sensitive to the virus with more consistent results. They also detected the virus in the saliva of two health-care workers who had tested negative using the nasopharyngeal swabs.
- It wasn’t long before the Yale study was the subject of enthusiastic tweets from researchers and luminaries in the coronavirus response, including Scott Gottlieb, the former FDA commissioner who is advising the U.S. government.
- Paul Romer, a Nobel Prize-winning economist, believes that significantly boosting the number of tests is the only way out of the economic and health crises. A simpler collection device that uses spit instead of swabs would make it easier to supersize the nation’s testing capacity, he said in an interview.
- The Yale research is supported by similar findings in Australia, Thailand and California in addition to the Rutgers test. It’s an exhilarating time for scientists who find themselves collaborating with strangers around the world through manuscripts and Twitter exchanges as the notoriously laborious process of academic publishing has accelerated to keep pace with the virus.
- “The more that we share and help each other out, it’s going to increase all of our capacities to respond to this,” Dr. Wyllie said. “This is not a time to be squirreling away your own secret research methods and working behind the scenes.”
- Dr. Wyllie’s work helped support the testing strategy already under way at Rutgers, Dr. Tischfield said. The New Jersey model has been adopted by Oklahoma, where state officials announced plans this week to use saliva tests instead of swabs on more than 40,000 residents and staff in long-term care facilities.
- The Rutgers researchers have since fielded calls from doctors and officials across the country, Dr. Brooks said. Other hospital systems have also started comparing swab and saliva samples from patients to see if they get similar results. The Wadsworth Center, the public health laboratory in New York, has been validating saliva paired with nasal swabs and expects to be able to deploy it in the field “very soon,” according to a statement from the New York State Department of Health.
- Infectious disease experts say that some of the early results are promising but likely need more data and bigger studies to back them up.
- “That was encouraging,” Daniel Kuritzkes, the chief of the division of infectious disease at Brigham and Women’s Hospital in Boston, said of the Yale preprint. “Saliva by itself won’t solve all the problems. It does solve some important bottlenecks.”
- Dr. Wyllie, who is from New Zealand and moved to the Netherlands for graduate school, concentrated on this line of research when she came across a study published in the 1930s and learned that saliva had once been used for pneumococcal carriage detection. Dr. Wyllie decided to find out whether that was still possible. Her promising results on children led to comparing saliva with nasopharyngeal and oropharyngeal swabs in adults and the elderly—and the spit tests were superior.
- She designed a similar experiment in New Haven, Conn., to build on that research. It was supposed to begin in early March.
- “We work with older adults,” Dr. Wyllie said. “How could we risk sending anyone into their homes when we knew they were vulnerable?”
- It appeared that Dr. Wyllie had picked quite possibly the worst time in a century to be a pneumococcologist. But it turned out her timing couldn’t have been any better. Dr. Wyllie turned her attention to SARS-CoV-2—and the Yale report was posted online less than a month later.
D. Lessons From Abroad
1. Danes and Czechs say easing lockdowns has produced no C19 surge
- Denmark and the Czech Republic have said partially easing their lockdowns has not led to a surge in new coronavirus infections, as the WHO continued to urge extreme caution and Germany relaxed some restrictions but extended others.
- As EU governments grappled with the complex and conflicting imperatives of easing the lockdowns crippling their economies while avoiding a disastrous second wave of infections, meanwhile, South Korea reported no new cases for the first time.
- Of the 44 European countries to have imposed restrictions to curb the spread of the virus, 21 had started easing some of them and a further 11 were planning to do so soon, said Hans Kluge, regional director of the WHO in Europe.
- Kluge warned that all governments must remain extremely circumspect. “As I have said before, this virus is unforgiving,” he said. “We must remain vigilant, persevere and be patient – and ready to ramp up measures again as and when needed.”
- There was, though, encouraging news from the Czech Republic and Denmark, where phased exits from strict lockdowns implemented early in the pandemic are under way. In Denmark, daycare facilities and schools began reopening two weeks ago, followed by hairdressers and other small businesses on 20 April.
- “There are no signs at all that the partial reopening has caused a bigger spread of infection,” said Christian Wejse, a scientist at the department of infectious diseases at Aarhus University. “At least there is no indication that we are heading into another wave. That has been the concern, but I can’t see that at all.”
- The Czech health minister, Adam Vojtěch, said the country’s number of new cases had been below 100 for the past eight consecutive days and also reported that a staggered reopening of shops and services had not so far led to a surge in infections.
- “So far we do not see a negative trend resulting from previous relaxations,” Vojtěch said. “We will proceed with caution, gradually in the upcoming waves, and I believe we are on a good path.”
- Proceeding cautiously, Germany on Thursday said places of worship, museums, gardens, zoos, playgrounds and monuments could reopen over the coming days after the chancellor, Angela Merkel, met the heads of the 16 German states.
- But the federal government and state leaders postponed decisions on whether to reopen all schools and kindergartens and said physical distancing rules would stay in place at least until 10 May, with no further relaxations to be decided before 6 May.
- Merkel said reopening cafes and restaurants at this stage would be problematic because of the difficulty of checking whether “people around one table are from one family, or from different households”. She said Germany’s goal currently remained to prevent the virus from spreading rapidly.
- “We don’t have any medication, we don’t have any vaccine against the virus and … therefore, the goal will always be to slow down the virus,” Merkel said, adding that Germany had so far been “successful in achieving this goal”.
- Germany began easing its lockdown last week, when some shops were allowed to open provided they practised strict social distancing, but Merkel and government advisers have expressed serious concerns about the dangers of going to far, too fast, with the risk of the infection rate stating to rise again.
- In Spain, where the daily death toll fell to its lowest in six weeks on Thursday, the health minister announced time slots for specific outdoor activities, in an effort to avoid confusion and further contagion when adults are allowed out on Saturday to exercise for the first time since mid-March.
- Salvador Illa said that except in smaller towns with fewer than 5,000 inhabitants, people would be allowed out to walk or take other exercise from 6am to 10am and 8pm until 11pm, while people who needed carers or were over 70 could be out from 10am to midday and from 7pm until 8pm.
- Parents will be able to accompany children aged under 14 on walks between midday and 7pm. “We need to keep acting very wisely and very prudently and follow expert advice,” Illa said. “We got into this together and we need to get out of it together. There’s no other way.”
- France categorised each of its 95 départements as either red, amber or green according to its risk level, with much of the north and east of the country – including Paris – red, and much of the west and south-west green. Based on infection rate and intensive care bed capacity, the designation will be updated daily until 7 May, when a decision will be made on how fast each will be able to come out of lockdown on 11 May.
- The country’s environment minister, Élisabeth Borne, said the government will contribute €50 per person towards bicycle repairs from 11 May, as part of a package of measures to encourage cycling and keep cars off city roads.
- Under pressure from some regional politicians to lift Europe’s longest lockdown sooner, Italy’s prime minister also said the country’s gradual return to normality must be carefully coordinated and based strictly on scientific advice, if it did not want to see a surge in infections.
- “I’ll say this clearly, at the risk of appearing unpopular,” Giuseppe Conte told parliament on Thursday. “The government cannot immediately ensure a return to normality … We are still in this pandemic.”
- The economic devastation wrought by C19 on the continent, however, is already apparent. After Germany on Wednesday said it faced its worst recession since 1949, France, Italy and Spain revealed equally dire figures on Thursday.
- France and Italy officially fell into recession following historic first-quarter economic declines, while Spain warned of an annual contraction “unprecedented in modern history”. The European Central Bank head, Christine Lagarde, said the crisis threatened “an economic contraction of a magnitude and speed unprecedented in peacetime”.
- South Korea, meanwhile, once one of the hardest-hit countries in a pandemic that has so far infected more than 3.2 million people worldwide and killed nearly 230,000, reported no new cases for the first time since the disease was detected there, boosting hopes of an eventual return to normality.
- An aggressive test-and-trace strategy and widespread social distancing had allowed the country to bring the spread of the virus under control, President Moon Jae-in said. “This is the strength of South Korea and its people,” he declared on Thursday.
- Elsewhere, the virus continued to advance. Cases in Russia surged past 100,000 on Thursday as the country recorded its largest daily increase. The country is now the centre of the outbreak in Europe, but a relatively low death total of 1,073 prompted the Kremlin spokesman Dmitry Peskov to say it had avoided a catastrophic “Italian scenario”.
2. Spain and Portugal share a peninsula, but their outbreaks are worlds apart
- The neighboring nations of Spain and Portugal are a study in how two places that share a 750-mile border can diverge drastically in both their experience of the coronavirus and in the political consensus around plans to combat it.
- As both Iberian nations appear to be emerging from the worst of their current outbreaks, Portugal’s government on Thursday will present a plan to ease its nationwide lockdown, broadly in line with that of neighboring Spain. But the reopening is likely to advance at a different pace given how different the nations’ outbreaks have been.
- Portugal has registered far fewer confirmed infections and deaths from the virus than Spain, which has the highest number of confirmed cases in Europe. Portugal is nearing 1,000 confirmed deaths from the virus out of 10 million residents, while Spain, which is home to 47 million people, is closing in on 25,000 fatalities.
- As Spain saw its hospitals and morgues overwhelmed, particularly in the Madrid region, Portugal’s outbreak progressed at a far slower rate.
- There is no clear explanation for the contrast, but some experts have noted that Portugal’s extensive testing and early attempts to curtail the movement of people earlier in its outbreak may have helped. When Portugal went into lockdown in mid-March, it had registered only two deaths, compared with 120 when Spain took the same step.
- And the political climate in the neighboring nations has been markedly different. Both countries have Socialist prime ministers who lead minority governments, but António Costa, Portugal’s leader, has received unwavering support from other political parties for his handling of the epidemic.
- Mr. Costa has repeatedly warned against complacency. On Monday, he said that his government would not hesitate to reverse course if the country had a pickup in the infection rate in coming weeks. “If things start to go wrong, we have to take a step backward,” he told local reporters while visiting a clothing company that is producing face masks.
- Portugal is expected to allow small shops, hairdressers and bookstores to reopen on Monday, while child care centers and big shopping malls will open on June 1, according to local news media reports.
- A plan presented this week by Prime Minister Pedro Sánchez of Spain to return the country to a “new normalcy” by the end of June has received strong criticism from opposition leaders.
E. Evidence of a Cover-up
1. Intelligence Report Details China Cover-up
- The Chinese Communist Party (CCP) intentionally destroyed evidence and covered up news about the Wuhan coronavirus outbreak to the “endangerment of other countries”, a leaked intelligence report has found.
- The report, a product of the Five Eyes intelligence alliance of the United Kingdom, the United States, Canada, Australia, and New Zeeland, found that the Chinese regime went about “disappearing” whistle-blowing doctors, censored news about the outbreak, destroyed samples of the virus in laboratories, and refused to hand over samples to international scientists, delaying the ability to manufacture a cure for the virus.
- The intelligence dossier, leaked to Australia’s Saturday Telegraph, found that as early as December 31st Communist officials began censoring terms such as “Wuhan Unknown Pneumonia”, “Wuhan Seafood Market”, and “SARS variation”.
- On January 1st the wet market in Wuhan was closed and disinfected with bleach, thereby eliminating the possibility of understanding the origin of an outbreak there.
- Later that week the health commission in the local Hubei province ordered laboratories to stop testing for the virus, as well as calling for the destruction of any samples of the coronavirus. The following day, the National Health Commission in China ordered that all samples of the novel coronavirus either be moved to secure facilities or be destroyed while introducing a “no-publication order” about the virus.
- The report chastised the communist regime for its “deadly denial of human-to-human transmission” and also took aim at the World Health Organization (WHO) for towing the CCP’s line on the virus.
- “Despite evidence of human-human transmission from early December, PRC [People’s Republic of China] authorities deny it until January 20th,” the report stated.
- “The World Health Organization does the same. Yet officials in Taiwan raised concerns as early as December 31st, as did experts in Hong Kong on January 4th,” the report added.
- The report also confirmed that the controversial Wuhan Institute of Virology laboratory had indeed been working on coronaviruses in bats, with one strain being a 96 per cent genetic match for the C19 virus that has claimed the lives of hundreds of thousands of people globally.
- The government of Australia is currently placing the likelihood that the coronavirus emerged from the Wuhan lab at around 5%, however, intelligence agencies in the United States consider the possibility much higher and are actively pursuing the theory, with President Donald Trump claiming that he has seen evidence that the virus originated in the Chinese laboratory.
- The work that was being conducted in the Wuhan Institute of Virology laboratory by lead scientist Shi Zhengli featured heavily in the Five Eyes report as a point of concern.
- In March, Shi said that she “wondered if [the municipal health authority] got it wrong,” adding: “I had never expected this kind of thing to happen in Wuhan, in central China” — believing that it would be more likely for a coronavirus outbreak to occur in southern China where the climate is warmer.
- “Could they [coronaviruses] have come from our lab?” she questioned.
- The acting Director of National Intelligence, Richard Grenell said the United States still believes that the virus originated in the wet market in Wuhan, but added that the government is investigating other options, including the lab theory.
- “The intelligence community will continue to rigorously examine emerging information and intelligence to determine whether the outbreak began through contact with infected animals or if it was the result of an accident at a laboratory in Wuhan,” Grenell said.
- Australia has a relationship with the lab that reportedly continues to this day, training and funding Chinese scientists at the Wuhan Institute of Virology as a part of the partnership between Australia’s Commonwealth Scientific and Industrial Research Organization (CSIRO) and the Chinese Academy of sciences.
- On Thursday, the last British governor of Hong Kong, Lord Chris Patten wrote to Foreign Secretary Dominic Raab, saying that there is an “overwhelming case” to establish “a multilateral expert mission to Wuhan to find out exactly what happened there”.
- “Since Chinese communists are adamant that they have nothing to hide, they would presumably welcome such an inquiry,” Patten wrote.
F. The Road Back?
1. As We Begin Leaving Lockdowns, Is Sweden Model the Way Forward?
- In most countries in Europe and North America, governments have imposed lockdowns of their populations and economies. At first glance, this strategy would seem to strike a reasonable, if painful, bargain: pay the price of (hopefully temporary) limits on civil liberties and economic recession (if not depression) to slow virus spread. The price has been very high. In the U.S. alone, the bill has already reached trillions of dollars of lost economic activity and tens of millions out of work. The material pain may go beyond economic insecurity. Many Americans face the real prospect of food shortages.
- Sweden, however, has forged its own path. The government is emphasizing voluntary action over government mandates. Elementary schools and businesses, including bars, cafés, restaurants and gyms, are open. The government has urged people to act responsibly and follow social distancing guidelines.
- Stockholm has reasoned that C19 will require sustained interventions, even under optimistic timelines for the development of a vaccine. If true, the economic hardship and sacrifices to civil liberties involved in long-term societal shutdowns would become unjustifiable. So, the Swedish Public Health Authority has elected to pursue what it regards as a feasible goal of slowing the spread to prevent the overwhelming of its health care system while protecting the most vulnerable populations.
- Commentators in the media have accused the Swedes of pursuing a “risky coronavirus virus strategy” or of “Russian roulette-style COVID strategy” that has caused an alarming acceleration of the pandemic, triggering a “death spike” leading to “10 times the number of deaths than its Nordic neighbors” have seen.
- These commentaries seem to extrapolate too much from a narrow view of the data coming out of Sweden or are under the false impression that Sweden is not socially distancing and simply allowing the disease to spread. In fact, recent reports claiming an acceleration in COVID deaths in Sweden appear to be based on misconstruing the data at hand and narrow comparisons to other countries.
- The Swedish Public Health Agency (SPHA) and the European Centre for Disease Prevention and Control (ECDC) have been reporting different daily C19 death counts in Sweden. The Swedish National Board of Health and Welfare also releases C19 death statistics. Although the cases reported by the SPHA and SNBHW show daily deaths on a decreasing trend, the data from the ECDC shows large swings in the death rate (Figure 1).
- To understand these discrepancies, one must look into the nature of the data. The ECDC uses the day that deaths are reported. The SPHA reports the actual date of death. Using their national identification system, they report the day of death for every confirmed C19 death. These numbers, unlike those in many other countries, include deaths that occur at home, nursing homes and long-term care facilities and not just those occurring at hospitals. The National Board of Health and Welfare examines the death certificates and looks for deaths that are attributable to C19 and reports the date of death. Thus, they report the day of COVID-related death regardless of whether the person was tested for C19 or not. It is interesting to note that roughly 4.5% of the C19 deaths in the SPHA count are cases where C19 was not listed as a cause of death; in other words, people died with C19, not from it. Further, there are reporting delays, with weekends having lower counts and larger counts occurring later in the week. Taken together, these distinctions can paint different pictures.
- Cross-country comparisons may suffer similar problems. Data cited in the press and on Twitter comparing Sweden to its Scandinavian neighbors are sometimes reported in cumulative numbers of deaths without adjusting for population size. The population of Sweden is roughly double the size of that of each of its Nordic neighbors. Such comparisons of death counts can misrepresent Sweden as a massive outlier (Figure 2).
- A fuller picture should bring into the comparison nearby Ireland and the United Kingdom. As daily counts can suffer from a great deal of random variability, plotting the data using a three-day rolling average of deaths per million (to account for population size differences) smooths out some of this noise and resolves the trajectory of the mortality rate into sharper focus. Appraised with this improved vision, Sweden does not appear to be such an extreme outlier (Figure 3).
- Sweden represents a unique alternative as a national approach to bending the C19 death curve. Perhaps as nations are contemplating relaxing their lockdowns, we should step back and take an objective, thoughtful look at what could prove to be an invaluable case study.
- Stockholm trusts that people will act in their own self-interest to reduce the viral spread and, therefore, in the interest of society. This voluntary approach, however, does not exclude selective interventions and closures. While primary schools remain open to assist parents who may be health care workers and to prevent infections of elderly neighbors or grandparents who otherwise would be pressed into service as child caregivers, secondary schools and universities are closed. Visits to nursing homes are banned, and people aged over 70 have been instructed to self-isolate. Distancing is required at restaurants and gatherings larger than 50 are banned.
- Judging by several indicia, Swedes are heeding the recommendations. Ridership on public transportation has dropped, working from home has increased, restaurants remain open but operate at lower capacity, and travel over the Easter holiday declined dramatically.
- Sooner or later the lockdowns must end, as people become more afraid of losing their livelihood than losing their life, or as other overlooked mental and physical costs pile up to the breaking point. In the absence of effective and widespread vaccination, the viral spread can be slowed but not stopped. Singapore, for example, initially did well at containment, but now new cases are appearing. It is possible that Sweden’s larger initial wave of infection pulled forward infections that other countries are likely to encounter in subsequent waves as those nations’ lockdowns are inevitably relaxed. Indeed, Dr. Michael Ryan, executive director of the health emergencies program of the World Health Organization, suggested that perhaps Sweden “represents a future model” of what a post-lockdown society might look like.
- It is too early to make definitive judgments on the relative merits and risks of the different national approaches to the C19 pandemic. Furthermore, given differences in population composition, culture, health care infrastructure and other factors, successful approaches in one country or even one region might not enjoy equal effectiveness elsewhere.
- But in the uncharted world of C19, we must learn from all available data, including that of systems and approaches that differ from convention. Sweden has embarked upon a promising, but unproven, departure from the orthodoxy of government-ordered lockdowns. To date, Stockholm’s reliance on individual responsibility has succeeded in holding caseloads within the country’s capacity to care for the stricken. As we prepare to slowly come out of lockdown and embark for the “new normal” of tomorrow, we have lessons to learn from Sweden today.
G. Easier Said Than Done
1. Is Isolation At Home Practical or Tolerable?
- If someone in our home becomes infected, the experts tell us to isolate infected person so that others in the house don’t get infected.
- Makes sense…at least in theory. But is that a reality we can live with?
- It is hard to disagree with isolating high risk people in our home from anyone that has become infected. On the hand, we can’t isolate kids from their parents. So, if they become infected, isolation is not practical.
- But, what if a husband or wife gets infected? Is he/she supposed to isolate from the other? While it seems likely to me that the infected spouse would want to isolate, may even insist on it, that might not be practical or effective. But, even if it is, will the other find isolation to be a tolerable situation?
- Of course, everyone dealing with that situation will have to decide what is the best course of action for them. But, having lived through this situation, I found the idea of being isolated to be intolerable. When my wife became infected, she immediately urged us to isolate. She said that she would not be able to live with herself if I became infected and became seriously ill or died. But, given the infectiousness of the virus and the time we have already spent together in close quarters before she developed symptoms, I thought it would be a useless gesture. So, I said no.
- But, in reality, something deeper was driving my decision. My wife has underlying health conditions, so the odds of the disease becoming a serious problem was elevated. A scary situation to be sure, but there was nothing we could do about that but ride it out. All we could control was how we would ride it out — together or apart.
- I did not want her to have to deal with any fear or anxiety alone. While I am sure that her inner strength and Christian beliefs would sustain her through any hardship, that seemed too much to ask (or accept) for whatever improvement in personal safety that I might have obtained from separation.
- Worse – far worse – were my fears and anxieties that she might get seriously ill or die and I would not be with her. How could I let her face that alone? I would have felt like a coward and my self-respect would have been decimated regardless of the outcome, especially since I know full well that there are no circumstances in which she would ever have isolated from me if I were sick.
- In my experience, regret is the hardest thing to live with. And I believe that isolating from my wife in this situation would have been the biggest regret of my life – no matter what happened.
- So, while the expert advice is fine in theory and we often include their advice in our Updates, I found that it can carry little weight in the harsh light of reality. On the upside, perhaps I have earned an immunity passport without even knowing it.
H. Georgia Reopening
- On Friday, 4/24, Gov Kemp reopened certain businesses (salons, gyms, bowling alleys), and on Monday, 4/27 private dine-in restaurants were allowed to reopen. On Friday, 5/1, Gov Kemp allowed the shelter-in-place order to expire for most residents.
- We are following Georgia’s progress because as the success or failure of its approach (the “Georgia Model”) will undoubtedly influence the approach taken by other States. While the path taken by Georgia is unquestionably controversial, only time will tell if the model is a good strategy or too aggressive. The stakes are high, particularly in light of President Trump’s criticism of some aspects of the plan and the fact that polls show that a majority of voters do not support reopening the Georgia economy at this time.
- Cases of the C19 and deaths will inevitably increase as the Georgia economy reopens. We believe that success or failure of the Georgia Model will depend in large part on how the public reacts to the increase in cases/deaths and whether the healthcare system can effectively manage the increase in cases. As a result, we will be following those metrics closely.
- As of Saturday, May 2:
- Georgia had (i) total cases of 28,332, an increase of 836 cases since the prior day, and (ii) total deaths of 1,175, an increase of 9 since the prior day.
- The number of hospitalizations for C19 totaled 5,388, an increase of +81 from Friday’s total of 5,307. Note the prior day’s increase in hospitalization was an increase of +117.
- The number of cases in Georgia is the 12th highest in the country. Georgia has 2,751 cases per 1 million in population while the US has 3,503 per 1 million in population, and Georgia has 114 deaths per 1 million in population compared while the US has 204 deaths per 1 million in population.
- In addition, Georgia has tested approx. 174,800 people, which translates into 16,975 tests per million in population while the US has done 20,922 per 1 million in population.
- According the IHME Model, as of April 28, Georgia had 8,323 hospital beds and 590 ICU beds available for C19, and no shortage of hospital or ICU beds is currently projected. The IHME Model also projects that Georgia’s peak hospital resource data was on April 28.
|Source: AJC.com, GA Department of Health|
2. A View from North Metro Atlanta
- As previously reported, GA restaurants were allowed to reopen on Monday, 4/27. We noted that in the North Metro suburb of Roswell, only two restaurants out of a total of 20 in the corridor known as “Canton St” were offering dine-in services on the reopen date.
- On Saturday, 5/2, there were 7 restaurants open and crowds were noticeably larger (See the pictures below). Additionally, the Governor’s order requires restaurants to meet the following requirements regarding social distancing:
- No more than ten patrons per 500 square feet are allowed inside at once
- Party size is limited to no more than 6 per table
- All employees will be required to wear masks at all times
- It’s too early to tell what effect the Georgia Model will have on the hospitalizations and death totals. Assuming a 14 day incubation day period, we could begin to see an increase in cases and hospitalizations over the next 2 week period.
3. Georgia Mall Openings Delayed until Monday 5/4
- We hoped to provide a frontline look at the reopening of GA’s malls last Friday, but Simon Properties, the owner of several of the largest malls, announced that it was delaying any reopenings until Monday 5/4. We suspect the delay was due to a lack of store operators who would be reopening. Coincidentally, Macy’s announced on Friday that it will reopen several of its stores on Monday. We will be watching closely and provide a report in our Tuesday Update.
4. Blue Angels & Thunderbirds — Atlanta Flyover
- On Saturday, thousands of Atlantans took to the streets, parking lots, parks, and driveways to watch flyover from the U.S. Navy’s Blue Angels and Air Force’s Thunderbirds honoring health workers fighting to save lives from C19. The flight path took them directly over several Atlanta hospitals.
- The “America Strong” tour already saluted New York City, Philadelphia, DC and Baltimore before buzzing over Atlanta to honor our frontline medical workers.
- We thank all of our frontline medical workers and first responders!
- Here’s a video of the flyover in Roswell:
I. Projections & Our (Possible) Future
1. There Is No Exit From C19, Only Containment
- Epidemics come in waves. In the Spanish flu pandemic of 1918, the deadliest in history, the first wave was nothing in comparison with the virulent second wave, which left a horrific trail. No doubt, this is a Catch-22 situation — whether suppressing the virus further to stall a repeat outbreak or the lifting of restrictions quicker to limit the economic fallout should take precedence. The biggest risk is that you open too fast, too broadly.
- The warning from Germany on lockdown easing conveys a somber message. Only a week since the easing began in Germany with the reopening of shops (with all conceivable precautions put in place with characteristic Teutonic efficiency and thoroughness), it appears that Berlin may have to re-tighten its lockdown because the virus is spreading too fast.
- The virus reproduction rate – measuring how many the average person with Covid-19 infects – increased to 1.0. (Any value above 1.0 is seen as leading to exponential increase in infections.) Chancellor Angela Merkel is on record that a rise to 1.2 ( of the so-called “RE number”) could mean hospitals reach a crisis point in July: “If we get to 1.2 people, so everyone is infecting 20 per cent more, out of five people one infects two and the rest one, then we will reach the limit of our healthcare system in July”.
- Remember, this is one of the richest countries in the world — and a social democracy with a well developed healthcare system. It is a worrying sign. Surely, there are many variables swirling in the ether, and epidemiology is a complex business.
- The bottom line is that with no vaccine or cure insight, the government will have to decide how many deaths would be acceptable to restore a shattered economy. If the “RE” number lifts after an easing of restrictions on 3rd May and we’re forced to back-pedal, the economic damage will be amplified, leave aside the potential to demoralize the public’s resolve.
- Mass testing of asymptomatic people appears to be the defining measure of success globally in tackling the virus. Time and testing are key and the longer a quarantine can be extended the better, and the more testing made available, the easier it would be to properly calibrate a reopening and respond to any new outbreak. No doubt, waiting until comprehensive testing provides a better map of where the infection has spread.
- Devi Sridhar, the chair of global public health at Edinburgh Medical School and director of the Global Health Governance program, recently tweeted on the three options open. Sridhar wrote:
- “There are few short-term options:
- Let the virus go and thousands die, or
- Lockdown and release cycles which will destroy economy and society, or
- Aggressive test, trace, isolate strategy supported with soft physical distancing.”
- Having said that, the horrifying twin-reality still remains to be that an end to lockdown will by no means represent a return to normality, and, equally, a second, far more destructive wave is virtually an unavoidable possibility, notwithstanding the infection-reducing social distancing as a “new normal” in our daily life.
- Under the circumstances, while dampening public expectations may not be the best option in politics, public morale is best sustained on the basis of transparent, realistic communication. This is a long haul. Make no mistake that in the absence of a safe and effective vaccine and/or a safe and effective drug to eliminate the COVID-19 infection once it has occurred, our narrative narrows down to a containment strategy – which, by no means, becomes an exit strategy.
J. Practical Tips & Other Useful Information
1. Should You Wear a Mask When Exercising Outdoors?
- Tara Dunn, a cyclist and corporate lawyer in Denver says the coronavirus pandemic has turned her into a connoisseur of neck gaiters. The bandanna-like tubes of fabric that some outdoor enthusiasts wear against extreme sun or cold have become her mask of choice for workouts. “I’ve been testing out the different fabrics,” Ms. Dunn says. “Some are Lycra-esque, others are made from a heavier thermal material. None are easy to breathe in.” She wears the gaiter around her neck and pulls it above her mouth and nose when she sees people as far as 12 feet away.
- Kinnier Lastimosa, a claims examiner in Chicago and his wife, Jennifer Cheng, who works as a project manager in the corporate real estate department of a major U.S. airline, are both marathoners and have felt social pressure to wear masks when they go outdoors to run. The couple tried wearing medical masks but they were tough to breathe in and fogged up their sunglasses. Over the years, they have collected dozens of gaiters from races and have found folding them in thirds creates a barrier that feels safe but breathable. In addition to their homespun masks, they have been vigilant about social distancing on city streets, keeping up to 15 feet from others and detouring from routes that look crowded. Many exercisers are experimenting with different types of masks and fabrics and are taking extra precautions to protect themselves and others when they head outdoors. We asked experts to weigh in on best practices.
Should I wear a mask during outdoor exercise?
- The CDC recommends that everyone now wear a mask of some kind when they leave home, and some cities and towns require a facial covering if you are outside. However, there is no compelling medical reason for people who are exercising outside and maintaining social distancing to wear a mask, says Henry Chambers, a professor in the Division of Infectious Diseases at the University of California, San Francisco.
- You’re wearing a mask to protect others so that if you are infected and discharging a virus through your mouth and nose—which is believed to be the most common mode of transmission—then the mask serves as a barrier between others and the infected droplets, he says. If you didn’t have the mask on, and are breathing really hard, could someone else breathe in those droplets? “That’s where the distancing comes in,” Dr. Chambers says.
- Paul Auerbach, an emergency medicine doctor at Stanford University School of Medicine, suggests having a mask hang around your neck while walking, running or cycling so that you can pull it over your mouth and nose when you see other people. “It’s an act of solidarity and courtesy, letting everyone know you are trying to be respectful, smart and safe,” he says. If you are in the water surfing, kayaking or paddling, he says you probably don’t need a mask, because it will most likely get wet and be difficult to use.
How likely are you to transmit or be infected by the virus outdoors?
- “There is a lot of air space and air flow outside,” Dr. Chambers says. “Data suggests that people who are infectious and generating infectious droplets are of greatest contagion within 6 feet of you.” If you are outdoors and closely packed together at the start of a foot race, for example, there is a risk, he says. “If you are outdoors and appropriately distanced from other people, then it is highly unlikely you will be exposed,” he says. Research simulating the aerodynamics of contagious droplets that walkers and runners leave in their slipstream has been criticized for not taking into account how air can dilute the droplets, he says. Whether running or walking, you are breathing in a large volume of air that is distributed over a broad area. Every breath is over 10 feet of air space. “It’s highly unlikely you’ll come in contact with someone’s airflow unless you’re directly behind them,” he says.
What kind of face covering is best for outdoor exercise?
- Surgical or medical-grade masks, such as the N95 device, prevent more of a barrier to the outflow or influx of germs compared with DIY versions.
- “Attempting to run in an N95 mask would feel like you’re running at 10,000 feet of elevation,” says Dr. Chambers, who emphasizes that these masks are needed by health-care workers, not exercisers.
- Dr. Auerbach recently attempted to run 5 miles in 81-degree weather while wearing a surgical mask. He pulled it over his mouth and nose when people were approaching and at a distance of about 20 yards and pulled it down when they were out of sight. “I didn’t feel constricted and never felt like I wasn’t getting enough air,” he says, noting he was going at a slow pace. “If I exhaled forcefully, air leaked out the sides.” He also notes the mask got wet from his sweat and exhalations and this made it susceptible to tearing.
- The CDC has officially recommended that cloth face coverings be worn in public places. Richard Martinello, associate professor of infectious disease at Yale School of Medicine in New Haven, Ct., says studies done on the effectiveness of nonmedical masks have generally failed to show much benefit. If you are going to wear a homemade mask, Dr. Auerbach suggests using a 100% cotton T-shirt or pillowcase or a bandanna or gaiter. The key, he says, is making sure it fits snugly and covers both your nose and mouth. And, he adds, be sure to clean your mask after using it.
- Experts warn that poorly fitted masks could impede the hearing or vision of walkers, runners and cyclists on the road. Dr. Auerbach says any type of mask will hinder breathing somewhat. He suggests testing out your mask close to home and advises stopping exercising if you feel dizzy or lightheaded. If you have previous respiratory issues, he says you might want to consider working out indoors.
How will wearing a mask affect my performance?
- Dr. Stuart Weiss, medical director of the New York Road Runners, wrote in a post to members that “running with a face covering will change the dynamics of breathing, depending on the material the face covering is made of. It will be harder to breathe in, and that may affect performance.” He cautioned that a mask may result in increased nasal mucus production, as well as create a pool of sweat around the mouth, which could lead to discomfort.
- Michael Joyner, an exercise researcher at the Mayo Clinic in Rochester, Minn., who has been wearing a cloth bandanna during his bike rides, says now is not the time to be attempting to set personal bests. “If you’re an elite athlete and really need to train hard, find a remote area outdoors and train without a mask,” Dr. Joyner says. “But for the rest of us, we need to follow the rules, use common sense and tone things back or we’re going to lose our outdoor privileges.”
- Is the effectiveness of a mask compromised if a person takes it on and off during exercise? Wouldn’t it be better to just keep the mask on all the time when exercising, especially since taking it on and off means you are touching your face all the time?
- “If you have thoroughly washed your hands before going outside and are keeping your distance from people while exercising then your hands should remain unexposed to any infected droplets and pulling your mask up and down should not be a risk,” says Dr. Joyner. “If you’re bottle-necked on a hiking trail and someone sneezes on your hands you don’t want to touch your face. But you should not be that close to people in the first place.”
- Dr. Joyner stresses that as the weather warms, exercisers who head outdoors should do so at off hours and seek out less-crowded hiking and biking trails and running routes. “It all comes down to common sense,” he says. “Wash your hands before you go out. Keep your distance. And wash your hands again when you return home before you take off your mask.”
- “Remember the mask usage is to prevent one who is infected from transmitting to others,” says Dr. Chambers. “There is probably efficacy in blocking transmission to an uninfected, exposed individual, but the magnitude of this effect is unknown and it will not prevent transmission to eyes or on the uncovered face that would be prevented by a face shield.”
- Bottom Line: If exercising outdoors, social distancing is likely the best method to stay healthy, though one may also need to wear a mask to keep from running afoul of the law, Dr. Martinello says.