Coronavirus Update 5-5

“We did the right thing and now we’re bringing the country back. And I think there’s a great optimism.”  — President Trump

“I quit in dismay at Amazon firing whistleblowers who were making noise about warehouse employees frightened of Covid-19.” 
— Tim Bray, VP 

“It was a worst-case scenario, especially with all the marketing we did. The reopening weekend was a disaster. We had two customers all weekend.  Our only decision right now is to survive.” 
— Mario Zelaya, Georgia small business owner

Today’s Features

• Recent Developments and Headlines
• Numbers and Trends
• Potential Treatments – Scientists discover antibody that prevents infection
• Antibody Testing – FDA clamps down on antibody tests
• New Scientific Findings – No evidence that lockdowns reduce infections
• Concerns & Unknowns – hypoxia baffles doctors
• Updates
• Lessons From Abroad
• The Road Back? – NY roadmap comes into view
• Projections & Our (Possible) Future – IHME model updates
• Technology
• Practical Tips

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Available Resource:  Having put together almost 70 daily updates, our team has compiled and distributed a tremendous amount of information about the coronavirus and COVID-19 and we are happy to share what we know.  So, if you have any questions regarding the virus or disease, please feel free to contact either pwduval@gmail.com or brian.sivy@gmail.com.  We’d be happy to respond by email or arrange a call with you or anyone you know as soon as we can.

A. Recent Developments and Headlines

Note: All changes noted in this Update are since the 5/4 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

• Internal FEMA document projects spike in daily coronavirus death toll, but data questioned
• President Trump ‘confident’ there will be coronavirus vaccine by end of year
• Scientists Say They’ve Discovered Antibody That Blocks Coronavirus From Infecting Cells (see story below)
• New York Urges Locals To Start Preparing “Now” For May 15 Reopening 
• CA Gov. Newsom announces second phase of reopening parts of California to start as early as Friday
• Protests Across California Show You Can Only Push People So Far
• New Mexico Governor Quarantines Entire City, Closes All Roads That Lead Into Town
• Poll: 71% of Conservatives Say It’s Time for U.S. to ‘Get Back to Work,’ 69% of Liberals Disagree
• Apple Data Shows Shelter-In-Place Is Ending, Whether Governments Want It To Or Not
• President Trump: White House Will Release ‘Conclusive’ Evidence Coronavirus Originated in Wuhan Lab
• The meat shortages are here: Costco and Kroger warn of limited supply
• Scientists say a vaccine for C19 could still be far off
• US government will decide where remdesivir goes amid coronavirus pandemic, drugmaker says
• Deaths decline for 5th day
• Japan extends state of emergency
• Spanish opposition threatens to torpedo vote to extend lockdown
• European clinical trial “Project Discovery” results to be released May 14
• NY reports uptick in deaths, still lower than last week’s average
• Macron warns European borders may remain closed until September
• Florida becomes latest state to reopen much of economy on Monday
• Italy, Spain and other European and Asian economies are also reopening
• Iran to allow Friday prayers
• UK defense secretary says China owes the world ‘an explanation’
• Majority Of Brits Uncomfortable About Going To Bars, Restaurants
• Greek Brothels To Reopen But Hookers And Clients Required To Wear Masks And Gloves
• China Faces “Economic Reckoning” As COVID-19 Turns World Against Globalization
• Majority Of Americans Don’t Trust Tech Companies With Contact-Tracing
• “We Had 2 Customers All Weekend” – Georgia’s Small Businesses Gripe About “Disastrous” Reopening
• Video Of NYPD Officer Brutalizing Bystander During ‘Social Distancing’ Arrest Sparks Outrage
• China Hid Severity Of Coronavirus To Hoard Supplies, New Intelligence Shows
• As lockdowns lift, ‘second wave’ concerns grow
• No evidence of a second wave in Germany after lockdown lifted
• German coronavirus cases may be 10 times higher than official figures
• Texas Beaches Packed:  It’s a Jungle Out There
• Five days after reopening, South Beach park closes as crowds defy face mask order
• Beef Prices Explode To Record High As More Stores Limit Meat Purchases
• It Is Not Our Ignorance That Will Kill Us, But Our Arrogance
• After Cuomo, Clintons And Newsom Call For ‘Army Of Contact Tracers’ To Monitor Citizens, DC Posts Job Openings For ‘Trace Force’
• Violent arrest raises concerns about NYPD distancing patrols
• Will international travel resume this year? Treasury Secretary Mnuchin says it’s ‘too hard to tell’
• USS Theodore Roosevelt sailors still showing virus symptoms despite month of isolation
• US Supreme Court conducts first-ever proceeding by teleconference
• More than 370 workers at a pork plant in Missouri tested positive for coronavirus – all were asymptomatic
• Woman arrested for licking spree
• Isolated by oceans, Hawaii and other islands have low number of infections
• As Latin America and Caribbean seek to reopen economies, Jamaica offers cautionary tale
• The pandemic has amplified ageism. ‘It’s open season for discrimination’ against older adults
• Fever-reading drones just first of a wave of privacy challenges, civil liberties advocates say
• Cameras in France to monitor masks and social distancing
• Senior Trump Aides Ease Up on China Pressure
• The Army Wants a Wearable C19 Detector
• With testing, Iceland claims major success against C19 (see story below)
• World leaders join to pledge $8 billion for vaccine, but the U.S. sits out
• With most sports leagues on pause, baseball in Taiwan and South Korea becomes a global hit
• Three C19n medics have plunged from windows after complaining about officials’ handling of the pandemic
• 10 German soccer players test positive for the virus as their league weighs restarting games
• Australia and New Zealand discuss possible trans-Tasman “travel bubble”
• In fight over Brazil leader’s virus test, crisis looms
• 15 kids hospitalized in NYC with rare disease possibly linked to coronavirus
• Iran opens long banned drive-in movies in midst of coronavirus pandemic
• Baseball resumes in South Korea as coronavirus spread slows
• Missouri sees record number of new coronavirus cases as state reopens
• Pro-lockdown extremists in denial about why we did it in the first place
• Bill de Blasio chooses to be helpless in the homeless subway crisis
• US factory orders hit a record low in March
• German nightclub hosts drive-in rave in spite of the coronavirus
• Pharma CEO says coronavirus drug remdesivir will be available this week
• California will allow some businesses to reopen with curbside pickup
• WHO calls claims that coronavirus originated in Chinese lab ‘speculative’
• FEMA prepares for hurricane season amid coronavirus challenges
• India orders coronavirus tracing app for all workers
• Carnival Cruise Line plans to return to service in August
• NYPD union wants cops out of ‘social distancing enforcement’
• We’re destroying hospitals in the name of fighting the coronavirus
• Mystery barber sets up shop on Brooklyn street for quarantine clients
• Anti-China sentiment surges in wake of coronavirus
• ‘Beach ambassadors’ enforce social distancing as Florida reopens
• Pork producers slowly bring back workers with partitions, temperature tests
• Amazon VP Tim Bray quits, calls company ‘chickens–t’ for firing protesters
• Jersey City offers free coronavirus tests to all residents
• Can parents survive months of hell as the coronavirus cancels summer camps?
• Heathrow Boss Says “Social Distancing” Will Never Work At Airports
• Mayor Of Nice Demands “Health Passports” To Enter/Leave France
• Millions return to work in Italy as coronavirus restrictions loosen
• Coronavirus contact tracing app could be forced on all UK visitors
• WHO envoy warns coronavirus vaccine may never be developed 
• Hundreds of sheep take over Turkish street during lockdown
• Pharma CEO says coronavirus drug remdesivir will be available this week
• It’s time to care for non-COVID patients as pandemic lessens, NY doctors say
• Researchers studying power of prayer in coronavirus patients

B. Numbers & Trends

Note:  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.

Sources: Worldometers and  ncov2019.live

1. Confirmed Total Cases and New Cases

• Worldwide:  
  • Total Cases = 3,643,271 (+2.2%)
  • New Cases = 79,582 (-3.4%) (-2,758)
  • New Cases (5 day avg) = 85,017 (-0.5%) (-419)
• Europe: 
  • Total Cases = 1,469,911 (+1.6%) 
  • New Cases = 22,408 (-3.2%) (-713)
  • New Cases (5 day avg) = 24,506 (-1.8%) (-453)
• Asia: 
  • Total Cases = 572,839 (+2.5%)
  • New Cases = 14,037 (+8.0%) (+1,045)
  • New Cases (5 day avg) = 13,102 (+2.3%) (+297)
• US: 
  • Total Cases = 1,212,835 (+2.1%)
  • New Cases = 24,713 (-9.6%) (-2,635)
  • New Cases (5 day avg) = 29,728 (-2.4%) (-743)
• US States & Territories:  
  • 45 States > 1,000 cases (+0), 
  • 41 States > 2,500 cases (+0), plus DC 
  • 36 States > 5,000 cases (+1)
  • 20 States > 10,000 cases (+0): NY, NJ, MA, IL, CA, PA, MI, FL, LA, CT, TX, GA, MD, OH, IN, CO, WA, VA, TN & NC
  • 15 States > 20,000 cases (+2): NY, NJ, MA, IL, CA, PA, MI, FL, LA, CT, TX, GA, MD, IN & OH
  • 5 States With Largest Number of Total Cases: 

State	Total Cases	Change in Total Cases (%)	New Cases	Change in New Cases (#)	Change in New Cases (%)
NY	327,374	1.1%	3,491	(1,179)	(25.3%)
NJ	129,345	1.5%	1,907	(1,814)	(48.8%)
MA	69,087	1.6%	1,060	(705)	(40.0%)
IL	63,840	3.8%	2,341	(653)	(27.9%)
CA	56,089	2.2%	1,230	(23)	(1.8%)
Total	645,735	1.6%	10,029	(4,474)	(30.4%)

• Top 5 States = 53.2% of Total US Cases (-0.3%)
• NY & NJ = 37.7% of Total US Cases (-0.3%)
• Trends:  Top 5 States and NY/NJ percentages of total cases are declining as their average number of new cases continue to decline while new cases in other States are increasing 
• 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 = 49,639 (-401)
• US serious or critical cases = 16,050 (-89) 
• US serious or critical cases = 1.7% of Active Cases compared with worldwide percentage of 2.3%

3. Deaths

• Worldwide deaths = 252,241 (+1.7%) 
• Worldwide new deaths = 4,095 (+17.6%) (+612)
• Europe deaths = 142,143 (+1.1%) (+1,540) 
• US deaths = 69,921 (+1.9%) 
• US new deaths = 1,324 (+14.8%) (+171)
• NY deaths = 24,648 (+1.2%) 
• NY new deaths = 269 (+5.7%) (+16)
• Deaths per 1M population of 5 Countries with Largest Number of Confirmed Cases: 
  • Spain: 544 (+4) 
  • Italy: 481 (+4) 
  • United Kingdom: 423 (+4)  
  • France: 386 (+5) 
  • United States: 211 (+4) 
  • New York: 1,271
• US Total Confirmed Case Fatality Rate = 5.9% compared with a Worldwide Confirmed Case Fatality Rate of 7.0%
  • [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.]

4. Recoveries

• Worldwide recoveries = 1,194,739 (+3.5%) (+40,892)
• Worldwide recoveries = 32.8% of Total Worldwide Cases
• US recoveries = 188,027 (+5.5%) (+9,764)
• US recoveries = 15.5% of Total US Cases (+0.5%)

5. Countries/States Under Review

• Sweden
  • Total Cases = 22,721 (+404)
  • Deaths = 2,769 (+90)
  • Deaths per 1 million population = 274
• Georgia
  • Total Cases = 29,438 (+767)
  • Deaths = 1,246 (+72)
  • Deaths per 1 million population = 121

C. Potential Treatments

1. Scientists discover antibody that prevents infection

• Scientists have discovered an antibody that prevents the coronavirus from infecting human cells in “groundbreaking research” which could lead to the development of new treatments.
• Building on research into the SARS coronavirus, scientists from Utrecht University in the Netherlands, as well as the Erasmus Medical Centre and the company Harbour BioMed (HBM), have identified a potential method of neutralizing C19.
• They discovered that an antibody which prevents the SARS virus from infecting human cells could also block the novel coronavirus from infecting human cells too, according a peer reviewed study published on Monday in the journal Nature Communications.
• Testing their collection of antibodies on cultured human cells, researchers discovered one which binds to a specific part which is present in both SARS and the virus causing C19.
• The discovery could offer an initial step towards developing a fully-human antibody to treat or prevent the disease.
• The neutralizing antibody “has potential to alter the course of infection in the infected host, support virus clearance or protect an uninfected individual that is exposed to the virus,” said Dr Berend-Jan Bosch, co-lead author on the study.
• Dr Frank Grosveld, the study’s other co-lead author, said the discovery provided “a strong foundation for additional research to characterize this antibody and begin development as a potential C19 treatment”.
• “The antibody used in this work is ‘fully human’, allowing development to proceed more rapidly and reducing the potential for immune-related side effects,” he added.
• The fully-human antibody is different from conventional therapeutic antibodies, which are often first developed in other species before being “humanized” so they can be transmitted to people.
• It was developed using Harbour BioMed’s H2L2 transgenic mouse technology — effectively a mouse which has been genetically engineered to contain human genes, enabling researchers to develop “human” antibodies without testing them on living people.
• “This is groundbreaking research,” said Dr Jingsong Wang, the chief executive of HBM.

Source: Coronavirus: Scientists hail ‘groundbreaking’ discovery of antibody which prevents infection

2. Researchers are adapting gene therapy to develop a vaccine

• Researchers at two Harvard-affiliated hospitals are adapting a proven form of gene therapy to develop a coronavirus vaccine, which they expect to test in people later this year, they announced on Monday.
• Their work employs a method already used in gene therapy for two inherited diseases, including a form of blindness: It uses a harmless virus as a vector, or carrier, to bring DNA into the patient’s cells. In this case, the DNA should instruct the cells to make a coronavirus protein that would stimulate the immune system to fight off future infections.
• So far, the team has studied its vaccine candidates only in mice. Tests for safety and potency in monkeys should begin within a month or so at another academic center, the researchers said. But two of seven promising versions are already being manufactured for studies in humans.
• At this early stage, Dr. Luk H. Vandenberghe, director of the Grousbeck Gene Therapy Center at Massachusetts Eye and Ear, estimates the manufacturing cost per dose of vaccine to be from $2.50 to $250.
• “We are presenting a different angle from everybody else,” Dr. Vandenberghe, director said. Several other vaccine projects involve viral vectors, but no others use adeno-associated viruses.
• The approach has several advantages, he added.
• One is that the type of vector, an adeno-associated virus, or AAV, is a harmless virus that is already used in two approved forms of gene therapy and has been tested in many patients and found to be safe. Another plus is that the technique requires very small amounts of the vector and DNA to produce immunity, so the yield of doses would be high. In addition, many drug and biotech companies, large and small, already produce adeno-associated virus and could easily switch to producing the form needed for the vaccine.
• The research is one of at least 90 vaccine projects speeding ahead around the world in desperate efforts that hold the best and probably only hope of stopping or at least slowing the pandemic.
• One potential problem that every vaccine project will be on the lookout for is disease enhancement: the possibility that a vaccine, instead of preventing infection, could actually make the disease worse.
• The two scientists said the many research groups forging ahead with vaccine projects were racing not against one another, but against the coronavirus.
• Source: New York Times here. 

D. Antibody Testing

1. FDA tightens oversight of blood tests used to detect antibodies

• The FDA announced plans Monday to bolster oversight of antibody tests by requiring commercial test makers to meet new standards of accuracy and submit information proving the testing quality. 
• The agency reversed its March 16 policy that allowed antibody test makers to sell their products without the normal step of sharing data with the agency to validate accuracy. 
• The agency said commercial test makers will have 10 business days to submit data and seek the agency’s emergency use authorization. The agency will recommend test makers meet accuracy, or “sensitivity and specificity,” thresholds as part of the tighter oversight.
• Public health experts questioned the precision of antibody tests deployed in communities nationwide. Public heath officials warned that elected officials, business leaders and consumers should be careful about making decisions based on antibody test results.
• Association of Public Health Laboratories CEO Scott Becker, who was critical of the FDA’s initial policy, said the agency made the right decision.
• “We’ve long been concerned that allowing tests on the market that have not been approved and authorized for use is a recipe for disaster,” Becker said. “This revised policy makes a lot of sense and should have been in place over the last six weeks.”

Source: Coronavirus: FDA tightens oversight of antibody tests after fraud

E. Scientific Findings & Conclusions

1. Full lockdown policies in Western Europe countries have no evident impacts on the C19 epidemic

Abstract of Study:

• This phenomenological study assesses the impacts of full lockdown strategies applied in Italy, France, Spain and United Kingdom, on the slowdown of the C19 outbreak. 
• Comparing the trajectory of the epidemic before and after the lockdown, we find no evidence of any discontinuity in the growth rate, doubling time, and reproduction number trends. 
• Extrapolating pre-lockdown growth rate trends, we provide estimates of the death toll in the absence of any lockdown policies, and show that these strategies might not have saved any life in western Europe.
• We also show that neighboring countries applying less restrictive social distancing measures (as opposed to police-enforced home containment) experience a very similar time evolution of the epidemic.

Source: Full lockdown policies in Western Europe countries have no evident impacts on the COVID-19 epidemic.

F. Concerns & Unknowns

1. Mysterious coronavirus condition ‘happy hypoxia’ baffles doctors

• [Note: We continue to recommend that our readers purchase a pulse oximeter (available on Amazon here). A pulse ox is one way to monitor your blood-oxygen saturation levels in your home. A reading below 93 could indicate that you should go to the hospital.]
• A strange phenomenon dubbed “happy hypoxia” has baffled doctors treating coronavirus patients who describe themselves as comfortable despite dangerously low oxygen levels that would typically leave them unconscious, or even dead, according to reports.
• The mysterious condition that appears to defy basic biology is raising questions about how C19 attacks the lungs, the Guardian reported.
• While a healthy person’s blood-oxygen saturation is at least 95 percent, doctors have reported some coronavirus-stricken patients with levels in the 80s or 70s — with some extreme cases below 50 percent, according to the outlet.
• And yet these so-called “happy hypoxics” have been observed scrolling on their phones, chatting with their health care providers and describing themselves as generally comfortable, Science Magazine reported.
• “There is a mismatch [between] what we see on the monitor and what the patient looks like in front of us,” Dr. Reuben Strayer, an emergency physician at Maimonides Medical Center in Brooklyn, told the magazine from his home as he recovered from the illness himself.
• Strayer said he and other doctors are seeking to understand the odd condition, which he first noticed in March as patients streamed into his ER, and how to treat it.
• Dr. Jonathan Bannard-Smith, a critical care specialist at the Manchester Royal Infirmary in the UK, told the Guardian that some patients are unaware that their oxygen saturations are so low.
• “We wouldn’t usually see this phenomenon in influenza or community-acquired pneumonia,” he said. “It’s very much more profound and an example of very abnormal physiology going on before our eyes.”
• Another British physician said people would ordinarily appear to be extremely ill with other lung conditions that could cause severe hypoxia.
• “We just don’t understand it. We don’t know if it’s causing organ damage that we’re not able to detect. We don’t understand if the body’s compensating,” added “Dr. Mike Charlesworth of Wythenshawe hospital in Manchester, who also was infected with C19.
• After coming down with a cough and fever, he spent 48 hours in bed, during which he said there were signs he was hypoxic.  “I was sending very strange messages on my phone. I was essentially delirious. Looking back, I probably should’ve come into hospital. I’m pretty sure my oxygen levels were low,” he told the news outlet.
• “My wife commented that my lips were very dusky. But I was probably hypoxic and my brain probably wasn’t working very well,” he added.
• What causes people suffering from lung diseases to feel breathless is not the fall in oxygen levels but rather the body sensing the rising levels of carbon dioxide.
• “The brain is tuned to monitoring the carbon dioxide with various sensors. We don’t sense our oxygen levels,” Paul Davenport, a respiratory physiologist at the University of Florida, told Science Magazine.
• But among some coronavirus patients, this response does not appear to be kicking in.
• During the early phase of C19, low saturation levels aren’t always accompanied with obvious respiratory difficulties.
• Carbon dioxide levels can be normal, and deep breathing may be comfortable, Dr. Elnara Marcia Negri, a pulmonologist at Hospital Sírio-Libanês in São Paulo, Brazil, told the magazine.
• “The lung is inflating so they feel OK,” she said, though their oxygen saturation can be in the 70s, 60s, 50s or even lower.
• Theories about what causes “happy hypoxia” are emerging, as many doctors recognize clotting as a major feature of severe C19.
• Negri believes slight clotting might start early in the lungs, perhaps a result of an inflammatory reaction in their fine blood vessels, which could trigger a cascade of proteins that prompts blood to clot.
• Strayer also finds it reasonable to imagine that hypoxia may be caused when “small blood vessels of the lung are being showered with clots.”
• His hospital and others are beginning to test many coronavirus patients for markers of excess clotting and treat those who show it with blood thinners. Science Magazine reported.
• But Strayer stressed that “it is simply not known” whether clotting causes “happy hypoxia.”
• Recent imaging of a hypoxic patient showed “almost waxy-looking film all around the lungs,” Caputo said. “I don’t know what is actually going on pathophysiologically down there.”

Source: Mysterious coronavirus condition ‘happy hypoxia’ baffles doctors 

2. More cases of rare syndrome in children reported globally

• Doctors around the world have reported more cases of a rare but potentially lethal inflammatory syndrome in children that appears to be linked to coronavirus infections.
• Nearly 100 cases of the unusual illness have emerged in at least six countries, with doctors in Britain, the US, France, Italy, Spain and Switzerland now reported to be investigating the condition.
• The first cases came to light this week when the NHS issued an alert to paediatricians about a number of children admitted to intensive care units with a mix of toxic shock and a condition known as Kawasaki disease, an inflammatory disorder that affects the blood vessel, heart and other organs. So far 19 children have been affected in the UK and none have died.
• The French health minister, Olivier Veran, said on Wednesday that the country had more than a dozen children with inflammation around the heart, and while there was insufficient evidence to prove a link with coronavirus, he said the cases were being taken “very seriously.”
• Veran told Franceinfo news radio he had received an alert from Paris concerning “about 15 children of all ages”, adding that other cases had been reported in Spain, Italy and Switzerland. He listed the symptoms as fever, digestive problems and vascular inflammation.
• At least three children in the US aged six months to eight years are being treated for a similar condition. Mark Gorelik, a specialist treating the patients at Columbia University Medical Center in New York, said all had fever and inflammation of the heart and gut. “Right now, we’re at the very beginning of trying to understand what that represents,” he told Reuters. Gorelik believes the cases are not Kawasaki disease but a similar condition that shares a common cause, namely an infectious agent that triggers an immune response.
• The three New York cases follow a report from Stanford University in California, in which a 6-month-old was admitted to hospital with Kawasaki disease and was later diagnosed with coronavirus.
• Many of the children having treatment for the new syndrome have tested positive for coronavirus, but others have not. That could mean that the syndrome is not related to coronavirus, that the children had cleared the virus before they were tested, or that the test missed the infection.
• Some doctors suspect the syndrome is a “post-infection inflammatory response” where the immune system overreacts in the wake of an infection. This would suggest that in some children the disease has two phases – the initial infection and a secondary immune response that takes hold later.
• Dr Nazima Pathan, a consultant in paediatric intensive care in Cambridge, said the number of children admitted to intensive care units with C19 was relatively low, but that some were presenting with what looked like toxic shock syndrome and Kawasaki disease. “These children have had a severe and prolonged inflammatory response to C19 infection and they have not had severe lung disease, unlike the majority of cases in adults,” she said.
• “Whilst this is an evolving situation, it is clear that these symptoms are reported in only handfuls of cases,” Pathan added. “The important message is that if parents are worried about their children’s health, they should seek medical advice.”
• The new syndrome, which has yet to be named, dominated discussion between leading doctors on a teleconference about C19 in children hosted on Tuesday by the World Health Organization.
• The first known cases in Britain emerged three to four weeks ago, but doctors now plan to look over the medical records of children in intensive care earlier this year to check whether earlier cases were missed.

Source: More cases of rare syndrome in children reported globally

G. Updates

1. Hydroxychloroquine is associated with a decreased mortality in critically ill patients with C19

Abstract of Study:

• Importance: Coronavirus disease 2019 (C19) is a pandemic with no specific drugs and high mortality. The most urgent thing is to find effective treatments. 
• Objective: To determine whether hydroxychloroquine application may be associated with a decreased risk of death in critically ill C19 patients and what is potential mechanism. 
• Design, Setting and Patients: This retrospective study included all 568 critically ill C19 patients who were confirmed by pathogen laboratory tests despite antiviral treatment and had severe acute respiratory distress syndrome, PAO2/FIO2 <300 with need of mechanical ventilation in Tongji Hospital, Wuhan, between February 1 of 2020 to April 8 of 2020. All 568 patients received comparable basic treatments including antiviral drugs and antibiotics, and 48 of them additionally received oral hydroxychloroquine (HCQ) treatment (200 mg twice a day for 7-10 days). Primary endpoint is mortality of patients, and inflammatory cytokines levels were compared between hydroxychloroquine and non-hydroxychloroquine (NHCQ) treatments. 
• MAIN OUTCOMES AND MEASURES: In-hospital death and hospital stay time (day) were obtained, level of inflammatory cytokine (IL-6) was measured and compared between HCQ and NHCQ treatments. 
• RESULTS: The median age of 568 critically ill patients is 68 (57, 76) years old with 37.0% being female. Mortalities are 18.8% (9/48) in HCQ group and 45.8% (238/520) in NHCQ group (p<0.001). The time of hospital stay before patient death is 15 (10-21) days and 8 (4 – 14) days for the HCQ and NHCQ groups, respectively (p<0.05). The level of inflammatory cytokine IL-6 was significantly lowered from 22.2 (8.3-118.9) pg/mL at the beginning of the treatment to 5.2 (3.0-23.4) pg/ml (p<0.05) at the end of the treatment in the HCQ group but there is no change in the NHCQ group. 
• CONCLUSIONS AND RELEVANCE: Hydroxychloroquine treatment is significantly associated with a decreased mortality in critically ill patients with C19 through attenuation of inflammatory cytokine storm. Therefore, hydroxychloroquine should be prescribed for treatment of critically ill C19 patients to save lives.

Source: Hydroxychloroquine application is associated with a decreased mortality in critically ill patients with COVID-19

H. Lessons From Abroad 

1. With testing, Iceland claims major success against C19

• Winter storms isolated the northern village of Hvammstangi from the rest of Iceland. Then spring brought the coronavirus, isolating villagers from each other. Now, as summer approaches, residents hope life is getting back to some kind of normal.
• High schools, hair salons, dentists and other businesses across Iceland are reopening Monday after six weeks of lockdown, after this North Atlantic nation managed to tame its coronavirus outbreak.
• Iceland has confirmed 1,799 cases of the virus, but just 10 people have died. The number of new C19 cases each day has fallen from 106 at the peak of the outbreak to single digits — even, on some days, zero.
• “I didn’t expect the recovery to be this fast,” said Iceland’s chief epidemiologist, Thorolfur Gudnason.
• Iceland’s success is partly testament to its tiny population — just 360,000 people. But it also reflects decisive action by authorities, who used a rigorous policy of testing and tracking to find and isolate infected people, even when they had no symptoms.
• That has helped Iceland weather the pandemic without resorting to the near-total social and economic shutdowns enforced in many other European countries. Infected people and their contacts were quarantined, but the rest of the population was not forced to stay inside, only to be careful.
• A volcanic island nudging the Arctic Circle, Iceland may be remote, but it is far from isolated. Its Keflavik Airport is a trans-Atlantic hub, and Icelanders are enthusiastic travelers. As in several other European countries, some of the first cases of the virus here were brought back from ski resorts in the Alps, including the Austrian village of Ischgl.
• Early vigilance was key to Iceland’s success. The country confirmed its first case of the virus on Feb. 28, and declared Ischgl a high-risk zone on March 5, two days before authorities there confirmed the first case.
• Gudnason said Iceland had been updating and testing its response to a global pandemic since 2004. Hospitals had been testing people arriving from abroad for a month before the first confirmed case, and a media campaign urged hand washing and social distancing.
• “Each institution involved in the response knew its role from the start,” he said.
• Iceland quarantined everyone returning from virus hotspots and began test-and-trace measures to locate and isolate every case. Bigger countries such as Britain took the same approach, at first. But the U.K. abandoned test-and-trace in March as the number of cases overwhelmed the country’s testing capacity. More than a month later and with almost 30,000 Britons dead, the U.K. is scrambling to resume testing and tracing as part of its route out of national lockdown.
• Iceland’s testing capacity was helped by the presence of Reykjavik-based biopharmaceutical company deCODE Genetics, which early in the outbreak teamed up with health authorities to ramp up public testing.
• Over six weeks, Iceland managed to test almost 50,000 people, more than 13 percent of the population, the biggest chunk of any country in the world.
• DeCODE did not test people already feeling sick or in quarantine, who were tested in hospitals. The company used its facilities to test a cross-section of the population, and identified scores of new cases, including people with mild or no symptoms.
• Kari Stefansson, deCODE’s ebullient CEO, said the approach showed that “with the use of modern science, even an epidemic like this one can be contained.”
• Iceland’s testing yielded new leads for scientists about how the virus behaves. Early results suggested 0.6 percent of the population were “silent carriers” of the disease with no symptoms or only a mild cough and runny nose.
• Preliminary research suggests one-third of those who tested positive at deCODE infected someone around them, providing evidence that silent carriers do transmit the disease but much less than symptomatic patients.
• In a random sample of 848 children under the age of 10, none of them tested positive, which guided Icelandic authorities’ decision to keep schools open for children under 16.
• Alongside the testing, civil defense authorities set up a Contact Tracing Team, including police officers and university students, which used legwork and phone calls to identify people who had come into contact with infected individuals. A mobile phone tracing app was up and running a few weeks later.
• Gudnason said the approach’s success is shown by the fact that about 60% of people who tested positive were already in quarantine after being contacted by the tracing team.
• Altogether, 19,000 people were ordered into two-week quarantine. Everyone else carried on with a semblance of normality. Primary schools remained open, and some cafes and restaurants kept operating, following social distancing rules: no more than 20 people gathered at once and everyone 2 meters (6.5 feet) apart.
• Starting Monday, gatherings of up to 50 will be permitted, high schools and colleges can resume classes and all businesses except bars, gyms and swimming pools can reopen.
• The entire country, however, must self-isolate from the rest of the world for the time being. Everyone arriving from abroad faces a 14-day quarantine.
• That means a bleak economic outlook for a country that depends on tourism. 

Source: With testing, Iceland claims major success against COVID-19

2. The Swedish Approach

• Sweden has been an outlier during the coronavirus outbreak. The country has not joined many of its European neighbors in imposing strict limits on citizens’ lives, and images of people heading to work on busy streets, or chatting at cafes and bars have raised eyebrows.
• Younger children have continued to go to school, although universities and schools for older students have switched to distance learning. Businesses — from hair salons to restaurants — have remained open, although people have been advised to work from home where possible.
• Among Nordic countries — which share similar cultural, geographical and sociological attributes — the contrast with Sweden is great. Finland declared a state of emergency, closed schools and banned gatherings of more than 10 people on March 16, restricted travel to and from its Uusimaa region on March 28 and closed restaurants, cafes and bars on April 1.
• The death rate in Sweden has now risen significantly higher than many other countries in Europe, reaching more than 22 per 100,000 people, according to figures from Johns Hopkins University, controlled for population.
• By contrast, Denmark has recorded just over 7 deaths per 100,000 people, and both Norway and Finland less than 4.
• Sweden has registered 18,926 coronavirus cases and 2,274 deaths among its population of 10.3 million people.  Denmark has had 9,049 cases and 427 deaths in a population of 5.8 million, Norway 7,599 cases and 206 deaths among its 5.4 million people, and Finland 4,695 cases and 193 deaths in its population of 5.5 million.
• Denmark and Norway are now beginning to ease their lockdowns, with children returning to school in the past 10 days, in smaller classes with markers to help keep them two meters apart. Salons and other businesses with one-to-one contact will reopen in Norway from Monday. Finland has extended its restrictions until May 13.
• Sweden has not had as many deaths as Italy or Spain, which have recorded around 45 and 51 deaths per 100,000 people respectively, or even the UK, where there have been about 32 deaths per 100,000 of the population. But there are various differences between Sweden and these countries that make direct comparisons harder, such as Italy having an older population, more smokers, and a larger number of close-knit multi-generational households.
• On March 28, a petition signed by 2,000 Swedish researchers, including Carl-Henrik Heldin, chairman of the Nobel Foundation, called for the nation’s government to “immediately take steps to comply with the World Health Organization’s (WHO) recommendations.”
• The petition said that trying to “create a herd immunity, in the same way that occurs during an influenza epidemic, has low scientific support.”
• Swedish authorities have denied having a strategy to create herd immunity, one the UK government was rumored to be working towards earlier on in the pandemic — leading to widespread criticism — before it enforced a strict lockdown.
• Lena Hallengren, Swedish Minister for Health and Social Affairs said “There is no strategy to create herd immunity in response to C19 in Sweden. Sweden shares the same goals as all other countries — to save lives and protect public health.”
• Jan Albert, a professor in the Department of Microbiology, Tumor and Cell Biology at the Karolinska Institutet said “It’s clear that Sweden had more deaths [than many other European countries] up until now, and that’s probably at least in part because we haven’t had as strict a lockdown and not a lockdown enforced by law.”
• But he said he believed the majority of scientists in Sweden had been “relatively quiet” about the herd immunity plan because they thought it could work.
• “What’s the strategy of the other countries?” he asked. “It [herd immunity] was already the only thing that will eventually stop this, unless there is a vaccine in time, which is quite unlikely.
• “The truth is that no one, no one in Sweden, no one elsewhere either, knows what the best strategy is. Time will tell.”
• He said that he believed that stricter lockdowns “only serve to flatten the curve and flattening the curve doesn’t mean that cases disappear — they are just moved in time.”
• “And as long as the healthcare system reasonably can cope with and give good care to the ones that need care, it’s not clear that having the cases later in time is better.”
• Albert believes that Sweden’s healthcare system is coping, as does Peter Lindgren, managing director at the Swedish Institute for Health Economics (IHE). Lindgren told CNN that the number of people treated in intensive care units over several weeks had been stable, “so in that aspect it has to be successful.”
• But he added: “What it failed at, I think, is that there has been disease transmitted into elderly care facilities. We have deaths occurring as a consequence of that.”
• Hallengren, the Swedish health minister, told CNN: “One of the main concerns now in Sweden is to strengthen the protection for those living in care homes for older people.”
• She said it was still “far too early to draw any firm conclusions as to the effectiveness of the measures taken in Sweden.”
• She said that just because Sweden did not have a “full lockdown” did not mean “that it’s business as usual” and that measure were being “continuously reassessed” with the help of experts “to ensure that the right measures are taken at the right time.”
• Gatherings of more than 50 people are banned and people are “strongly recommended” to avoid non-essential domestic travel, she added.
• Sweden’s foreign minister on Monday told UK newspaper The Guardian that it was far too soon to judge her country’s approach to C19.
• “There’s been a lot of misunderstanding,” Ann Linde said. “We have pretty much the same goals as every other government … And as we have always said, we are perfectly ready to go with more binding regulations if the population does not follow.”
• She said the fairly high death toll was “certainly not part of the plan” and said the high number of care home deaths was “one area where we have failed.”
• The Swedish Public Health Agency this week forecast that almost a third of people in Stockholm County would have been infected by C19 by May 1. That would be more than 600,000 people — far higher than the number of cases recorded nationally so far.
• Less than 24 hours later, there was confusion when the health agency announced on Twitter that it had “detected errors” in the report, but it then said its mathematical model had been updated and reiterated that 26% of the Stockholm population would have been infected by May 1.
• It said that there were approximately 75 unconfirmed cases for each reported case of C19 — but that the peak of the spread of infection had passed.
• Sweden’s state epidemiologist Anders Tegnell said on Friday that Sweden would likely be in a better place to withstand a second wave of coronavirus because so many people in Sweden have now been exposed to the virus.
• He told the BBC that the relatively relaxed approach had “worked in some aspects,” since there had always been at least 20% of intensive care beds empty and able to take care of C19 patients.
• “We believe we passed the peak of the transmission a week ago,” he added.
• Asked whether Sweden’s approach will help it withstand a possible second wave, Tegnell said he believed it would. “It will definitely affect the reproduction rate and slow down the spread,” he said, but added that it wouldn’t be enough to achieve “herd immunity.”
• “We know very little about the immunity of this disease, but most of the experts in Sweden agree that some kind of immunity we definitely will have because a lot of people that have been tested so far have produced antibodies … We hope this will make it easier for us in the long run.”
• Asked whether the death toll would have been lower if Sweden had followed the same path as other European countries in introducing strict restrictions, Tegnell replied: “That’s a very difficult question to answer at this stage. At least 50% of our death toll is within the elderly homes and we have a hard time understanding how a lockdown would stop the introduction of the disease into the elderly homes.”
• Whether Sweden’s C19 strategy has succeeded or failed may not be clear for months to come, but as countries across the globe count their dead and wonder whether they could have done more to halt the spread of the virus, the world will be watching.

Source: Sweden says its coronavirus approach has worked. The numbers suggest a different story

3. Is Sweden’s C19 Handling A Failure Or A Success?

• Sweden did not have a hard lockdown like its neighbors although people were advised to work from home when possible. It also banned nursing home visits on April 7.

• Sweden says its model worked, but Numbers Suggest a Different Story.  Sweden’s C19 deaths per capita are 3 to 6 times its Nordic neighbors.

Nordic Country Restrictions

Sweden vs Nordic Neighbor Deaths

• On a per capita basis, Sweden’s C19 deaths are 3 to 5.5 times the other Nordic countries.
• Sweden has just over 3 times the death rate of Denmark. But note Denmark’s population density disadvantage of 138:25.

Success or Failure?

• Success is in the eyes of the beholder. A death rate 5.5x is acceptable to some but not others. 
• But Sweden has a ton of pressure to under-report C19 deaths. I would be shocked if they didn’t.
• Regardless, one can easily look at this data, ignore the undercounts (perhaps even factor some in), and conclude Sweden did the right thing. 
• But how does that translate to the US?

Population Density of NYC

• For comparison purposes, the Population Density of New York City is 26,403 people per square mile (10,194/km²), makes it the densest of any American municipality with a population above 100,000.
• Manhattan’s population density is 66,940 people per square mile (25,846/km²), highest of any county in the United States

Sweden Not a Good Model 

• Even if one is happy with Sweden’s results, it is not a representative model for large US cities.

R0 – Infection Transmission

• Nate Silver has an Interesting Twitter Thread on R0, the number of people someone will infect on average, if they catch it.

Nate Silver Followups

• The positive test rate, which I believe is a better metric than the raw number of + tests, continues to show slow, incremental improvement. But I do mean *slow*. It’s consistent with a nationwide R of around 0.9, where R>1 means the epidemic is growing & R<1 means it’s shrinking.
• That is a national average, however. There are places like NY where there’s a reasonably steep decline (R of perhaps 0.7-0.8). In turn, there are likely to be other places where infections are still growing (R of perhaps 1.1 to 1.3) and it isn’t just an artifact of more testing.
• Overall, there isn’t a lot of room for error. A few states have had clear, sustained improvement and may have room in their R “budget” to relax restrictions. But for many others, even slight changes could bring R >1. Or R may be >1 already.
• That’s not to say it’s necessarily up to policymakers. I don’t care about the state capitol protests, which are an overplayed story. But it’s clear from mobility data that people are moving around more and abiding less strictly by social distancing.
• I wish we knew more about what this activity consisted of. Taking a nice, long drive to a non-crowded state park should be pretty safe, for instance. But pressure points seem to be outdoor activity in more crowded spaces, and small-to-medium-sized social gatherings.

Reopening Too Early 

• At an R0 that’s well below 1, the disease will die out (but perhaps return later in the Autumn or Winter).
• At R0 of 1, the current results can go on for a long time. 
• An end to the lockdowns too early could easily send R0 back well above 1, which is what everyone wants to avoid.

Source: Zerohedge here. 

4. Goldman Explains Why Sweden’s Coronavirus Success Can’t Be Replicated In Europe & US

• in a research note published Monday, a team of analysts at Goldman Sachs confronts the question of whether Sweden is truly a viable model for other EU member states – and particularly the “EMU-4” – Italy, Spain, France and Germany.
• In the report, the team concludes that unfortunately, Sweden’s approach likely can’t be easily replicated by the rest of the world.
• Sweden has imposed significantly less strict measures to curb the spread of the coronavirus compared with other major European economies. While legal factors might have played a role – the Swedish constitution does not allow for a state of emergency in peacetime – the Swedish government has put the emphasis on citizens’ self-responsibility.
• Although gatherings of more than 50 people are banned and distance learning in high schools has been introduced, these measures are much less stringent than elsewhere in Europe.
• Some commentators have suggested that Sweden is aiming for herd immunity, although this is not official government policy. As a result of the less stringent measures, high-frequency proxies suggest activity in Sweden has slowed less than in other economies in Europe.
• This also is true when looking at Norway and Denmark, which are more similar in nature to Sweden in terms of demographics and economy.
• Despite a less aggressive response than in the EMU-4, Sweden has experienced slower growth of confirmed cases of coronavirus and lower fatality rates than other European countries. However, a striking comparison arises between Sweden and Norway: Sweden has more confirmed cases than Norway despite a lower testing rate, which, all else equal, suggests that the number of undetected cases in Sweden could be even higher. Taking the numbers at face value, our previous work suggests that one reason for this gap in the number of confirmed cases in Norway and Sweden is Sweden’s more lenient approach to containment measures.
• While Sweden and Norway have broadly similar demographic characteristics, there are likely a number of idiosyncratic factors that sets these countries apart from other major European economies. Focusing on Sweden, there is anecdotal evidence to suggest that Swedes practice social distancing of their own accord, without fines or binding legislation. For example, newspaper reports suggest that public transport usage has fallen by 50% and streets are about 70% less busy than usual in Stockholm.
• Sweden also has more favorable geographic and demographic factors relative to the EMU-4 which are likely to slow the spread of the virus: its population density is about half that of Italy, and Sweden has a high proportion of single-occupancy households, and a relatively low proportion of multi-generational households.
• Beyond testing capacity, another factor that will likely play an important role in shaping re-opening is the ability to contain the human cost in terms of fatalities. Germany, for example, has a lower fatality rate than other economies and its health system is well-equipped to cope with the coronavirus pandemic. To assess countries’ likely ability to contain fatalities from the coronavirus, we therefore estimate a simple model to quantify the importance of demographic and health factors. The model is estimated on a cross-section of 22 European economies.
• As explanatory variables, we include the proportion of single-occupancy households (which reduce transmission risks and are a proxy for younger households), the share of the population aged 65 and older, hospital beds per million inhabitants as a measure of health system capacity, and confirmed cases per million.
• Despite its simplicity, the cross-sectional fit of the model is good, with an R-squared of 0.90.
• The Swedish experience is therefore not vastly different from other economies: the factors that explain fatality rates elsewhere also have explanatory power in Sweden. However, Sweden’s success in limiting fatalities might be hard to reproduce in other countries: while Sweden does have lower hospital capacity, demographic factors appear to counteract this.
• While the model predicts a broadly similar fatality rate in Sweden and Denmark, it suggests that the Swedish fatality rate would be about a third lower if it had the same hospital capacity as Norway. We conclude that Sweden is not particularly suited as a reference point for the coronavirus response of other countries, as our analysis suggests that lower infection rate is likely to reflect in part less testing, while demographic and healthcare factors may help explain the fatality rate. In our view, the Swedish experience therefore can not be extrapolated to support a swift reopening elsewhere. That said, our analysis suggests that Germany could be in a better position to lift containment measures than southern Europe.

Source: Goldman Explains Why Sweden’s Coronavirus Success Simply Can’t Be Replicated In Europe & The US

H. The Road Back?

1. Governor Cuomo outlines New York’s four-phase reopening

• Gov. Andrew Cuomo on Monday fleshed out his plans for awakening New York’s economy from its coronavirus-induced slumber, laying out a four-phase strategy for reopening businesses.
• “People are all talking about reopening, which we should be talking about,” said Cuomo in a press briefing at the Wegmans Conference Center in Rochester, NY. “This is not a sustainable situation, close down everything, close down the economy, lock yourself in the home.”
• Cuomo last month said that construction and manufacturing gigs in less hard-hit regions would be the first sectors to trickle back on once the current installment of the statewide prohibition on non-essential business expires on May 15.
• On Monday, he expanded on that plan, now divided into four phases.
• In addition to construction and manufacturing, the first group of services to return will include wholesale suppliers and select retail businesses that offer curbside pickup, Cuomo said.
• The second phase would see the return of sectors including finance and insurance, real estate and other retail businesses.
• Restaurants and hotels would come back online in the third phase, while the fourth phase would bring arts and entertainment venues, as well as education.
• “Density is not your friend here, large gatherings are not your friend,” said Cuomo. “That’s why those situations would be down at the end.”
• Cuomo additionally introduced a region-by-region scorecard, grading areas of the Empire State on seven metrics they would need to meet in order to consider a gradual return to normalcy:
  • A 14-day drop in hospitalizations, or fewer than 15 new admissions in a three-day rolling average
  • A 14-day decline in hospital deaths, or fewer than five total deaths across a three-day rolling average
  • A rate of new hospitalizations below 2 per 100,000 residents, across a three-day rolling average
  • At least 30% of total hospital beds unoccupied
  • At least 30% of ICU hospital beds unoccupied
  • At least 30 tests for every 1,000 residents per month
  • At least 30 contact tracers retained per 100,000 residents
• As of Monday, no region in the state had ticked more than 5 of the 7 boxes.
• New York City now meets three of the criteria: the 14-day declines in both hospitalizations and deaths, plus the monthly testing numbers.
• Long Island is the farthest off, having met only the 14-day decline in hospitalizations and the monthly testing threshold.
• Cuomo articulated his vision for the future as the statewide numbers continued to trend in the right direction.

Source: Andrew Cuomo outlines New York’s four-phase coronavirus reopening

2. Wearables Track Social Distancing and Sick Employees 

• As shuttered businesses make plans to resume on-site operations, many plan to outfit their employees with new, anti-pandemic gear: wearable tech that could prevent the spread of C19 inside the workplace.
• Ford employees are experimenting with smartwatches that vibrate when workers come within six feet of each other. The accounting firm PricewaterhouseCoopers (PwC) has developed an app that turns employees’ phones into contact tracing devices, notifying them when they’ve been exposed to a coworker with the novel coronavirus. 
• Other employers are considering equipping their workforces with wearables—separate from their phones—that are capable of granular on-site and indoor location tracking and contact tracing. CarePredict recently rolled out such devices for senior living facilities. 
• In fact, in a survey of 871 finance executives at companies in 24 countries, 21% said they were eyeing location tracking and contact tracing for their workforces, according to PwC, which conducted the survey and posted it online this week.  
• These private sector systems are meant for the workplace alone, unlike the digital contact tracing apps developed by Google and Apple, which are intended for the general public under the tutelage of public health authorities. 
• Workplace contact tracing devices would enable companies to selectively isolate any employees with exposure to C19, allowing the rest of the company to keep working. The devices raise privacy concerns, but they could also make employees feel safer about going to work. 
• Tech companies nimble enough to have pivoted, in a matter of months, to making this kind of gear have found themselves in high demand.
• “The phone is ringing off the hook,” says Sean Stinson, vice president of sales and product development at Blackline Safety. Stinson’s company last week announced that its systems, which monitor industrial worker safety through connected, wearable devices, can now also perform contact tracing and social distance monitoring. 
• Blackline’s rugged, walkie talkie-sized device, called G7, tracks workers’ movements with GPS and by pinging indoor beacons placed around a workplace, and sends the data to Blackline’s cloud. The on-body devices use accelerometers to detect an accident, such as a fall, or potentially dangerous situation, like a gas leak, and call for help. Oil and gas refineries, water treatment plants, road maintenance companies, and other tough-job employers use Blackline’s systems, Stinson says.
• Blackline adapted to C19 by enabling its location tracking systems to generate close contact reports. The datasets show which workers are frequently going near other workers, and where in the workplace that’s occurring. If an employee gets the coronavirus, the company can use the system to review the employee’s location history on-site to find out which coworkers might have been exposed.  
• “You can pick a person—say me—and in one column you’d see my name, and in the second column you’d see all the people I came into close contact with over the prior two weeks,” says Stinson. “There’s also a map there so we can tell where these interactions are happening.” The maps can display the location information down to the individual person, and can also display company-wide movement, like a heat map, he says.
• The data help leadership teams make decisions, Stinson says. “You can get a feel for how your social distancing policies are working,” he says. “You can talk to an individual and ask them to stop being a [potential] super-spreader,” or figure out a way to change that person’s job so that they don’t have to interact with as many people. (As awkward as that sounds, that might be HR’s new normal for the next couple of years.) 
• Estimote, a location and proximity services provider, also quickly pivoted for the pandemic. The company makes programmable Bluetooth-based beacons for item tracking. Estimote had also recently begun making wearable panic buttons for the hotel industry. Hotels place the company’s beacons in every room, and housekeepers wear a panic button that will ping their location on the nearest beacon, and call for help in the event of an attack.
• When the pandemic hit, Estimote adapted its panic button systems to proximity and contact tracing. “We’ve deployed to 25 or 35 companies already,” says Steve Cheney, co-founder of Estimote.
• The device comes in three forms: a wristwatch, a pendant or lanyard, and a card shape. When the distance between two employees is too close, or when an employee enters an area that has been deemed off-limits due to C19, the device beeps.
• If a worker gets C19, a central manager can run an historical “trace” that lists everyone that person has been in close contact with, and how for long. Estimote is also developing mapping capabilities that will show where interactions are occurring in an aggregated way, such as a heat map.   
• Tools like those from Estimote and Blackline could give employees more confidence about going back to work. Walking around the office with a beeping device might feel a bit like being a dog with an invisible fence, but at least it will keep that close-talker at bay.  
• But such tools also raise concerns about privacy in the workplace. Building a centralized database of workers’ every move and interaction is akin to giving someone a Marauder’s Map, à la Harry Potter, only with a saved digital history.  
• The information, in the wrong hands, is sure to stir gossip: John took a really long lunch today. The boss spends far more time with James than with Kate. Celeste and Mark were together on the patio for an hour. Tim from payroll visited the legal team every day last week. Anne went to the vending machine six times yesterday. Joe was in the nursing mother’s room by himself all afternoon.  
• Cheney at Estimote says that if a customer wants that kind of information, he simply won’t give it to them. “I’m not building that product for them,” says Cheney. “They’d have to email me and I’d be like: ‘No I’m not pulling that,’” he says. “Only when they need to run a trace [on an infected employee] do they get their connections.” 
• Cheney says that at all other times, the data is anonymized and can be used for the purposes of understanding whether employees are social distancing, and where the trouble spots are on the floor plan. “It’s a product decision,” says Estimote, “And we think it’s probably going to be more successful because of this, not in spite of it.”
• Blackline provides its customers more granular information about individual employees’ whereabouts and movements. Stinson says that in working with customers, Blackline helps them craft acceptable use policies for the data, and recommends that only one or two people at a company have access to the centralized information.
• “I can’t point to a single case where I’ve had a customer that’s abused the data,” says Stinson, referring to years of deploying non-C19 location tracking products. “It’s in my best interest for the company to make sure my customers don’t misuse data. Ultimately I’d end up with no customers if this becomes a misused technology,” he says.

Source: Back to Work: Wearables Track Social Distancing and Sick Employees in the Workplace

I. Projections & Our (Possible) Future

1. Updated IHME C19 Projections: Predicting the Next Phase of the Epidemic

• The Institute for Health Metrics and Evaluation (IHME) released a substantial update to its epidemiological model that projects an increase in coronavirus deaths to 134,475 in the United States by August 4.
• The new projections represent an 82% increase from the April 29 projections of 74,073 coronavirus deaths in the country.
• The IHME report acknowledges that the country is now entering a new phase of the C19 pandemic.
  • More locations are easing previously implemented social distancing policies, and 
  • Human mobility patterns are trending upward – even in places where distancing measures remain in place. 
  • Testing has scaled up in many parts of the world, but such progress has been uneven and is not keeping pace with the growing demand for lifting business and gathering restrictions. 
• The primary change is the IHME platform is the incorporation of a susceptible-exposed-infected-recovered (SEIR) component into the model. [NOTE: The primary criticism by epidemiologists of the IHME model had been the lack of an SEIR component.] The SEIR methodology established, calculates how many people are Susceptible to a virus (in the case of the new coronavirus, everyone), how many become Exposed, how many of those become Infected, and how many Recover and therefore have immunity (at least for a while). Such “SEIR” models then use what researchers know about a virus’s behavior, such as how easily it spreads and how long it takes for symptoms of infection to appear, to calculate how long it takes for people to move from susceptible to infected to recovered (or dead)
• Primary drivers in the new IHME model include: (i) daily temperature, (ii) percentage of population living in highly dense areas, (iii) C19 testing per capita, and (iv) changes in human mobility and its relationship to social distancing policies

KEY FINDINGS FROM TODAY’S RELEASE (MAY 4, 2020)

• Based on the updated IHME model and latest available data, a projected 134,475 cumulative C19 deaths (estimate range of 95,092 to 242,890) could occur in the US through August. These projections are considerably higher than previous estimates, representing the combined effects of death model updates and formally incorporating the effect of changes in mobility and social distancing policies into transmission dynamics.
• New York, New Jersey, Pennsylvania, Massachusetts, and Michigan are projected to have the highest cumulative C19 death toll through August (summarized in the table below). While these states have generally been among those with the highest predicted tolls from C19, each of their cumulative death projections have increased by at least 2,000. This is due in part to updates to death data and modeling approaches, with the latter now estimating longer epidemic peaks and slower downward trajectories following those peaks in many locations.

• In addition to the states listed above, the IHME updated modeling strategy shows noticeable changes for some other states’ cumulative C19 death trajectories (as summarized below). Exact reasons vary by state, but at least for some states, a few commonalities emerge. Based on the latest available data and updated models, most of these states are currently experiencing or have yet to experience their epidemic peaks – all of which appear to be lasting longer and declining more slowly after their peaks. Further, for a subset of states, the easing of social distancing policies has begun and mobility patterns are on the rise (or even started increasing before easing actions occurred).

• Per IHME, the updated modeling approach indicates that the US appears to be in a prolonged epidemic peak, averaging near or over 2,000 predicted C19 deaths a day for the last few weeks. [Note: a FEMA study leaked on 5/4 indicated daily deaths could reach 3,000 (see next story)]. 
• Several states with large epidemics are following a similar trajectory (e.g., New Jersey, Pennsylvania, Massachusetts); New York is the main exception, with its predicted peak in early-mid April and gradual downward trend in predicted deaths. 
• In contrast, several states have predicted peaks from early May into June. These include states with larger epidemics (e.g., California, Georgia, Massachusetts, Ohio, Pennsylvania, Texas), as well as others (e.g., Arkansas, Delaware, Nebraska, New Hampshire, New Mexico).
• Starting on 5/4, the IHME visualization tool depicts state-level changes in mobility, as well as estimated trends in C19 infections and testing. The new visualization shows changes in the composite mobility indicator over time, as well as predictions, overlaid against the timing of social distancing policy implementation – and for some locations, easing. 
• Relative to baseline levels of mobility, most states experienced substantive declines in mobility by late March or early April. 
  • Several states recorded decreases of at least 50% or even 60%; such states included Alaska, Colorado, Florida, Massachusetts, Michigan, New Jersey, New York, and Washington. 
  • Many states are seeing mobility rise now – and these increases appear to have begun even before policies were eased. These patterns have been observed in Alabama, Florida, Georgia, Idaho, Louisiana, Minnesota, Montana, and Texas, among others.
• [Note: We include updates to the IHME projections in the Updates because the projections have been cited by public officials as justification for public policy, including lockdowns that have had devastating consequences for our economy.  However, we note that prior projections by the IMHE model have been materially inaccurate.  Their initial projections were subsequently reduced by a material amount, and those projections are not being increased by a substantial amount.  Given the multiple material revisions to the projections, it is prudent to view the updated projections with skepticism and caution is warranted in using the projections develop policy.] 

Source: COVID-19 estimation updates 

2. Internal FEMA document projects spike in daily coronavirus death toll, but data questioned

• An internal document featuring charts produced by FEMA projects far more new coronavirus cases than the White House has forecast and nearly double the current daily death toll by the end of the month — but sources have raised questions about the reliability of the data.
• Those projections claim that by the end of May, there will be 200,000 new coronavirus cases and 3,000 deaths every day. This is a significant jump from current numbers of roughly 25,000 new cases and 1,750 deaths each day.
• Fox News has confirmed the existence of the document, which was first reported by The New York Times. Sources told Fox News that while a significant portion of the data comes from the Centers for Disease Control and Prevention, the projections of new cases and deaths come from modeling done at Johns Hopkins University.
• This is not a White House document nor has it been presented to the Coronavirus Task Force or gone through interagency vetting,” White House deputy press secretary Judd Deere said in a statement. “This data is not reflective of any of the modeling done by the task force or data that the task force has analyzed.”
• While such projections are sure to raise concerns about plans – at the national and state level – to begin reopening parts of the economy, sources said the modeling behind these projections did not take into account mitigation guidelines during that phased reopening. Further, they noted some of the data in the report was out of line with other projections.
• Meanwhile, several states have begun to gradually reopen their economies and are relaxing restrictions from stay-at-home orders. None of those states, however, have abided by the White House’s recommendation to wait for a 14-day decline in cases before beginning the reopening process.
• Deere said the Trump administration’s guidelines for reopening “are a scientific driven approach” that leading health and infectious disease experts agreed with.
• “The health of the American people remains President Trump’s top priority and that will continue as we monitor the efforts by states to ease restrictions,” he said.

Source: Internal FEMA document projects spike in daily coronavirus death toll, but data questioned

3. Three potential futures for C19: recurring small outbreaks, a monster wave, or a persistent crisis

• As epidemiologists attempt to scope out what C19 has in store for the U.S. this summer and beyond, they see several potential futures, differing by how often and how severely the no-longer-new coronavirus continues to wallop humankind. But while these scenarios diverge on key details — how much transmission will decrease over the summer, for instance, and how many people have already been infected (and possibly acquired immunity) — they almost unanimously foresee a world that, even when the current outbreak temporarily abates, looks and feels nothing like the world of just three months ago.
• It is a world where, even in Western countries, wearing a face mask is no more unusual than carrying a cellphone. A world where even at small social gatherings a friend’s occasional cough feels threatening, where workplaces have the feel of hot zones, and where taking public transit is not as much environmentally correct as personally dangerous.
• “October 2020,” said emerging diseases expert Amesh Adalja of the Johns Hopkins University Center for Health Security, “won’t look nothing like October 2019.”
• And neither will October 2021, according to an analysis released on Thursday by epidemiologist Michael Osterholm of the University of Minnesota and his colleagues. They envision three possible futures, depicted as seascapes, their waves of different heights and widths approaching the unseen and unsuspecting beachcombers on a placid shore.
• In one future, a monster wave hit in early 2020 (the current outbreak of millions of cases and a projected hundreds of thousands of deaths globally by August 1), but is followed by alternating mini-waves of much smaller outbreaks every few months with only a few (but never zero) cases in between.
• In the second scenario, the current monster wave is followed later this year by one twice as fierce and even longer-lasting, as the outbreak rebounds after a summer when a significant drop in the number of cases and deaths led officials and individuals to let down their guard, relax physical distancing more than was safe, and fail to heed (or even detect) the early warning signs that a new outbreak was gathering force. After this doubly disastrous second wave, the sea is almost calm, marred only by an occasional wave of cases that number barely one-fifth of what the fall and spring of 2020 saw.
• In the third possible future, the current wave creates a new normal, with C19 outbreaks of nearly equal size and, in most cases, duration through the end of 2022. At that point, the best-case scenario is that an effective vaccine has arrived; if not, then the world experiences C19 until at least half of the population has been infected, with or without becoming ill.
• What all three scenarios agree on is this: There is virtually no chance C19 will end when the world bids good riddance to a calamitous 2020. The reason is the same as why the disease has taken such a toll its first time through: No one had immunity to the new coronavirus.
• “This pandemic is not going to settle down until there is sufficient population immunity,” slightly above 50%, epidemiologist Gabriel Leung of the University of Hong Kong told a New York Academy of Sciences briefing.
• Since the world “is far from that level of immunity,” said Osterholm (he estimates that no more than 5% of the world population is immune to the new coronavirus as a result of surviving their infection), “this virus is going to keep finding people. It’s going to keep spreading through the population.” And that, he said, “means we’re in for a long haul.”
• The uncertainty over what the long haul will look like — a staggering third scenario or a much less brutal first — reflects the host of unknowns surrounding an outbreak unparalleled in modern history. Scientists are still racing to understand everything from the basic biology of the virus (how much do warm temperatures and high humidity reduce transmission? how many people were infected, and if they have immunity, how long does it last?) to the impact of mitigation strategies (does closing K-12 schools help enough to justify the cost to children’s education?). The answers will affect which future comes to pass.
• Perhaps the greatest unknown involves human and social values. To put it bluntly, how many deaths can a particular country, city, or community tolerate? “Reducing infections to zero is not possible, and would come at too high a cost,” Leung said.
• Different countries will decide what “too high” means; Sweden, for instance, has imposed only modest physical distancing steps, such as banning large gatherings, but its schools, restaurants, stores, and workplaces have remained open. It has fewer cases per 1 million people than Spain, Italy, the U.S., France, the U.K., and other countries that adopted stricter measures.
• When STAT last asked experts what might happen if the new coronavirus were not contained, three months ago, Wuhan, China — the origin of the pandemic — had been on lockdown only a week. The world had just passed 10,000 cases. The U.S. had one (a man returning to Washington state after visiting family in Wuhan). Its first documented case of community transmission was still three weeks away. Yet there was a consensus that the outbreak would not be contained.
• Instead, the experts told us, while the new coronavirus might settle down and simply cause colds like the other four human coronaviruses already in circulation, it was more likely to return year after year like seasonal flu, causing illnesses much more serious than sniffles.
• Now, more than 1 million U.S. cases and 64,000 deaths later, here are three possible futures that leading epidemiologists think the Northern Hemisphere could see. In each, the small wave in early 2020 represents China’s C19 outbreak, which peaked in late January and February but was mostly gone by March (the dip). The next, much larger crest represents the pandemic outside of China, especially in Europe and the U.S. Each scenario runs through 2022, when there’s a reasonable chance a vaccine will have arrived and there will have been enough of it produced to inoculate hundreds of millions of people.

Scenario One: Small waves as far as the eye can see

• In this future, the current peak in C19 cases is followed over the next two years by crest and dip, crest and dip. The crests will be less than half the size of this spring’s outbreak, with some of the highest numbers coinciding with flu season next fall and troughs this summer and next. There will likely be regional variation due to factors including random outbreaks, the bad luck of having super-spreaders, and too little testing and contact tracing to extinguish new outbreaks before they explode.
• The crest-and-dip possibility reflects an emerging consensus that this coronavirus has some seasonality but will not be eliminated by hot, humid weather.
• “The consensus among scientists is that climate is unlikely to substantially suppress C19 on its own during the summer of 2020 because we will still have a population that is almost completely susceptible to the virus,” biologist Marta Shocket of the University of California, Los Angeles, told reporters. As a result, any seasonal reduction “won’t have as big of an effect.”
• That’s because of how the virus is transmitted. Heat and humidity can kill virus on surfaces, said Adalja, “but in the summer, there will still be plenty of people who can transmit it person-to-person,” by sneezing, coughing, and even speaking.
• How many people? “It is our estimate that there is maybe a 20% reduction in transmissibility in the summer,” said epidemiologist Marc Lipsitch of Harvard T.H. Chan School of Public Health, who helped develop the scenarios. “If it’s similar to the other [four] human coronaviruses,” which cause common colds, “that’s not enough to stop it, just to slow it down,” he told JAMA Live.
• Osterholm’s summertime mini-wave shows more than a 20% reduction in cases, however, reflecting what experts predict will be one of the pandemic’s long-lasting legacies: Governors can open up bars and beaches all they want, but large indoor gatherings will still likely be off-limits, and many people will continue to practice voluntary social distancing.
• “Even without mandates for social distancing, people will be doing it anyway,” Adalja said. “It’s been built into our lives.” As a result, he said, “spectator sports and rock concerts probably won’t be part of the equation. I suspect certain malls will close; they were already dying, so [people’s reluctance to be close to others] is likely to be their death knell.”
• Measures that retailers, employers, and others are readying for when they re-open, from staggering work shifts to erecting partitions between cubicles to sending home any employee who runs even a slight fever, the new normal will lock in some of the physical distancing that has kept the worst forecasts for C19’s first wave from coming true. For many, donning a face mask before meeting friends at a park or going to the gym will become as natural as pocketing their cellphone. At restaurants, patrons will likely have their temperatures taken before being seated and servers will wear a mask and gloves, Gov. Gavin Newsom of California predicted last month.
• And when local outbreaks occur anyway, those measures will become stricter, even if only through voluntary measures. Many workers, frightened by a local flare-up, will telecommute if they can. People will again shun public transit, even taxis and ride apps. They will postpone scheduled surgeries and doctor visits, especially as telemedicine takes hold.
• “If you can speak to a doctor on the phone instead of getting in your car, driving through traffic, and traveling to the surgery … well, who wouldn’t want that?,” said futurist Patricia Lustig, CEO of the consulting firm LASA Insight.
• And then the outbreak will dissipate again, thanks to such measures. Many people will take that as a signal that it is safe to let down their guard. Social distancing will be less strict. The next wave will hit … over and over until so many people have been infected, or a vaccine succeeds, to produce herd immunity.
• Said Osterholm, “I keep telling people, the outbreak will not end with this one wave.”

Scenario Two: History redux

• March 1918 brought the first, moderate wave of the Spanish flu. Cases fell over that summer, but six months later, in the fall, the epidemic exploded. That was followed by smaller peaks in early 1919. And then the pandemic ended. The influenza pandemics of 1957 and 1958, and 2009’s swine flu, followed a similar pattern.
• In this scenario, rather than reappearing throughout the year as the crests and troughs of the first scenario, C19 would return with more ferocity in the late summer and fall and then dissipate, settling into a small but near-constant number of cases. “You would have what we call a case cliff,” Osterholm said.
• The precipitous, and lasting, fall-off would have two causes. First, so many people would be infected in the moderate first wave (now) and the gargantuan second wave (peaking around October) that the population might approach herd immunity. Second, the second wave, Osterholm said, “would absolutely take the health system down.”
• Avoiding that was the whole point of efforts to “flatten the curve” in the U.S. beginning in March, and they largely succeeded. But even if hospitals and others use the summer lull to load up on personal protective equipment, ventilators, and other needs, and to otherwise prepare for a full-blown return of C19 in the autumn and winter, it would likely not be enough.
• “If we also had a bad flu season, it would be really difficult for hospitals to cope,” Hopkins’ Adalja said.
• An imminent or actual crash of the health care system, similar to what northern Italy experienced in March, would force national, state, and local officials to impose mitigation measures even stricter than those of the last six weeks, which — as happened in China from late January to early March — would mostly snuff out C19.
• Because the new coronavirus would continue to circulate, like the four other human coronaviruses, there would still be low-level transmission. But cases would be so few they would hardly count as “outbreaks;” instead, C19 would be with us at a fairly low level, perhaps thousands of cases at any one time.

Scenario Three: The Worst Groundhog Day

• If everything breaks wrong, “we just keep having outbreaks in this city or that city and we keep trying to smother them,” Osterholm said, who calls this the “slow burn” scenario.
• The waves keep coming because the size of the outbreaks that follow the current one are smaller than in the monster-wave second scenario. It therefore takes longer for population immunity to build up. Local outbreaks occur, worse in some places than others due to, among things, different capacity to conduct widespread, regular testing and contact-tracing.
• No past influenza pandemic has ever followed this pattern. There are two reasons C19 might, however.
• One is biological: Coronaviruses, as shown by the four endemic ones, are frighteningly adept at continuing to circulate and never disappearing (the SARS coronavirus in the early 2000s was an exception).
• The other is sociological: There are real questions about society’s capacity to withstand another economic shutdown, let alone repeated ones. In the future, those policies, at least in some cities and states, may well be less stringent, and therefore less effective at controlling outbreaks, than those imposed this spring. That’s why future outbreaks in this scenario keep coming, with durations and case loads comparable to the current one.
• Do the endless waves mean that social distancing will have to be reimposed over and over, forcing the repeated closures of businesses that just reopened and the laying off of employees whose jobs keep being eliminated? Although it’s hard to remember, the stay-at-home orders, business shutdowns, and other mitigation measures were all in service of flattening the curve: slowing the spread of C19 enough to keep the number of patients needing hospitalization, intensive care, or a ventilator no greater than the health system’s capacity. Flattening the curve did not mean zero cases and deaths, or even a few thousand.
• If that remains the goal for future C19 waves, then mitigation might not be as severe, as a growing number of epidemiologists recognize: Having seen how disastrously short of supplies and capacity they were, many hospitals will use the summer lull “to manage capacity better and make adjustments to be better able to absorb a surge of cases,” Adalja said. “Hopefully, it won’t be a calamity every time.”
• Ironically, that may increase somewhat people’s tolerance for high numbers of illnesses, especially if the arrival of effective treatments means the return of C19 is less lethal than it was initially.
• Society must referee what Leung calls “a three-way tug of war” among a trio of competing needs: to keep cases and deaths low, to preserve jobs and economic activity, and to preserve people’s emotional well-being. “It’s a battle between what we need to do for public health and what we need to do for the economy and for social and emotional well-being,” he said. If the public health part of the tug-of-war weakens, then the waves will keep on coming through the end of 2022.
• And which scenario is most likely? Osterholm isn’t sure. “This virus is on its own time schedule,” he said. “But we will have some tough months ahead.”

[Note:  None of the scenarios presented in this story take into account the effects of potential new treatments or vaccines, which could substantially change the outcomes of all three scenarios.]

Source: Stat News here. 

J. Technology 

1. Wearable sensor can track symptoms

• It looks like a Band-Aid, but it’s a flexible wireless sensor that sits where your throat and chest meet, picking up coughing and breathing problems associated with C19. The device, announced Monday, can monitor early signs of coronavirus infection and the progression of the illness.
• Developed in hard-hit Chicago by Northwestern University and the Shirley Ryan AbilityLab, the device adheres to the skin below your suprasternal notch — the little well at the base of your throat where airflow is closest to the skin and where tracheostomies are also performed. This patch, however, is non-invasive and is related to a sensor for monitoring speech and swallowing in recovering stroke patients. That design was tuned to track coughing and breathing problems that are central to C19.
• “We don’t use a microphone,” says Professor John Rogers, director of Northwestern University’s Center on Bio-Integrated Electronics. “There are problems with microphones with ambient noise and tremendous invasions of privacy. We use a high-bandwidth, tri-axis accelerometer to measure movement of the surface of the skin” to capture details of breathing and coughing, not unlike a digital stethoscope. 
• The patch also detects heart rate and temperature.
• Once a day you peel it off and place it on a wireless charger, which triggers the patch to sync its stored data with a nearby iPad. From there the data is uploaded to a HIPAA-compliant cloud where a proprietary AI algorithm examines it for anomalies related to C19. The device has no external ports for power or connectivity, making it easier to disinfect.
• The sensor is delivered to healthcare teams complete with an iPad configured to upload its data to the cloud, and a wireless charger since the device is sealed and has no external connections.
• “We like AI, but we’re not wedded to it. We’re wedded to things that work,” says Rogers. “We use digital filtering algorithms that look for particular signatures in the data. We’re looking for trends, not an absolute gold standard measurement. And we have a good understanding of the underlying physics.” 
• At this early stage, the data is double-checked by a trained human before any indications are forwarded to medical providers. Twenty-five test subjects have been wearing the device for two weeks so far, generating about 1,500 hours of history and one terabyte of data.
• Dr. Arun Jayaraman of the Shirley Ryan AbilityLab leads algorithm development for the new C19 sensor. The team is using AI but backing it up with human confirmation before sending alerts to medical providers..
• Missing from the sensor patch is a blood oxygen perfusion sensor, but Rogers suggests that is coming in the near future. Fingertip pulse oximeters, which measure oxygen perfusion, are the latest personal health product to be snapped up after some reports indicated that low blood oxygen was a hallmark of onset of C19. 
• A lab at Northwestern’s Chicago campus is currently producing dozens of new patches a week. It has the ability to scale to hundreds of devices a week before making the patch available for volume manufacturing via license.
• Beyond this pandemic, the Northwestern C19 sensor joins an array of activity trackers, glucose monitors, and blood-pressure sensors that suggest we’ll soon wear a clinic’s worth of medical sensors to get in front of health issues before they turn serious. 
• “I think that demands a hardware platform that is virtually imperceptible,” says Rogers. “Health care in general will be improved when you move from episodic monitoring of status to continuous. I’ve always thought that makes sense.”

Source: CNET here. 

K. Practical Tips & Other Useful Information

1. Safety Advice for Reopening: How to Reduce Your Risks as Coronavirus Lockdowns Ease

• As communities and businesses across the country begin to reopen, more people are weighing whether—and how—they should head into work and, perhaps, visit restaurants, retail shops and hair salons.
• Public-health experts generally agree that to reopen society safely, communities need widespread testing so officials can be confident that the number of coronavirus cases in the population is low and people who are positive can be quarantined. Communities also need a system to trace people who have come into contact with positive cases so they too can be isolated, doctors say. “Otherwise you simply let everybody out for a few days and two weeks later have a surge in cases and have to start all over again,” says Gregory Poland, director of the Mayo Clinic’s Vaccine Research Group in Rochester, Minn. The U.S. so far largely lacks widespread testing and tracing, he says. “Most communities do not have that capacity.”
• So the safest move for most people is still to stay home as much as possible. But if you do go out, there are ways to reduce the risks. Here’s what the experts say:

Commuting

• Walking or biking to work or driving your own car are the safest options, says Dr. Poland. “If you’re on a train or bus, you have to realize that this is a very effective petri dish for the spread of respiratory pathogens,” he says. If you must use public transportation, wear a face mask and “be really cautious about hand hygiene,” using hand sanitizer and washing hands with soap and water for at least 20 seconds, says Daniel Kuritzkes, chief of the division of infectious diseases at Brigham and Women’s Hospital in Boston.
• Taking a taxi or using Uber or Lyft is generally less risky than the bus or train, “particularly if the driver is wearing a mask,” says Dr. Kuritzkes. You’re likely near only one potentially infectious person rather than the dozens on public transportation, and the driver’s mask “will provide some protection for the passenger” by trapping droplets that are emitted while coughing, sneezing or exhaling. Dr. Kuritzkes notes that those old-school plexiglass shields in some taxis can provide some protection, too. He suggests opening the car windows to increase air circulation, which can dilute the number of virus particles per volume of air.
• The CDC has issued recommendations for ride-share and taxi drivers that include wearing face-coverings in public and asking customers to handle their own bags. Uber says it has shipped disinfecting wipes and spray and 800,000 face masks to drivers around the country, prioritizing hard-hit areas like New York City. Lyft says it has distributed more than 40,000 “sanitizing products” and has begun handing out “hundreds of thousands of cloth face coverings” to drivers.

In the Office

• Some businesses are planning to bring back only a portion of workers to the office or are instituting shifts to allow for social distancing. Those moves are important, doctors say.
• Elevators can be a problem, says George Rutherford, professor of epidemiology at the University of California, San Francisco, since it is nearly impossible to keep an appropriate distance from other people in such a small space. Everyone should be wearing masks. And “face the wall so you’re not breathing in someone else’s breath,” he says.
• Surfaces like elevator buttons, doorknobs and printer buttons should be disinfected regularly. Even so, employees should use a tissue or paper towel to handle them and immediately use sanitizer or wash their hands, says Dr. Poland. “Every hard surface should be considered potentially contaminated,” he says.
• But it is the office bathroom that is the real hot zone, says Dr. Poland. Some research has found that the novel coronavirus is present in stool and can remain in the digestive tract long after it has been cleared from the respiratory system. Many company bathrooms have removed the lids from toilets so “when they flush, it causes a plume cloud and any virus that was in that stool is now on every surface you can culture, the air ducts, the ceilings, the floors and you,” he says. Dr. Poland suggests waiting until no one else is in the bathroom to use it. Avoid the hand dryers, too, since the forced air “very effectively disseminates virus everywhere,” he says.
• Use a paper towel on doorknobs and to turn faucets on and off, too. And, it goes without saying: Wash your hands for at least 20 seconds.

At a Restaurant

• The National Restaurant Association has released “C19 Reopening Guidance” that includes recommendations such as spacing tables at least 6 feet apart, providing hand sanitizer for customers and eliminating unwrapped straws from self-service drink stations.
• Benjamin Chapman, a professor of food safety at North Carolina State University, who co-authored the restaurant recommendations, says the biggest risk in restaurants is being around other people. He suggests avoiding any crowds that can occur while waiting for tables or clustered at the bar. Donald K. Milton, professor of environmental and occupational health at the University of Maryland School of Public Health, says outdoor dining is safest since there will be more ventilation and air flow.
• Dr. Chapman notes that restaurants should either be using paper menus that are thrown away after every patron or disinfecting reusable menus between customers. Even better would be to avoid physical menus altogether by downloading the menu on your phone, he says. Customers should be wary of “all high touch surfaces” like salt and pepper shakers, pens and those little leather holders that waitstaff use to present your check. (Hand sanitizing and hand washing are key here.) Dr. Chapman says that restaurant cutlery and dishes are less of a concern—though not risk-free—since they are heated, cleaned and sanitized and handled only by employees who should be trained in food safety. “I’m much more worried about the 40 or 50 other patrons that might have touched a menu.”
• A study published in the New England Journal of Medicine in March found that the virus that causes C19 can live on cardboard for up to 24 hours and on hard surfaces such as stainless steel and plastic for two to three days. There appears to be no risk of contracting the virus by eating it in cooked food, experts say.

In a Retail Store

• Supermarkets, liquor stores and hardware stores, among others, have been operating throughout the pandemic and have employed social-distancing measures like limiting the number of shoppers, keeping people apart in checkout lines and encouraging shoppers to order online and have items delivered or picked up. Other retailers could quickly adopt these practices. But public-health experts urge people to limit nonessential shopping trips. “It is harder to have a dozen people browsing in the shop trying to see what they want or going in changing rooms to try on clothing,” Dr. Kuritzkes says.

At the Hairdresser or Barbershop

• Check out those YouTube tutorials, because Dr. Poland urges people to postpone trips to the salon until there’s more evidence that community transmission of the novel coronavirus is very low. Dr. Kuritzkes concurs. “It’s going to be basically rolling the dice and hoping the person doing your hair hasn’t been recently exposed by another client or somebody in their neighborhood and is shedding virus.” He notes that some research has found that people are most contagious in the two or so days before they exhibit symptoms of C19.
• If you do go to the hairdresser or barber shop, Dr. Milton says because “people are going to be really close for an extended period of time,” it is important that both client and professional wear masks. Dr. Kuritzkes says that it probably is safer to have your hairdresser make a house call (if he or she is willing) and cut your hair outside in your backyard.

Outdoor Exercise

• As long as you can maintain social distance, public health experts generally agree that solo outdoor exercise is safe. Dr. Poland says he does caution people against going running with someone they don’t live with since “the nature of more rapid and deep exhalation puts people around you at greater risk.”
• Golf courses are now open in many states. And Dr. Kuritzkes says as long as golfers can maintain an appropriate social distance on the course, “I can’t see that as a serious threat.” The bigger concern is “people gathering in the clubhouse having drinks together afterward.” Tennis is relatively low-risk, too, he says, since people are usually far apart and outdoors—again, as long as you maintain distance. But avoid touching your face and use hand sanitizer and wash your hands after handling the ball, he says. Basketball and soccer are more concerning since “people do literally get in each others’ faces,” Dr. Kuritzkes says.
• With more beaches open, swimming in the ocean or in a lake or surfing should be fine if you keep your distance from other people, says Dr. Rutherford. That is the same for pools since chlorine kills the virus, he says.

At the Gym

• Health experts suggest waiting to head back to the gym. “You’ve got everybody huffing and puffing, coughing, touching everything,” says Dr. Poland. Dr. Kuritzkes says he can envision a way to do a yoga or spin class relatively safely if participants were spaced out and wearing masks and if the equipment was thoroughly disinfected between users. But he says that it would be difficult to “decontaminate things often enough or reliably enough to make it safe to go back to doing free weights or weight machines until we can be confident enough that any one person in the gym isn’t carrying infection.”

In a Movie Theater

• Movie theaters are now allowed to open in Georgia and Texas. But even if theaters implement strict social-distancing protocols like blocking out rows and spacing family groups 6 feet apart, the problem is that people spend such a long time (sometimes two hours or more) sitting in them, says Dr. Kuritzkes. That gives people that many more opportunities to breathe in any virus that may be lingering in the air.

Coming Home

• Health-care workers often have elaborate personal-safety rituals for when they return home, like stripping down in the garage, throwing clothes in the wash and immediately taking showers before they join their families. Front-line employees like bus drivers and grocery store staffers often do the same. The University of Maryland’s Dr. Milton says most other workers probably don’t have to go through such a rigorous regimen. “We should wash our hands as soon as we get home,” he says. “Really the bigger risk is what you could be carrying inside of you.”

Source: Safety Advice for Reopening: How to Reduce Your Risks as Coronavirus Lockdowns Ease