Coronavirus Update

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Coronavirus Update 5-13

“This damn virus is going to keep going until it infects everybody it possibly can.”

Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota

“The course of disease could last 30 to 50 days for some patients.”

Wu Zunyou, chief epidemiologist at the Chinese Center for Disease Control and Prevention  (!)

“The man or woman or child who will not wear a mask now is a dangerous slacker.”  

Red Cross Public Service Announcement during the Spanish Flu Pandemic (1918-20)

“I think we are going in the right direction, but the right direction does not mean we have total control of this outbreak.” 

Dr. Fauci

“Outside of New England, we’ve had a relatively benign course for this virus nationwide, and I think a one-size-fits-all national strategy is kind of ridiculous.”

US Senator Rand Paul (KY)

“I don’t want a stupid handout from the government.  I want my hands untied so I can work.”

Steve Walker, music store owner in Michigan forced to permanently close his business due to lockdown order

Today’s Features

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A. Recent Developments and Headlines

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

B. Numbers & Trends

Note: All changes noted in this Update are since the 5/10 Update

Sources: Worldometers

1. Confirmed Total Cases, New Cases and Tests

  • Worldwide:  
    • Total Cases = 4,337,605 (+2.0%)
    • New Cases = 85,280 (+15.0%) (+11,109)
    • New Cases (5 day avg) = 84,792 (-2.0%) (-1,704)
  • US: 
    • Total Cases = 1,408,636 (+1.7%)
    • New Cases = 18,196 (+25.3%) (+4,606)
    • New Cases (5 day avg) = 23,203 (-5.5%) (-1,346)
    • Number of Tests = 9,935,720 (+315,865)

2. Deaths

  • Worldwide Deaths = 292,451 (+1.9%) 
    • New Deaths = 5,314 (+56.2%) (+1,911)
    • New Deaths (5 day avg) = 4,405 (-1.2%) (-55)
  • US Deaths = 83,425 (+2.0%) 
    • New Deaths = 1,630 (+61.7%) (+622)
    • New Deaths (5 day avg) = 1,300 (-7.1%) (-99)
  • 5 Countries with Largest Number of Confirmed Deaths: 
CountryTotal DeathsDeaths Per 1M Population
US83,425 (+1,630)252 (+5)
UK32,629 (+627)482 (+10)
Italy30,911 (+172)511 (+3)
Spain26,920 (+176)576 (+4)
France26,991 (+348)408 (+4)
Worldwide292,451 (5,320)37.5
  • 5 Countries = 68.7% of Worldwide Total Confirmed Deaths (-0.3%)
  • US = 28.5% of Worldwide Total Confirmed Deaths (+0%)
  • 5 States with Largest Number of Confirmed Deaths: 
StateTotal  DeathsDeaths Per 1M Population
New York27,175 (+172)1,397 (+9)
New Jersey9,451 (+200)1,074 (+18)
Massachusetts5,141 (+33)746  (+5)
Michigan4,674 (+90)468 (+8)
Pennsylvania3,918 (+77)306 (+6)
US83,425 (+1,630)252 (+5)
  • 5 States = 60.4% of US Total Confirmed Deaths (-0.6%)
  • NY = 32.6% of US Total Confirmed Deaths (-0.4%)

3. Countries/States To Watch

  • Sweden [Note: The World Health Organization has cited the Swedish approach as a model for reopening economies]
    • Total Cases = 27,272 (+602)
    • Deaths = 3,313 (+57)
    • New Deaths (5 day avg) = 55 (-13.3%) (-8)
    • Deaths per 1M population = 328 (+6) 
  • Below are 5 of the States moving quickly to reopen their economies (and OK never locked down).   
StateTotal CasesTotal  DeathsDeaths Per 1M Pop
Georgia34,848 (+846)1,494 (+50)141 (+5)
Florida41,923 (+386)1,782 (+47)83 (+2)
Texas41,866 (+1,011)1,179 (+26)41 (+1)
Ohio25,264 (+477)1,438 (+78)123 (+7)
Oklahoma4,732 (+119)278  (+4)70 (+1)
US1,408,636 (+22,802)83,425 (+622)252 (+5)

C. Does Infection Prevent Future Infection?  Maybe, But Maybe Not.

1. C19 and Post-infection Immunity: Limited Evidence, Many Remaining Questions  

  • In the absence of effective treatment or biomedical prevention, efforts to control the coronavirus disease 2019 (C19) pandemic have relied on non-pharmaceutical interventions such as personal preventive actions (e.g., handwashing, face covers), environmental cleaning, physical distancing, stay-at-home orders, school and venue closures, and workplace restrictions adopted at the national, state, and local levels. 
  • In addition to these public health interventions, development of herd immunity could also provide a defense against C19. However, whether immunity occurs among individuals after they have recovered from C19 is uncertain. Many human infections with other viral pathogens, such as influenza virus, do not produce a durable immune response.
  • Understanding whether and how recovery from C19 confers immunity to, or decreased severity of, reinfection is needed to inform current efforts to safely scale back population-based interventions, such as physical distancing. Understanding potential post-infection immunity also has important implications for epidemiologic assessments (e.g., population susceptibility, transmission modeling), serologic therapies (e.g., convalescent plasma), and vaccines. In this Viewpoint, we describe what is currently known about the immune response to C19, highlight key gaps in knowledge, and identify opportunities for future research.
  • C19 is caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Following infection, detectable IgM and IgG antibodies develop within days to weeks of symptom onset in most infected individuals. Why some patients seem not to develop a humoral immune response, as reflected by detectable antibodies, is uncertain. Adding to this uncertainty is the unclear relationship between antibody response and clinical improvement. 
  • The findings from a small study of 9 patients with C19 found that greater clinical severity produced higher antibody titers. However, antibody detection and higher titers have not always been found to correlate with clinical improvement in C19. Moreover, mild C19 symptoms can resolve prior to seroconversion (as reflected by detectable IgM and IgG), although detectable IgM and IgG antibodies have preceded declines in SARS-CoV-2 viral loads. 
  • What appears more certain is that viral burden typically peaks early in illness, and then declines as antibodies develop and antibody titers rise over the subsequent 2 to 3 weeks. Success in culturing virus from nasopharyngeal specimens declines quickly during the first week of mild illness, but the absolute duration that a patient might shed infectious virus is unknown. Persistent detection of viral RNA many days to weeks after recovery from C19 at concentrations near the detection limit of available assays likely does not represent a meaningful clinical or public health risk, especially in the absence of symptoms; however, definitive evidence does not yet exist.
  • The durability of neutralizing antibodies (NAbs, primarily IgG) against SARS-CoV-2 has yet to be defined; persistence up to 40 days from symptom onset has been described.  Duration of antibody responses against other human coronaviruses may be relevant in this context. For example, following infection with SARS-CoV-1 (the virus that caused SARS), concentrations of IgG remained high for approximately 4 to 5 months before subsequently declining slowly during the next 2 to 3 years.  Similarly, NAbs following infection with MERS-CoV (the virus that caused Middle East respiratory syndrome) have persisted up to 34 months in recovered patients. 
  • Detection of IgG and NAbs is not synonymous with durable immunity. With regard to C19, a small, non-peer reviewed, preprint report provides the only data thus far on possible post-infection immunity in primates.6 In this study, 4 rhesus macaques were infected with SARS-CoV-2, and following recovery did not become reinfected when rechallenged with the same virus 28 days after the first inoculation. Whether persons can be reinfected with SARS-CoV-1 and MERS-CoV is unknown; SARS has not reemerged since 2004 and MERS cases remain sporadic. Reinfections can occur with at least 3 of the other 4 common human coronaviruses—specifically, 229E, NL63, and OC43—all of which generally cause milder respiratory illnesses. The reasons for this reinfection are not fully known, but evidence suggests that possibilities include both short-lived protective immunity and re-exposure to genetically distinct forms of the same viral strain.
  • To date, no human reinfections with SARS-CoV-2 have been confirmed.  Evidence of reinfection typically requires culture-based documentation of a new infection following clearance of the preceding infection or evidence of reinfection with a molecularly distinct form of the same virus. In one report, among 2 otherwise healthy individuals who had recovered from C19 and had 2 or more sequentially polymerase chain reaction (PCR)–negative upper respiratory specimens at least 24 hours apart, SARS-CoV-2 RNA was detected again in throat swabs sporadically for up to 10 days.  SARS-CoV-2 RNA has also been detected in throat or nasopharyngeal swabs more than 20 days after negative test results. 
  • In another report among 18 patients, viral burdens (as determined by PCR cycle threshold) were generally lower than, and had declined substantially from, values during peak of illness. At the time of post-recovery positive test results, the patients described in these reports had few, if any, symptoms, and when radiographically examined, they demonstrated stable or improving pneumonia. There is also no evidence at present that such persons transmitted SARS-CoV-2 to others after they had clinically recovered. However, this possibility of transmission cannot be ruled out, especially for persons who may be predisposed to prolonged shedding of other pathogens, such as due to immunocompromised states.
  • It is also possible these cases represent persistent or recrudescent C19 illness or even true reinfection. On the other hand, these cases may also represent prolonged sporadic viral RNA shedding at or near the limit of assay detection or variation in collection technique, specimen handling, or storage conditions affecting test performance. Data to effectively differentiate these possibilities are lacking, highlighting an area of substantial uncertainty. Routine collection of such data, specifically viral burden (as measured by PCR assay cycle threshold) and viral culture, and from a larger sample of patients under standard protocols, is needed.
  • Serological assays to detect SARS-CoV-2 antibodies are rapidly becoming available and will be critical to estimate the prevalence of infections, including those that are asymptomatic. However, it is presently premature to use such assays to determine whether individuals are immune to reinfection. 
  • Performance standards, including sensitivity and specificity, for the burgeoning number of serologic assays and the potential for cross-reactivity with other coronaviruses (yielding false-positives) have yet to be determined. Widespread testing of persons who have not had C19, a population with low SARS-CoV-2 prevalence, can generate more false-positives than true-positives. This phenomenon may complicate clinical and epidemiologic interpretation of results, especially if the serologic tests do not have high specificity or some form of confirmatory testing is not used. 
  • More fundamentally, it remains to be determined whether a robust IgG response corresponds with immunity. Well-designed longitudinal cohort studies of persons who recovered from C19 are needed to monitor for signs and symptoms of recurrent illness. Such longitudinal studies could also document possible re-exposure events, all linked with clinical and laboratory investigations of other alternate etiologies, serologic testing, attempts to isolate virus by culture, and viral genomic comparisons of isolated viral specimens. However, in the short-term, possible recurrences of infection can be identified by monitoring surveillance data and by requesting clinicians and public health authorities to report and investigate cases of possible recurrence to determine whether recurrence can be confirmed.
  • In summary, existing limited data on antibody responses to SARS-CoV-2 and related coronaviruses, as well as one small animal model study, suggest that recovery from C19 might confer immunity against reinfection, at least temporarily. However, the immune response to C19 is not yet fully understood and definitive data on post-infection immunity are lacking. Amidst the uncertainty of this public health crisis, thoughtful and rigorous science will be essential to inform public health policy, planning, and practice.

Source: COVID-19 and Postinfection Immunity: Limited Evidence, Many Remaining Questions | Infectious Diseases | JAMA

D. Symptoms

1. Symptoms of COVID-related inflammatory syndrome in kids are not subtle  

  • As many as five children in New York have reportedly died from a “pediatric multisystem inflammatory syndrome,” which pediatricians believe is triggered by the coronavirus. The syndrome, first reported in London, has been compared to other autoimmune conditions such as Kawasaki disease (KD) and toxic shock syndrome (TSS). But in interviews with Yahoo Life, multiple pediatricians say that the illness is increasingly different from those illnesses — and that the symptoms are unmistakable.
  • “I believe and I think many people believe it’s a different problem, a different syndrome that’s not typical Kawasaki disease,” says Dr. Stanford Shulman, a professor of pediatrics with a focus on infectious disease at Northwestern University. “This syndrome has a few features similar to Kawasaki, but many more features that are very different.”
  • While most of the cases have been reported in New York thus far, doctors in Boston, Philadelphia, Los Angeles and — according to Shulman — Chicago now say that they’ve seen suspected cases as well. Thus far, the pediatricians say the patients seem to be responding well to treatment and that the majority make a full recovery. Many of the kids have tested positive for COVID-19 antibodies, suggesting that they contracted the virus weeks before and recovered.
  • Given that timeline, experts believe that more cases will be appearing in other states in the coming weeks. To help alleviate fears among parents, here’s what the experts know thus far.
Two key symptoms are high fever and gastrointestinal distress
  • Shulman says that one of the biggest differences between this new syndrome and KD is the prevalence of gastrointestinal symptoms. “The symptoms patients are presenting with … there’s lots of abdominal pain and diarrhea, which are very uncommon in Kawasaki children,” says Shulman. The other obvious symptom is a fever above 102°F for multiple days. “If a child develops high fevers, lots of abdominal pain — with or without diarrhea or vomiting — and looks really sick, they need to go to an emergency room to be evaluated.” Other symptoms to look for include rash, conjunctivitis and difficulty breathing.
Shock is likely what is driving the fatalities
  • Dr. Steven Kernie, chief of pediatric critical care medicine at New York-Presbyterian Hospital, has seen multiple cases of the syndrome as well and says that, aside from abdominal pain and high fever, parents should look out for symptoms of shock, such as clammy skin and racing heart rate. Shock, according to the Mayo Clinic, is defined as “a sudden drop in blood flow” that can deprive the organs of blood and oxygen.
  • This reaction seems to align more with toxic shock syndrome, which is caused by a bacterial infection, than KD. “It’s the shock piece that is different … where they need to be in the ICU and they need to be on medications to help their heart work better,” Kernie tells Yahoo Life. In a press conference Monday, health officials in New York said they’ve seen evidence that shock in these patients is causing “multi-organ failure.” They note that if recognized early, shock is treatable — and that if treated early, long-term effects are likely “pretty negligible.”
It is unlikely to be contagious
  • Both Kernie and Shulman say the syndrome is essentially a “hyper-inflammation” in the body, typically post-infection. But while COVID-19 is very easy to pass on to others, Kernie says this syndrome is not transmissible. “It’s not running in families, and it’s not contagious,” says Kernie. “Although we’re seeing a lot of it now, we have seen things like Kawasaki disease that oftentimes occur after a viral infection, so I believe that it’s really just because of the sheer volume of kids that have been exposed to COVID that we’re seeing a cluster of cases.”
It does not appear more prevalent among Asian children
  • Kawasaki disease, named after the Japanese researcher who discovered it, is much more common among kids of Asian and Pacific Island descent. But Kernie says that’s not the case here. “We’ve called our colleagues in Japan who are Kawasaki experts, and they’re not seeing any of this. None. Same thing for China,” says Shulman. He notes that it’s too soon to draw any conclusions about who is most at risk, but he reveals that six out of the eight children in London with the syndrome were of Afro-Caribbean descent. “So far, the demographics are very different,” he says. No data on the demographics of the kids affected in the U.S. has been released, but the National Institutes of Health has begun studying the syndrome.
Toddlers do not appear to be at heightened risk
  • Another marked change from KD, which generally affects children under 5, and TSS, which is most common among teens, is the demographic affected. “The average age of this new syndrome is about 8 to 12 years old. In Kawasaki disease, the average age is 2,” Shulman says. In New York, officials say, the patients range in age from 5 to 9 years old.
Doctors have been using the same treatment used for KD, and it’s working
  • Treatment for KD is typically what’s known as intravenous immunoglobulin (IVIG), a concentrated amount of healthy antibodies from thousands of blood donors. While not all symptoms align with KD, this method seems to be working. “Kawasaki disease is typically treated with IVIG, and patients overall do quite well. It seems like the patients we’ve heard about have also responded to IVIG,” he says. “Most of those patients have recovered and been discharged. So that’s the good news.”
Overall, it remains rare and symptoms are tough to miss
  • It’s too soon to know exactly how many kids will be affected, but Shulman says he “[does] not expect this to turn out to be an extremely common problem.” Kernie agrees. “I would reassure parents that I believe it’s a rare complication,” Kernie says. Both suggest parents stay vigilant, but also take solace in the fact that if a child has this syndrome, it will likely be near impossible to miss. “The symptoms aren’t subtle. The kids look sick. They have a fever. They often have abdominal distension and diarrhea,” says Kernie. “There are diseases where you put a perfectly healthy child to bed at night and you wake up and they’re horribly sick. This is not that — it isn’t coming out of nowhere.”

Source: Symptoms of COVID-related inflammatory syndrome in kids are ‘not subtle’ — here are the two key signs to look for

E. Operation Warp Speed: The Oxygen Mask Approach

1. The audacious goal of having 300,000,000 doses of an effective vaccine by January 2021   

  • Conventional wisdom is that a vaccine for C19 is at least 1 year away, but the organizers of a U.S. government push called Operation Warp Speed have little use for conventional wisdom. The project, vaguely described to date but likely to be formally announced by the White House in the coming days, will pick a diverse set of vaccine candidates and pour essentially limitless resources into unprecedented comparative studies in animals, fast-tracked human trials, and manufacturing. Eschewing international cooperation—and any vaccine candidates from China—it hopes to have 300 million doses by January 2021 of a proven product, reserved for Americans.
  • Those and other details, spelled out for Science by a government official involved with Warp Speed, have unsettled some vaccine scientists and public health experts. They’re skeptical about the timeline and hope Warp Speed will complement, rather than compete with, ongoing C19 vaccine efforts, including one announced last month by the National Institutes of Health (NIH). “Duplication only leads to infighting and slowing people down,” says Nicole Lurie, former U.S. assistant secretary for preparedness and response, who advises the Coalition for Epidemic Preparedness Innovations (CEPI), a nonprofit funding and helping coordinate C19 vaccine efforts. “The U.S., and others around the world, should be engaged in this competition against the virus, not against one another.”
  • Warp Speed, first revealed by Bloomberg News on 29 April, has so far only been outlined. President Donald Trump briefly discussed the initiative the next day, saying, “We’re going to fast track it like you’ve never seen before.” According to a CNN report on 1 May, which the source who spoke to Science confirmed, Warp Speed intends to deliver the first 100 million doses of a vaccine in November and another 200 million over the following 2 months.
  • An extraordinary 110 C19 vaccines are in development, and eight candidates—four from Chinese companies—have entered small trials in people, according to an 11 May update from the World Health Organization (WHO). But there’s less than meets the eye in many of the efforts, says a vaccine veteran who asked not to be named. “Half of them are companies that have three guys, an administrative assistant, and a dog.”
  • The idea for Warp Speed was hatched in early April, says the official, a scientist, who was given permission to discuss it with Science if his name was not used. “Looking around, it became clear that without a really heroic effort, none of the existing efforts to produce vaccine was going to lead us to have vaccine to prevent what looks increasingly like a second wave that could sweep come October, November,” he says. Warp Speed will have three separate “virtual teams” to address development, supply and manufacturing, and distribution, led by a “core team” of a few dozen experts from government, industry, and academia.
  • Warp Speed has already narrowed its list of vaccine candidates to 14 and plans to push ahead with eight, the official says. “The idea for us is to pick a diversified portfolio” of vaccines made with different technologies, or platforms. Organizers were concerned that other government vaccine investment has been “heavily weighted” toward just two candidates: one made with messenger RNA encoding the coronavirus surface “spike” protein and the other using a cold-causing adenovirus to deliver the same protein’s gene. Neither technology, the official notes, has yet led to approved vaccines for any disease.
  • The official declined to identify Warp Speed’s vaccine candidates, but he stressed two key criteria: safety and the potential to make hundreds of millions of doses quickly. “We don’t have time to debug manufacturing issues here,” he says. By July, Warp Speed hopes to have its eight lead candidates in human trials. At the same time, it will fund a large-scale comparison of their safety and efficacy in hamsters and monkeys to help winnow down that group. “If something’s really bad, we’ll get rid of it,” he says.
  • In parallel with the trials, the project will lay the groundwork for “heavy duty manufacturing” of as many as four different vaccines. More than one may prove worthy, and multiple options guard against contamination incidents and other supply concerns.
  • Although Warp Speed has not ruled out any type of vaccine, it will not consider ones made in China, such as the inactivated virus vaccine recently shown to protect monkeys from the coronavirus, a first. “We can’t partner with Chinese companies,” the official says. “That’s just not going to happen.” The decision was “above my pay grade,” he adds. But the chosen vaccines could be made by a company that is not headquartered in the United States. (White House trade adviser Peter Navarro in a February memo to the Coronavirus Task Force championed a “Manhattan Project” for C19 vaccines that would prioritize U.S.-based companies.)
  • Warp Speed’s main goal is to protect the United States. “The attitude here is the oxygen mask approach,” the official says. “We want to get our oxygen mask on first and then we’re going to help the people around us.” Warp Speed, he says, plans to “freely disseminate information” to other countries and share manufacturing technologies, and it may make extra doses for the world.
  • Many scientists and organizations have argued, however, that any proven C19 vaccines should be accessible and affordable to everyone in the world at the same time. WHO and other groups on 24 April formed the Access to C19 Tools Accelerator that aims to speed development of diagnostics, therapeutics, and vaccines, and ensure “equitable global access to safe, quality, effective, and affordable” products. 
  • The European Commission, in turn, organized a fundraiser on 4 May, the Coronavirus Global Response, at which world leaders from many countries and some philanthropists pledged $8 billion; the United States did not participate. CEPI and another nonprofit group, GAVI, the Vaccine Alliance, will oversee the vaccine drive. “It’s a global problem, and it needs a global solution,” says Seth Berkley, who heads GAVI.
  • Berkley supports Warp Speed’s plan to triage the many candidates, but he calls it a shortsighted mistake to rule out Chinese products, “given the fact that they’re a couple of months ahead.” The Bill & Melinda Gates Foundation is closely following “15 or so” vaccine candidates, including ones from China, and will support the most promising ones, adds Emilio Emini, a former vaccine developer now with the foundation. “You need to have a global portfolio so that you’re not putting all your chips on one part of the roulette table,” he says.
  • WHO has yet another ambitious C19 vaccine project, the Solidarity Trial, that plans to compare candidates in human studies. That effort is headed by Andrew Witty, former CEO of GlaxoSmithKline, a major vaccine manufacturer. On Monday, WHO Director-General Tedros Adhanom Ghebreyesus said there are seven or eight “top” vaccine candidates the group hopes to accelerate. What will happen with production and supply if one of these other groups and Warp Speed select the same vaccine to prioritize is unknown.
  • Warp Speed’s relationship to the NIH initiative, Accelerating C19 Therapeutic Interventions and Vaccines (ACTIV), remains unclear. That project plans to coordinate clinical trials of several C19 vaccines and use common institutional review boards, safety monitors, and protocols, NIH Director Francis Collins and co-authors explain in a commentary published online on 11 May by Science. ACTIV is also considering controversial human “challenge” studies, which would fast-track a vaccine’s evaluation by immunizing healthy people and deliberately infecting them with the new coronavirus or a weakened form of it.
  • When asked about the NIH effort, the Warp Speed official said there is “no conflict at all—they are working together—one intellectually (ACTIV) and one operationally (Warp Speed).” But several scientists on the ACTIV vaccine subcommittee say they know little about Warp Speed. And one member, Peter Hotez of the Baylor College of Medicine, worries about both its name and timeline, noting the anti-vaccine movement argues products are often rushed to market without adequate testing. “Some of the language coming out of the White House is very damaging,” says Hotez, who is part of a team making a C19 vaccine candidate. As for the January delivery of 300 million doses, “I don’t see a path by which you can collect enough efficacy and safety data by the end of the year.”
  • Kathryn Edwards, a vaccine specialist at Vanderbilt University who is also participating in ACTIV, notes that the efficacy trials, which will ideally track symptomatic disease in areas of high transmission, also face complicated logistical issues given that many people will only have mild cases of C19 or not know they are infected at all.
  • The official acknowledges Warp Speed is aiming high. “I know that there’s a reasonable probability that we’re going to fail,” he says. “And if we fail, I want to make sure we’ve investigated all of the different potential ways we could have gone.”

Source: Unveiling ‘Warp Speed,’ the White House’s America-first push for a coronavirus vaccine 

F. Concerns & Unknowns

1. With little data and insufficient supply, doctors struggle to decide which C19 patients should get remdesivir  

  • Now that the federal government has begun distributing the experimental C19 drug remdesivir, hospitals are in a bind. So far, it’s the only medication that has shown benefit for coronavirus patients in rigorous studies. But there isn’t enough for everyone who’s eligible. That leaves doctors with a wrenching ethical decision: Who gets the drug, and who doesn’t?
  • As if the question wasn’t hard enough on moral grounds alone, it’s made even trickier by a dearth of data: Clinicians still don’t have the fine-grained study results showing which patients are most likely to benefit from the medication. Other antiviral medications work best when given earlier on in the course of illness — and anecdotally, that seems true for remdesivir, too — but it’s hard to make such calls with any certainty if you don’t have robust data.
  • “We hate being in this position. We want to have enough for everyone,” said Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital. “And if we don’t, we want to have enough information, so with this limited resource, we can distribute it in the best way possible. We feel like our hands are tied without those data.”
  • What doctors do have is the press release put out by the National Institute of Allergy and Infectious Diseases on April 29, saying that hospitalized patients who’d gotten remdesivir had recovered quicker than those who’d received a placebo — an average of 11 days versus 15 days. The improvement was enough for researchers to start giving the placebo group the drug as well, before they could statistically prove whether or not it increased a person’s chances of surviving C19.
  • Within days of the announcement, the FDA issued an emergency authorization so clinicians could start treating patients with remdesivir. The plan was for the federal government to distribute 607,000 vials — enough for around 78,000 people — which the manufacturer, Gilead Sciences, had committed to donating over the next 6 weeks as it raced to ramp up production.
  • But the initial allocation of the drug last week was heavily criticized by clinicians, who were baffled as to why some of the hardest-hit medical centers had been skipped over. In Massachusetts, for instance, the four hospitals initially chosen to receive remdesivir decided the federal allocation wasn’t equitable, and agreed to donate their supply to the state’s Department of Public Health, for redistribution to around 40 medical centers with the highest numbers of C19 inpatients.
  • Then, over the weekend, the Trump administration announced it had adopted a similar plan for the whole country, with state health agencies coordinating distribution.
  • Already, families are clamoring for remdesivir. Israel Dahan, an attorney from outside of New York City, knows how terrible this virus can be. On March 31 — the day his 54-year-old brother died of C19 — their mother was taken to the hospital and put on a ventilator for the same disease. She’s been at Westchester Medical Center ever since, sedated, with machines helping her lungs to breathe. Dahan is now trying to get remdesivir for her, but he said the hospital hadn’t initially received any.
  • “We’ve heard this medication has worked for Covid patients,” Dahan said. “This is our mother. Why wouldn’t we give her every opportunity to get better? I recognize there’s no guarantee, but why wouldn’t I try?”
  • His family was especially frustrated to hear that hospitals in New York City had received some of the drug. “It’s there, it’s sitting in hospitals 20 miles away,” he said. He knows that other families are in the exact same position, that they want the drug just as much as he does: “I don’t know how they’re rationing it. … I mean, I get it, there are only so many doses, so how do you decide?”
  • That’s exactly what clinicians are racing to figure out. As Erin Fox, director of drug information and support services at the University of Utah Medical Center, explained, the eligibility criteria from the federal government aren’t much help.
  • “It’s very broad,” Fox said. “If you have 20 patients but only two vials, how do you decide which two patients get those vials? There’s no severity criteria for who would best be helped by this product. That’s why we need to see the data from the trial.”
  • As the federal guidance stands, anyone with C19 severe enough to bring their blood oxygen saturation down to 94% is eligible, whether they need a bit of extra oxygen, a machine to push air into their own lungs, or a device that will pump their blood out to an external lung-replacing machine.
  • “This could be somebody who is mildly short of breath and is uncomfortable and who might be more comfortable on a wee bit of oxygenation — some people don’t even detect that their oxygenation is low at 94%,” said Walensky. But, she went on, it could also be somebody on the brink of death. “It’s almost the entire spectrum of inpatient disease.”
  • Most specialists agree that the earlier you treat someone, the better, because part of what makes some people so sick is not the infection itself, but the inflammation that comes with the immune response.
  • “The key thing is that the antiviral blocks the virus,” said Francisco Marty, an infectious disease physician at Brigham and Women’s Hospital, in Boston, who is running a clinical trial of remdesivir. That means that the medication probably can’t undo all the lung damage the illness has already caused.
  • But that isn’t ironclad. It’s based partially on what researchers have seen in other viral diseases, and partially on anecdotes from clinicians conducting trials. “We know so little about how patients respond to remdesivir that it’s unclear if remdesivir use is more impactful for lower-acuity, earlier disease-state patients vs. higher-acuity, late disease-state patients,” said Ryan Bariola, an infectious disease specialist at the University of Pittsburgh Medical Center.
  • Even the evidence on how many doses each patient should receive is still up in the air, Bariola added.
  • For now, hospitals are scrambling to figure out how to make their allocations do the most good for the greatest number of people. “In terms of extrapolating the results to the very elderly and all the other patients that have Covid — I think we have to just take our best guess,” said Dan Culver, a pulmonologist at Cleveland Clinic. “Remdesivir, from what we can tell right now, looks like it may be helpful, but I think it would be a mistake to think of this as a cure.”
  • At Mass. General, meanwhile, clinicians are considering prioritizing those who are sick enough to be hospitalized — after all, the drug is delivered intravenously — but haven’t been sick for too long. “At some point, there’s going to be a lottery because there are going to be too many patients for the drug,” Walensky said. “If somebody has been in the ICU for two weeks, we think that it’s probably not going to do much good in that patient. They may have a different lottery system than patients who are earlier in the course of disease.”
  • Most of all, she wishes there were more drug to go around, and more data about it. “We’re in this position of rationing this drug that we’re not confident will make for meaningful differences in outcomes — like differences in survival.”

Source: Doctors are unsure which Covid-19 patients should get remdesivir

2. Organ transplants plummet amid coronavirus crisis  

  • Organ transplants took a sharp downturn as C19 swept through communities, with surgeons wary of endangering living donors and unable to retrieve possibly usable organs from the dead — and hospitals sometimes too full even when they could.
  • Deceased donor transplants — the most common kind — dropped by about half in the U.S. and 90% in France from late February into early April, researchers reported Monday in the journal Lancet.
  • Transplants from living donors had a similarly staggering dive, according to the United Network for Organ Sharing, which runs the U.S. transplant system. There were 151 living donor transplants in the U.S. in the second week of March when a pandemic was declared. There were only 16 such transplants the week of April 5, according to UNOS.
  • It’s too soon to know how many people waiting for a lifesaving organ transplant may die not from C19 infection but because the pandemic blocked their chance at a new organ. Kidney transplants make up the vast majority of the drop, but heart, lung and liver transplants declined, too.
  • Living donations might be rescheduled, but missed organs from a deceased donor are lost opportunities, wrote Lancet lead author Dr. Alexandre Loupy, a kidney specialist who heads the Paris Transplant Group.
  • More recent counts by UNOS show that transplants starting inching back in late April, with U.S. hospitals trying to decide how to safely ramp up.
  • Geographic variation could offer important lessons, said another study author, Dr. Peter Reese of the University of Pennsylvania.
  • “Transplant centers and patients really want to get going again, but there are all these questions,” said Reese, whose team is collecting data from Canada and other parts of Europe for a closer look. “We need to be finding places that maintained their transplant rates and finding out what they did.”
  • Hospitals worldwide have postponed all kinds of medical care as they were flooded with coronavirus patients. Transplants are among the hardest choices. They’re not elective surgeries. But patients must take immune-suppressing medicines to prevent rejection of their new organ — putting them at greater risk if they encounter the virus.
  • France’s larger drop may be due to more centralized public health policies than in the state-by-state variations in the U.S., Reese said.
  • “That equation changes depending on what area of the country you’re in,” agreed Dr. Abhinav Humar, transplant chief at the University of Pittsburgh Medical Center. His transplant center, still running, has taken in patients from New York and other harder-hit areas who needed a new liver, had a willing living donor and “can’t afford the luxury of waiting two or three months at least” in hopes their original hospital could take them back.
  • In an average month, New York does about 220 transplants statewide. In the first weeks of April, that had dropped to 23, Samantha Delair of the New York Center for Liver Transplantation told a recent UNOS video conference.
  • In contrast, the University of California, San Francisco, in an area that has been less affected by the pandemic, has seen small transplant drops, said interim transplant director Dr. Chris Freise.
  • “We’re one of the few centers that kept going through all of this, but it was not without a lot of careful thought,” said Freise, who needed daily updates in deciding what transplants were safe to schedule — and remains on guard as California’s social distancing restrictions are gradually lifted.
  • For example, Freise’s team allowed living kidney transplants for people like Herb Hoeptner, who was on the brink of needing dialysis.
  • “When you have kidneys that have nothing left, you either go on dialysis or you die. That was much more of a concern to me than coronavirus,” said Hoeptner.
  • The 66-year-old from Gilroy, California, realized only after his surgery on March 31 how rare a transplant during the pandemic was.
  • “I was extremely lucky,” added Hoeptner, whose wife, Diane, was his donor and rebounded quickly from the surgery.
  • In places where C19 is more widespread, living donors are understandably nervous. “We don’t yet have a way to talk to living organ donors about what’s a reasonable risk,” said Penn’s Reese.
  • Deceased donations are even more complicated. Early on, testing shortages made it hard to be sure would-be donors who died of something unrelated like a car crash were virus-free, a problem that’s easing. Still, hospitals don’t want out-of-town surgeons visiting to retrieve organs and can’t always spare a local surgeon to do the job or find a plane to fly the organs where they need to go.
  • Surgeons must weigh if it makes sense to accept less-than-perfect organs that might work but could keep the recipient hospitalized for longer.
  • University of Iowa kidney surgeon Dr. David Axelrod said his team is “trying to be careful about it, trying to make sure that they’re organs that we think people can come in and get transplanted successfully and go home quickly.”

Source: Organ transplants from deceased donors plummet amid coronavirus crisis

G. Updates

1. Hydroxychloroquine 

Below is a summary of a study published in the Journal of American Medical Association regarding the effectiveness of hydroxychloroquine.  

Overview:

  • In a retrospective cohort study of 1,438 patients hospitalized in metropolitan New York, compared with treatment with neither drug, the adjusted hazard ratio for in-hospital mortality for treatment with hydroxychloroquine alone was 1.08, for azithromycin alone was 0.56, and for combined hydroxychloroquine and azithromycin was 1.35. None of these hazard ratios were statistically significant.
  • Among patients hospitalized with C19, treatment with hydroxychloroquine, azithromycin, or both was not associated with significantly lower in-hospital mortality.

Abstract:

  • Importance:  Hydroxychloroquine, with or without azithromycin, has been considered as a possible therapeutic agent for patients with coronavirus disease 2019 (C19). However, there are limited data on efficacy and associated adverse events.
  • Objective:  To describe the association between use of hydroxychloroquine, with or without azithromycin, and clinical outcomes among hospital inpatients diagnosed with C19.
  • Design, Setting, and Participants:  Retrospective multicenter cohort study of patients from a random sample of all admitted patients with laboratory-confirmed C19 in 25 hospitals, representing 88.2% of patients with C19 in the New York metropolitan region. Eligible patients were admitted for at least 24 hours between March 15 and 28, 2020. Medications, preexisting conditions, clinical measures on admission, outcomes, and adverse events were abstracted from medical records. The date of final follow-up was April 24, 2020.
  • Exposures:  Receipt of both hydroxychloroquine and azithromycin, hydroxychloroquine alone, azithromycin alone, or neither.
  • Main Outcomes and Measures:  Primary outcome was in-hospital mortality. Secondary outcomes were cardiac arrest and abnormal electrocardiogram findings (arrhythmia or QT prolongation).
  • Conclusions and Relevance:  Among patients hospitalized in metropolitan New York with C19, treatment with hydroxychloroquine, azithromycin, or both, compared with neither treatment, was not significantly associated with differences in in-hospital mortality. However, the interpretation of these findings may be limited by the observational design.

Source: Treatment With Hydroxychloroquine or Azithromycin and In-Hospital Mortality in Patients With COVID-19

H. Projections & Our (Possible) Future

1. Coronavirus will rage ‘until it infects everybody it possibly can’  

  • A high-profile infectious disease researcher warns C19 is in the early stages of attacking the world, which makes it difficult to relax stay-at-home orders without putting most Americans at risk.
  • Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said the initial wave of outbreaks in cities such as New York City, where one in five people have been infected, represent a fraction of the illness and death yet to come. 
  • “This damn virus is going to keep going until it infects everybody it possibly can,” Osterholm said Monday during a meeting with the USA TODAY Editorial Board. “It surely won’t slow down until it hits 60% to 70%” of the population, the number that would create herd immunity and halt the spread of the virus.
  • Even if new cases begin to fade this summer, it might be an indicator that the new coronavirus is following a seasonal pattern similar to the flu.
  • During the 1918 flu pandemic that sickened one-third of the world’s population, New York City and Chicago were hit hard in the first wave of illness that largely bypassed other cities such as Boston, Detroit, Minneapolis and Philadelphia. The second wave of illness was much more severe nationwide.
  • If C19 retreats only to return in the fall, the number of cases could peak and overwhelm hospitals that must deal with cases of flu and respiratory viruses. Furthermore, Asian nations such as South Korea and Singapore, lauded for strict controls and rapid testing to avoid damage during the first wave, might be vulnerable to a second wave of infections, he said. 
  • “It’s the big peak that’s really going to do us in,” he said. “As much pain, suffering, death and economic disruption we’ve had, there’s been 5 to 20% of the people infected, … That’s a long ways to get to 60 to 70%.”
  • Still, there are key differences between C19 and the flu. The average incubation period for the new virus is five days, compared with just two days for the flu, according to a Center for Infectious Disease Research and Policy report comparing the pandemics. 
  • The longer incubation period and a higher transmission rate suggest the C19 virus spreads more easily than the flu.
  • Osterholm said only an effective vaccine can slow the virus before a large enough segment of the population becomes infected and develops some level of immunity. Even if a vaccine works, Osterholm said, it’s unknown whether it would be durable enough to confer long-lasting protection from the coronavirus. 
  • Most states are easing stay-at-home orders though patchwork measures that vary from one to the next. Georgia began opening in late April amid national criticism, allowing tattoo parlors, bowling alleys and hair and nail salons to reopen with restrictions. California has taken a slower, phased approach, allowing some retailers and manufacturers considered low-risk to resume operations. 
  • Governors worry about the economic harm social distancing measures have caused with shuttered businesses and the growing ranks of jobless Americans. Unemployment has reached 15% nationwide, and a Trump administration economic adviser warned unemployment could soon reach 20%. 
  • Osterholm acknowledges that the nation “can’t lock down for 18 months” and said political and business leaders need to find a way to resume activities while adapting to a virus that won’t soon disappear. He doesn’t believe there has been enough of a frank assessment on the economic harm the virus will cause over coming months and its disruption to international supply chains. 
  • “We all have to confront the fact there’s not a magic bullet, short of a vaccine, that’s going to make this go away,” he said.  “We’re going to be living with it. And we’re not having that discussion at all.”

Source:  Coronavirus: Expert Michael Osterholm warns pandemic is far from over 

2. Why an added month of lockdown will devastate New York small businesses  

By Betsy McCaughey is a former lieutenant governor of New York, chairwoman of the Committee to Reduce Infection Deaths and author of the book “The Next Pandemic,”

  • As the shutdown drags on, New York officials fear that half the city’s smallest businesses are going to fail. Restaurants, bars, shops and salons will become boarded-up storefronts. Neighborhoods will feel like ghost towns.
  • It’s a grim prospect, yet officials seem ready to let it happen. Gem Spa in the East Village, known since the 1920s for its egg creams, is shutting for good, and the Strand, the iconic book store, says it may also.
  • Gov. Andrew Cuomo hasn’t indicated when the city will reopen as part of his multiphase reopening plan. Mayor Bill de Blasio hinted on Monday that the process might start sometime in June, but in recent days he has also said reopening is “a few months away at minimum.”
  • The city’s small-business commissioner said: “I don’t think the New York that we left will be back for some years.” He added: “I don’t know if we’ll ever get it back.”
  • New Yorkers don’t deserve such defeatism. Owners have invested their savings and decades of their lives to build these businesses. People with secure government jobs and paychecks don’t get that.
  • Small businesses are generally cash-strapped. On average, they can ride out two months’ worth of expenses, according to the Harvard Business Review. The shutdown in New York began March 22. Thus, when Cuomo and de Blasio moved the goal posts to sometime in June, they doomed many businesses to die.
  • The new federal Paycheck Protection Program provides eight weeks’ of funding for small businesses to pay employees and meet other overhead expenses. Again, not indefinite help. And only 20% of New York’s small businesses qualified for the PPP loans to begin with, according to the New York Federal Reserve.
  • Looking at the benchmarks Cuomo says a region must meet before reopening, Nassau County Executive Laura Curran estimates that Long Island will meet them at the end of June — too late for many businesses. “My concern,” she admits, “is our economy is not going to be able to hang on.”
  • Across the nation, small businesses are hanging on by a thread. Some are fighting back. In Castle Rock, Colo., a breakfast restaurant opened up for Mother’s Day brunch; 500 people showed up. The owners said they did it to bring in cash — but also to make a statement about freedom. The state shut them down again.
  • Here on the Upper East Side, Eliot Rabin defiantly opened his tiny tailor’s shop, with masks and hand sanitizer on hand for customers. People are smart enough to decide for themselves whether or not to go shopping.
  • In Pennsylvania, Michigan, Wisconsin and Louisiana, GOP state lawmakers are challenging lockdowns, warning that businesses and neighborhoods are on the brink of destruction. But in New York, a one-party state, there is no political voice challenging Cuomo’s shutdown.
  • Same is true in California, another one-party state. But there, Elon Musk reopened his manufacturing plant, in defiance of health officials, and announced plans to relocate to Texas or Nevada to avoid further hassles. Democratic state lawmaker Lorena Gonzalez said “F - - k Elon Musk.” Doesn’t she understand who is really getting screwed? Tesla is California’s largest manufacturing employer.
  • As for New York City, some 830,000 people have filed for unemployment since businesses were forced to close.
  • Cuomo claims “nobody wants to get the economy going more than me.” But he adds: “When you start to open business … you’re going to see more infections. You see that infection rate rise, and then you’re going to be back to where we were.”
  • Wrong, Governor. The shutdown was never intended to make the virus disappear. It bought us time to prepare hospitals with beds, ventilators and supplies. Some experts warn more capacity may be needed if the virus resurges. If so, let’s build that capacity now and keep our field hospitals ready.
  • Our businesses and neighborhoods are on the brink of disappearing. New York officials need to reopen the economy, with reasonable safety precautions.

Source:  Why an added month of lockdown will devastate New York small businesses

I. Lockdowns vs. Reopenings

1. It’s Time To End the Lockdowns   

  • Dr. Steven Shapiro, the chief medical officer of Pennsylvania’s huge and powerful UPMC medical system, is calling for an end to the lockdowns.
  • As we prepared for the pandemic, we radically transformed our hospital operations to create a safe environment for patients and staff, we delayed non-urgent surgery, reducing it by 70%, and we scaled up telemedicine 38-fold, performing 250,000 visits in April.
  • We saw a steady stream of patients but never “surged.” At the peak in mid-April, C19 patients occupied 2% of our 5,500 hospital beds and 48 of our 750 ventilators. Subsequently, admissions have been decreasing with very few patients now coming from the community, almost all now being from nursing homes. Of note, in the 36 UPMC-owned senior facilities we have had zero positive cases.
  • Our outcomes are similar to the state of Pennsylvania, where the median age of death from C19 is 84 years old. The few younger patients who died all had significant preexisting conditions. Very few children were infected and none died. Minorities in our communities fared equally as well as others, but we know that this is not the case nationally. In sum, this is a disease of the elderly, sick, and poor. 
  • We are now actively bringing back our patients for essential care following CMS guidelines. To assure a safe environment, we use adequate PPE and test all, even asymptomatic, preoperative patients for active viral infection with PCR. To date, 0 out of 1,000 tested positive in western Pennsylvania, New York and Maryland. 3 of 500 are positive in central Pennsylvania. Our community prevalence is low, which we will soon confirm with antibody testing.
  • Of course, we still need effective prevention and therapy. The scientific community has never worked so rapidly or collaboratively. UPMC and Pitt, home of Jonas Salk, has been in the thick of it. Intense efforts are underway to find antibodies that bind to the virus and prevent it from entering cells. Crude antibody-rich convalescent plasma is already being administered to patients, while the development of highly effective synthetic antibodies and vaccines is moving at breakneck speed.
  • He acknowledged there is still a lot we don’t know, but emphasized it is time to open back up:
  • The question before us is what will happen as we re-open society and how should we manage it?  For New York and a handful of other cities with high case rates as a result of density, travel and socioeconomic issues, they must open up in a measured step-wise manner with extensive testing, tracing and treatment.
  • But for the rest of the country, as people come out of their homes cautiously and safely, if we protect our vulnerable seniors, particularly those in nursing homes, we should be able keep case rates low, buying time for a potential resurgence as we bolster our supply chain and find effective intervention.
  • C19 is a disease that ravages those with preexisting conditions – whether it be immunosenescence of aging or the social determinants of health. We can manage society in the presence of this pathogen if we focus on these preexisting conditions.
  • What we cannot do, is extended social isolation. Humans are social beings, and we are already seeing the adverse mental health consequences of loneliness, and that is before the much greater effects of economic devastation take hold on the human condition.

Source: Dr. Steven Shapiro, head of huge, powerful UPMC, said it’s time to end the lockdowns

2. Some countries reimpose lockdowns  

  • As many parts of the world, including the United States, explore ways to ease lockdowns aimed at containing the spread of the coronavirus, countries that had already opened up are closing down again after renewed spikes in infections.
  • A resurgence of cases had been widely predicted by experts, but these increasing numbers come as a sobering reminder of the challenges ahead as countries chafing under the social and economic burdens of keeping their citizens indoors weigh the pros and cons of allowing people to move around again.
  • Lebanon on Tuesday became the latest country to reimpose restrictions after experiencing a surge of infections, almost exactly two weeks after it appeared to have contained the spread of the virus and began easing up. Authorities ordered a four-day, near-complete lockdown to allow officials time to assess the rise in numbers.
  • The reemergence of coronavirus cases in many parts of Asia is also prompting a return to closures in places that had claimed success in battling the disease or appeared to have eradicated it altogether, including South Korea, regarded as one of the continent’s top success stories.
  • South Korea last week rescinded a go-ahead for bars and clubs to reopen after a spike in cases, hours after officials announced the lifting of previous social distancing restrictions and the start of a “new everyday life with the coronavirus.”
  • South Korean President Moon Jae-in warned his country Sunday to “brace for the pandemic’s second wave,” calling the battle against covid-19 a “prolonged” war.
  • In the Chinese city of Wuhan, where the pandemic first emerged, authorities on Tuesday ordered the testing of all 11 million inhabitants after a cluster of six new infections emerged, five weeks after the city had apparently rid itself of the disease.
  • Germany, which is widely regarded as the model in Europe of a balanced coronavirus response, is warning that some areas may have to reinstate restrictions after localized outbreaks caused a rise in cases.
  • “We always have to be aware that we are still at the beginning of the pandemic,” German Chancellor Angela Merkel cautioned last week as a cluster of new cases in a meatpacking plant raised fears of an intensified outbreak. “And there’s still a long way in dealing with this virus in front of us.”
  • Some countries are going ahead with plans to lift restrictions despite evidence that cases are on the rise and the disease is far from being contained. India and Russia eased their restrictions on Tuesday even as the number of infections in both countries continued to soar. France experienced a spike on Monday, the same day that the country eased its lockdowns, with 263 new cases reported, compared to 70 the previous day.
  • Iran, the epicenter of the disease in the Middle East, with more than 110,000 reported cases, has ordered a county in the southwestern province of Khuzestan to reimpose a lockdown after cases spiked there. But the government is still planning to proceed with the reopening of schools later this week, despite a marked jump in new infections since restrictions were eased in late April.
  • The new spikes underscore the question of when – or whether – it will ever be safe for coronavirus-stricken countries to lift their lockdowns.
  • The latest cluster in Wuhan demonstrates how hard it will be to measure whether any location is truly free of coronavirus. The new cases there suggest the coronavirus can flare up in patients up to 50 days after they have apparently recovered, said Wu Zunyou, chief epidemiologist at the Chinese Center for Disease Control and Prevention, in an interview with state broadcaster CCTV.  
  • “The course of disease could last 30 to 50 days for some patients,” Wu said. “The virus could take longer to manifest itself in patients with weak immunity, who are also prone to ‘ons’ and ‘offs’ of symptoms.”
  • He sought to reassure citizens that the new cases did not represent a new wave of the pandemic.
  • “There will not be a new minor peak,” Wu said. “We have had the epidemic under control after more than three months of efforts and accumulated considerable experience in both diagnosis and [epidemic] notification. Therefore, we will not allow scattered cases to develop into massive outbreaks.”
  • Firass Abiad, who oversees coronavirus efforts at the Rafik Hariri University Hospital in Beirut, Lebanon’s main government hospital, said a country’s success will depend less on how it curtails the spread of disease during a lockdown than on how the country manages the inevitable resurgence after lockdowns end.
  • “A lockdown is a means and not an end,” he said. “It’s a means either to allow you to regain control or put measures in place to control coronavirus when it comes back. When we eased the lockdown, we knew there would be an increase in the number of cases.”
  • Lebanese government officials said the lockdown was being reimposed for four days starting at midnight on Wednesday to allow the authorities time to conduct contact tracing and isolation for several new clusters that have broken out in different parts of the country. They represent 104 cases in the past four days, a big jump in a small country after infections had stabilized at the rate of one or two new cases a day.
  • Most are linked to some of the thousands of Lebanese who have been repatriated in recent weeks from around the world, said Souha Kanj, who heads the infectious diseases department at the American University of Beirut.
  • All the returnees are tested for C19 and required to quarantine for two weeks even if they are negative. But some have not been adhering to the requirement, she said, citing the case of a man who returned from Nigeria and then held a party for his relatives, infecting at least 10 of them. One was a member of the security forces, who has in turn infected a dozen or so of his colleagues.
  • There may also be cases of renewed local transmission, perhaps stemming from people who were asymptomatic but have been silently spreading the disease, said Abiad. Lebanese released from nearly six weeks of lockdown last month have surged onto the streets, openly defying some of the continued restrictions and social distancing rules that remain in force.
  • Similar scenes have occurred in other countries that are ending closures. Crowds of Parisians gathered on the banks of the Seine River to toast their release on Monday from six weeks of one of the world’s toughest confinements, prompting police on Tuesday to ban the consumption of alcohol in the vicinity of the river.
  • “In any country where people don’t adhere to social distancing this is going to happen. You are going to have a surge in cases for sure,” said Kanj.

Source: Some countries reimpose lockdowns

J. Lessons from the Spanish Flu

1. When Mask-Wearing Rules in the 1918 Pandemic Faced Resistance 

  • The influenza pandemic of 1918 and 1919 was the most deadly flu outbreak in history, killing up to 50 million people worldwide. In the United States, where it ultimately killed around 675,000 people, local governments rolled out initiatives to try to stop its spread. These varied by region, and included closing schools and places of public amusement, enforcing “no-spitting” ordinances, encouraging people to use handkerchiefs or disposable tissues and requiring people to wear masks in public.
  • Mask-wearing ordinances mainly popped up in the western states, and it appears most people complied with them. The nation was still fighting in World War I, and officials framed anti-flu measures as a way to protect the troops from the deadly outbreak.
  • The first recorded infection was in a U.S. Army private stationed at Fort Riley, Kansas on March 4, 1918. Although the United States and the other nations at war initially suppressed news of the flu (neutral Spain freely reported it, hence the misnomer “Spanish flu”), there was a sense that following these new health precautions was patriotic.
  • As one Red Cross PSA put it, “the man or woman or child who will not wear a mask now is a dangerous slacker.” This sense of wartime duty—and the fear of being seen as a “slacker”—may have motivated those who complied with mask orders in cities like San Francisco, Seattle, Denver and Phoenix.
  • Yet even though compliance was high, some complained that the masks were uncomfortable, ineffective or bad for business. Officials were caught in public without masks. And after the war ended, and there was no longer a sense that people should wear masks to keep the troops safe, some dissenters even formed an “Anti-Mask League” in San Francisco.
  • In 1918, advanced masks like the N95s that healthcare workers use today were a long way off. Surgical masks were made of gauze, and many people’s flu masks were made of gauze too. Red Cross volunteers made and distributed many of these, and newspapers carried instructions for those who may want to make a mask for themselves or donate some to the troops. Still, not everyone used the standard surgical design or material.
  • “To entice people to get them to wear them, [cities] were pretty lax in terms of what people could wear,” says J. Alex Navarro, assistant director of the Center for the History of Medicine at the University of Michigan and one of the editors-in-chief of The American Influenza Epidemic of 1918-1919: A Digital Encyclopedia.
  • In October 1918, the Seattle Daily Times carried the headline “Influenza Veils Set New Fashion: Seattle Women Wearing Fine Mesh With Chiffon Border to Ward Off Malady.” These “fashionable” masks and others made from dubious material probably weren’t helping much. Yet there was also debate within the medical and scientific community about whether multiple-ply gauze masks were effective either.
  • For instance, Detroit health commissioner J.W. Inches said gauze masks were too porous to prevent the spread of the flu among the public. Also, masks are most effective when worn properly, which wasn’t always what happened. In Phoenix, where most people apparently complied with the city’s mask order, some nonetheless poked holes in their masks to smoke—which greatly reduced their effectiveness.
‘Mask Slackers’ Faced Enforcement, Punishment 
  • Still, for the small percentage of people who went without a mask entirely, reports suggest their issue had less to do with the science behind them, and more to do with personal comfort.
  • “You read routinely about people not wanting to wear them because they’re hot and stuffy,” says Nancy Bristow, chair of the history department at the University of Puget Sound and author of American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic. “Some people argue against them because they say that they create fear in the public, and that we want to keep people calm; which I think is really an excuse to critique them because someone doesn’t want to wear them.”
  • Some businesses worried customers would shop less if they had to wear a mask when they went outside, and some people claimed mask ordinances were an infringement upon civil liberties. Yet “more important in terms of critiques,” Bristow says, “is this idea that we’ve heard today as well that they give people a false sense of security.” As she points out, wearing a mask is less effective when people don’t follow other health guidelines too (and especially if some are poking holes in their masks to smoke).
  • Cities that passed masking ordinances in the fall of 1918 struggled to enforce them among the small portion of people who rebelled. Common punishments were fines, prison sentences and having your name printed in the paper. In one horrific incident in San Francisco, a special officer for the board of health shot a man who refused to wear a mask as well as two bystanders.
  • This was far different from the treatment San Francisco’s leaders received when they didn’t comply. At a boxing match, a police photographer captured images of several supervisors, a congressman, a justice, a Navy rear-admiral, the city’s health officer and even the mayor, all without masks. The health officer paid a $5 fine and the mayor later paid a $50 fine, but unlike other “mask slackers,” they received no prison time (not to mention no one shot at them).
Mask-Wearing Declines After the War
  • San Francisco’s first masking order began in October and ended in November after the World War I armistice. In January, when flu cases began to surge again in San Francisco, the city implemented a second mask order. This time, the resistance was much more intense. A group of dissenters that included a few physicians and one member of the Board of Supervisors formed the “Anti-Mask League,” which held a public meeting with over 2,000 attendees.
  • Navarro speculates the resistance to San Francisco’s second mask order may have been more intense because the country was no longer at war, and some residents didn’t feel the same sense of patriotic duty they had before. In any case, the city was an outlier. It doesn’t appear that there were similar leagues or protests in other cities.
  • Nancy Tomes, a distinguished professor of history at Stony Brook University who has written about public health measures during the 1918-1919 flu pandemic says while there were pockets of resistance to mask-wearing in 1918 and 1919, it was not widespread.
  • And, unlike handkerchiefs and paper tissues, which Tomes says people began to use more regularly because of the pandemic, mask-wearing did not catch on in the United States after the ordinances ended. It’s still difficult to say how effective mask-wearing on its own was in 1918 and 1919. What is clear is that communities that implemented stronger health measures overall fared better than those that didn’t.
  • “Today we can look back and see that they flattened the curve and the communities that did enforce much stricter regulations and for a longer period of time and began earlier had lower death rates,” Bristow says. “But they didn’t have that data tabulated yet, so I think in the aftermath it wasn’t as clear that what they had done had been effective.”

Source: When Mask-Wearing Rules in the 1918 Pandemic Faced Resistance

K. Should C19 Vaccines Be Mandatory?

1. To put C19 behind us, all Americans should be vaccinated against it  

By Lauren S. Grossman, a physician, assistant professor of emergency medicine at the University of Colorado School of Medicine

  • My work as an emergency medicine physician has taken me to urban and rural areas on both coasts and in the middle of the country. No matter where I see patients, I hear excuses like these for not getting immunized against influenza:
    • “Flu shots don’t work.”
    • “I got the vaccination once and it made me sick.”
    • “We don’t believe in vaccination.”
    • “Vaccination is dangerous.”
  • It puzzles me, then, that they’ve come to the emergency department because they are feeling awful with fever, chills, cough, body aches, and fatigue — in other words, with the flu — expecting a fix for something that could have been easily prevented.
  • Indeed, 43% of Americans forgo getting vaccinated against influenza. That doesn’t bode well for the highly anticipated vaccine against coronavirus, something that President Donald Trump has said we might have by the end of the year, though others say it will take longer.
  • To achieve herd immunity, which makes it more difficult for an infectious disease to spread through a population, 80% or more of us need to be immune to C19, either because we’ve been infected with the virus that causes it or we’ve gotten the vaccine against it.
  • I fear that many Americans will resist getting vaccinated against the coronavirus even after having been bombarded by news reports of the number of cases and the number of deaths, or having seen images of refrigerated trucks in New York City storing the bodies of people who died of C19.
  • To put this scourge behind us, I believe that our nation should, for the first time ever, require all Americans — or at least schoolchildren and workers in direct-contact jobs — to be vaccinated against this coronavirus.
  • Scientists are moving at “Warp Speed” to develop a coronavirus vaccine. Researchers at the University of Oxford intend to try one on 6,000 people by the end of May. The NIH has created a partnership with 16 pharmaceutical companies to speed vaccine development.
  • That means we need to develop vaccination policies and programs now, since they will take time to enact.

Here’s what I think we should do:

  • Create a federally mandated vaccination policy. No federal laws require vaccination, and states have a smorgasbord of policies. 
  • A 1905 Supreme Court decision established the constitutionality of compulsory state vaccination laws to protect the public health. Although all 50 states and the District of Columbia now require diphtheria, tetanus, pertussis, polio, measles, rubella, and varicella vaccinations before attending public school, all also offer a variety of vaccine exemptions for medical, religious, and philosophical reasons. Only 11 states can override these exemptions in an outbreak. Court decisions, including from the Supreme Court, have upheld both state-imposed fines for refusing to be vaccinated and the exclusion of unvaccinated children from schools.
  • Because people often travel across state lines, we need a unified national approach, perhaps something like the military’s Army Medicine 2020 initiative, which requires vaccination but also allows for rigorously controlled exemptions that are medical (such as pregnancy), religious (in consultation with a chaplain), and administrative (such as plans to leave the military).
  • Test, test, test. The only way that individuals should be allowed not to get the vaccine against coronavirus is to prove they’ve been infected with it. Testing for the presence of the virus, the antibodies to it, or both, will need to be proven, accurate, and available to everyone.
  • Make influenza and coronavirus vaccinations mandatory for public school children. Only five states — New York, California, Maine, Mississippi, and West Virginia — have eliminated religious and philosophical vaccination exemptions for children entering public kindergarten. This applies to the standard childhood immunizations only and does not include influenza. In fact, only one state, Connecticut, requires influenza vaccination for public school attendance. Only a few states require flu vaccination for day care and pre-K attendance. While I respect individual health care choices and acknowledge that some citizens will not avail themselves of the protection afforded by a vaccine, the enormity of the C19 pandemic demands that the welfare of the community take precedence and all children be vaccinated against the virus that causes this disease.
  • Require vaccination for workers in direct-contact jobs. Health care workers are the only adults in the U.S. required either by state law or individual employers to be vaccinated against the flu, though they can file an exemption and instead wear a mask at work from October through March. (For coronavirus, that might mean wearing one year-round.) Requiring immunization for a broader range of people with direct-contact jobs, like those working in restaurants and food stores, flight attendants, hair stylists and barbers, nail salon workers, teachers, and others, would decrease the spread of infection and the resulting hospitalizations and deaths.
  • This is especially important for the coronavirus because it has a higher viral load in the nose, mouth and throat, making transmission more likely via a simple conversation or a sneeze. In one recent study, 71% of individuals who tested positive for C19 but who had no symptoms had detectable levels of the coronavirus up to six days before becoming ill.
  • Make the vaccine easier to get.  One key to widespread uptake of vaccination against the coronavirus is making it as easy as possible for people to get it, like buying groceries or filling up a gas tank. Here are a few ways to do that:
    • Combine the coronavirus vaccine with another one (like influenza) and package them in a form that patients can take on their own.
    • Allow it to be administered to individuals with low-grade symptoms. Tetanus immunization has been wildly successful in part because we administer the vaccination when someone is being seen for a wound, not weeks later when it has healed.
    • Make coronavirus vaccination available in all health care facilities, physicians’ offices (no matter what the specialty), local health departments, and emergency or urgent care facilities. Make it clear that any physician or advanced practice provider can administer a vaccine.
    • Offer vaccinations in workplaces, schools, pharmacies, and community organizations. That could mean visits from mobile teams (perhaps run by medical school students as part of their public health training) to provide immunizations.
  • Make vaccinations inexpensive. Instead of costing as much as $70, the price tag for a high-dose influenza vaccination for seniors, the cost of a coronavirus vaccine should be affordable for all. Stores like Walmart, with its $4 medication list, could add immunizations and offer them as people come in to pick up their prescriptions.
  • To add one more incentive, health insurers should require either a test result showing immunity to influenza and coronavirus or proof of vaccination in exchange for full coverage. We all pay for those who eschew prevention but who then seek medical care when they become ill.
  • Finally, we should do a better job of teaching kids about the value of vaccination so they can make good choices. Misinformation is the enemy of good public health.
  • We can’t afford another pandemic with millions sick or dying, a health care system stretched beyond its limits, and a devastated economy. Immunization for all is a simple way to prevent that from happening.

[Note:  Of course, there is a risk that adverse health effects may result from taking any vaccine.  But, given the speed with which vaccines are being developed for the coronavirus, a vaccine for coronavirus will arguably have greater risk than other vaccines, which are tested for many years before being given to the public.  As Dr. Grossman can’t guaranty a coronavirus vaccine won’t have an adverse effect on anyone’s health, it is striking if not breathtaking that he (or anyone) would assert the right to force everyone to take a vaccine, including those that have little risk of becoming seriously ill from C19 (which includes children, who are at very low risk).  Forcing someone to take a vaccine to protect others seems manifestly unfair when anyone that wants protection is free to take the vaccine.]

Source: When a Covid-19 vaccine is available, all Americans should get it? 

L. Up to 70% of NY Restaurants Estimated to Fail – What Will Replace Them?

1. Eating out—NY’s favorite pastime—will return, but it’s unclear what restaurants will look like in the future  

  • The C19 lockdown gravely threatens New York City’s vast and indispensable restaurant industry. But while some of our 26,000 eateries won’t return, and some owners face economic ruin, it by no means follows that we’ll be left with nowhere to eat—or that new places will be inferior to old ones.
  • No other business is as tightly woven into the urban fabric as restaurants. Forced closures cost 370,000 workers their livelihoods, the city tax revenue of $750 million, and residents a defining pleasure of New York life. Unlike sports or live entertainment, restaurant meals can’t be experienced in diminished form on TV or on YouTube. Restaurants have nourished our social and business lives since the Swiss-born Delmonico brothers brought New York City its first full-fledged oyster and chop house in 1837. New York’s restaurant scene prior to March 20, 2020, was more diverse, creative, and festive than it had ever been.
  • But kiss the fun goodbye, claim revered master chefs David Chang and Tom Colicchio. Colicchio estimates that 70% of NY restaurants won’t reopen. The federal Paycheck Protection Program bill—meant to aid “small” businesses through forgivable loans—didn’t help many small or midsize restaurants. Ambiguous application rules ended up favoring large chains with thousands of employees such as Shake Shack and Ruth’s Chris (which were since shamed into returning the money). To small owners’ further chagrin, the loans had to cover payroll for eight weeks following approval— impossible for places that were entirely closed for the foreseeable future, unlike for larger companies with functioning back offices.
  • There’s no minimizing what damage the pandemic will do before it’s contained. While the financially strong empires of Danny Meyer, Daniel Boulud, and Stephen Starr will come through this, smaller operators who lost their businesses through no fault of their own face possible ruin. Among them is Gabriel Stulman, proprietor of downtown gastropub Joseph Leonard and other popular, previously profitable spots, whose landlords are threatening to hold him personally liable for full payment of leases with years left to run.
  • Even if owners can scramble up fresh capital to take the reopening plunge, government decree might reduce seating to 50 percent of capacity, or less. That would be a death sentence for a business with paper-thin, 10 percent profit margins, which even slight intrusions—like a scaffold erected over the entrance—can easily erode. Owners of the 60-seat Mermaid Inn on Tenth Avenue and the 350-seat Bond 45 in the theater district are strategizing and sweating alike. Fewer seats mean much less revenue, with no corresponding reduction in rent. Le Bernardin chef and co-owner Eric Ripert says that his three-Michelin-star seafood temple could survive for only a few months with 50 rather than 150 seats.
  • The C19 undertow will surely sink some popular places. Most at risk are jumbos, where the nightly mob scene is part of the draw. They include the Tao Group’s 350-plus-seaters, like Tao and Cathedrale, and One Group’s STK steakhouses. Shrinking their seating while still making money will be a challenge, especially since many customers go there precisely for the dubious thrill of jam-packed human bodies. Yet owners of only slightly smaller establishments such as Carmine’s and Bond 45 are already formulating with chefs, lawyers, accountants, and architects how to downsize and stay afloat.
  • A hint of what could be in store comes from Shanghai. A manager of high-end restaurants at that city’s Three on the Bund complex, including one by the renowned chef Jean-Georges Vongerichten, describes an austere, almost clinical environment since a cautious reopening in February. Guests get their temperatures taken at the door. A government snooping app charts where they’ve been in recent weeks; those whose movements raise alarms are barred. Patrons can remove their masks at tables—now 50% fewer than before—but must put them back on for restroom runs. Customers scan menus via iPhone apps.
  • Business was a mere 5% to 10% of the previous norm at first but has slowly climbed upward, to 40%. It will surely rise over time. The example might be inapplicable at New York restaurants, which will emphasize safety but without a martial atmosphere. Worst-case scenarios ignore the human factor of pent-up demand. People are already ignoring social-distancing rules to mingle on beaches and in parks. Cruise ship bookings are reportedly strong for 2021 despite shipboard coronavirus outbreaks. For how long might New Yorkers shun their favorite places to eat?
  • A more plausible threat lies in the loss of private-room dining business, which accounts for up to 40% of profit at some larger venues. Will families and businesses again spend big on celebrations amid a recession, and so soon after horrendous loss of life?
  • So many perils and unknowns in combination might seem unsurmountable. But previous crises were regarded as mortal blows, too. The aftermath of 9/11, the 2008 financial crash, and even the 2002 smoking ban were all cited as restaurant-industry killers. Every closure of a bagel shop gets blamed on the recent statewide minimum-wage increase. And of course, the city’s high rents are always poised to wipe out middle-market and mom-and-pop eateries entirely. Yet, somehow, more restaurants operate than ever, as is evident to any New Yorker out for a stroll.
  • A toned-down dining scene to supplant its overheated predecessor might be a welcome course change. Many New Yorkers were fed up with raucous, uncomfortable, and overcrowded restaurants, but they had little choice. Our dining rooms are louder and more densely packed than in Los Angeles, London, or Tel Aviv, all great eating towns but without half the tumult to which New Yorkers are inured. Many of us won’t miss restaurant bars, where no-reservations policies generated a sardine-can crush of patrons waiting for tables.
  • The new dining age will dawn tremulously. There will be failures. It will change and grow unpredictably over time. But landlords desperate to fill vacant storefronts will offer lower rents to restaurateurs and retailers. Owners will return, and so will sidelined chefs, who right now wish they’d chosen different careers. New venues will replace the old. And New Yorkers’ insatiable desire to eat, drink, and make merry outside cramped apartments will carry the day.

Source: Restaurants in New York Post Coronavirus

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