“We have to get your governor of Pennsylvania to start opening up a little bit.”President Trump
Many people are saying they can’t go on living off their credit line, skipping meals and waiting in lines for food.”Lebanon County Chairman Bob Phillips(PA)
“I don’t have an income due to the extended shutdown orders and it is time to allow Americans to make adult decisions about going back to work.”Reopen Minnesota Protestor
“The fact of the matter is, these protests — in a perverse way — make it likelier that we are going to have to stay in a stay-at-home posture.”Michigan Governor Whitmer
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- Recent Developments and Headlines
- Numbers and Trends
- Potential Treatments
- Concerns & Unknowns
- New Scientific Findings & Research
- Collateral Damage
- Projections & Our (Possible) Future
- Rise of the Anti-Vaxxers
- The Road Back?
- Can the Numbers Be Trusted?
- John Hopkins Daily COVID-19 Update (see Annex I)
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
- Trump Admin. to Extend Border Restrictions Until Coronavirus No Longer Poses a ‘Danger’
- Large parts of Central and Northern NY will open on Friday
- Michigan medical groups sue Gov. Gretchen Whitmer over ‘drastic’ and ‘unconstitutional’ coronavirus lockdown
- President Trump to tap former pharma exec for ‘Operation Warp Speed,’ wants military to distribute coronavirus vaccine by end of the year
- President Trump says Fauci’s cautious stance on reopening schools is ‘not an acceptable answer’
- The CIA believes Chinese officials threatened the WHO to keep the truth about COVID-19 dangers secret. Meanwhile, they stockpiled medical supplies.
- Reopenings are clouded by a potentially dangerous blend of partisan politics and confused health guidance
- Texas Sees Record Jump In COVID-19 Deaths 2 Weeks Into Reopening
- Trump Plans to Add One Billion N-95 Masks to National Stockpile
- Poll: 40% of Families More Likely to Homeschool When Pandemic Ends
- DeSantis Grants Miami-Dade, Broward Counties’ Request to Reopen
- Going Rogue: PA County Charges Ahead to Reopen in Fiery Letter to Governor
- Pennsylvania State Lawmaker Blasts Governor’s ‘Draconian’ Lockdown
- Delaware Senate Candidate Witzke: Defy State’s ‘Political Control,’ Come Worship on Sunday
- Politico: Ron DeSantis Was ‘More Right’ About Coronavirus; Victim of Media Bias
- CDC issues re-opening guidelines to help schools and workplaces determine whether they are ready to open for business.
- Jersey Shore Reopening in Time for Memorial Day Weekend
- Coronavirus Has Hurt 90% of Small Businesses in the U.S.
- Reopen Minnesota Protester: I Don’t Have Income Right Now
- Three PA Counties Weigh Reopening Friday Despite Governor’s Threats
- Fresno County Sheriff Won’t Enforce Stay-at-Home Orders — Too Busy Re-arresting Freed Criminals!
- Trump Says Mobilizing Military to Distribute Future Vaccine
- NY investigating 110 cases of mysterious pediatric respiratory illness
- NIH launches study of hydroxychloroquine and Z-Pak
- New study sheds light on how loud talks can spread virus
- German new infections hit 5-day high
- Trump praises Wisconsin Supreme Court decision
- Trump: ‘I wonder what would happen if we cut ties with China?’
- Maryland to start reopening Friday
- French government ‘incensed’ by Sanofi offer to give vaccine to US first
- Singapore reports another 750+ cases
- Japan starts using remdesivir on COVID-19 patients
- Burundi latest African country to boot WHO
- UK minister defends timing of nursing home lockdown
- Spain sees ‘center’ of outbreak shift from area surrounding Madrid to Catalonia
- Restaurants Betting On Vaccine To Reopen Will Be Disappointed
- Life After Lockdown – Get Ready For “Social Bubbles”
- Lockdown-Defying Speakeasies Cropping Up Across Manhattan
- Mexico Is Cremating Bodies On An “Industrial Scale”
- Free COVID Testing For Ultra Rich At This Miami Condo High Rise
- “These Threats Will Not Be Taken Lightly”: States Mull Crackdown On Intentional Corona Spreaders
- Tyson Foods Slashes Meat Prices To “Keep Beef On Family Tables”
- China: Federalism, Lack of ‘National Tracking’ Mean U.S. Cannot Defeat Coronavirus
- Report: NYC Health Head Turns Down NYPD’s Urgent Mask Request
- Coronavirus Takes Toll as Delta Grounds Fleet of 777 Jumbo Jets
- Homeless Removed from NYC Subways Lie Inches Apart in Shelter
- Disney World Sets May 20th Reopening Replete with Masks, Temperature Checks, Plexiglass Dividers
- WVU President Says College Football Will Happen, Even if He Has to Play
- Pretty Much a Done Deal: Fox Will Use Fake Crowd Noise, Virtual Fans for NFL Games
- Florida Gov. Ron DeSantis Sees 1/7 of NY’s Nursing Home Deaths After Banning Coronavirus Patients’ Entry
- Poll: Economic Downturn Drives Fears of Having Enough to Eat
- Uber to Require Masks for Drivers, Riders
- Work from Home Boom Leads to ‘Tattleware’ Surveillance by Employers
- New York barber who cut hair ‘the last few weeks’ tests positive for coronavirus
- Chicago’s Cook County has surpassed Queens as the county with the most reported coronavirus cases in the United States
- CDC warns of Kawasaki-like condition linked to coronavirus in children
- Trump’s Mar-a-Lago club to partially reopen — with social distancing in the Jacuzzi
- The trikini: When you want to be sexy at the beach, but also don’t want coronavirus
- NYSE aims to partially reopen iconic trading floor on May 26
- Argentinian woman faces jail for throwing ‘riotous’ kids birthday in lockdown
- Nearly 1 in 3 Americans planning a road trip this summer, as low gas prices outweigh coronavirus fears
- Restaurant slammed for ‘COVID-19 surcharge’ on meal
- Leaked data suggests China may have 640K coronavirus cases — not 80K
- South African food aid draws thousands for second time in two weeks
- More people opting to go naked during quarantine
- De Blasio says NYC coronavirus indicators show it’s ‘a perfect day’
- N. Carolina sheriff says he won’t enforce social distancing for churchgoers
- ‘I’d rather die of corona’: Barstool Sports founder unloads over lockdowns
- Patients at Louisiana mental hospital sue to be released due to coronavirus
- ‘Pub-on-wheels’ in London is pulling pints on people’s doorsteps
- 37% of coronavirus patients at NYC hospitals had kidney failure
- Iceland reopening for tourists — free coronavirus tests included
- Doctors Without Borders sends team to US to help Navajo Nation fight coronavirus
- Wisconsin bars packed after court blocks coronavirus shutdown order
- Washington state restaurants must log all dine-in customers to reopen
- ‘No one can leave’: Domestic violence calls increase amid stay-at-home orders
- California county gives the all-clear for Tesla plant to ‘possibly reopen’ — even though it already has
- Disease expert: I caught coronavirus after traveling on packed plane
- New Zealand drops stringent coronavirus restrictions, starts reopening
- UN chief warns psychological suffering from coronavirus is growing
- Restaurant in Thailand seats stuffed pandas to enforce social distancing
- Factory makes coronavirus hospital beds that can be turned into coffins
- Tesla workers: We’re being pressured to return to production line
- Men less likely to wear face masks because they’re ‘not cool’ and ‘a sign of weakness’
- Coronavirus pandemic may actually be bringing families together: Devine
B. Numbers & Trends
Note: All changes noted in this Update are since the 5/14 Update
1. Confirmed Total Cases, New Cases and Tests
- Total Cases = 4,521,989 (+2.2%)
- New Cases = 96,332 (+9.4%) (+8,820)
- New Cases (5 day avg) = 84,870 (+1.8%) (+1,467)
- Total Cases = 1,457,593 (+1.9%)
- New Cases = 27,245 (+25.5%) (+5,533)
- New Cases (5 day avg) = 22,057 (+1.6%) (+344)
- Number of Tests = 10,638,893 (+368,897)
- Worldwide Deaths = 303,082 (+1.8%)
- New Deaths = 5,317 (+0.1%) (+3)
- New Deaths (5 day avg) = 4,572 (+4.9%) (+214)
- US Deaths = 86,912 (+2.0%)
- New Deaths = 1,715 (-3.2%) (+57)
- New Deaths (5 day avg) = 1,375 (1.3%) (+16)
- 5 Countries with Largest Number of Confirmed Deaths:
|Country||Total Deaths||Deaths Per 1M Population|
|US||86,912 (+1,715)||263 (+6)|
|UK||33,614 (+428)||495 (+6)|
|Italy||31,368 (+262)||519 (+5)|
|Spain||27,321 (+217)||584 (+4)|
|France||27,425 (+351)||420 (+5)|
- 5 Countries = 68.2% of Worldwide Total Confirmed Deaths (-0.2%)
- US = 28.7% of Worldwide Total Confirmed Deaths (+0.1%)
- 5 States with Largest Number of Confirmed Deaths:
|State||Total Deaths||Deaths Per 1M Population|
|New York||27,426 (+136)||1,410 (+7)|
|New Jersey||9,946 (+219)||1,120 (+25)|
|Massachusetts||5,482 (+167)||795 (+16)|
|Michigan||4,787 (+73)||479 (+7)|
|Pennsylvania||4,294 (+147)||335 (+9)|
|US||86,912 (+1,715)||263 (+6)|
- 5 States = 61.9% of US Total Confirmed Deaths (+1.8%)
- NY = 31.6% 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).
|State||Total Cases||Total Deaths||Deaths Per 1M Pop|
|Georgia||35,977 (+550)||1,544 (+27)||145 (+3)|
|Florida||43,210 (+808)||1,876 (+47)||87 (+2)|
|Texas||44,775 (+1,273)||1,258 (+41)||43 (+1)|
|Ohio||26,367 (+638)||1,537 (+52)||131 (+4)|
|Oklahoma||4,962 (+110)||284 (+6)||72 (+2)|
|US||1,457,593 (+27,246)||86,912 (+1,715)||263 (+6)|
- 5 States = 10.7% of US Total Confirmed Cases
- 5 States = 7.5% of US Total Confirmed Deaths
C. Potential Treatments
1. Convalescent Plasma Is Safe to Treat C19
- A study of thousands of C19 patients who received blood plasma transfusions from recovered patients indicates the experimental therapy appears to be safe, paving the way for future studies and clinical trials.
- A team of researchers at Mayo Clinic, Michigan State University and Johns Hopkins University examined health outcomes of 5,000 hospitalized patients around the U.S. who received convalescent plasma treatment, and found the transfusions resulted in few serious side effects and there wasn’t an excessive mortality rate.
- The study, posted Thursday on a public server called Medrxiv, hasn’t undergone peer review or publication in a scientific journal. Researchers found serious adverse events occurred in fewer than 1% of the treated patients, and the mortality rate seven days after transfusion was 14.9%.
- “The mortality rate does not appear excessive,” the researchers concluded, given the lethal nature of the novel coronavirus and the fact that two-thirds of the patients in the study were critically ill in intensive care units when they received the transfusions. The patients got the convalescent plasma as part of an expanded-access, or “compassionate use,” program overseen by the U.S. Food and Drug Administration.
- Researchers hope transfusions of antibody-rich plasma from recovered C19 patients can help neutralize the coronavirus in patients who are sick. Investigators cautioned that it isn’t possible to determine from this study if the plasma was the cause of improved health outcomes, because every patient received the plasma. Proving that a drug works involves comparisons with a group of similar patients who don’t receive the experimental therapy.
- The safety data is likely to bolster efforts to conduct more controlled clinical trials to test if convalescent plasma is an effective treatment for C19, the investigators said. The findings also could reassure clinicians who want to give convalescent plasma to patients as a stopgap measure until vaccines or more targeted therapies are developed.
- “The data are reassuring,” said Arturo Casadevall of Johns Hopkins University, one of the authors of the study. “Now we can focus on finding out if it is effective.”
- A separate study, this one involving 25 patients with severe or life-threatening C19 infections who received convalescent plasma transfusions, also was posted on the public server Wednesday. That study, at the Houston Methodist hospitals, found no adverse events associated with the therapy, and investigators indicated safety risks were comparable to what any seriously ill patient getting a transfusion would face.
- The Houston study reported the death of one patient who received plasma, but investigators don’t believe it was related to the transfusion. The patient was severely ill, and the transfusion was a last-ditch lifesaving effort, said James Musser of Houston Methodist Hospital, the senior author on the study. “We feel comfortable giving additional patients the transfusions,” he said.
- A concern about convalescent plasma therapy has been the potential for a serious side effect known as antibody-dependent enhancement, when transfused antibodies don’t neutralize a virus but rather make the infection worse. Investigators in both studies reported they observed no such effect in their convalescent plasma patients so far.
- John Roback, director of Emory University School of Medicine’s Center for Transfusion and Cellular Therapy, who wasn’t involved in the large national study, said its safety findings are encouraging. But controlled clinical trials are needed to evaluate the 14.9% mortality rate, he said. “The number may be lower or no worse than these patients would be expected to experience as a group. But you don’t know until you do the trials.”
- Still, the findings could encourage families of sick patients to request convalescent plasma. Programs now exist all over the country to collect convalescent plasma from recovered C19 patients.
- Moises Batista, age 61, received convalescent plasma as part of the compassionate-use program and says he is convinced the transfusions helped him. He said he started feeling sick after a double shift at his job as a correction officer at Sing Sing Correctional Facility in Ossining, N.Y. He had a fever and lost his sense of taste and smell; he spent more than a week at home in New York City, taking Tylenol and resting, but nothing helped. “I felt horrible. I was trembling,” he said.
- Mr. Batista’s 25-year-old son came to visit and was surprised to learn his father had not eaten in days. He called an ambulance. Mr. Batista was admitted to Mount Sinai Morningside “with obvious Covid,” according to John Puskas, chairman of cardiovascular surgery at Mount Sinai Morningside, who was on call the night Mr. Batista arrived.
- Dr. Puskas said they treated Mr. Batista with medicine including steroids, antibiotics and high doses of oxygen. “All those things together did not keep him from deteriorating,” he said.
- Mr. Batista didn’t immediately improve and spent a week in the intensive care unit. Nonetheless, Dr. Puskas said, after receiving the plasma, Mr. Batista “seemed convinced the minute he got it that he was going to do fine.”
- Now at home, Mr. Batista says he feels much improved, though he still has to catch his breath when he walks. Thinking back on all the things the doctors did to save his life, Mr. Batista said, “I think the convalescent plasma made a difference. It came from a person who beat the disease. When they gave it to me, I felt it would help.”
- Dr. Puskas said he can’t be sure how much Mr. Batista’s recovery was due to convalescent plasma versus “other therapies, his good attitude, his own immune response and other mechanisms independent of receiving another person’s plasma.”
- “The short answer to those important questions is, we don’t know,” Dr. Puskas said
D. Concerns & Unknowns
1. Study predicts COVID-19 burden among pregnant women
- A recent model estimated that more than 16,000 pregnant women delivering at hospitals in the United States in 2020 will have C19. The model also predicted there will be 52 C19-related maternal mortalities, according to research published in the American College of Obstetrics & Gynecology MFM.
- “We know that pregnancy alters the immune system and given the fact that the majority of American women deliver in a hospital setting, it creates a unique challenge in the fight against the novel coronavirus,” David N. Hackney, MD, director of maternal fetal medicine at UH Cleveland Medical Center, said in a press release.
- “The goal of our research is to best predict the impact of C19 on obstetric care in the United States in order to better prepare maternity units and caregivers,” he continued.
- Hackney and colleagues used a phenomenological model that had previously been used to predict the incidence of C19 in provinces in China. The model used case data reported by the CDC from Mar. 1, 2020 through Apr. 14, 2020 to forecast the daily incidence of C19 in the United States through Dec. 31, 2020.
- The researchers also implemented the Monte-Carlo simulation using data from studies on the prevalence of pregnancy-specific critical and severe cases of C19 among women aged 20 to 29 years and those aged 30 to 39 years.
- Hackney and colleagues forecasted 860,475 C19 cases in the general population from March through December 2020, with 16,601 cases occurring among pregnant women hospitalized for delivery (95% CI, 9,711-23,491). Among these hospitalized cases, the researchers predicted that 3,308 (95% CI, 1,755-4,861) will be severe and 681 (95% CI, 1,324-1,038) will be critical.
- The researchers also predicted there will be 52 (95% CI, 23-81) maternal mortalities during delivery hospitalization due to C19, yielding an overall mortality rate of 18.7 (95% CI, 18–19.5) maternal deaths per 100,000 live births in 2020, up from 17.4 maternal deaths per 100,000 live births in 2018.
- “To our knowledge this is the first study on the incidence of C19 in pregnancy,” Manesha Putra, MD, a fellow in maternal fetal medicine at UH Cleveland Medical Center, said in the release. “Despite its limitations, this study has the ability to guide resource allocation and better prepare hospitals and caregivers on the frontlines.”
2. Smoking Nearly Doubles the Rate of COVID-19 Progression
- Smoking significantly worsens C19, according to a new analysis by UC San Francisco of the association between smoking and progression of the infectious disease.
- In a meta-analysis of studies that included 11,590 COVID patients, researchers found that among people with the virus, the risk of disease progression in those who currently smoke or previously smoked was nearly double that of non-smokers. They also found that when the disease worsens, current or former smokers had more acute or critical conditions or death. Overall, smoking was associated with almost a doubling of the risk of disease progressing.
- The report was published May 12, 2020, in Nicotine & Tobacco Research.
- “Smoking is associated with substantially higher risk of C19 progression,” said Stanton A. Glantz, PhD, professor of medicine and director of the UCSF Center for Tobacco Control Research and Education. “This finding suggests that California’s ongoing strong tobacco control measures that have lowered smoking may, together with the state’s other strong public health interventions, be contributing to California’s efforts to thwart the effect of C19.”
- Smoking and e-cigarette use increase the risk and severity of pulmonary infections because of damage to upper airways and a decrease in pulmonary immune function in general, although these effects have not yet been studied for SARS-COV-2, the virus that causes C19. Smokers have a known higher risk of infection and mortality from MERS-COV, a viral respiratory illness caused by a different coronavirus.
- In the new meta-analysis, the authors identified 19 peer-reviewed scientific papers published in PubMed as of April 28, 2020, that included data on smoking behavior and severity of C19. The studies, from China, Korea and the United States, were mostly based on hospitalized patients, although two studies included both hospitalized patients and outpatients.
- Reviewed studies used a variety of definitions of “smoking,” sometimes including both current and former smokers. There was also variability in how disease “progression” was defined. In addition, the levels of smoking reporting were below the levels reported in the population.
- A total of 11,590 patients were ultimately identified for the study: 2,133 (18 percent) experienced disease progression, and 731 (6.3 percent) had a history of smoking. Among smokers, 218 patients (29.8 percent) experienced disease progression, compared with 17.6 percent of non-smoking patients.
- “The fact that smoking prevalence is lower among COVID patients than the general population has been cited as evidence for a protective effect of smoking,” said Roengrudee Patanavanich, MD, PhD, a visiting scholar at UCSF from the Department of Community Medicine at Ramathibodi Hospital at Mahidol University, Thailand. “But this low prevalence may actually be due to an under-assessment of smoking, especially when you consider the difficult conditions involved when caring for people in often overwhelmed health systems.”
- The authors note that limitations in the studies bias results toward underestimating the risks of smoking.
- All 19 studies were of patients who had already developed C19, so the risk estimate report does not represent the effect of smoking on the risk of contracting C19 in the general population. As population-level testing ramps up, the authors said it would be useful to collect data on smoking and e-cigarette use to determine what risks these behaviors impose on infection.
- They suggested that both smoking cessation and e-cigarette cessation, given the pulmonary effects of e-cigarette, be added to the list of practices to blunt the C19 pandemic.
3. Kidney injury seen in more than a third of hospitalized C19 patients
- Over a third of patients treated for C19 in a large New York medical system developed acute kidney injury, and nearly 15% required dialysis, U.S. researchers reported on Thursday.
- The study was conducted by a team at Northwell Health, the largest health provider in New York state.
- “We found in the first 5,449 patients admitted, 36.6% developed acute kidney injury,” said study co-author Dr. Kenar Jhaveri, associated chief of nephrology at Hofstra/Northwell in Great Neck, New York, whose findings were published in the journal Kidney International.
- Acute kidney injury occurs when the kidneys fail and become unable to filter out waste.
- Of those patients with kidney failure, 14.3% required dialysis, Jhaveri said in a phone interview.
- The study is the largest to date to look at kidney injury in C19 patients. It may be helpful, Jhaveri said, as other hospitals face new waves of patients with the disease caused by the novel coronavirus that has infected more than 4.3 million people and killed over 295,000 globally.
- Several groups have noted increased rates of kidney failure among patients with C19. Jhaveri and colleagues set out to quantify it by combing through medical records of 5,449 C19 patients hospitalized between March 1 and April 5.
- They found that kidney failure occurred early on, with 37.3% of patients arriving at the hospital with failing kidneys, or developing the condition within the first 24 hours of being admitted.
- In many cases, the kidney failure occurred around the time severely ill patients needed to be placed on a ventilator, Jhaveri said.
- Among the more than 1,000 patients who needed to be placed on a ventilator, about 90% developed acute kidney failure. That compared with 21.7% of the 925 patients who developed the condition but did not need mechanical breathing assistance.
- Very ill patients often develop kidney failure as their conditions become more and more severe, Jhaveri said.
- “It’s not specific to C19. It’s more related to how sick you are,” he said.
- Nevertheless, knowing the proportion of patients at risk for this condition could help hospitals as they plan equipment and staffing needed for future coronavirus surges, he said.
E. New Scientific Findings & Research
1. Even talking can propel the droplets that spread the virus
- Coughs or sneezes may not be the only way people transmit infectious pathogens like the coronavirus to one another. Talking can also propel thousands of droplets so small they can remain suspended in the air for eight to 14 minutes, according to a new study.
- The research, published on Wednesday in the Proceedings of the National Academy of Sciences, could help explain how people with mild or no symptoms may infect others in close quarters such as offices, nursing homes, cruise ships and other confined spaces.
- The study’s experimental conditions would need to be replicated in more real-world circumstances, and researchers still do not know how much virus has to be transmitted from one person to another to cause infection. But its findings strengthen the case for wearing masks and taking other precautions to reduce the spread of the virus.
2. Sex should be avoided for 30 days after coronavirus recovery
- You’ve survived the coronavirus, you’re feeling frisky — and now you’ve got to wait 30 days until you have sex.
- Experts are warning people off intimacy — anything from kissing to full intercourse — for more than a month once they’ve recovered from C19.
- The advice comes after a Chinese study found that not only saliva but semen may carry the virus.
- Now Veerawat Manosutthi, a senior medical expert at the Thai Disease Control Department, is suggesting celibacy for 30 days once someone seems clear of the bug, according to Insider.
- The study, published in the Journal of the American Medical Association (JAMA), took semen samples from 38 male patients with C19 in China’s Henan province, which borders Wuhan, where the virus is believed to have originated.
- Researchers who analyzed the samples on January 26 and again on February 16 found that about 16% of the men surveyed had traces of C19 in their semen.
- They said while they are still unsure whether the illness can be sexually transmitted, it was safer for people to take precautions. This is because other nonsexually transmitted diseases, such as Zika and Ebola, have been proven to spread through sex in the past.
- The team of scientists wrote: “The presence of viruses in semen may be more common than currently understood, and traditional nonsexually transmitted viruses should not be assumed to be totally absent in genital secretions.”
- The novel coronavirus is principally spread through droplets of saliva, but it isn’t yet clear whether the virus is replicated in men’s testicles. The JAMA study suggests it could be that traces of the virus were found in semen because of the imperfect barrier between the bloodstream and the part of the testicles where semen is made. Therefore the virus may have found its way from the blood into the semen.
- Manosutthi went on to say that, after the 30 days of no sex, men who’ve recovered from C19 should wear a condom when they become active in that department again.
F. Collateral Damage
1. Coronavirus Keeps Heart, Stroke Patients Away from ER
- Andrea Gleason feels lucky to be alive. A few weeks ago, she started feeling pains in her chest but didn’t go to the hospital because she was worried about catching C19, or needlessly burdening doctors.
- “I pictured the New York scenario with lots of people in the hallways and I didn’t need to be there,” she said. The Walnut Creek, Calif., resident finally went to the emergency room after the pain became unbearable. Doctors discovered that her coronary artery was almost entirely blocked and swiftly fitted a stent. The cardiologist told her that if she had waited another day she would likely have had a heart attack that could have killed her.
- Mrs. Gleason, 72 years old, is one of the fortunate ones. As coronavirus patients fill up critical-care units in hospitals around the world, doctors treating other serious illnesses say their workload has suddenly dropped. They say people with conditions such as heart disease, epilepsy and cancer aren’t seeking help, and they are starting to see cases of serious harm to patients’ health, and even deaths, as a result.
- Rates of hospitalizations for serious, acute conditions that require timely care fell sharply in March—when the coronavirus first took hold in the U.S.—according to claims data from insurer Cigna Corp. The rates of admission for transient ischemic attacks, or “mini strokes,” fell 31%, it said, while those for epilepsy and seizures fell 28%. The admission rate for acute coronary syndromes—which include heart attacks and unstable angina—fell 11%. Those drops are the largest the company has ever seen, according to Glen Stettin, senior vice president and chief innovation officer of Cigna’s Express Scripts.
- “It suggests that people are afraid to go to the hospital right now and are trying to deal with these problems at home,” he said. “But these are life-threatening events. The danger of these conditions is much greater than the theoretical danger of getting C19 at the hospital.”
- A poll of 2,201 adults by the American College of Emergency Physicians and Morning Consult found that four in five (80%) respondents were concerned about contracting the virus from another patient or visitor if they went to the emergency room. Nearly a third of those polled in mid-April said they have actively delayed or avoided seeking medical care because of concerns about getting the virus.
- Comilla Sasson, an emergency medicine doctor at various hospitals in Denver, said she had spoken to a number of patients who refused to come to the emergency room for chest pain because they were afraid of contracting the coronavirus. “They’d tell me they’d rather die than be infected with Covid,” she said.
- Doctors say delays in seeking treatment are harming some patients’ long-term health. Akshay Khandelwal, associate head of cardiology at Henry Ford hospital in Detroit, had a patient who delayed attending the emergency room despite clear heart-attack symptoms. The patient survived, but with permanent damage to the heart.
- Others are dying. Kevin Sheth, a neurologist at Yale New Haven Hospital, where the volume of stroke patients dropped dramatically in the first month of the outbreak, said one of his patients died of stroke after delaying a visit to the emergency room. “One of the things that was in the background was certainly this fear and hesitation to call 911,” he said. “Because people think hospitals are Covid reservoirs, which in some ways they are.”
- Hospitals are trying to reassure patients that they won’t be exposed to C19 if they visit the emergency room. John Mathew, medical director of the emergency department at St. Joseph Hospital in Nassau County, N.Y., said the hospital has created two separate emergency departments with two separate ambulance dropoffs.
- Within the Covid unit, patients are separated by plastic sheets with zippers duct-taped onto them. Staff change their gowns, gloves and masks before crossing between the two areas.
- Nevertheless, Dr. Mathew said, emergency-room traffic is down more than 40% in April compared with last year. For example, patients are delaying coming in with appendicitis until it has ruptured, requiring a more complicated operation, he said.
- “I’m scared about where my sick patients are,” he said. “I want them to know that I’m prepared, we’re prepared.”
- Longer term, doctors are concerned about an increase in advanced cancer cases because of missed diagnoses. The Dana-Farber Cancer Institute in Boston has put mammogram appointments on hold since March, said Ann Partridge, the hospital’s vice chair of medical oncology. The hospital plans to slowly begin screenings again in June. Preventive screenings for cervical, colon and breast cancer dropped between 86% and 94% in March compared with the historic average, according to data from 190 hospitals in 23 states from Epic Systems Corp., a large electronic health-record provider.
- “But that doesn’t stop cancers from forming and growing,” Dr. Partridge said. “We’re worried if this goes on for too long and we don’t get to do screening tests, we’ll get a wave of cancers at a later stage.”
- Lower hospital attendance by cancer patients could cause a 20% increase in deaths among newly diagnosed patients in the U.S. over the next year, according to a disease model developed by DATA-CAN, a U.K.-based research collaboration that focuses on cancer. That prediction—yet to be peer reviewed—was based on data from several U.K. hospitals showing that chemotherapy admissions have fallen about 60% since the pandemic hit, while urgent appointments for early cancer diagnosis dropped 76%.
- While the indirect death toll of C19 isn’t yet known, mortality statistics offer some alarming clues. Data from the National Center for Health Statistics show that an estimated 28% of “excess deaths”—a count of the number of deaths over and above the historic rate—for the week ended April 11 weren’t attributed to the virus. Some of those deaths may have been caused by the virus and inaccurately recorded as another cause, but the trend is nonetheless concerning, said Bob Anderson, chief of the mortality-statistics branch of the NCHS.
- The U.S. isn’t alone. Data on all deaths in England and Wales—where emergency room admissions also fell sharply in March—show that around 25-30% of excess deaths in the weeks since the pandemic broke out weren’t linked to C19 on death certificates.
- “It really does concern me,” said Carl Heneghan, director of the Centre for Evidence-Based Medicine at the University of Oxford, of the U.K. data. “What’s going on here is the collateral damage of just focusing on a single disease that’s dominating health services is now creating a significant problem.”
G. Projections & Our (Possible) Future
1. World Health Organization: This virus may never go away
- The coronavirus that causes C19 could become endemic like HIV, the World Health Organization said on Wednesday, warning against any attempt to predict how long it would keep circulating and calling for a “massive effort” to counter it.
- “It is important to put this on the table: this virus may become just another endemic virus in our communities, and this virus may never go away,” WHO emergencies expert Mike Ryan told an online briefing.
- “I think it is important we are realistic and I don’t think anyone can predict when this disease will disappear,” he added. “I think there are no promises in this and there are no dates. This disease may settle into a long problem, or it may not be.”
- However, he said the world had some control over how it coped with the disease, although this would take a “massive effort” even if a vaccine was found — a prospect he described as a “massive moonshot”.
- More than 100 potential vaccines are being developed, including several in clinical trials, but experts have underscored the difficulties of finding vaccines that are effective against coronaviruses.
- Ryan noted that vaccines exist for other illnesses, such as measles, that have not been eliminated.
- WHO Director General Tedros Adhanom Ghebreyesus added: “The trajectory is in our hands, and it’s everybody’s business, and we should all contribute to stop this pandemic.”
- Ryan said “very significant control” of the virus was required in order to lower the assessment of risk, which he said remained high at the “national, regional and global levels”.
- Governments around the world are struggling with the question of how to reopen their economies while still containing the virus, which has infected almost 4.3 million people, according to a Reuters tally, and led to over 291,000 deaths.
- The European Union pushed on Wednesday for a gradual reopening of borders within the bloc that have been shut by the pandemic, saying it was not too late to salvage some of the summer tourist season while still keeping people safe.
- But public health experts say extreme caution is needed to avoid new outbreaks. Ryan said opening land borders was less risky than easing air travel, which was a “different challenge”.
- “We need to get into the mindset that it is going to take some time to come out of this pandemic,” WHO epidemiologist Maria van Kerkhove told the briefing.
1. FDA: Data suggests Abbott’s rapid coronavirus diagnostic test is delivering inaccurate results
[Note: As reported in yesterday’s Update, a study indicated that approximately 50% of tests reported false negative results. Abbott vehemently denied the results. On Thursday, the FDA issued an alert as described below.]
- The U.S. Food and Drug Administration issued an alert on Thursday saying there is early data that suggests Abbott Labs’ rapid Covid-19 diagnostic test may be delivering inaccurate results.
- Specifically, the Abbott ID NOW test may return false negative results, the FDA said.
- “We are still evaluating the information about inaccurate results and are in direct communications with Abbott about this important issue,” said Tim Stenzel, director of the Office of In Vitro Diagnostics and Radiological Health at the FDA’s Center for Devices and Radiological Health, in a statement. “We will continue to study the data available and are working with the company to create additional mechanisms for studying the test.”
- Despite these concerns, ID NOW may continue to be used to correctly identify positive cases, but negative results may need confirmation from a high-sensitivity authorized molecular test Stenzel said.
- Abbott’s share price dropped following the FDA alert, and it is down more than 3% in after-hours trading.
- The FDA alert comes a day after researchers at New York University published a study claiming the ID NOW test missed a third of samples collected with nasopharyngeal swabs that tested positive with a test from rival Cepheid.
- Abbott Labs refuted the NYU study’s claims that its rapid coronavirus diagnostic test could be missing nearly half of positive cases.
- “While we understand no test is perfect, test outcomes depend on a number of factors including patient selection, specimen type, collection, handling, storage, transport and conformity to the way the test was designed to be run,” Abbott said in a statement on Thursday. “ID NOW is intended to be used near the patient with a direct swab test method.”
2. Patients Given Drug Combo with Hydroxychloroquine 44% Less Likely to Die
- Researchers at NYU’s Grossman School of Medicine found patients given the antimalarial drug hydroxychloroquine (HCQ) along with zinc sulphate and the antibiotic azithromycin (AZN) were 44% less likely to die from the coronavirus.
- “Certainly we have very limited options as far as what we have seen work for this infection so anything that may work is very exciting,” said Dr. Joseph Rahimian, Infectious Disease Specialist at NYU Langone Health.
- The study looked at the records of 932 C19 patients treated at local hospitals with hydroxychloroquine and azithromycin.
- More than 400 of them were also given 100 milligrams of zinc daily.
- Researchers said the patients given zinc were one and a half times more likely to recover, decreasing their need for intensive care.
- One theory is that HCQ may aid a cell’s ability to absorb the zinc which has antiviral properties and responds to the infection.
- “It sort of boosts the zinc activity which is one of the reasons we thought to look at zinc here and in this observational study we did see a difference suggesting that maybe that boosting activity of the HCQ with the zinc helps the zinc to work better and lead to a benefit,” Rahimian said.
- Dr. Rahimian says patients in the more critical stages of infection did not fare as well.
- And he cautioned that more research is needed – in particular a randomized controlled trial – to prove how and how well the drug combination works.
- Meanwhile, a study in the Journal of the American Medical Association on Monday found that treating patients only with HCQ, AZN, or both did not reduce hospital deaths.
- The study by the State Health Department and the SUNY Albany School of Public Health involved 1,500 patients.
- President Donald Trump has hailed hydroxychloroquine as a potential game changer. Governor Andrew Cuomo also was upbeat about the drug but late last month he revealed that the preliminary findings of the state study were a disappointment.
- “Basically it was not seen as a positive. Not seen as a negative. And didn’t really have much of an effect on the recovery rate,” Cuomo said.
- Other studies of HCQ are continuing.
3. National Institute of Health begins clinical trial of hydroxychloroquine (HCQ) and antibiotic azithromycin (AZN) to treat C19
- A clinical trial has begun to evaluate whether the malaria drug HCQ, given together with AZN, can prevent hospitalization and death from coronavirus disease 2019 (C19). The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, is sponsoring the trial, which is being conducted by the NIAID-funded AIDS Clinical Trials Group (ACTG). Teva Pharmaceuticals is donating medications for the study.
- The Phase 2b trial will enroll approximately 2,000 adults at participating ACTG sites across the United States. Study participants must have confirmed infection with coronavirus and be experiencing fever, cough and/or shortness of breath. The investigators anticipate that many of those enrolled will be 60 years of age or older or have a comorbidity associated with developing serious complications from C19, such as cardiovascular disease or diabetes. Participants will be randomly assigned to receive short-term treatment with either hydroxychloroquine and azithromycin or matching placebos. People living with HIV and pregnant and breastfeeding women also are eligible to participate in the study. The first participant enrolled today in San Diego, California.
- “We urgently need a safe and effective treatment for C19. Repurposing existing drugs is an attractive option because these medications have undergone extensive testing, allowing them to move quickly into clinical trials and accelerating their potential approval for C19 treatment,” said NIAID Director Anthony S. Fauci, M.D. “Although there is anecdotal evidence that HCQ and AZN may benefit people with C19, we need solid data from a large randomized, controlled clinical trial to determine whether this experimental treatment is safe and can improve clinical outcomes.”
- Currently, there are no specific therapeutics approved by the FDA to treat people with C19. HCQ is FDA-approved to prevent and treat malaria, as well as to treat the autoimmune diseases rheumatoid arthritis and lupus. Some preliminary reports have suggested that HCQ, alone or in combination with the FDA-approved AZN, may benefit people with C19.
- Numerous clinical trials are planned or underway, including a recently launched study supported by NIH’s National Heart, Lung and Blood Institute evaluating the safety and effectiveness of HCQ for treatment of adults hospitalized with C19. On March 28, FDA issued an Emergency Use Authorization (EUA) to allow HCQ and medical-grade chloroquine to be distributed from the Strategic National Stockpile and prescribed by doctors to hospitalized adolescents and adults with C19, as appropriate, when a clinical trial is not available or feasible.
- Participants in the ACTG study, called A5395, will receive oral medications to take at home. Those randomly assigned to the experimental treatment group will take 400 milligrams (mg) of hydroxychloroquine twice on the first day and 200 mg twice daily for an additional 6 days. They also will take 500 mg of azithromycin on the first day and 250 mg daily for an additional four days. The control group will receive equivalent numbers of placebo pills. Neither the participants nor the study team will know who received experimental treatment or placebo until the end of the trial.
- Participants will record their symptoms, adherence to treatment, and major events such as hospitalizations in a diary for 20 days. Study staff will follow up with participants by telephone during this period. When possible, participants will come to the clinical research site for an in-person visit at day 20. Additional follow-ups will be conducted by telephone three and six months after treatment starts.
- The main objective of the study is to determine whether HCQ and AZN can prevent hospitalization and death due to C19. Additionally, investigators will evaluate the safety and tolerability of the experimental treatment for people with SARS-CoV-2 infection. While HCQ and AZN are both considered safe in most people, they can cause side effects ranging from headache and nausea to, rarely, heart rhythm problems that can be life-threatening. Because of the risk of heart problems when hydroxychloroquine is used alone or combined with azithromycin, FDA cautions that use of hydroxychloroquine for C19 should be limited to clinical trials or for treating certain hospitalized patients under EUA so clinicians can monitor patients for adverse effects.
- “This study will provide key data to aid responses to the C19 pandemic,” said ACTG Chair Judith Currier, M.D., of the University of California, Los Angeles. “We are pleased to be able to leverage ACTG’s existing infrastructure for HIV treatment clinical trials to quickly implement this important study.”
- The study team is led by Protocol Chair Davey Smith, M.D., of the University of California, San Diego. David Wohl, M.D., of the University of North Carolina at Chapel Hill, and Kara W. Chew, M.D., and Eric S. Daar, M.D., both of the University of California, Los Angeles, serve as protocol vice-chairs. The trial is expected to enroll quickly given the high incidence of C19, and initial results may be available later this year.
4. Why Hospitals in NYC Have Abandoned Hydroxychloroquine
- President Donald Trump put hydroxychloroquine on the map by cheerleading for the drug before researchers could determine its effectiveness.
- Now, it is all but disappearing as a treatment for COVID-19.
- “We know now it probably doesn’t help much,” said Dr. Thomas McGinn, Deputy Physician-In-Chief at Northwell Health. “We’re not recommending it as a baseline therapy anymore. It is only in a treatment protocol in a study that we’re recommending it.”
- Hospitals began using the drug early on in hopes it could calm the overactive immune response to C19. But now that little proven benefit has been found, many doctors here in New York have moved on.
- Just days ago, Mount Sinai changed course.
- “As of last week, we stopped using hydroxychloroquine as a routine medication in our hospital based upon the cumulative experience in our hands and in others, and recommendations by the FDA that it should not be used outside of clinical trials,” said Dr. Charles Powell, chief of the Division of Pulmonary, Critical Care and Sleep Medicine at the Mount Sinai Health System and CEO of the Mount Sinai-National Jewish Health Respiratory Institute.
- It wasn’t just Trump: Governor Andrew Cuomo also expressed optimism about hydroxychloroquine’s potential. But studies, including one that looked at 600 patients in the New York City area, were inconclusive.
- “Basically it was not seen as a positive. Not seen as a negative. And didn’t really have much of an effect on the recovery rate,” Cuomo said of the results during a CNN town hall on April 23.
- Shortly thereafter, the FDA warned the drug was linked to heart problems, and had not been shown to be safe and effective in treating C19.
- NYU Langone is now also using hydroxychloroquine only in clinical trials, where a more controlled setting will yield more reliable data. [Note: See results of NYU clinical trial in story above, which did have positive results.]
- “I was really looking for a study that showed that people who were treated with it were less likely to get intubated,” said Dr. Luke O’Donnell, attending physician at NYU Langone. “And I think more and more data is showing that there is minimal to no difference.”
I. Rise of the Anti-Vaxxers
1. Anti-Vaxxers’ Social Networks are Ripe With People Susceptible to Misinformation
- When physicist Neil Johnson moved to Maryland in 2018 to take a job at George Washington University (GW), he looked online to see what medical requirements his son would have to meet before entering high school. He quickly stumbled upon many parents having online conversations about tactics they could use to get out of vaccinations — something that had never crossed his mind.
- A year later, the U.S. experienced its biggest measles outbreak in almost three decades, with the majority of cases involving people who hadn’t been vaccinated. Johnson — who had, since 2014, been applying tools from physics and math to study the online behavior of terrorist and hate groups — suspected that something interesting, and unsettling, was happening on the web to shape attitudes toward vaccines and advice from the medical establishment in general.
- He and his colleagues soon launched an investigation into the matter. In mid-December 2019, while Johnson and company were drafting a report of their findings for publication, they started hearing news of unusual cases of pneumonia breaking out in China. Within the next few weeks, they had broadened the scope of their study to include the debate over COVID-19 vaccinations.
- The team’s findings were published today in the journal Nature. Their study focused on 100 million Facebook subscribers who followed more than 1,000 pages that discussed vaccinations from varying perspectives. Johnson’s team created a map that identified all these pages, labeling them with either red, blue or green dots — red signifying an anti-vax message; blue conveying a mainstream, pro-vaccination theme; and green representing curious people who weren’t clearly aligned with either faction.
- This “map” shows the connections between vaccine-related Facebook pages visited by 100 million Facebook users. These pages, which the researchers call clusters, are color-coded as pro-vaccination (blue), anti-vaccination clusters (red) or undecided (green). Even though more people subscribe to the (pro-vaccination) blue viewpoint than to the (anti-vaccination) red, the researchers found the red partisans have both created more clusters and forged more links with the unaligned green clusters. The figure also shows how the Reds have positioned themselves in the center of things, surrounded by a large number of Greens, whereas the Blues are mostly far above, missing the main action. (Credit: Johnson et al. 2020 Nature)
Creating a Battlefield Map for the Vaccine Fight
- Johnson compares the map, which reveals the links between the colored dots (or “clusters,” representing Facebook pages), to a battlefield map. “You never win a battle without a map of the battlefield,” he says, and he believes a battle is being now waged “for the hearts and minds of the undecideds.” And for those who place their faith in reason and the scientific method, the fight is not going well.
- “Before we drew the map, we expected to see the Blues — the Centers for Disease Control [and Prevention], the [Bill & Melinda] Gates Foundation, et cetera — at the center of things,” Johnson says, “with the Reds, who represent the ideological fringe, buzzing around the edges.”
- But that’s not happening, according to the map. Although the Reds (anti-vaxxers) are a numerical minority, they have formed many more clusters, which in turn forge many more links with the Greens than do the Blues. “The insurgent Reds are completely embedded with the Greens,” Johnson adds, “while the Blues are off on their own, fighting the battle in the wrong place.”
- The Reds are making inroads, not only because they have more pages and more connections to the Greens, but also because their pages, which do not focus solely on vaccines, provide “a greater diversity of narratives,” Johnson says. The message from a blue page, such as that coming from the CDC, tends to be “like vanilla, always the same. But red has all these strange flavors we don’t even have a name for. People who are still looking can find what they want — or what they think they need.”
Stemming the Tide of Misinformation
- The theoretical model developed by Johnson and his collaborators predicts that anti-vax views will dominate within a decade. In fact, a poll carried out last week found that 19 percent of Americans will refuse to take a COVID-19 vaccine, while 26 percent are undecided — a situation that could amplify outbreaks of the disease, as happened with the measles in 2019. Meanwhile, some protesters in the U.S. and Europe are spreading delusional fantasies, claiming, for instance, that Bill Gates plans to use coronavirus vaccines to inject microchips into the world’s population.
- Facebook cannot simply shut down all the “infectious” pages, because the company is obliged to support freedom of speech so long as people are not inciting violence or criminal acts. But Facebook could, Johnson suggests, accord low priority to links that distribute misinformation, which would force people to scroll down a very long way to find them.
- The problem, of course, is not limited to Facebook. There’s a growing number of social media platforms out there today — thanks, in part, to open-source software that makes it easy for people to set up their own platforms, which may not be moderated at all. Establishing cooperation between all social media platforms is not realistic, Johnson says, but if pernicious information is passing between a few sites, it might be possible to reach an agreement to inhibit that flow.
- He’s currently working with researchers at GW and Google, trying to come up with strategies for impeding the transmission of malicious content within a single platform or from one platform to another. “Now that we have a detailed map that shows all the connections, we can do what-if scenarios,” Johnson says. “If I blocked off this link, what would happen to the flow?”
- Ever since he shifted his gaze from traditional problems in physics to studying the online dissemination of violent, racist and otherwise dangerous and distorted views, Johnson has been engaged in a never-ending battle. The fact that his business is booming, he acknowledges, is not great news for the rest of the world.
J. The Road Back?
1. Ending Lockdowns Without a Guidebook
- If locking down entire populations is an unparalleled global experiment in disease control, so is releasing them.
- Scientists studying the novel coronavirus say that without a vaccine or widespread immunity it is almost inevitable that easing lockdown measures in Europe and the U.S. will trigger second or even multiple waves of infection. China, Singapore, South Korea, Iran and Germany are among a handful of countries that have seen signs of the virus re-emerging to varying degrees as stringent containment measures have been relaxed.
- So far, the number of new cases in these second waves has been small. But the prospect of a severe resurgence has sent researchers scrambling to determine how best to prevent any trickle of new infections turning into a flood as hibernating economies are brought back online. The “Spanish flu” pandemic that began in 1918 killed more people world-wide in its second wave than in the first.
- Disease experts’ clearest message: Governments must scale up testing to identify the infected, trace those with whom they have been in contact, and isolate those individuals to impede the virus’s spread. “Test, trace, isolate is a kind of old adage in epidemiology,” said Joshua Moon, a researcher in global health emergencies at the University of Sussex, U.K.
- Policy makers, though, must make dozens of other judgments. Should schools reopen, and if so with what safeguards for staff and pupils? Should people wear masks when going about their daily lives? Should the elderly and other vulnerable groups cocoon themselves at home for months to come? And if so, how should those caring for them best shield them from the virus?
- Scientists are examining these and other questions to advise governments on how to keep transmission of the virus low and prevent the need to reverse course on lockdowns. But data are limited, the precedents are in Asia where most countries started and ended lockdowns with fewer cases than in the West, and studies sometimes reach conflicting conclusions.
- Only by gently easing the stringent measures that reduced the spread of the virus can we improve our understanding of what works and what doesn’t, they say.
- “There’s so much uncertainty,” said Mike Tildesley, an associate professor in life sciences at the University of Warwick in England, who models infectious diseases. “As we start to relax, we will get more information. But that’s a really hard sell to the public.”
- Most European countries are now gradually easing monthslong lockdowns after growth in case numbers and fatalities has slowed. So are many U.S. states. The economic cost in jobs and income lost to the restrictions is expected to dwarf the losses of the financial crisis a decade ago. In March and April alone, employers in the U.S. shed more than 21 million jobs. The economies of France, Spain and Italy reported record falls in output during the first quarter.
- Public-health officials are urging policy makers to relax restrictions cautiously. In Senate testimony this week, Dr. Anthony Fauci, the U.S. government’s leading infectious diseases doctor, told senators to brace for more infections. “There is no doubt that when you pull back on mitigation, you will see some cases reappear,” he said Tuesday, warning that the country faces “needless suffering and death” if the nation reopens too rapidly.
- As the disease has spread, data on its effects have multiplied and a few clearer signals have emerged. Perhaps the strongest is that children predominantly suffer only mild symptoms if infected with the virus. Their role in transmission of the bug is less clear but that has given many countries, including Denmark and Germany, the confidence to begin reopening schools, albeit with extra hygiene measures and smaller classes.
- Public-health authorities have also increasingly swung behind the idea that face masks can be helpful in impeding transmission. The Centers for Disease Control and Prevention provides an easy guide to making a homemade mask on its website. A review of 84 studies published online and awaiting peer review looked at the effectiveness of face masks in limiting the spread of the virus and concluded that governments should strongly encourage their regular use.
- One advantage of the ballooning amount of data on C19 is that disease experts can increasingly rely on abundant real-world observations to guide policy and not just on computer models. By melding modeling and actual European case data, researchers at the U.K.’s University of East Anglia determined that school closures, banning mass gatherings and closing businesses early in the outbreak worked well to stanch the spread of the disease. In a surprise finding, they concluded stay-at-home orders had little additional impact on disease spread.
- The still-developing picture of which measures are most effective means countries easing out of lockdown are taking different approaches to containing the virus. Elementary schoolchildren may have returned to class in Denmark and Germany but not in Spain or Italy. In the U.S., states including Florida and Indiana have allowed nonessential businesses adhering to hygiene and social-distancing guidelines to reopen, while in California and Illinois they remain closed.
- Epidemiologists say the gaps in our knowledge of the virus reinforce the need for effective test, trace and isolate programs to locate and quarantine infected individuals. The more effective those systems are, the more scope there is for relaxing social-distancing measures, said Mark Woolhouse, professor of infectious disease epidemiology at the University of Edinburgh. Some countries are experimenting with cellphone apps to alert citizens to the proximity of suspected cases.
- One potential wrinkle for the West: In China, though the virus reached Beijing and Shanghai, it was mostly contained in Hubei province and its capital Wuhan, the city of 11 million where the outbreak started. Elsewhere in Asia, case levels at the start and end of lockdowns were lower than in the West. In the U.S. and some European countries such as the U.K., the disease is more dispersed, with cases and deaths reported in major urban centers countrywide, making it possible for clusters of new infections to spring up and proliferate at the same time.
- That could stretch tracing systems and give the virus a chance to spread. “If a fire is confined to your chip pan there’s a chance of putting it out. Leave it one minute and it’s got your kitchen,” said David Leon, professor of epidemiology at the London School of Hygiene and Tropical Medicine.
2. CDC Posts Advice on Reopening U.S. Bars, Restaurants and Workplaces
- New guidance from the U.S. Centers for Disease Control and Prevention advising States on how to reopen bars, restaurants and workplaces was posted by the agency on Thursday.
- The guidance outlines a series of steps that should be taken to keep employees and customers safe, including encouraging hand-washing, social distancing and how to check for symptoms of potential C19 cases.
- The White House task force issued broad guidelines for reopening the country on April 16 but largely left the specifics to States on how to restart economic and social activities. Around the U.S., States have begun moving forward with reopening plans, even as cases of the virus continue to circulate.
- But in the absence of guidance from the CDC, providing rules and advice had largely been left to State and local groups, or not dispensed at all. Some businesses that have reopened have said they’ve seen few customers as people are reluctant to resume shopping, dining out and socializing while still worried about the illness.
- Under the newly issued CDC guidelines, businesses would be encouraged to follow a series of steps.
- Bars and restaurants, for example, shouldn’t reopen until they can follow applicable State and local orders, and until they’re ready to protect people who are at higher risk for severe illness, the guidelines say. Then they should encourage social distancing — add spacing of tables and stools; encourage drive-through, delivery and curb-side pick up; limit party sizes and occupancy; avoid self-serve stations; and restrict employee shared spaces. Employers should check staff for signs and symptoms of illness as they arrive, “as feasible.”
- Mass-transit operators should limit routes to and from high-transmission areas before increasing to full service, as well as space out passengers by closing every other row of seats, according to the guidelines. Youth programs, camps and childcare programs should change activities and procedures to limit shared toys and supplies, according to the guidelines.
- The new CDC guidelines are valuable and may be a step in the right direction, said Howard Forman, director of the Yale School of Public Health’s health-care management program.
- “You don’t want 1,000 or more municipalities, States, governments of different sizes having to reinvent the wheel,” Forman said in an interview. But “the CDC is way behind in leading on this,” he said. “And that’s a shame.”
- The CDC reopening guidelines became a political football earlier this month, caught up in a debate about whether one national standard was too prescriptive, since some parts of the country have been hit harder than others.
- A White House official said the guidelines were the result of a collaboration between the CDC and the administration’s coronavirus task force. The official, who spoke on condition of anonymity, disputed the claim that the guidance had ever been quashed.
- Earlier reports by the Associated Press and the Washington Post described pushback inside the administration over a draft of the guidelines. A version of the guidelines posted by the AP contained far more detailed instructions to churches, camps and other businesses and gathering places, setting up small groups to limit interactions, or suggested restrictions on how to serve food, for example.
K. Can the Numbers Be Trusted?
1. Virginia Mixes Testing Data to Improve Ranking Against Other States
- The United States’ ability to test for the novel coronavirus finally seems to be improving. As recently as late April, the country rarely reported more than 150,000 new test results each day. The U.S. now routinely claims to conduct more than 300,000 tests a day, according to state-level data compiled by the COVID Tracking Project at The Atlantic.
- But these rosy numbers may conceal a problem: A lack of federal guidelines has created huge variation in how states are reporting their C19 data and in what kind of data they provide to the public.
- These gaps can be used for political advantage. In at least one state, Virginia, senior officials are blending the results of two different types of coronavirus test in order to report a more favorable result to the public. This harms the integrity of the data they use to make decisions, reassure residents, and justify reopening their economies.
- Other differences make it hard to track the pandemic. In at least three other states, officials have lumped together probable and confirmed C19 deaths; most don’t specify how they’re counting deaths. While most states report the number of people who have been tested for the coronavirus, six states say they track the number of samples that have been tested—and California and New Jersey switched methods in the past few weeks. Louisiana, Nebraska, Nevada, Vermont, and New York do not report the racial or ethnic breakdown of coronavirus cases. Even more states fail to report the racial breakdown of deaths. It is still impossible to know, for example, how many black people have died of C19, though the data that do exist suggest that black people are dying at much higher levels than other groups.
- There are many ways that the lack of data has complicated the outbreak. Until May 12, the Centers for Disease Control and Prevention had not reported state-level testing data, leaving efforts such as our COVID Tracking Project to fill that gap. The lack of reliable national testing data has made it difficult for modelers, policy analysts, and others to understand the true scope of the outbreak. Data about hospitalizations have been even harder to understand. Because the states report hospitalization counts in fundamentally different ways, there is no way to calculate the number of people who have been hospitalized with C19 in the U.S. [NOTE: Several states do not report current hospitalizations, which, in our opinion, is one of the most important metrics to follow].
- Many pandemic response efforts assumed clean, standard, accessible data would exist, but they do not. That said, Virginia’s decision to mix the results of two different kinds of tests marks a new low in data standards.
- The state is reporting viral tests and antibody tests in the same figure, even though the two types of test answer different questions about the pandemic and reveal different types of information. By combining these two types of test, the state is able to portray itself as having a more robust infrastructure for tracking and containing the coronavirus than it actually does. It can represent gains in testing that do not exist in reality, says Ashish Jha, the K.T. Li Professor of Global Health at Harvard.
- “It is terrible. It messes up everything,” Jha told us. He said that combining the test results, as Virginia has done, produces information that is impossible to interpret.
- The state’s decision to combine the tests was first reported by the Richmond Times-Dispatch.
- The two tests have little in common. Viral tests help officials do the basic blocking and tackling necessary to contain an outbreak. If someone tests positive on a viral test, they are still infectious, so they can be told to self-isolate in order to protect the susceptible population. Public-health workers can trace their contacts to find others who may be infected with the coronavirus but who are not yet experiencing symptoms. Viral tests can also be used to monitor people who work in high-risk environments—such as a meatpacking plant—to diagnose a contagious person before they spread the disease.
- Antibody tests, on the other hand, allow for something closer to post-game analysis. They help officials understand the true number of people in a state or city who have been exposed to the coronavirus. But they do so on a lag: Individuals who test positive on an antibody test are likely no longer infectious, and were infected by the coronavirus at least a week earlier.
- The two tests do not even examine the same specimens. Viral tests analyze a throat swab, nasal swab, or saliva sample. They are sometimes called “PCR” tests, after the polymerase-chain-reaction technique used to isolate viral genetic material. But antibody tests use a blood sample. They are sometimes called “serological” tests, because they analyze the blood serum.
- In other words, combining positive and negative results from the two tests in the same statistic, as Virginia has done, makes no sense.
- But commonwealth officials say they have no choice. Other states are mixing their results, claimed Clark Mercer, the chief of staff to Governor Ralph Northam, at a press conference this week.
- “You can’t win” by keeping viral and antibody findings separate in public data, he said, adding that combining the two tests’ results was the only way to improve Virginia’s position in a list of states ranked by the number of tests they had conducted per capita.
- “If another state is including serological tests, and they’re ranked above Virginia, and we are not, and we’re getting criticized for that, [then], hey, you can’t win either way. Now we are including them, and our ranking will be better, and we’re being criticized,” he said.
- We could not find evidence that other states are blending test results in the way that Mercer claimed. In an email, a spokesperson for the Virginia Department of Health claimed that Arizona, West Virginia, and the District of Columbia also mingled viral and antibody results. This is false: Those three governments either separate out, or do not report, the result of negative antibody tests to the public.
- While including antibody tests in a state’s total creates too rosy of a testing picture for a state, reporting only probable positive cases without disclosing how many antibody tests are being completed could actually make the situation look more dire in a state than it is.
- The spokesperson said that Virginia planned to “disaggregate” its viral and antibody results in the future, but he did not provide a firm date.
- Kathy Turner, deputy state epidemiologist for Idaho and the presenting author of the CSTE standards document, did not criticize Virginia’s decision, but she did lay out why her own state decided to keep PCR and serology tests separate.
- “[I]n Idaho, we have decided to only display viral tests because those are the denominator we use to calculate our percent positivity rate and we are very confident what they mean,” she told us. “Additionally, we focus on the PCR tests because we can compare the percent positivity over time—before serology tests were available.”
- Blending the results also misstates Virginia’s success at improving this crucial metric, sometimes called the “test-positivity rate.” This measurement compares the number of people who have tested positive for the coronavirus to the number of people who have been tested overall. In April, one in five Americans who received PCR tests for the virus were found to be infected, a very high rate that suggested only the sickest people could get a test. For the past week, fewer than one in 10 tests in the U.S. have found a positive result, according to state data. Some of this improvement is certainly the result of the New York metro area’s waning outbreak.
- Leaders in many states, including Virginia, have cited the local test-positivity rate to justify loosening shelter-in-place restrictions. Northam has repeatedly said that Virginia’s test-positivity rate had to fall for 14 days before he would loosen restrictions.
- But because Virginia combines viral and antibody results, its positivity rate is unusable, said Jha, the Harvard professor. The positivity metric is only useful when describing the result of viral tests, because it is meant to provide a rough estimate of how many people infected with the coronavirus are getting tested for it. Antibody tests, which are meant to sample a broad swath of the healthy population, should not be included in it. By lumping the two tests together, as Virginia has done, states can artificially improve their test-positivity rate.
- Only by keeping the two types of test separate can the country—and the commonwealth of Virginia—understand the true scope of its outbreak, experts say.
- “You’re comparing apples to pears,” Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, told us. Viral and antibody tests “look a little bit alike, but it doesn’t let you make the comparison needed. So why not keep them separate?” Gronvall has written about the need to expand antibody testing across the U.S.
- She is also worried that the data are statistically meaningless, because viral tests have fewer false-positive errors than antibody tests. “There’s so much variability in the antibody tests that it’s like taking an iffy number and throwing it in with some more reliable numbers,” she said.
- Although combining the data from two different tests may seem like a technicality, the decision threatens to confound some of the most important questions about the coronavirus’s path in the United States. How many people are sick right now? How many people can the U.S. actually test for the coronavirus every week? Is the situation outside the New York metropolitan area getting better or worse? Answering these questions requires stable data about how many people have received a diagnostic test and how many of those people are infected.
Annex I. Johns Hopkins Daily Update
EPI UPDATE The WHO COVID-19 Situation Report for May 13 reports 4.17 million confirmed cases (81,577 new) and 287,399 deaths (4,245 new). The global total could potentially reach 300,000 deaths by this weekend.
At the continent level, South America, Asia, and Africa are all reporting increasing per capita daily incidence. South America is now on par with Europe, as national epidemics in European countries are largely on the decline. North America is exhibiting decreasing daily incidence, but this is largely driven by the United States.
In the Eastern Mediterranean, several countries are exhibiting concerning elevated and increasing trends in per capita daily C19 incidence. Bahrain, Kuwait, Qatar, and Saudi Arabia are all reporting more than 50 new cases daily per million population. Because these are relatively small countries, the total daily incidence is not necessarily enough to garner global attention; however, the daily incidence is very high relative to their total population. Saudi Arabia is currently reporting nearly the same per capita daily incidence as the United States—55.36 new cases per million in Saudi Arabia compared to 61.38 in the United States. Bahrain (171.41) and Kuwait (182.65) are approximately three times that value, and at 464.99 new cases per million, Qatar is 9 times that amount. According to multiple reports, much of the elevated C19 incidence in these countries is among foreign, expatriate, or migrant workers, many of whom live in camps or dormitories like the situation in Singapore. Ministry of Health updates in Bahrain, Kuwait, Qatar, and Saudi Arabia indicate that the majority of cases in each country are not citizens.
Russia reported nearly 10,000 new cases, continuing its recent trend of elevated incidence. Russia reached 250,000 cases, and it has reported more than 9,000 new cases per day since May 2. The United Kingdom continues to report steadily decreasing daily incidence, but it moved up to #3 in the world in terms of total cases with 230,985. Spain and Italy are now #4 and #5, respectively.
India reported 3,722 new cases, continuing its recent trend of elevated daily incidence. India could surpass China in terms of total incidence by this weekend. Tamil Nadu state, where a large outbreak has been linked to one of Asia’s largest markets, reported 509 new cases and has nearly 7,000 active cases, the second highest total of all Indian states. Singapore reported 752 new cases, including 750 (99.7%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing C19 epidemic. Singapore estimates that 7.36% of the total population across all migrant worker dormitories are confirmed cases, compared to only 0.03% of the general public population. Of the 26,098 total C19 cases reported in Singapore, 23,758 (91.0%) are among residents of migrant worker dormitories, including 98.4% of cases reported over the past 2 weeks.
The US CDC reported 1.36 million total cases (21,467 new) and 82,246 deaths (1,426 new). The United States could potentially reach 1.5 million cases by Tuesday next week. In total, 9 states (increase of 2) reported more than 40,000 cases, including New York with more than 300,000; New Jersey with more than 125,000; and Illinois and Massachusetts with more than 75,000. Additionally, 35 states (no change), plus Guam, are reporting widespread community transmission.
New York state and New York City both reported increases in daily incidence from the previous day; however, they both reported a substantial increase in the number of tests performed as well. New York City reported a 54% increase in the number of tests from the previous day (compared to a 47% increase in new cases), and the state reported a 65% increase in tests (compared to a 52% increase in new cases).
The New York Times continues to track state-level C19 incidence, with a focus on state policies regarding social distancing.
The Johns Hopkins CSSE dashboard is reporting 1.40 million US cases and 84,313 deaths as of 11:30am on May 14.
FRANCE ECONOMIC AID MEASURES France announced that it will implement a set of economic relief measures totaling to €18 billion (US$19.4 billion) to aid the country’s tourism industry. Tourism accounts for nearly 8% of France’s economy, and the industry has suffered substantially during the pandemic. The government will reportedly reimburse companies 70% of furloughed workers’ wages, with hopes that financial support can be phased out as businesses reopen in regions of low transmission. Prime Minister Edouard Philippe remains hopeful that restrictive social distancing measures, currently including prohibitions on travel exceeding 100km and beach closures, can be lifted in time to allow for summer vacations in France.
UN URGES MENTAL HEALTH SUPPORT In a recently published policy brief, the UN urged “governments, civil society, health authorities and others” to unite and address the short- and longer-term mental health impacts of the C19 pandemic. The report highlights the needs of vulnerable populations, including first responders and front-line healthcare workers, older adults, children, women, and refugees or those in conflict settings. In addition to fear of illness or death and the growing challenges posed by mis- and disinformation, individuals are also experiencing a broad scope of secondary mental health effects, including financial insecurity or social isolation. The report advises that emergency psychosocial support should become more widely available, including remote mental health care. Furthermore, the report calls for prioritizing the protection and promotion of human rights of those with severe mental health conditions, as their needs can often be neglected in major emergencies.
TYPHOON IN THE PHILIPPINES Typhoon Vongfong hit the Philippines, its first of the year, with wind gusts of more than 150 miles per hour (240 kph), causing substantial damage to parts of the country. The C19 pandemic response is posing major logistical and financial constraints for the Philippines, and it is particularly difficult to provide shelter to affected communities while maintaining social distancing. An estimated 200,000 people need to be evacuated from their homes due to concerns of winds, flooding, and landslides. Certain evacuation centers, including school classrooms, are reportedly only able to house a fraction of their former capacity in order to avoid overcrowding, which can facilitate SARS-CoV-2 transmission. Additional shelters have been opened, and evacuees are being given masks to reduce the risk of transmission. The Philippines averages 20 typhoons a year, so responders are only beginning their annual struggle, this time complicated by the ongoing pandemic response.
WUHAN PLANS FOR WIDESPREAD TESTING Chinese officials have outlined the plan to implement widespread testing of Wuhan’s 11 million residents following the recent detection of a cluster of C19 cases. The plan is scheduled to be completed in 10 days, an unprecedented scale for SARS-CoV-2 testing in any country. After excluding those who have already been recently tested, Wuhan authorities would still need to conduct at least 730,000 tests per day to meet the 10-day timeline. The current testing capacity for Wuhan is estimated to be approximately 100,000 tests per day. The Hubei Province Health Commission reported that Wuhan currently has 63 testing sites and 386 sampling sites, which would correspond to 1,890 people per day at each sampling site. The highest daily total reported at any site in Wuhan to date is 1,741, so this will be an enormous undertaking. Local officials are distributing notices and informational fliers to spread awareness of the testing efforts. Companies developing testing kits are reportedly rushing to meet the sudden high demand.
JAPAN LIFTS STATE OF EMERGENCY Japanese Prime Minister Shinzo Abe announced that Japan will lift the state of emergency in all but 8 prefectures, based on assessments that C19 incidence is slowing and testing capacity is increasing. Residents in the remaining prefectures—Hokkaido, Tokyo, Chiba, Saitama, Kanagawa, Osaka, Hyogo, and Kyoto—are still being asked to limit social interactions by 80%, and the possibility of lifting social distancing measures in those prefectures will reportedly be reconsidered next week. While the Prime Minister acknowledged that lifting restrictions will enable some businesses to reopen, social distancing in public should continue as the “new normal.”
C19 THREATENS SUSTAINABLE DEVELOPMENT GOALS WHO Director-General Tedros Adhanom Ghebreyesus discussed the recently published 2020 World Health Statistics Report, which monitors health statistics for the Sustainable Development Goals. The report indicates that significant progress has been made globally, with some of the biggest gains in low- and middle-income countries (LMICs). From 2000 to 2016, life expectancy increased by 21% in LMICs and approximately 4% in higher-income countries. Access to preventative health and treatments for common illnesses like HIV and malaria facilitated much of the improvement. The C19 pandemic threatens to stall or reverse some of this progress. Vulnerable aspects of global health, such as maintaining routine immunization coverage and access to other common essential health services, are being negatively impacted by the pandemic and associated response measures. In addition to effects on the provision and availability of health services, the ability to pay for healthcare is likely to be impacted as well. The WHO estimates that 1 billion people worldwide (13% of the global population) could be 10% or more of their income on health services by the end of 2020, the majority of which will be from LMICs.
WHO ANNOUNCES LAUNCH OF NEW INFORMATIONAL APPS The WHO announced the launch of 2 different C19 smartphone apps, for healthcare workers and the general public. The WHO Academy app provides health workers with information on C19 resources and guidance developed by the WHO as well as training and virtual workshops to support efforts to safely and effectively care for C19 patients. A survey of healthcare workers found that many felt that they lacked sufficient information about infection prevention and control measures (including the proper use of personal protective equipment (PPE) and case management. The WHO Info app is designed to provide updated and accurate C19 information to the general public as well as details on WHO efforts to combat C19. Both apps are available for Apple and Android devices.
NATIONAL TESTING STUDIES Several European countries recently published data from large surveys to estimate the scope of their national C19 epidemics. France and Spain both conducted serological surveys to determine the proportion of the population that has ever been infected with SARS-CoV-2. In France, the study estimated that 4.4% of the population had previously been infected, and similarly, Spain estimated that 5% of the population had been infected. For comparison, France has reported 140,734 confirmed cases, representing approximately 0.2% of the entire population, and Spain has reported 229,540 confirmed cases, representing approximately 0.5% of its population. Both studies also provide regional breakdowns for the data. These two serological studies indicate that there could potentially be 10-20 undetected infections for every known case. While this may seem like a large number, consider that at least 95% of both populations in both countries still have not been infected, based on these results.
Sweden announced results from two studies conducted utilizing molecular diagnostic tests, one on a national level and one in Stockholm. The national study involved more than 2,500 participants from across the country, but results are not available for individual regions. A press release issued by Sweden’s Public Health Authority reports that the study estimated 0.9% of the national population had active SARS-CoV-2 infection at the time of the study (April 21-24). A smaller study conducted in Stockholm (679 participants) estimated that 2.3% of local residents had active infection during the same time period, which is similar to a previous study conducted several weeks earlier. Unlike the serological studies, these data only represent ongoing active infections at the time of the survey, as the molecular tests cannot detect prior infections. The press release states that more detailed results will be presented in the coming days.
STATE TESTING & REPORTING US states have taken a variety of approaches to reporting C19 cases, hospitalizations, and deaths as well as SARS-CoV-2 testing capacity, with varying degrees of detail. An article published in The Atlantic, which operates the COVID Tracking Project, discusses the challenges and limitations associated with differences in how states report C19 data. The article uses Virginia’s recent decision report molecular and serological tests performed as a single value to illustrate the problem, but the challenge applies broadly to all states. There are not sufficient standards or requirements for state-level reporting of disease data, including for C19, and the way states report data can make it difficult to compile an accurate picture of the current status of the US C19 epidemic, compare states, or identify relevant trends. Independent efforts, such as the COVID Tracking Project or the Johns Hopkins CSSE dashboard, attempt to compile various state-level data into centralized databases to support analysis, but they are not able to effectively capture or compare data that is not reported by every state. Data is critical to making informed decisions regarding epidemic response operations and policies, and the absence of a coordinated and consistent reporting mechanism in the United States can pose a major barrier to state and national epidemic response efforts.
US HOUSE OF REPRESENTATIVES HEARING This morning, Dr. Rick Bright, former Director of the Biomedical Advanced Research and Development Authority (BARDA), testified in a hearing at the US House of Representatives. Dr. Bright filed a whistleblower complaint shortly after being removed from his position at BARDA, alleging that he was removed in retaliation for conflicts regarding US government policies regarding medical countermeasures for C19. In his opening statement, Dr. Bright forecasts that “2020 will be the darkest winter in modern history” and emphasizes the importance of basing policy and operational decisions on reliable scientific evidence. Following the whistleblower complaint, several reports emerged claiming that the Office of the Special Counsel had found “reasonable grounds” that Dr. Bright’s removal was retaliatory and that he should be temporarily reinstated; however, the Office of the Special Counsel has not confirmed that.WISCONSIN SUPREME COURT OVERTURNS “SAFER AT HOME” ORDER The Wisconsin Supreme Court (US) ruled yesterday that the state’s “safer at home” order, issued by Secretary of the Department of Health Services Andrea Palm, was issued outside the scope of her authority. The decision largely nullified the order with immediate effect, which permitted businesses to reopen and removed prohibitions on large gatherings. The court allowed existing restrictions that closed schools to remain as well as language permitting local governments to implement their own restrictions. Following the decision, some restaurants and bars reopened, some of which did not appear to impose any social distancing or other protective measures. Some local governments are reportedly developing and implementing their own restrictions, but they will likely result in inconsistencies across the state. Any future efforts by the governor or appointed state officials to implement C19 policies will be required to utilize the normal process, which involves the state legislature and could take weeks or longer to pass.