Recent Developments & Information
June 18, 2020
Reliable information is the best tool available to protect your family from the pandemic and its shockwaves
“At this very moment, little is known about [COVID-19] antibodies and their utility.”Michael Mina, assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health
“Coronavirus could be transmitted through a long-lasting cloud of virus-containing aerosol droplets ejected from a flushing toilet.” Research Paper,Yikes! Flushing Toilets Create Long-Lasting Clouds of Virus-Containing Particles
“It’s one thing to say, ‘I want a vaccine fast,’ but if you’re fast and wrong or you miss some things, imagine how that fuels concerns about having any type of vaccine at all.”Dr. Tim Persons, chief scientist at the U.S. Government Accountability Office
“People keep talking about a second wave. That is not accurate, we’re still in a first wave.”Dr. Fauci
Index of Featured Stories:
Note: All of the stories listed below are included in this update, but we have embedded links in the title of the stories to the extent available so that you can quickly jump to a story if you want.
Concerns & Unknowns
What Recovery For Severely Ill C19 Patients Looks Like
New Scientific Findings & Research
Technology vs. C19
The Road Back?
Johns Hopkins COVID-19 Update
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A. The Coronavirus As Seen Through Headlines
(In no particular order)
- Dr. Fauci warns of coronavirus resurgence
- US coronavirus deaths projected to be over 200,000 by October
- CDC report confirms elderly, minorities at highest risk for coronavirus
- A new outbreak in Beijing has prompted mass flight cancellations, school closings and sealed-off neighborhoods
- Brazil Reports Big Surge In Coronavirus Infections
- After Weeks Of No New Cases Of COVID-19 In New Zealand, 2 Arrivals Test Positive
- CureVac starts trial of experimental coronavirus vaccine, eyes launch next year
- A Mad Scramble to Stock Millions of Malaria Pills, Likely for Nothing
- Could a global ‘observatory’ of blood help stop the next pandemic?
- McDonald’s Workers Urge Company to Put People Above Profits
- The Pandemic Is Upending the Lives of People With Disabilities—and Those of Their Caregivers
- Close That Toilet Lid Before You Flush
- The Pandemic Shows Us the Genius of Supermarkets
- The president of Honduras, Juan Orlando Hernández, his wife and two aides tested positive for the virus
- Coins are in short supply at U.S. banks after the pandemic disrupted their circulation and production
- New York City is “on track” to enter the next phase of reopening as soon as Monday, Gov. Andrew Cuomo. Outdoor dining and some in-store shopping would be allowed, and hair salons and some offices could resume business.
- Washington, D.C., is scheduled to enter its second reopening phase next week, which would allow gatherings of up to 50 people and indoor dining at half capacity.
- In New Jersey, colleges and universities will be allowed to resume in-person clinical, laboratory and hands-on programming as soon as July 1.
- Premier League soccer has returned to England after a three-month hiatus
- Online for-profit colleges have seen an opportunity to increase enrollment during the crisis
- As the world reopens, fossil fuel emissions are rebounding more quickly than scientists anticipated
- President Trump pushing officials to speed up already-ambitious coronavirus vaccine timeline
- Nine states hit record highs for covid-19 cases as Vice Pence calls fear of a second wave ‘overblown’
- Rising Covid-19 cases and hospitalizations underscore the long road ahead
- WHO drops hydroxychloroquine from Covid-19 clinical trial
- Hong Kong will relax some social-distancing restrictions on Thursday, allowing wedding banquets and live music to resume
- Parts of the US midwest and northeast continue to see declining cases, leading many officials to forge ahead with reopenings, including outdoor sports sites in NY and bars in Chicago
- UK Prime Minister Johnson Promises to Cut 2-Meter Rule If Virus Cases Keep Falling
- Prime Minister Ardern Calls In Military After New Zealand Quarantine Bungle
- Fresh outbreak tests Berlin’s resilience
- Once a Covid Role Model, Chile Now Among the World’s Worst
- Europe’s Airlines Dangle Summer Bargains to Unlocked Masses
- Brexit Heartlands Pay the Highest Price for Coronavirus
- China Shies From Salmon on Virus Fears
- Second Wave Concerns Boost Nintendo
- The border between the U.S. and Canada will remain closed until July 21
- The San Francisco Opera and the Lyric Opera of Chicago are canceling their fall seasons
- Local officials are pleading with President Trump to cancel his campaign rally in Tulsa, Okla., on Saturday or move it outdoors
- In New York State, hospital visits will resume with restrictions, three months after being suspended
- The death toll from the virus in nursing homes and other long-term care facilities in the U.S. has topped 50,000
- To fight Covid-19, open access to scientific publishing
- COVID-19 hot spots emerge in South, Southwest
- An Army of Volunteers Is Taking On Vaccine Disinformation Online
- Beijing Shuts Schools to Stem Virus as Cases Spread Beyond City
- Germany Rolls Out Coronavirus-Tracing App to Fight Second Wave
- Urban Living Might Just Survive Coronavirus
- Second U.K. Vaccine to Combat Covid to Begin Human Testing
- Coronavirus still raging in Florida as over 2,600 new cases recorded
- Rich Americans slashed spending amid coronavirus, hurting poor workers
- The five largest known coronavirus clusters in the United States are not in nursing homes or meat packing plants — they are all inside prisons and jails
- The virus was slow to start in many African countries, but the number of confirmed cases on the continent is rising fast
- Sixteen friends tested positive for Covid-19 after a night out at a bar in Jacksonville Beach, Fla
- FDA warns humans can spread coronavirus to pets in new video
- NYC, state failed to fund nursing home watchdogs, report says
- NYC businesses are clamoring to enter Phase Two, but confused by de Blasio
- Biden rips Trump’s coronavirus response — but offers few solutions
- Prince Charles has not fully regained sense of taste, smell after coronavirus
- NY Gov. Cuomo: Coronavirus patients put in nursing homes ‘probably not contagious’
- COVID-19 Hospitalizations Increase in Texas: Deaths per Capita Remain Among Lowest in Country
- Sharp Spike in COVID-19 Cases Reported in Gulf, Iran, Egypt
- De Blasio, Cuomo are making children bear the worst of the lockdowns
- Reversing course, Arizona and Texas allow some local governments to require masks
- India records its highest single-day toll as officials move to account for unreported virus deaths
- Haitian migrants face risks after outbreaks at the border
- U.C. Berkeley says in-person attendance will be optional, and students who live in dorms must self-isolate at first
- U.S. cities that initially avoided the worst of the virus see surge in cases since reopening
- Beijing outbreak raises coronavirus fears for rest of the world
- Human trials to start on coronavirus drug derived from cow blood
- Woman tests positive for coronavirus months after recovering
- NYC Apple Stores reopen this week
- Young people to blame for record virus surge, Texas governor says
- Putin has his own ‘disinfection tunnel’ to ward off coronavirus
- Florida won’t back off reopening plans despite record coronavirus cases
- High and dry: Airlines ban alcohol to stop the spread of coronavirus
- Parents are dropping $150K on luxury summer camps for their kids
- Congress demands documents, briefing on Cuomo’s deadly nursing-home order
- Subway homeless incidents halved since start of nightly shutdowns: MTA stats
- China eager to profit off coronavirus-distressed US assets, group says
- Special dogs are being trained to sniff out coronavirus
- Miami pauses reopening as Florida’s new coronavirus cases rise
- Majority of American families in desperate need of digital detox
- FDA approves system to warn doctors before coronavirus patients deteriorate
- Regal Entertainment parent to open all movie theaters by July
- ‘Still scared’: Health workers feeling toll of coronavirus fight
- NY Gov. Cuomo silent on who approved coronavirus nursing home policy
- Nathan’s Hot Dog Eating Contest 2020 to take place without a live audience
- Customers asked to waive right to sue in case of coronavirus infections
- California gym reopens with individual pods to maintain social distancing
- US Open will be played in Queens — without fans
- Poll confirms US hasn’t been this bummed out in nearly 50 years
- McDonald’s recovery heating up with most locations reopened
- Retail sales surge record 18 percent as coronavirus lockdowns ease
- Amazon to use AI tech in its warehouses to enforce social distancing
- Pence defends holding Tulsa campaign rally, says precautions are in place
- ‘The Bold and the Beautiful’ to resume production
- Life returns to normal in the original coronavirus epicenter (Wuhan)
- Major US airlines may ban passengers who don’t wear face masks
- WWE shuts down after wrestler tests positive for coronavirus
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
- Total Cases = 8,393,096 (+1.7%)
- New Cases = 141,871 (-685)
- Growth Rate of New Cases (7 day average) = 1.9%
- New Cases (7 day average) = 135,267 (+1,120)
- Third highest number of new cases since the beginning of the pandemic
- During the last week, cases have ranged from 123,807 to 142,557, but are generally trending higher
US Cases & Testing:
- Total Cases = 2,234,471 (+1.2%)
- New Cases = 26,071 (+621)
- Percentage of New Global Cases = 18.4% (+1.7%)
- Growth Rate of New Cases (7 day average) = 1.1% (+0%)
- New Cases (7 day average) = 24,010 (+746)
- Total Number of Tests = 26,243,811
- Percentage of positive tests (7 day average) = 4.6% (+0%)
- Although new cases have generally been trending down, new cases have spiked by an average of more 5,000 per day over the last 2 days, but remain less than the 7 day high of 27,221
- It is too early to tell if the recent spike in new cases is the beginning of an upward trend or typical variability
- Total Deaths = 450,452 (+1.2%)
- New Deaths = 5,264 (-1,328)
- Growth Rate of Deaths (7 day average) = 1.1% (+0.2%)
- New Deaths (7 day average) = 4,616 (+19)
- Although new deaths have generally been trending down since April 17, new deaths spiked by an average of approx. 2,500 per day over the last 2 days, and the number of new deaths over the last 2 days are the highest during the last 7 days
- It is too early to tell if the recent spike is the beginning of an upward trend or typical variability
- 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)
- Although new deaths have generally been trending down, new deaths have spiked by more 5,000 over the last 2 days, but remain less than the 7 day high of 27,221
- It is too early to tell if the recent spike in new deaths is the beginning of upward trend or typical variability
3. Potential Emerging Hotspots in US
- Florida, Texas and Arizona—states that were among the first to reopen—all saw new record highs for cases reported in a single day yesterday (Florida reported 2,783 new cases, Texas reported 2,622, and Arizona reported 2,392 ). The alarming data suggest those three states are shaping up as the next major virus hotspots in the U.S.
- Still, leaders in those states have been largely reluctant to reinstate restrictions. “We’re not rolling back,” Florida Governor Ron DeSantis said during a news conference yesterday. That’s despite stories like that of a group of 16 friends who all tested positive for the virus after a night out at a recently reopened Florida bar. “We want to raise awareness and get ahead of it,” one of the friends, Kat Layton, told CNN’s Chris Cuomo about the group’s diagnoses. “We want to tell people it’s really not ready for what we thought it was ready for, it’s too soon.”
- At least some officials elsewhere are worried that the virus could be spreading at bars, clubs and other party venues. “When I see packed nightclubs, I’m deeply concerned,” Phoenix Mayor Kate Gallego told the Los Angeles Times. Cases are rising significantly throughout Arizona, as is the percentage of adult ICU beds in use.
- In Texas, at least nine mayors, including those of Houston, Austin and Dallas, have written a letter to Governor Greg Abbott asking for the authority to mandate mask-wearing, particularly in “public venues where physical distancing cannot be practiced.” The request comes as Texas has reported record-breaking coronavirus hospitalization numbers for the fifth day in a row, according to the Texas Tribune.
Source: Time Coronavirus Brief
4. Additional Information
- For additional information on global and US cases and trends, see the Johns Hopkins COVID-19 Report at the end of this Update
C. Potential Treatments
1. Dexamethasone Touted as Major Advance in Treatment of Seriously Ill C19 Patients, But Skeptics Urge Caution and Want More Data
- WHO chief Tedros Adhanom Ghebreyesus said research was at last providing “green shoots of hope” in treating the virus, which has killed more than 400,000 people worldwide and infected more than 8 million.
- Trial results announced on Tuesday by researchers in Britain showed dexamethasone, a generic drug used since the 1960s to reduce inflammation in diseases such as arthritis, cut death rates by around a third among the most severely ill coronavirus patients admitted to hospital.
- That makes it the first drug proved to save lives in fighting the disease. Countries are rushing to ensure that they have enough of it on hand, although medical officials say there is no shortage.
- Some doctors were cautious, citing possible side-effects and asking to see more data.
- A patient in Denmark received dexamethasone on Wednesday, local news agency Ritzau reported. The doctor who prescribed the drug said the medical profession was well acquainted with its side-effects.
- The head of the WHO’s emergencies program, Mike Ryan, said the drug should only be used in those serious cases where it has been shown to help.
- “It is exceptionally important in this case, that the drug is reserved for use in severely ill and critical patients who can benefit from this drug clearly,” he told a briefing.
- Britain has increased the amount of dexamethasone it has in stock and on order to 240,000 doses, Health Minister Matt Hancock said.
- Methylprednisolone, a steroid similar to but less potent than dexamethasone, has been used in Sweden since March, a Stockholm-based doctor told media.
- The steroid was introduced to standard practice after it proved effective on a coronavirus patient who wasn’t showing signs of recovery with other treatments, Lars Falk, of the New Karolinska Hospital, told Sweden’s Dagens Nyheter.
- The dexamethasone study’s results are preliminary, but the researchers behind the trial said it suggests the drug should become standard care in severely stricken patients.
‘No Silver Bullet’
- For patients on ventilators, the treatment was shown to reduce mortality by about a third, and for patients requiring only oxygen, deaths were cut by about one fifth, according to preliminary findings shared with the WHO.
- “This is the first treatment to be shown to reduce mortality in patients with C19 requiring oxygen or ventilator support,” Tedros said in a statement late on Tuesday.
- “WHO will coordinate a meta-analysis to increase our overall understanding of this intervention. WHO clinical guidance will be updated to reflect how and when the drug should be used in C19,” the agency added.
- South Korea’s top health official expressed caution about dexamethasone and the European Union and Switzerland both said they were awaiting more information.
- An Italian expert said that dexamethasone was no silver bullet.
- “The study showed a marginal reduction in deaths,” said Lorenzo Dagna, immunology head at IRCCS San Raffaele Scientific Institute in Milan. “We’re light years away from being able to say we’ve found the cure against COVID.”
- On the positive side, he added, the drug is cheap and plentiful.
- As the new coronavirus has wreaked havoc on global economies, some countries have moved quickly to authorize emergency use of medicines only to later backtrack.
- The FDA, for instance, withdrew emergency authorization for hydroxychloroquine after studies showed it did not help.
- The WHO said on Wednesday that testing of hydroxychloroquine in its large multi-country trial of treatments for C19 patients had been halted after research showed no benefit.
- “We have been burned before,” Dr. Kathryn Hibbert, director of the medical intensive care unit at Harvard’s Massachusetts General Hospital, said, expressing caution about dexamethasone.
2. New Biomimetic Nanosponges Soak Up Coronavirus
- Nanoparticles cloaked in human lung cell membranes and human immune cell membranes can attract and neutralize the coronavirus in cell culture, causing the virus to lose its ability to hijack host cells and reproduce.
- The first data describing this new direction for fighting C19 were published today (June 17, 2020) in the journal Nano Letters. The “nanosponges” were developed by engineers at the University of California San Diego and tested by researchers at Boston University.
- The UC San Diego researchers call their nano-scale particles “nanosponges” because they soak up harmful pathogens and toxins.
- In lab experiments, both the lung cell and immune cell types of nanosponges caused the coronavirus to lose nearly 90% of its “viral infectivity” in a dose-dependent manner. Viral infectivity is a measure of the ability of the virus to enter the host cell and exploit its resources to replicate and produce additional infectious viral particles.
- Instead of targeting the virus itself, these nanosponges are designed to protect the healthy cells the virus invades.
- “Traditionally, drug developers for infectious diseases dive deep on the details of the pathogen in order to find druggable targets. Our approach is different. We only need to know what the target cells are. And then we aim to protect the targets by creating biomimetic decoys,” said Liangfang Zhang, a nanoengineering professor at the UC San Diego Jacobs School of Engineering.
- His lab first created this biomimetic nanosponge platform more than a decade ago and has been developing it for a wide range of applications ever since. When the novel coronavirus appeared, the idea of using the nanosponge platform to fight it came to Zhang “almost immediately,” he said.
- In addition to the encouraging data on neutralizing the virus in cell culture, the researchers note that nanosponges cloaked with fragments of the outer membranes of macrophages could have an added benefit: soaking up inflammatory cytokine proteins, which are implicated in some of the most dangerous aspects of C19 and are driven by immune response to the infection.
Making and testing C19 nanosponges
- Each C19 nanosponge–a thousand times smaller than the width of a human hair–consists of a polymer core coated in cell membranes extracted from either lung epithelial type II cells or macrophage cells. The membranes cover the sponges with all the same protein receptors as the cells they impersonate–and this inherently includes whatever receptors the coronavirus uses to enter cells in the body.
- The researchers prepared several different concentrations of nanosponges in solution to test against the coronavirus. To test the ability of the nanosponges to block coronavirus infectivity, the UC San Diego researchers turned to a team at Boston University’s National Emerging Infectious Diseases Laboratories (NEIDL) to perform independent tests. In this BSL-4 lab–the highest biosafety level for a research facility–the researchers, led by Anthony Griffiths, associate professor of microbiology at Boston University School of Medicine, tested the ability of various concentrations of each nanosponge type to reduce the infectivity of live coronavirus–the same strains that are being tested in other C19 therapeutic and vaccine research.
- At a concentration of 5 milligrams per milliliter, the lung cell membrane-cloaked sponges inhibited 93% of the viral infectivity of the coronavirus. The macrophage-cloaked sponges inhibited 88% of the viral infectivity of the coronavirus. Viral infectivity is a measure of the ability of the virus to enter the host cell and exploit its resources to replicate and produce additional infectious viral particles.
- “From the perspective of an immunologist and virologist, the nanosponge platform was immediately appealing as a potential antiviral because of its ability to work against viruses of any kind.
- This means that as opposed to a drug or antibody that might very specifically block coronavirus infection or replication, these cell membrane nanosponges might function in a more holistic manner in treating a broad spectrum of viral infectious diseases.
- I was optimistically skeptical initially that it would work, and then thrilled once I saw the results and it sunk in what this could mean for therapeutic development as a whole,” said Anna Honko, a co-first author on the paper and a Research Associate Professor, Microbiology at Boston University’s National Emerging Infectious Diseases Laboratories (NEIDL).
- In the next few months, the UC San Diego researchers and collaborators will evaluate the nanosponges’ efficacy in animal models. The UC San Diego team has already shown short-term safety in the respiratory tracts and lungs of mice. If and when these C19 nanosponges will be tested in humans depends on a variety of factors, but the researchers are moving as fast as possible.
- “Another interesting aspect of our approach is that even as the coronavirus mutates, as long as the virus can still invade the cells we are mimicking, our nanosponge approach should still work. I’m not sure this can be said for some of the vaccines and therapeutics that are currently being developed,” said Zhang.
- The researchers also expect these nanosponges would work against any new coronavirus or even other respiratory viruses, including whatever virus might trigger the next respiratory pandemic.
Mimicking lung epithelial cells and immune cells
- Since the novel coronavirus often infects lung epithelial cells as the first step in C19 infection, Zhang and his colleagues reasoned that it would make sense to cloak a nanoparticle in fragments of the outer membranes of lung epithelial cells to see if the virus could be tricked into latching on it instead of a lung cell.
- Macrophages, which are white blood cells that play a major role in inflammation, also are very active in the lung during the course of a C19 illness, so Zhang and colleagues created a second sponge cloaked in macrophage membrane.
- The research team plans to study whether the macrophage sponges also have the ability to quiet cytokine storms in C19 patients.
- “We will see if the macrophage nanosponges can neutralize the excessive amount of these cytokines as well as neutralize the virus,” said Zhang.
- Using macrophage cell fragments as cloaks builds on years of work to develop therapies for sepsis using macrophage nanosponges.
- In a paper published in 2017 in Proceedings of the National Academy of Sciences, Zhang and a team of researchers at UC San Diego showed that macrophage nanosponges can safely neutralize both endotoxins and pro-inflammatory cytokines in the bloodstream of mice. A San Diego biotechnology company co-founded by Zhang called Cellics Therapeutics is working to translate this macrophage nanosponge work into the clinic.
- A potential C19 therapeutic, the C19 nanosponge platform has significant testing ahead of it before scientists know whether it would be a safe and effective therapy against the virus in humans, Zhang cautioned. But if the sponges reach the clinical trial stage, there are multiple potential ways of delivering the therapy that include direct delivery into the lung for intubated patients, via an inhaler like for asthmatic patients, or intravenously, especially to treat the complication of cytokine storm.
- A therapeutic dose of nanosponges might flood the lung with a trillion or more tiny nanosponges that could draw the virus away from healthy cells. Once the virus binds with a sponge, “it loses its viability and is not infective anymore, and will be taken up by our own immune cells and digested,” said Zhang.
- “I see potential for a preventive treatment, for a therapeutic that could be given early because once the nanosponges get in the lung, they can stay in the lung for some time,” Zhang said. “If a virus comes, it could be blocked if there are nanosponges waiting for it.”
Growing momentum for nanosponges
- Zhang’s lab at UC San Diego created the first membrane-cloaked nanoparticles over a decade ago. The first of these nanosponges were cloaked with fragments of red blood cell membranes. These nanosponges are being developed to treat bacterial pneumonia and have undergone all stages of pre-clinical testing by Cellics Therapeutics, the San Diego startup cofounded by Zhang.
- The company is currently in the process of submitting the investigational new drug (IND) application to the FDA for their lead candidate: red blood cell nanosponges for the treatment of methicillin-resistant staphylococcus aureus (MRSA) pneumonia. The company estimates the first patients in a clinical trial will be dosed next year.
- The UC San Diego researchers have also shown that nanosponges can deliver drugs to a wound site; sop up bacterial toxins that trigger sepsis; and intercept HIV before it can infect human T cells.
- The basic construction for each of these nanosponges is the same: a biodegradable, FDA-approved polymer core is coated in a specific type of cell membrane, so that it might be disguised as a red blood cell, or an immune T cell or a platelet cell. The cloaking keeps the immune system from spotting and attacking the particles as dangerous invaders.
- “I think of the cell membrane fragments as the active ingredients. This is a different way of looking at drug development,” said Zhang. “For C19, I hope other teams come up with safe and effective therapies and vaccines as soon as possible. At the same time, we are working and planning as if the world is counting on us.”
D. Concerns & Unknowns
1. Immune Systems Fight C19 Differently
- In the largest study to date looking at the antibodies produced by people who have recovered from C19, researchers uncovered a few surprises that could have implications for not only how useful antibody-based treatments might be, but also what the results from an individual’s antibody test actually means.
- In the study, which was published in medRxiv, a preprint server for posting studies before they are peer-reviewed, a team at the Lindsley F. Kimball Research Institute of the New York Blood Center and Rockefeller University analyzed 370 plasma samples donated from people who recovered from C19 and found some surprising results. The researchers used several antibody testing methods, including two commercially available tests, to document levels of immune system antibodies those patients generated against SARS-CoV-2, the virus behind C19. (All produced similarly reliable readings.) The researchers then tested these antibodies against a SARS-CoV-2 virus substitute in the lab to see if the antibodies could actually neutralize the virus (such stand-ins, which mimic actual viruses without being infectious, are often used to laboratory research settings to avoid spreading disease).
- Overall, around 88% of the people generated varying levels of antibodies to the virus. But only about 10% of them had high levels that were able to neutralize the lab-based version of the C19 virus—and, on the other side of the spectrum, 17% had almost no antibody response to their infection.
- What that means is so-called “natural immunity” to SARS-CoV-2 may be more complicated than the idea that everyone infected with C19 is robustly protected from getting the disease again, says Dr. Larry Luchsinger, assistant member at the research institute and the lead author of the paper. “There was a very significant group of people who had essentially no neutralizing activity [against the virus]. What we found was that surprisingly, across all tests, there was a very wide deviation or range of antibody results that people were experiencing.”
- More data needs to be collected to understand why recovered patients have such a wide range in antibody levels, and how that could affect people’s ability to fight off future infections with the virus.
- The findings imply, for example, that there may be different ways of fighting the coronavirus infection. Since all of the people recovered from their infections, some people’s immune systems may rely heavily on antibodies, while others turn to different types of cells to fend off the virus.
- The results make a strong case for doctors to not just test for antibody levels, but to learn what those levels might mean for each patient’s ability to fight further infection. Making those sorts of determinations isn’t possible yet, but it might be with more data on the antibody levels of recovered patients.
- “At this very moment, little is known about antibodies and their utility,” Michael Mina, assistant professor of epidemiology and faculty member at the Center for Communicable Disease Dynamics at the Harvard T.H. Chan School of Public Health said in a question-and-answer session with reporters. As more data become available, doctors might be able to determine what level of antibodies are more likely to provide protection against getting infected with coronavirus again, and share this information with their patients, who would then know how vulnerable they might be to re-infection.
- Luchsinger’s results are a start for building that data; the study does include detailed results on levels of two commercial antibody tests, one from Ortho and the other from Abbott, as well as results on how well those antibodies identified by the tests could neutralize the virus in a lab setting. However, “The unfortunate thing is, the only way to know [for sure] what level of neutralizing activity is required is to take individuals and re-expose them to C19,” Luchsinger says. “There are ethical dilemmas in doing something like that.”
- Still, being able to use antibody tests to identify people who have little ability to neutralize the virus, and those who are better able to do so, could be important in advising them about how they can stop the spread of C19. “The people who don’t have a lot of neutralizing activity should be cautious, and take precautions to keep themselves and their loved ones safe,” says Luchsinger.
- To get a fuller picture of what antibody responses to C19 actually mean for immunity, Luchsinger is expanding the study and matching up people’s antibody levels with their symptoms, to see if there is any correlation between how severe people’s symptoms were and how actively their antibodies could neutralize the virus.
- Such information will be even more crucial in coming months, as employers and public health officials rely on these data to track how people can stay safe in communities when they are at work, or using public transportation or at public gatherings. Antibody testing will also be important as vaccines are rolled out, as public health officials will likely want to get vaccination to those with low or no antibody levels, who are more vulnerable to infection. Tracking these antibody levels over time among the vaccinated will also give experts useful information on how well the vaccines are working.
- “We just have to be a little patient and let the studies come in,” says Mina. “But the infrastructure for antibody testing needs to be built up even if right now we’re not seeing immediate benefit beyond [finding people who have been infected].”
2. Why does C19 spare some and kill others?
- The novel coronavirus can be a killer — or no big deal. It can put a person in the intensive care unit on a ventilator, isolated from family, facing a lonely death — or it can come and go without leaving a mark, a ghost pathogen, more rumor than reality.
- Among their lines of inquiry:
- Are distinct strains of the coronavirus more dangerous?
- Does a patient’s blood type affect the severity of the illness?
- Do other genetic factors play a role?
- Are some people partially protected from C19 because they’ve had recent exposure to other coronaviruses?
- Much of the research remains provisional or ambiguous, and for now scientists can’t do much better than say that C19 is more likely to be worse for older people — often described as over the age of 60 — and for those with chronic conditions such as hypertension, diabetes, lung disease and heart disease.
- That describes tens of millions of people in the United States alone. It also isn’t much of an explanation: The link between chronic disease and the severity of C19 is more in the category of correlation than causation. The “why” of the matter remains unclear.
- The issue of disease variability “is the most critical question about covid,” said Edward Behrens, chief of the rheumatology division at Children’s Hospital of Philadelphia.
- “Why do some people get sick? Why do some people have no problem at all?” he said.
- Social and demographic factors, including sex, race, ethnicity, income and access to quality health care, play major roles in how this pandemic affects people and who suffers the most. The ultimate goal of many researchers is to develop a personalized risk score — so that a person who has C19, or remains vulnerable to catching the disease, would have some idea of how to navigate the pandemic.
- One potential breakthrough was highlighted by National Institutes of Health Director Francis Collins on his blog: Scientists developed an artificial intelligence tool that sorted the blood of C19 patients and found 22 proteins that consistently appear among the patients who are severely ill.
- At this point, such a blood marker only tells doctors what they can already see with their own eyes — a very sick patient. But if such a blood test and analysis could be rolled out early in the course of the disease, it could help doctors decide which patients are most vulnerable.
- Blood-type research is also intriguing. This month, European scientists posted online a study — not yet peer-reviewed — that found strong links between variations on two places in the genome and respiratory failure in C19 patients in Italy and Spain.
- One, the ABO gene, determines blood type. The researchers found that patients who had Type A blood had a 50 percent higher risk of needing oxygen or a ventilator. Type O blood seemed to have a partial protective effect.
- Why that gene matters remains unknown, according to co-author Andre Franke, a professor of molecular medicine at the University of Kiel in Germany. The genetic variant may cause the risk by being associated with inflammation.
- Another possibility is that Type A blood is associated with small blood clots that characterize some severe C19 cases. And “there may be other things cooking in that region” of the genome, Franke said.
- The consumer genetics giants Ancestry.com and 23andMe are getting involved. 23andMe recently released preliminary findings showing that people with Type O blood are 9 to 18% less likely to test positive for C19 than people with other blood types. The company is still exploring links between blood type and disease severity.
- More than 750,000 of the company’s customers have completed a web-based survey about their experiences with C19, and 2,000 of them said they’d been hospitalized from the disease. The company is now recruiting 10,000 non-customers who have been hospitalized with C19.
- “It would be very nice if there was a single gene that we could understand as conferring different levels of risk for C19,” said Adam Auton, 23andMe’s principal scientist. “In reality, dozens or hundreds or even thousands of genes are all making very small contributions toward disease risk.”
- Jean-Laurent Casanova, head of the St. Giles Laboratory of Human Genetics of Infectious Diseases at Rockefeller University, is co-leading an international team searching the genomes of “outliers” — patients younger than 50 who had no known preexisting conditions, but were hospitalized with life-threatening cases of C19. They’re looking for unusual gene variants that these patients have in common.
- Casanova and his colleagues have previously found genetic mutations that increase a person’s susceptibility to infectious diseases, such as severe pneumonia caused by influenza.
- “There are many, many infectious diseases for which genetic variations have been shown to be causal,” Casanova said. “So when covid occurred, if I may say, it’s business as usual.”
How the virus infects you — and how much
- Numerous papers have explored whether different strains of the virus are more transmissible or lethal. One strain has become dominant in much of Europe and the United States. That strain has a genetic mutation affecting what is called the spike protein — the structure that lets the virus bind to receptor cells in humans.
- So far, there is no consensus that this or other mutations are significant from a clinical standpoint. Collins, the NIH director, says of the different strains, “I think they’re all acting the same.”
- Another possibility frequently discussed by researchers is that the mode of transmission is key to understanding the severity of the disease. Many scientists argue that, contrary to what the World Health Organization and the Centers for Disease Control and Prevention have repeatedly stated, the virus sometimes spreads through tiny aerosol particles, not simply through large respiratory droplets.
- That leads some scientists to think the aerosol transmission could enable the virus to penetrate deep into the lungs and trigger a more severe infection.
- The body has an “innate immune system” that includes physical obstacles for any invading viruses. But tiny particles can go with the air flow and potentially reach the deepest regions of the lungs, said Raymond Tellier, a microbiologist at McGill University Health Center.
- For Tellier, that’s a sign that this virus must be spreading in part through aerosols.
- “How else would the virus go down the lower respiratory tract where the cells can be infected?” he asks.
- The amount of virus initially transmitted from one person to another could play a role in determining the course of illness: more virus, sicker patients. Albert Ko, an infectious-disease epidemiologist at the Yale School of Public Health, said, “If I spew out a lot of virus at you and you’re one foot away, you’re going to get a higher inoculum than if you’re six feet away.”
Immune system idiosyncrasies
- Even with all the focus on the virus, and its potential mutations and dosages, the most critical factor is the person getting infected — the “host.” Not everyone hosts the virus the same way. The human immune system is “a complicated tangle of pathways and partners,” as Collins puts it.
- It’s conceivable, Collins said, that some people have immune systems that are better primed for this new invader because of previous exposure to genetically related coronaviruses. That’s still highly conjectural.
- The immune system not only can be protective, it can also go haywire and make an illness catastrophically worse. If the immune system is an army that attacks infections, molecules called cytokines are the messengers that tell the troops what to do to beat back the invader. Too few cytokines, and the defense will be too weak, allowing the infection to progress. Too many, and the commands become a cacophony that causes an erratic and overreactive immune response — a cytokine storm.
- “The army goes crazy and just sort of does more damage than they would intend to do,” said Behrens, of Children’s Hospital of Philadelphia.
- “You start making too many cytokines all at the same time. Now your immune cells are confused. They’re trying to do everything all at once,” he said. “Now it’s no longer the virus that’s killing you, it’s the immune system that’s killing you.”
- Some children infected with the coronavirus have a severe, sometimes fatal Kawasaki-like syndrome. It affects multiple organs — “the gut, the heart, the skin, the eyes,” Behrens said — and research by his team suggests it is a cytokine storm. Behrens hopes the team’s study of children with C19 will also shed light on why some adults get so sick.
- Quickly identifying a storm of cytokines, which can be detected in blood tests, is key, he said. In March, CHOP developed a rapid diagnostic test, which delivers patients’ results in a day. But there’s much more to learn.
- “What is their particular storm? Where in the process are they? Which drug should we pull off the shelf?” Behrens said. “That kind of personalized precision medicine is the holy grail for all this.”
- In the United Kingdom, health officials have released two different measures of risk. One developed by the National Health Service looks at age, gender and very granular medical factors such as whether you have preexisting conditions such as high blood pressure or diabetes.
- Those at low risk are asked to social distance as the economy reopens. Those at higher risk are asked to “shield,” which means staying inside as much as possible and avoiding contact with others.
- Jennifer Lighter, a hospital epidemiologist at NYU Langone, found that obesity was the No. 1 risk factor in her hospital system among those younger than 60. Patients with a body mass index between 30 and 34 — obese under CDC definitions — were two times as likely to be admitted to the ICU than patients with a BMI under 30. Those with a BMI of 35 and over were three times more likely to die than those with a healthy BMI.
- “As we are opening up the nation, one idea is to consider opening up by risk groups,” Lighter said.
- In the broadest sense, the risk of a bad outcome is pretty clear. It’s better to be young and healthy if the coronavirus pays a visit.
- Among the 238 sailors aboard the aircraft carrier USS Theodore Roosevelt who tested positive for the virus after an outbreak on the ship, only two required hospitalization, according to a new study from the CDC. One out of 5 reported no symptoms at all.
- Older people suffer from immunosenescence. Their immune systems become “dysregulated.” Casanova describes this as “the inevitable descending slope of life from about the age of 18 or 19.”
- The median age of people who died in virus-ravaged northern Italy was 81.
- “The difference between catching covid and dying is so stark the older you get, it’s important to recognize that,” said Carl Heneghan, director of the Center for Evidence-Based Medicine at Oxford University. In the U.K., there’s been “virtually no excess death” for people under age 45 since the pandemic began, he said.
- Another wrinkle: People who have little history of viral infections tend to have more severe reactions when they get infected later in life.
- “You have to try and stay healthy, get fit,” Heneghan said. “If you’ve got diabetes, you’ve got to lose weight and moderate that. If you do all those things, your risk of dying is small, or very small.”
3. What Recovery For Severely Ill C19 Patients Looks Like
- In parts of the U.S. like New York City, where coronavirus cases are on a steady downward trend, the front lines of the crisis have shifted from emergency rooms and intensive-care units to recovery wards. But even after the worst is over for the severely ill, their comeback can be a long, difficult process.
- C19 patients who were transferred to the I.C.U. generally remained there a long time — at least two weeks, one study found — leading to more muscle loss and to increased risk for other physical and cognitive issues.
- After a long stint on a ventilator, they often wake up confused and may need to relearn how to eat without choking. Even if their lungs have mostly healed, they may still be debilitated after not moving for so long and receiving high doses of sedatives. Some must work with physical therapists and push walkers to be able to walk again.
- The psychological toll can also be immense. Some patients are traumatized, prompting nightmares and fears of being alone and sleeping. “A lot of people told me they felt lost,” Dr. Alka Gupta, the director of a recovery unit in Manhattan, said.
- Once patients are home, their recovery may still be far from over, with some requiring walking aids and visits from health care workers.
- It’s not just the sickest: A growing number of young C19 patients with “mild” cases have experienced recoveries lasting more than a month, Business Insider reports.
- Symptoms can come in waves and persist much longer than the two weeks suggested by the CDC.
Source: The New York Times Coronavirus Briefing
E. New Scientific Findings & Research
1. How Deadly is C19? Scientists Zero In on Infection Fatality Rate
- One of the most crucial questions about an emerging infectious disease such as the new coronavirus is how deadly it is. After months of collecting data, scientists are getting closer to an answer.
- Researchers use a metric called infection fatality rate (IFR) to calculate how deadly a new disease is. It is the proportion of infected people who will die as a result, including those who don’t get tested or show symptoms.
- “The IFR is one of the important numbers alongside the herd immunity threshold, and has implications for the scale of an epidemic and how seriously we should take a new disease,” says Robert Verity, an epidemiologist at Imperial College London.
- Calculating an accurate IFR is challenging in the midst of any outbreak because it relies on knowing the total number of people infected — not just those who are confirmed through testing. But the fatality rate is especially difficult to pin down for C19, the disease caused by the caronavirus, says Timothy Russell, a mathematical epidemiologist at the London School of Hygiene and Tropical Medicine. That’s partly because there are many people with mild or no symptoms, whose infection has gone undetected, and also because the time between infection and death can be as long as two months. Many countries are also struggling to count all their virus-related deaths, he says. Death records suggest that some of those are being missed in official counts.
- Data from early in the pandemic overestimated how deadly the virus was, and then later analyses underestimated its lethality. Now, numerous studies — using a range of methods — estimate that in many countries some 5 to 10 people will die for every 1,000 people with C19. “The studies I have any faith in are tending to converge around 0.5–1%,” says Russell.
- But some researchers say that convergence between studies could just be coincidence. For a true understanding of how deadly the virus is, scientists need to know how readily it kills different groups of people. The risk of dying from C19 can vary considerably depending on age, ethnicity, access to healthcare, socioeconomic status and underlying health conditions. More high-quality surveys of different groups are needed, these researchers say.
- IFR is also specific to a population and changes over time as doctors get better at treating the disease, which can further complicate efforts to pin it down.
- Getting the number right is important because it helps governments and individuals to determine appropriate responses. “Calculate too low an IFR, and a community could underreact, and be underprepared. Too high, and the overreaction could be at best expensive, and at worst [could] also add harms from the overuse of interventions like lockdowns,” says Hilda Bastian, who studies evidence-based medicine, and is a PhD candidate at Bond University in the Gold Coast, Australia.
Bridging the gap
- Some of the first indications of the virus’s deadliness were gleaned from the total number of confirmed cases in China. In late February, the World Health Organization crudely estimated that 38 people had died for every 1,000 with confirmed C19 diagnoses. The death rate among these people — known as the case fatality rate (CFR) — reached as high as 58 out of 1,000 in Wuhan, the city where the virus emerged. But such estimates exaggerated the disease’s deadliness because they did not account for the many people who had the virus but were not tested, obscuring the outbreak’s true spread.
- Researchers tried to address this gap by estimating the IFR from models that projected the virus’s spread. The result from these early analyses hovered around 0.9% — 9 deaths for every 1,000 people infected — with a broader range of 0.4–3.6%, says Verity. His own modelling estimated an overall IFR for China of 7 deaths for every 1,000 people infected (0.7%), increasing to 33 per thousand among those aged 60 or older (3.3%).
- Russell’s team also used data gathered from a large C19 outbreak on the Diamond Princess cruise ship in early February to estimate an IFR in China. Almost all of the 3,711 passengers and crew were tested, enabling researchers to count the total number of infections, including asymptomatic ones, and deaths in a known population. From this, his team estimated an IFR of 0.6%, or 6 deaths for every 1,000 infected people.
- “The intention of these studies was to gain some ball-park estimates of how deadly C19 is,” says Verity.
- But researchers also had to make complicated estimates, which still need to be verified, about the number of confirmed cases and the actual number of infected people. “There is value to obtaining rapid early estimates of the IFR, [but] these should be updated as a matter of urgency once better data becomes available,” he says.
- Widespread population surveys that test people for antibodies to the virus, known as seroprevalence surveys, were expected to help refine IFR estimates even further. About 120 seroprevalence surveys are under way worldwide.
- But results from the first antibody studies only muddied the water, suggesting that the virus was less deadly than previously thought. “It got a bit messy,” says Russell.
- One of the earliest studies tested 919 people in the German town of Gangelt, where a large outbreak had occurred. Of these people, about 15.5% had antibodies against the virus — five times higher than the percentage of people known to have had C19 in the town at the time. The figure was used to estimate an IFR of 0.28%. But researchers noted that the study was based on a relatively small number of people.
- Other early seroprevalence studies did not properly account for the lack of sensitivity and specificity in the antibody test kits that were used, or for discrepancies between the sampled and underlying populations, says Verity.
- These issues could have inflated estimates of the total number of infected people and so made the virus seem less deadly, he says. Equally, if C19 deaths go undetected — a problem in many countries that aren’t testing all deceased people for the virus — that, too, can bias the fatality rate, says Gideon Meyerowitz-Katz, an epidemiologist and PhD candidate at the University of Wollongong, Australia.
- Some larger seroprevalence studies have emerged in recent weeks, and these estimate a higher fatality rate than do early studies. One survey, posted on medRxiv, of more than 25,000 people across Brazil, estimated an IFR of 1%.
- Another survey that tested more than 60,000 people across Spain reports a prevalence of 5%, although the results have not been formally analysed. The survey team did not calculate a fatality rate themselves, but on the basis of the results, Verity estimates that Spain has an IFR of around 1% — or 10 deaths for every 1,000 infected individuals.
- Several researchers, including Russell and Verity, find it interesting that a growing number of studies from different regions have estimated IFRs in the range of 0.5–1%. But other scientists are cautious about suggestions of agreement. “The trend is potentially more luck than anything else,” says Meyerowitz-Katz.
- Marm Kilpatrick, an infectious disease researcher at the University of California, Santa Cruz, also notes that most of the serological data haven’t been published in scientific manuscripts. It’s hard to know when and how they were collected, and to properly calculate an IFR that accounts for the delay between people getting infected and dying, he says.
- Kilpatrick and others say they are eagerly awaiting large studies that estimate fatality rates across age groups and among those with pre-existing health conditions, which will provide the most accurate picture of how deadly the disease is. One of the first studies to account for the effect of age was posted on a preprint server last week. The study, based on seroprevalence data from Geneva, Switzerland, estimates an IFR of 0.6% for the total population, and an IFR of 5.6% for people aged 65 and older. [Read the study here: https://osf.io/wdbpe/]
- The results have not been peer reviewed, but Kilpatrick says the study addresses many of the issues in previous seroprevalence surveys. “This study is fantastic. It’s precisely what should be done with all of the serological data,” he says.
2. A Growing Consensus on How People Catch C19
- Six months into the coronavirus crisis, there’s a growing consensus about a central question: How do people become infected?
- It’s not common to contract C19 from a contaminated surface, scientists say. And fleeting encounters with people outdoors are unlikely to spread the coronavirus.
- Instead, the major culprit is close-up, person-to-person interactions for extended periods. Crowded events, poorly ventilated areas and places where people are talking loudly—or singing, in one famous case—maximize the risk.
- These emerging findings are helping businesses and governments devise reopening strategies to protect public health while getting economies going again. That includes tactics like installing plexiglass barriers, requiring people to wear masks in stores and other venues, using good ventilation systems and keeping windows open when possible.
- Two recent large studies showed that wide-scale lockdowns—stay-at-home orders, bans on large gatherings and business closures—prevented millions of infections and deaths around the world. Now, with more knowledge in hand, cities and states can deploy targeted interventions to keep the virus from taking off again, scientists and public health experts said.
- That means better protections for nursing-home residents and multigenerational families living in crowded conditions, they said. It also means stressing physical distancing and masks, and reducing the number of gatherings in enclosed spaces.
- “We should not be thinking of a lockdown, but of ways to increase physical distance,” said Tom Frieden, chief executive of Resolve to Save Lives, a nonprofit public-health initiative. “This can include allowing outside activities, allowing walking or cycling to an office with people all physically distant, curbside pickup from stores, and other innovative methods that can facilitate resumption of economic activity without a rekindling of the outbreak.”
- The group’s reopening recommendations include widespread testing, contact tracing and isolation of people who are infected or exposed.
- One important factor in transmission is that seemingly benign activities like speaking and breathing produce respiratory bits of varying sizes that can disperse along air currents and potentially infect people nearby.
- Health agencies have so far identified respiratory-droplet contact as the major mode of C19 transmission. These large fluid droplets can transfer virus from one person to another if they land on the eyes, nose or mouth. But they tend to fall to the ground or on other surfaces pretty quickly.
- Some researchers say the new coronavirus can also be transmitted through aerosols, or minuscule droplets that float in the air longer than large droplets. These aerosols can be directly inhaled.
- That’s what may have happened at a restaurant in Guangzhou, China, where an infected diner who was not yet ill transmitted the virus to five others sitting at adjacent tables. Ventilation in the space was poor, with exhaust fans turned off, according to one study looking at conditions in the restaurant.
- Aerosolized virus from the patient’s breathing or speaking could have built up in the air over time and strong airflow from an air-conditioning unit on the wall may have helped recirculate the particles in the air, according to authors of the study, which hasn’t yet been peer-reviewed.
- Sufficient ventilation in the places people visit and work is very important, said Yuguo Li, one of the authors and an engineering professor at the University of Hong Kong. Proper ventilation—such as forcing air toward the ceiling and pumping it outside, or bringing fresh air into a room—dilutes the amount of virus in a space, lowering the risk of infection.
- Another factor is prolonged exposure. That’s generally defined as 15 minutes or more of unprotected contact with someone less than 6 feet away, said John Brooks, the Centers for Disease Control and Prevention’s chief medical officer for the C19 response. But that is only a rule of thumb, he cautioned. It could take much less time with a sneeze in the face or other intimate contact where a lot of respiratory droplets are emitted, he said.
- At a March 10 church choir practice in Washington state, 87% of attendees were infected, said Lea Hamner, an epidemiologist with the Skagit County public health department and lead author of a study on an investigation that warned about the potential for “superspreader” events, in which one or a small number of people infect many others.
- Members of the choir changed places four times during the 2½-hour practice, were tightly packed in a confined space and were mostly older and therefore more vulnerable to illness, she said. All told, 53 of 61 attendees at the practice were infected, including at least one person who had symptoms. Two died.
- Several factors conspired, Ms. Hamner said. When singing, people can emit many large and small respiratory particles. Singers also breathe deeply, increasing the chance they will inhale infectious particles.
- Similar transmission dynamics could be at play in other settings where heavy breathing and loud talking are common over extended periods, like gyms, musical or theater performances, conferences, weddings and birthday parties. Of 61 clusters of cases in Japan between Jan. 15 and April 4, many involved heavy breathing in close proximity, such as karaoke parties, cheering at clubs, talking in bars and exercising in gyms, according to a recent study in the journal Emerging Infectious Diseases.
- The so-called attack rate—the percentage of people who were infected in a specific place or time—can be very high in crowded events, homes and other spaces where lots of people are in close, prolonged contact.
- An estimated 10% of people with C19 are responsible for about 80% of transmissions, according to a study published recently in Wellcome Open Research. Some people with the virus may have a higher viral load, or produce more droplets when they breathe or speak, or be in a confined space with many people and bad ventilation when they’re at their most infectious point in their illness, said Jamie Lloyd-Smith, a University of California, Los Angeles professor who studies the ecology of infectious diseases.
- But overall, “the risk of a given infected person transmitting to people is pretty low,” said Scott Dowell, a deputy director overseeing the Bill & Melinda Gates Foundation’s C19 response. “For every superspreading event you have a lot of times when nobody gets infected.”
- The attack rate for C19 in households ranges between 4.6% and 19.3%, according to several studies. It was higher for spouses, at 27.8%, than for other household members, at 17.3%, in one study in China.
- Rosanna Diaz lives in a three-bedroom apartment in New York City with five other family members. The 37-year-old stay-at-home mother was hospitalized with a stroke on April 18 that her doctors attributed to C19, and was still coughing when she went home two days later.
- She pushed to get home quickly, she said, because her 4-year-old son has autism and needed her. She kept her distance from family members, covered her mouth when coughing and washed her hands frequently. No one else in the apartment has fallen ill, she said. “Nobody went near me when I was sick,” she said.
- Being outside is generally safer, experts say, because viral particles dilute more quickly. But small and large droplets pose a risk even outdoors, when people are in close, prolonged contact, said Linsey Marr, a Virginia Tech environmental engineering professor who studies airborne transmission of viruses.
- No one knows for sure how much virus it takes for someone to become infected, but recent studies offer some clues. In one small study published recently in the journal Nature, researchers were unable to culture live coronavirus if a patient’s throat swab or milliliter of sputum contained less than one million copies of viral RNA.
- “Based on our experiment, I would assume that something above that number would be required for infectivity,” said Clemens Wendtner, one of the study’s lead authors and head of the department of infectious diseases and tropical medicine at München Klinik Schwabing, a teaching hospital at the Ludwig Maximilian University of Munich.
- He and his colleagues found samples from contagious patients with virus levels up to 1,000 times that, which could help explain why the virus is so infectious in the right conditions: It may take much lower levels of virus than what’s found in a sick patient to infect someone else.
- Based on this emerging picture of contagion, some policies are changing. The standard procedure for someone who tests positive is to quarantine at home. Some cities are providing free temporary housing and social services where people who are infected can stay on a voluntary basis, to avoid transmitting the virus to family members.
- The CDC recently urged Americans to keep wearing masks and maintaining a distance from others as states reopen. “The more closely you interact with others, the longer the interaction lasts, the greater the number of people involved in the interaction, the higher the risk of C19 spread,” said Jay Butler, the CDC’s C19 response incident manager.
- If the number of C19 cases starts to rise dramatically as states reopen, “more extensive mitigation efforts such as what were implemented back in March may be needed again,” a decision that would be made locally, he said.
- CDC guidelines for employers whose workers are returning include requiring masks, limiting use of public transit and elevators to reduce exposure, and prohibiting hugs, handshakes and fist-bumps.
- The agency also suggested replacing communal snacks, water coolers and coffee pots with prepacked, single-serve items, and erecting plastic partitions between desks closer than 6 feet apart.
- Current CDC workplace guidelines don’t talk about distribution of aerosols, or small particles, in a room, said Lisa Brosseau, a respiratory-protection consultant for the University of Minnesota’s Center for Infectious Disease Research and Policy.
- “Aerosol transmission is a scary thing,” she said. “That’s an exposure that’s hard to manage and it’s invisible.” Ensuring infected individuals stay home is important, she said, but that can be difficult due to testing constraints. So additional protocols to interrupt spread, like social distancing in workspaces and providing N95 respirators or other personal protective equipment, might be necessary as well, she said.
- Some scientists say while aerosol transmission does occur, it doesn’t explain most infections. In addition, the virus doesn’t appear to spread widely through the air.
- “If this were transmitted mainly like measles or tuberculosis, where infectious viruses lingered in the airspace for a long time, or spread across large airspaces or through air-handling systems, I think you would be seeing a lot more people infected,” said the CDC’s Dr. Brooks.
- Sampling the air in high-traffic areas regularly could help employers figure out who needs to get tested, said Donald Milton, professor of environmental and occupational health at the University of Maryland School of Public Health.
- “Let’s say you detect the virus during lunchtime on Monday in a dining hall,” he said. “You could then reach out to people who were there during that time telling them that they need to get tested.”
- Erin Bromage, a University of Massachusetts Dartmouth associate professor of biology, has been fielding questions from businesses, court systems and even therapists after a blog post he wrote titled “The Risks—Know Them—Avoid Them” went viral. [We highly recommend reading this blog at https://www.erinbromage.com/post/the-risks-know-them-avoid-them]
- Courts are trying to figure out how to reconvene safely given that juries normally sit close together, with attorneys speaking to them up close, Dr. Bromage said. Therapists want to be able to hold in-person counseling sessions again. And businesses are trying to figure out what types of cleaning and disease-prevention methods in which to invest most heavily.
- He advises that while wiping down surfaces and putting in hand-sanitizer stations in workplaces is good, the bigger risks are close-range face-to-face interactions, and having lots of people in an enclosed space for long periods. High-touch surfaces like doorknobs are a risk, but the virus degrades quickly so other surfaces like cardboard boxes are less worrisome, he said. “Surfaces and cleaning are important, but we shouldn’t be spending half of our budget on it when they may be having only a smaller effect,” he said.
- Drugmaker Eli Lilly & Co. has a medical advisory panel that’s reading the latest literature on viral transmission, which it is using to develop recommendations for bringing back the company’s own workers safely.
- To go into production facilities, some of which are in operation now, scientists must don multiple layers of personal protective equipment, including gloves, masks, goggles and coveralls. That’s not abnormal for drug-development settings, said Lilly Chief Scientific Officer Daniel Skovronsky. “The air is extensively filtered. There’s lots of protection,” he said.
- The places he worries about are the break rooms, locker rooms and security checkpoints, where people interact. Those are spaces where the company has instituted social distancing measures by staggering the times they are open and how many people can be there at once. Only a few cafeterias are open, and those that are have socially distanced seating. In bathrooms, only half the stalls are available to cut down on the number of people.
- “We’ll never be more open than state guidelines,” Dr. Skovronsky said, but “we’re often finding ourselves being more restrictive because we’re following the numbers.”
3. Yikes! Flushing Toilets Create Long-Lasting Clouds of Virus-Containing Particles
Coronavirus could be transmitted through a long-lasting cloud of virus-containing aerosol droplets ejected from a flushing toilet
- Researchers used a computer simulation to show how a flushing toilet can create a cloud of virus-containing aerosol droplets that is large and widespread and lasts long enough that the droplets could be breathed in by others.
- With recent studies showing the coronavirus can survive in the human digestive tract and show up in feces of the infected, this raises the possibility the disease could be transmitted with the use of toilets.
- Toilet flushing creates a great deal of turbulence, and qualitative evidence suggests this can spread both bacteria and viruses. The public, however, remains largely unaware of this infection pathway, since few quantitative studies have been carried out to investigate this possible mechanism.
- In the journal Physics of Fluids, by AIP Publishing, precise computer models were used to simulate water and air flows in a flushing toilet and the resulting droplet cloud. The investigators used a standard set of fluid dynamic formulas, known as the Navier-Stokes equations, to simulate flushing in two types of toilet — one with a single inlet for flushing water, and another with two inlets to create a rotating flow.
- The investigators also used a discrete phase model to simulate movement of the numerous tiny droplets likely to be ejected from the toilet bowl into the air. A similar model was used recently to simulate the movement of aerosol droplets ejected during a human cough.
- The results of the simulations were striking.
- As water pours into the toilet bowl from one side, it strikes the opposite side, creating vortices. These vortices continue upward into the air above the bowl, carrying droplets to a height of nearly 3 feet, where they might be inhaled or settle onto surfaces. These droplets are so small they float in the air for over a minute. A toilet with two inlet ports for water generates an even greater velocity of upward flowing aerosol particles.
- “One can foresee that the velocity will be even higher when a toilet is used frequently, such as in the case of a family toilet during a busy time or a public toilet serving a densely populated area,” said co-author Ji-Xiang Wang, of Yangzhou University.
- The simulations show that nearly 60% of the ejected particles rise high above the seat for a toilet with two inlet ports. A solution to this deadly problem is to simply close the lid before flushing, since this should decrease aerosol spread.
- However, in many countries, including the United States, toilets in public restrooms are often without lids. This poses a serious hazard. The investigators also suggest a better toilet design would include a lid that closes automatically before flushing.
4. UV light breaks down coronavirus particles in seconds
- Lighting firm Signify says one of its ultraviolet lights can “degrade” the coronavirus in a matter of seconds.
- The world’s biggest lighting maker tested its latest technology with researchers at Boston University and found that the exposure of the virus to UV light helps eradicate it.
- Signify hopes the product can be used to reduce the amount of C19 in indoor areas and plans to make it available to other lighting companies.
- Eric Rondolat, Signify CEO, told CNBC’s “Squawk Box Europe” that UV light particles are capable of disrupting virus DNA chains, rendering them ineffective.
- “We knew that it (UV light) was effective against viruses in general, but we didn’t know if it was the case with C19 so we worked with Boston University,” Rondolat said. “We carried out the tests many, many times and the metrics are quite interesting.”
- Rondolat said the company’s UV light is able to eradicate 96% of the coronavirus with three seconds of exposure. That goes up to 99% for six seconds of exposure.
- “It’s a preventive measure, meaning we are disinfecting objects, environments, surfaces, and the air,” said Rondolat, adding that schools, offices, hospitals, warehouses and manufacturing plants will all need to be disinfected in the future.
- Retailers could also use a UV light chamber to disinfect clothes after people have tried them on, he said.
F. Technology vs. C19
1. Wearable Smart Ring Can Detect C19 Before Symptoms Develop
- A prominent Las Vegas casino operator is embarking on a novel strategy to fight coronavirus among its staff, giving them wearable “smart rings” that can detect infection before symptoms occur.
- Las Vegas Sands, which owns the Venetian and Palazzo resorts, bought 1,000 “smart rings” from Oura, a Finnish wearable technology start-up, after two studies indicated that the discreet products worn on a finger can accurately predict the onset of C19 symptoms.
- It will be the first big US company to deploy such pre-symptomatic virus detection devices internally.
- Rob Goldstein, Sands’ president, said if the pilot program goes well, he anticipates purchasing a $300 wearable for each of his 9,300 employees.
- “Our approach is to be measured, to make sure this makes sense, and if it does, we’ll expand it,” he said. “We need to protect our people and make it a very safe place to work.”
- The Oura ring was originally designed as a fashionable sleep-tracker, counting Prince Harry and Twitter’s Jack Dorsey among its more than 150,000 customers. Unlike the Apple Watch and Fitbit, and Garmin’s fitness trackers, Oura detects body temperature in addition to heart rate, heart rate volatility and respiratory rate.
- The rollout comes as researchers are turning increasingly to wearable technologies to track the spread of the pandemic in real time, often before symptoms appear.
- The Oura ring detects body temperature in addition to data gauged by other fitness devices
- When a person is infected by coronavirus, the body’s efforts to fight back result in a series of patterns that the Oura ring can detect with “unparalleled” accuracy, said Dr Ali Rezai, director of the Rockefeller Neurosciences Institute at West Virginia University.
- Dr Rezai has been conducting a study of 900 frontline workers over the past two months and determined that the Oura ring can detect the presence of the virus up to three days before symptoms appear.
- “Studies show that two days before the first onset of any symptoms, you’re actually contagious and shedding the virus,” he said. Subtle changes in temperature, sleep patterns and heart rate detected by Oura “allow us to have a behind-the-scenes understanding of disease coming on, when it’s imperceptible [to] you”, he said.
- The Oura ring’s C19-detection capabilities were first discovered in March when a Finnish entrepreneur, Petri Hollmen, received an alert on the device’s app one morning that his “readiness level” was just 54, versus 80-90 on a typical day.
- Having just travelled to Tyrol, Austria — then a coronavirus hotspot — he decided to get tested and was surprised when he received a positive result, despite not having experienced any symptoms.
- Dr Ben Smarr, a professor of data science at the University of California, San Diego, said research of more than 12,000 Oura users makes him “extremely confident” that wearers could arm themselves with useful data and build an early warning system for coronavirus.
- To combat privacy concerns, the voluntary pilot at Sands will not allow the company to access employees’ metrics directly. Wearers will have real-time access to their own “Risk Score”, while Sands’ human resources team will only be alerted if an individual’s patterns indicate a high risk of developing Covid symptoms.
- The hope is that the ring will help Sands to determine who should be advised to quarantine and get a test, given limited capacity to check every employee daily.
- “The company will have access to one thing and one thing alone,” said Zac Hudson, Sands’ general counsel, referring to the company’s data gathering. Beyond that, “we don’t need that information and we don’t want it.”
G. Herd Immunity
1. Sweden’s top epidemiologist at a loss to explain why herd immunity is going ‘surprisingly slow’
- Sweden has made less progress than expected in achieving immunity to the coronavirus, according to its state epidemiologist.
- After leaving schools, shops and restaurants open throughout the pandemic, contagion rates in Sweden are much higher than anywhere else in the Nordic region. Its C19 mortality is among the worst in the world. Scientists have been eager to learn whether the flipside of widespread contagion is a higher level of immunity.
- But according to Anders Tegnell, Sweden’s state epidemiologist, “the trends in immunity have been surprisingly slow.” He also says “it’s difficult to explain why this is so.”
- Speaking in an interview with Swedish Radio on Wednesday, Tegnell said it’s important to remember “that there is a time lag in all such measurements.”
- An analysis of 50,000 tests by Werlabs AB, a private company, shows that about 14% of people tested over the past six weeks in the Stockholm region have developed C19 antibodies. That compares with a study published this month of Bergamo — once the C19 epicenter in Italy — which showed that 57% had developed antibodies.
- In Sweden, “the number of immune cases today is much closer to our forecasts than it has been before,” Tegnell told Swedish Radio. “The 14% of those surveyed is from two or three weeks ago, meaning that immunity levels are higher today.”
- Sweden’s approach to tackling C19 has been among the most controversial in the world. Unlike the rest of Scandinavia, where governments quickly imposed strict lockdowns, Sweden advised its citizens to observe social distancing rules, but left most of society open.
- Some analysts have predicted that the softer lockdown means Sweden’s economy will fare better than others. But the country’s high death rate has triggered considerable backlash, and a recent poll suggested most Swedes have lost faith in their country’s strategy to fight the virus.
- Tegnell and Prime Minister Stefan Lofven have insisted that Sweden’s strategy is the right one. That’s based on an assumption that C19 will be around for a long time, meaning short-term lockdowns ultimately won’t help, and governments need to come up with more sustainable models for living with the virus.
H. The Road Back?
1. C19 Planning Guide and Self-Assessment for Higher Education
Tools and resources to support safer higher education operations during the C19 pandemic
Published by Johns Hopkins Center for Health Security, the Council for Higher Education Accreditation (CHEA), and Tuscany Strategy Consulting (TSC)
- Globally, institutions of higher education are facing unprecedented challenges related to coronavirus disease (C19). The resulting academic, financial, ethical, and operational questions are complex and high-stakes. The C19 pandemic may represent an inflection point, fundamentally altering how we work, socialize, and learn. The authors of this toolkit collectively believe that our institutions need near-term tools to ensure continuity through this pandemic as well as methods for rethinking the basic assumptions and values of their institutions.
- This guide and accompanying risk assessment are designed to provide practical planning resources to help institutions gauge how effectively they are addressing a range of C19 scenarios. It is intended to accommodate a wide range of institutions: public, private, large, small, comprehensive, specialized, urban, and rural. Each institution will need to develop and implement its own tailored approach to reopening in-person instruction.
- Retooling for the future, with urgency, involves a significant planning effort to manage the present environment as well as the opportunity to envision new ways to fulfill institutional missions. Plans need to address the safety of students, faculty, and staff, the financing of our colleges and universities, and preservation of equity and diversity. They will also need to address short- and long-term investment in academic tools that will be essential for education in the period of C19 – adding instructional and enterprise technologies, expanding the range of capabilities of faculty, improving the nature of the curriculum, and strengthening the network of student support. We encourage leadership and planning committees to use this opportunity to set their institutions on new pathways supporting academic excellence, health, and equity. This process begins with four guiding principles.
- To successfully address the challenge of the C19 pandemic, the first opportunity is to acknowledge that all major dimensions of higher education will benefit from being reimagined to address the impact of the C19 pandemic and beyond.
- The health and safety of all members of the community are paramount. Special care and attention must be given to the needs of vulnerable populations.
- The commitment to academic excellence must not wavier under these challenging circumstances. This commitment crosses all instructional modalities in-person, online, and hybrid instructional modes.
- Equity and inclusion are critical components of institutional responses. The economic, health, academic, and operational challenges are immense. It is incumbent upon institutions to engineer responses that serve and support the entire community.
- Note: The full planning guide & Self-Assessment can be found at Home – Open Smart EDU
- Note: This is the first of a series of stories regarding what higher education is doing (and should be doing) to prepare for the return of students to college campuses.
2. The Coronavirus Pandemic: Delivering Science in a Crisis
Lessons from science’s role in the response to the Deepwater Horizon disaster can guide research during the pandemic.
- The C19 pandemic has taken a heavy human toll all over the world. Evidence suggests that the coronavirus is disproportionately affecting racial and ethnic minorities in the United States and other countries, exposing longstanding economic disparities and inequities in health care. The United States is experiencing extreme unemployment. Economies have been shut down and supply chains disrupted. Society is depending on science to deliver us from this health, social, and economic crisis.
- An obvious role for science is to develop novel vaccines and effective therapies, and in that pursuit biomedical research has retooled diverse laboratories toward this singular problem. But there is a broader array of answers we need from science to see our way forward—for example, how to mitigate the spread of the virus, prevent a recurrence, and design a more resilient future for humanity.
- To effectively provide these answers, we must recognize that science in crisis is special. Here I offer a framework for providing answers based on experience developed with my colleague Gary Machlis during the Deepwater Horizon oil spill in 2010. (I was director of the US Geological Survey at the time; Machlis was science advisor to the director of the National Park Service.) At the National Academies of Sciences, Engineering, and Medicine, we are now embracing this framework to address the C19 pandemic.
Actionable Science to Inform Rapid Decision Making
- In the early days of the crisis, national leaders needed to make informed decisions on short notice. They needed actionable science, defined as science delivered to a decision-maker that is timely; understood by the nonscientist; provided in the context of the decision at hand; of the highest standards that timeliness allows; and meaningful—in terms of safety, economics, health, welfare, security, or any other values that matter to society. At the National Academies, our standing committee on emerging infectious diseases has provided actionable science to the US government on such topics such as the effectiveness of homemade face masks, the costs and benefits of social distancing, crisis standards of care, the seasonality of the virus, and the possibility of bioaerosol spread.
- And because the pandemic has an immediate impact on almost all aspects of daily life, we recently partnered with the National Science Foundation to launch a network that will bring the full range of scientific expertise across the social, natural, and biomedical sciences to provide actionable science on issues such as how to reopen schools, the best practices for distance teaching and learning, and how to strengthen mental health services during this crisis. The network is poised to address these and myriad other questions that are being raised by mayors, governors, local representatives, and other leaders.
Strategic Science to Guide Long-Term Planning
- Although much focus in the early days of a crisis is by necessity on actionable science, it is also important to plan for the longer term. Whereas it took mere weeks for the coronavirus to upend almost every sector of society, it is looking increasingly likely that a full recovery could take years. For the foreseeable future, policy-makers and communities will struggle to make decisions now that position them well for an uncertain future: Will there be a vaccine? Even if there is, will C19 be with us for the long term, like the seasonal flu or the measles? For this type of longer-term planning, strategic science involves interdisciplinary teams of scientists, engineers, and medical professionals in scenario planning to consider a range of futures, along with estimates of their uncertainties, and their possible chains of consequences for health, the environment, the economy, and infrastructure. The scenarios allow decision-makers to invest resources to prevent a long-term legacy of problems that cascade, in this case, from the virus, to people’s health, to society, to national economies, and even to global political stability.
- For example, in the near term, researchers could examine the possible impacts of a new round of infections on migrant farm workers, a vulnerable population with housing incompatible with self-quarantine and concerns about immigration status that might interfere with seeking timely medical attention. An epidemic in this population could have ramifications far beyond themselves and their immediate families, potentially disrupting food supplies and local, regional, and even the national economy. How could such a scenario be prevented or mitigated? Or as the pandemic wears on, strategic science could be used to weigh a range of scenarios that could ensure that the capacity of research universities—major stimulators of innovation, ingenuity, and economic growth—is maintained in an era of severe financial challenges and fiscal constraints.
- The National Academies as an organization is well positioned to provide strategic science, and we are launching an initiative in this area. We have the capacity to convene experts across the full range of natural, life, environmental and social sciences, engineering, and medicine, and those experts have reach-back to more colleagues to provide additional expertise as scenarios develop. The users of these scenarios could be federal agencies; national, state, and local governments; institutions; and even private industry.
Irreplaceable Science to Understand What Works
- Although no one would wish a pandemic on a society, or a major oil spill for that matter, crises provide an opportunity to conduct irreplaceable science. This is a special type of research that takes advantage of the unusual conditions existing during a crisis; requires rapid response by funders and researchers; is constrained by a requirement to not interfere with response efforts or actionable science; and poses challenges for scientific reproducibility. The results might, or might not, be directly relevant to the solutions to the crisis at hand.
- For example, no scientist would be able to devise an experiment in which a large fraction of the global population is asked to socially distance for months, but now that it has happened, it is important to understand the impacts on mental health, family relationships, and the social fabric of society. Such knowledge will be valuable in understanding how best to respond to a second wave of C19 or another pandemic. In another example, ocean scientists have been hoping to organize a “quiet day” for the oceans—a 24-hour period of relative silence from the cultural noise of human disturbance. Instead, thanks to the pandemic, they got months of relative quiet to observe the impact on marine life of turning down the noise level in the oceans. Although most irreplaceable science will be done by researchers at universities and other labs, I see a role for the National Academies in helping to identify important opportunities for irreplaceable science and in integrating the results where appropriate into actionable and strategic science.
- The C19 pandemic is the classic example of a problem that we will not solve anywhere until we solve it everywhere. This scientific framework including actionable, strategic, and irreplaceable science (and with that I include engineering and medicine) will bring much-needed focus and cohesion to public- and private-sector research efforts related to the pandemic, and will encourage collaboration and cooperation in the United States and around the world. We’ve already seen many examples of scientists teaming up across borders in new ways to work on developing vaccines and treatments. During an era of growing nationalization, researchers must resist that constriction and continue to share knowledge so that lessons learned in one country can inform response and recovery in other nations.
- Our national and global research enterprise houses the expertise to conquer the pandemic and at the same time help shape a stronger, better prepared nation and world. As we fight this worldwide emergency, employing actionable, strategic, and irreplaceable science can help society recover from this crisis and also emerge better positioned to respond to inevitable future challenges for many generations to come.
I. Johns Hopkins COVID-19 Updates
- The WHO C19 Situation Report for June 16 reports 7.94 million confirmed cases (118,502 new) and 434,796 deaths (3,255 new). The global cumulative incidence could reach 8 million cases in today’s Situation Report. Overall, the global daily incidence continues to increase.
2. Overseas Hotspots
- India’s daily incidence remains above 10,000 new cases for the sixth consecutive day. India remains #3 globally in terms of daily incidence. Following 2 days of decreased C19 incidence reporting, Pakistan reported 5,839 new cases, its fourth highest daily total to date. With this decrease, Pakistan is currently #6 globally in terms of daily incidence. Bangladesh reported its 2 highest daily totals over the past 2 days—3,862 new cases on June 15 and 4,008 on June 16. Bangladesh’s C19 epidemic continues to accelerate, and Bangladesh is currently #11 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.
- Iran reported 2,612 new cases, bringing the national total to 195,511 cumulative cases. Iran could reach 200,000 cases by Friday. While lower than both the peak last week and its first peak in late March, Iran’s current daily incidence continues to increase. Iran is #12 globally in terms of daily incidence.
- Brazil reported 34,918 new cases, its highest daily total to date. Brazil resumed the #1 position in terms of daily incidence, once again surpassing the United States. 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), Mexico (#8), Peru (#9), and Colombia (#13)—and 4 of the top 10 in terms of per capita daily incidence—Chile (#2), Panama (#6), Peru (#7), and Brazil (#10).
- The Eastern Mediterranean Region also remains an emerging hotspot, representing 5 of the top 11 countries in terms of per capita incidence: Qatar (#1), Bahrain (#3), Oman (#4), Saudi Arabia (#7), and Kuwait (#9). Additionally, nearby Armenia is #5. Notably, Qatar remains #1, but its per capita daily incidence has decreased substantially since late May, down from 730 cases per million on May 31 to 424 cases per million today (42.5% decrease). Saudi Arabia climbed to #7 globally in terms of total daily incidence.
3. United States
- The US CDC reported 2.10 million total cases (18,577 new) and 116,140 deaths (496 new). 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.
- Recent C19 incidence reports by the CDC appear to be slightly higher than in previous weeks. Considering the variation from day to day, it is difficult to determine if this is the beginning of a national-level trend or if it is simply an anomaly. A recent publication by the CDC’s C19 Emergency Response team, in its Morbidity and Mortality Weekly Report, presents analysis of the C19 incidence through May 30. The analysis indicates that the 7-day average incidence decreased from the first peak in early April through the end of May. It appears that the 7-day average has increased since that date, but it is difficult to determine if it will continue to increase further.
- A number of US states are reporting increased daily C19 incidence, but most are also reporting increased testing, which could potentially be responsible for a proportion of the increase in reported cases. As part of its analysis, ProPublica compiles state-level test positivity rates and indicates whether each is currently increasing, decreasing, or holding steady. In total, at least 15 states are reporting increasing test positivity (out of 47 states with available data). Among these states, 2 states, Alabama and Arizona, are reporting positive results in more than 10% of all tests, and an additional 5 states—Arkansas, Florida, Mississippi, South Dakota, and Texas—are reporting test positivity greater than 5% (the benchmark recommended by the WHO). Three (3) states—Louisiana, North Carolina, and Utah—are reporting steady test positivity greater than 5%. Another expert analysis shows 20 states with increasing test positivity (out of 50), including 3 states greater than 10%—Alabama, Arizona, and South Carolina—and another 7 greater than 5%.
- The Johns Hopkins CSSE dashboard reported 2.15 million US cases and 117,129 deaths as of 12:30pm on June 17.
- Earlier this week, researchers described findings from study that suggest the steroid dexamethasone could be effective at reducing C19 mortality. The drug is part of the RECOVERY clinical trials conducted in the United Kingdom, one of the largest clinical trials testing potential C19 therapeutics. The preliminary results have not undergone peer review. The study tested a small daily dose of the drug in 2,104 hospitalized C19 patients. When compared to a non-placebo-controlled control group who received the normal standard of care, dexamethasone was associated with a 34% decrease in mortality for patients on mechanical ventilation and 20% decrease for those receiving oxygen therapy.
- These results show promise, and the UK government reportedly already announced plans to distribute doses of the drug currently available in its national stockpile, potentially as many as 200,000 doses. Some health experts have criticized the researchers for publishing the preliminary results in a press release rather than making the data publicly available or awaiting peer review, particularly in light of recent retractions for other C19 analyses.
5. C19 Risk Factors
- Efforts are ongoing around the world—by government health agencies, academic institutions, and others—to better characterize and understand risk factors for SARS-CoV-2 infection as well as severe disease and death. While it is generally understood that older individuals and those with underlying health conditions are at elevated risk of severe disease and death, a myriad of other factors influence infection and disease risk. Beyond physical and health characteristics, numerous studies are evaluating the role of race and other social factors in C19 risk. Several studies found that Black Americans are at elevated risk of death from C19, after adjusting for income, health insurance coverage, comorbidities, and other factors. Issues such as disparities in the quality of health care and access to testing as well as broader challenges associated with systemic inequalities likely factor into this increased risk. Another study conducted by researchers at the Harvard Center for Population and Development Studies found similar results in terms of mortality risk among racial and ethnic minorities. The researchers found that racial and ethnic minorities (age 24-56 years) experienced 5-9 times the mortality risk as non-Hispanic White individuals, depending on age within that range.
- A study published in The Lancet: Global Health, evaluated the prevalence of known risk factors for severe disease around the world. The researchers estimate that 1.7 billion people globally (approximately 22% of the global population) have existing health conditions that increase risk for severe C19 disease, including nearly 350 million (4% of the global population) with conditions that would put them at “high risk” of severe disease. The study also stratifies the results by countries and continents/regions and provides distributions of relevant health conditions by age. Another study, published in Nature Medicine, found that children are half as likely to get infected with SARS-CoV-2 as adults. The researchers fit an age-structured model to C19 data from China, Italy, Japan, Singapore, Canada, and South Korea in order to better characterize age-based C19 risk. In addition to the age-based infection risk, the model also projects the proportion of SARS-CoV-2 infections that become symptomatic, stratified by age. The researchers found that among children aged 10-19 years, 21% of SARS-CoV-2 infections develop symptoms, which increases with age, up to 69% for adults 70 years and older.
6. US Social Distancing
- Multiple US states continue to report elevated or increasing C19 incidence. Elected officials, including President Donald Trump and Vice President Mike Pence, have identified increased testing as the driver of increased C19 reporting; however, other indicators suggest that this may not be the whole story. At the national level, the United States has reported relatively steady incidence over the past several weeks; however, there are notable regional and state-level differences. One analysis combined state-level data to track regional trends, and found that the South, Southwest, and West Coast regions are exhibiting increased incidence, while New England, the Mid-Atlantic, and the Midwest are declining. Additionally, the test positivity rate in the South and Southwest is increasing, which indicates that the increased incidence in these regions may not be wholly attributable to increased testing. Furthermore, C19 incidence is decreasing in states that were affected earlier in the US epidemic—Massachusetts, Michigan, New York, New Jersey, and Pennsylvania—but it is increasing steadily across the rest of the country.
- Some states and cities are taking notice of recent increases in C19 incidence and have begun slowing efforts to ease social distancing restrictions. Other states, however, continue on their intended course, despite increased incidence, hospitalizations, or test positivity. At the state level, the governors of Utah and Oregon recently announced that increased transmission would slow progress statewide in terms of easing social distancing restrictions. Health officials and experts nationwide continue to emphasize that the pandemic is not over or under control in the United States, and they highlight the risk of complacency among the general public.
- Several governors have acknowledged the increasing C19 incidence and associated risk, but note that this will not affect existing plans or timelines to relax statewide social distancing policies. Arkansas Governor Asa Hutchinson stated, “Regardless of what we see in the next week, we made the right decision to…lift some of these restrictions so we don’t cause more damage to people’s lives and their livelihood.” Arkansas’ C19 incidence, hospitalizations, and active cases have all doubled (or more) since Memorial Day Weekend (May 25), and the statewide test positivity increased since that time as well. Similarly, Florida Governor Ron DeSantis stated that the state would not be “rolling back” recent efforts to relax social distancing as a result of recent increases in C19 incidence, citing the need to maintain a functioning society. Rather, Florida continues forward with its recovery plan, including permitting major amusement parks such as Universal Studios and Disney to reopen, while reporting record daily C19 incidence. Florida’s daily incidence has increased from fewer than 1,000 new cases per day on June 1 to 2,800 on June 15.
- The US FDA revoked an Emergency Use Authorization for hydroxychloroquine and chloroquine. The EUA for both drugs was issued last month, but recent studies have not provided sufficient evidence that the drugs provide treatment benefit. Additionally, several studies have found that the drugs are associated with increased risk of cardiac arrest and other serious adverse events. The WHO recently suspended clinical trials of the drugs in order to evaluate the available data, but they soon resumed these studies. The decision has larger implications for the United States’ continued C19 response. Following early pressure from US political leaders, a number of states invested significant resources in building stockpiles of hydroxychloroquine.
8. Monoclonal Antibodies
- In the search for tools in the fight against C19, many discussions have focused on vaccines, antiviral agents, and convalescent plasma; however, these are not the only options. As discussed in a viewpoint published in The Journal of the American Medical Association (JAMA), monoclonal antibodies may offer an alternative strategy for treating those already infected with SARS-CoV-2 and could potentially offer prophylactic protection for those at increased risk for infection. While neutralizing antibodies could be isolated from the blood serum of recovered C19 patients, they can also be isolated from other sources, including infected animals, or even developed synthetically.
- For SARS-CoV-2, neutralizing antibodies could interfere with the interaction between the virus’ spike protein and the ACE-2 receptor on host cells, which could prevent the virus from infecting host cells. This mechanism could potentially offer treatment for patients (e.g., to reduce symptom severity) or offer temporary prophylaxis against the infection. Current monoclonal antibody drug formulations are administered via infusion into the bloodstream, and clinical trials for some products are anticipated to begin this summer.
9. New Zealand
- Eight days after New Zealand Prime Minister Jacinda Ardern announced that the country had reached zero active C19 patients, New Zealand reported 2 imported cases. Yesterday, New Zealand Minister of Health Dr. Ashley Bloomfield announced that 2 women who recently arrived from the United Kingdom tested positive for SARS-CoV-2 in New Zealand. Following the discharge of New Zealand’s last C19 patient on June 8, New Zealand lifted many of its social distancing measures; however, arriving travelers were still required to undergo a mandatory 14-day quarantine upon arrival. The 2 women arrived in New Zealand on June 7 to visit an ill relative, and they were permitted to leave their mandatory 14-day quarantine period early, on June 13, under a “compassionate exemption.” They traveled from Auckland to Wellington (approximately 400 miles/645 km) by car. They reportedly had no contact with anyone while en route or after their arrival, except the family member they visited in Wellington.
- As part of a plan agreed to by the New Zealand Ministry of Health, the 2 women were tested in Wellington, and both received positive results. One of the women reported experiencing mild symptoms, and the other was reportedly completely asymptomatic. Contact tracing efforts are ongoing to identify, quarantine, and test potentially exposed individuals, including passengers on their flights and customs or border security personnel at the airport in Auckland. While no subsequent transmission has yet been identified in New Zealand, this highlights the importance of continued vigilance and rapid response in order to quickly identify and contain possible chains of transmission, via arriving travelers or other sources. Of note, Dr. Bloomfield stated that anyone released quarantine early under “compassionate exemption” in the future will be required to be tested prior to being released.
10. Beijing Outbeak
- The C19 outbreak in Beijing continues, and China is implementing increasingly restrictive measures, including lockdown-style policies in affected parts of the city, in an effort to contain transmission. China’s National Health Commission reported 137 cases in Beijing between June 11 and June 16, including 31 new cases reported yesterday. In response to the outbreak, China deployed significant resources to identify and contain chains of transmission, including teams with experience responding to the C19 epidemic in Wuhan. Chinese health officials have already conducted interviews with approximately 200,000 individuals who visited the Xinfadi market since late May and implemented movement restrictions, fever and symptom screening, and other measures in at least 21 communities in Beijing. In addition to closing the Xinfadi market to allow for environmental testing and disinfection, Chinese officials also closed 11 other “underground and semi-underground markets” across Beijing.
- Cases linked to the market have also been identified in other cities, some of which have increased their own social distancing and travel restrictions, including mandatory 14-day quarantine for individuals with recent travel to Beijing. China appears to be implementing a robust response to the Beijing outbreak, in an effort to prevent broader community transmission in the country’s second most populous city.
11. Health Care System Capacity & Patient Surge
- Over the course of the C19 pandemic, healthcare systems have braced for the possibility that patient surge could exceed available capacity. In New York, which emerged as the major US hotspot early in the US epidemic, the state required hospitals and health systems to submit plans to effectively double patient capacity in anticipation of a major local epidemic. Strategies included converting spaces otherwise used for suspended activities (e.g., elective procedures) into intensive care units and using conference rooms and other non-clinical spaces for patient triage and care. To supplement capacity at hospitals, New York also established field hospitals at multiple locations around New York City. In addition to bed space for patients, hospitals also needed to account for additional staff and associated personal protective equipment and other supplies. Ultimately, New York did not exceed its total capacity, and efforts are ongoing to understand why the models used to estimate the clinical capacity needs did not necessarily align with the actual experience.
- Even as cases are beginning to recede in certain localities, many healthcare workers and health experts emphasize that continued vigilance and adherence to social distancing and other recommended protective measures are critical to mitigating the risk of a surge in transmission as states resume economic and social activity. Health systems need to learn from these early lessons and plan for the potential of future patient surge, particularly in areas that were not severely affected early in the epidemic. Changes to hospital procedures and policies can have a major effect on nosocomial transmission risk, and critical changes should be implemented in advance of a patient surge, or be available for rapid implementation, in order to have the greatest effect.
12. C19 & Food Insecurity
- C19 continues to impact human health well beyond direct morbidity and mortality. There is growing concern that a food crisis in Latin America and the Caribbean could be imminent, as food insecurity and hunger are on the rise. The Food and Agriculture Organization and the UN’s Economic Commission for Latin America and the Caribbean report that C19 could result in more than 83 million people in Latin America and the Caribbean living in extreme poverty. Pandemic-related economic disruptions have influenced the aability to access and pay for food has been reduced for many households, and economic growth in many countries has stagnated. The organizations proposed 10 measures that could provide financial stability to the region and bolster food security during and after the pandemic. One proposal, “anti-hunger grants,” would provide cash subsidies, food vouchers, and access to baskets of food for individuals and families in need. Additionally, the organizations called on national governments to expand social and financial support programs, including to migrant workers and those working outside traditional employment (i.e., “informal workers”).