Coronavirus Update

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Coronavirus Update 6-4

Recent Developments & Information

June 4, 2020

“There is no evidence that any drug is reducing mortality of patients that have COVID-19.” 

World Health Organization

“Clearly, there is potential for improvement in what we have done in Sweden.” 

Anders Tegnell, Sweden’s chief epidemiologist

“This virus made it halfway around the world without us having a heads-up from the CDC.  Over two months after the disease surfaced, I would have expected better.” 

Tim Putnam, hospital chief executive

Index Of Featured Stories & Links

Note:  All of stories listed below are included in this Update, but we have included links to the stories upfront so that you can quickly jump to a story if you want.

Notes: 

  • You can access all of the updates on our website at https://dailyC19post.com/ and on Facebook at https://www.facebook.com/groups/2467516816834782/group_quality/.  Please share the website and Facebook addresses with anyone you believe might be interested in the updates.  Also, some have asked me to attach a copy of the update to each email, so I will do that going forward.  
  • We are happy to add anyone to the distribution list – just let me know.  And, for those of you that are on social media, feel free to forward or post any or all of our updates or recommendations.  Also, please forward to me any information than you believe should be included in any update, including any precautions that you recommend.  Comments and suggestions are always welcome.  
  • We do not endorse, and may not agree with, any opinion or view included in this Update.  We include a wide spectrum of opinions and views as we believe that it gives perspective on what people are thinking and may give insights into our future.

A. Our World As Seen Through Headlines

(In No Particular Order)

B. Key Numbers & Trends

Note: Unless otherwise noted, all numbers in this Update are as of 5/31 and changes are since the prior day.  Unless otherwise specified, all cases/deaths are confirmed cases/deaths that have been reported.  Please note that the reporting of cases/deaths for a state/country may be delayed (which often occurs over weekends and holidays), and the number of cases/deaths for a state/country can be revised, which can result in some unusual short-term changes in numbers. 

Source: https://www.worldometers.info/coronavirus/  

1. Cases & Tests

  • Worldwide:  
    • Total Cases = 6,562,695 (+1.3%)
    • New Cases = 83,518 (-33,511)
    • New Cases (7 day average) = 111,156 (-2.9%) (-3,227)
  • US: 
    • Total Cases = 1,901,783 (+1.1%)
    • New Cases = 925 (-162)
    • New Cases (7 day average) = 22,283 (+0.03%) (+7)
    • Although the 7 day average of new cases has stabilized, the number of new cases is generally trending down.  
    • Total Number of Tests = 19,096,671 (+493,497) 
    • 5.9% of US Population has been tested 

2. Deaths

  • Worldwide Deaths 
    • Total Deaths = 386,788 (+1.3%) 
    • New Deaths = 4,929 (+222)
    • New Deaths (7 day average) = 4,264 (-1.2%) (-50)
  • US Deaths 
    • Total Deaths = 109,142 (+1.0%)
    • New Deaths = 1,083 (-51) 
    • New Deaths (7 day average) = 1,005 (-5.6%) (-64)

C. Potential Treatments

1. Ibuprofen tested as a treatment for C19

  • Scientists are running a trial to see if ibuprofen can help hospital patients who are sick with coronavirus.
  • The team from London’s Guy’s and St Thomas’ hospital and King’s College believe the drug, which is an anti-inflammatory as well as a painkiller, could treat breathing difficulties.
  • They hope the low-cost treatment can keep patients off ventilators.
  • In the trial, called Liberate, half of the patients will receive ibuprofen in addition to usual care.
  • The trial will use a special formulation of ibuprofen rather than the regular tablets that people might usually buy. Some people already take this lipid capsule form of the drug for conditions like arthritis.
  • Studies in animals suggest it might treat acute respiratory distress syndrome – one of the complications of severe coronavirus.
  • Prof Mitul Mehta, one of the team at King’s College London, said: “We need to do a trial to show that the evidence actually matches what we expect to happen.”
  • Early in the pandemic there were some concerns that ibuprofen might be bad for people to take, should they have the virus with mild symptoms.
  • These were heightened when France’s health minister Oliver Veran said that taking non-steroidal anti-inflammatory drugs, such as ibuprofen, could aggravate the infection and advised patients to take paracetamol instead.
  • A review by the Commission on Human Medicines quickly concluded that, like paracetamol, it was safe to take for coronavirus symptoms. Both can bring a temperature down and help with flu-like symptoms.
  • For mild coronavirus symptoms, the NHS advises people try paracetamol first, as it has fewer side-effects than ibuprofen and is the safer choice for most people. You should not take ibuprofen if you have a stomach ulcer, for example.

Source: Coronavirus: Ibuprofen tested as a treatment 

D. Is the Virus Weakening?

1. Could the Coronavirus Be Weakening as It Spreads?  

Comments from two Italian doctors have triggered a wave of expert rebukes, but not everyone thinks that their views are far-fetched
  • On May 31, the news agency Reuters published an article with an optimistic but incendiary headline: “New coronavirus losing potency, top Italian doctor says.”
  • The story included comments from hospital leaders in Milan and Genoa, cities in two regions of northern Italy that have been hit hard by C19. The doctors’ comments were pulled from published news reports in the Italian media, and both suggested that the virus is growing weaker. Matteo Bassetti, MD, PhD, is head of the Infectious Diseases Clinic at the San Martino-IST University Hospital and a professor of infectious diseases at the University of Genoa. He is quoted in the Reuters piece as saying that, “The strength the virus had two months ago is not the same strength it has today.”
  • Reached for comment on Tuesday, Bassetti elaborated on his prior statement for Elemental. “What is happening in our hospitals — at least in the northern part of Italy — the clinical impression is that the disease is now different compared to the disease of three months ago,” he says. “The majority of patients who presented in our emergency rooms or wards during March and April were very sick with acute respiratory distress syndrome, shock, multiple organ failure, and the majority died in the first days after admission. Now in May, we no longer see these types of patients.”
  • Bassetti completed a post-doctoral fellowship at Yale University. He’s quick to say that he is not basing his views on lab-confirmed findings; his statements are based on his own interactions with patients and his conversations with other doctors. “The clinical impression here is that the virus is different,” he says. “Is this because the virus lost some viral potency? Or because the viral load or total count of the virus is lower? I don’t know.”
  • Expert speculation that the virus could be weakening is unpopular — and maybe also dangerous. The Reuters piece was republished in the New York Times and elsewhere, and it triggered an immediate wave of backlash. Health officials within Italy and at WHO refuted the Italian doctors’ comments, and a panel of U.K.-based experts said that any claims that the virus is weakening are dubious and not supported by evidence.
  • “I think it’s just not plausible at this point in time,” says Oscar MacLean, PhD, one of those panelists and a bioinformatician at the Institute for Infection, Immunity, and Inflammation at the University of Glasgow in the U.K. “We’ve seen no evidence of widespread attenuation.”
  • “Yes, the Golden Rule is that viruses tend to mutate and evolve over time to become less pathogenic while we become more resistant, but that doesn’t happen over a matter of a few months — it’s more like a matter of years.”
  • It’s also worth noting that the push to loosen business and quarantine restrictions in Italy is politicized, as it is in the U.S. Some government officials there have accused their colleagues in the north of manipulating patient data and testing protocols in order to expedite the reopening process in their regions.
  • But some say the Italian doctors’ claims are plausible — if not proven. “Every time a virus passes from one person to another, it goes through mutations,” says Lee Riley, MD, a professor and chair of the division of infectious disease and vaccinology at the University of California, Berkeley School of Public Health. “Over time these mutations can accumulate, and the virulence of the virus can ultimately lessen.”
  • He says it’s possible that these mitigating mutations are occurring in Italy — and maybe even in parts of the U.S. “I think this is happening in many places already, including in New York City,” he says. “It’s the nature of these viruses to get tired after a while.”
How some viruses evolve
  • While plenty of viruses kill, high lethality is not a trait that the most successful viruses possess — at least not in the long term. And no one doubts that C19 could, theoretically, become weaker as time passes. “This is definitely something that can happen,” MacLean says. “Over time there can be a general selection for decreased virulence.”
  • How does that occur? In oversimplified terms, some different mutations or “strains” of C19 (scientists around the world have already identified roughly 10,000 of them) could be milder than others. 
  • And if this mildness helps them spread more rapidly — for example, by helping them elude detection — then that could lead to a softening of the virus over time. But MacLean says that plenty of scientists are on the lookout for these types of changes — in large populations and in small communities — and so far they don’t see evidence that a mild strain or strains are taking hold and displacing more severe ones.
  • That doesn’t mean patient outcomes are not improving in some places — as Bassetti says he’s observed. MacLean highlights an Italian study published late in May that found that the virus’s lethality in April had “significantly decreased” compared to its lethality in March. But that study’s authors cite improved clinical management as the likeliest cause of the decrease. “This makes sense,” MacLean says. As doctors and health care systems gain experience treating the virus, they’re likely to get better at it. “Along with changes in hospital capacity, triage, and treatment methods, as testing efforts get amplified, more mild and asymptomatic cases will be detected,” he says. “On the ground, that will probably look like a change on the virus’s part, but you need to be far more systematic, and control for those confounders, to make the claim that it’s attenuating.”
  • Other experts echo his sentiments and say that C19 is unlikely to weaken in the near term. “According to Mark Cameron, PhD, an infectious disease researcher and associate professor at Case Western Reserve University in Cleveland, coronaviruses, compared to other viruses such as influenza, are genetically very stable, which means they’re less likely to mutate in ways that could lessen the severity of the resulting illness. 
  • He says that, in some ways, this stability is a good thing; it means that if and when a C19 vaccine is available, we won’t have to worry about the virus changing in ways that render the vaccine ineffective. “The virus has changed with small mutations since it emerged from Wuhan, however, the sum total of those mutations has not changed the pathogenesis or severity of the disease it causes in humans, or its ability to spread among us,” he explains. “I think it’s highly unlikely that this virus is going to help us out by evolving into a less pathogenic version.”
  • One of his colleagues at Case Western Reserve, Robert Salata, MD, is a professor of medicine and also physician in chief at the University Hospitals. “To make these statements without genetic evidence, in my opinion, was the wrong thing to do,” he says of the Italian doctors’ comments.
  • He says that these sorts of unsubstantiated claims are dangerous because they may encourage some people to lower their guard or take fewer precautions, which could lead to an elevated risk of infection. He also says that, in his hospital system in Cleveland, he’s seen no evidence that the virus is weakening or changing.
An uncertain outlook
  • UC-Berkeley’s Riley says that his belief that C19 could be weakening is not one his colleagues share. “I don’t know of other experts who think the way I do, and I could be totally off the mark,” he allows. “But I look at real-world data instead of predictive models to come up with my ideas.”
  • He points out that the number of new cases and deaths has steadily declined in New York City and many other hard-hit areas, and that there are no places in Asia where, once the epidemic swept through a city or a community, another wave of similar magnitude returned. 
  • He says that there are, of course, multiple explanations for this, and that social-distancing guidelines partly explain the encouraging trends. “But a more likely reason is that the virus itself has evolved during the initial big wave of the epidemic and lost its high pathogenicity,” he says.
  • He offers a hopeful prediction, though one he readily admits is speculative: “We’ll continue to see low numbers of mild-to-moderate cases, but the severe cases and deaths are likely to gradually disappear over the six months following the initial big wave.” But, he adds, this prediction assumes that most people will continue to wear masks in public places, practice social distancing, and follow other safety measures.
  • Others say the data — both on C19, and on related viruses — does not support such a sanguine take. “In Toronto in 2003, we thought we’d beaten back SARS, but then we got hit with a second wave that lasted as long as the first,” says Case Western Reserve’s Cameron. “That may be where we are now. We think the worst might be over, but a second wave may wash over us and reset the clock.”
  • If people underestimate C19 or ignore their state’s public-health guidelines, he says a second wave is still the likeliest scenario. “That’s the risk we’re taking right now if we loosen our public-health response,” he says. “I hope it doesn’t take a new peak in infections to get people to adhere to some of the simple things that they can do to prevent new infections and potential suffering.”

Source: Is The Coronavirus Losing Potency as It Spreads?

E. New Scientific Findings & Research 

1. Biomedical Scientists Create New Tool for Developing C19 Treatments & Vaccines  

  • Biomedical scientists working with C19 have an important new tool to help them better understand the virus and feel confident about the structural models they are using in their research.
  • Wladek Minor, PhD, of the School of Medicine, and other top structural biologists have led an international team of scientists to investigate the protein structures contained in the virus – structures that are vital to developing treatments and vaccines. The team has created a Web resource that provides scientists an easy way to see the progress of the structural biology community in this area. It also includes the team’s assessment of the quality of the individual models and enhanced versions of these structures, when possible.
  • “We have carefully analyzed the available models of coronavirus proteins and present the results with the aim of helping the broad biomedical community. Structural models are ultimately the interpretation of the original researchers and sometimes are suboptimal. This is why a second set of eyes to validate important structures is so crucial,” said Minor, of UVA’s Department of Molecular Physiology and Biological Physics. “In most cases, only minor corrections could be suggested. However, in several cases, the revisions were significant, especially in the sensitive area of protein-ligand complexes that are critical for follow-up research, like drug discovery work. The current health crisis demands that all coronavirus structures are of the highest quality possible.”
Science at Lightning Speed
  • When the threat of the coronavirus became apparent, scientists worldwide responded at an unprecedented pace to determine the atomic structure of the virus and its protein constituents.
  • Researchers are using the resulting structural models in a variety of applications, ranging from structure-based drug design to planning a range of biomedical experiments. For that reason, it is essential that the atomic models are as accurate as possible. Because of the urgency of the pandemic, most of these structures are deposited in the Protein Data Bank (PDB), a global repository of macromolecular structures, before publication and peer review. 
  • The members of the team, who are experts in structure validation and interpretation, noticed opportunities to improve several coronavirus models using state-of-the-art refinement approaches. 
  • That led them to create the new web resource. It is updated with new structures weekly, in sync with the PDB.
  • In some cases, the team has worked with the researchers who generated the original structure to ensure that the site contains the most accurate models. This team has longstanding experience in correcting biomedically important structural models – for instance, in the field of antibiotic resistance.
  • “Working on a project driven by strong international collaborations is an enormous opportunity for younger scientists, like Ivan Shabalin and Dariusz Brzezinski, who will undoubtedly lead other highly impactful studies in the near future,” Minor said.
  • “It is extremely rewarding to be able to add my expertise to a project that has the potential to make an immense impact on the lives of millions of people,” Shabalin said.

Source: Biomedical Scientists Create a New Tool for Developing COVID-19 Treatments & Vaccines

2. Humidity Dampens Virus  

  • Summary: A new study reveals C19 infection rates may correlate with seasonality. Lower humidity is associated with an increase in locally acquired positive cases of coronavirus. The study reports a 1% decrease in humidity could increase the number of coronavirus cases by 6%.
  • A study conducted in Sydney during the early epidemic stage of C19 has found an association between lower humidity and an increase in locally acquired positive cases. Researchers discovered a 1 percent decrease in humidity could increase the number of C19 cases by 6 percent.
  • The research led by Professor Michael Ward, an epidemiologist in the Sydney School of Veterinary Science at the University of Sydney, and two researchers from our partner institution Fudan University School of Public Health in Shanghai, China, is the first peer-reviewed study of a relationship between climate and C19 in the southern hemisphere.
  • “C19 is likely to be a seasonal disease that recurs in periods of lower humidity. We need to be thinking if it’s wintertime, it could be C19 time,” said Professor Ward.
  • The study is published today in Transboundary and Emerging Diseases.
  • Further studies – including during winter in the southern hemisphere – are needed to determine how this relationship works and the extent to which it drives C19 case notification rates.
  • Previous research has identified a link between climate and occurrence of SARS-CoV cases in Hong Kong and China, and MERS-CoV cases in Saudi Arabia, and a recent study on the C19 outbreak in China found an association between transmission and daily temperature and relative humidity.
  • “The pandemic in China, Europe and North America happened in winter so we were interested to see if the association between C19 cases and climate was different in Australia in late summer and early autumn,” Professor Ward said.
  • “When it comes to climate, we found that lower humidity is the main driver here, rather than colder temperatures,” Professor Ward said. “It means we may see an increased risk in winter here, when we have a drop in humidity. But in the northern hemisphere, in areas with lower humidity or during periods when humidity drops, there might be a risk even during the summer months. So vigilance must be maintained.”
Why humidity matters
  • Professor Ward said there are biological reasons why humidity matters in transmission of airborne viruses.
  • “When the humidity is lower, the air is drier and it makes the aerosols smaller,” he said. “When you sneeze and cough those smaller infectious aerosols can stay suspended in the air for longer. That increases the exposure for other people. When the air is humid and the aerosols are larger and heavier, they fall and hit surfaces quicker.”
Method
  • Professor Ward and his team studied 749 locally acquired cases of C19 – mostly in the Greater Sydney area of the state of New South Wales – between February 26 and March 31. The team matched the patients’ postcodes with the nearest weather observation station and studied the rainfall, temperature and humidity for the period January to March 2020.
  • The study found lower humidity was associated with an increased case notifications; a reduction in relative humidity of 1 percent was predicted to be associated with an increase of C19 cases by 6 percent.
  • “This means we need to be careful coming into a dry winter,” Professor Ward said, adding that the average humidity in Sydney is lowest in August.
  • “Even though the cases of C19 have gone down in Australia, we still need to be vigilant and public health systems need to be aware of potentially increased risk when we are in a period of low humidity,” Professor Ward said. “Ongoing testing and surveillance remain critical as we enter the winter months, when conditions may favour coronavirus spread.”
  • Professor Ward said the study was limited to cases contracted in the summer months mostly in and around Sydney, so further research is needed in the months to come and further afield. In winter, cooler temperatures may be also be a factor.
  • “The role of climate during the COVID‐19 epidemic in New South Wales, Australia”. by Michael P. Ward, Shuang Xiao, Zhijie Zhang. Read the report here: The role of climate during the COVID‐19 epidemic in New South Wales, Australia 

Source: COVID-19 could be a seasonal illness 

F. The Road Back?

1. Johns Hopkins Experts Say There Is An Urgen Need to Reopen K-12 Schools This Fall  

School Closures have led to growing public health crises for children, including hunger and a lack of health services

  • Johns Hopkins School of Education Dean Christopher Morphew and Bloomberg School of Public Health Vice Dean Josh Sharfstein say there is an urgent need to reopen America’s K-12 schools this fall, citing an expected academic backslide known as the “COVID slide” and burgeoning public health issues faced by vulnerable children, including hunger and decreased access to health care.
  • In an article published Monday in the Journal of the American Medical Association, Morphew and Sharfstein write that the closure of K-12 schools nationwide likely has helped the country avert a medical catastrophe sparked by the C19 pandemic. “This decisive step, however, is casting a long shadow,” they write. 
  • Among the fallout: More than 20 million children in the U.S. rely on school breakfast or lunch for food, and surveys now indicate one in five mothers report that their children younger than 12 years old are going hungry. What’s more, millions of children have lost access to school-based health services.
  • Morphew and Sharfstein collaborated on a six-point plan to safely and thoughtfully reopen America’s K-12 schools, while prioritizing access to on-site education for young children, children who experience barriers to remote learning, and children who receive special education or nutritional support..
  • An urgent first step toward creating successful school reopening conditions, as well as reducing chances that schools need to close again, Sharfstein and Morphew write, is driving down the spread of C19 this summer while building a strong public health response for the fall—with rigorous programs of testing, contract tracing, isolation, and quarantine. “In the event of significant community spread in the fall and winter months,” they write, “parents and teachers are likely to again demand school closure, and if they do, elected leaders are likely to agree.”
    • Other elements key to successful school reopenings, according to Sharfstein and Morphew, include:
    • Establishing appropriate social distancing protocols at each school
    • Prioritizing on-site education for at-risk children
    • Preparing a strong school-based public health and environmental response that includes on-site screening
    • Respecting and assisting the valid concerns of individual families and teachers
    • Linking curricula, teaching strategies, and remote learning technologies
  • Morphew and Sharfstein acknowledge that any successful school reopening, including their recommendation, will require substantial resources and personnel. They call on Congress to quickly make sufficient funds available to states and localities to support K-12 education.
  • “The C19 pandemic is more than a short-term threat to the nation’s health,” they write. “Through its effects on children, the legacy of C19 will last for years.”

Source: What it will take to safely reopen K-12 schools this fall

2. Reducing Risk in the Workplace  

By Rajaie Batniji, physician and co-founder and chief health officer of Collective Health 
  • Consensus seems to be emerging that businesses can safely reopen by checking the temperatures of people entering them and by putting in place environmental controls — from social distancing and wearing masks to improved air circulation — to reduce the spread of SARS-CoV-2 in the workplace.
  • This consensus is rational. It is convenient. And it is driven by the well-founded desire to bring life back to normal by reopening businesses, schools, places of worship, and more. The consensus is also reinforced by guidance from the Centers for Disease Control and Prevention and the White House on the steps needed to reopen the U.S.
  • I worry that this consensus is built on optimism, and reopening in this way will provide people with a false sense of security and a false impression they are reducing their risk of infection that is not supported by evidence.
  • There are two main types of risk-reduction efforts in the workplace: 
    • those designed to keep infected individuals out, and 
    • those designed to limit the spread of the coronavirus within the workplace, given the likelihood that some infected individuals will get in.
  • Since we can accurately and rapidly measure the sensitivity of screening measures for the coronavirus, it is easier to measure the potential efficacy of interventions designed to keep infected individuals out of the workplace. The published scientific literature and data on testing accuracy can inform workplace interventions, since the primary question is: What works in identifying who is infected? 
  • It is much more difficult to establish the evidence for preventing the spread of the coronavirus within the workplace, since environmental studies on masks, air recirculation, and sanitation will need to isolate the key factors and account for the variations across environments, and these studies have not been done for this virus.
Keeping infected individuals out of the workplace
  • Without a way to identify individuals infected with the coronavirus who have no symptoms or mild symptoms before entering the workplace, American business may be forced to close soon after reopening.
  • Measuring temperature to allow employees into the workplace has become a common strategy. This approach is being used to screen employees by Amazon, major car producers, technology employers, airlines, and others. Some employers eschew thermometers and opt for the more efficient and precise-sounding “thermal scanner,” basically a camera that looks for heat.
  • This approach has limitations, as Ford recently learned. It had to shut down production at two plants after reopening when employees who had been checked for fever were later found to be infected with the coronavirus.
Measure Used to Detect C19% An Infected Person is Missed
Temperature Screening/”thermal scanning” with best in class scanner> 86%
Symptom checks with best-in-class symptom screener>46%
Universal antibody testing with best-in-class FDA-approved test~36%
Universal PCR testing with typical FDA-approved test~2%
  • Temperature screening provides false assurance to employees entering the workplace. One recent study showed that about 70% of patients sick enough to be hospitalized for C19 did not have fevers. Coupled with the fact that most people infected with the coronavirus do not have symptoms, screening for temperatures will miss at least 86% of infected individuals, and likely miss an even higher percentage.
  • A “barrier” that allows nearly 9 in 10 infected individuals to enter a workplace or business is not one that should be used to provide reassurance to employees.
  • A slightly better method for keeping infected individuals out of the workplace is daily symptom screening coupled with clear instructions to stay home if symptoms appear. The primary weakness of this method is that only a minority of individuals infected with the coronavirus develop symptoms. 
  • A nursing home study in Washington state showed that 56% of infected individuals were asymptomatic, while broader studies in Wuhan showed 69% were asymptomatic. Studies among pregnant women in New York and tourists and crew on an Antarctic cruise ship showed that more 80% of infected individuals were asymptomatic.
  • If we use the optimistic scenario and rely on expanded symptom screening done daily, this approach identifies only about half of infected individuals, though likely only several days after they became contagious, allowing for workplace spread in the interim. More realistically, based on recent data outside of nursing homes, symptom-tracking will miss upwards of 80% of infections.
  • This approach is compounded by the risk of underreporting symptoms, especially when employees are not paid when they are cannot come to work.
  • The only approaches that can reliably reduce the number of people with active C19 infections coming into the workplace involve testing. There has been a great deal of debate on various tests. While antibody tests may play a role in some settings, the greatest limitation to their use in risk reduction is that tests do not reliably turn positive in infected people until about a week after being infected (and thus missing a key window for transmission risk). Tests that look for the virus, typically via PCR (but also possibly other emerging modalities such as loop-mediated isothermal amplification [LAMP)], CRISPR, next-generation sequencing, and antigen testing), are the most useful in reducing the spread of the virus in the workplace.
  • Tests that look for the virus identify infections early on and with high sensitivity. With testing, employers can reliably identify almost all infected individuals and keep them from entering the workplace. The emergence of self-administered testing from several companies via a swab placed in the front of the nose or saliva are making this kind of testing more convenient, while also eliminating the need for protective equipment and exposure of health care staff.
  • By using testing protocols based on local epidemiology of C19, personal and workplace risk factors, and tracking symptoms and contacts, employers can calibrate how often they need to test workers to greatly reduce the risk of workplace transmission. These protocols need to be updated frequently to account for changes in epidemiology and in science, like the protocol a colleague and I have published with input from several leading experts.  (see Occupational Health Protocol to Reduce Transmission of SARS-CoV-2 Coronavirus (COVID-19) at Worksites)
  • Employer-based testing won’t be easy. The annual per employee cost of making testing part of risk reduction — while less than one day’s wages for the average worker — may be a deterrent to some organizations. The data on test reliability and testing types are evolving quickly. Without employer-led strategies to make testing convenient for asymptomatic workers, many will not pursue testing. And even the most sophisticated employers would not wish to invent their own testing or clearance protocols, but will need to depend on evidence-based reference protocols.
  • Gathering test results from diverse labs where workers will be tested in their communities, and from employer-facilitated lab testing partners, is a technical challenge, matched only by the technical challenge of communicating the relevant information to the employer in a manner that preserves worker privacy. How will an employer make sense of the testing information? Employers will need to know who is and who is not at risk of being infected, and that is not simply just who has or has not been recently tested negative.
  • Despite these challenges, employers that implement testing based on protocols will be in good positions to reduce risk by keeping enough infected people out of the workplace to avoid a workplace epidemic.
Limiting spread from infected individuals in the workplace
  • Even the most complete testing will not create an impermeable barrier to the coronavirus, so employers must assume that infected individuals will enter the workplace and implement measures to limit the spread of the virus from infected to uninfected individuals. The challenge with assessing these measures is that they have not yet been reliably studied in the workplace.
  • Sensible best practices complement efforts to keep infected individuals out of the workplace but cannot replace them. These practices include:
    • Wearing masks indoors
    • Reducing the number of people in the workplace and spacing out those who are there
    • Encouraging frequent hand sanitizing
    • Limiting meeting sizes and the number of people in a room
    • Taking steps to avoid or reduce physical contact, including at meals and entrances
    • Frequent cleaning of spaces
    • Increasing air circulation
    • Some employers have also sought to keep individuals who may be at higher risk for serious illness from C19, out of the workplace, asking older workers, those who are obese, those with diabetes, and others to remain at home. These practices, however, may be discriminatory, and should be instituted with caution.
An evidence-based approach to return to work
  • Workplace risk-reduction strategies need to do exactly what their name implies: reduce risk in a demonstrable manner and to a level that would be acceptable to employers and employees. Disease modeling suggests that a risk-reduction protocol that includes both evidence-based testing and environmental controls can meaningfully bring down the risk of workplace transmission of C19.
  • Employers should be sharing with employees the expected impact of risk reduction strategies. That’s a fair and necessary exchange of transparency for asking employees to be subject to additional screening designed to protect them. Efforts to keep infected individuals out of the workplace will backfire on employers who provide misguided or overstated reassurance.
  • Workplaces and public spaces across the nation were shut down to slow the spread of disease so it wouldn’t overwhelm our health care systems. It was also done to buy us time to develop at least one of the three options that would enable the country to reopen safely: widespread testing so we could contain the virus, treatments that could sharply reduce the threat of the virus, and a broadly distributed vaccine that could limit infection with the coronavirus. 
  • While there is some promise in vaccines and treatments, they will take longer — and possibly be less effective — than we want to believe.
  • We have developed the testing capacity, workplace protocols, and the data framework to enable organizations across the U.S. to sharply reduce workplace C19 risk. If we do not take advantage of the emerging ability to use testing and workplace protocols to safely re-open our businesses and schools, then we will have squandered our massive investment to buy time over the last several weeks.

Source: Optimism, not evidence, is driving America’s return-to-work strategy

3. Easing C19 Lockdowns Slowly May Be Better for Global Economy  

  • The paper, published on June 3, 2020 in Nature Human Behaviour, is the first peer-reviewed study to comprehensively assess potential global supply chain effects of C19 lockdowns, modeling the impact of lockdowns on 140 countries, including countries not directly affected by C19.
  • The study found that stricter lockdowns imposed earlier — such as the two-month lockdown imposed in China — are economically preferable to more moderate lockdowns imposed for four or six months, as duration of lockdown matters more to economies than their severity. This is because businesses can absorb the shock of a brief lockdown better by relying on reserves and because shorter lockdowns cause less disruption to regional and global supply chains.
  • Researchers also found that countries not directly affected by C19 may nonetheless experience large losses of more than 20% of their GDP due to falls in consumer demand and bottlenecks in supply chains.
  • Particularly at risk are open or highly specialized economies, such as Caribbean countries that rely on tourism and Central Asian countries such as Kazakhstan that rely on energy exports. Also vulnerable are globalized industries that rely on difficult-to-replace suppliers, such as automobile manufacturing, where production is estimated to fall by up to half.
  • Lead author Professor Dabo Guan (UCL Bartlett School of Construction & Project Management and Tsinghua University) said: “Our study shows the ripple effects caused by lockdowns along global supply chains, with countries not directly affected by C19 still experiencing heavy economic losses.
  • “While predicting the true cost of lockdowns is not possible at this stage, our research suggests that shorter, stricter lockdowns minimize the impact on supply chains, while gradually easing restrictions over the course of a year may also be less disruptive than a swift lifting of restrictions followed by another lockdown.”
  • The researchers estimated that gradually easing lockdown measures over 12 months would minimize supply chain impacts compared to lifting restrictions more quickly, over two months, and then introducing a second round of lockdowns in January next year, which they estimated would increase the cost by one-third.
  • Co-author Professor Steven Davis (University of California, Irvine) said: “Our analysis quantifies the global economic benefits of robust public health responses and suggests that economic justifications to re-open businesses could backfire if they result in another round of lockdowns.”
  • Looking ahead to a potential second wave, the researchers found that a strict, globally co-ordinated lockdown implemented for two months would be less economically costly than lockdowns happening in different parts of the world at different times — risking a potential economic loss to global supply chains by 50% rather than 60%. This is because the economic cost of a lockdown goes beyond national borders and a shorter, one-off shock is easier to absorb.
  • Professor Guan said: “Companies will survive the supply chain failures that lockdowns cause by relying on reserves of stock or finding new suppliers. If a second shock hits, reserves may be low and supply chains only recently repaired — making a new break much more costly.”
  • If recurrent global lockdowns occur, New Zealand’s food services sector and Jamaica’s tourism industry would face estimated productivity losses of about 90%, while China’s electronics business and Iran’s oil industry would face productivity losses of about two thirds.
  • The cost to the UK economy, meanwhile, would rise from a potential supply chain loss of 38% (one lockdown gradually eased over 12 months) to 57% (recurrent global lockdowns happening at different times in different countries).
  • In the United States, the cost to the financial sector would nearly double if a second global lockdown occurs, with potential supply chain loss rising from 33% (one lockdown gradually eased over 12 months) to 57% (recurrent global lockdowns happening at different times in different countries).
  • The most important factor affecting the global economic cost of lockdowns, the study found, was the number of countries implementing them, highlighting the importance to the global economy of one country containing an epidemic.
  • Co-author Professor D’Maris Coffman (UCL Bartlett School of Construction & Project Management) said: “Just as individuals staying at home protect others as well as themselves, so countries imposing strict lockdowns provide a public good to other countries.
  • “In preparing for the next pandemic, a global facility, in all likelihood administered by the IMF, could ensure that the costs of containing an outbreak are not borne by one country alone. This would remove some of the disincentives to early action and provide enormous health and economic benefits over the long term.”
  • The paper used a “disaster footprint” economic model to quantify the direct costs of lockdowns in terms of labor reduction as well as the cascading effects of loss of labor on the supply chain, simulating how constraints to output affect upstream suppliers as well as the firms to which the goods are being supplied. Supply chain data was drawn from the Global Trade Analysis Project (GTAP) database, which divides the world into 141 economies, with 60 sectors within each economy.
  • Researchers simulated three kinds of lockdown: strict lockdown in which 80% of travel and labor ceases; a more moderate lockdown with a 60% reduction; a third, lighter lockdown with a 40% reduction in travel and labor. 
  • The strict, 80% reduction is based roughly on China’s lockdown, during which data suggests 80% of travel stopped, while the 60% lockdown broadly reflects the approach taken in Europe and the United States.

Source: Easing COVID-19 Lockdowns Slowly May Be Better for Global Economy

G. Vaccines

1. White House Picks 5 ‘Finalists’ For Vaccine Candidate Trials  

  • Despite a paucity of scientific evidence that has prompted many experts to warn that these decisions are dangerously premature, the White House has reportedly selected five companies as “the most likely candidates to produce a vaccine”, in keeping with “Project Warpspeed”, Trump’s White House-based initiative to start mass-innoculation by the end of the year.
  • The five companies mentioned are Moderna, AstraZeneca, J&J, Merck, and Pfizer. The decision will reportedly be made over the next few weeks.
    • The Trump administration has selected five companies as the most likely candidates to produce a vaccine for the coronavirus, senior officials said, a critical step in the White House’s effort to deliver on its promise of being able to start widespread inoculation of Americans by the end of the year.
    • By winnowing the field in a matter of weeks from a pool of around a dozen companies, the federal government is betting that it can identify the most promising vaccine projects at an early stage, speed along the process of determining which will work and ensure that the winner or winners can be quickly manufactured in huge quantities and distributed across the country.
  • The announcement of the decision will be made at the White House in the next few weeks, government officials said. Dr. Fauci apparently hinted at the coming action on Tuesday when he told a medical seminar that “by the beginning of 2021 we hope to have a couple of hundred million doses,” according to the NYT, though this isn’t the first time Dr. Fauci has made that claim. It is, after all, the stated goal of “Project Warp Speed”.
  • Moderna has long been a White House favorite: Its vaccine candidate is already participating in a trial being run in partnership with the NIH. When Moderna released an extremely preliminary statement about its progress last month. 
  • Dr. Fauci has said he expects Moderna to enter the final phase of clinical trials as soon as next month. The alliance between Oxford University and AstraZeneca, which has received a fair amount of coverage, is on a similar track. 
  • Meanwhile, three pharma giants – Johnson & Johnson, Merck and Pfizer – are each taking what the NYT described as a “somewhat different” approach.
  • However, most experts believe the White House’s goal is unrealistic. Developing vaccines is notoriously tricky, and early reports about an 18-24 month timeline are based on guesswork by “credible” officials like Dr. Fauci.

Source: White House Picks 5 ‘Finalists’ For Vaccine Candidate Trials

H. A Bold But Flawed Strategy

1. Our strategy resulted in too many deaths 

  • Sweden’s chief epidemiologist and the architect of its light-touch approach to the coronavirus has acknowledged that the country has had too many deaths from C19 and should have done more to curb the spread of the virus.
  • Anders Tegnell, who has previously criticized other countries’ strict lockdowns as not sustainable in the long run, told Swedish Radio on Wednesday that there was “quite obviously a potential for improvement in what we have done” in Sweden.  
  • Asked whether too many people in Sweden had died, he replied: “Yes, absolutely,” adding that the country would have to consider in the future whether there had been a way of preventing such a high toll.
  • Sweden’s death rate per capita was the highest in the world over the seven days to 2 June, figures suggest. This week the government bowed to mounting opposition pressure and promised to set up a commission to look into its C19 strategy.
  • “If we were to encounter the same disease again knowing exactly what we know about it today, I think we would settle on doing something in between what Sweden did and what the rest of the world has done,” Tegnell said. It would be “good to know exactly what to shut down to curb the spread of infection better”, he added.
  • According to the scientific online publication Ourworldindata.com, the number of C19 deaths per capita in Sweden was the highest in the world in a rolling seven-day average to 2 June. The country’s rate of 5.29 deaths per million inhabitants a day was well above the UK’s 4.48.
  • The Swedish prime minister, Stefan Löfven, told the Aftonbladet daily that the country’s overall approach “has been right”, but it had failed to protect care homes where half of all Sweden’s C19 deaths have occurred. Social affairs minister Lena Hallengren told Reuters that the government had been “at all times prepared to introduce wider, further measures recommended by the expert authority”.
  • Relying on its citizens’ sense of civic duty, Sweden closed schools for all over-16s and banned gatherings of more than 50, but only asked – rather than ordered – people to avoid non-essential travel and not to go out if they were elderly or ill. Shops, restaurants and gyms have remained open.
  • Although there are signs that public opinion is starting to shift, polls have shown a considerable majority of Swedes support and have generally complied with the government’s less coercive strategy, which is in stark contrast to the mandatory lockdowns imposed by many countries, including Sweden’s Nordic neighbors.
  • But the policy, which Tegnell has said was aimed not at achieving herd immunity but at slowing the spread of the virus enough for health services to cope, has been increasingly and heavily criticised by many Swedish experts as the country’s death toll has increased.
  • Sweden’s 4,468 fatalities from C19 represent a death toll of 449 per million inhabitants, compared with 45 in Norway, 100 in Denmark and 58 in Finland. Its per-million tally remains lower than the corresponding figures of 555, 581 and 593 in Italy, Spain and the UK respectively.
  • Norway and Denmark announced last week that they were dropping mutual border controls but would provisionally exclude Sweden from a Nordic “travel bubble” because of its much higher coronavirus infection rate.
  • Tegnell told Swedish Radio it was not clear yet exactly what the country should have done differently, or whether the restrictions it did impose should have been introduced simultaneously rather than step by step.
  • “Other countries started with a lot of measures all at once. The problem with that is that you don’t really know which of the measures you have taken is most effective,” he said, adding that conclusions would have to be drawn about “what else, besides what we did, you could do without imposing a total shutdown.”
  • Annike Linde, Tegnell’s predecessor as chief epidemiologist from 2005 to 2013, said last week that she had initially backed the country’s strategy but had begun to reassess her view as the virus swept through the elderly population.
  • “There was no strategy at all for the elderly, I now understand,” Linde told the Swedish state broadcaster. “I do not understand how they can stand and say the level of preparedness was good, when in fact it was lousy.”
  • She said another key mistake was to assume that the coronavirus would behave like seasonal flu. “It does not behave like the flu at all,” she said. “It spreads more slowly and has a longer incubation time. This makes it more difficult to detect, and to build immunity in the population.”
  • Sweden would have done better to follow its Nordic neighbours, close its borders and invest in testing and tracking to a far greater extent, she said. A study last month found that only 7.3% of Stockholm’s inhabitants had developed C19 antibodies by the end of April. 

Source: We should have done more, admits architect of Sweden’s Covid-19 strategy 

I. Epic Failure

1. The CDC Waited ‘Its Entire Existence for This Moment.’ What Went Wrong?  

  • The technology was old, the data poor, the bureaucracy slow, the guidance confusing, the administration not in agreement. The coronavirus shook the world’s premier health agency, creating a loss of confidence and hampering the U.S. response to the crisis.
  • Americans returning from China landed at U.S. airports by the thousands in early February, potential carriers of a deadly virus who had been diverted to a handful of cities for screening by the Centers for Disease Control and Prevention.
  • Their arrival prompted a frantic scramble by local and state officials to press the travelers to self-quarantine, and to monitor whether anyone fell ill. It was one of the earliest tests of whether the public health system in the United States could contain the contagion.
  • But the effort was frustrated as the C.D.C.’s decades-old notification system delivered information collected at the airports that was riddled with duplicative records, bad phone numbers and incomplete addresses. For weeks, officials tried to track passengers using lists sent by the C.D.C., scouring information about each flight in separate spreadsheets.
  • “It was insane,” said Dr. Sharon Balter, a director at the Los Angeles County Department of Public Health. When the system went offline in mid-February, briefly halting the flow of passenger data, local officials listened in disbelief on a conference call as the C.D.C. responded to the possibility that infected travelers might slip away.
  • “Just let them go,” two of the health officials recall being told.
  • The flawed effort was an early revelation for some health departments, whose confidence in the C.D.C. was shaken as it confronted the most urgent public health emergency in its 74-year history — a pathogen that has penetrated much of the nation, killing more than 100,000 people.
  • The C.D.C., long considered the world’s premier health agency, made early testing mistakes that contributed to a cascade of problems that persist today as the country tries to reopen. It failed to provide timely counts of infections and deaths, hindered by aging technology and a fractured public health reporting system. And it hesitated in absorbing the lessons of other countries, including the perils of silent carriers spreading the infection.
  • The agency struggled to calibrate its own imperative to be cautious and the need to move fast as the coronavirus ravaged the country, according to a review of thousands of emails and interviews with more than 100 state and federal officials, public health experts, C.D.C. employees and medical workers. In communicating to the public, its leadership was barely visible, its stream of guidance was often slow and its messages were sometimes confusing, sowing mistrust.
  • “They let us down,” said Dr. Stephane Otmezguine, an anesthesiologist who treated coronavirus patients in Fort Lauderdale, Fla. Richard Whitley, the top health official in Nevada, wrote to the C.D.C. director about a communication “breakdown” between the states and the agency. Gov. J.B. Pritzker of Illinois lashed out at the agency over testing, saying that the government’s response would “go down in history as a profound failure.”
  • “The C.D.C. is no longer the reliable go-to place,” said Dr. Ashish Jha, the director of the Harvard Global Health Institute.
  • Even as the virus tested the C.D.C.’s capacity to respond, the agency and its director, Dr. Robert R. Redfield, faced unprecedented challenges from President Trump, who repeatedly wished away the pandemic. His efforts to seize the spotlight from the public health agency reflected the broader patterns of his erratic presidency: public condemnations on Twitter, a tendency to dismiss findings from scientists, inconsistent policy or decision-making and a suspicion that the “deep state” inside the government is working to force him out of office.
  • Mr. Trump and his top aides have grown increasingly bitter about perceived leaks from the C.D.C. they say were designed to embarrass the president and to build support for decisions that ignore broader concerns about the country’s vast social and economic dislocation. At the same time, some at the C.D.C. have bristled at what they see as pressure to bend evidence-based recommendations to help Mr. Trump’s political standing.
  • Located in Atlanta, the C.D.C. is encharged with protecting the nation against public health threats — from anthrax to obesity — and serving as the unassailable source of information about fighting them. Given its record and resources, the agency might have become the undisputed leader in the global fight against the virus.
  • Instead, the C.D.C. made missteps that undermined America’s response.
  • “Here is an agency that has been waiting its entire existence for this moment,” said Dr. Peter Lurie, a former associate commissioner at the Food and Drug Administration who for years worked closely with the C.D.C. “And then they flub it. It is very sad. That is what they were set up to do.”
  • The agency’s allies say it is just one part of a vast network of state and local health departments, hospitals, government agencies and suppliers that were collectively unprepared for the speed, scope and ferocity of the pandemic. They also point out that lawmakers have long failed to adequately prioritize funding for the kind of crisis the country now faces.
  • Dr. Amy Ray, an infectious disease specialist in Cleveland, said the C.D.C. did not “get enough credit,” adding, “They are learning at the same time the world is learning, by watching how this disease manifests.”
  • The agency, which declined repeated requests for interviews with its top officials, said in a statement: “C.D.C. is at the table as part of the larger U.S. government response, providing the best, most current data and scientific understanding we have.”
  • “It’s important to remember that this is a global emergency — and it’s impacting the entire U.S.,” the agency said. “That means it requires an all-of-government response.”
‘Not Our Culture to Intervene’
  • In early March, Dr. Redfield led Mr. Trump on a V.I.P. tour of the high-tech labs at the C.D.C.’s Atlanta headquarters, standing off to the side as the president spoke.
  • Wearing a red “Make America Great Again” cap, Mr. Trump falsely asserted that “anybody that wants a test can get a test,” claimed he had a “natural ability” for science and noted that he might keep holding campaign rallies even as the virus spread.
  • “Thank you for your decisive leadership in helping us, you know, put public health first,” Dr. Redfield told the president as they posed for the cameras.
  • The moment underscored the challenge for the director and his agency. To combat the virus, he would have to manage the mercurial demands of the president who appointed him and the expectations of the career scientists he leads.
  • The sensibilities could not be more different. At one point that month, White House officials asked the agency to provide feedback on possible logos — including “Make America Healthy Again” — for cloth face masks they hoped to distribute to millions of Americans. The plan fell through, but not before C.D.C. leaders agreed to the request, according to one person familiar with the discussions.
  • White House aides saw Dr. Redfield, 68, as an ally, but as the coronavirus crisis intensified, his meandering manner in television appearances and congressional hearings irritated a president drawn to big personalities and assertive defenders of his administration.
  • A former military virologist who specialized in H.I.V., Dr. Redfield was Mr. Trump’s second choice after his first C.D.C. director resigned. He had no experience leading a government agency — though he had been considered for jobs in previous Republican administrations — and often told associates that he was happiest treating patients in Africa or Haiti.
  • Dr. Robert C. Gallo, who founded the Institute of Human Virology at the University of Maryland School of Medicine with Dr. Redfield in 1996, said he had warned him against taking the C.D.C. post, describing it as “massive public health, lots of politics, lots of pressure.”
  • While praising his friend as “a terrific, dedicated infectious disease doctor,” Dr. Gallo, who also co-founded the Global Virus Network, said in an interview that Dr. Redfield “can’t do anything communication-wise.” He added, “He’s reticent, never wanting the front of anything — maybe it’s extreme humility.”
  • The C.D.C., established in the 1940s to control malaria in the South, has the feel of an academic institution. There, experts work “at the speed of science — you take time doing it,” said Dr. Georges C. Benjamin, executive director of the American Public Health Association.
  • The agency, a division of the Department of Health and Human Services with 11,000 employees, cannot make policy, but it guides federal and state public health systems and advises government leaders.
  • The C.D.C.’s most fabled experts are the disease detectives of its Epidemic Intelligence Service, rapid responders who investigate outbreaks. But more broadly, according to current and former employees and others who worked closely with the agency, the C.D.C. is risk-averse, perfectionist and ill suited to improvising in a quickly evolving crisis — particularly one that shuts down the country and paralyzes the economy.
  • “It’s not our culture to intervene,” said Dr. George Schmid, who worked at the agency off and on for nearly four decades. He described it as increasingly bureaucratic, weighed down by “indescribable, burdensome hierarchy.”
  • The exacting culture shaped its scientists’ ambitions; it also locked some into a fixed way of thinking, former officials said. And it helped produce the C.D.C.’s most consequential failure in the crisis: its inability early on to provide state laboratories around the country with an effective diagnostic test.
  • The C.D.C. quickly developed a successful test in January designed to be highly precise, but it was more complicated to use and turned out to be no better than versions produced overseas. And in manufacturing test kits to send to the states, the C.D.C. contaminated many of them through sloppy lab practices. That, along with the administration’s failure to quickly ramp up commercial and academic labs, delayed the rollout of tests and limited their availability for months.
  • In late January, the agency sent epidemiologists to Seattle to help local health officials learn whether what was then the country’s first known patient — a 35-year-old man who had visited Wuhan, China — had infected others.
  • After an initial round of tests, the agency imposed restrictive testing standards. When doctors in Washington State and elsewhere forwarded the names of about 650 people in January who might have been infected — they had contact with a confirmed patient, had been admitted to a hospital or had other risk factors — the C.D.C. agreed to test only 256. That group consisted primarily of people traveling from Wuhan and their contacts.
  • In part because of capacity issues, the agency typically did not recommend testing people without symptoms — even though Chinese doctors were reporting that people could spread the virus without ever feeling ill. Dr. Redfield mentioned the possibility of asymptomatic spread in a CNN interview in February, but the C.D.C. did not emphasize such transmission until late March.
  • In mid-February, C.D.C. officials announced plans for a national surveillance effort — by testing samples from people with flulike symptoms — to determine whether the virus was spreading undetected. The effort was to begin in Seattle, New York and three other cities, but after disagreements over how to proceed, it did not start.
  • Later that month, public health officials across the country were increasingly concerned about visitors streaming into the United States from South Korea, Japan, Italy and other European countries engulfed by the virus.
  • On phone calls with the C.D.C., worried state officials kept asking: “Are there plans to expand the travel monitoring?” The response, according to a participant from New York, was always the same: “We’re still actively considering that.”
  • Mr. Trump announced a European travel ban on March 11, a few days after meeting with Dr. Redfield and others. But it was too late. Genomic tracing would later show that European travelers had brought the virus into New York as early as mid-February; it multiplied there and elsewhere in the country. In Seattle, a strain from China had struck nursing homes in late February.
  • “If we were able to test early, we would have recognized earlier” the scale of the outbreak, said Dr. Jeffrey Duchin, the chief health officer in King County, Wash. “We would have been able to put prevention measures in place earlier and had fewer cases.”
  • Part of the C.D.C.’s start-up troubles, current and former employees said, was that the group in charge of the response initially — the Division of Viral Diseases — is smaller and has far less staff focused on contagious respiratory diseases than the C.D.C.’s Influenza Division, which eventually took more a leading role. “They were very quickly overwhelmed by what they had to do,” said Dr. Pierre Rollin, a virologist who left last year.
  • Now, more than 3,000 C.D.C. employees are aiding the coronavirus response, analyzing data, performing lab work and deploying to cities where local health departments need help. While other federal agencies are also involved — including the F.D.A., which has speeded the use of antibody tests; the Federal Emergency Management Agency, which has worked to get ventilators and other supplies; and the National Institutes of Health, which has studied vaccines and possible treatments — the C.D.C. is the reigning expert.
  • Even before the current crisis, Dr. Redfield had kept a low profile. Some days he could be spotted in a corner of the cafeteria, sipping coffee alone.
  • Although he is on the White House coronavirus task force, Dr. Redfield found himself eclipsed by Dr. Anthony S. Fauci, the nation’s most famous infectious disease specialist, and Dr. Deborah Birx, an AIDS expert and former C.D.C. physician.
  • Meanwhile, his bonds with some of his own staff have frayed. One associate recounted him saying that the agency’s scientists had a “myopic” view of their roles, and characterized his relationship with his top deputy, Dr. Anne Schuchat, a career C.D.C. scientist deeply respected in the agency, as growing strained.
  • He has not been in Atlanta recently, shuttling instead between his home in Baltimore and the West Wing. One person familiar with his thinking described Dr. Redfield as feeling “a little bit on an island.”
  • The C.D.C. still has many defenders who say it has done the best it could battling a stealthy, previously unknown virus. “When they do release something, it does what C.D.C. ought to do — retain the voice of credibility,” said Dr. James A. Town, medical director of the intensive care unit at Harborview Medical Center in Seattle. “Even if it’s coming at a slower pace, which can be frustrating, I think they’re pretty thoughtful and trying to make even-keeled investigations.”
  • Dr. Redfield declined to comment for this article. But in a recent interview with The Hill, he said, “I would say C.D.C. has never been stronger.”
  • In a briefing last week, he acknowledged that the nation must work to improve its systems to track disease outbreaks, though he disputed that the agency was somehow unable to detect when the coronavirus started to spread in the United States. “We were never really blind to the introduction of this virus,” he said.
The Data Pipeline
  • Inside Building 21, the C.D.C.’s gleaming 12-story headquarters, nothing has been more critical than getting fast, accurate information on how the virus is spreading, who is getting sick, how best to treat them and how quickly the country can reopen.
  • But that has proved difficult for the agency’s antiquated data systems, many of which rely on information assembled by or shared with local health officials through phone calls, faxes and thousands of spreadsheets attached to emails. The data is not integrated, comprehensive or robust enough, with some exceptions, to depend on in real time.
  • The C.D.C. could not produce accurate counts of how many people were being tested, compile complete demographic information on confirmed cases or even keep timely tallies of deaths. Backups on at least some of these systems are made on recordable DVDs, a technology that was state-of-the-art in the late 1990s.
  • The result is an agency that had blind spots at just the wrong moment, limited in its ability to gather and process information about the pathogen or share it with those who needed it most: front-line medical workers, government health officials and policymakers.
  • “That specific, granular data has huge implications,” said Julie Fischer, a professor of microbiology at Georgetown University who studies community preparedness for emerging diseases. “We lost precious time in decision-making and putting public health resources to use.”
  • When C.D.C. officials urged states to track travelers from China in February for possible infection, the agency turned to a computer network called Epi-X. It sent emails to state officials, one at a time, for each arriving flight so they could download a list of targeted passengers.
  • In California, state health officers received as many as 146 notification emails a day, forcing them to spend time forwarding them to the appropriate local health departments. In some cases, the information, collected for the C.D.C. by the Department of Homeland Security, listed incorrect dates or times; in other cases, passenger data was sent to the wrong state or came more than a week after the travelers had entered the United States.
  • “We got crappy data,” said Fran Phillips, Maryland’s deputy health secretary. “We would call them up and people would say, ‘Well, I was in China, but that was three years ago.’”
  • On Feb. 11, Mr. Whitley, Nevada’s top health official, complained to Dr. Redfield in a letter about “the breakdown” in “communication the states have received from the C.D.C.” The agency had said three travelers from China could “go along with their normal day-to-day business” — advice that conflicted with the C.D.C.’s message to monitor such passengers and make sure they were in self-quarantine.
  • One week later, the C.D.C.’s Epi-X system stopped sending notices entirely, even though flights kept coming. The agency had temporarily shut the system down to “improve data quality,” it told state officials in an email.
  • The travel-monitoring program screened at least 268,000 passengers through mid-April. A C.D.C. report cited 14 Covid cases that were traced back to those passengers, but lapses and errors in the data made that tally far from conclusive. The agency went on to say that the program did not stop the disease from being introduced to California, where incomplete information, high travel volume and the possibility of asymptomatic spread made it ineffective.
  • Once coronavirus cases started developing in earnest in the United States in March, federal and state officials began demanding information to make key decisions. Among them: where to move ventilators from the national stockpile and where to build temporary hospitals.
  • State and local officials were quickly overwhelmed trying to document hospitals’ needs. Staff at the Los Angeles County Public Health Department, for example, called each of the 94 county hospitals in the early weeks of the outbreak, asking nurses how many coronavirus patients were in intensive care units and how many were on ventilators.
  • The C.D.C. tried to repurpose one of its data systems to collect the information directly from hospitals, but it had significant gaps. Finally, the Department of Health and Human Services in April also enlisted a private contractor, TeleTracking Technologies, only to have hospitals struggle to log on to the system.
  • Hospital executives resorted to finding aid themselves. Scott Malaney, head of Blanchard Valley Health System in Ohio, got a phone call from an official at a Michigan health care system that was running short on beds and equipment. It was asking neighboring facilities to share supplies or take in overflow patients if necessary.
  • “She said they were looking up the phone book up and down Highway 75 to see if there were other places that could help,” Mr. Malaney recalled.
  • The disconnects in the public health record-keeping system delayed sharing critical data that could help patients, said Dr. Thomas Inglesby, director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health.
  • Hospitals look to the C.D.C. for that information. “Is it higher risk to be a healthy person at age 75 with coronavirus or a diabetic with the disease at age 45?” Dr. Inglesby said. “We should have the data to know the answer to this question quickly, and we should be using it to make better decisions.”
  • As the number of suspected cases — and deaths — mounted, the C.D.C. struggled to record them accurately. The agency rushed to hire extra workers to process incoming emails from hospitals. Still, many officials turned to Johns Hopkins University, which became the primary source for up-to-date counts. Even the White House cited its numbers instead of the C.D.C.’s lagging tallies.
  • Some staff members were mortified when a Seattle teenager managed to compile coronavirus data faster than the agency itself, creating a website that attracted millions of daily visitors. “If a high schooler can do it, someone at C.D.C. should be able to do it,” said one longtime employee.
  • For years, federal and state governments have not invested enough money to insure that the nation’s public health system would have critical data needed to respond in a pandemic. Since 2010, for example, grants to help hospitals and states prepare for emergencies have declined.
  • In 2019, more than 100 public health groups pressed congressional leaders to allocate $1 billion over a decade to upgrade the infrastructure. The C.D.C. received $50 million toward the effort this year. Then, as coronavirus cases and deaths mounted in March, the federal government committed to $500 million under the emergency CARES Act.
  • “The crisis has highlighted the need to continue efforts to modernize the public health data systems that C.D.C. and states rely on,” Dr. Redfield told a Senate committee on May 12. “Timely and accurate data are essential as C.D.C. and the nation work to understand the impact of C19 on all Americans.”
  • Data is one of the essential tools of public health; Mr. Trump, though, often appears to see it as a weapon against him. He has suggested that testing is “overrated” and that it makes the United States look bad by increasing the number of confirmed cases. He has seized on lower-end projections of the virus’s toll, only to see them eclipsed as the cases and deaths rose.
  • Recently, the C.D.C. drew criticism after media reports disclosed that in tracking how many Americans had been tested, the agency had breached standard practice by combining data from antibody tests, which can indicate past infections, with diagnostic tests. The agency said it was caused by confusion in overworked state and local health officials reporting results, but the mistake muddied the picture of the pandemic.
  • “The scientists at the C.D.C. are still great,” Dr. Jha said. “It’s very puzzling to all of us why C.D.C. performance has been so poor.”
A Strained Relationship
  • Late in the evening on March 15, the C.D.C. put a bold statement on its website: All gatherings of more than 50 people should be canceled, the agency said, effectively calling for an end to large public events.
  • Reporters soon were peppering the White House with questions about whether it was overruling the C.D.C. Some of Mr. Trump’s aides shrugged it off as a miscommunication. But others viewed it as the C.D.C. insisting it knew best.
  • The episode underscored the strained relationship between the health agency and the White House. Veteran officials at the C.D.C. were not unfamiliar with the ways of Washington. But they had never dealt with a president like Mr. Trump or a White House like his.
  • Already under siege for problems with the agency’s diagnostic test, C.D.C. officials watched with growing alarm as Mr. Trump, facing criticism for his administration’s response, repeatedly undermined the agency.
  • Though the task force was occasionally ahead of the C.D.C. in its cautions to the public, Mr. Trump and his aides often expressed extraordinary skepticism about the coronavirus and the steps required to combat it. He said the virus would disappear “like a miracle” even as C.D.C. scientists described it as a real threat. When the C.D.C. urged Americans to wear masks, he said, “I don’t see it for myself.”
  • And when Dr. Redfield told The Washington Post that a second wave of the virus could be “even more difficult” than the first, Mr. Trump insisted that he publicly claim to have been misquoted during a White House briefing. Dr. Redfield, with the president standing next to him, scowling, said he had been misunderstood.
  • At one point, Mr. Trump even complained about the agency to his 80 million Twitter followers, saying, “For decades the @CDCgov looked at, and studied, its testing system, but did nothing about it.”
  • “There comes a time,” said Dr. Jeffrey Koplan, who served as C.D.C. director in the Clinton and Bush administrations, “when it makes it very hard to operate effectively, when things are being suggested, requested, ordered that you think are contrary to the containment of the pandemic.”
  • The president and his aides viewed the civil servants at the C.D.C. — many of whom had worked under presidents from both parties — as disloyal liberals eager to wound Mr. Trump politically by leaking to the press. In private, some senior administration officials began referring to agency scientists as members of the “deep state,” according to several people who participated in the conversations but requested anonymity to discuss the meetings.
  • As the crisis deepened, tensions between Washington and Atlanta increased.
  • In late February, Dr. Nancy Messonnier, who oversees the C.D.C.’s respiratory diseases center and had been leading the agency’s emergency response, was sidelined after she issued a stark public warning that the virus would disrupt American lives. The comments sent stocks tumbling and infuriated Mr. Trump, who had not been told in advance. Public health officials, inside and outside the agency, saw her forced retreat as an effort to silence the truth.
  • Often, the clashes have centered on the economic consequences of shutdowns, which have forced 40 million people into unemployment, companies into bankruptcy and fueled resentment across the country.
  • In early April, the C.D.C. posted an extension of its “no sail” order for cruise ships, forbidding them from operating through August and warning that the ban could become indefinite. The White House had supported the original order, but privately objected to an indefinite ban, fearing lasting harm to an industry that employs tens of thousands of people.
  • The posting quickly came down, replaced by an order ending the ban in July. “Those things aren’t helpful,” Dr. Redfield would tell his colleagues when disputes between the C.D.C. and the task force erupted.
  • The White House was soon put on the defensive when USA Today cited internal emails about the pressure. “Sorry to do this, but the Office of the Vice President has instructed us to pull the No Sail Order Extension from the website immediately,” the paper quoted a C.D.C. official as writing to agency colleagues.
  • To the president’s aides, one of the most frustrating moments came on May 1, when Dr. Schuchat published one of the agency’s regular reports on morbidity and mortality without giving the White House any notice, according to two of Mr. Trump’s advisers.
  • Written in dry, scientific language, the report offered a blunt assessment of the virus’s spread, showing how travel from Europe and mass gatherings had accelerated it. Dr. Schuchat went further when interviewed for an Associated Press article — “Health Official Says U.S. Missed Some Chances to Slow Virus” — saying that “taking action earlier could have delayed further amplification.”
  • As the president pushed governors to “liberate” their states from virus lockdowns, top C.D.C. officials in April delivered a draft of new guidance full of caveats about lifting the restrictions. In it, the agency urged schools, churches, child care centers, day camps, restaurants and bars to take numerous precautions and move slowly.
  • Trump aides were furious when they saw the draft. To them, it was more evidence that the C.D.C. refused to consider political, economic and social effects in weighing how and when to reopen the country. The agency’s recommendations for houses of worship, particularly annoyed some aides, who resisted the advice that churches stop giving communion.
  • When the White House sat on the draft guidance for weeks, a copy was leaked.
  • While the C.D.C. delayed posting the draft guidance that would allow churches to reopen, Mr. Trump all but ordered it to do so. During a visit to Michigan on May 21, the president — who the next day would explain, “In America, we need more prayer, not less” — made it clear the C.D.C. no longer had any choice.
  • “I said, ‘You better put it out,’” Mr. Trump told reporters. “And they’re doing it.”
  • Lawrence Gostin, the director of a legal center at the World Health Organization, and a former C.D.C. official, chided the White House for exerting undue pressure on the C.D.C. throughout the crisis.
  • “Public health is politics. But this is different,” he said. “It’s criticizing its public health agencies in public. It’s rejecting guidelines it puts out. It tells them you can’t even put guidelines out.”
  • “I would expect the C.D.C. to coordinate with the White House,” he added. “But this is not team work. This is not coordination. This is confrontation.”
Where’s the Guidance?
  • As the battle against the coronavirus stretches into summer and the United States lurches toward restarting its economy, the mayor of Miami Beach wants to know what to do if C19 cases explode after the city’s famous beaches open again.
  • Doctors and nurses remain desperate for updates on how to protect themselves. School superintendents and college presidents need to decide how to hold classes in the fall. And employers want advice about whether to test all of their workers before returning to business as usual.
  • The C.D.C. is where they expect to get answers. As the national clearinghouse for critical public health information, it has dual missions: to provide medical guidance to health workers while offering easy-to-understand information for political leaders, business executives and the general public.
  • But many say the agency has struggled at times to provide clear and timely guidance.
  • At Margaret Mary Community Hospital in rural Batesville, Ind., doctors and nurses got sick after following C.D.C. guidance in mid-March that masks were necessary only when treating patients with respiratory symptoms or fever. The first patients who tested positive for C19 there instead showed up with headaches, fatigue, nausea and diarrhea.
  • “This virus made it halfway around the world without us having a heads-up to our providers that this is how the disease can present,” said Tim Putnam, the hospital’s chief executive. “Over two months after the disease surfaced, I would have expected better.”  
  • Front-line doctors and nurses have long relied on the agency for advice on clinical best practices, and many said in interviews that they were satisfied with the C.D.C.’s advisories, especially given the novelty of the coronavirus.
  • The agency has issued 114 advisory documents for disaster and homeless shelters, retirement communities, taxis, pediatric clinics and other venues. “We have issued countless guidance and recommendations based on the best available science and data,” an agency press officer said. Its experts have also held about a dozen calls for clinicians about caring for Covid patients, and other calls for medical groups.
  • But in interviews with medical practitioners across the country, many said they now look elsewhere for detailed recommendations about how to safely care for infected patients, posing questions about the new virus on mailing lists or scouring online research articles.
  • In a crisis, one of the C.D.C.’s main roles is to explain its guidance and reasoning, provide a rationale for when its thinking changes and acknowledge what it does not know. The agency’s routine in past emergencies was to hold press briefings almost daily; Dr. Thomas Frieden, Dr. Redfield’s predecessor, was highly visible during the Ebola and Zika crises. But in this case, medical workers and the public were left to make sense of often-opaque postings on the C.D.C.’s website after ​its leadership stopped holding regular briefings on March 9.
  • “Right now, they only have the PDFs that are out there, without any kind of a conversation,” said Dr. Jennifer Nuzzo, an epidemiologist at Johns Hopkins. “That is a real shortcoming.”
  • Medical specialty and public health organizations have sometimes taken it on themselves to identify and highlight updates for their members.
  • “It would be awesome if C.D.C. could actually announce significant changes rather than bury it on their website and assume it is done,” Jim Collins, Michigan’s director of communicable diseases, complained to his colleagues in an email on Jan. 31.
  • The C.D.C., some medical workers complain, has provided limited guidance on how children transmit the virus, when to ventilate patients and how to prioritize use of isolation rooms. And it took until April 27 for the agency to expand its list of possible symptoms to include more than a dozen signs of illness that some medical specialty societies had reported weeks earlier.
  • To many anxious doctors and nurses, some of the C.D.C.’s clinical guidance often seemed driven by the nationwide shortages of personal protective equipment, not the best interests of health care workers.
  • Initially, the C.D.C. recommended that all doctors and nurses coming in contact with coronavirus patients wear N95 respirators, which filter out 95 percent of all airborne particles. But on March 10, with supplies dwindling, the C.D.C. announced that less protective surgical masks were “an acceptable alternative” except during procedures that might aerosolize the virus. Days later, the agency said health workers could even wear “homemade masks (e.g., bandanna, scarf) for care of patients with C19 as a last resort.”
  • “Mistrust crept in,” said Lori Freeman, chief executive of the National Association of County and City Health Officials. “‘Are we really being protected?’”
  • The relaxed guidance on protective equipment matched advice from the World Health Organization on surgical masks. But the C.D.C. did not highlight that fact in its update and gave no public explanation other than acknowledging the worsening shortages. An analysis published this week suggests that N95 and other respirator masks are superior to surgical or cloth masks in protecting medical workers against the virus.
  • Leaders of schools, businesses and other organizations also said they were confused by the C.D.C.’s advice, which sometimes conflicted with that of the White House coronavirus task force.
  • In one such instance on March 16, the White House urged limiting gatherings to no more than 10 people and “schooling from home whenever possible” for at least the next 15 days. But days earlier, the C.D.C. had recommended that schools close only if someone in the building tested positive or there was evidence of “substantial community transmission.”
  • On March 17, nearly 2,500 superintendents from around the country were hoping to get some clarity during an online seminar with the C.D.C. Why was the C.D.C. recommending most schools could remain open?
  • But just 40 minutes before the seminar was to start, the C.D.C. canceled it without explanation and never rescheduled. The agency later told reporters it had decided “to fully adapt to the new guidance from White House” before addressing the superintendents.
  • In Miami Beach, densely packed with tourists, older residents and service workers, Mayor Dan Gelber dreads the prospect of new outbreaks. While he appreciated the reopening guidance that the C.D.C. published recently, Mr. Gelber, a Democrat, said he wished the agency would also lay out specific steps to follow if cases surge again.
  • “It’s almost as if they just said, ‘Open up and figure out whether it’s a good idea or not afterward,’” he said of the C.D.C. “We don’t have a net here.”

Source: The C.D.C. Waited ‘Its Entire Existence for This Moment.’ What Went Wrong?

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