Coronavirus Update

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Coronavirus Update 5-22

“We can put out the fires. Whether it is an ember or a flame, we are going to put it out.  But we are not closing our country.”  

President Trump

“Simply put, there is no pandemic exception to the U.S. Constitution and its Bill of Rights.” 

Eric Dreiband, US Department of Justice

“The infection will still take its toll, and we’ll all get it. Those meant to die will die. Everyone dies. Even if it’s coronavirus, so what? Of course, you need to get a test to avoid infecting others, but you do understand it’s an illusion. We’ll run out of tests if everyone runs out to check after every sneeze.”  

Alexander Myasnikov, Russia Coronavirus Information Chief

Today’s Features

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A. Recent Developments and Headlines

B. Numbers & Trends

Note: All changes noted in this Update are since the 5/21 Update

Sources: Worldometers

1. Cases & Tests

  • Worldwide:  
    • Total Cases = 5,190,496 (+2.1%)
    • New Cases = 107,835 (+8.1%) (+8,111)
    • New Cases (5 day avg) = 94,697 (+2.7%) (+2,448)
  • US: 
    • Total Cases = 1,620,902 (+1.8%)
    • New Cases = 28,911 (+35.1%) (+7,503)
    • New Cases (5 day avg) = 22,626 (+5.0%) (+1,085)
    • Total Number of Tests = 13,439,114 

2. Deaths

  • Worldwide Deaths = 334,173 (+1.5%) 
    • New Deaths = 4,879 (+2.9%) (+139)
    • New Deaths (5 day avg) = 4,254 (+0.6%) (+26)
  • US Deaths = 96,354 (+1.5%) 
    • New Deaths = 1,418 (+1.1%) (+15)
    • New Deaths (5 day avg) = 1,248 (-2.9%) (-38)
  • 5 Countries with Largest Number of Confirmed Deaths: 
CountryTotal DeathsNew DeathsDeaths Per 1M Population
US96,3541,418 (+15)291 (+4) 
UK36,042338 (-25)531 (+10)
Italy32,486156 (-5)537 (+2)
France28,21583 (-27)432 (+2)
Spain27,94052 (-58)598 (+2)
Worldwide334,1734,934 (+194)42.29
  • 5 States with Largest Number of Confirmed Deaths: 
StateTotal  DeathsNew DeathsDeaths 5 Day AverageDeaths Per 1M Population
New York28,88569 (-99)150 (-98)1,485 (+4)
New Jersey10,852105 (-51)118 (-1)1,222 (+12)
Massachusetts6,14882 (-46)89 (-5)892  (+12)
Michigan5,12969 (+26)50 (+3)517 (+7)
Pennsylvania4,92098 (+27)86 (+8)384 (+7)
US96,3541,418 (+15)1,248 (-27)291 (+4)

3. Countries/States To Watch

CountryTotal DeathsNew DeathsDeaths 5 Day AvgDeaths Per 1M Pop
Sweden3,87140 (-48)39 (+2)384 (+4)
Europe166,8051,007 (-217)1,027 (-37) 
  • Below are 5 of the US States moving quickly to reopen their economies (OK never locked down).   
StateTotal  DeathsNew DeathsDeaths 5 Day AvgDeaths Per 1M Pop
Georgia1,77578 (+66)35 (+14)167 (+7)
Florida2,14549 (+5)36 (+0)100 (+2)
Texas1,48663 (+42)29 (+6)51 (+2)
Ohio1,84059 (+2)45 (+6)157 (+5)
Oklahoma3056 (+1)3 (+0)77 (+1)
US96,3541,418 (+15)1,248 (-27)291 (+4)

4. Changes in Cases In States During Past Week

https://pbs.twimg.com/media/EYjRytAUwAIpj4Z?format=png&name=small

C. Vaccines & Testing

1. 6 Vaccine Candidates Most Likely To Succeed & Timelines  

  • With about 8 coronavirus vaccine candidates in clinical trials and 110 more in clinical testing, the race to a commercial product is intensifying. Against this backdrop, an analyst at Morgan Stanley looked at the most promising programs. 
  • Millions of doses of the vaccine could be available by fall 2020, and over 1 billion in 2021, analyst Matthew Harrison said in a note. The analyst sees safety as the biggest hurdle for these expedited programs.
  • It should be noted that earlier Monday, Moderna Inc. reported positive interim Phase 1 data for its coronavirus vaccine candidate mRNA-1273.
The Coronavirus Vaccine Frontrunners
  • Six candidates — 4 clinical pipeline candidates and 2 preclinical candidates — have a reasonable likelihood of success and can be manufactured at a notable scale, Harrison said.
  • The analyst projects three waves of commercially available vaccines. The candidates, sponsors and the timelines are as follows:
By The End Of 2020 
  • Moderna
  • Pfizer Inc./BioNTech
  • AstraZeneca/University of Oxford
  • CanSino
First Half Of 2021
  • Johnson & Johnson 
Second Half Of 2021
  • Sanofi SA/GlaxoSmithKline plc
Table compiled using Morgan Stanley data.
Judging Initial Coronavirus Efficacy Data
  • Although conceding that initial clinical data might be difficult to judge, Morgan Stanley said it would look ahead to the proportion of patients that achieve neutralizing antibody levels.
  • Since these have not been established, the firm said it will compare against animal models as well as antibody titers achieved in cohorts of patients who have recovered from C19.
  • Morgan Stanley said it believes the NIAID is working on neutralizing titer thresholds that could potentially confer protection, adding that the thresholds could become available prior to the release of initial vaccine data.  

Source: These 6 Coronavirus Vaccine Candidates Are The Likeliest To Succeed, Says Morgan Stanley

2. U.S. secures 300 million doses of potential AstraZeneca C-19 vaccine

  • The United States has secured almost a third of the first one billion doses planned for AstraZeneca’s experimental COVID-19 vaccine by pledging up to $1.2 billion, as world powers scramble for medicines to get their economies back to work.
  • While not proven to be effective against the coronavirus, vaccines are seen by world leaders as the only real way to restart their stalled economies, and even to get an edge over global competitors.
  • After President Donald Trump demanded a vaccine, the U.S. Department of Health agreed to provide up to $1.2 billion to accelerate AstraZeneca’s vaccine development and secure 300 million doses for the United States.
  • “This contract with AstraZeneca is a major milestone in Operation Warp Speed’s work toward a safe, effective, widely available vaccine by 2021,” U.S. Health Secretary Alex Azar said.
  • The vaccine [commonly referred to as the “Oxford Vaccine”], previously known as ChAdOx1 nCoV-19 and now as AZD1222, was developed by the University of Oxford and licensed to British drugmaker AstraZeneca. Immunity to the new coronavirus is uncertain and so the use of vaccines unclear.
  • The U.S. deal allows a late-stage – Phase III – clinical trial of the vaccine with 30,000 people in the United States.
  • AstraZeneca, based in Cambridge, England, said it had concluded agreements for at least 400 million doses of the vaccine and secured manufacturing capacity for one billion doses, with first deliveries due to begin in September.
  • A Phase I/II clinical trial of AZD1222 began last month to assess safety, immunogenicity and efficacy in over 1,000 healthy volunteers aged 18 to 55 years across several trial centers in southern England. Data from the trial is expected shortly.

Source: US secures 300 million doses of potential AstraZeneca COVID-19 vaccine 

3. 25% of Americans hesitant about a coronavirus vaccine  

  • A quarter of Americans have little or no interest in taking a coronavirus vaccine, a Reuters/Ipsos poll published on Thursday found, with some voicing concern that the record pace at which vaccine candidates are being developed could compromise safety.
  • While health experts say a vaccine to prevent infection is needed to return life to normal, the survey points to a potential trust issue for the Trump administration already under fire for its often contradictory safety guidance during the pandemic.
  • Some 36% of respondents said they would be less willing to take a vaccine if U.S. President Donald Trump said it was safe, compared with only 14% who would be more interested.
  • Most respondents in the survey of 4,428 U.S. adults taken between May 13 and May 19 said they would be heavily influenced by guidance from the FDA or results of large-scale scientific studies showing that the vaccine was safe.
  • Less than two-thirds of respondents said they were “very” or “somewhat” interested in a vaccine, a figure some health experts expected would be higher given the heightened awareness of C19 and the more than 92,000 coronavirus-related deaths in the United States alone.
  • “It’s a little lower than I thought it would be with all the attention to C19,” said Dr. William Schaffner, an infectious disease and vaccine expert at Vanderbilt University Medical Center in Nashville. “I would have expected somewhere around 75 percent.”
  • Fourteen percent of respondents said they were not at all interested in taking a vaccine, and 10% said they were not very interested. Another 11% were unsure.
  • Studies are underway, but experts estimate that at least 70% of Americans would need to be immune through a vaccine or prior infection to achieve what is known as “herd immunity,” when enough people are resistant to an infectious disease to prevent its spread.
  • Trump has vowed to have a vaccine ready by year’s end, although they typically take 10 years or longer to develop and test for safety and effectiveness. Many experts believe a fully tested, government-approved vaccine will not be widely available until mid-2021 at the earliest.
  • There are more than 100 C19 vaccine candidates in development globally, including some already in human clinical trials. Earlier this week, U.S. biotech Moderna Inc (MRNA.O) announced potentially promising preliminary results from just eight individuals who took part in a safety study.
  • Among those respondents who expressed little or no interest in a coronavirus vaccine, nearly half said they were worried about the speed with which they are being developed. More than 40% said they believe the vaccine is riskier than the disease itself.

Misinformation Hurdle

  • Overall, 84% of respondents said vaccines for diseases such as measles are safe for both adults and children, suggesting that people hesitant to take a coronavirus vaccine might reconsider, depending on safety assurances they receive.
  • For example, among those who said they were “not very” interested in taking the vaccine, 29% said they would be more interested if the FDA approved it.
  • Some experts have said the White House’s emphasis on speed – its vaccine effort is called “Operation Warp Speed” – could leave people worried that safety was being sacrificed for swiftness.
  • In addition, misinformation about vaccines has grown more prevalent on social media during the pandemic, according to academic researchers.
  • “It’s not surprising a significant percentage of Americans are not going to take the vaccine because of the terrible messaging we’ve had, the absence of a communication plan around the vaccine and this very aggressive anti-vaccine movement,” said Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, where he is developing a vaccine.
  • The poll underscores how the country’s deepening polarization has affected people’s view of the pandemic.
  • Nearly one in five Republicans say they have no interest in a vaccine, more than twice the proportion of Democrats who said the same.
  • Trump, a Republican, has offered mixed messages during the outbreak. He has at times downplayed the seriousness of the pandemic and encouraged public protests against his government’s own stay-at-home guidelines intended to slow the pathogen’s spread.
  • He has also urged Americans to try unproven treatments for C19, such as the malaria drug hydroxychloroquine, which he said on Monday he has taken for weeks despite warnings about its use from the FDA and other health experts.
  • The poll responses varied among certain demographic groups. Only half of black Americans, who represent a disproportionate percentage of coronavirus deaths, said they were somewhat or very interested in a vaccine, perhaps reflecting memories of an infamous U.S. government study that left black men deliberately untreated for syphilis.
  • College-educated white women – a politically important demographic that has moved sharply away from the Republican Party during the Trump era – were particularly concerned about how quickly the vaccine is being developed. More than 40% said Trump’s reassurance would make them less willing to take it.

Source: Exclusive: A quarter of Americans are hesitant about a coronavirus vaccine – Reuters/Ipsos poll 

D. Potential Treatments

1. Could interferon stop the virus?  

  • A deep dive into how the new coronavirus infects cells has found that it orchestrates a hostile takeover of their genes unlike any other known viruses do, producing what one leading scientist calls “unique” and “aberrant” changes.
  • Recent studies show that in seizing control of genes in the human cells it invades, the virus changes how segments of DNA are read, doing so in a way that might explain why the elderly are more likely to die of C19 and why antiviral drugs might not only save sick patients’ lives but also prevent severe disease if taken before infection.
  • “It’s something I have never seen in my 20 years of” studying viruses, said virologist Benjamin tenOever of the Icahn School of Medicine at Mount Sinai, referring to how the coronavirus hijacks cells’ genomes.
  • The “something” he and his colleagues saw is how the coronavirus blocks one virus-fighting set of genes but allows another set to launch, a pattern never seen with other viruses. Influenza and the original SARS virus (in the early 2000s), for instance, interfere with both arms of the body’s immune response — what tenOever dubs “call to arms” genes and “call for reinforcement” genes.
  • The first group of genes produces interferons. These proteins, which infected cells release, are biological semaphores, signaling to neighboring cells to activate some 500 of their own genes that will slow down the virus’ ability to make millions of copies of itself if it invades them. This lasts seven to 10 days, tenOever said, controlling virus replication and thereby buying time for the second group of genes to act.
  • This second set of genes produce their own secreted proteins, called chemokines, that emit a biochemical “come here!” alarm. When far-flung antibody-making B cells and virus-killing T cells sense the alarm, they race to its source. If all goes well, the first set of genes holds the virus at bay long enough for the lethal professional killers to arrive and start eradicating viruses.
  • “Most other viruses interfere with some aspect of both the call to arms and the call for reinforcements,” tenOever said. “If they didn’t, no one would ever get a viral illness”: The one-two punch would pummel any incipient infection into submission.
  • The coronavirus, however, uniquely blocks one cellular defense but activates the other, he and his colleagues reported in a study published last week in Cell. They studied healthy human lung cells growing in lab dishes, ferrets (which the virus infects easily), and lung cells from C19 patients. In all three, they found that within three days of infection, the virus induces cells’ call-for-reinforcement genes to produce cytokines. But it blocks their call-to-arms genes — the interferons that dampen the virus’ replication.
  • The result is essentially no brakes on the virus’s replication, but a storm of inflammatory molecules in the lungs, which is what tenOever calls an “unique” and “aberrant” consequence of how the coronavirus manipulates the genome of its target.
  • In another new study, scientists in Japan last week identified how the coronavirus accomplishes that genetic manipulation. Its ORF3b gene produces a protein called a transcription factor that has “strong anti-interferon activity,” Kei Sato of the University of Tokyo and colleagues found — stronger than the original SARS virus or influenza viruses. The protein basically blocks the cell from recognizing that a virus is present, in a way that prevents interferon genes from being expressed.
  • In fact, the Icahn School team found no interferons in the lung cells of C19 patients. Without interferons, tenOever said, “there is nothing to stop the virus from replicating and festering in the lungs forever.”
  • That causes lung cells to emit even more “call-for-reinforcement” genes, summoning more and more immune cells. Now the lungs have macrophages and neutrophils and other immune cells “everywhere,” tenOever said, causing such runaway inflammation “that you start having inflammation that induces more inflammation.”
  • At the same time, unchecked viral replication kills lung cells involved in oxygen exchange. “And suddenly you’re in the hospital in severe respiratory distress,” he said.
  • In elderly people, as well as those with diabetes, heart disease, and other underlying conditions, the call-to-arms part of the immune system is weaker than in younger, healthier people, even before the coronavirus arrives. That reduces even further the cells’ ability to knock down virus replication with interferons, and imbalances the immune system toward the dangerous inflammatory response.
  • The discovery that the coronavirus strongly suppresses infected cells’ production of interferons has raised an intriguing possibility taking interferons might prevent severe C19 or even prevent it in the first place, said Vineet Menachery of the University of Texas Medical Branch.
  • In a study of human cells growing in lab dishes, described in a preprint (not peer-reviewed or published in a journal yet), he and his colleagues also found that the coronavirus “prevents the vast amount” of interferon genes from turning on. But when cells growing in lab dishes received the interferon IFN-1 before exposure to the coronavirus, “the virus has a difficult time replicating.”
  • After a few days, the amount of virus in infected but interferon-treated cells was 1,000- to 10,000-fold lower than in infected cells not pre-treated with interferon. (The original SARS virus, in contrast, is insensitive to interferon.)
  • Ending the pandemic and preventing its return is assumed to require an effective vaccine to prevent infection and antiviral drugs such as remdesivir to treat the very sick, but the genetic studies suggest a third strategy: preventive drugs.
  • It’s possible that treatment with so-called type-1 interferon “could stop the virus before it could get established,” Menachery said.
  • Giving drugs to healthy people is always a dicey proposition, since all drugs have side effects — something considered less acceptable than when a drug is used to treat an illness. “Interferon treatment is rife with complications,” Menachery warned. The various interferons, which are prescribed for hepatitis, cancers, and many other diseases, can cause flu-like symptoms.
  • But the risk-benefit equation might shift, both for individuals and for society, if interferons or antivirals or other medications are shown to reduce the risk of developing serious C19 or even make any infection nearly asymptomatic.
  • Interferon “would be warning the cells the virus is coming,” Menachery said, so such pretreatment might “allow treated cells to fend off the virus better and limit its spread.” Determining that will of course require clinical trials, which are underway.

Source: Coronavirus hijacks cells in unique ways that suggest how to treat it

2. Cannabis could help prevent and treat coronavirus  

  • A team of Canadian scientists believes it has found strong strains of cannabis that could help prevent and then treat coronavirus infections, according to interviews and a study.
  • Researchers from the University of Lethbridge said that a study in April showed at least 13 cannabis plants high in CBD that appeared to affect the ACE2 pathways that the bug uses to access the body.
  • “We were totally stunned at first, and then we were really happy,” one of the researchers, Olga Kovalchuk, told CTV News.
  • The results, printed in online journal Preprints, indicated hemp extracts high in CBD may help block proteins that provide a “gateway” for C19 to enter host cells.
  • Kovalchuk’s husband, Igor, suggested cannabis could reduce the virus’ entry points by up to 70%. “Therefore, you have more chance to fight it,” he told CTV.
  • “Our work could have a huge influence — there aren’t many drugs that have the potential of reducing infection by 70 to 80%,” he told the Calgary Herald.
  • Stressing that more research was needed, the study gave hope that if proven to modulate the enzyme it “may prove a plausible strategy for decreasing disease susceptibility” as well as “become a useful and safe addition to the treatment of C19 as an adjunct therapy.”
  • Cannabis could even be used to “develop easy-to-use preventative treatments in the form of mouthwash and throat gargle products,” the study suggested, with a “potential to decrease viral entry” through the mouth.
  • “The key thing is not that any cannabis you would pick up at the store will do the trick,” Olga told CTV, with the study suggesting just a handful of more than 800 varieties of sativa seemed to help.
  • All were high in anti-inflammatory CBD — but low in THC, the part that produces the cannabis high.
  • The study, which is yet to be peer-reviewed, was carried out in partnership with Pathway Rx, a cannabis therapy research company, and Swysh Inc, a cannabinoid-based research company.
  • The researchers are seeking funding to continue its efforts to support scientific initiatives to address C19.
  • “While our most effective extracts require further large-scale validation, our study is crucial for the future analysis of the effects of medical cannabis on C19,” the research said.
  • “Given the current dire and rapidly evolving epidemiological situation, every possible therapeutic opportunity and avenue must be considered.”

Source: Scientists believe cannabis could help prevent, treat coronavirus

E. New Scientific Findings & Research

1. Older people’s noses may make them more vulnerable to coronavirus  

  • Adults’ noses may make them more vulnerable to catching coronavirus than kids — possibly explaining why cases are less prevalent among children, according to a new study.
  • The receptors that let the virus inside cells are more common in the noses of adults than children, according to a report published in the Journal of the American Medical Association.
  • Researchers from the Icahn School of Medicine at Mount Sinai looked at nasal samples from around 300 people ages 4 to 60 — which were taken for an earlier, unrelated study on asthma.
  • In the new study, the samples were evaluated for the expression of the ACE2 gene, which the virus uses as a receptor to invade the body.
  • The expression of the gene in the cells lining the nose was lowest in younger children, while it was significantly higher in the other age groups and rose with age, the researchers said.
  • “Lower ACE2 expression in children relative to adults may help explain why C19 is less prevalent in children,” the researchers wrote.
  • However, the researchers noted that the study had limitations because there were no samples from people above 60 — one of the most vulnerable groups for the virus.

Source: Older people’s noses may make them vulnerable to coronavirus

2. Taking High Doses of Vitamin D Has No Effect on C19  

  • Doctors warn that taking high doses of Vitamin D has little or no effect on C19, and they urge against taking more of the supplement than is recommended since it can have adverse health effects.
  • This update comes in the wake of people pounding down the D vitamin as a prophylactic measure, after learning that many patients with the worst symptoms and outcomes, when diagnosed with C19, have also been vitamin D deficient.
  • Countries where C19 cases have resulted in the highest death rates, are also those where more of the population has D deficiencies. Researchers have found that the sickest patients often have the lowest levels of vitamin D. These facts have led individuals who are not sick to start taking large doses of vitamin D.
Vitamin D to Treat or Prevent C19? Not true. Here is What Science Tells Us:
  • Experts say healthy blood levels of vitamin D may give some protection against the worst symptoms if you do contract C19. One possible advantage is that vitamin D can help prevent the body from experiencing the so-called “cytokine storm,” when the body’s own immune system overreacts and attacks its own cells and tissues, much like a histamine response to an allergen. But this turns out not to be the case.
  • But a new warning by doctors in the UK tells people to not overdose themselves with D to gain any potential benefits or edge against the virus. According to The Independent, hundreds of people in the UK are regularly taking toxic doses of vitamin D in supplements bought online. The pills contain up to 2,250 times the recommended daily dose, and are putting people at risk of heart and kidney problems, according to the NHS lab, which said it sees two to three overdose cases every week.
  • Scientists from the UK, Europe and the US, including experts from the University of Birmingham, have published a consensus paper warning against taking high doses of vitamin D supplementation.
  • According to the study, current research shows vitamin D has no benefit in preventing or treating C19. Its authors advise that the population adhere to Public Health England guidance on supplementation.
  • Following unverified reports that high doses of vitamin D (higher than 4000IU/d) could reduce the risk of contracting C19 and be used to successfully treat the virus, the new report published in the journal BMJ, Nutrition, Prevention and Health, investigated the current scientific evidence base on the vitamin and its use in treating infections.
  • Vitamin D is a hormone produced in the skin during exposure to sunlight, and helps regulate the amount of calcium and phosphate in the body, which are needed to keep bones, teeth and muscles healthy.
Spend Time in the Sunlight, Instead of Taking Supplements
  • “Most of our vitamin D comes from exposure to sunlight, however for many people, particularly those who are self-isolating with limited access to sunlight during the current pandemic, getting enough vitamin D may be a real challenge. Supplementing with vitamin D … should be done under the current UK guidance,”  said Professor Carolyn Greig, a co-author of the paper, also from the University of Birmingham.
  • Professor Judy Buttriss, Director General British Nutrition Foundation and a co-author of the research said: “In line with the latest … guidance on vitamin D, we recommend that people consider taking a vitamin D supplement of 10 micrograms a day during the winter months (from October to March), and all year round if their time outside is limited.
  • “Although there is some evidence that low vitamin D is associated with acute respiratory tract infections, there is currently insufficient evidence for vitamin D as a treatment for C19 and over-supplementing must be avoided as it could be harmful.”
  • Examining previous studies in this field, the scientists found no evidence of a link between high dose supplementation of vitamin D in helping to prevent or successfully treat C19 and cautioned against over-supplementation of the vitamin, without medical supervision, due to health risks. Scientists concluded that assertions about the benefit of the vitamin in treating the virus are not currently supported by adequate human studies and are based on findings from studies that did not specifically examine this area.
  • Claims of a link between vitamin D levels and respiratory tract infections were also examined by scientists. Previous studies in this area have found that lower vitamin D status is associated with acute respiratory tract infections however limitations of the findings of these studies were identified.  Findings from the majority of studies were based on data gathered from population groups in developing countries and cannot be extrapolated to populations from more developed countries due to external factors. Scientists believe that there is currently no firm link between vitamin D intake and resistance to respiratory tract infections.
Too Much Vitamin D  Can Be Harmful to Your Health
  • Vitamin D toxicity, also called hypervitaminosis D, is a rare but potentially serious condition that occurs when you have excessive amounts of vitamin D in your body.
  • Vitamin D toxicity is usually caused by taking supplements — not diet or sun exposure. Your body regulates the amount of vitamin D produced by sun exposure, and even fortified foods don’t contain enough vitamin D to worry about.
  • Too much D can lead to a buildup of calcium in your blood (hypercalcemia), which can cause nausea and vomiting, weakness, and frequent urination. Vitamin D toxicity can also lead to bone pain and kidney stones.
  • Treatment includes stopping vitamin D intake and restricting your calcium intake. Your doctor might also prescribe intravenous fluids and corticosteroids or bisphosphonates.
  • Doctors warn against taking anything more than the U.S. Recommended Dietary Allowance of 600 IU of vitamin D per day.
  • “An adequate level of vitamin D in the body is crucial to our overall health, too little can lead to rickets or the development of osteoporosis but too much can lead to an increase in calcium levels in the blood which could be particularly harmful,” Professor Sue Lanham-New, Head of the Department of Nutritional Sciences at the University of Surrey and lead author of the study, said.
  • “Levels of the vitamin in the body can also be supplemented through a nutritionally balanced diet including foods that provide the vitamin, such as fortified foods such as breakfast cereals, and safe sunlight exposure to boost vitamin D status.”
  • You can get enough vitamin D with about ten to 15 minutes of direct sunlight a day.

Source: Doctors: Taking High Doses of Vitamin D Has No Effect on COVID-19

3. Study Yields New Information Regarding Risks to Critically Ill Patients 

Background

  • This prospective observational cohort study took place at two NewYork-Presbyterian hospitals affiliated with Columbia University Irving Medical Center in northern Manhattan.
  • The researchers identified adult patients (aged ≥18 years) admitted to both hospitals from March 2 to April 1, 2020, who were diagnosed with laboratory-confirmed C19 and were critically ill with acute hypoxaemic respiratory failure, and collected clinical, biomarker, and treatment data. The primary outcome was the rate of in-hospital death.
  • Secondary outcomes included frequency and duration of invasive mechanical ventilation, frequency of vasopressor use and renal replacement therapy, and time to in-hospital clinical deterioration following admission.

Findings and Conclusions

  • Of the 1,150 critically ill adults with C19 admitted to two hospitals in New York City during the first month of the city’s outbreak, the majority were men over 60 years of age with hypertension and diabetes, nearly half had obesity, and 5% were health-care workers. 79% of patients received invasive medical ventilation (IVM) and a third received renal replacement therapy (RRT). As of April 28, 2020, 39% of patients had died in hospital.
  • Novel findings in this study include establishing independent associations between biomarkers for inflammation (IL-6) and thrombosis (D-dimer) and in-hospital mortality, as well as identifying a high incidence of critical illness among racial and ethnic minorities in the current epicenter of the C19 pandemic. Strengths of this study include prospective and complete collection of detailed clinical data and outcomes, and use of multivariable, time-varying analyses to quantify independent risk factors for in-hospital death in one of the largest studies to date of critically ill patients with C19 in the USA.
  • 257 (22%) of the 1,150 patients were critically ill with acute hypoxaemic respiratory failure. This is consistent with reports from China, Italy, and preliminary data released by the CDC, in which the incidence of ICU admission among patients admitted with C ranged from 7–26%. This high incidence of critical illness among hospitalized patients has acute implications for US hospital systems, specifically the potential need to increase ICU surge capacity in preparation for large numbers of patients requiring IMV and other forms of organ support.
  • 79% of patients received IMV during hospitalization for median durations of 27 days among survivors and 10 days among non-survivors. This included 62% of patients who initially received less invasive methods of respiratory support. Although the proportion of patients in our cohort receiving IMV was higher than that reported in observational studies from China and Washington state, it is similar to the rate recently reported from Italy, in which IMV was provided to 88% of critically ill patients with COVID-19. As in Italy, where the median ratio of PaO2 to FiO2 at ICU admission was 160, the higher proportion of patients requiring IMV in our cohort could be explained by the severity of hypoxaemia, as the median nadir PaO2 to FiO2 ratio in our population was 129.
  • In our cohort of patients with acute hypoxaemic respiratory failure, whose respiratory system compliance was severely reduced, frequency of adherence to standard-of-care lung-protective ventilation was high, as were levels of positive end-expiratory pressure. 25% of intubated patients received early neuromuscular blockade, 17% received prone positioning ventilation, and 3% received extracorporeal membrane oxygenation (ECMO). 
  • The sudden surge of critically ill patients admitted with severe acute respiratory distress syndrome initially outpaced our capacity to provide prone-positioning ventilation, which was only performed in three of eight ICUs at our institution at the start of the outbreak. We have since expanded our capacity for prone-positioning ventilation by deploying dedicated proning teams to all ICUs, including non-traditional ICU locations. The low volume of ECMO used during the study period is primarily a reflection of the low number of patients within our hospital system meeting criteria after initiating other therapies, such as lung-protective IMV and prone-positioning ventilation. As an ECMO referral center for regional hospitals, we received a moderate-to-high volume of ECMO referrals during that period, the majority of which were optimised with conventional management strategies and did not ultimately meet criteria for ECMO or were excluded on the basis of low probability of benefit.
  • As of April 28, 2020, 101 (39%) patients had died and 94 (37%) remained hospitalized. Similar to data reported elsewhere, we identified older age, cardiopulmonary comorbidities, and higher concentrations of D-dimer as independent risk factors for poor outcomes. 
  • Higher concentrations of IL-6, which have been observed among patients with C19 with more severe clinical illness, were also associated with in-hospital mortality. Although the pathogenesis of severe C19 remains to be completely understood, emerging data suggest that organ dysfunction and poor outcomes could be mediated by high concentrations of proinflammatory cytokines, including IL-6 and dysregulated coagulation and thrombosis.
  • Continued investigation of these pathological processes and the utility of their biomarkers is needed, given increasing reports of corticosteroid use and ongoing clinical trials of IL-6 receptor antagonists among critically ill patients with C19 as well as rapidly evolving guidelines for anticoagulant use in this population.
  • Consistent with data from China and Italy, hypertension was associated with poor in-hospital survival. Given the globally high burden of hypertension and emerging understanding of interactions between the coronavirus and angiotensin-converting-enzyme-2, further investigations are needed to better define a relation—if any—between hypertension, exposure to renin angiotensin aldosterone system antagonists, and severe C19.
  • 31% of patients in our cohort developed severe acute kidney injury requiring RRT during hospitalization. Consistent with emerging data from China, a high proportion of patients (87%) had proteinuria. The high frequency of RRT in our patient population has considerable implications for resource allocation, given the limited available supplies of RRT machines and consumables, and staffing requirements necessary to provide continuous or intermittent RRT to critically ill patients. As the general incidence and underlying mechanisms of severe C19-related kidney injury remain poorly understood, epidemiological, clinical, and biological investigations are necessary to inform hospital preparedness strategies and development of targeted preventive and treatment interventions.
  • 46% of critically ill patients had obesity. This observation is consistent with trends seen in hospitalized patients with C19 in the UK, where obesity has been associated with increased incidence of ICU admission and mortality. However, although obesity was more common in our adult patient population than in the general New York City adult population (where prevalence of obesity is 22%), we did not identify severe obesity (BMI ≥40) as an independent risk factor for mortality. Similar to other cardiometabolic comorbidities, further studies are needed to identify the mechanisms that mediate the association of obesity with susceptibility to or severity of C19.
  • Hydroxychloroquine or remdesivir, antiviral agents which have shown activity against the coronavirus in vitro, were administered to 81% of patients in this study. The efficacy of remdesivir among patients with severe C19 remains uncertain. A randomized, double-blind, placebo-controlled clinical trial from China reported no significant differences in time to clinical improvement or 28-day mortality among patients with laboratory-confirmed the coronavirus infection admitted to hospital receiving remdesivir.
  • However, this trial was underpowered, given a lack of patients eligible for enrolment. More recently, based on preliminary, unpublished data from an adaptive, placebo-controlled clinical trial sponsored by the US National Institute of Allergy and Infectious Diseases and an open-label trial sponsored by Gilead Sciences, the US Food and Drug Administration issued an emergency use authorization for remdesivir among severely ill inpatients with C19.
  • For hydroxychloroquine, emerging observational data from the USA have not reported signals of clinical benefit for use of this agent among inpatients with C19.
  • To better evaluate the safety and efficacy of hydroxychloroquine in this setting, investigators at Oxford University (Oxford, UK) and the US National Heart, Lung, and Blood Institute have launched randomized clinical trials among hospitalized patients with C19 in the UK  and the USA.
  • 5% of critically ill patients were health-care workers. Although nosocomial coronavirus infection cannot be determined with certainty given widespread community transmission, C19-related critical illness in these individuals highlights the risks facing frontline health-care workers in the USA, where at least 9000 health-care workers have been infected as of April 9, 2020.
  • Continued and consistent access to personal protective equipment for hospital staff is imperative to prevent nosocomial transmission, optimize health-care worker safety, and ensure an adequate workforce.
  • In conclusion, critical illness among patients admitted to hospital with C19 in New York City is common and associated with a high frequency of invasive mechanical ventilation, extrapulmonary organ dysfunction, and substantial in-hospital mortality.

Source:  Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study

4. Smokers more at risk of getting coronavirus  

  • Smokers are more at risk from the coronavirus — and more likely to get seriously ill once they are infected, according to a new study.
  • A survey of 2.4 million Britons found current smokers were 14 percent more likely to develop C19 symptoms than non-smokers.
  • The survey, by the Imperial College in London, also found that when smokers do catch the virus, they were more than twice as likely as non-smokers to need hospitalization.
  • The London survey results conform to previous studies showing smokers are more prone to catching respiratory viruses in general, since they touch their mouths more and are more likely to have damaged airways.
  • But the results run counter to other recent studies on smoking and C19.
  • Last month, a study showing lower-than-expected numbers of smokers among hospitalized C19 patients led France to ban the online sale of nicotine gum and patches, for fear of a run on the products.

Source: Smokers more at risk of getting coronavirus, new study claims

G. Lockdowns

1. How Fear, Groupthink Drove Unnecessary Global Lockdowns  

  • In the face of a novel virus threat, China clamped down on its citizens. Academics used faulty information to build faulty models. Leaders relied on these faulty models. Dissenting views were suppressed. The media flamed fears and the world panicked.
  • That is the story of what may eventually be known as one of the biggest medical and economic blunders of all time. The collective failure of every Western nation, except one, to question groupthink will surely be studied by economists, doctors, and psychologists for decades to come.
  • To put things in perspective, the virus is now known to have an infection fatality rate for most people under 65 that is no more dangerous than driving 13 to 101 miles per day. Even by conservative estimates, the odds of C19 death are roughly in line with existing baseline odds of dying in any given year.
Laurence Fox 🥦 on Twitter: "I know it's not going to happen ...
  • Yet we put billions of young healthy people under house arrest, stopped cancer screenings, and sunk ourselves into the worst level of unemployment since the Great Depression. This from a virus that bears a survival rate of 99.99% if you are a healthy individual under 50 years old.
  • New York City reached over a 25% infection rate and yet 99.98% of all people in the city under 45 survived, making it comparable to death rates by normal accidents.
  • But of course the whole linchpin of the lockdown argument is that it would have been even worse without such a step. Sweden never closed down borders, primary schools, restaurants, or businesses, and never mandated masks, yet 99.998% of all  their people under 60 have survived and their hospitals were never overburdened. 
  • Why did we lock down the majority of the population who were never at significant risk? What will be the collateral damage? That is what this series will explore.

Experts took a measured approach early on

  • In early February the World Health Organization said that travel bans were not necessary. 
  • On Feb. 17, just a month before the first U.S. lockdown, Dr. Anthony Fauci, the longtime director of the National Institute of Allergy and Infectious Diseases said that this new strain of coronavirus possessed “just minuscule” danger to the United States. 
  • In early March the U.S. surgeon general said that “masks are NOT effective in preventing [the] general public from catching coronavirus.” 
  • As late as March 9, the day Italy started its lockdown, Dr. Fauci did not encourage cancellation of “large gatherings in a place [even if] you have community spread,” calling it “a judgment call.” NBA games were still being played.
  • So how did we go from such a measured tone to locking up 97% of Americans in their homes seemingly overnight?

Enter faulty assumptions and faulty models

  • China concealed the extent of the viral outbreak, which, if you believed its data, led many scientists to believe that 2% to 5% of all infected patients would die. 
  • This turned out to be off by a factor of 10, but academic epidemiologists have a history of wildly-off-the-mark doomsday predictions.
ICU with mitigation strategies

Politicians claim lockdowns were the cause of fewer deaths

  • It would be highly embarrassing to force citizens to quarantine themselves only to later admit it was all a colossal blunder, so it is easier for politicians and modelers to claim the lower death rates were based on the lockdowns themselves. It was a success!
  • But several inconvenient thorns keep bursting that narrative — and none larger than Sweden,  the only Western country not to lock down its citizens. Sweden never closed borders, restaurants, businesses, or primary schools. The only legal action officials took was to ban events that entail crowds larger than 50 people.
  • One of the most well-known and respected models in the United States is from the Institute for Health Metrics and Evaluation and is commonly cited by the White House. Since the IHME model accounts for lockdowns and social distancing, or lack thereof, they should be validated by their predictions on Sweden.
  • Below is a screenshot of the IHME model for Sweden taken on May 3, along with actual results (black line). The model predicted up to 2,800 daily deaths within 11 days and a final death total as high as 75,000 if Sweden didn’t enact strict social distancing measures.
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  • These were not complicated long-term projections; they were predicting what would happen in the next two weeks based on months of data. Yet the daily death peak was 75% lower than the baseline prediction and 96% lower than the worst-case prediction.
  • Not to be outdone, Uppsala University (the oldest university in Sweden) also presented a model that could have caused the Swedes to abandon course and lock down as the U.K. did. However, Sweden did not buckle. While the Uppsala University model predicted 90,000 deaths within a month, the actual result was around 3,500.
http://assets.realclear.com/images/51/510642_5_.jpeg
  • Besides deaths, there were also doomsday projections about hospital capacity, but those models also proved to be grotesquely exaggerated. 
  • On March 29, Columbia University projected a need for 136,000 hospital beds in New York City. The maximum ever used was under 12,000. At peak, New York City still had around 1 in 6 hospital beds open and around 1 in 10 ICU beds open. Hospitals had capacity, both in New York City and in Sweden.
  • While far below projections, Sweden’s short-term results are worse than Norway, Finland, and Denmark, but better than the U.K., France, Spain, Italy, and Belgium. Sweden likely also benefits from longer-term herd immunity, faster economic recovery, and fewer deaths from lockdown collateral damage.

Political leaders ignored early evidence when it conflicted with their models

  • There are those who say that we couldn’t have known these outcomes early on, so even if lockdowns were unjustified later they were still necessary early due to lack of information. That is plainly false. 
  • Italy’s alarming number of deaths fanned many of the early fears across the world, but by March 17 it was clear that the median age of Italian deaths was over 80 and that not a single person under 30 had died in that country. Furthermore, it was known that 99% of those who died had other existing illnesses.
  •  
http://assets.realclear.com/images/51/510643_5_.jpg
  • A much more rational strategy would have been to lock down nursing homes and let young healthy people out to build immunity. 
  • Instead we did the opposite, we forced nursing homes to take C19 patients and locked down young people. 
  • There are now places like Santa Clara County in California, entering its third month of lockdown despite C19 patients occupying less than 2% of hospital capacity and none on ventialtors. Yet there are 2 million county residents effectively under house arrest. Some doctors and nurses in the area had their pay cut by 20% so hospitals could avoid bankruptcy, reflecting perhaps the epitome of this senseless catastrophe.
  • There were, of course, people warning us all along. Among them was as John P.A. Ioannidis of Stanford University School of Medicine, who ranks among the world’s 100 most-cited scientists on Google Scholar. 
  • On that pivotal day of March 17 he released an essay titled “A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data” — but it got little attention. Mainstream media was not interested in good news stories or dissenting views. The world instead marched lock step into its man-made calamity.

Source: How Fear, Groupthink Drove Unnecessary Global Lockdowns

G. Reopenings: Progress & Setbacks

1. Former WHO doctor says coronavirus cases are not increasing as expected in areas that reopen  

“It’s as though something has changed, and none of us can explain why.”

  • A former official of the World Health Organization said on Tuesday evening that there has not been an increase in coronavirus cases around the world as countries and societies begin to lift restrictions.
  • “As you look at all the data around the world where people have come out of lockdowns, things are actually going along quite nicely on the whole, and it’s strange,” Professor Karol Sikora, an oncologist and professor at the University of Buckingham Medical School, said during an appearance on Laura Ingraham’s show. “It’s as though something has changed, and none of us can explain why.”
  • When asked about increasing immunity to the virus, Sikora said, “there are almost certainly other immune mechanisms going on, including T-cells, helper cells, natural killer cells, a whole range of things that we don’t understand as well as we understand antibodies.” 
  • In reference to the antibody tests that have become popular, Sikora observed, “You measure what you can see, rather than what you probably really need to measure.”
  • Sikora is skeptical of the “doom-laden theories” about a second wave of the virus coming in the fall. He says that sometimes a pandemic’s conclusion can be mysterious and initially difficult for the medical and scientific communities to understand. “We’ve seen them peter out, we don’t understand this petering out, despite all the very sophisticated computer mathematical models we’ve seen, we just don’t know what’s going to happen.” 

Source: Former WHO doctor says coronavirus cases are not increasing as expected in areas that reopen

2. Maryland reopens—and quickly sees its largest spike in C19cases  

  • Maryland reported its highest number of new C19 cases on Tuesday—just four days after the state began easing public health restrictions aimed at thwarting the spread of disease.
  • Though state officials note that an increase in testing and a backlog of test results may partly explain the spike, the case counts overall suggest that disease transmission has not declined in the lead-up to re-opening—and transmission could very easily increase as residents begin venturing into public spaces more frequently.
  • Maryland’s outcome may hold lessons for other states attempting their own reopening. As of today, May 20, all 50 states have begun easing restrictions at some level, according to The Washington Post.
  • In Maryland, officials reported 1,784 newly confirmed C19 cases on Tuesday. That figure surpasses the previous highest daily toll on May 1 of 1,730 new cases. Otherwise, the state’s other high daily tolls are around 1,200 new cases.
  • In the 24-hour period in which the spike was reported, the Old Line State also reported that 5,368 people had tested negative, according to NPR. That means that about 25 percent of tests from that time frame were positive for the disease.
  • Health experts generally consider a positive rate of 10% or less as a benchmark indicating that an area is performing enough testing and has a good handle on the state of an outbreak.
  • Despite the new cases and the fact that it is under a state of emergency, Maryland began reopening businesses last Friday. Retailers, churches, and hair salons were allowed to reopen at 50% capacity under a Safer at Home policy.
  • Republican Gov. Larry Hogan made the decision given that hospitalizations and hospital bed occupancy were either stable or in decline, as NPR noted. He also said the state had the means to perform contact tracing for up to 1,000 cases per day—a figure that was significantly surpassed on Tuesday.
  • In total, Maryland has confirmed over 42,000 cases and over 2,000 deaths. Many of those are in a corridor stretching from Baltimore to Washington, DC. Montgomery County, Maryland, which borders Northwest DC, reported 533 of the state’s 1,784 new cases Tuesday, for instance.
  • The DC metro area in particular has had a hard time shaking the outbreak. Reuters reported Tuesday that a senior White House official said that the DC metro area—along with Chicago, Los Angeles, and Minneapolis—remains in an unexpected “plateau” of C19 transmission.

Source: Maryland reopens—and quickly sees its largest COVID-19 spike 

H. The Road Back?  

1. Restaurants prepare for “distance eating”  

  • Shorter menus, pricier food, less service, servers wearing masks and surgical gloves: The future of dining out looks far from festive.
  • Why it matters: Eating in restaurants is a creature comfort that matters a lot to many people, and the fact that the experience won’t just go back to normal will unnerve and disappoint everyone who wishes the coronavirus would simply go away.
  • A lot of restaurants that closed because of C19 will never reopen, and those that do will have to pour a lot of money into keeping diners away from one another and the wait staff, according to restaurateurs and industry consultants.
  • Tables and booths will be separated by everything from plexiglass shields to clear shower curtains.
  • Diners may have to wait in their cars or on the sidewalk for a text saying their table is ready.
  • People may have to order their whole meal — from appetizers through dessert — all at once, to minimize encounters with the staff.
  • Paper tablecloths will replace fabric ones, condiments won’t be left on the table, and disposable plates and glasses may reign supreme.
  • “It’s not going to be as romantic as it has been in the past,” Larry Lynch of the National Restaurant Association tells Axios.
  • Driving the news: Restaurant executives met with President Trump this week to ask him to boost federal assistance.
  • The OpenTable CEO predicts that 25% of restaurants will close permanently.
  • Tom Colicchio, the “Top Chef” star, co-founded a group called the Independent Restaurant Coalition to lobby for small eateries affected by C19.
  • “At least for the next year, until there’s a vaccine… we’re looking at a possibility of maybe 30% of our original business,” which is unsustainable, Coliccio said in an NPR interview.
  • Between the lines: While some restaurants have stayed in business during the pandemic by selling takeout food, meal kits and even groceries, the industry’s economics are predicated on table service, which will likely look very different.
  • Occupancy restrictions will mean that restaurants can serve only a fraction of the number of people they did before. (In Florida, for instance, re-opening restaurants must operate at no more than 25% capacity.)
  • As a result, there will be pressure to turn tables quickly, and “peak” service hours will be expanded. The lunch rush will likely happen from 11 a.m. to 3 p.m., and dinner from 5 p.m. to 11 p.m.
  • To make ends meet, restaurants will have to streamline their menus, offering perhaps half as many dishes as they used to — the most lucrative ones, most likely — and prices will have to be jacked up.
  • Will consumers play along? After the initial burst of interest in going out to eat again subsides, it’s hard to tell, industry consultants say.
  • “We don’t know if they’re going to accept a 15% price increase,” David Hopkins, president of the Fifteen Group, a hospitality management consultancy, tells Axios. “We don’t know if they’ll be okay with going out to lunch at 11:15 instead of noon.”

Here’s what else you can expect:

  • Less frequent busing of tables, to avoid contact. Patrons will likely be asked to wear masks on their way to their table or when visiting the restroom (though not while actually eating).
  • To meet demand for “distanced” tables, some restaurants are seeking to expand into sidewalk cafes.
  • Some are converting event spaces into regular dining rooms, or putting up tents in parking lots to add extra tables. One restaurant in Amsterdam installed striking glass tents, one for each party of diners.
  • Restaurants will continue to lean heavily on takeout as a revenue engine.
  • From a social distancing perspective, “the biggest challenge is going to be the bar,” Clark Wolf, a food, restaurant, and hospitality consultant, told Axios. “We’re going to have to find other ways of having cocktails, because that is such a profitable part of the business.”
  • The bottom line: The fun and relaxing atmosphere we’ve come to expect from dining out may be lost — along with many neighborhood favorites.
  • “Many mom and pops are just not going to reopen, no matter how much money is thrown at them by the government,” Doug Roth, a former restaurateur who now serves as an adviser to the industry, tells Axios. “And once they’re open, what is the attractiveness of going out to eat?”

Source: The future of dining: shorter menus, pricier food, less service 

2. Estonia starts testing digital immunity passport for workplaces  

  • Estonia has started to test one of the world’s first digital immunity passports, created by a team including founders of global tech startups Transferwise and Bolt, seeking a safer return to workplaces following the coronavirus lockdown.
  • A digital immunity passport collects testing data and enables people to share their immunity status with a third party, like an employer, using a temporary QR-code generated after digital authentication.
  • “Digital immunity passport aims to diminish fears and stimulate societies all over the globe to move on with their lives amidst the pandemic,” said Taavet Hinrikus, founder of Transferwise and a member of Back to Work, the non-governmental organisation developing the passport.
  • Many countries and businesses are rushing to develop apps for contact-tracing.
  • The World Health Organization (WHO) has warned governments against issuing immunity passports as there was no evidence that people who have recovered from C19 and have antibodies and are protected from a second coronavirus infection.
  • Hinrikus said the team’s passport could help once immunity is better understood.
  • “We don’t know many details and nuances about immunity yet. How strong is it, how long does it last? We hope that we can evolve simultaneously with scientists who are seeking answers,” he said.
  • In addition to technology entrepreneurs, Back to Work includes local medical experts and state officials. Radisson hotels and food producer PRFoods are among the first companies that have started to test the passport.
  • “We are seeking every solution to have our employees back to work and clients sleeping in our hotels again,” said Kaido Ojaperv, CEO of Radisson Blu Sky Hotel at Tallinn.
  • Estonia, which has so far recorded 64 deaths due to C19 and 1,791 infections, has started to ease the lockdown measures this month, and opened last week with Lithuania and Latvia the first “travel bubble” within the European Union.

Source: Estonia starts testing digital immunity passport for workplaces 

3. Ten reasons why immunity passports are a bad idea 

  • Imagine a world where your ability to get a job, housing or a loan depends on passing a blood test. You are confined to your home and locked out of society if you lack certain antibodies.
  • It has happened before. For most of the nineteenth century, immunity to yellow fever divided people in New Orleans, Louisiana, between the ‘acclimated’ who had survived yellow fever and the ‘unacclimated’, who had not had the disease. Lack of immunity dictated whom people could marry, where they could work, and, for those forced into slavery, how much they were worth. Presumed immunity concentrated political and economic power in the hands of the wealthy elite, and was weaponized to justify white supremacy.
  • Something similar could be our dystopian future if governments introduce ‘immunity passports’ in efforts to reverse the economic catastrophe of the C19 pandemic. The idea is that such certificates would be issued to those who have recovered and tested positive for antibodies to the coronarvirus. Authorities would lift restrictions on those who are presumed to have immunity, allowing them to return to work, to socialize and to travel. This idea has so many flaws that it is hard to know where to begin.
  • On 24 April, the World Health Organization (WHO) cautioned against issuing immunity passports because their accuracy could not be guaranteed. It stated that: “There is currently no evidence that people who have recovered from C19 and have antibodies are protected from a second infection”(see go.nature.com/3cutjqz). Nonetheless, the idea is being floated in the United States, Germany, the United Kingdom and other nations.
  • China has already introduced virtual health checks, contact tracing and digital QR codes to limit the movement of people. Antibody test results could easily be integrated into this system. And Chile, in a game of semantics, says that it intends to issue ‘medical release certificates’ with three months’ validity to people who have recovered from the disease.
  • In our view, any documentation that limits individual freedoms on the basis of biology risks becoming a platform for restricting human rights, increasing discrimination and threatening — rather than protecting — public health. Here we present ten reasons why immunity passports won’t, can’t and shouldn’t be allowed to work.
Ten points
  • Four huge practical problems and six ethical objections add up to one very bad idea.
  • C19 immunity is a mystery.  Recent data suggest that a majority of recovered patients produce some antibodies against the coronavirus. But scientists don’t know whether everyone produces enough antibodies to guarantee future protection, what a safe level might be or how long immunity might last. Current estimates, based on immune responses to closely related viruses such as those that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), suggest that recovered individuals could be protected from re-infection for one to two years. But if the coronavirus immunity instead mimics that seen with the common cold, the protection period could be shorter.
  • Serological tests are unreliable. Tests to measure coronavirus antibodies in the blood can be a valuable tool to assess the prevalence and spread of the virus. But they vary widely in quality and efficacy. This has led the WHO and former FDA commissioner Scott Gottlieb to caution against their use in assessing individual health or immune status. Several available tests are sufficiently accurate, meaning they are validated to have at least 99% specificity and sensitivity. But preliminary data suggest that the vast majority aren’t reliable. Low specificity means the test measures antibodies other than those that are specific to the coronavirus. This causes false positives, leading people to think they are immune when they aren’t. Low sensitivity means that the test requires a person to have a high concentration of coronavirus antibodies for them to be measured effectively. This causes false negatives in people who have few antibodies, leading to potentially immune individuals being incorrectly labelled as not immune.
  • The volume of testing needed is unfeasible. T ens to hundreds of millions of serological tests would be needed for a national immunity certification program. For example, Germany has a population of nearly 84 million people, so would require at least 168 million serological tests to validate every resident’s C19 immune status at least twice. Two tests per person are the minimum, because anyone who tested negative might later become infected and would need to be retested to be immune certified. Repeat testing, on no less than an annual basis, would be necessary to ensure ongoing immunity. From June, the German government will receive 5 million serological tests a month from the Swiss firm Roche Pharmaceuticals — a leading supplier of one coronavirus serological test that has been approved by regulators. This will allow only 6% of the German population to be tested each month.
  • Even if immunity passports were limited to health-care workers, the number of tests required could still be unfeasible. The United States, for example, would need more than 16 million such tests. At the time of writing, the US Centers for Disease Control and Prevention and US public-health laboratories have performed more than 12 million diagnostic tests for the coronavirus (3% of the total US population; see go.nature.com/2wemdd2). Even South Korea, a country with high testing rates, had managed to test only 1.5% of its population by 20 May (see go.nature.com/2aztfvp).
  • Too few survivors to boost the economy. The proportion of individuals known to have recovered from C19 varies widely in different populations. Reports from hot spots in Germany and the United States suggest some locations could have recovery rates between 14% and 30%. In New York state, for example, where 3,000 people were tested at random in grocery shops and other public locations, 14.9% had antibodies against C19 (see go.nature.com/2waaku9). But these seem to be the exception. In an April press conference, the WHO estimated that only 2–3% of the global population had recovered from the virus.
  • Low disease prevalence combined with limited testing capacity, not to mention highly unreliable tests, means that only a small fraction of any population would be certified as free to work. Based on current numbers of confirmed US cases, for example, only 0.43% of the population would be certified. Such percentages are inconsequential for the economy and for safety. A cafe can’t open and serve customers without risk if only a fraction of its staff are certified as immune. A shop can’t turn a profit if only a minuscule proportion of customers are allowed to enter.
  • Monitoring erodes privacy. The whole point of immunity passports is to control movement. Thus, any strategy for immunity certification must include a system for identification and monitoring. Paper documentation could be vulnerable to forgery. Electronic documentation integrated into a smartphone app would be more resistant to fraud and more effective for contact tracing, retesting and updates of immune status.
  • But electronic documents present a more serious risk to privacy. In some Chinese provinces, QR codes on smartphones control entrance into public places on the basis of the individual’s C19 health status. However, these apps report more than C19 information — including people’s locations, travel history, who they’ve come into contact with and other health information, ranging from their body temperature to whether they’ve recently had a cold. Taiwan is also using smartphone apps with alert systems that are directly linked to police departments. The United Kingdom, United States and many other countries are testing various app options. Yet there’s no guarantee that the apps will recede when C19 does. China has announced that elements of its QR-code tracking system are likely to remain in place after the pandemic ends.
  • Marginalized groups will face more scrutiny. With increased monitoring comes increased policing, and with it higher risks of profiling and potential harms to racial, sexual, religious or other minority groups. During the pandemic, China has been accused of racially profiling residents by forcing all African nationals to be tested for the virus. In other parts of the world, people from Asia have faced spikes in racialized prejudice.
  • Before this pandemic, stop-and-frisk laws in the US already disproportionately affected people of color. In 2019, 88% of people who were stopped and searched in New York City were African American or Latin American (go.nature.com/2jntjym). And during the pandemic, policing continues to target people from minority groups. Between mid-March and the start of May in Brooklyn, New York, 35 of the 40 people arrested for violating physical distancing laws were black6.
  • These numbers are deeply concerning, but would be even more so if monitoring and policing for C19 immunity were to be used for ulterior motives. For example, ‘digital incarceration’ has already increased in countries such as the United States, Brazil and Iran, where individuals have been released from prison to minimize the spread of C19 and then monitored using digital ankle bracelets. In the United States, where people of colour are racially segregated by neighbourhood and disproportionately incarcerated, digital incarceration could be used to monitor large segments of certain communities. The risk would be even higher if digital monitoring were to be linked to immigration status.
  • Unfair access. With a shortage of testing, many will not have access. Experience so far suggests that the wealthy and powerful are more likely to obtain a test than the poor and vulnerable. In tiered health-care systems, these inequities are felt even more acutely. In early March, for example, when professional sports teams, technology executives and film celebrities were getting tested, dozens of US states were conducting fewer than 20 tests per day (see https://covidtracking.com/data). The very people who need to get back to work most urgently — workers who need to keep a roof over their head and food on the table — are likely to struggle to get an antibody test. Testing children before they return to school could be a low priority, as would testing retired older people and those who face physical, mental-health or cognitive challenges.
  • Societal stratification. Labelling people on the basis of their C19 status would create a new measure by which to divide the ‘haves’ and the ‘have-nots’ — the immunoprivileged and the immunodeprived. Such labelling is particularly concerning in the absence of a free, universally available vaccine. If a vaccine becomes available, then people could choose to opt in and gain immune certification. Without one, stratification would depend on luck, money and personal circumstances. Restricting work, concerts, museums, religious services, restaurants, political polling sites and even health-care centers to C19 survivors would harm and disenfranchise a majority of the population.
  • Social and financial inequities would be amplified. For example, employers wanting to avoid workers who are at risk of becoming unwell might privilege current employees who have had the disease, and preferentially hire those with ‘confirmed’ immunity.
  • Immunity passports could also fuel divisions between nations. Individuals from countries that are unable or unwilling to implement immunity passport programmes could be barred from travelling to countries that stipulate them. Already people with HIV are subjected to restrictions on entering, living and working in countries with laws that impinge on the rights of those from sexual and gender minorities — such as Russia, Egypt and Singapore.
  • New forms of discrimination. Platforms for coronavirus immune certification could easily be expanded to include other forms of personal health data, such as mental-health records and genetic-test results. The immunity passports of today could become the all-encompassing biological passports of tomorrow. These would introduce a new risk for discrimination if employers, insurance companies, law-enforcement officers and others could access private health information for their own benefit. Such concerns have been catalogued over the past few years in debates about who should have access to genetic information, as demand rises from clinicians, researchers, insurers, employers and law enforcers, for example.
  • Threats to public health.  Immunity passports could create perverse incentives. If access to certain social and economic liberties is given only to people who have recovered from C19, then immunity passports could incentivize healthy, non-immune individuals to wilfully seek out infection — putting themselves and others at risk. Economic hardship could amplify the incentive if an immunity passport is the only way to a pay cheque. Individuals might obtain documents illicitly, through bribery, transfer between individuals or forgery. These could create further health threats, because people claiming immunity could continue to spread the virus. Crises tend to foster nefarious trade, as happened during the Second World War when food rations in Britain caused the emergence of a robust underground exchange system.
Next steps
  • Strategies that focus on the individual — using conceptions of ethics rooted in libertarianism — contradict the mission of public health. They distract attention from actions that benefit all, such as funding international collaborations, practising effective public-health measures and redressing income inequity. In North America (and elsewhere), because of structural inequities, people of colour are dying from C19 at much higher rates than are white people, and the virus is disproportionately affecting those who live in First Nations territories. Success depends on solidarity, a genuine appreciation that we are all in this together. An ethic premised on individual autonomy is grossly inappropriate during a public-health crisis; the overarching aim must be to promote the common good.
  • Instead of immunity passports, we contend that governments and businesses should invest available time, talent and money in two things.
  • First is the tried and true formula of pandemic damage limitation — test, trace and isolate — that has worked well from Singapore and New Zealand to Guernsey and Hanoi. Health status, personal data and location must be anonymized. Apps that empower individuals to make safe choices about their own movements should be prioritized.
  • Second is the development, production and global distribution of a vaccine for the coronavirus. If universal, timely, free access to a vaccination becomes possible, then it could be ethically permissible to require vaccine certification for participation in certain activities. But if access to a vaccine is limited in any way, then some of the inequities we highlight could still apply, as the literature on uptake of other vaccines attests.
  • Threats to freedom, fairness and public health are inherent to any platform that is designed to segregate society on the basis of biological data. All policies and practices must be guided by a commitment to social justice.

Source: Ten reasons why immunity passports are a bad idea 

J. Projections & Our (Possible) Future  

1. Model Says Lockdown Delays Caused 36,000 More Deaths  

  • Modelers find that tens of thousands of U.S. deaths could have been prevented.
  • If the United States had begun imposing social-distancing measures one week earlier in March, about 36,000 fewer people would have died in the pandemic, according to new estimates from Columbia University disease modelers.
  • And if the country had begun locking down cities and limiting social contact on March 1, two weeks earlier than when most people started staying home, a vast majority of the nation’s deaths — about 83 percent — would have been avoided, the researchers estimated.
  • The enormous cost of waiting to take action reflects the unforgiving dynamics of the outbreak that swept through American cities in early March. Even small differences in timing would have prevented the worst exponential growth, which by April had subsumed New York City, New Orleans and other major cities, the researchers found.
  • “It’s a big, big difference,” said Jeffrey Shaman, an epidemiologist at Columbia and the leader of the research team. “That small moment in time, catching it in that growth phase, is incredibly critical in reducing the number of deaths.”
  • The findings are based on infectious-disease modeling that gauges how reduced contact between people starting in mid-March slowed transmission of the virus.
  • On March 16, President Trump urged Americans to limit travel, avoid groups and stay home from school. Mayor Bill de Blasio of New York City closed schools on March 15, and Gov. Andrew M. Cuomo of New York issued a stay-at-home order that took effect on March 22.
  • But in cities like New York, where the virus arrived early and spread quickly, those actions were too late to avoid a calamity. Dr. Shaman’s team modeled what would have happened if those same changes had taken place one or two weeks earlier and estimated the spread of infections and deaths until May 3.
  • The results show that as states reopen — all 50 states had eased restrictions somewhat as of Wednesday — outbreaks can easily get out of control unless officials closely monitor infections and immediately clamp down on new flare-ups.
  • And they show that each day that officials waited to impose restrictions in early March came at a great cost.

Source: Coronavirus Live Updates: All 50 States Have Begun to Reopen to Some Degree 

Annex I. John Hopkins Daily C19 Updates

May 21, 2020

EPI UPDATE The WHO COVID-19 Situation Report for May 20 reports 4.79 million confirmed cases (57,804 new) and 318,789 deaths (2,621 new). After several days of reported incidence of nearly or more than 100,000 new cases, today’s update is much lower. The global total incidence could reach 5 million cases by Friday or Saturday.

At the global level, the relative proportion of COVID-19 cases continues to shift away from Europe and North America and toward Africa, South America, and Asia. After at one point peaking at more than 75% of the global COVID-19 daily incidence, new case in Europe now represent less than 15% of the daily total. Similarly, North America, driven largely by the United States, represented nearly 45% of the global total in early April, and now constitutes slightly more than 25%. For reference, Europe and North America represent approximately 9.6% and 4.7% of the global population, respectively. Asia and South America have steadily increased their relative contribution to the global incidence, up to nearly 25% for Asia and more than 30% for South America. Africa is slowly but steadily increasing as well, now up to approximately 4% of the global total.

Brazil reported 19,951 new cases, its highest daily incidence to date and an increase of more than 2,500 (14.6%) compared to the previous high reported yesterday. Brazil is now #3 globally in terms of total incidence, and it could potentially surpass Russia to become #2 by early next week. Brazil’s daily per capita incidence is now more than 20% greater than the United States’. The per capita incidence in Peru and Chile is even higher, however, with Peru reporting nearly 120 new cases per million population each day and Chile reporting 172, more than double Brazil’s current per capita daily incidence. Like Brazil, the daily incidence in Peru and Chile are also increasing rapidly.

Russia reported 8,849 new cases, its second consecutive day with fewer than 9,000 new cases. After peaking at more than 11,000 new cases in mid-May, Russia’s daily incidence has decreased over the past week. India reported 5,609 new cases, continuing its recent trend of elevated and increasing daily incidence. On a per capita basis, India’s daily incidence is still well below the global average; however, the increasing trend is concerning. The state of Tamil Nadu, where a large outbreak has been linked to one of Asia’s largest markets, reported 743 new cases.

Singapore reported 448 new cases, including 434 (96.8%) among residents of migrant worker dormitories. Outbreaks in migrant worker dormitories continue to drive Singapore’s growing COVID-19 epidemic. Singapore estimates that the cases confirmed so far represent 8.53% of the total population across all migrant worker dormitories, compared to only 0.03% of the general public population. Of the total confirmed cases reported in Singapore, 92.4% are among residents of migrant worker dormitories.

UNITED STATES

The US CDC reported 1.53 million total cases (23,405 new) and 91,664 deaths (1,324 new). Daily COVID-19 deaths in the United States are declining, but the total could potentially reach 100,000 deaths in the next 6-8 days. In total, 10 states (no change) reported more than 40,000 cases, including New York with more than 350,000; New Jersey with more than 125,000; and California, Illinois, and Massachusetts with more than 75,000.

The New York Times continues to track state-level COVID-19 incidence, with a focus on state policies regarding social distancing. This tracker now differentiates between states that have relaxed social distancing measures statewide and those that have done so on a regional basis.

The Johns Hopkins CSSE dashboard is reporting 1.56 million US cases and 93,606 deaths as of 11:30am on May 21.

US MEDICAL SUPPLY CHAIN The US government awarded a 4-year, US$354 million contract to a startup pharmaceutical company to establish and operate domestic production capacity for various generic drugs and active pharmaceutical ingredients (APIs). The contract, awarded through the Biomedical Advanced Research and Development Authority to Phlow Corp., aims to shift production of critical pharmaceuticals back to the United States in order to reduce reliance on foreign production and build a domestic inventory of APIs and surge production capacity for future emergencies. Many generic drugs and APIs used in the United States are currently produced overseas, particularly in China and India, and the COVID-19 pandemic has highlighted the vulnerability of these supply chains to major global health emergencies. The contract could be extended for up to a total of 10 years and $812 million.

In another effort to streamline the domestic medical supply chain, the US Department of Health and Human Services is considering a program to implement a centralized public-private management infrastructure for the Strategic National Stockpile (SNS). The Office of the Assistant Secretary for Preparedness and Response posted a request for information to solicit public input regarding the program’s “strategy and structure” and the role of public-private partnerships in managing the SNS. The program, referred to as NextGen SNS, looks to streamline procurement, inventory management, and distribution of critical stockpiles supplies and equipment during health emergencies, which have been identified as barriers to the US COVID-19 response.

NEW YORK COVID-19 EPIDEMIOLOGY A study published in The Lancet evaluated the clinical records from 1150 hospitalized patients at 2 Manhattan (New York, US) hospitals. Of the 1,150 patients included in the study, 257 (22%) were critically ill. Out of those critically ill patients, 212 (82%) had at least 1 chronic condition, most commonly hypertension, obesity, and diabetes. The study also found that people of color came to the hospital later in the course of their disease compared to white patients.

COVID-19 ALERT LEVELS Resolve to Save Lives released a color-coded COVID-19 alert system to signify the risk of transmission in communities and recommend appropriate levels of individual precautions. Dr. Tom Frieden, former director of the US CDC, likened this system to wildfire risk level signs on hiking trails or ocean hazard flags on beaches; it is up to individuals reading these signs to understand the risk level around them and act accordingly. This system includes four levels ranging from “new normal” to “high alert,” with corresponding measures that communities and individuals can take at each level to mitigate transmission risk. COVID Exit Strategy, a collaborative COVID-19 data visualization website, has incorporated live data into the Resolve to Save Lives system to make a state-by-state alert system, including metrics for 3 key areas: disease situation, healthcare systems, and disease control. Notably, every US state is evaluated as High Alert as of today, even as all states begin to ease social distancing measures.

DOWNSTREAM EFFECTS We continue to describe a variety of second- and third-order effects of the COVID-19 pandemic, with a focus on impacts on health beyond COVID-19 cases and deaths. We have noted previously that emergency department (ED) volume has decreased since the onset of the US epidemic and implementation of community mitigation measures. A substantial portion of this decrease is due to fewer trauma patients, which is believed to be, in part, a result of fewer cars on the roads and fewer automobile collisions. The sharp decline in trauma patients has led to an associated decline in available organs for transplants. We also noted previously that EDs are reporting decreases in the number of stroke and heart attack patients as well, another major source of organ donations. Additionally, donor patients are often kept on ventilators and other life support to keep the organs viable until a recipient can be identified and the transplant surgery scheduled, but there is concern in some areas that these ventilators could be needed for COVID-19 patients. Overall, transplant surgeries in the United States reportedly decreased by more than 50% compared to this time last year.

SWEDEN SEROLOGICAL STUDY Sweden’s Public Health Authority announced preliminary results from a serological study, based on more than 1,100 specimens collected across 9 regions. The study is ongoing and aims to collect 1,200 specimens per week over an 8-week period. The preliminary results described in the press release correspond to Week 18 (April 27-May 3). During that period, 7.3% of participants in Stockholm had SARS-CoV-2 antibodies, the highest of the regions tested. The press release included results from two other regions—4.2% in Skåne and 3.7% in Västra Götaland. Among the specimens tested, participants aged 20-64 years had the highest seroprevalence (6.7%), followed by 0-19 years (4.7%) and 65-70 years (2.7%). Sweden has previously reported results of studies conducted using molecular tests (e.g., PCR). Molecular tests only detect active infection, whereas serological testing can identify individuals who were previously infected. Sweden has been criticized for not implementing more restrictive mandatory community mitigation measures. Sweden continues to report elevated per capita incidence compared to most of Europe, and its daily per capita deaths is currently the highest in Europe.

PITFALLS OF IMMUNITY PASSPORTS The concept of “immunity passports” based on COVID-19 antibody testing has been the subject of much discussion. The authors of a recent Nature commentary argue against the use of such passports for both practical and ethical reasons. On the practical side, little is known about the durability of immunity in individuals who recover from SARS-CoV-2 infection, and the scale at which serological testing would need to be conducted for such a program would be enormous. Rather than focus resources and efforts on a system of immunity passports, the authors recommend that governments should instead redouble efforts on testing, contact tracing, and vaccine development. Although the WHO has recommended against the use of immunity passports, some countries are still reportedly considering them as an option to bolster efforts to relax community mitigation measures. For example, Estonia has reportedly started testing digital immunity passports, which would enable individuals to temporarily share their “immune status” with a third party through a smartphone app, although it is unclear how this status would be determined. Chile is reportedly planning to offer “virus-free” certificates to certify that an individual has recovered from COVID-19. One health official maintained this would certify that the individual was fully recovered and has completed the associated isolation period; the certificates will not serve the same purpose as an immunity passport.

HOST FACTORS A recent study published in Nature found that host factors were better determinants of severe disease than variations in viral genetics. The study included analysis of molecular and immunologic data from 326 COVID-19 patients from Shanghai, China. Phylogenetic analysis was performed with 221 samples from the GISAID database. With 2 major lineages of SARS-CoV-2 currently circulating, some experts have expressed concern that genetic differences between these lineages could have implications for transmissibility or pathogenicity. This study found no significant differences in transmissibility or in clinical manifestations between patients infected with the 2 different lineages. Instead, the levels of cytokines IL-6 and IL-8 and T lymphocytes were associated with clinical disease severity.

OXFAM SCALES BACK OPERATIONS Oxfam International, a major international humanitarian aid organization, announced that it will restructure its global operations, in part, as a result of financial challenges associated with the COVID-19 pandemic. The new strategic framework aims to improve efficiency by shifting operations and reallocating resources to where they can provide the most benefit. Oxfam will scale back its global footprint from 66 countries to 48, and “it will phase out 18 of its country offices.” The global financial crisis stemming from the pandemic has hindered fundraising opportunities, which have had a major effect on many non-profit and non-governmental organizations like Oxfam.

VENEZUELAN MIGRANT WORKERS As cases in South American countries continue to rise, strict “lockdowns” and associated job losses have disproportionately affected migrant workers from Venezuela. Due to the unstable political, social, and economic situation in Venezuela, thousands of Venezuelans migrate to neighboring countries in search of work. The growing COVID-19 pandemic has led many Venezuelans to attempt to return home. Approximately 40,000 Venezuelans have already returned, and a program implemented by the Venezuelan government, called “Return to the Homeland,” is currently prioritizing the repatriation of homeless migrant workers from Chile, Educador, and Peru—3 of the hardest-hit countries in South America. Wait lists for repatriation are extensive, however, and workers in non-prioritized countries are reportedly attempting to cross into priority counties in an effort to improve their chance of swift repatriation.TIMING OF COMMUNITY MITIGATION MEASURES A modeling study by researchers at Columbia University (New York, US) evaluated the role that the timing of community-level social distancing measures in the United States played on COVID-19 incidence and mortality. The study (preprint) found that implementing widespread social distancing measures (e.g., “stay at home” orders) 1 week before that point could have reduced the cumulative COVID-19 incidence and mortality through May 3 by more than 60% and 50%, respectively, saving nearly 36,000 lives. According to the authors, initiating social distancing measures an additional week earlier, at the beginning of March, could have prevented nearly 100,000 cases and 54,000 deaths, reducing the total mortality by 83%. The study also models the effects of relaxing community-level social distancing on transmission and mortality. They forecast that decreases in reported incidence resulting from existing measures could continue for several weeks after they are relaxed, due to the time delay in detecting and reporting increased community transmission. Even if social distancing measures are re-implemented at the first sign of increased incidence, the increased community transmission could feed a resurgence of COVID-19 that could persist for several weeks.

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