Recent Developments & Information
June 29, 2020
Reliable information is the best tool available to protect your family from the pandemic and its shockwaves
“We’ve got our fatality rates and our hospitalization rates at the lowest they’ve been in two months, but this is a very serious situation.”HHS Secretary Azar
“The U.S. is experiencing a disturbing surge of infections after states reopened too quickly and without adequate plans for testing and contact tracing. Over all, the situation in the U.S. is a mixed bag, with areas like New York substantially reducing cases, while infections spike in other states. The next couple of weeks are going to be critical in our ability to address those surges we are seeing in Florida, Texas, Arizona and other states.”Dr. Fauci
“The coronavirus crisis had brought this nation to its knees. When it coincides with flu season this year, hospitals and health workers would face a tremendous strain. Getting a flu shot will be imperative. This single act will save lives.”Dr. Redfield, CDC Director
A. The Pandemic As Seen Through Headlines
B. Numbers & Trends
C. US Hotspots
Trends of Top Hotspot States
D. New Scientific Findings & Research
E. Concerns & Unknowns
F. The Road Back?
G. Back to School!?
H. Johns Hopkins C19 Update
I. Links to Other Interesting Stories
- The number of new coronavirus cases in the U.S. is surging to levels not ever seen in the course of the pandemic
- Leaders are urgently rethinking their strategies for curbing the spread, which Dr. Anthony Fauci said were “not working
- Some Mississippi intensive care units are at capacity
- Residents of Texas’s largest county, which includes Houston, received an emergency alert urging them to remain at home
- World Leaders Insist ‘Economic Lockdowns Ravage the Very Fabric of Societies’
- Safer reopening will require millions more Covid-19 tests per day. One solution: ‘pool testing’
- WHO, partners unveil ambitious plan to deliver 2 billion doses of Covid-19 vaccine to high-risk populations
- CDC broadens guidance on Americans facing risk of severe Covid-19
- Covid-19 can spread without symptoms, but for months health officials minimized that risk and pushed misleading messages despite mounting evidence
- Texas abruptly changes strategy in an attempt to stave off surge in coronavirus cases
- CDC chief says coronavirus cases may be 10 times higher than reported
- VP Pence’s Arizona, Florida Events Scrapped as Virus Cases Jump
- Black Americans are far more likely to know someone who has died from coronavirus
- Reopenings, record cases and full hospitals: America’s dissonant response to the pandemic
- The race to make buildings safe from coronavirus as Americans weigh returning to school and work
- How Arizona ‘lost control of the epidemic’
- Death threats, shoves, and throwing blood: Anti-vaxxers’ bullying of public health officials endangers our country
- Fauci blames young Americans for new coronavirus surge
- Airlines banning passengers who refuse to wear masks on flights
- NYC Phase Three (as early as July 6)will see restaurants reopen, whole blocks set up for outdoor dining
- NJ school reopening plan unveiled for fall classes amid coronavirus
- Florida bans booze at bars as it nearly doubles record for daily coronavirus cases Texas closes bars, scales back restaurants amid coronavirus surge
- The COVID-19 pandemic in the U.S. is officially worse than it’s ever been
- Most Kids Do Not Get Severe COVID-19
- ‘Superspreading’ Events Drive Most Spread
- The Pandemic’s Worst-Case Scenario Is Unfolding in Brazil
- The European Union will allow travelers from more than a dozen nations to enter again starting July 1, but the U.S. won’t be one of them.
- India plans to test all 29 million residents of New Delhi as nationwide infections near 500,000.
- The virus is hitting Latinos especially hard
- A federal judge ruled houses of worship in NYC can hold indoor services at 50% capacity, rather than the 25% allowed under the state’s reopening plan
- Trump Admin Lacks Solid Plan to Reopen Federal Offices, GAO Says
- Illinois museums, zoos and bowling alleys reopened, along with indoor dining at restaurants
- In South Africa casinos, restaurants and cinemas will reopen on Monday
- Restaurants, cafes and mosques to begin reopening in Egypt after 3 months
- During a heat wave in Britain, tens of thousands of people packed beaches, swarmed parks and attacked police officers who tried to break up block parties
- Most of the 121 cruise ships that entered U.S. waters after March 1 had Covid-19 cases on board
- A Russian hacking group has targeted Americans working from home during the pandemic
- There has been a surge in demand for underground bunkers as some people try to prepare for the next local or global crisis.
- Casual-dining chains are rethinking safety protocols and food for diners who fear the virus
- Costco’s half-sheet cakes appear to be the latest casualty of the pandemic — and customers are not happy
- Giving has surged across the U.S. during the coronavirus crisis, surpassing donations during the 2008 recession and after 9/11
- NY student sparks COVID-19 cluster after returning from Florida
- ‘The Bachelorette’ still on track to start filming in California in July
- India’s coronavirus cases skyrocket to more than 500,000
- West Village, Upper East Side, Astoria top NYC areas for social-distancing violators
- Anti-mask group issues bogus ‘exemption’ card
- If New York protests OK amid coronavirus, so is outdoor worship, federal judge rules
- Patients relieved to undergo elective surgeries banned during pandemic
- Schumer urges Trump admin to renew coronavirus emergency declaration
- Mike Pence, Nancy Pelosi clash over implementing face mask mandate
- NY Gov. Cuomo complains of ‘political heat’ over coronavirus nursing home deaths
- Archbishop Dolan celebrates first in-house Mass at St. Pat’s since March
- Florida records over 8,500 new coronavirus cases in a single day
- HHS Sec. Azar says ‘window is closing’ to curb coronavirus surge
- ReOpen Maryland co-founder catches coronavirus, won’t help contact tracers
- Australian Virus Hot Spot Considers Suburban Lockdowns
- Mass Transit Is Returning but New Yorkers Prefer Cars For Now
- Bankers in India Are More Productive Working From Home
- Brazil Reaches Deal to Produce Oxford Covid-19 Vaccine
- Country artist slammed for holding packed concert with maskless fans
- Amsterdam gives green light to reopen red-light district
- 28 members of a California family all catch coronavirus
- Arizona breaks new record for coronavirus cases in a single day
- Amazon workers in Germany will strike over COVID-19 infected workplace
- At least 85 infected with coronavirus after outbreak at college bar
- Gov. Newsom orders LA bars to immediately close amid coronavirus surge
- Coronavirus cases stabilize in China while Italy sees drop in deaths
- India’s coronavirus cases skyrocket to more than 500,000
- NYC’s potter’s field has quintupled its usual burials during coronavirus outbreak
- Increased restaurant spending linked to rise in coronavirus
- Scorn on the Fourth of July: Florida bans drinking in bars, Miami beaches closed ahead of holiday
- Clemson football’s coronavirus problem is getting much worse
- American Airlines will begin filling planes to capacity on July 1
- Nurses, Doctors Feel Strain as Virus Races through Arizona
- Paranoid hallucinations plague many virus patients who end up in the I.C.U.
- At a Houston hospital bracing for a virus peak, new patients are often young
- With flights banned, a son sailed solo across the Atlantic to reach his father
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 = 10,238,287 (+1.6%)
- New Cases = 163,172 (-13,612)
- Growth Rate of New Cases (7 day average) = 2.8%
- New Cases (7 day average) = 170,3310 (+4,624)
- New cases have decreased for 2 consecutive days, which frequently happens during weekends
- 7 day average growth rate in new cases is high
- More than one million cases are now being reported each week
US Cases & Testing:
- Total Cases = 2,637,077 (+1.6%)
- New Cases = 40,540 (-3,041)
- Percentage of New Global Cases = 24.8%
- Growth Rate of New Cases (7 day average) = 5.5%
- New Cases (7 day average) = 39,797 (+2,066)
- Total Number of Tests = 32,445,700
- Percentage of positive tests (7 day average) = 6.9%
- The 7 day average of new cases have been rapidly rising since 6/9
- Although new cases have decreased for 2 consecutive days, the 7 day average of 39,797 is a record high
- 7 day average growth rate in new cases is very high
- 7 day average of positive test percentage is increasing rapidly (the average increased 1.5% over 7 days), which indicates that the virus is spreading rapidly in hotspots
- Daily testing is in excess of 500,000
- Total Deaths = 496,077 (+1.1%)
- New Deaths = 3,454 (-1,093)
- Growth Rate of New Deaths (7 day average) = 0.4%
- New Deaths (7 day average) = 4,645 (+16)
- New deaths have declined for 3 consecutive days (3 day average has decreased by 11.5%)
- 7 day average of new deaths have been rising gradually since 5/26
- Since 5/26, the 7 day average of new deaths has increased from 4,094 to 4,645, an increase of 13.5%
- Total Deaths = 128,437 (+0.2%)
- New Deaths = 285 (-227)
- Percentage of Global New Deaths = 8.3%
- Growth Rate of New Deaths (7 day average) = -3.8%
- New Deaths (7 day average) = 596 (-23)
- 7 day average of new deaths is lowest since March 30
- 3 day average has decreased by 37.8%
- New deaths continue to decline as new cases rise
3. Top 5 States in Deaths & Cases (5/28)
- New York 32
- California 31
- New Jersey 27
- Florida 27
- Massachusetts 19
- Florida 8,530
- California 5,240
- Texas 4,330
- Arizona 3,857
- Georgia 2,225
Deaths Per 1 Million Population
- New Jersey 1,702
- New York 1,618
- Connecticut 1,211
- Massachusetts 1,169
- Rhode Island 875
C. US Hotspots
1. Trends of Top Hotspot States
- Since 6/1, the 7 day average of new cases has increased from 726 to 6,255, an increase of 761.6%
- 7 day average of new cases began to increase rapidly on 6/16
- Since 6/15, the 7 day average of new cases increased from 2,016 to 6,255, an increase of 210.3%
- A record number of 9,585 new cases was set on 6/27
- 7 day average of new deaths has varied between 30 and 39 since 6/1
- Since 6/1, the 7 day average of new deaths has increased from 30 to 36, an increase of 20%
- Current 7 day average of new deaths is 36, which is 29.4% less than the peak on 5/1
- Record number of 83 new deaths was set on 4/28
- Since 6/1, the 7 day average of new cases has increased from 2,607 to 5,360, an increase of 105.6%
- 7 day average of new cases began to rapidly increase on 6/19
- Since 6/19, 7 day average of new cases has increased 59.7%
- Record number of 6,503 new cases was set on 6/23
- 7 day average of new deaths has varied between 55 and 73 since 6/1
- Since 6/1, the 7 day average of new deaths decreased from 68 to 59, a decrease of 13.2%
- Current 7 day average of new deaths is 59, which is 28% less than the peak on 5/21
- Record number of 121 new deaths was set on 4/22
- Since 6/1, the 7 day average of new cases has increased from 1,130 to 5,520, an increase of 388.5%
- 7 day average of new cases began rise rapidly on 6/16
- Since 6/16, the 7 day average of new cases has increased 130%
- Record of number of 6,177 new cases was set on 6/24
- 7 day average of new deaths has varied between 20 and 31 since 6/1
- Since 6/1, the 7 day average of new deaths increased from 23 to 30, an increase of 30.4%
- Current 7 day average of new deaths is 30, which is 21% less than the peak on 5/5
- Record number of 63 new deaths was set on 5/21
- Since 6/1, the 7 day average of new cases has increased from 187 to 3,074, an increase of 1,543.9%
- 7 day average of new cases began rise rapidly on 6/16
- Since 6/16, the 7 day average of new cases has increased 99.2%
- Record of number of 3,857 new cases was set on 6/28
- 7 day average of new deaths has varied between 16 and 36 since 6/1
- Since 6/1, the 7 day average of new deaths has increased from 11 to 36, an increase of 227.3%
- The current 7 day average of new deaths is 36, which is a record high number of new deaths
- Although the 7 day average of new cases have been rapidly increasing in FL and TX since 6/1, there have only been relatively modest (20-30%) increases in their 7 day averages of deaths during the same period.
- Although new cases in CA have more than doubled since 6/1, the 7 day average of new deaths as decreased during the same period.
- The 7 day average of new cases and new deaths have both been rapidly increasing in AZ since 6/1, and both high record highs on 6/28. The much higher death rate in AZ (vs. FL, TX and CA) indicates that one or more vulnerable populations have been infected by the virus (there have been reports of significant virus spread throughout Native American Tribes as well as a significant outbreak near the southern border).
2. Increase in New Cases: It’s Not Just More Testing
- As case counts surge, we look at regional and state-level numbers to find out which recent jumps in C19 case counts are likely to be explained by increased testing, and which are not. For the states with the worst recent numbers, the news is not good.
- Outside of the original epicenter in the Northeast, C19 cases are rising across the United States. In fourteen states, the number of new cases discovered each day has increased in the last two weeks, some quite sharply: in Georgia, cases are up 27%; in California 37%; in Florida, 55%; in Texas, 56%. In Arizona, cases have risen from 28,296 to 58,179, an increase of more than 105%.
- But we also know that the United States has substantially expanded C19 testing. Testing numbers we compile from states and territories are up 30% in the last two weeks alone, and the seven-day average for daily tests is finally over the 500k/day initial acceptable minimum from the Harvard Global Health Institute (which has now been increased to 900k/day). Florida posted how many people were hospitalized with C19 on a given day for only a few days before taking this data offline.
Two charts that can help us understand the case count jumps
- So how can we tell whether the increase in cases is an accurate indication of worsening outbreaks or an artifact of expanded testing? Rising C19 hospitalizations are suggestive of worsening outbreaks, but if a state is doing enough tests to discover mild or pre-symptomatic cases, hospitalizations may lag behind positive tests by days or weeks.
- There’s a simple way to get closer to a definitive answer about which case count numbers indicate new or worsening hotpots. The%-positive rate shows us how many tests come back positive, out of all tests performed. This rate can help us interpret case count increases:
- If case counts go up, but the%-positive rate goes down or holds steady, the rise in cases can be partially explained by the increase in testing.
- If case counts and the%-positive rate both go up, the increase cannot be explained entirely by an increase in testing. If case counts and the%-positive rate both go up, but testing decreases or holds steady, the rise in cases could indicate new outbreaks of the virus in communities.
- In the states with big percentage increases in case counts, percentage-positive rates tell a more specific story. California’s percentage-positive rate has remained a steady 5%, and Georgia’s percentage-positive rate is up from 7 to 9%—higher than anyone would like to see, but not a huge increase. Texas, on the other hand, has gone from 7% to 12% positive in the last two weeks, and Florida from 6% to 15% positive. Arizona remains an outlier among outliers: their already high 16% positive rate has nearly doubled to 28%.
- Another way to look at the relationship between case counts and test counts is to compare the rate of change for a state’s case-count rise to the rate of change for its testing numbers. If we chart the week-over-week increase in cases and tests from the last two weeks, we can see more clearly that for a few states, increased testing really does seem to account for some or all of the increase in new cases. The same comparison also makes it clear that in the states with the worst case numbers, testing explains only a fraction of the rise in cases.
- Testing is booming in Arizona, but even this major testing increase hasn’t caught up to the rise in new cases. Week over week, Texas has also posted a big gain in testing—but again, this growth has been outstripped by the increase in new cases. California, on the other hand, has increased testing by the same proportion as Texas, but has seen a much smaller increase in new cases—testing probably accounts for more of California’s rise in cases than Texas’s.
- The starkest example, Florida, has actually slowed testing almost 10%, week over week, while seeing a 65% jump in the cases in the same time span. Florida’s rising cases, we can conclude, have nothing to do with expanded testing. South Carolina and Kentucky have followed the same pattern as Florida, with testing increases slowing while cases rise.
- Given the high%-positive rates and the degree to which case counts have outpaced tests in Arizona, Florida, and Texas, we interpret the case counts as indicators of sharply worsening outbreaks. In California and Georgia, where%-positive rates remain relatively steady, the numbers are more difficult to interpret, but we’ll be watching them closely over the coming weeks.
Source: Blog | It’s Not Just Testing
3. White House Coronavirus Task Force Touts Decline In Virus Deaths, Addresses Spike In Positive Cases
- Despite the recent rise in virus cases, Vice President Mike Pence confirmed C19 fatalities are declining all across the country.
- During Friday’s task force briefing, he said only 5% of virus patients are being hospitalized for coronavirus symptoms, compared to 15% at the peak of the pandemic.
- While 16 states have seen a surge in positive cases, 34 are experiencing a “stability” in cases as they safely reopen.
- “Because of what the American people have done, because of the incredible work of our health care workers, because of a partnership with governors in every state, we slowed the spread,” stated Pence. “We flattened the curve, we saved lives.”
- According to Dr. Deborah Birx, the increasing rate of cases is not as bad as was it was months ago. During the briefing, she touted the success of therapeutic treatments, including Remdesivir.
- Moving forward, the task force urged younger generations to get tested, as many may be asymptomatic carriers.
- The vice president announced he will be travelling to U.S. virus hot spots, including Texas, Arizona and Florida next week.
- Meanwhile, the Trump administration is considering a new testing strategy for coronavirus infections. Task force Dr. Anthony Fauci explained officials are having “intense discussions” about adopting pool sampling.
- The new method can test groups of five to 20 people at a time. If the test comes back positive, they can then test each person in the group individually.
- This would cast a broader net and would allow officials to find cases faster. The technique has been used in the past for testing HIV, Hepatitis B and C, and other viruses.
4. Where are the deaths?
- The coronavirus doomsayers could not even wait until the fall for the apocalyptic announcements of the dreaded second wave. Because the red states recklessly loosened their lockdowns, we are now told, the US is seeing a dangerous spike in coronavirus cases.
- ‘EXPERTS SKETCH GLOOMY PICTURE OF VIRUS SPREAD: FAUCI TELLS OF “DISTURBING” WAVE, WITH A VACCINE MONTHS AWAY,’ read the front-page lead headline in the New York Times on Wednesday.
- ‘VIRUS SPREAD AKIN TO “FOREST FIRE”’ read another front page headline in the Los Angeles Times on Monday, quoting Michael Osterholm, one of the media’s favorite public health experts. Osterholm had told NBC’s Meet the Press: ‘I’m actually of the mind right now — I think this is more like a forest fire. I don’t think that this is going to slow down.’
- The ‘this’ is an uptick in daily new cases from 19,002 on June 9 to 38,386 on June 24. The high to date in new daily cases was on April 24 — 39,072. Since April 24, the daily case count started declining, then began rising again after around June 9.
- What virtually every fear-mongering story on America’s allegedly precarious situation leaves out, however, is the steadily dropping daily death numbers — from a high of 2,693 on April 21 to 808 on June 24. That April high was driven by New York City and its environs; those New York death numbers have declined, but they have not been replaced by deaths in the rest of the country. This should be good news. Instead, it is no news.
- The New York Times put three reporters on a full-page article on Texas, published June 25 under the headline ‘AS NEW CASES SOAR, THE GOVERNOR FACES FALLOUT FROM A RUSH TO REOPEN.’
- The story never mentioned coronavirus deaths. Texas’s daily death count has bounced around since early May without a sharp rise — a high of 63 new deaths on May 21, 42 on June 24. Arizona, another state facing media contempt, finally beat its earlier high of 67 deaths on May 8 with 79 deaths on June 24. Between those two dates, however, the curve was steady. The Arizona mortalities are concentrated on Indian reservations and to a lesser extent around the Mexican border.
- In May, Georgia was the main target of expert contempt for its allegedly premature reopening. Since then, the media have gone silent, due to the state’s truly discouraging downward daily death toll from a high of 119 on April 7, long before the reopenings, to 10 on June 24.
- There are no crises in hospital capacity anywhere in the country. Nursing homes, meat-packing plants, and prisons remain the main sources of new infections. Half the states are seeing cases decline or hold steady. Case counts are affected by more testing; the positive infection rate captured by testing is declining. The current caseload is younger, which is a good thing. The more people who have been infected and who recover, the more herd immunity is created. Meanwhile, daily deaths from heart disease and cancer — about 3,400 a day combined — go ignored in the press.
- But the drum beat to halt the still far too tentative reopenings gets louder by the day. It should be resisted. The lockdowns were a mistake the first time around; to reimpose them would be disastrous for any remaining hope of restoring our economy.
- The damage that has been done to people’s livelihoods and future prosperity will continue to outweigh the damage done by the coronavirus. The only vaccine against poverty and resulting despair is a robust economy.
Source: Where are the deaths?
D. New Scientific Findings & Research
1. Coronavirus use zombie cells to invade other cells; cancer drugs may disrupt them
- The new coronavirus’ reputation for messing with scientists’ assumptions has taken a truly creepy turn.
- Researchers exploring the interaction between the coronavirus and its hosts have discovered that when the coronavirus infects a human cell, it sets off a ghoulish transformation. Obeying instructions from the virus, the newly infected cell sprouts multi-pronged tentacles studded with viral particles.
- These disfigured zombie cells appear to be using those streaming filaments, or filopodia, to reach still-healthy neighboring cells. The protuberances appear to bore into the cells’ bodies and inject their viral venom directly into those cells’ genetic command centers — thus creating another zombie.
- The authors of the new study, an international team led by researchers at UC San Francisco, say the coronavirus appears to be using these newly sprouted dendrites to boost its efficiency in capturing new cells and establishing infection in its human victims. Their research was published Friday in the journal Cell.
- The scientists also believe they have identified several drugs that could disrupt the viral takeover of cells and slow the process by which C19 takes hold. These compounds, many of which were designed as cancer treatments, seem likely to work because they block the chemical signals that activate filopodia production in the first place.
- Among the 7 drugs they identified as potentially useful against C19 are Silmitasertib, a still-experimental drug in early clinical trials as a treatment for bile duct cancer and a form of childhood brain cancer; ralimetinib, a cancer drug developed by Eli Lilly; and gilteritinib (marketed as Xospata), a drug in use already to treat acute myeloid leukemia.
- The new research emerges from an ambitious effort to identify promising C19 treatments using the science of “proteomics,” the interactions among proteins. Scientists set out to identify the chemical signals and cascading chain of events that take place when a virus meets and overtakes a host cell. Then, they look for drug compounds that could scramble those chemical signals and disrupt the process of infection.
- Until now, the process by which the coronavirus was thought to infect cells was pretty run-of-the-mill for a virus: It found receptors on the surface of the cells that line humans’ mouth, nose, respiratory tract, lungs and blood vessels.
- Like space invaders in a science fiction tale, the tiny virus was known to dock on the surface of the much larger cell. A viral landing party came aboard and hijacked the cell’s usual function, making it a factory for its replication.
- The discovery that the coronavirus initiates the sprouting of filopodia in infected cells suggests that it has, at some point in its evolution, developed more than one way to ensure it gets passed quickly from cell to cell.
|An electron microscopy image of a cell infected by the coronavirus that causes COVID-19.(UC San Francisco)|
- Typically, a rapid rise in infected cells will raise a victim’s viral load, make her feel sick and promote the transmission of the virus to other people. UC San Francisco’s Nevan Krogan, one of the paper’s senior authors, said there is much about the coronavirus that doesn’t match scientists’ expectations.
- But the discovery of filopodia in coronavirus-infected cells suggests that this virus has developed more than one way to wheedle its way into cells and establish itself as a force to be reckoned with.
- “It’s just so sinister that the virus uses other mechanisms to infect other cells before it kills the cell,” Krogan said. Other researchers include scientists from Mt. Sinai in New York, Rocky Mountain Labs in Montana (where these electron microscopy images were made), the Pasteur Institute in Paris and the University of Freiburg in Germany.
- Cells sprouting filopodia not only look creepy. They keep some pretty nasty company as well.
- Vaccinia, a member of the poxvirus family that causes smallpox, uses filopodia that sprout from infected cells to “surf” toward those cells and inject them with more viral particles, a 2008 study found. HIV and some influenza viruses have been known to use filopodia to enhance their ability to break and enter into cells. Many viruses alter the exoskeleton of the cells they infect, and inducing filopodia is one way they do it, said Columbia University virologist Angela L. Rasmussen. And while enhancing infection is one role they often play, there are many others.
- But Krogan said even those viruses do not seem to set off the prolific growth of filaments that was seen by his colleagues on coronavirus-infected cells. The branching tentacles protruding from those cells were highly unusual, he said.
- Columbia University microbiologist Stephen P. Goff urged caution in assuming that filopodia are necessarily behaving as a second mode of infecting cells with virus.
- “It’s intriguing and a really cool observation,” Goff said. The study’s striking images show that the filopodia contain a lot of virus and that in the lab, inhibiting their growth seemed to reduce viral replication. This strongly suggests that filopodia are somehow amping up the virus’ ability to infect cells, he acknowledged.
- “But we don’t yet know what stage [of infection] is affected” by the strange protrusions, he said. “It will be great fun to find out.”
2. C19 Depletes T-Cells, an Eerie Parallel with HIV
- At the beginning of the pandemic, the coronavirus looked to be another respiratory illness. But the virus has turned out to affect not just the lungs, but the kidneys, the heart and the circulatory system — even, somehow, our senses of smell and taste.
- Now researchers have discovered yet another unpleasant surprise. In many patients hospitalized with the coronavirus, the immune system is threatened by a depletion of certain essential cells, suggesting eerie parallels with HIV.
- The findings suggest that a popular treatment to tamp down the immune system in severely ill patients may help a few, but could harm many others. The research offers clues about why very few children get sick when they are infected, and hints that a cocktail of drugs may be needed to bring the coronavirus under control, as is the case with HIV.
- Growing research points to “very complex immunological signatures of the virus,” said Dr. John Wherry, an immunologist at the University of Pennsylvania whose lab is taking a detailed look at the immune systems of C19 patients.
- In May, Dr. Wherry and his colleagues posted online a paper showing a range of immune system defects in severely ill patients, including a loss of virus-fighting T cells in parts of the body.
- In a separate study, the investigators identified three patterns of immune defects, and concluded that T cells and B cells, which help orchestrate the immune response, were inactive in roughly 30% of the 71 C19 patients they examined. None of the papers have yet been published or peer reviewed.
- Researchers in China have reported a similar depletion of T cells in critically ill patients, Dr. Wherry noted. But the emerging data could be difficult to interpret, he said — “like a Rorschach test.”
- Research with severely ill C19 patients is fraught with difficulties, noted Dr. Carl June, an immunologist at the University of Pennsylvania who was not involved with the work.
- “It is hard to separate the effects of simply being critically ill and in an ICU, which can cause havoc on your immune system,” he said. “What is missing is a control population infected with another severe virus, like influenza.”
- One of the more detailed studies, published as a preprint and under review at Nature Medicine, was conducted by Dr. Adrian Hayday, an immunologist at King’s College London.
- He and his colleagues compared 63 C19 patients at St. Thomas’s Hospital in London to 55 healthy people, some of whom had recovered from coronavirus infections.
- Dr. Hayday and his colleagues began with the assumption that the patients would generate a profound immune response to the coronavirus. That is why most people recover from infections with few, if any, symptoms.
- But those who get very sick from the virus could have immune systems that become impaired because they overreact, as happens in sepsis patients. Alternatively, the scientists hypothesized, these patients could have immune systems that struggle mightily, but fail to respond adequately to the virus.
- One of the most striking aberrations in C19 patients, the investigators found, was a marked increase in levels of a molecule called IP10, which sends T cells to areas of the body where they are needed.
- Ordinarily, IP10 levels are only briefly elevated while T cells are dispatched. But in C19 patients — as was the case in patients with SARS and MERS, also caused by coronaviruses — IP10 levels go up and stay up.
- That may create chaotic signaling in the body: “It’s like Usain Bolt hearing the starting gun and starting to run,” Dr. Hayday said, referring to the Olympic sprinter. “Then someone keeps firing the starting gun over and over. What would he do? He’d stop, confused and disoriented.”
- The result is that the body may be signaling T cells almost at random, confusing the immune response. Some T cells are prepared to destroy the viruses but seem undermined, behaving aberrantly. Many T cells apparently die, and so the body’s reserves are depleted — particularly in those over age 40, in whom the thymus gland, the organ that generates new T cells, has become less efficient.
- The research also suggests that a popular idea for treatment may not help most people.
- Some patients are severely affected by coronavirus infections because their immune systems respond too vigorously to the virus. The result, a so-called cytokine storm, also has been seen in cancer patients treated with drugs that supercharge T cells to attack tumors.
- These overreactions can be quelled with medications that block a molecule called IL-6, another organizer of immune cells. But these drugs have not been markedly effective in most C19 patients, and for good reason, Dr. Hayday said.
- “There clearly are some patients where IL-6 is elevated, and so suppressing it may help,” he explained. But “the core goal should be to restore and resurrect the immune system, not suppress it.”
- The new research may help answer another pressing question: Why is it so rare for a child to get sick from the coronavirus?
- Children have highly active thymus glands, the source of new T cells. That may allow them to stay ahead of the virus, making new T cells faster than the virus can destroy them. In older adults, the thymus does not function as well.
- The emerging picture indicates that the model for HIV treatment, a cocktail of antiviral drugs, may be a good bet both for those with mild illnesses and those who are severely ill.
- Some experts have wondered if antiviral treatment makes sense for severely ill C19 patients, if their main affliction is an immune system overreaction.
- But if the virus directly causes the immune system to malfunction, Dr. Hayday said, then an antiviral makes sense — and perhaps even more than one, since it’s important to stop the infection before it depletes T cells and harms other parts of the immune system.
- “I have not lost one ounce of my optimism,” Dr. Hayday said. Even without a vaccine, he foresees C19 becoming a manageable disease, controlled by drugs that act directly against the virus.
- “A vaccine would be great,” he said. “But with the logistics of its global rollout being so challenging, it’s comforting to think we may not depend on one.”
3. Coronavirus antibodies can fade in 2 months
- A new Chinese study published in Nature Medicine suggests that people who develop antibodies after becoming infected with the coronavirus may not keep them for more than two months — a growing concern as several states in the U.S. see alarming spikes in C19 cases.
- Antibodies are the proteins produced by the immune system that can grant protection against reinfection. When the coronavirus hit the United States, Americans went to antibody test sites in droves to find out if they had been infected by C19 and therefore would have some level of protection from the virus, but findings like this calls into question just how safe people who have antibodies to the virus really are from reinfection.
- “When you get an antibody test, we don’t really know enough to be able to assure you that you’re safe. And I think the more we’re learning about antibodies, the more we’re beginning to say we’re not so sure that you’re safe,” Dr. Daniel Griffin, an infectious disease specialist at Columbia University Medical Center, told Fox News.
- In the study, researchers from Chongqing Medical University in China looked at 37 people who became infected with the coronavirus and showed symptoms and 37 people who became infected and showed no symptoms. Out of the participants involved, antibody levels fell to undetectable levels in 40% of asymptomatic people and 13% of symptomatic people just eight weeks after they recovered from C19.
- “Many of us were quite disturbed when we saw this study out of China, which actually demonstrated that in a number of individuals, particularly these individuals with more mild disease, that we’re worried are the silent spreaders, that these individuals were losing their antibodies shield after just a month or two,” Griffin said.
- Like many doctors, Griffin hoped that C19 would leave those infected with a protective shield for a year or two since past studies on similar viruses like SARS and MERS found that antibodies last for at least a year.
- “This is why we keep seeing the common cold coronaviruses cause infections on a yearly basis, often in the same individuals and we’ve even seen them do this in the same individual just a few months apart,” Griffin explained. “So this is quite worrisome that here we’re seeing evidence that maybe a person can get C19 more than once, maybe more than once in a short period of time.”
- The findings in the new Chinese study also calls into question the idea of “immunity passports,” which some countries may issue to recovered C19 patients to allow them to go back to work and travel because they’re supposedly immune to the virus. But Griffin doesn’t think we’re ready for this type of approach quite yet.
- “We certainly don’t know if people who have been infected have durable protection because we haven’t shown that certain antibody level when you’ve been re-exposed protects you,” Griffin said. “We also don’t know if natural infection is durable. So even if we found that, hey, a certain level of antibodies correlates with protection, how often do you need to check that individual to make sure that they’re maintaining that level?”
- As new coronavirus hot spots begin to emerge across the U.S. in states like Texas, California, Florida and Arizona, Griffin believes the summer weather, which some experts originally thought would help slow the spread, is actually playing a large part in the virus’ resurgence.
- “You look at a lot of places where the numbers are rising and these are places where it’s gotten quite warm, but it’s gotten so warm that a lot of people are inside in the air conditioning,” Griffin explained. “Everyone wants to blame people [and] say they must be doing something wrong, but what they’re doing is they’re trying to get out of the heat. They’re in the air conditioning. They’re too close to one another, which is a very human thing to want to do, but that puts us in harm’s way.”
4. Urban density doesn’t cause more C19 infections, even promotes lower death rates
- New research contends that potential mass exoduses from densely populated U.S. cities may actually be a bad idea for everyone.
- Crowded city streets, subways, and buses have been considered the most likely places to become infected with C19 over the past few months. Surprisingly, however, a new study from the Johns Hopkins Bloomberg School of Public Health concludes that densely populated spaces aren’t actually linked to higher infection rates.
- Even more confounding, the study’s analysis indicates that crowded, dense locations are associated with lower coronavirus death rates.
- In all, C19 infection and death rates were assessed across 913 U.S. metropolitan counties. After researchers accounted for additional factors like race and education, the population density within each county was not significantly linked to infection rates.
- As mentioned, denser counties, as opposed to more rural, sprawling areas with smaller populations, were associated with lower death rates. The study’s authors speculate this is because denser, urban areas often offer better healthcare services.
- Instead, higher coronavirus infection and death rates seem to be linked to a metropolitan area’s size, not its density. So, cities that are very big and stretch across multiple counties that are “tightly linked together through economic, social, and commuting relationships” appear to be most at risk of high coronavirus infection rates.
- “These findings suggest that urban planners should continue to practice and advocate for compact places rather than sprawling ones, due to the myriad well-established benefits of the former, including health benefits,” says study lead author Shima Hamidi in a release. PhD. Hamidi is an assistant professor of American Health in Environmental Challenges in the university’s Department of Environmental Health and Engineering.
Heading to the burbs an unwise move
- Lots of recent polls have indicated that plenty of Americans are considering packing up and leaving cities and urban areas in favor of more open spaces due to the coronavirus. The study’s authors say such decisions may be misguided.
- “The fact that density is unrelated to confirmed virus infection rates and inversely related to confirmed C19 death rates is important, unexpected, and profound,” Hamidi explains. “It counters a narrative that, absent data and analysis, would challenge the foundation of modern cities and could lead to a population shift from urban centers to suburban and exurban areas.”
Higher urban density offers greater protection?
- After accounting for a variety of factors (metro size, age, race, education), the study concludes that doubling the activity density of a given area would result in a 11.3% reduction in coronavirus deaths.
- How is this possible? Researchers theorize it’s because of faster, more widespread adoption of social distancing in urban areas, as well as superior medical services.
- So what are the factors that increase rates? The authors say that a higher overall county population, a higher number of residents over 60, a smaller proportion of college graduates, and higher proportions of African American residents are all associated with greater infection and death rates.
- As unbelievable as some of these findings sound, the research team say they’ve continued to update their projections as the pandemic has progressed over time, and all of the data continues to validate their conclusions.
- The study is published in the Journal of the American Planning Association, a copy of which can be found at: Full article: Does Density Aggravate the COVID-19 Pandemic?
5. Public Transit Associated With Higher Coronavirus Death Rates
- African-Americans may be dying at higher rates than white people from C19, the disease caused by the novel coronavirus, in part because of black people’s heavier reliance on public transportation for commuting, two new studies by economists suggest.
- One of the studies, by University of Virginia economist John McLaren, found that the racial discrepancy remained even after controlling for income or insurance rates. Instead, Mr. McLaren found the gap was due in part to the fact that black workers are more likely to get to work via public transit, including subways and buses.
- About 10.4% of black commuters take public transit, versus 3.4% of white commuters, according to the Census. After controlling for the use of public transit, Mr. McLaren finds the racial disparity in C19 deaths is less pronounced.
- Both studies raise the possibility that other causes could contribute to the discrepancy in deaths, such as gaps in access to paid sick leave, residential segregation and discrimination in health services. They also cited the higher likelihood that African-Americans work in essential occupations, such as health care, which have required employees to stay on the job through the pandemic.
- Black people are more than 3.5 times as likely to die of C19 than white people, and Latino people are nearly twice as likely to die of the disease as white people, according to researchers at Yale University and the University of Pittsburgh. Both new studies look at black deaths from the disease as a share of the overall black population rather than as a share of those infected with the disease.
- The other study, by Christopher Knittel and Bora Ozaltun, both of the Massachusetts Institute of Technology, found that a 10% increase in the share of a county’s residents who use public transit versus those who telecommute raised C19 death rates by 1.21 per 1,000 people when looking at counties around the U.S.—or by 0.48 per 1,000 people when focusing only on counties within individual states. In their analysis, the researchers controlled for race, income, age, climate and other characteristics.
- In part, that could be because there is something specific about public transit—close proximity to strangers on crowded railcars or buses on a daily basis for extended periods, for instance—that makes people particularly vulnerable to getting sick, wrote Mr. Knittel and Mr. Ozaltun.
- Counties with higher shares of people who drove or walked to work versus telecommuting also saw higher death rates, a sign that perhaps some of the greater risk simply comes from leaving the house, they found.
- But transit use isn’t the whole story, both papers say. Mr. Knittel and Mr. Ozaltun find there is still a racial disparity in death rates in counties across the country when controlling for transit use.
- Both papers also note that New York City accounts for a very large share of the country’s transit ridership as well as its virus-related deaths. In both cases, the authors left out New York City and reached similar results.
- The transportation data used in both cases measure people’s commuting patterns before the start of the epidemic. It is possible the epidemic altered those habits or made people more likely to stay home in ways that these studies don’t measure.
- The results could complicate cities’ efforts to reopen their economies. With many urban workers and residents reliant on transit, the studies suggest that reviving business activity will depend on authorities’ ability to ensure that buses and trains are safe to use.
- Early indications from transit systems abroad offer hopeful signs. In Paris, transit users must wear face masks and authorities require that every other seat on trains and subways be kept open. Since May 9, only 1% of the new disease clusters—defined as three cases of common origin recorded over seven days—have come from transit, according to the French health agency.
- Already, New York’s subway system has stepped up its disinfecting of trains and buses, and launched an app that tells riders on some lines how crowded railcars are. The system is also considering checking riders’ temperatures and rolling out robot cleaners.
E. Concerns & Unknowns
1. C19 May Cause Diabetes
- Recent studies from England and other countries have suggested that adults with both types 1 and 2 diabetes have an increased risk of death if they catch C19, especially if they have poor glucose control. The weight of evidence is building up to support this theory. And when the dust settles, a more critical analysis of the data will probably confirm this increased risk.
- But in early June, several well-respected academics from around the world wrote a letter to the New England Journal of Medicine (NEJM) suggesting that C19 is not just a risk for people with diabetes – it may actually cause diabetes.
- There are two main types of diabetes. Type 1, caused by the body’s own immune system attacking the islet cells in the pancreas that produce insulin, a so-called autoimmune disease. Eventually, there are no islets left and hence no insulin can be made to control blood glucose levels. We don’t know what starts this autoimmunity, but viral infections have been suggested as a possible trigger.
- Type 2 diabetes happens when the islet cells have to produce vast amounts of insulin because the main target organs (liver, muscle, fat) do not respond as well as they should to insulin’s message. Finally, the islet cells become exhausted and die.
- We have known for many years that viral infections may be linked to the first time a patient has diabetes symptoms. (Type 1 diabetes presents in a seasonal fashion, a fact often seen with viral infections.) And viral infections may also trigger the destruction of the insulin-producing islet cell “factories” in the pancreas, setting up a chronic autoimmune response.
- There are recorded cases of acute diabetes developing during mumps and enterovirus infections. And there is significant evidence linking one particular enterovirus, Coxsackie-B1, with classical autoimmune type 1 diabetes. In addition, The Environmental Determinants of Diabetes in the Young (TEDDY) study from the US and Europe documented an increased risk of developing signs of islet cell autoimmunity after respiratory infections caught in the winter months.
- What about C19? There has been a case report from China of a young man of previous good health presenting with new-onset, severe diabetes, termed keto-acidosis, after contracting C19.
- Before the C19 pandemic, east Asia experienced the Sars outbreak (2002-04), which was also caused by a coronavirus. There were documented cases of acute onset diabetes in people with Sars pneumonia, which was not seen in those with pneumonia of other causes. In most cases, diabetes resolved after three years, but it persisted in 10% of patients.
- The coronaviruses responsible for the current and previous outbreaks share a similar way of getting into cells. The now-familiar protein spikes on the surface of the virus attach to ACE2 receptors are abundant in lung, kidney and islet cells in the pancreas. It is proposed that once in islets, C19 disrupts normal cell function leading to abnormalities in the pathways that maintain blood glucose through insulin secretion. It is also possible that cell invasion leads to acute inflammation that kills islet cells.
- So does C19 cause diabetes? The answer is, we don’t know, and the NEJM letter makes it clear that a lot of this is still conjecture. C19 may trigger type 1 or type 2 diabetes. This might even be a new form of diabetes.
- Unlike the wealth of data presented on the risk of death with known diabetes, severe obesity, high blood pressure, and ethnicity, there is little data on C19 and newly diagnosed diabetes. To address this, the authors of the NEJM letter have developed a register to record all Covid-related diabetes cases.
- A register is essential to gather enough data to start unraveling the mystery of any direct link between C19 and diabetes. And if such a link is found, it will be equally important to determine how C19 causes the damage to best identify treatments, given that C19 may be around for quite some time yet.
2. C19 may cause brain complications
- Brain complications, including stroke and psychosis, have been linked to C19 in a study that raises concerns about the potentially extensive impact of the disease in some patients.
- The study is small and based on doctors’ observations, so cannot provide a clear overall picture about the rate of such complications. However, medical experts say the findings highlight the need to investigate the possible effects of C19 in the brain and studies to explore potential treatments.
- “There have been growing reports of an association between C19 infection and possible neurological or psychiatric complications, but until now these have typically been limited to studies of 10 patients or fewer,” said Benedict Michael, the lead author of the study, from the University of Liverpool. “Ours is the first nationwide study of neurological complications associated with C19, but it is important to note that it is focused on cases that are severe enough to require hospitalisation.”
- Scientists said the findings were an important snapshot of potential complications, but should be treated with caution as it is not possible to draw any conclusions from the data about the prevalence of such complications.
- The study, published in the journal Lancet Psychiatry, focused on patients treated in UK hospitals during the exponential phase of the C19 pandemic in April. Michael and colleagues asked specialist doctors to report clinical details of C19 patients, who were experiencing a range of neurological and psychiatric complications that were potentially linked to the disease.
- Of the 125 cases reported in detail, the most common brain complication observed was stroke, which was reported in 77 patients. Of these, 57 patients had a stroke caused by a blood clot in the brain, known as an ischaemic stroke, nine patients had a stroke caused by a brain haemorrhage, and one patient had a stroke caused by inflammation in the blood vessels of the brain. Previously, C19 has been found, in some patients, to cause severe inflammation and blood clots in the lungs and elsewhere in the body.
- A further 39 patients showed signs of confusion or changes in behaviour reflecting an altered mental state, with seven of these having inflammation of the brain, medically termed encephalitis. The remaining 23 patients with an altered mental state were diagnosed with psychiatric conditions, including psychosis, a dementia-like syndrome and mood disorders. Although most psychiatric diagnoses were recorded as new, the researchers say they cannot exclude the possibility that these were undiagnosed before the patient developed C19.
- Michael Sharpe, a professor of psychological medicine at the University of Oxford, said: “This report describes often striking cases of neurological and psychiatric illness as being sometimes associated with severe C19 in hospitalised patients. It reminds us that C19 is more than a respiratory infection and that we need to consider its link to a variety of other illnesses.”
- However, he added, further research was needed to rule out the possibility that the illnesses were simply co-occurring with C19 rather than caused by it. “At present people in the general population should not worry too much about these possibly associated illnesses as they are probably relatively rare in those who become infected with this coronavirus,” he said.
- Dame prof Til Wykes, vice dean psychology and systems sciences at King’s College London, said that there was an awareness that there have been mental health problems associated with the pandemic, due to indirect impacts of the virus. “We thought that these problems would just be increases in anxiety and depression but clearly there is a possibility that a small number of people may experience a first episode of psychosis following hospitalisation with severe C19 – 8% of the total cases reported in this paper,” she said.
- Study: Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study
3. The list of who’s most at risk for severe cases just got longer
- The older you are, the greater your risk of suffering a severe case of C19, according to new guidance from the CDC.
- The CDC has previously warned that people over 65 were especially vulnerable to severe illness if they became infected by the coronavirus. And that is still true.
- But more recent data from across the United States shows that younger adults are also at risk and should not assume they will be spared from a serious case of the disease.
- “CDC now warns that among adults, risk increases steadily as you age, and it’s not just those over the age of 65 who are at increased risk for severe illness,” the agency warned Thursday. “Age is an independent risk factor for severe illness.”
- Data published last week in the CDC’s Morbidity and Mortality Weekly Report revealed that the median age of Americans with confirmed coronavirus cases was 48 years old. That means half of those infected were older than 48 and half were younger.
- In fact, among more than 1.3 million cases reported through May 30, the incidence was higher among people in their 40s and 50s than for those in their 60s and 70s. Specifically, there were 541.6 cases per 100,000 people ages 40-49 and 550.5 cases per 100,000 people ages 50-59, compared with 478.4 cases per 100,000 people ages 60-69 and 464.2 cases per 100,000 people ages 70-79. [NOTE: The fact that younger people are being infected at greater rates than the elderly is that the elderly are practicing greater caution and social distancing than the younger age groups.]
- The highest incidence was seen in the oldest Americans, with 902 cases per 100,000 people ages 80 and up, according to the report.
- Among those who become infected with the coronavirus, the risk of dying from C19 increases sharply with age, the latest data show. Although the overall mortality rate for those 1.3 million cases was 5.4%, it was 1% or lower for Americans under 50. However, it was 2.4% for those in their 50s, 6.7% for those in their 60s, 16.6% for those in their 70s and 28.7% for those 80 and up.
- The risk of being hospitalized for C19 was slightly higher for people in their 70s (34.1% of those infected) than for those who had passed their 80th birthday (32.5%). Similarly, the risk of being admitted to an intensive care unit was higher for those in their 60s (4.1%) and 70s (5.6%) than for those 80 and above (3.6%).
- The new CDC statement also updated the list of underlying health conditions that are associated with an increased risk of a severe case of C19. The most common is obesity, a condition that affects 42.5% of adults in the U.S. (Obesity is defined as having a body mass index of 30 or greater. You can check yours online.)
- The estimated 14% of U.S. adults who have chronic kidney disease are also more vulnerable to a severe case of C19, as are the roughly 12% of U.S. adults with type 2 diabetes, according to the CDC’s new guidance.
- Other medical conditions that increase the risk for severe C19 illness include serious heart conditions like coronary artery disease and heart failure; chronic obstructive pulmonary disease; sickle cell disease, and taking drugs that suppress the immune system after receiving an organ transplant.
- There is “consistent evidence” in reliable medical studies that each of these conditions is associated with an increased risk of developing a severe case of C19. And when combined, the risk is even greater.
- “The more underlying medical conditions people have, the higher their risk,” the CDC said.
- The agency also updated its list of conditions that might belong on that list and could be added as researchers learn more about C19. These include:
- Moderate or severe asthma
- Cerebrovascular disease, which affects the blood vessels that supply the brain
- Cystic fibrosis
- High blood pressure
- Being immunocompromised as a result of a bone marrow transplant, HIV infection or another reason besides an organ transplant
- Dementia and other neurologic conditions
- Liver disease
- Pulmonary fibrosis
- Thalassemia, a disorder that reduces the amount of oxygen carried by red blood cells
- Type 1 diabetes
4. C19 attacks like no other ‘respiratory’ infection
- The reports seemed to take doctors by surprise: The “respiratory” virus that causes C19 made some patients nauseous. It left others unable to smell. In some, it caused acute kidney injury.
- As the pandemic grew from an outbreak affecting thousands in Wuhan, China, to some 10 million cases and 500,000 deaths globally as of late June, the list of symptoms has also exploded. The CDC constantly scrambled to update its list in an effort to help clinicians identify likely cases, a crucial diagnostic aid at a time when swab tests were in short supply and typically took (and still take) days to return results. The loss of a sense of smell made the list only in late April.
- “For many diseases, it can take years before we fully characterize the different ways that it affects people,” said nephrologist Dan Negoianu of Penn Medicine. “Even now, we are still very early in the process of understanding this disease.”
- What they are understanding is that this coronavirus “has such a diversity of effects on so many different organs, it keeps us up at night,” said Thomas McGinn, deputy physician in chief at Northwell Health and director of the Feinstein Institutes for Medical Research. “It’s amazing how many different ways it affects the body.”
- One early hint that that would be the case came in late January, when scientists in China identified one of the two receptors by which the coronavirus enters cells. It was the same gateway, called the ACE2 receptor, that the original SARS virus used. Studies going back some two decades had mapped the body’s ACE2 receptors, showing that they’re in cells that line the insides of blood vessels — in what are called vascular endothelial cells — in cells of the kidney’s tubules, in the gastrointestinal tract, and even in the testes.
- Given that, it’s not clear why the new coronavirus’ ability to wreak havoc from head to toe came as a surprise to clinicians. Since “ACE2 is also the receptor for SARS, its expression in other organs and cell types has been well-known,” said Anirban Maitra of MD Anderson Cancer Center, who led a study mapping the receptor in cells of the GI tract. (Maitra is an expert in pancreatic cancer and, like many scientists this year, added C19 to his research.)
- Infecting cells is only the first way the coronavirus wreaks havoc. Patients with severe C19 also suffer a runaway inflammatory response and, often, clot formation, said infectious disease physician Rochelle Walensky of Massachusetts General Hospital. That can cause symptoms as different as a lack of blood flow to the intestines and the red, inflamed “Covid toe.”
- “We’ve had five cases of patients who’ve had to have their gut removed,” Walensky said. “You see these cases and you say, wait a minute; the virus is doing this, too? It has definitely been keeping us on our toes.”
- Venky Soundararajan had a hunch that the extent of ACE2 distribution throughout the body was lying in plain sight. The co-founder and chief scientific officer of nference, which uses artificial intelligence to mine existing knowledge, he and his colleagues turned their system into a hunt for ACE2 knowledge. Combing 100 million biomedical documents from published papers to genomic and other -omics databases, they uncovered multiple tissues and cell types with ACE2 receptors, they reported last month in the journal eLife.
- They also calculated what percent of each cell type expresses “reasonable amounts” of ACE2, Soundararajan said. On average, about 40% of kidney tubule cells do, and in a surprise for a “respiratory” virus, cells in the GI tract were “the strongest expressors of ACE2 receptors,” he said.
- The data mining found that ACE2 is also expressed in the nose’s olfactory cells. That’s not a new finding per se — the nference system found it in existing databases, after all — but it hadn’t been appreciated by scientists or clinicians. It explains the loss or altered sense of smell that C19 patients experience. Its importance became clear earlier this month, when scientists at the Mayo Clinic and nference reported that loss of a sense of smell is “the earliest signature of C19,” appearing days before a positive swab test.
- That study, using health records of 77,167 people tested for C19, showed how the assumption that infection would first and foremost cause respiratory symptoms was misplaced. In the week before they were diagnosed, C19 patients were 27 times more likely than people who tested negative for the virus to have lost their sense of smell. They were only 2.6 times more likely to have fever or chills, 2.2 times more likely to have trouble breathing or to be coughing, and twice as likely to have muscle aches. For months, government guidelines kept people not experiencing such typical signs of a respiratory infection from getting tested.
- Faced with a disease the world had never seen before, physicians are learning as they go. By following the trail of ACE2 receptors, they are more and more prepared to look for, and treat, consequences of the coronavirus infection well beyond the obvious:
- The coronavirus infects cells that line the inside of the large and small intestine, called gut enterocytes. That likely accounts for the diarrhea, nausea, and abdominal pain that about one-third of C19 patients experience, said MD Anderson’s Maitra: “The GI symptoms reflect physiological [dysfunction] of cells of the lower GI tract.”
- Why don’t all patients have GI symptoms — or indeed, the whole panoply of symptoms suggested by the near ubiquity of ACE2 receptors? For those with mild to moderate C19, “the infectious load in the GI tract may simply not be sufficient to cause symptoms,” Maitra said.
- The cells lining the tubules that filter out toxic compounds from the blood are rife with ACE2 receptors. Last month, scientists studying 1,000 C19 patients at a New York City hospital reported that 78% of those in intensive care developed acute kidney injury.
- An analysis of 24 studies with data from 8,438 C19 patients from 13 countries found this month that 41% had lost their sense of taste or smell, or both.
- That shouldn’t be surprising, said Fabio Ferreli of Humanitas University in Milan: “Perhaps the highest levels of ACE2 receptors are expressed in cells in the nasal epithelium.” The sensory loss isn’t due to nasal inflammation, swelling, or congestion, he said, “but to direct damage” to these epithelial cells. Loss of smell also impacts taste, but the virus may also have a direct effect on taste: The nference analysis found high levels of the ACE2 gene in tongue cells called keratinocytes, which contribute to the sense of taste.
- There is another implication of the high expression of ACE2 in olfactory epithelium cells, scientists at Johns Hopkins concluded in a paper posted to the preprint site bioRxiv last month: ACE2 levels in the olfactory epithelium of the upper airways that are 200 to 700 times higher than in the lower airways might explain the virus’s high transmissibility. It was weeks before experts recognized that the virus could spread from person to person.
- This is where a respiratory virus should strike, and the coronavirus does. The lungs’ type II alveolar cells — among other jobs, they release a compound that allows the lungs to pass oxygen to the blood and take carbon dioxide from it — are studded with ACE2 receptors.
- Once infected with the coronavirus, they become dysfunctional or die, and are so swarmed by immune cells that this inflammatory response can explode into the acute respiratory distress syndrome (ARDS) that strikes many patients with severe C19, Walensky said.
- There is new evidence that the virus also attacks platelet-producing cells, called megakaryocytes, in the lungs. In a study published on Thursday, pathologist Amy Rapkiewicz of NYU Winthrop Hospital found something she had “never seen before”: extensive clotting in the veins and other small blood vessels of patients’ hearts, kidneys, liver, and lungs. She suspects that the platelets produced by infected megakaryocytes travel through the bloodstream to multiple organs, damaging their vasculature and producing potentially fatal clots. “You see that and you say, wow, this is not just a ‘respiratory’ virus,’” Rapkiewicz said.
- In April, scientists in China reported that there was higher expression of the gene for ACE2 in the pancreas than in the lungs. Genetic data are an indirect measure of ACE2 receptors themselves, but could have been a tip-off to physicians to monitor patients for symptoms there. As it happens, the Chinese researchers also found blood markers for pancreas damage in C19 patients, including in about 17% of those with severe disease.
- Patients with severe C19 have a high incidence of cardiac arrests and arrhythmias, scientists at the Perelman School of Medicine at the University of Pennsylvania recently found. That’s likely due to an extreme inflammatory response, but there might be more direct effects of the coronavirus, too.
- A large team of European researchers reported in April that arrhythmia (including atrial fibrillation), heart injury, and even heart failure and pulmonary embolism might reflect the fact that ACE2 receptors are highly expressed in cells along the inside walls of capillaries.
- When these “vascular endothelial” cells become infected, the resulting damage can cause clots, MGH’s Walensky said, which in turn can cause Covid toe, strokes, and ischemic bowel (too little blood flow to the gut). Studies from around the world suggest that 7% to 31% of C19 patients experience some sort of cardiac injury.
- Specialized cells in this organ, too, have high levels of ACE2 receptors. Damage to the gallbladder (like the pancreas) can cause digestive symptoms.
- With the number of C19 patients closing in on 10 million, physicians fervently hope the virus has no more surprises in store. But they’re not counting on it.
- “I’ve seen patients every day during this crisis,” said Northwell’s McGinn. “There have been times when I’ve said, wait, the virus can’t do anything new — and then there’s a young woman with a stroke or an older man with myocarditis,” inflammation of the heart muscle. “I keep thinking I’m going to run out of material” for the teaching videos he does on C19, “but it hasn’t happened.”
F. The Road Back?
1. Safer reopenings require millions more C19 tests per day. One solution: ‘pool testing’
- If the country wants to crank up its C19 testing capacity into the millions — the range that could be required for safer reopenings of businesses and universities — experts say it’s time to ramp up a technique known as “pool testing.”
- It’s a simple construct: combine — or pool — samples from multiple people and test them as a group for the coronavirus. It’s a way to dramatically and efficiently increase volume, to churn through what you expect to be a lot of negative samples at a fast clip.
- “Pooling would give us the capacity to go from a half a million tests a day to potentially 5 million individuals tested per day,” Deborah Birx, who is helping lead the White House’s coronavirus response, told an American Society for Microbiology virtual conference this week.
- Despite progress after a notoriously fumbled rollout, the U.S. testing landscape continues to face challenges. There remain shortages of swabs and reagents; machines can’t keep up with demand as local outbreaks increase; and some places lack adequate testing sites. Those will have to be addressed in order for testing capacity to expand to the levels experts say is necessary to allow people to return to work and keep the virus at bay.
- Pool testing isn’t meant to verify whether or not a person has C19, the way an individual diagnostic test does.
- Rather, it’s part of a broader disease surveillance strategy, one that allows for regular screening of people who are not experiencing C19 symptoms. Testing asymptomatic people is important because a large portion of people with the coronavirus either show no symptoms or take a few days to start feeling sick, but they can still spread the virus.
- Take a warehouse with 100 employees. Every so often (experts are still weighing how frequently this testing should occur), the company could test the staff, and instead of running 100 separate analyses, it could group 10 samples into a pool and only run 10 analyses.
- “You could test everyone as they walk into the door,” said Paul Sax, an infectious disease specialist at Brigham and Women’s Hospital, who has written about the challenges of returning to work during the pandemic.
- If one of those pools came back positive, those 10 employees could be retested individually to see who was infected and could remain out of work in the interim. The 90 other employees, in the pools that tested negative, wouldn’t need to be retested. The goal would be to try to detect a case before the person potentially spread the coronavirus to others. Scientists are increasingly finding that such large-scale superspreading events at workplaces, restaurants and bars, and places of worship are driving a large amount of transmission.
- Identifying asymptomatic and presymptomatic people could also enable a more aggressive contact tracing approach, Birx said in her talk this week.
- Beyond workplaces and universities, regularly testing groups of people in a given community could also provide a harbinger of increased spread if suddenly a higher portion of pools came back positive. That could serve as an early signal to local officials that they may need to increase distancing strategies, before hospitalizations started to increase.
- “It allows you to test more frequently in a population that may have a low prevalence of disease,” said Benjamin Pinsky, the medical director of Stanford’s Clinical Virology Laboratory, who has led pooling studies for the coronavirus. “That would allow you to test a lot of negatives, but also identify individuals who are then infected, before they develop symptoms.”
- As Pinsky noted, pooling only makes sense in places with low rates of C19 where you expect the large majority of tests to be negative; otherwise, too many of the pools would come back positive for it to work as a useful surveillance tool.
- “You wouldn’t want to be doing it right now in Texas, but you could do it in Massachusetts,” Sax said. Texas this week has been reporting record levels of new cases — several thousand each day; Massachusetts, meanwhile, reported 226 on Thursday and has been trending downward.
- Pool testing relies on the same PCR technology as individual diagnostic tests. The number of people’s samples that can be grouped together depends on which machine is running the test, but scientists say that up to 10 samples could be pooled in some cases. (These are different from the rapid, point-of-care tests that researchers hope to roll out in the coming months. Results from pool testing could still take hours to days, depending on the demand on local labs.)
- For all the advantages in efficiency that pooling offers, there is a downside: It increases the risk of a false negative. That is, if someone does have the virus, the viral level in that individual sample will be diluted when combined with other samples, perhaps to the point where the machine can no longer detect it.
- “The goal is to increase the capacity of testing in a relatively straightforward fashion,” Pinsky said. “The caveat is that by pooling the sample, you’re going to reduce the sensitivity of the test.”
- One way to compensate for that risk of false negatives is to conduct testing frequently, experts say.
- The Food and Drug Administration recently released guidance describing what labs need to do to validate their pooling strategies and is sponsoring its own validation studies, Brett Giroir, an assistant health secretary who has served as the Trump administration’s point person for testing, said on a call with reporters this week.
2. Going Up? Not So Fast: Strict New Rules to Govern Elevator Culture
- Kiss the elevator pitch goodbye — at least if it takes place in an elevator.
- Change is coming to the daily vertical commute, as workers begin to return to tall office buildings in New York and other cities. The elevator ride, a previously unremarkable 90 or so seconds, has become a daunting puzzler in the calculus of how to bring people back to work safely after the coronavirus pandemic kept them home for months.
- Employers and building managers are drafting strict rules for going up: severe limits on the number of riders (four seems to be the new magic number), designated standing spots to maximize social distance, mandatory masks, required forward-facing positions — and no talking.
- Some companies are hiring “elevator consultants” to figure how best to get thousands of people to their desks, balancing risk of elevator density against a potential logjam as riders wait — at least six feet apart — for their turn.
- Reflecting the widespread interest and concern, the Centers for Disease Control and Prevention plans to weigh in as early as next week with guidance for elevators and escalators. For escalators, it will advise one rider every other step and hand sanitizer at the top. For elevators, it will recommend limiting the number of riders but won’t specify a number; arrows showing different paths to get on and get off; masks; and signs urging people to “not talk unless you have to,” said Nancy Clark Burton, a senior industrial hygienist at the C.D.C. who is part of the group developing the new guidance.
- The changes are the result of clear science. C19 is most transmittable when people are in tight confines, particularly indoor settings, where invisible droplets can travel from one person to the next, collateral damage of a seemingly innocuous conversation.
- “The good news is: If you don’t like small talk in the elevator, those days are over,” said Jonathan Woloshin, head of U.S. real estate at UBS Global Wealth Management’s chief investment office, who has spoken to executives from major companies rethinking elevator policy and technology, including the eventual use of elevators called by voice command or app.
- Richard Corsi, dean of engineering and computer science at Portland State University, has calculated how much virus would remain in an elevator if an infected person rode 10 floors, coughing once and talking on a smartphone. After exiting the elevator — an act that released some of that person’s emissions from the elevator — approximately 25 percent of the person’s discharge would remain by the time the empty elevator returned to the first floor, he estimated.
- Given all the unknowns with the coronavirus — like how much is needed to cause illness and how much of the aerosol would spread to another rider’s lungs — Dr. Corsi couldn’t determine the likelihood of transmission. But he said that the excretion from an infected person not wearing a mask would make an elevator far riskier than, say, standing in much less confined space, for the same amount of time, even indoors — “100 to 1,000 times more particles per liter of air,” he estimated.
- His counsel?
- “Standing as far as way as you can diagonally in elevator would be good, and do not speak,” he said.
- “That needs to be part of new etiquette,” he added. “They should put big signs on the elevator: Do Not Speak.”
- Part of the challenge is that commercial elevator dimensions, while they vary, aren’t built for social distancing; to meet most state standards, an elevator should be 51 inches deep and 68 inches wide (4 feet 3 inches by roughly 5 feet 8 inches), according to Stanley Elevator Company. Even many larger elevators won’t leave riders six feet apart.
- “More like three to four feet,” said Douglas Linde, president of Boston Properties, which owns such landmark buildings as the Prudential Tower in Boston, General Motors Building in New York City and Salesforce Tower in San Francisco. “But, again, you have a mask on and you’re not speaking to each other.”
- Mr. Linde said Boston Properties retained consulting services from Joseph Allen, a Harvard University assistant professor, who specializes in indoor environmental quality, and experts in managing elevator traffic. They helped work out a math problem: What should the limit on elevator capacity be so as not to create a traffic jam in the lobby for those waiting to ride?
- The consultants figured four could be a reliable limit even in the tallest buildings, so long as total building occupancy remained below 60 percent. Otherwise, people will have to wait too long.
- Mr. Linde said that assuming less than 60 percent occupancy seemed reasonable, given that some cities weren’t allowing full occupancy in buildings yet and that many companies continued to allow or encourage working from home.
- But some companies are taking issue with the limits on the number of riders, arguing that they test patience and promise more safety than can be guaranteed.
- “I can’t give you the six feet in an elevator — you’d have to have someone on the ceiling and someone on the floor,” said Andrew Hardy, head of operations at JEMB Realty, a privately held company that owns and operates residential and commercial properties, including Resorts Casino Hotel in Atlantic City, a retail space in Herald Square and a 33-story commercial building in the financial district in New York.
- “Our sign is going to say, ‘When riding elevators we recommend using your best judgment,’” Mr. Hardy said. “If an elevator comes and two or three people are in it and you feel comfortable, you’ll get in, and if you don’t feel comfortable, wait for the next one.”
- “If I put two circles in an elevator and four people get in, what am I going to do, arrest these people?”
- The campaign to make the elevator safe reflects in part the new economic reality of commercial real estate, which has seen its fortunes flipped by the coronavirus. Many companies are reviewing whether they need pricey downtown offices if employees can work from home, so landlords are working to make their buildings feel as safe and welcoming as possible.
- JEMB Realty is building a new commercial high-rise in Brooklyn that will have new elevator technology: a key card or fob that allows tenants through a turnstile and automatically calls an elevator to take them to their floors. Mr. Hardy said that technology was planned before C19, but others said the touchless elevator would become much more common now.
- There’s only so much, though, that can be done with elevators. Some buildings are opening stairwells, including those run by CBRE, one of the world’s largest commercial real estate operators. Some are asking tenants to stagger employee start times.
- “Imagine if you have a 30-story office building in New York City and you’re trying to get 5,000 people in between 7 and 9 in the morning,” said Brian Jennings, CBRE’s managing director of business operations in the Americas, who said elevator safety ranked as a top five concern among clients.
- Other ideas include better air ventilation, use of ultraviolet lighting to kill germs, and antimicrobial surfaces, said Prof. Lee Gray, an elevator historian from the University of North Carolina at Charlotte and correspondent for Elevator World Magazine. He said the density in elevators hadn’t face such a challenge since 1918, when elevators weren’t touched by riders at all but by an attendant.
- Today, the challenge is more widespread.
- “I can’t think of anything comparable to this,” he said. “This is the world’s smallest room and I don’t want to be in there with someone else.”
3. Gyms Reopening May Not Spread Coronavirus
- European countries that have allowed gyms to reopen have reported no uptick in coronavirus infections, suggesting fitness studios might be relatively safe.
- A study sponsored by the Norwegian government and published this week provided the latest indication that with certain hygiene rules, people who exercise at the gym might not be at a higher risk of infection than those who don’t.
- Fitness facilities in the Nordic country reopened June 15. Germany and Austria have gradually reopened gyms since May, after policy makers there decided that the benefits of exercising outweighed concerns about contracting C19.
- So far, no major outbreak has been linked to gyms, pools and other indoor sport venues, which are all subject to heightened hygiene and distancing guidelines.
- The Norwegian study showed that gyms were safe if rules were enforced. The study conducted by researchers from the University of Oslo and other research institutions hasn’t yet been peer-reviewed for publication in a scientific journal.
- The study, conducted over two weeks in May, randomly selected 3,764 individuals aged 18 to 64 from the capital Oslo, of which 1,896 were asked to train in gyms while 1,868 didn’t and served as a control group.
- In the gym-going group, 81.8% visited at least once and 38.5% went six times or more. Out of 3,016 participants who were then tested for C19, only one was positive. It was determined that this person had become infected at work.
- The subjects were required to follow hygiene rules and stay two meters from others during high-intensity training. They weren’t allowed to use the showers at the gyms. No masks were required.
- “The results of the study are applicable to other areas of the world such as the U.S. or the U.K,” said Prof. Michael Bretthauer, one of the authors of the study.
- Mr. Bretthauer said he had expected more people to test positive. The overall rate of coronavirus infections in Oslo was 3.5 per 100,000 inhabitants in the first week of the study and 11.7 in the second week.
- “You should be very strict with the measures like distance and hygiene; in Norway, people complied with the measures rigorously,” Mr. Bretthauer said.
- A spokeswoman for the Norwegian government said that the decision to open the gyms was guided by studies and empirical evidence, as well as by the premise that a lack of exercise could be detrimental to public health.
- In most of Germany, gym members must keep a minimum distance of 1.5 meters (4.9 feet) from each other and facilities are frequently disinfected. High-intensity training, such as indoors cycling, is prohibited in some German states due to the higher release of tiny particles through heavy breathing that could linger and infect others in closed rooms for hours.
- Exercising indoors is riskier than outdoors, but if distancing and hygiene rules are observed, gyms are safe to use, said Professor Andreas Dotzauer, a virologist with the University of Bremen in Germany.
- In Austria, where similar rules are in place, authorities haven’t registered any spread of the virus in fitness centers, according to a government spokesman.
- [NOTE: This is an interesting study but we urge caution. If you attend a gym in an area that has a rate of infectivity, your risk of infection is likely to increase.]
G. Back to School!?
1. Colleges Spend Millions to Prepare to Reopen Amid Coronavirus
- As colleges around the country map out plans to reopen their campuses in the fall, they have embarked on some unique and pricey shopping expeditions: sourcing miles of plexiglass, hundreds of thousands of face masks and, in the case of the University of Central Florida, trying to get in an order for 1,200 hand-sanitizer stations before neighboring theme parks could buy them all up.
- Costs for protective gear, cleaning supplies and labor for employees to take students’ temperatures and conduct hourly wipe-downs of doorknobs are already running into the millions of dollars.
- The added expenses come as many schools face severe budget crunches due to lower enrollment and tuition revenue, refunded housing fees from the spring and costs tied to shifting online. Even well-resourced schools are trying to fundraise to stock up on supplies.
- Reopening college campuses is contingent on approval from local health officials, who in some states haven’t yet signed off on campus-based instruction. Still, many schools remain hopeful and are pushing ahead with planning, with some already bringing student-athletes back for voluntary workouts.
- In Florida, one of the first states to reopen for business during the coronavirus pandemic, the University of Central Florida in Orlando will issue one reusable, washable face covering each to all students, faculty and staff—about 100,000 items. The school ordered another 250,000 disposable masks for visitors and those who forget their face coverings. The bill for masks was $309,000.
- The school, which had 69,500 students last year and expects about 30% of classes to be taught face-to-face this fall, spent another $491,000 on 1,200 touchless hand-sanitizer dispensers, 600 stations for disinfecting-wipe dispensers and many thousands of refills.
- One challenge is that officials don’t know how soon they will have to reorder supplies and if the products will be available when needed. “We have no historical trending to know how far those will go,” said Vice President and Chief Operating Officer Misty Shepherd.
- Other big-ticket items for Central Florida include $500,000 to upgrade ventilation systems with ultraviolet lighting that can help kill bacteria. It will spend $600,000 to retrofit doors with motion-sensor technology or foot-operated openers and to install $54-apiece plexiglass panels in the welcome center, student advising office and other high-traffic areas where social distancing isn’t really possible.The school is also budgeting an extra $3 million for labor and materials costs tied to increased cleaning of common areas, elevator buttons, door handles and bathrooms.
- Chapman University in Orange, Calif., put the price tag for all its extra precautions and gear at $8.3 million. That includes $1.65 million to contract with Laboratory Corp. of America Holdings for mass testing, $350,000 for upgraded heating, ventilation and air-conditioning equipment, and $260,000 for all 8,500 students to get three washable masks with the Chapman logo. Hundreds of thousands of dollars will likely be needed for infrared technology that can detect potentially feverish people entering high-traffic areas like the library, where it is not practical to take every person’s temperature with a forehead thermometer. The school is still getting price estimates for that technology.
- The reopening costs hit Chapman as the school is anticipating financial strain, including expecting its student body to be about 10% smaller than normal. It is staring down a $57 million budget gap.
- President Daniele Struppa and Harold Hewitt Jr., the executive vice president and chief operating officer, have filled that budget hole by restricting travel, cutting senior-staff pay, freezing new hiring and stalling some capital projects. If Orange County health officials don’t authorize reopening for fall term, Mr. Hewitt said, “We will have to revisit that concept fundamentally” and make more dramatic cuts, though expenses would also be lower.
- Chapman also landed a $1 million unsolicited gift from a parent for tests and masks and is looking to raise another $2 million off that.
- Purdue University in Indiana has budgeted $50 million for safety materials and measures, including buying 5 miles of plexiglass to date to help protect faculty in classrooms.
- “We’re going to try to leave nothing to chance,” President Mitch Daniels said at a Senate hearing earlier this month.
- To help buy supplies, Purdue created a dedicated fundraising campaign for protective gear. A donation of $62.50 can buy one student protection kit with masks, sanitizer, wipes and a thermometer, while $1,250 will get 50 antibody tests.
- It had raised more than $214,000 from nearly 800 donors as of early Wednesday, according to the crowdfunding website.
- “You can help us protect our students, student-athletes, faculty, staff, residences and facilities by making a gift to support the Protect Purdue Initiative,” Mr. Daniels says in a video promoting the campaign. “Together, we can make Purdue safe.”
H. Johns Hopkins C19 Update
June 23, 2020
1. Cases & Trends
- The WHO COVID-19 Situation Report for June 25 reports 9.30 million cases (167,056 new) and 479,133 deaths (5,336 new). This is the third highest global daily incidence to date, continuing on pace to reach 10 million cumulative cases by the middle of next week. The global deaths could reach 500,000 by the middle of next week as well. The global daily incidence continues to increase, and the pandemic is again growing exponentially.
- While Mexico has not received the same level of attention as other countries in the Americas, including Brazil and the United States, its recent increased incidence is a major cause for concern, particularly considering Mexico’s role as a travel and trade partner. While the epicenter of Mexico’s epidemic is its capital, Mexico City, every state has experienced increased incidence, ranging from 23% and 63% higher incidence from June 6 to June 21.
- Mexico’s healthcare system, hindered by resource shortages and an aging infrastructure, has struggled to support a large population with underlying health conditions that elevate individuals’ risk of severe C19 disease and death, such as diabetes and hypertension. Mexico initially resisted implementing large-scale social distancing restrictions or recommending widespread use of face masks.
- Additionally, broad mistrust in the government drove many to ignore recommended protective measures when they were eventually implemented. At one of the region’s largest food markets, the Central de Abasto market in Mexico City, a major C19 outbreak spread among vendors and customers before the government sent in health workers to check temperatures and offer testing. The market provides the city with approximately 80% of its produce and is also vital for the food supply chain to other Mexican states. Reportedly many vendors did not view C19 as a major threat until cases and deaths began to be reported at the market.
- Mexican health authorities deployed more than 400 personnel to conduct epidemiological investigations, screen and test vendors and patrons, and promote improved sanitation and hygiene, including the use of hand sanitizer. It is unclear exactly how many cases and deaths are linked to the market outbreak, but one report indicates that more than 500 cases have tested positive and dozens have died. Unlike some affected markets in other countries, the market remained operational during the outbreak. Despite many workers visibly falling ill or dying, others kept working, with many citing financial stress as a major factor in their decision.
India, Pakistan & Bangladesh
- India reported 17,296 new cases, setting a new high daily incidence for the third consecutive day. India’s daily incidence has increased by more than 70% since June 11, and its epidemic continues to accelerate. India is currently #3 in terms of daily incidence.
- Pakistan appears to have passed its first peak—6,825 new cases on June 13—and its daily incidence has decreased by nearly 60% since then, down to 2,775 new cases yesterday (its lowest daily total since May 29). Pakistan fell to #10 globally in terms of daily incidence.
- Following several days of slightly lower daily incidence, Bangladesh reported its second and third highest daily totals over the past 2 days, 3,946 and 3,868 new cases, respectively. Notably, Bangladesh’s test positivity continues to hold steady at slightly greater than 20%, which is considerably higher than the WHO’s 5% benchmark for relaxing social distancing measures. Bangladesh remains at #9 globally in terms of daily incidence.
Central & South America
- Brazil reported 39,483 new cases. Brazil has reported its second, third, and fourth highest daily totals over the past 3 days. The only higher daily incidence was reported on June 19, which was elevated due to reporting delays from the previous day. It appears that Brazil’s epidemic continues to accelerate. Brazil is currently #1 globally in terms of daily incidence, but the US daily C19 incidence is increasing rapidly as well. Mexico reported 5,943 new cases, recording its highest daily incidence for the third consecutive day. Mexico continues to report increasing daily incidence and remains #5 globally.
- Broadly, the Central and South American regions are still a major C19 hotspot. Including Brazil and Mexico, the region represents 6 of the top 14 countries globally in terms of daily incidence, including:
- Peru (#7) Chile (#8), Colombia (#12), and Argentina (#14)—and 5 of the top 15 in terms of per capita daily incidence—Chile (#5), Brazil (#7), Panama (#8), Peru (#10), and Bolivia (#15).
Eastern Mediterranean Region
- Iran reported 2,628 new cases, holding relatively consistent with other recent reports. Since its second peak on June 5, Iran has reported approximately 2,300-2,500 new cases per day. Iran remains #13 globally in terms of daily incidence.
- Overall, the Eastern Mediterranean Region remains a global hotspot, representing 5 of the top 13 countries in terms of per capita incidence: Qatar (#1), Bahrain (#2), Oman (#4), Kuwait (#6), and Saudi Arabia (#13). Additionally, nearby Armenia is #3. The region also includes several notable countries in terms of total daily incidence. In addition to Iran and Pakistan, Saudi Arabia is #11, and several other countries in the region are reporting more than 1,000 new cases per day.
- A number of countries in Africa are reporting substantial increases in C19 incidence as well. In terms of biweekly growth rate—the relative change between the number of cases reported over the past 2 weeks and the 2 weeks prior to that—at least 21 countries are reporting a 50% or more increase, including 14 countries reporting more than a 100% increase. Many of these countries are currently reporting relatively low incidence, so even small absolute changes in daily incidence can be large proportionate changes.
- A number of the countries discussed above—including multiple countries in the Eastern Europe, Eastern European, and Central and South American regions—are reporting large relative increases as well.
- Additionally, Africa’s relative contribution to the daily global incidence continues to increase. Africa now represents approximately 6-7% of the global daily total, nearly equal to Europe (8-10%). South Africa is among the top countries globally in terms of both per capita (#12) and total daily incidence (#6).
- The US CDC reported 2.37 million total cases (37,667 new) and 121,809 deaths (692 new). This is the United States’ second highest daily incidence to date. The US record was reported on April 7 (43,438 new cases), which may have been elevated as a result of reporting delays over the Easter holiday weekend. The CDC has reported more than 25,000 new cases for 7 consecutive days, and 8 out of the last 9 days. Prior to that, the national daily incidence exceeded 25,000 cases only 3 times between June 1 and June 15.
- In total, 18 states (no change) and New York City reported more than 40,000 total cases, including New York City with more than 200,000; California and New York state with more than 175,000; New Jersey with more than 150,000; and Illinois and Texas more than 125,000. Following an overall decrease in daily incidence from mid-April through the end of May, the United States’ national C19 incidence is clearly increasing.
- The New York Times reported that the national daily incidence (weekly average; based on state-level reporting) set a new record this week, surpassing the first peak in April with no sign of slowing. As testing increases in the United States, and elsewhere, we expect to detect more cases; however, it does not appear that the increased testing in the United States wholly accounts for increased incidence.
- While the test positivity in the United States decreased from mid-April through mid-June, the decrease reached an inflection point in mid-May and has been increasing since early June. This indicates that community transmission is outpacing testing capacity. The COVID Tracking Project published an excellent overview of the relationship between testing and reported incidence in the context of the current surge in US C19 incidence. Notably, 3 states—Florida, Kentucky, and South Carolina—reported increased C19 incidence compared to the previous week while also reporting decreased testing.
- Additionally, the COVID Exit Strategy dashboard, which analyzes state-level conditions based on the White House strategy gating criteria, finds that 33 states are “trending poorly,” based on trends in C19 incidence, hospitalizations, and testing.
- Notably, Arizona is currently reporting higher per capita incidence than Brazil or any European country at the height of its epidemic. Additionally, Maricopa County, home to Phoenix, is reporting higher incidence than New York City boroughs, “even on their worst days.” In addition to C19 incidence, Arizona reported a record high on June 24 for both hospitalized C19 patients (2,453) and C19 patients on mechanical ventilators (415). Arizona is also currently reporting test positivity of 20%, which has steadily increased from 5% for the week of May 10.
- New Jersey reported probable C19 deaths for the first time since the onset of the pandemic, following a retrospective review of death certificates and other clinical information. The state reported a total of 1,854 probable deaths, and it will continue to report probable deaths weekly moving forward. These deaths are not yet included in the CDC data, but they should be soon.
- The Johns Hopkins CSSE dashboard reported 2.43 million US cases and 124,544 deaths as of 1:00pm on June 26.
2. US State & Local Response
- A number of US states are exhibiting concerning trends in terms of C19 incidence, hospitalizations, and testing. In light of increased transmission, some state and local governments are strengthening social distancing policies and slowing plans to relax existing measures.
- In Palm Beach County, Florida, local elected officials voted unanimously to implement mandatory mask use, but a number of local residents expressed opposition to the policy. Notably, the decision follows several weeks of concerning increases in C19 incidence, with daily incidence nearly tripling since the end of May and the cumulative incidence doubling over that same period. A number of local governments in South Carolina have also implemented mandatory mask policies. This week, South Carolina’s Attorney General weighed in on these orders, confirming that they are valid under the state’s constitution.
- North Carolina Governor Roy Cooper issued an executive order pausing the state’s recovery plan in Phase 2 for at least 3 more weeks. The order also institutes statewide mandatory mask use in public where appropriate physical distancing (eg, 6-foot separation) is not possible. The order applies for customers and employees of some businesses as well, including retail stores, restaurants, child care facilities, some government agencies, public transportation, healthcare settings, and agricultural and meat processing facilities. Nevada Governor Steve Sisolak also issued an executive order to mandate mask use, following 4 weeks of increasing C19 incidence. The order applies to adults and adolescents aged 9 years and older while in any public space. Notably, the order does not appear to be limited to situations in which it is difficult to maintain physical distancing, with the exception of outdoor activities such as swimming and exercising.
- Texas Governor Gregg Abbott issued an executive order directing hospitals in several counties to postpone elective services and procedures in order to ensure available hospital capacity for C19 patients. Texas is currently exhibiting significant increases in C19 incidence, as well as increasing numbers of hospitalized C19 patients and increasing test positivity, following efforts to relax social distancing measures across the state. The number of hospitalized C19 patients has more than doubled since June 15. The previous executive order issued by Governor Abbott (June 3) moved Texas into Phase 3 of its recovery plan, including increasing the permissible capacity at many restaurants and other businesses from 25% to 50%. Governor Abbott announced yesterday that Texas will suspend further efforts to relax social distancing and remain in Phase 3 while it attempts to contain the current level of community transmission. Furthermore, Governor Abbott issued another executive order earlier today that re-imposed some social distancing restrictions that were recently relaxed. In particular, the order prohibits dine-in service at bars and requires that any outdoor gatherings of 100 or more people receive approval by local governments. This represents a major shift in Texas’ approach to C19, particularly considering that it was one of the earliest and most aggressive states in easing statewide social distancing measures.
- Analysis published by The Philadelphia Inquirer identifies an association between state-level C19 incidence and mandatory mask policies. States that mandate mask use in public reported a 25% decrease in incidence over the past 2 weeks, and states that require mask use by employees and patrons of businesses exhibited a 12% decrease. In contrast, states that only require mask use by employees (but not patrons) reported a 70% increase in C19 incidence, and states with no mandatory mask policy at the state level reported an 84% increase. There are a broad scope of factors beyond mask use that influence C19 incidence, so this is likely not a direct causal relationship. Mandatory mask use could be associated with other state-level social distancing and response policies, however, which could be driving the success of states’ containment and mitigation efforts.
3. US Domestic Travel Advisory
- The governors of Connecticut, New Jersey, and New York announced a joint travel advisory that will require travelers from states with high SARS-CoV-2 transmission to quarantine upon their arrival. The policy will mandate a 14-day quarantine for anyone arriving in the tri-state area who has recently been in any state with a test positivity greater than 10% or with C19 incidence greater than 10 new cases per 100,000 population—both based on a rolling 7-day average. At the time of the announcement, the policy would apply to 8 states—Alabama, Arkansas, Arizona, Florida, North Carolina, South Carolina, Utah, and Texas. The 14-day period will be measured from the last date the individual was in any of the affected states. These 3 states were among those hit the hardest early in the US C19 epidemic, but they were able to bring their respective epidemics under control and maintain relatively low levels of transmission. They are concerned that travel from areas of high transmission could ignite local outbreaks. Previously, several states imposed restrictions on travelers from the tri-state area, including Florida and neighboring Rhode Island.
4. Scale of US Epidemic
- During yesterday’s US CDC C19 telebriefing, CDC Director Dr. Robert Redfield commented that the United States has likely only detected about 10% of the total SARS-CoV-2 infections nationally. Based on recent serological studies, CDC officials believe that testing capacity and strategies are only detecting 1 out of every 10 infections and that 5-8% of the US population has been infected already. If this is the case, the national cumulative incidence would be closer to 23 million cases, instead of the current 2.3 million. Considering the potential volume of unidentified cases in the community, social distancing becomes that much more critical to mitigating transmission risk, as the vast majority of affected individuals would not be aware they are infected and potentially able to transmit the infection to others.
- The New York Times published an interactive multimedia feature on the evolution of the US C19 epidemic. It includes information about key points in the epidemic’s trajectory and the US response, from the introduction of SARS-CoV-2 through this week, illustrating how the epidemic gained a foothold, even before the earliest cases were detected and reported, and grew to a major epidemic affecting millions of people. The text is accompanied by a variety of visualizations that illustrate local-, regional-, and national-level spread.
5. European Travel Restrictions
- The current EU C19 travel policy is set to expire on June 30, and efforts are ongoing to determine how European countries will permit travelers from outside the continent. Multiple media outlets are reporting that the new plan may permit international travelers from some countries but restrict those from countries that are exhibiting concerning C19 trends. Reportedly, multiple draft lists of countries facing restrictions include Brazil, Russia, and the United States, among others. Earlier in the pandemic, the United States imposed travel restrictions for European countries, but the recent surge in US C19 incidence may be giving EU countries pause with respect to welcoming American travelers. It is unclear when the new policy will be made public; however, it is likely that an announcement will be made in the coming days, considering that the current policy expires next week.
6. Economic Outlook
- The International Monetary Fund (IMF) recently updated its global economic projections, now predicting that the global economy could contract by 4.9% this year. In April, the IMF predicted a 3% global economic contraction. No country has escaped from the economic downturn caused by the pandemic, but global pandemic control measures to mitigate a large second wave could lead to a quicker rebound. The IMF also predicted that the US GDP would decrease by 8% in 2020. The US GDP already fell 5% in the first quarter of this year.
- As the United States continues to battle to contain C19, unemployment claims have decreased weekly since the major spike in March but still remain at record highs. More than 47.3 million Americans have filed for unemployment benefits over the past 14 weeks. Last week, 1.5 million Americans filed for unemployment benefits, even as states continue to ease social distancing measures and resume economic activity.
I. Links to Other Scientific & Notable Stories
- Structural basis for inhibition of the RNA-dependent RNA polymerase from SARS-CoV-2 by remdesivir
- Vaccine Makers Turn to Microchip Tech to Beat Glass Shortages
- Effectiveness of Antibodies from Convalescent Plasma
- Promising antiviral protease inhibitors
- Hospitals in Hard hit regions step up use of steroids on COVID-19 patients
- CDC indicates COVID infection-fatality rate less than 1%
- Judge Orders N.Y. Lockdown Measures Unconstitutional
- The Good News About C19 the Media Keeps Hidden