Recent Developments & Information
June 16, 2020
Reliable information is the best tool available to protect your family from the pandemic and its shockwaves
“Between 10% and 20% of patients with COVID-19 show no antibodies in serological tests. 75% or more of coronavirus patients develop antibodies, but they aren’t the neutralizing kind, indicating immunity to the disease might not last long in most people.”Dr. George Rutherford, a UCSF infectious disease specialist
“An extraordinary percentage of people infected by the virus behind the ongoing deadly C19 pandemic—up to 45%—are people who never show symptoms of the disease.”Scripps Research analysis of public datasets on asymptomatic infections
Index of Featured Stories:
Note: All of the stories listed below are included in this Update, but we embedded links in the title of the stories so that you can quickly jump to a story if you want (except for original content, which has no link).
1. Beyond The Headlines: A Closer Look at US Hotspots
- Top 10 States For New Cases, Positive Test Percentages & New Deaths
2. Concerns & Unknowns
- C19 far more dangerous for patients with heart disease or diabetes
- C19 may trigger onset of diabetes and cause severe complications of pre-existing diabetes
- C19 Threatens the Entire Nervous System
- C19 can damage lungs of victims beyond recognition
4. New Scientific Findings & Research
- “Silent” Carriers: Extraordinary Percentage of Coronavirus Infections May Be Asymptomatic
- Maintaining 40-60% Humidity Indoors Reduces Transmission of Virus Neutralizing Antibodies Are Key to Long-Term Immunity, But Less than 5% of Recovered C19 Patients Have Them
- Why C19 Makes People Lose Their Sense of Smell
- Coronavirus can infect the brain and replicate
- Scientists report flaws in WHO-funded study on 2-metre distancing
5. The Road Back?
- Reduce Our Exposure to Superspreaders by Avoiding the 3 Cs of Transmission
- Contact tracing is ‘best’ tool we have until there’s a vaccine
6. Projections & Our (Possible) Future
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A. Our World As Seen Through Headlines
(In no particular order)
- Beijing lockdown tightens as new coronavirus outbreak spreads
- Bars, karaoke and gyms can aid ‘superspread’
- Lockdowns are largely over. The CDC has new guidelines for being safe out in the world.
- Chile Health Minister Resigns as Covid-19 Deaths Hit Record
- Latin American scientists join the coronavirus vaccine race: ‘No one’s coming to rescue us’
- Sinovac says early data show its Covid-19 vaccine generated immune responses
- AstraZeneca agrees to supply Europe with 400 million doses of COVID-19 vaccine
- FDA Revokes Emergency Use Ruling for Hydroxychloroquine
- CDC director thanks Americans but warns pandemic is far from over
- Reopenings Slowly Energize U.S. Economy Amid Rise in Virus Cases
- ‘Do your job’: Gov. Cuomo urges de Blasio amid lack of NYC social distancing
- Oscars 2021 postponed to later date due to the coronavirus
- A month after reopening, Pakistan has recorded 100,000 new virus cases as hospitals become overwhelmed and health care workers fall ill
- President Macron of France declared a “first victory” over the virus and said all business could resume this week
- Coronavirus lockdown is over, so stop dressing like slobs
- Early test results show only a few Minnesota protesters got coronavirus
- Europe’s borders reopen but long road for tourism to recover
- Florida sees second day in a row of over 2,000 new coronavirus cases
- Stocks expected to tumble amid fears of coronavirus second wave
- More than half of all four-year colleges in the U.S. won’t require SAT or ACT scores for applicants this fall
- Alarming spikes in coronavirus cases across the U.S.
- In England, stores that sell nonessential goods reopened with restrictions today, and for the first time people taking public transit must wear face coverings
- the door to fraud, and threatened the credibility of prestigious publications
- New Zealand is no longer coronavirus-free after traveling Brits test positive
- First coronavirus vaccine may protect against disease, but not infection
- The US Tennis Association will hold the 2020 United States Open as originally scheduled starting Aug. 31, but without spectators.
- NFL plans to test players for coronavirus three times per week
- If it’s OK to protest, how can you ban funerals?
- Recent retractions from respected medical journals are alarming scientists who fear that the rush for research on the virus has opened
- NYC welds shut gate to Williamsburg playground amid coronavirus
- American Airlines not enforcing own mask policy, passenger claims
- Meatpacking workers often absent after order to reopen
- ‘We’ve missed it’: Long lines form outside shops in England
- Israel deports Shari Redstone’s son for breaking quarantine to visit model girlfriend
- Tulsa health director ‘wishes’ Trump would reschedule rally amid coronavirus spike
- Illnesses and deaths from preventable diseases like measles have skyrocketed in many poor countries after immunization efforts halted due to the coronavirus.
- Covid-19 patients, through federal aid packages, are supposed to be largely exempt from paying for their care, but mistakes are leaving some with eye-popping bills
- American-made social media conspiracy theories about the virus are getting amplified by Russia.
- Avoiding a coronavirus second wave is up to each of us
- Take that, coronavirus! 20,000 fans go wild at sporting event
- De Blasio fires back at Cuomo’s threat to shut down Manhattan again
- Ohio State making football players sign coronavirus risk waiver
- WHO warns England on further removing lockdown rules
- Putin claims Russia handled coronavirus better than the US
- Cuomo threatens Manhattan, Hamptons shutdown
- Beijing Bars ‘High Risk’ Residents From Leaving, Closes 7 Compounds As Lockdowns Return
- US Restaurant Traffic Suddenly Craters Amid Second Wave Fears
- MLB Commissioner Says 2020 Baseball Season Will Likely Be Canceled Amid Labor Dispute
- In Second Blow To Hydroxychloroquine, FDA Warns Against Combining With Remdesivir
- NYC Mayor Orders Army Of COVID-19 Contact-Tracers Not To Ask About BLM Protests Attendance
- The COVID-19 Pandemic Has Caused A Global Bicycle Shortage
- Half a million fewer children? The coming COVID baby bust.
- Cuomo threatens reopen rollbacks over social distancing, business violations
- Prison deaths tied to the virus have risen 73 percent since mid-May
- New Zealand records two new cases, breaking a 24-day streak
- Orthodox Jews Cut Open Bill de Blasio’s Locked Parks
- Indian Supreme Court: Corona Patients Treated ‘Worse than Animals’
- Kudlow: Spike in COVID-19 Cases ‘Not a Second Wave’
- Central Park sunbathers skip masks — and pants — in coronavirus defiance
- Global Sugar Consumption Declines For First Time In Forty Years
B. Numbers & Trends
Note: Unless otherwise noted, (i) all cases/deaths are confirmed cases/deaths that have been reported, (ii) all numbers reported in this update are as of the end of the most recent reporting period, and (iii) all changes reflect changes since the preceding day. Green highlights indicate a decrease or no change and yellow highlights indicate an increase.
1. Cases & Tests
- Worldwide Cases:
- Total Cases = 8,108,667 (+1.6%)
- New Cases = 124,360 (+553)
- Growth Rate of New Cases (7 day average) = 1.9%
- New Cases (7 day average) = 131,257 (+2,441)
[Note: For a more detailed analysis of global cases and trends, see the Johns Hopkins COVID-19 Report at the end of this Update]
- US Cases & Testing:
- Total Cases = 2,182,950 (+1.0%)
- New Cases = 20,806 (+886)
- Percentage of New Global Cases = 16.7%
- Growth Rate of New Cases (7 day average) = 1.1% (+0%)
- New Cases (7 day average) = 22,351 (+252)
- Total Number of Tests = 25,259,007 (+468,076)
- Percentage of positive tests (7 day average) = 4.5% (-0.1%)
- Worldwide Deaths:
- Total Deaths = 438,596 (+0.8%)
- New Deaths = 3,420 (+162)
- Growth Rate of Deaths (7 day average) = 0.9% (-0.1%)
- New Deaths (7 day average) = 4,337 (+37)
- US Deaths:
- Total Deaths = 118,283 (+0.4%)
- New Deaths = 430 (+104)
- Percentage of Global New Deaths = 12.6%
- Growth Rate of Deaths (7 day average) = -2.9% (-3.6%)
- New Deaths (7 day average) = 747 (-22)
- Deaths have been trending down since April 21 (although there have been some significant ups and downs)
C. Beyond the Headlines: A Closer Look at US Hotspots
1. Top 10 States For New Cases, Positive Test Percentages & New Deaths
- Below are the top hotspots for new cases, positive test rates and new deaths
- Some of the States that have aggressively reopened their economies have had significant increases in the number of new cases and positive test percentages. CA, NY and IL have been under strict lockdowns and are reopening slowly, but are still in the top 10 for the highest number of cases (with CA having the highest 7 day average number of new cases). While increasing numbers of cases is a warning of potential increases in hospitalizations and deaths, we believe that the positive test rate is a better indicator of potential future increases in hospitalizations and deaths.
- All 10 of the States with the highest positive test percentages are in excess of the national average of 4.5%, with SC and AL more than 2x the national average and AZ more than 3x the national average. The high (and in most cases) increasing positive test percentages among these States indicate that the spread of the virus is growing, which is indicative of potential increases in hospitalizations and deaths.
- Ultimately, the number of deaths may be the most important metric for how well a State is managing the pandemic. Notably, NJ, CA, IL, MA and NY are in the top 6 highest 7 day average of new deaths even though these States have been subject to strict lockdowns and are opening slowly. TX and FL, the second and third most populated States and have reopened aggressively, have less deaths than NY, CA, IL, MA and NJ. Also, the per capita deaths of TX, FL, GA and OH are all well below the national average of 357 per million, while per capita deaths in NY, NJ, MA and IL are all well above the national average.
D. Concerns & Unknowns
1. C19 far more dangerous for patients with heart disease or diabetes
- Patients with an underlying health condition were six times more likely to end up in the hospital and 12 times more likely to die if they contracted C19 than otherwise healthy people, a new federal study shows.
- Less than 2% of previously healthy people died from the infection, compared to nearly 20% with preexisting conditions, most often heart disease, diabetes or lung disease, according to the new data, released Monday by the Centers for Disease Control and Prevention.
- Overall, 14% of people who developed C19 have been hospitalized, and 5% of those people died, according to the CDC study.
- According to data from Johns Hopkins University, which is compiling C19 infections and deaths worldwide, more than 2 million people have become infected with the virus in the United States. Nearly 116,000 Americans have died.
- The numbers of confirmed cases and deaths due to C19 are believed to be underestimates. Many people with symptoms were discouraged from getting tests early on because of a shortage, and many people have died at home and not been counted.
- The elderly are at highest risk of dying from C19
- Age was a major factor in infection, hospitalization and death. The elderly — defined as people over 80 — were at highest risk of dying regardless of any underlying health conditions, according to the study.
- The virus killed 50% of hospitalized elderly patients with underlying conditions and 30% of hospitalized elderly patients who were previously healthy, the study found. Age also affected incidence of disease, with people over 80 at nearly twice the risk of contracting the coronavirus, which causes C19, than those just a decade younger.
- Among about 600,000 patients whose racial and ethnic information were known, about 36% were white, 33% were Hispanic, 22% were Black, 4% were Asian, and 1.3% were American Indian or Alaska Native, the study found. That breakdown confirms previous reports that people of color, who represent about 32% of the U.S. population, are over-represented among those diagnosed with and hospitalized for C19.
- In a smaller group for whom information was known about underlying health conditions, 32% had heart disease, 30% had diabetes and 18% had chronic lung disease. About half of the diagnosed patients over 70 reported having heart disease.
- About 45% of patients with underlying health issues reported being hospitalized for C19, compared to 8% of patients of previously healthy people.
- Although the study found no difference in the rate of infection between men and women, men with underlying health conditions were more likely to end up in the hospital and to die than women with similar conditions. But the difference was not as large as in some previous reports.
- About 11% of patients were reported to be pregnant.
- An unknown number of people can develop C19 without ever having symptoms or knowing that they have the coronavirus. These people were not reflected in the new report.
2. C19 may trigger onset of diabetes and cause severe complications of pre-existing diabetes
- Emerging evidence suggests that C19 may actually trigger the onset of diabetes in healthy people and also cause severe complications of pre-existing diabetes.
- A letter published today in the New England Journal of Medicine and signed by an international group of 17 leading diabetes experts involved in the CoviDiab Registry project, a collaborative international research initiative, announces the establishment of a Global Registry of new cases of diabetes in patients with C19.
- The Registry aims to understand the extent and the characteristics of the manifestations of diabetes in patients with C19, and the best strategies for the treatment and monitoring of affected patients, during and after the pandemic.
- Clinical observations so far show a bi-directional relationship between C19 and diabetes. On the one hand, diabetes is associated with increased risk of C19 severity and mortality. Between 20 and 30% of patients who died with C19 have been reported to have diabetes. On the other hand, new-onset diabetes and atypical metabolic complications of pre-existing diabetes, including life-threatening ones, have been observed in people with C19.
- It is still unclear how the coronavirus impacts diabetes. Previous research has shown that ACE-2, the protein that binds to the coronavirus allowing the virus to enter human cells, is not only located in the lungs but also in organs and tissues involved in glucose metabolism such as the pancreas, the small intestine, the fat tissue, the liver and the kidney. Researchers hypothesize that by entering these tissues, the virus may cause multiple and complex dysfunctions of glucose metabolism. It has also been known for many years that virus infections can precipitate type 1 diabetes.
- Francesco Rubino, Professor of Metabolic Surgery at King’s College London and co-lead investigator of the CoviDiab Registry project, said: “Diabetes is one of the most prevalent chronic diseases and we are now realizing the consequences of the inevitable clash between two pandemics. Given the short period of human contact with this new coronavirus, the exact mechanism by which the virus influences glucose metabolism is still unclear and we don’t know whether the acute manifestation of diabetes in these patients represent classic type 1, type 2 or possibly a new form of diabetes”.
- Paul Zimmet, Professor of Diabetes at Monash University in Melbourne, Honorary President of the International Diabetes Federation and co-lead investigator in the CoviDiab Registry project said: “We don’t yet know the magnitude of the new onset diabetes in C19 and if it will persist or resolve after the infection; and if so, whether or not or C19 increases risk of future diabetes. By establishing this Global Registry, we are calling on the international medical community to rapidly share relevant clinical observations that can help answer these questions”.
- Stephanie Amiel, Professor of Diabetes Research at King’s College London and a co-investigator of the CoviDiab Registry project said: “The registry focuses on routinely collected clinical data that will help us examine insulin secretory capacity, insulin resistance and autoimmune antibody status to understand how C19 related diabetes develops, its natural history and best management. Studying C19-related diabetes may uncover novel mechanisms of disease.”
3. C19 Threatens the Entire Nervous System
- A new review of neurological symptoms of C19 patients in current scientific literature reveals the disease poses a global threat to the entire nervous system, reports a Northwestern Medicine study published this week in Annals of Neurology.
- About half of hospitalized patients have neurological manifestations of C19, which include headache, dizziness, decreased alertness, difficulty concentrating, disorders of smell and taste, seizures, strokes, weakness and muscle pain.
- “It’s important for the general public and physicians to be aware of this, because a coronavirus infection may present with neurologic symptoms initially, before any fever, cough or respiratory problems occur,” said lead author of the review, Dr. Igor Koralnik, Northwestern Medicine chief of neuro-infectious diseases and global neurology and a professor of neurology at Northwestern University Feinberg School of Medicine.
- The review describes the different neurological conditions that may occur in C19 patients and how to diagnose them, as well as likely pathogenic mechanisms.
- “This understanding is key to direct appropriate clinical management and treatment,” Koralnik said.
- The disease may affect the entire nervous system, including the brain, spinal cord and nerves as well as the muscles. There are many different ways C19 can cause neurological dysfunction, he said. Because this disease may affect multiple organs (lung, kidney, heart), the brain may also suffer from lack of oxygenation or from clotting disorders that may lead to ischemic or hemorrhagic strokes.
- In addition, the virus may cause direct infection of the brain and meninges. Finally, the reaction of the immune system to the infection may cause inflammation that can damage the brain and nerves.
- Koralnik and colleagues have formed a Neuro-COVID research team and started a retrospective analysis of all C19 patients hospitalized at Northwestern Medicine to determine the frequency and type of neurological complications, as well as response to treatment.
- Since knowledge about the long term outcome of neurologic manifestations of C19 is limited, Koralnik also will follow some of those patients prospectively in his new outpatient Neuro-COVID clinic to determine if neurological problems are temporary or permanent. These studies will provide the foundation on how to diagnose, manage and treat the many neurologic manifestations of C19, he said.
4. C19 can damage lungs of victims beyond recognition
- C19 can leave the lungs of people who died from the disease completely unrecognisable, a professor of cardiovascular science has told parliament.
- It created such massive damage in those who spent more than a month in hospital that it resulted in “complete disruption of the lung architecture”, said Prof Mauro Giacca of King’s College London.
- In findings that he said showed the potential for “real problems” after survival, he told the Lords science and technology committee that he had studied the autopsies of patients who died in Italy after 30 to 40 days in intensive care and discovered large amounts of the virus persisting in lungs as well as highly unusual fused cells.
- “What you find in the lungs of people who have stayed with the disease for more than a month before dying is something completely different from normal pneumonia, influenza or the Sars virus,” he said. “You see massive thrombosis. There is a complete disruption of the lung architecture – in some lights you can’t even distinguish that it used to be a lung.
- “There are large numbers of very big fused cells which are virus positive with as many as 10, 15 nuclei,” he said. “I am convinced this explains the unique pathology of C19. This is not a disease caused by a virus which kills cells, which had profound implications for therapy.”
- His evidence came as the Lords committee heard from medical scientists and doctors grappling with the nature of C19 six months after its emergence in Europe, its behaviour, treatments, vaccines and the possibility of immunity.
1. The First Covid Vaccines May Not Prevent C19 Infection
- Desperation for a way to keep economies from collapsing under the weight of C19 could mean settling for a vaccine that prevents people from getting really sick or dying but doesn’t stop them from catching the coronavirus.
- Although a knock-out blow against the virus is the ultimate goal, early vaccines may come with limitations on what they can deliver, according to Robin Shattock, an Imperial College London professor leading development of an experimental shot.
- “Is that protection against infection?” Shattock said. “Is it protection against illness? Is it protection against severe disease? It’s quite possible a vaccine that only protects against severe disease would be very useful.”
- As countries emerge warily from lockdowns, leaders are looking to a preventive shot as the route to return to pre-pandemic life. Fueled by billions of dollars in government investment, vaccines from little-known companies like China’s CanSino Biologics Inc. and giants like Pfizer Inc. and AstraZeneca Plc are in development.
- At least one of the fastest-moving experimental shots has already advanced into human trials after showing an impact on severe disease — but less so on infection — in animals. Experts say such a product would probably be widely used if approved, even if that’s as much as it contributes, until a more effective version comes to market.
- “Vaccines need to protect against disease, not necessarily infection,” said Dennis Burton, an immunologist and vaccine researcher at Scripps Research in La Jolla, California.
- There are drawbacks, though. While holding the potential to save lives, such vaccines might lead to complacency in lockdown-weary nations, said Michael Kinch, a drug development expert who is associate vice chancellor at Washington University in St. Louis.
- “My guess would be that the day after someone gets immunized, they’re going to think, ‘I can go back to normal. Everything will be fine,’” he said. “They’re not going to necessarily realize that they might still be susceptible to infection.”
- C19 is already thought to be spread by people without symptoms, and a symptom-preventing vaccine may create even greater numbers of them.
- Vaccines are among the most effective weapons against infectious disease, and prevent up to 3 million deaths a year, according to the World Health Organization. Yet few, if any, are 100% effective in all people who get them. For example, about 3% of people who get measles vaccine develop a mild form of the disease, and can spread it to others.
- How the shot being developed by Oxford and AstraZeneca affects infections and infectiousness still isn’t clear. William Haseltine, a former HIV researcher at Harvard University, pointed out in a blog for Forbes that animals had roughly the same amount of viral genetic material, called RNA, in their systems, whether or not they’d received shots. Levels of antibodies against the virus weren’t as high as in very protective vaccines, he said.
- However, clinical signs of severe infection, like high breathing rate and pneumonia, were better in vaccinated monkeys. That might still make such a shot useful, according to Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.
- “That vaccine doesn’t look like it’s a knockout for protecting against infection, but it might be really very good at protecting against disease,” Fauci told the medical news website Stat.
- The vaccine will be a success whether it heads off infections or severe symptoms, AstraZeneca Chief Executive Officer Pascal Soriot said in a BBC interview. The vaccine’s progress to advanced studies was approved by an independent scientific panel, and the company is waiting to see how it performs, a spokesman said.
- Fauci’s NIAID is partnered with Moderna Inc. on a Covid vaccine test whose primary goal is to show their vaccine prevents people from developing symptoms, the company said June 11. Preventing infections is a secondary goal.
- Successful preventives must also bar onward transmission, said Dan Barouch, a researcher at the Center for Virology and Vaccine Research at Beth Israel Deaconess Medical Center and Harvard University. Effective shots may allow some cells to become infected, but control the growth of the virus before it can be passed on to others, said Barouch, who is developing a vaccine with Johnson & Johnson. He said his efforts are aimed at a vaccine that prevents infections.
- The FDA is considering options for a vaccine that prevents illness.
- “We would potentially consider an indication related to prevention of severe disease, provided available data support the benefits of vaccination,” FDA spokesman Michael Felberbaum said in response to questions. “For licensure we would not require that a vaccine protect against infection.”
- Licensed vaccines including some against whooping cough have not been demonstrated to protect against infection with the pathogen that causes the disease but have been demonstrated to protect against symptomatic disease, Felberbaum said.
- The notion of using imperfect vaccines and therapies is “fine,” Kinch said. “That’s just practicality. And we may follow those up with more-perfect. There will never be a truly perfect vaccine.”
F. New Scientific Findings & Research
1. “Silent” Carriers: Extraordinary Percentage of Coronavirus Infections May Be Asymptomatic
- An extraordinary percentage of people infected by the virus behind the ongoing deadly C19 pandemic—up to 45%—are people who never show symptoms of the disease, according to the results of a Scripps Research analysis of public datasets on asymptomatic infections.
- The findings, recently published in Annals of Internal Medicine, suggest that asymptomatic infections may have played a significant role in the early and ongoing spread of C19 and highlight the need for expansive testing and contact tracing to mitigate the pandemic.
- “The silent spread of the virus makes it all the more challenging to control,” says Eric Topol, MD, founder and director of the Scripps Research Translational Institute and professor of Molecular Medicine at Scripps Research. “Our review really highlights the importance of testing. It’s clear that with such a high asymptomatic rate, we need to cast a very wide net, otherwise the virus will continue to evade us.”
- Together with behavioral scientist Daniel Oran, Topol collected information from testing studies on 16 diverse cohorts from around the world. These datasets—gathered via keyword searches of PubMed, bioRxiv and medRxiv, as well as Google searches of relevant news reports—included data on nursing home residents, cruise ship passengers, prison inmates and various other groups.
- “What virtually all of them had in common was that a very large proportion of infected individuals had no symptoms,” says Oran. “Among more than 3,000 prison inmates in four states who tested positive for the coronavirus, the figure was astronomical: 96 percent asymptomatic.”
- The review further suggests that asymptomatic individuals are able to transmit the virus for an extended period of time, perhaps longer than 14 days. The viral loads are very similar in people with or without symptoms, but it remains unclear whether their infectiousness is of the same magnitude. To resolve that issue, we’ll need large-scale studies that include sufficient numbers of asymptomatic people.
- The authors also conclude that the absence of symptoms may not imply an absence of harm. CT scans conducted on 54% of 76 asymptomatic individuals on the Diamond Princess cruise ship, appear to show significant subclinical lung abnormalities raising the possibility of coronavirus infection impacting lung function that might not be immediately apparent. The scientists say further research is needed to confirm the potential significance of this finding.
- The authors also acknowledge that the lack of longitudinal data makes distinguishing between asymptomatic and presymptomatic individuals difficult. An asymptomatic individual is someone who is infected with coronavirus, but never develops symptoms of C19, while a presymptomatic person is similarly infected, but will eventually develop symptoms. Longitudinal testing, which refers to repeated testing of individuals over time, would help differentiate between the two.
- “Our estimate of 40 to 45% asymptomatic means that, if you’re unlucky enough to get infected, the probability is almost a flip of a coin on whether you’re going to have symptoms. So to protect others, we think that wearing a mask makes a lot of sense,” Oran concludes.
2. Maintaining 40-60% Humidity Indoors Reduces Transmission of Virus
- Scientists now concur that C19 spreads primarily in droplets through the air—be it from coughing or just talking—so public health officials recommend that people wear masks and face shields, and maintain social distancing of at least 6 feet.
- But many researchers believe that these guidelines don’t go far enough. To truly help protect people from transmitting C19, we need to fix the air we breathe.
- Over the past months, Fast Company has connected with many experts on the topic of air quality and circulation. They’ve offered a variety of best practices for everyone, from restaurant owners to CEOs to families, to consider. Here’s what we’ve learned so far.
Social Distancing Isn’t Nearly Enough
- We’ve heard it again and again that 6 feet of social distance creates a safe buffer, and restaurants, offices, and even Starbucks cafes are being redesigned around that tenant. Social distance does help prevent transmission, but according to new modeling, even a small breeze can spread the coronavirus up to 20 feet.
- Dimitris Drikakis, the professor at University of Nicosia, Cyprus, who created the model, insists that this finding doesn’t mean that someone coughing 20 feet away will get you instantly sick. The overall amount of virus you breathe in over time matters, too.
- But his research does confirm that even outdoors, distance gatherings come with some risk.
- And given these findings, we should scrutinize our indoor air aggressively, too.
Add Filters and User Fresh Air Indoors
- Something experts in air quality talk about a lot is how many liters of air a person is getting per minute. Whether that’s inside a cruise ship or a building, a portion of that air might be fresh air pumped in from outside, and a portion will be recirculated (and hopefully, filtered).
- According to Qingyan Chen, professor of mechanical engineering at Purdue University, planes are pretty good about providing clean air to passengers, because floor vents suck air away from passengers, and through HEPA filters you don’t see, before pumping it back through the cabin. This system is by no means perfect, but HEPA filters capture 99% or more of viruses that are .3 microns or larger.
- On cruise ships and in many buildings, HVAC systems use lower-quality air filters, which might catch just 20% to 40% of viruses passing through. On the tragic Diamond Princess cruise ship, which quarantined thousands of passengers to their rooms for nearly a month while the ship was dry-docked in Tokyo Bay, air circulated between cabins without HEPA filtering, infecting 700 people and killing 8 people who were breathing the same old stew of air.
- In our reporting from architects and office specialists, we’ve heard that U.S. office buildings may begin to retrofit with higher-end HVAC systems (with HEPA filters and even UV light sterilization hiding in the ducts), which are more common in China, but it’s hard to quantify how many companies and landlords are actually taking those steps.
- The safest option for quarantining viruses in the air are negative pressure rooms, which operate like vacuum cleaners, ensuring that no pathogens can escape. But they’re designed for hospitals. They’re not feasible for hotels, offices, and other buildings for a variety of reasons—including expense, the difficulty in validating their design, and the fact that every office worker in America would need their own office with a door that is always closed. Only 2% to 4% of all hospital rooms are equipped to be negative pressure spaces as it is.
Humidity is Important
- Some scientists believe that summer could help curtail the spread of C19 due to heat. Indeed, researchers have shown that extreme heat can kill the virus; Ford even retrofitted police cruisers to sterilize car cabins with nothing but the hot air blowing in from the engine.
- One component of air quality that hasn’t gotten as much attention is humidity. Stephanie Taylor, infection control consultant at Harvard Medical School, is petitioning alongside companies that make sensors and humidifiers to improve air quality, for the CDC and WHO to adopt guidelines around safe humidity levels—specifically that indoor humidity should be kept between 40% to 60% (the current recommendation of the EPA). That’s the range of what most people consider comfortable humidity indoors, with air that won’t dry out your nose. (By comparison, the Mohave Desert ranges from 10% to 30% humidity.)
- Taylor’s own interest in humidity began in 2013 when she was studying how infections spread at a new hospital. Her research isolated just about every aspect of a hospital you could imagine, and she discovered a link between infection rates and humidity in patient rooms. In fact, it was the single biggest correlation she found. “I was totally blown away,” Taylor says. “And to tell you the truth, I was skeptical.”
- But Taylor has since validated these findings on studies at nursing homes and schools. And from her research and others in the industry, she identifies three ways that midrange humidity levels stop the spread of airborne pathogens. First, when air is too dry, large droplets don’t fall to the ground as quickly as they normally would. Instead, they dry out to become smaller droplets, which float in the air longer (and also take longer to drop to surfaces, meaning the surfaces can continue to be contaminated).
- Secondly, airborne viruses that thrive in winter, like coronaviruses, simply aren’t as infectious when they float through moister air—whatever tools the viruses use to be virulent are somehow stunted. “There are a few theories as to why,” says Taylor. “But to tell you the truth, I don’t think we fully understand the mechanism.”
- The final reason is that your respiratory immune system just works better in greater humidity. Recent research out of Yale exposed mice to a strain of influenza. The mice were kept in the same air temperature, but researchers tweaked the humidity levels. They found that mice in low-humidity chambers had a worse immune response. Humidity didn’t actually remove the influenza droplets from the air; instead, the air moisture helped their bodies fight off the virus better—all the way down to the cellular level in their respiratory system.
- Distancing. Filtering. Humidity. None of these individual solutions can prevent the spread of C19. But used in combination, we can make our indoor air safer—to make it through this pandemic, sure, but also cold and flu season, and whatever pandemic awaits us in the future.
- “This type of infectious disease will come every few years,” warned Chen, the Purdue engineer, back in March. “I started doing research when SARS broke out in 2004. Then another time was the 2009 influenza from Mexico, which killed 150,000 people around the globe. Today we have coronavirus. Every couple of years, this type of thing will come back.”
3. Neutralizing Antibodies Are Key to Long-Term Immunity, But Less than 5% of Recovered C19 Patients Have Them
- The discovery of antibodies that block the most infectious elements of the coronavirus is helping Bay Area scientists unlock the many mysteries of human immunity, and could be crucial in the development of a vaccine.
- Epidemiologists have found “neutralizing antibodies” in fewer than 5% of C19 patients, which are the ones they are now attempting to isolate are unique in their ability to prevent the coronavirus from entering human cells.
- It means anyone with these antibodies would almost certainly be immune to the disease and that their blood plasma could potentially be used to inoculate others, according to several studies published over the past month by research laboratories in the United States and China.
- Dr. George Rutherford, a UCSF infectious disease specialist, said neutralizing antibodies attack the virus’ crown-like spikes, which are the genesis of the name “corona,” preventing them from poking into and hijacking human cells.
- This particular antibody prevents “the key from going into the lock,” Rutherford said, referring to the spike proteins, which must latch onto a human cell before the parasitic virus can replicate itself. “That’s what you want if you are going to have immunity.”
- The super-strength antibody is one of many discoveries over the past three months by scientists in laboratories, hospitals and universities searching for a way to neutralize C19. One thing that’s clear from the research is how inconsistent the human immune system is. Researchers say, for instance, that while some infected people develop killer antibodies, others have no antibodies at all.
- Between 10% and 20% of patients with C19 show no antibodies in serological tests, Rutherford said. The remaining 75% or more of coronavirus patients develop antibodies, he said, but they aren’t the neutralizing kind, indicating immunity to the disease might not last long in most people.
- “The way I think about it, we have a certain amount of the population that, even if they have a history of infection, won’t have any measurable antibodies and therefore won’t have immunity,” Rutherford said. “Then there is a certain proportion who will have high levels of antibodies and some who have transient antibodies, where we don’t know how long those antibodies will last.”
- Antibody tests, also called serological tests, can determine whether someone had the disease — even if the person never had symptoms. The antibodies researchers are looking for generally show up 11 or 12 days after infection and, although nobody knows exactly how long they remain in the body, they persist for quite awhile and are easily measured. Researchers have found that as people get better, their antibody levels rise. It is believed that repeated exposure to the virus may actually boost the antibody response.
- The problem is, nobody knows yet whether someone with antibodies is protected from getting sick again. To date, there have been no verified cases of reinfection, so it appears there is some immunity in people who have gotten sick. But researchers want to know how long that resistance lasts.
- When they are detected, neutralizing antibodies are generally found in low concentrations. So epidemiologists must figure out how to increase their numbers, create an effective serum and safely immunize people with it.
- “We are still trying to learn more about the nature of neutralizing antibodies,” said Dr. Yvonne Maldonado, chief of infectious diseases in the Department of Pediatrics at the Stanford University School of Medicine, who is using blood plasma from infected individuals to see if she can artificially inactivate the virus. “We still need to determine how much do you need, how long does it last (and) does it protect you from infection.”
- Her team of researchers is trying to identify the specific white blood cells, known as B cells, that secrete the neutralizing antibodies. The plan is to clone the B cells, mass produce the antibodies and give them to people in trials to see if they reduce infection.
4. Why C19 Makes People Lose Their Sense of Smell
We’re beginning to understand the mechanism behind this relatively common symptom
- In some people, anosmia (decrease or loss of smell) is the first or an early symptom, and for some the only symptom, of C19. It is therefore tempting to look to anosmia as diagnostic. Indeed, right now, with the novel coronavirus raging across the country and world, a sudden loss of smell, especially in a city with large infection rates, is more likely associated with C19 than anything else. Olfactory dysfunction is now listed as one of the key symptoms of the disease, and physicians are offered guidance for testing olfactory function.
- However, smell loss is an important component of many conditions, from a simple cold, to a sinus infection, to early stage Alzheimer’s and Parkinson’s diseases, or simply aging. Hyposmia and anosmia are quite common, 12.4 percent of Americans over the age of 40 have some hyposmia and 3 percent of Americans are anosmic across a wide range of ages. While anosmia might be a helpful symptom to suspect infection in the midst of a pandemic, and indicate a test, it’s not by itself diagnostic of C19. It is also tempting to use the loss of smell to predict how a patient will fare. A new study from researchers at the University of California, San Diego, tested a relatively small cohort of patients and suggests that smell loss may predict less severe disease less likely to require hospitalization. However, the small number of subjects who were hospitalized and for whom smell data were collected in that study suggests that little can yet be concluded regarding prognosis from smell loss alone.
- On a more positive note, the sudden loss of smell in C19 may help us understand how the coronavirus works. In late February, chemosensory scientists began discussing reported C19 associated anosmia on twitter and other social media, and formed an international group called Global Chemosensory Research Consortium. This fast and extremely collaborative effort resulted in the creation of an online survey hosted at Penn State and began collecting data globally. To date, there are over 30,000 responses to the survey in 31 languages. The results will allow researchers in the consortium to ask whether there is significant decrease in smell, taste, or nasal/oral chemesthetic (chemical sensitivity of mouth, nose and skin) sensation associated with C19 and other respiratory illnesses.
- The first paper from a planned data pull 11 days after the survey was posted show an average loss of close to 80% of normal smell function, 69% of normal taste function, and 39% of normal chemesthetic function from C19. The next paper will address the differences between chemosensory symptoms of C19 compared to other respiratory illnesses. This has been a tremendous effort in international open science, with preregistered hypotheses, openly available analysis code and data, and a large team science approach to collecting and analyzing crowd-sourced data, in a slack group of over 700 scientists. Several other crowd-sourced studies are in the early and late planning phases and will be released in the near future.
- Why would we need surveys to tell us that anosmia is a symptom when worldwide reports of anosmia in the news led scientists to start these projects? The rate of infection of C19 across the globe means that there are many times more people infected with a respiratory virus at the same time than is normally the case. Respiratory viruses can often lead to temporary or permanent anosmia and dysgeusia (distortions in taste). It was possible that the sheer number of infected people led us to notice the usual level of anosmia and to consider this as extraordinary.
- It does appear, however, from a few early studies, that the anosmia seen with C19 is present in 30–98% of infected people seen in hospitals, far more than occurs with other known respiratory infections. (Testing smell function is notoriously difficult to standardize across locations, cultures and scenarios, so this leads to a high variance in the estimated prevalence of hyposmia.) Another international crowdsourced study asked people to test themselves with household items and report the intensity of the odors of, for example, peanut butter, vanilla and toothpaste.
- A recent study looked at the subset of those data from Sweden and reported that the prevalence of hyposmia tracks with the estimated population infection rate. These studies indicate that there is something special about the virus that attacks the sense of smell in particular, which may help us understand how the virus works.
- How does the virus attack the sense of smell? Research is coming out fast, and we have access to early reports, often via preprint servers that have not yet passed the peer review process and should be interpreted with caution (as is the case with many of the studies discussed above). Mechanistic studies indicate what factors are relevant to hyposmia and anosmia. Most scientists agree that the coronavirus, like the earlier known SARS-CoV, uses the angiotensin-converting enzyme 2 (ACE2) receptor to gain entry to cells via binding with spike protein. The coronavirus additionally appears to need TMPRSS2, a protease, to help prime the spike protein in the process of gaining entry to cells and a few other proteins. This means that cells must express all of these proteins for the virus to be able to infiltrate them and hijack their machinery to replicate.
- ACE2 and TMPRSS2 are expressed in many types of cells, and quite abundantly in the nose, throat, and upper bronchial airways. In the nose, expression is seen in both the respiratory epithelium (RE) and the olfactory sensory epithelium (OSE) but in much higher levels in the OSE. In the OSE, the proteins are expressed in the sustentacular (supporting) and olfactory stem cells as well as in the Bowman’s (mucus) glands and microvillar cells in lower levels. All of these cells help maintain the health of the sensory neurons and the mucus layer so that odors can properly activate the neurons. So far, it appears that olfactory sensory neurons themselves do not have the right expression patterns to bind SARS-CoV-2, which means that the virus may not directly invade these neurons that synapse directly in the cortex in the olfactory bulbs.
- There is evidence that the virus can migrate into the central nervous system via the nose and olfactory bulbs as well as by other routes without invading the sensory neurons. However, the expression patterns of ACE2 and TMPRSS2 and the sudden onset and relatively fast recovery suggest that C19 anosmia is not caused by damage to the central nervous system but rather by the loss of smell information before it gets to the brain. If the symptoms were centrally driven, we would expect a slower process and recovery as well as a more complex range of symptoms, including possibly parosmia or phantosmia (distorted or hallucinated smells), which have not been reported.
- Inflammation in the sensory epithelium could restrict airflow to the relatively small olfactory cleft, high up in the nose, without causing the feeling of a stuffy nose or interruption of breathing, as demonstrated in a published case report. Damage to the sustentacular cells in the SE could also affect functioning of the sensory neurons in many ways (metabolic, structural, inflammatory), so that even if odors can get to the neurons, they may not be able to transmit signals.
- The relatively fast recovery of olfactory function in most patients also lends support to a peripheral cause that does not kill the olfactory sensory neurons. Although these neurons do regenerate throughout life, they do not do so suddenly but rather in a process that takes 30 days or more in which sensation would gradually improve. (Some people who became anosmic as a result of the virus have not yet recovered their sense of smell. This may point to widespread death of sensory neurons or central damage in some individuals.) Because olfactory symptoms can occur very early in the disease, before respiratory symptoms, this may make understanding the virus’ entry into cells in the olfactory sensory epithelium particularly important for understanding infection.
- There are still many open questions to this mystery, but unprecedented international collaborations and sharing of early data will undoubtedly move research forward faster than usual. The olfactory link is an important clue as to the virus’ mechanisms and has leveraged many decades of basic research from chemosensory scientists that has gone on in relative obscurity and put a spotlight on anosmia as a sensory disability.
5. Coronavirus can infect the brain and replicate
- The coronavirus is capable of infecting the brain and then replicating within the cells — with virus levels increasing tenfold within three days, a new study has found.
- The new research, which is under peer review at the journal Altex but not yet published, looked at potential neurological effects of the illness by injecting the virus into lab-grown brains, which are developed from human stem cells, the Financial Times reported.
- “It is really critical to know that our most precious organ can be directly affected by the virus,” said Thomas Hartung, a professor at Johns Hopkins Bloomberg School of Public Health, according to the outlet.
- Hartung and his team discovered once the virus entered neurons in the artificial brains, it made copies of itself, the report said. The levels of the virus were found to increase 10 times in just three days.
- But the research was unable to prove whether the virus can get past the blood-brain barrier of the brain that protects the organ against many viruses and chemicals, as well as often prevents infections.
- Though the lab-grown brains share many features with real ones, they lack the blood-brain barrier, according to the report.
- “Whether or not the coronavirus passes this barrier has yet to be shown, but it is known that severe inflammations, such as observed in C19 patients, make the barrier disintegrate,” Hartung told the newspaper.
- More research into the neurological impacts of the virus could have important implications for treating patients, the report said.
- If the virus does infect the brain, certain medications would not be effective since some cannot get past the blood-barrier, according to the report.
6. Scientists report flaws in WHO-funded study on 2-metre distancing
- Senior scientists have reported flaws in an influential World Health Organization-commissioned study into the risks of coronavirus infection and say it should not be used as evidence for relaxing the UK’s 2-metre physical distancing rule.
- Critics of the distancing advice, which states that people should keep at least 2 metres apart, believe it is too cautious. They seized on the research commissioned by the WHO, which suggested a reduction from 2 metres to 1 would raise infection risk only marginally, from 1.3% to 2.6%.
- But scientists who delved into the work found mistakes they believe undermine the findings to the point they cannot be relied upon when scientists and ministers are forming judgments about what constitutes safe physical distancing.
- “The analysis of infection risk at 1 metre versus 2 metre should be treated with great caution,” said Prof David Spiegelhalter, a statistician at Cambridge University, who has participated in the government’s Scientific Advisory Group for Emergencies . “I’m very suspicious of it.”
- Prof Kevin McConway, an applied statistician at the Open University, went further and called the analysis inappropriate. He said the work “should not be used in arguments about how much greater the infection risk is at 1-metre minimum distance as opposed to 2 metres”.
- The study, published in the Lancet, is the latest to come under fire from experts who fear that in the midst of the pandemic some research papers are being written, reviewed and published too fast for sufficient quality checks to be performed. Earlier this month, the Lancet and another elite publication, the New England Journal of Medicine, were forced to retract coronavirus studies after flaws in the papers emerged.
- Doubts about the study emerged as Boris Johnson announced a formal review of the 2-metre physical distancing rule, which is expected to report by 4 July, the earliest date pubs and restaurants may reopen in England. In recent weeks, Johnson has come under intense pressure from Conservative MPs to relax the advice to help businesses, particularly in the hospitality sector.
- Led by researchers at McMaster University in Ontario, the report pooled data from previously published studies to estimate the risk of becoming infected with coronavirus at different distances. It also considered how face masks and eye protection might help prevent the spread of disease.
- But in the analysis the authors assume the proportional impact on risk of moving from 2 metres to 1 metre is the same as moving from 1 metre to zero. “They are forcing the proportional fit to be the same,” Spiegelhalter told the Guardian.
- McConway believes there is a more fundamental problem in the way the risks of infection at different distances are compared in the study. He said: “The method of comparing the different distances in the paper is inappropriate for telling you exactly how the risk at 2-metre minimum distance compares to a 1 metre minimum distance. It does not support, and should not be used in, arguments about how much greater the risk is with a 1 metre limit versus a 2-metre limit.”
- Another scientist, Prof Ben Cowling at the WHO Collaborating Centre for Infectious Disease Epidemiology and Control at the University of Hong Kong, flagged further issues with the work. He tweeted that he was “not taking the whole paper very seriously” because it looked only at distance and not how long a person was exposed for.
- McConway said he had raised questions about the analysis with the authors and was waiting to hear back. He believed peer review by the Lancet and the WHO should have spotted the problems. “I think they did it in such a rush – the authors, possibly the WHO, and the Lancet peer reviewers – that important things were missed,” he said.
- “Everyone believes that the risk of infection at 1-metre is higher than at 2-metre and we need to know how much higher because there’s a trade-off between the increased risk and the gains from moving to 1-metre. But if you don’t know how the risks at 1 metre and 2 metres compare, how do you know how to trade it off? It’s finger in the air stuff,” McConway said.
- The most recent public Sage document on physical distancing, updated on 2 May, makes clear that multiple streams of evidence are used to advise on safe distancing, including how long people are together, ventilation and room size, and that the 2-metre advice is no more than a ballpark guide for face-to-face meetings.
- In a statement, the WHO said it recommends keeping a distance of 1 metre or more.
- “The evidence used to inform this guidance was based on a systematic review of all available, relevant observational studies concerning protective measures to prevent transmission of the coronaviruses that cause Sars, Mers and C19. After checking for relevance, 44 comparative studies done in health-care and non-health-care settings were included.
- “The findings of this systematic review and meta-analysis support physical distancing of 1 metre or more, which is in line with the existing WHO recommendation that people should physically distance at least 1 metre,” the statement said.
G. The Road Back?
1. Reduce Our Exposure to Superspreaders by Avoiding the 3 Cs of Transmission
- As we learn more about how the coronavirus spreads between people, there’s more evidence to suggest most infections are transmitted by a select few individuals we call “superspreaders.” Here’s what a superspreader is, how and why they are so effective at transmitting the virus to others, and what we’re trying to do about it.
What is a superspreader?
- A generic term for an unusually contagious individual who’s been infected with disease. In the context of the coronavirus, we still haven’t pegged a specific number as to how many infections someone needs to cause to qualify as a superspreader, but generally speaking it far exceeds the two-to-three individuals researchers initially estimated the average infected patient could infect.
What’s the impact of superspreaders for C19?
- Researchers are beginning to come to a consensus after several new studies that coronavirus transmission more or less follows the 80/20 Pareto Principle (named after Italian economist Vilfredo Pareto): 80% of all consequences come from just 20 percent of the possible causes. For C19, this means 80% of new transmissions are caused by fewer than 20% of the carriers—the vast majority of people infect very few others or none at all, and it’s a select minority of individuals who are aggressively spreading the virus.
- Lots of outbreaks around the world have been linked to single events where a superspreader likely infected dozens of people. For example, a choir practice in Washington State infected about 52 people; a megachurch in Seoul was linked to the majority of initial infections in South Korea; and a wedding in Jordan with about 350 guests led to 76 confirmed infections.
What makes someone a superspreader?
- We don’t know for sure yet. Biologically speaking, we don’t yet have a clear sense of what distinguishes a superspreader from others, and what causes them to be more contagious than others. It might have something to do with increased viral loads, and shedding more virus than is normal, but we still don’t know what would trigger this, let alone how to identify it through practical means.
What do we do about superspreaders?
- Though we can’t biologically identify superspreaders, we can still limit their impact.
- Contact tracing is still critical for identifying potential carriers and isolating them and anyone they have been in contact with—which keeps superspreaders from moving around and spreading the virus.
- Epidemiologists also point to mitigating the “three Cs” of transmission:
- closed spaces with poor ventilation,
- crowded settings, and
- close contact with others.
- That means encouraging outdoor seating when possible and maximizing ventilation in any indoor settings, limiting the number of people inside rooms and buildings, and continuing to keep individuals spaced apart by at least six feet or more.
2. Contact tracing is ‘best’ tool we have until there’s a vaccine
- It has quelled outbreaks of Ebola, allowed smallpox to be corralled before being vanquished by a vaccine, and helped turn HIV into a survivable illness. And whenever a new infectious disease emerges, contact tracing is public health’s most powerful weapon for tracking transmission and figuring out how best to protect the population.
- But now, as coronavirus cases are surging in hot spots across the country, the proven strategy’s effectiveness is in doubt: Contact tracing failed to stanch the first wave of coronavirus infections, and today’s far more extensive undertaking will require 100,000 or more trained tracers to delve into strangers’ personal lives and persuade even some without symptoms to stay home. Health departments in many of the worst-affected communities are way behind in hiring and training those people. The effort may also be hobbled by the long-standing distrust among minorities of public health officials, as well as worries about promising new technologies that pit privacy against the public good.
- “We don’t have a great track record in the United States of trust in the public health system,” said David C. Harvey, executive director of the National Coalition of STD Directors. Ever since the 40-year Tuskegee experiment, which withheld treatment for syphilis from poor black men, officials have had to make special efforts, he said, to reach those now “disproportionately impacted by covid who are African Americans and Latinos.”
- Still, as states relax restrictions, public health experts say wide-scale contact tracing is the price that must be paid to reopen safely without reverting to the blanket shutdowns that put nearly 40 million Americans out of work. Time is of the essence, they say, taking advantage of the drop in cases resulting from the shutdowns.
- “Contact tracing is finding the next generation before they happen, getting ahead of that transmission cycle to stop it,” said Emily Gurley, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health and the instructor of the school’s new six-hour online contact-tracing course. Gurley doesn’t believe the strategy will stop transmission but that, in concert with testing and other measures, it can prevent the disease from spreading exponentially.
- Right now, though, the virus is showing signs of taking the lead again, as states relax restrictions on large gatherings and welcome customers back into bars, restaurants and movie theaters. Cases are on the rise in more than 20 states across the country, with new highs in Arizona, Texas and Florida, which tallied 2,581 confirmed cases Saturday, an increase of several hundred from the previous day’s peak.
- In a news briefing, Florida Gov. Ron DeSantis (R) attributed the spike to more testing. But some businesses took the unusual step of shutting back down after staff members or customers tested positive.
- In Central Florida, Kiwi’s Pub & Grill announced Friday that it would close, after six people who were in the restaurant in the past week said they tested positive. Owner Rick Culmer wrote on Facebook that health officials told him the area has been “hammered with new infections.”
- “It is heartbreaking to feel that we have to take this drastic step,” Culmer wrote. “We feel that your time at Kiwis is supposed to be a fun and relaxing experience and currently I don’t feel that we can guarantee that.”
- In Arizona, Gov. Doug Ducey (R) reopened the state before local health departments had trained its new army of contact tracers, said Will Humble, former director of the state’s health department.
- “We flattened the curve. Then, by the time we ended, the contact tracers weren’t up and running yet,” said Humble, who described case investigation and contact tracing as key elements of a multipronged response, including mask-wearing and social distancing. The health departments in the state’s hard-hit urban counties have been repurposing staff, in addition to making new hires, he said, using federal dollars and support from an Arizona-based nonprofit group, the Crisis Response Network.
- Incentives could have been built in, tying each region’s reopening to its hiring of adequate contact tracers, Humble said.
- “We didn’t do that here,” he said. “Now we have to ramp up a contact-tracing workforce that isn’t going to get to everything, probably.”
- Texas, also seeing a dramatic surge, has relaxed restrictions after hiring about 3,000 of the 4,000 contact tracers Gov. Greg Abbott (R) said in April he planned to have in place as part of his reopening strategy.
- “Both we and the local health departments continue to add staff,” said Chris Van Deusen, spokesman for the Texas Department of State Health Services. “We can scale up further if that becomes necessary.”
- Michael Sweat, director of the Center for Global Health at the Medical University of South Carolina, said that the state’s health department, which has suffered from long-term underfunding, was trying hard to ramp up contact tracing as parts of the state suffer “worrisome micro-epidemics.”
- “There’s a lot of effort going into training and deploying people, and working on technology to help. But they are still getting their footing,” Sweat said, as the infection growth rate in Charleston, S.C., suddenly doubled.
- In April, the Centers for Disease Control and Prevention awarded $631 million from the Cares Act to state and local health departments for surveillance, including contact tracing, even as a report from the Association of State and Territorial Health Officials and the Johns Hopkins Center for Health Security estimated 100,000 new hires will be needed to trace all contacts, safely isolate the sick, and quarantine those exposed, at a cost of $3.6 billion.
- Across the country, the efforts to ramp up are vast and varied.
- The University of California at San Francisco has been tapped by the state to create a Pandemic Workforce Training Academy that will train as many as 3,000 people for the state’s 58 county health departments, many of them focusing on low-income communities where requests to self-isolate can be financially devastating.
- In Fairfax County, the health department has subcontracted a private company, GattiHR, to create a 400-strong, largely remote contact-tracing team, looking for people with “empathy, attention to detail, resilience [and] investigative skills,” and finding successful applicants among those furloughed from the hospitality industry.
- In Rhode Island, Gov. Gina Raimondo (D) unveiled a free voluntary app that health officials hope will prove more reliable than people’s memories in re-creating their recent contacts — one of numerous cellphone tracking innovations, including the Apple-Google exposure notification system, that have prompted privacy concerns from civil libertarians.
- And in Florida, the Coalition of Immokalee Workers has been teaming urgently with Doctors Without Borders in an effort to win the confidence of migrant workers, as 37 percent of tests at pop-up clinics came back positive. Their goal is to slow the virus’s spread before farmworkers leave for summer jobs in Georgia, South Carolina and beyond.
- “We have a window of opportunity,” said Gerardo Reyes Chavez, a former farmworker, who said that as people have become sick, they have worried they might lose their jobs. “They are having to weigh what is scarier for them — to know they have the disease or not.”
- But several people who, like Chavez, work with immigrant groups said people have grown more willing to respond to contact tracers as the virus has sickened more of the population, giving them concerns about infecting their own family members.
- In San Francisco, librarian Ramses Escobedo, who became a contact tracer after two weeks of training, said the health department gave out a 60-page instruction document. “It has information from the scripts you’re supposed to follow, the questions you’re supposed to ask.” (Escobedo, who speaks Spanish, noticed some errors in the Spanish translations and said he had them fixed.)
- Of the 30 people Escobedo spoke to in his first three weeks as a contact tracer, only one refused to answer his questions.
- Susie Welty, a Spanish-speaking contact tracer who joined the UCSF effort after her own overseas research on HIV was suspended by the pandemic, also said people have largely been responsive. Getting them to agree to voluntarily self-isolate is far easier when resources are available to provide food and help with other out-of-pocket payments during the 14-day period.
- Welty described a conversation with a pastor whose wife had tested positive. When the pastor explained he did not want his congregation to know and so did not want members to bring them food during their isolation period, Welty was able to refer them to SNAP, the food supplement program.
- “San Francisco has resources,” Welty said. “That is not the case in many jurisdictions,” she added, saying it is particularly hard for undocumented workers to comply if they are unable to feed their families.
- “They’re scared,” said Venus Ginés, founder of the Latino community health organization Dia de la Mujer Latina, which operates in Houston and other cities.
- After the Houston Health Department asked Ginés to help fill contact-tracing positions, her organization supplied 200 résumés of Spanish-speaking applicants within 24 hours, and Ginés said the health department told her that hires will be made from that pool.
- Kirstin Short, Houston Health Department bureau chief of epidemiology, said her agency relies on Dia de la Mujer Latina and other organizations to “speak as that trusted authority within that community to vouch for us as a government entity.”
- But the possibility of data falling into hostile hands worries representatives of immigrant groups.
- The app rolled out in Rhode Island is voluntary — an effort to walk a line between digital data collection and protecting civil liberties.
- “Privacy and data protection are paramount,” Raimondo said in an interview. “Which means I need to give you confidence that if you opt in, your data is safe.”
- “How do citizens know what is actually happening? What data are you collecting, where is it going, how is it used, and when and how is it destroyed?” she asked.
- Because people can become contagious in just a few days — as opposed to two weeks for syphilis, for example — contact tracers have limited time to reach them before the virus moves on, leading some epidemiologists to believe digital technologies are key to stopping it.
- The best way to establish the truth, infectious-disease specialists say, is to use contact tracing to build a fuller picture of the virus’s habits and preferences, including information about people who for some reason escape infection.
- “It’s not a silver bullet. It won’t reach everyone; not everybody will comply,” Welty said. “But it’s the best we have now, the best we will have until we have a vaccine.”
H. Projections & Our (Possible) Future
1. A Second Wave Is On the Way, And We Lack the Will To Deal With It
- A second wave of the coronavirus is on the way. When it arrives, we will lack the will to deal with it. Despite all the sacrifices of the past months, the virus is likely to win—or perhaps it would be more accurate to say that it already has.
- In absolute terms, the United States has been hit harder than any other country. About a quarter of worldwide deaths have been recorded on these shores. And while the virus is no longer growing at an exponential rate, the threat it poses remains significant: According to a forecasting model by Morgan Stanley, the number of American cases will, if current trends hold, roughly double over the next two months.
- But neither the impact of mass protests over police brutality nor the effect of the recent reopening of much of the country—including the casinos in Las Vegas—is reflected in the latest numbers. It can take at least 10 days for people to develop symptoms and seek out a test, and for the results to be aggregated and disseminated by public-health authorities.
- Even so, the disease is slowly starting to recede from the public’s attention. After months of dominating media coverage, C19 has largely disappeared from the front pages of most national newspapers. In recent polls, the number of people who favor “reopening the economy as soon as possible” over “staying home as long as necessary” has increased. And so it is perhaps no surprise that even states where the number of new infections stands at an all-time high are pressing ahead with plans to lift many restrictions on businesses and mass gatherings.
- When the first wave of C19 was threatening to overwhelm the medical system, back in March, the public’s fear and uncertainty were far more intense than they are now. So was the reason to hope that some magic bullet might rescue us from the worst ravages of the disease.
- At this point, such hopes look unrealistic. After months of intense research, an effective treatment for C19 still does not exist. A vaccine is, even if we get lucky, many months away from deployment. Because the virus is spreading especially rapidly in parts of the Southern Hemisphere, from Latin America to Africa, heat is clearly no impediment to its dissemination.
- Perhaps most important, it is now difficult to imagine that anybody could muster the political will to impose a full-scale lockdown for a second time. As one poll in Pennsylvania found, nearly nine out of 10 Republicans trusted “the information you hear about coronavirus from medical experts” back in April. Now just about one in three does. With public opinion more polarized than it was a few months ago, and the presidential election looming, any attempt to deal with a resurgence of the virus is likely to be even more haphazard, contentious, and ineffective than it was the first time around.
- In the fullness of time, many books will be written about why a country as rich, powerful, and scientifically advanced as the United States failed quite so badly at coping with a public-health emergency that experts had predicted for many years. As is always the case, competing explanations will quickly emerge. Some will focus on the incompetence of the Trump administration, while others will draw attention to the country’s loss of state capacity; some will argue that the United States is an outlier, while others will put its failure in the context of other countries, such as Brazil and Russia, that are also faring poorly.
- I do not intend to offer a first draft of history. We are too close to the events to judge, with a cool head, which factors are most responsible for putting us in our current tragic situation. But I would like to offer a partial list of individuals and institutions who, however central or peripheral their contribution to the ultimate outcome, have helped to get us into this mess:
- If the virus wins, it is because the World Health Organization downplayed the threat for far too long.
- If the virus wins, it is because Donald Trump was more interested in hushing up bad news that might hurt the economy than in saving American lives.
- If the virus wins, it is because the Centers for Disease Control and Prevention, created to deal with just this kind of emergency, has proved to be too bureaucratic and incompetent to do its job.
- If the virus wins, it is because the White House did not even attempt to put a test-and-trace regime into place at the federal level.
- Although we do not yet know the effect of more recent events on the course of the pandemic, or what exactly will happen in the coming weeks and months, the list of culprits will likely be even longer than that.
- If the virus wins, it may also be because Derek Chauvin kept his knee on George Floyd’s neck for eight minutes and 46 seconds as Floyd was pleading for his life, setting off protests that—as righteous as they are—could well result in mass infections.
- If the virus wins, it may also be because 1,200 public-health experts obfuscated the mortal risk that these mass protests would pose to the most vulnerable among us by declaring not only (as would be reasonable) that they supported them as citizens, but also (which is highly implausible) that they had determined, as scientists, that they would actively serve “the national public health.”
- If the virus wins, it may also be because so many states moved to reopen before getting the pace of infections under control.
- If the virus wins, it may also be because the right-wing-media echo chamber is starting to downplay the risk that a second wave poses to Americans.
- If the virus does win, then, it is because American elites, experts, and institutions have fallen short—and continue to fall short—of the grave responsibility with which they are entrusted in ways too innumerable to list.
- About a month ago, I started to write a very different article. “Is it possible,” I wondered, “that with the benefit of hindsight, this cruel period will seem rather more heroic than is obvious to its contemporaries? One thing is clear: If we had let the virus rip through the population unchecked, the consequences would have been unspeakable. But if—a big if—we manage to contain the pandemic, and avert millions of deaths, it would constitute one of the greatest achievements in human history.”
- Hoping to publish the article in The Atlantic, I kept waiting for the situation in the United States to recover sufficiently to justify my guarded optimism. But that moment never arrived. Now it feels more remote than ever.
- We were on the brink of doing something incredible. And much of the credit for that would have gone to the many ordinary citizens who lived up to their moral responsibility in an extraordinary moment.
- Scientists have desperately searched for a vaccine. Despite the real risks to their health, doctors, nurses, cooks, cleaners, and clerical staff have reported for duty in their hospitals. Suddenly declared “essential,” workers who have long enjoyed little respect and low wages helped to keep society afloat.
- For the rest of us, the order of the day was simply to stay at home and slow the spread. It was a modest task, which made it all the more galling that some people fell short. But this nitpick obscures how many people did do what they could to get us all through the crisis: They checked in with their relatives and cooked for the elderly. They took to their balconies to thank health-care workers or sang songs to cheer up the neighbors. By and large, they stayed at home and slowed the spread.
- Thanks to the effort of millions of people, we were close to a great success story. But because of the failures of Trump and Chauvin, of the CDC and the WHO, of public-health experts and Fox News hosts, we are, instead, likely to give up—and tolerate that hundreds of thousands of our fellow citizens will die needless deaths.
- Pandemics reveal the true state of a society. Ours has come up badly wanting.
Source: The Coronavirus Will Win
I. Johns Hopkins COVID-19 Updates
1. Cases & Trends
- WHO C19 Situation Report for June 14 reports 7.69 million confirmed cases (137,526 new) and 427,630 deaths (4,281 new). The WHO reported 142,672 new cases on June 13, the highest global daily incidence to date. Overall, the global daily incidence continues to increase, and the pandemic appears as though it may be accelerating. The global cumulative incidence could reach 8 million cases by Wednesday’s Situation Report.
- Europe continues to represent a decreasing proportion of new C19 incidence, down to approximately 12% of the global total.
- North America has accounted for approximately 20-25% of new daily cases since late May, and it is holding relatively steady.
- The relative contributions of Asia and South America continue to increase. Asia now represents approximately 30% of the global daily incidence, up from 15% in early May. South America accounts for 25-35% of the global incidence, which fluctuates considerably from day to day. Africa’s contribution continues to increase steadily as well, although to a lesser extent.
- Africa is now representing more than 7% of the global daily incidence, its highest to date. Looking at the relative change in growth rate over the past 2 weeks, the majority of countries with increases of 25% or greater are in Asia, Africa, and South America. Notably, there are at least 10 countries in Africa that have relative increases of 100% or greater over the past 2 weeks.
- Following a week of reporting slightly fewer than 10,000 new cases per day, India’s daily incidence jumped to more than 11,500 new cases over 2 days and remained there over the weekend. India has reported its 4 highest daily totals over the past 4 days, including its record high of 11,929 new cases on June 14. India remains #3 globally in terms of daily incidence. India is now reporting more than 300,000 cumulative cases, surpassing the United Kingdom over the weekend to become #4 globally in terms of cumulative incidence.
- After reporting a new high daily incidence for 5 consecutive days, including its current record of 6,825 new cases on June 13, Pakistan reported 5,248 new cases yesterday. While this is a decrease of more than 1,500 cases from the previous day, it is still Pakistan’s sixth highest daily total. With this decrease, Pakistan is currently #6 globally in terms of daily incidence. [Note: see below for additional details on Pakistan]
- Bangladesh also reported a slight decrease from its daily record, down from 3,471 new cases on June 11 to 3,099 new cases yesterday—this is also Bangladesh’s sixth highest daily total. Bangladesh is currently #11 globally in terms of daily incidence.
- Iran reported 2,449 new cases. While lower than both the peak last week and its first peak in late March, Iran’s current daily incidence increased over the weekend, compared to the end of last week. Iran is #13 globally in terms of daily incidence.
- Russia has remained relatively steady at approximately 8,500-9,000 new cases per day for the past several weeks, currently #4 in terms of daily incidence.
- Brazil reported 17,110 new cases, but this low value, relative to other recent reports, is likely the result of delayed weekend reporting. Last week, Brazil reported its highest weekly incidence; however, it was only a slight increase over the previous week—177,668 new cases compared to 174,406 the previous week. This was the smallest weekly increase in 11 weeks (when Brazil reported only 2,784 total cases), which suggests that Brazil could be approaching a peak or plateau. Brazil is currently #2 globally in terms of daily incidence, behind the United States, but Brazil will likely regain the #1 spot this week.
- Broadly, the Central and South American regions are still a major C19 hot spot. In total, the region represents 5 of the top 12 countries globally in terms of daily incidence— including Chile (#5), Peru (#7), Mexico (#8), and Colombia (#12)—and 4 of the top 11 in terms of per capita daily incidence—Chile (#2), Panama (#6), Peru (#7), and Brazil (#11).
- The Eastern Mediterranean Region also remains an emerging hotspot, representing 5 of the top 11 countries in terms of per capita incidence: Qatar (#1), Oman (#3), Bahrain (#5), Kuwait (#8), and Saudi Arabia (#9). Additionally, nearby Armenia is #4. Additionally, Saudi Arabia ranks #9 globally in terms of total daily incidence.
- The US CDC reported 2.06 million total cases (24,468 new) and 115,271 deaths (646 new). The United States surpassed 2 million cases in Friday’s, and the overall trend in daily incidence appears to have plateaued over the past several weeks. In total, 16 states (increase of 2) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; New Jersey and New York state with more than 150,000; and California and Illinois with more than 125,000.
- The New York Times, ProPublica, Johns Hopkins University, and others continue to track state- and local-level C19 incidence in a variety of forms. A number of states began to relax social distancing measures at the end of April/early May. Increased social interaction as well as mass gatherings associated with the Memorial Day holiday weekend and large-scale protests against racial and social injustice could potentially contribute to increased community transmission. We will continue monitoring these trends over the coming weeks.
- The Johns Hopkins CSSE dashboard reported 2.10 million US cases and 115,827 deaths as of 12:30pm on June 15.
2. Beijing C19 Outbreak
- China has reported increased SARS-CoV-2 transmission in Beijing over the past several days and re-instituted some social distancing measures in order to contain an emerging outbreak. Beijing health authorities first identified the outbreak on June 11, linked the Xinfadi market, the largest in Beijing. The market is temporarily closed as health officials conduct their epidemiological investigation, including extensive environmental testing. China deployed 100,000 responders in Beijing to support the response activities.
- Officials aim to test 90,000 people in the Beijing area, and by Sunday afternoon, health officials had already tested more than 29,000 individuals who recently visited the market and more than 76,000 total across the affected communities. Additionally, affected areas in Beijing were placed under restrictive social distancing measures, including prohibiting the entry of visitors and vehicular traffic, closing non-essential businesses and public spaces, and prohibiting mass gatherings.
- Communities in Beijing that do not currently have C19 cases are implementing screening measures as well, including temperature checks and symptoms monitoring. While the Xinfadi market remains closed, other markets and chain stores are increasing the supply of vegetables and other food products to ensure availability in Beijing.
- As a result of a “failure” to prevent or immediately contain the outbreak, several local officials were removed from office.
- In terms of population, Beijing is considerably larger than Wuhan, and it is a major global transit hub. A significant C19 epidemic in Beijing could be a major global problem, and Chinese officials appear to be implementing rapid and aggressive containment and investigation measures in an effort to contain the transmission before it can gain a foothold in the broader public.
- Pakistan continues to exhibit an overall increase in C19 incidence, following national steps to relax social distancing measures. Pakistan largely lifted social distancing restrictions on May 9 in order to resume economic activity. According to a New York Times report, some hospitals are already turning away patients, because they do not have capacity available to treat them. Other reports indicate that some severe C19 patients are unable to be transferred to intensive care units, because there are no available beds, meaning that they may not get the level of care needed.
- Pakistan is currently reporting 144,478 confirmed cases, including 5,248 in the past 24 hours. One report indicates that Pakistani health officials anticipate as many as 1.2 million cases by the end of July. Increasing transmission could overwhelm what is already an overburdened health system, and incidence on the order of a million cases over the next several months could be devastating. Notably, more than 18% of tests performed yesterday in Pakistan were positive, which suggests that testing is not sufficient to fully capture the volume of ongoing transmission. Additionally, Pakistan has reported its 6 highest daily incidence totals over the past 6 days. While the most recent report was lower than the previous 5 days, it is still twice the daily incidence at the end of May.
4. Mayo Client Neutralizing Antibody Test
- The Mayo Clinic announced that it will begin using a novel SARS-CoV-2 neutralizing antibody test as part of ongoing efforts to develop convalescent plasma and other C19 treatments. The test was developed and validated through a collaboration between the Mayo Clinic; Vyriad, Inc.; Regeneron; and Imanis Life Sciences. Many existing serological tests detect antibodies that indicate ongoing or prior infection, but the new test provides a “semi-quantitative” assessment specifically for the presence of neutralizing antibodies against SARS-CoV-2. Potential uses include identifying ideal convalescent plasma donors (i.e., those with high levels of neutralizing antibodies) and testing the efficacy of investigational vaccines.
5. Vaccine Delivery
- As the world looks ahead in hopeful anticipation of a SARS-CoV-2 vaccine, one major outstanding challenge is how to best make that vaccine available around the world. While major hurdles still remain in terms of testing and producing even the most advanced vaccine candidates—as well as developing and testing others—efforts need to begin now to address challenges associated with allocating limited initial inventory, communicate about vaccine efficacy and safety, and coordinate international distribution logistics.
- Having these plans in place, coordinated on the global level, will help mitigate delays and barriers to global vaccine access once approved products become available. On Wednesday, June 17, at 1pm EDT, experts from the Johns Hopkins University International Vaccine Access Center will host a webinar to discuss challenges and associated communication and policy considerations in order to support global efforts to establish effective plans and programs in advance of vaccine availability and ensure equitable global access.
6. Public Attitudes and Social Distancing
- On Friday, the US CDC hosted its first C19 briefing in several months. US CDC Director Dr. Robert Redfield and C19 Incident Manager Dr. Jay Butler discussed the US C19 response as well as a recent publication on the public’s perception of social distancing orders. They cautioned that the US C19 epidemic is not over and that continued vigilance and adherence to recommended preventive measures are necessary to mitigate the risk of increased transmission as social distancing measures are relaxed. The study, published in the CDC’s Morbidity and Mortality Weekly Report, surveyed US households—with a particular focus on New York and Los Angeles—to better understand perceptions of “stay at home” orders and other social distancing restrictions as well as the public’s adherence to those orders. The researchers found that the public generally agreed with the restrictions and believed they struck an appropriate balance between permitting necessary activities and reducing transmission risk. The survey respondents also reported high levels of compliance with the orders.
- On Friday, the CDC also published updated guidance to help the general public mitigate transmission risk as they begin to resume social activities. One document aids in making informed decisions regarding going out or engaging in social activities, and the other assists with planning events and other gatherings.
- From a local standpoint, government leaders are concerned that complacency in maintaining mask usage and social distancing measures could lead to decreased compliance and increased transmission. For example, New York Governor Andrew Cuomo expressed unease following reports of New York City residents failing to maintain recommended physical distancing or wear masks while in crowded public areas. After bars and restaurants in several other US cities were forced to close following C19 cases among bartenders and other employees, Governor Cuomo emphasized that increased transmission could result in closing businesses in New York as well.
7. US CDC Consolidated Testing Guidance
- On Friday, the US CDC updated its SARS-CoV-2 testing guidance, publishing a consolidated testing strategy that includes high-risk populations and critical infrastructure sectors. The new guidance brings together numerous existing and updated guidance documents related to SARS-CoV-2 testing and provides a common location from which to access testing recommendations.
- Notably, the document addresses both diagnostic tests and serological tests, and the document provides links to specific guidance for a variety of purposes and in a variety of populations and individuals. These include diagnostic and clinical purposes for individuals exhibiting symptoms, asymptomatic individuals with and without known exposures, and decisions regarding patient discharge or ending isolation as well as public health surveillance. Special instructions are provided for high-risk settings, such as long-term care facilities and correctional facilities, and critical infrastructure workplace settings following the identification of a confirmed or suspected case.
8. Clinical Trials
- CoronaVac, a SARS-CoV-2 vaccine created by Sinovac Biotech based in Beijing, has shown preliminary success in a Phase 2 clinical trial. The company enrolled 743 healthy participants in the randomized, double-blinded, placebo-controlled Phase 1 and 2 trials. In a press release, Sinovac announced that the Phase 2 trial data indicate that the vaccine induced neutralizing antibodies in 90% of the participants 2 weeks after the second dose of the vaccine. No serious adverse events were reported in either trial. The company anticipates publishing the clinical trial data in an academic journal in the near future, but results of animal challenge studies were published in Science in April. Sinovac also announced a plan to conduct a Phase 3 clinical trial in Brazil. The company is constructing a manufacturing facility that is designed to produce up to 100 million doses of the vaccine per year in anticipation of further success in the clinical trials.
- Regeneron Pharmaceuticals announced that it will commence clinical trials at multiple sites to test its dual antibody cocktail, REGN-COV2, as both a prophylactic and treatment. Hospitalized and non-hospitalized C19 patients will be involved in testing REGN-COV2 as a treatment, and prophylactic effects will be tested in uninfected individuals at high risk of exposure, such as healthcare workers, and those with close contact with a C19 case. Regeneron also noted that 2 manuscripts have been accepted for publication by Science, which are scheduled to be available online today. The manuscripts describe preclinical studies regarding the creation of the cocktail and how the dual antibody approach is more likely to provide protection than a single antibody approach.
As we have covered previously, the prospect of effective vaccines, treatments, and other drugs against C19 has raised concerns about drug pricing and availability. An article published by STAT News discusses the process of determining a drug’s value, using remdesivir as a hypothetical case study. The article discusses ongoing efforts to determine the drug’s value and associated pricing models and limitations of these methods as well as the importance of accounting for the value of public investment in these products and continued investments to develop improved products in the future.