Recent Developments & Information
July 6, 2020
Reliable information is the best tool available to protect your family from the pandemic and its shockwaves
“The death rate in a given country depends a lot on the age structure, who are the people infected, and how they are managed. For people younger than 45, the infection fatality rate is almost 0%. For 45 to 70, it is probably about 0.05%-0.3%. For those above 70, it escalates substantially.”Dr. John Ioannidis, Stanford University’s Disease Prevention Chairman
A. The Pandemic As Seen Through Headlines
B. Numbers & Trends
1. Top 5 States in Deaths & Cases (7/5)
D. Risk Assessment
E. New Scientific Findings & Research
F. Potential Treatments
H. Concerns & Unknowns
I. Projections & Our (Possible) Future
J. The Road Back?
K. Technology vs. Coronavirus
A. The Pandemic As Seen Through Headlines
(In no particular order)
- US Surgeon General Warns of a Two-Week ‘Lag’ Time on COVID Deaths, Urges Americans to Wear Masks
- Vindicated? Trump-Touted COVID-19 Drug Hydroxychloroquine Works, New Study Finds
- Remdesivir being surged to coronavirus hot spots, FDA commissioner says
- FDA chief ‘concerned’ quarter of Americans could reject coronavirus vaccine
- Post-Pandemic Americans May Be Done With Taking Orders
- Gilead’s COVID-19 antiviral remdesivir gets conditional EU clearance
- College Students Busted Throwing “COVID-19 Parties” To Infect All Their Friends
- NYC To Install PPE Vending Machines In Subway System
- Some jobs are coming back, but economy may need years to heal
- India’s First Covid-19 Vaccine Races to Meet Mid-August Target
- Tokyo Wants Travel Limit as Cases Rise
- The big factor holding back the U.S. economic recovery: Child care
- Mexico Overtakes France to Have Fifth Deadliest Virus Outbreak
- Fearful and Frugal: Coronavirus Wreaks Havoc on America’s Psyche
- U.K. Considers Joining EU Virus Vaccine Drive in Race for Supply
- Coronavirus will undermine trust in government, ‘scarring body and mind’ for decades, research finds
- Contact tracing is a race. But few U.S. states say how fast they’re running.
- People are driving less and skipping the toll roads, leaving less money for local projects
- As Pandemic Continues, World Health Organization Struggles To Maintain Coherent Response
- UAE In Drastic Government Shake-Up Seeking More “Swift & Agile” COVID Economy
- Low-Income Households Crushed By Covid Inflation Shock
- Texas sees record jump in hospitalizations
- Taj Mahal closed until further notice
- India surpasses Russia in total cases
- Florida reports over 10,000 new cases
- Arizona sees roughly 3,500 new cases
- South Africa sees record jump in new cases
- WHO cancels hydroxychloroquine trials
- Russia cases near 700,000 cases
- Japan sees another 277 new cases
- Mexican state closes border with US
- South Carolina positivity rate hits 20.7%
- Latin America surpasses US case total
- More MLB, NBA players test positive
- Arizona hospitalizations at new record high
- 105 University of Washington students living in frat houses off campus test positive
- Sweden sees deaths, hospitalizations tumble
- WHO warns against trying to predict when vaccine will be ready
- Britain mandates quarantine for all American visitors
- Washington State Governor pauses reopening
- South Korea sees another 60+ cases
- China cluster eases
- Peru death toll tops 10,000
- 80% Of NYC Restaurants Couldn’t Afford June Rent
- Manhattan Apartment Sales Plummet, Worst In Three Decades
- Goldman Cuts GDP Forecast Due To Coronavirus “Resurgence”
- Morgan Stanley Gets Even More Bullish Because Mass Layoffs Mean Even Higher Profits
- “Don’t Let Them Vaccinate You”: Farrakhan Warns Africans That Dr. Fauci and Bill Gates Is Trying To Kill Them
- US Recovery Set To Stall As Virus Cases Surge
- Yale Study Suggests COVID Death Toll In US Has Been “Substantially Undercounted”
- “Things Don’t Look Good In Las Vegas” – Nevada Suffered Biggest Economic Blowback From COVID-19
- NYC tattoo shop says coronavirus is becoming sought-after ink design
- Maskless patrons flock to London pubs on first night of reopening
- American couple fined $2,000 in Canada for defying quarantine orders
- Miami mayor hopeful closing beaches will slow new coronavirus cases
- Labor secretary confident businesses can reopen with safety precautions
- After alarming uptick, NY’s coronavirus cases drop
- What coronavirus? Maskless partiers pack lake on July 4th
- More than 1,300 NYC COVID-19 victims in freezers awaiting burial
- College football moving to spring is a very real possibility
- The virus is accelerating a trend toward a cashless future.
- More New Yorkers are now traveling by bus than by subway.
- Rooftop eatery features private greenhouses for socially distanced dining
- Man booted from Florida-bound flight at LGA for not wearing mask
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 = 11,550,542 (+1.6%)
- New Cases = 178,340 (-11,286)
- Growth Rate of New Cases (7 day average) = 1.1%
- New Cases (7 day average) = 188,619 (+1,956)
- Number of new cases have declined for 3 consecutive days
- 7 day average growth rate in new cases has declined significantly since 7/2
- 7 day average of new cases was a record high on 7/5
US Cases & Testing:
- Total Cases = 2,982,928 (+1.5%)
- New Cases = 44,530 (-652)
- Percentage of New Global Cases = 25.0%
- Growth Rate of New Cases (7 day average) = 1.6%
- New Cases (7 day average) = 49,486 (+780)
- Total Number of Tests = 37,600,814
- Percentage of positive tests (7 day average) = 7.5%
- Number of new cases has declined for 3 consecutive days
- 7 day average of 49,486 new cases was a record high on 7/5
- 7 day average growth rate in new cases has declined by more than 65% since July 2
- 7 day average positive test rate has increased by 70.5% since 6/9
- Total Deaths = 536,445 (+0.7%)
- New Deaths = 3,554 (-928)
- Growth Rate of New Deaths (7 day average) = 0.3%
- New Deaths (7 day average) = 4,532 (+12)
- Number of new deaths has decreased for 2 consecutive days
- Number of new deaths have been rising since 5/26, increasing approx. 10.2% between 5/26 and 7/5
- Total Deaths = 132,569 (+0.2%)
- New Deaths = 251 (-3)
- Percentage of Global New Deaths = 7.1%
- Growth Rate of New Deaths (7 day average) = (-0.9%)
- New Deaths (7 day average) = 511 (-5)
- Lowest number of new deaths since 4/23
- 7 day average of new deaths has declined by 2,255 new deaths on 4/21 to 511 on 7/5, a decrease of 77.3%
- Lowest 7 day average of new deaths since 3/30
C. US Hotspots
1. Top 5 States in Deaths & Cases (7/5)
- Florida 10,059
- Texas 5,183
- California 4,625
- Arizona 3,536
- Georgia 2,197
- New York 33
- Florida 29
- Texas 27
- New Jersey 22
- Massachusetts 11
Most Deaths Per 1 Million Population
- New Jersey 1,720
- New York 1,658
- Connecticut 1,216
- Massachusetts 1,187
- Rhode Island 906
Deaths Per 1 Million Population (Most Populated States)
- California 160
- Texas 92
- Florida 174
- New York 1,658
- Illinois 571
United States 401
2. What Makes Bars and Restaurants Potential C19 Hot Spots
- Public-health experts and government officials say they are worried bars and restaurants are playing a significant role in increasing C19 case counts across parts of the U.S.
- These spaces pose particular challenges for transmission control because of both human behavior and the way the coronavirus spreads most efficiently—indoors through close, prolonged contact without protection. Potentially risky behavior includes loud talking, not wearing masks and drinking alcohol, which can make people less risk-conscious, scientists said.
- To limit transmission, public-health experts recommend people stay 6 feet apart, wear masks, practice good hand hygiene and avoid touching their faces.
- “It’s much harder to do those four things in a bar or restaurant than in a workplace,” said Lisa Lee, an infectious-disease epidemiologist and associate vice president at Virginia Tech. In work and office settings, it can be easier to socially distance, control who is present and wear masks continuously, plus people aren’t normally drinking, she said. “Generally, office work will be much less risky than a bar kind of situation.”
- At least 158 new cases of C19 were recently traced back to a bar in East Lansing, Mich., according to Ingham County Health Officer Linda Vail. Based on case investigations and contact tracing, health officials found that as of July 3, 131 of those cases were people who contracted the virus while at the bar. The other 27 were secondary infections—people who were infected by someone who caught the disease at the bar.
- The bar’s owners told Ms. Vail that they were operating at 45% capacity, but video on social media showed many patrons lined up outside were clustering together, without masks. Ms. Vail said her office got complaints of overcrowding and inconsistent mask-wearing by staff inside; many patrons weren’t wearing masks inside, some complaints said.
- Some state and local governments are winding back reopening plans and renewing restrictions on bars, restaurants, movie theaters, zoos and museums after seeing record numbers of daily coronavirus infections. Colorado Gov. Jared Polis ordered bars and nightclubs to stop in-person service. Texas Gov. Greg Abbott said the state’s coronavirus crisis was driven in part by people congregating in bars. He closed bars and capped restaurant capacity at 50%. In California, where cases are also rising, Gov. Gavin Newsom on Wednesday ordered restaurants to close for indoor dining and shut down bars in much of the state.
- In New York City, restaurants are open for dining, but can only serve patrons outdoors, where transmission risk is lower. Air flow dilutes the amount of virus hanging around.
- “We have to think about this in terms of relative risk. There’s no absolutes,” said Thomas Russo, professor and chief of infectious disease at the Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo.
- There is a general pecking order to risk in dining out, he said. The safest route is simply getting food through a drive-through or takeout. Outdoor dining comes next, with caveats: Tables need to be spaced out, and the farther the better. Least safe is dining indoors at a restaurant.
- This echoes the CDC recommendations, which note that drive-through, delivery, takeout and curbside pickup carried the lowest risk of transmission because they limited the number and duration of interactions among potentially infected individuals. On-site dining, indoors and outdoors, represented the highest risk if capacity wasn’t reduced and tables weren’t spaced at least 6 feet apart.
- Indoor dining is particularly dangerous in crowded settings where ventilation and air filtration are poor, experts say, because viral particles can build up in the air. In January, an infected diner who wasn’t yet symptomatic transmitted the virus to five others while eating in a restaurant in Guangzhou, China. Some researchers looking at the case noted that ventilation was poor. They hypothesized that aerosolized virus from the patient’s breathing or speaking built up in the air over time, while strong airflow from an air-conditioning unit helped recirculate particles.
- Even the safer option of outdoor dining has risks, experts say. Viral particles dissipate more outdoors, lowering the risk of coming into contact with enough virus to get infected. On a population level, being outdoors lowers the risk of a superspreader event. But on an individual level, experts say, if someone is outside and sitting or standing next to an infectious person, there isn’t as much dilution. The likelihood of breathing in what they are breathing out is high, especially if they aren’t wearing masks and are talking and sharing food for a prolonged period.
- “That creates the greatest risk for a transmission,” said Rachael Jones, a University of Utah occupational-health and safety expert.
- In crowded urban settings like New York City, tables might be crammed together on a sidewalk, exposing people to diners outside their own party. “It’s difficult to maintain separation,” Dr. Jones said. “You can’t wear a mask while you eat.”
- Bars are “logarithmically worse” than restaurants, Dr. Russo said. People in bars tend to be clustered together, he said, and are more likely to be moving around. That means one person who has the virus can spread it to many more than if the individual was seated at a table eating a meal.
- Another thing to keep in mind, infectious-disease experts said: When people drink, they become more relaxed and sometimes their risk tolerance is higher. Even if they start off well-intentioned, wearing masks and social distancing, they are likely to be more lax about those things as the drinks progress. People in bars are also more likely to shout, spraying respiratory droplets into the air, the experts said.
- “I think it’s important for us to get the younger people to understand that it’s imperative that they take this seriously,” said Charlie Latham, mayor of Jacksonville Beach, Fla. He said the city didn’t see an appreciable increase in cases when restaurants reopened at 25% capacity and then expanded to 50%, but did experience one when bars reopened. As of June 26, Florida bars can’t sell alcohol for consumption on-site.
- The National Restaurant Association has issued reopening guidelines based on CDC recommendations, encouraging the use of face coverings for employees, socially-distanced seating, mobile payments and limits on the number of employees in break rooms. Temperature checks for staff are at management’s discretion.
- “We ask all of our customers to help us keep our employees and their fellow diners safe by following all of the existing guidelines,” a spokesperson said.
- While there are ways to make dining-out safer, there will always be some level of risk around other people, said Benjamin Chapman, professor and food-safety specialist at North Carolina State University, who has worked with state and industry officials to develop a best-practices training program for restaurants looking to reopen.
- Contact tracing will play a big part in dictating the pace of reopening restaurants, bars and other businesses, epidemiologists and infectious-disease experts said. As states reopen, it is critical to monitor the number of new infections and hospitalizations and re-evaluate which businesses can remain open and which should cut back, they said.
- “The more we reopen, each increment—each thing you do—does increase the risk,” said Lisa Winston, vice chief for inpatient medical services and an epidemiologist at Zuckerberg San Francisco General Hospital, who works closely with the local health department. “As with most things, it’s a balance.”
D. Risk Assessment
1. Odds of catching the coronavirus are nearly 20 times higher indoors than outdoors
- With the virus raging in many parts of the country, new restrictions have left many wondering about the safety of a backyard barbecue or picnic.
- As the coronavirus continues to rage throughout the country, public health officials are telling us to stay home this holiday weekend. Beaches in Texas, Florida and California are closed. And now some recent backyard gatherings are being blamed for new cases of C19.
- The new restrictions and outbreaks have led to new confusion about the safety of socializing outdoors. But experts say the science hasn’t changed: Your risk of catching the virus is much lower outdoors than indoors. If you want to spend time with friends, taking the party outside will reduce your risk of contracting C19.
- “Outside is definitely safer,” said Erin Bromage, a comparative immunologist and biology professor at the University of Massachusetts, Dartmouth. “But it’s the type of interactions you have when you’re outside that are important.”
- A Japanese study of 100 cases found that the odds of catching the coronavirus are nearly 20 times higher indoors than outdoors. Outdoor gatherings lower risk because wind disperses viral droplets, and sunlight can kill some of the virus. Open spaces prevent the virus from building up in concentrated amounts and being inhaled, which can happen indoors when infected people exhale in a confined space for long stretches of time, said Dr. Julian W. Tang, a virologist at the University of Leicester.
- If you socialize outdoors, it’s important to keep the guest list small. Socializing with just one additional household is safer than mixing multiple households. Make sure that the rate of C19 in your community is low and falling. It’s safest to socialize when the test positivity rate is at 5 percent or lower — a level that reduces your chances of inviting an infected person to the party.
- Recent clusters of cases have been linked to home gatherings that appear to have broken those rules. After an estimated 100 people gathered for a party in Rockland County, N.Y., public health officials tracked nine cases to the event. In Washington D.C., a June 18 backyard fund-raiser with about two dozen guests made headlines when the host and a few guests were reportedly diagnosed with C19. In Texas, a May 30 surprise party infected 18 family members.
- But adding to the confusion about outdoor gatherings is the fact that the continuing protests over police brutality and the killing of George Floyd in Minneapolis have not been associated with spikes in cases. The reason the protests haven’t caused a surge may be because protesters were often moving, lowering the risk of spending extended time with an infected person. Many marchers were also wearing masks.
- “I can tell you from our own testing in Minnesota, which has been substantial, we have seen no evidence of any kind of measurable impact of protests on cases,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “There could have been cases, surely, but it was not a major amplifying event.”
- Julia Marcus, an infectious disease epidemiologist and assistant professor in the department of population medicine at Harvard Medical School, said the data collected from protesters so far, along with studies suggesting that outdoors is lower risk for transmission, should reassure public health officials about the safety of masked outdoor gatherings and prompt them to open beaches and public outdoor spaces to help people gather more safely during the pandemic.
- “Outdoors is what will save us,” Dr. Marcus said. “Why can’t the message be: ‘We understand you want to get together with friends. There are ways to do this safely.’ We’re just telling them not to gather. That doesn’t recognize basic human behavior and basic human needs.”
- A review of 7,000 cases in China documented only a single instance of outdoor transmission — but it apparently occurred during a long conversation between two friends. One of them had just returned from Wuhan, the center of the outbreak.
- If you attend a social event and find yourself in close conversation with someone from outside your household, even outdoors, wear a mask. Keep music levels low so people don’t have to shout. (Loud speaking expels more droplets than a quiet voice.) Don’t share food or serving utensils.
- “I think people hear that it’s outdoors and think everything is fine,” said Linsey Marr, an engineering professor and aerosol scientist at Virginia Tech. “But it should be outdoors with distancing. If you have an outdoor gathering with a lot of people talking, you stand close. It’s loud, so you talk louder.”
- Limiting the number of partygoers not only lowers your risk of running into someone who has the virus, but small numbers also make it easier to keep track of just a few people and maintain physical distance, said Dr. Asaf Bitton, executive director of Ariadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.
- Dr. Bitton notes that when a group gets larger, even outdoors, it can affect our overall spatial awareness, including proprioception — which is knowing where our body is in space without relying on visual cues. Add in alcohol, and our ability to keep our distance falls short.
- “We also know that alcohol or other drugs and medications can significantly alter all senses, with a particularly large effect on proprioception,” Dr. Bitton said.
- Dr. Osterholm agreed that people should be aware of the effect alcohol can have on efforts to keep a physical distance.
- “One of the problems that happens with parties or events like this if alcohol is involved, even the most well-meaning individual who is trying to stay apart a certain number of feet, it’s an unnatural act,” he said. “People do come together. That’s just human nature.”
- Even though socializing outdoors is relatively safe, people need to stay aware and vigilant. While it’s easy to keep your distance from strangers, it’s tougher to stay six feet from people you know, Dr. Tang said.
- “It is different when you are interacting with people that you know. I was chatting to my gardener outside earlier this week when I realized that neither of us had masks on and we were getting too close,” Dr. Tang said. “So whilst people can be more socially distanced when outdoors, especially amongst strangers, with friends and family and once you start talking to someone at a garden party, people forget themselves, and they get too close.”
Source: How Safe Are Outdoor Gatherings?
E. New Scientific Findings & Research
1. WHO and CDC ignore risk that coronavirus floats in air as aerosol
- Six months into a pandemic that has killed over half a million people, more than 200 scientists from around the world are challenging the official view of how the coronavirus spreads.
- The WHO and the CDC maintain that you have to worry about only two types of transmission: inhaling respiratory droplets from an infected person in your immediate vicinity or — less common — touching a contaminated surface and then your eyes, nose or mouth.
- But other experts contend that the guidance ignores growing evidence that a third pathway also plays a significant role in contagion.
- They say multiple studies demonstrate that particles known as aerosols — microscopic versions of standard respiratory droplets — can hang in the air for long periods and float dozens of feet, making poorly ventilated rooms, buses and other confined spaces dangerous, even when people stay six feet from one another.
- “We are 100% sure about this,” said Lidia Morawska, a professor of atmospheric sciences and environmental engineering at Queensland University of Technology in Brisbane, Australia.
- She makes the case in an open letter to the WHO accusing the United Nations agency of failing to issue appropriate warnings about the risk. A total of 239 researchers from 32 countries signed the letter, which is set to be published next week in a scientific journal.
- In interviews, experts said that aerosol transmission appears to be the only way to explain several “super-spreading” events, including the infection of diners at a restaurant in China who sat at separate tables and of choir members in Washington state who took precautions during a rehearsal.
- WHO officials have acknowledged that the virus can be transmitted through aerosols but say that occurs only during medical procedures such as intubation that can spew large quantities of the microscopic particles. CDC officials did not respond to multiple requests for comment.
- Dr. Benedetta Allegranzi, a top WHO expert on infection prevention and control, said in responses to questions from The Times that Morawska and her group presented theories based on laboratory experiments rather than evidence from the field.
- “We value and respect their opinions and contributions to this debate,” Allegranzi wrote in an email. But in weekly teleconferences, a large majority of a group of more than 30 international experts advising the WHO has “not judged the existing evidence sufficiently convincing to consider airborne transmission as having an important role in C19 spread.”
- She added that such transmission “would have resulted in many more cases and even more rapid spread of the virus.”
- Since the coronavirus was first detected in China in December, understanding of how it spreads has evolved considerably, resulting in shifting guidelines regarding the use of masks.
- At first, the WHO and CDC said masks were overkill for ordinary people and should be conserved for health workers. Later, the CDC recommended masks only for people with C19 symptoms.
- Then in April, after it became clear that people without symptoms could also spread the virus, the CDC suggested masks for everybody when physical distancing was difficult, a position the WHO eventually adopted.
- Now as outbreaks proliferate and governors order a new round of closures, nearly all U.S. states have made face coverings mandatory or recommended them, primarily to prevent wearers from spreading the disease.
- The proponents of aerosol transmission said masks worn correctly would help prevent the escape of exhaled aerosols as well as inhalation of the microscopic particles. But they said the spread could also be reduced by improving ventilation and zapping indoor air with ultraviolet light in ceiling units.
- Jose Jimenez, a University of Colorado chemist who signed the letter, said the idea of aerosol transmission should not frighten people. “It’s not like the virus has changed,” he said. “We think the virus has been transmitted this way all along, and knowing about it helps protect us.”
- He and other scientists cited several studies supporting the idea that aerosol transmission is a serious threat.
- As early as mid-March, a study in the New England Journal of Medicine found that when the virus was suspended in mist under laboratory conditions it remained “viable and infectious” for three hours, which researchers said equated to as much as half an hour in real-world conditions.
- It had already been established that some people, known as “super spreaders,” happen to be especially good at exhaling fine material, producing 1,000 times more than others.
- A recent study found coronavirus RNA in hallways near hospital rooms of C19 patients. Another raised concerns that aerosols laden with the virus were shed by floor-cleaning equipment and by health workers removing personal protective gear.
- Researchers in China found evidence of aerosols containing the coronavirus in two Wuhan hospitals.
- It was the outbreak among choir members in Mount Vernon, Wash. — and a report about the incident in The Times — that first piqued the interest of several of the aerosol proponents. Of 61 singers at a March 10 rehearsal, all but eight became sick, despite the members using hand sanitizer and avoiding hugging or shaking hands. Two people died.
- A team led by Shelly Miller, a University of Colorado professor of mechanical engineering, dug into church-hall blueprints, furnace specifications, locations of choir members and hours of attendance. The researchers diagrammed movements of the singer who was identified as the person who unwittingly brought the virus to practice.
- Inhalation of aerosols “most likely dominated infection transmission during this event,” the researchers wrote in a paper undergoing peer review, concluding that the ill person, who had symptoms similar to a common cold, was unlikely to have spent time within six feet of many singers or to have touched surfaces in common with them.
- “We believe it likely that shared air in the fellowship hall, combined with high emissions of respiratory aerosol from singing, were important contributing factors,” the paper said.
- Eventually researchers from a broad spectrum of disciplines, including several who have studied the role of aerosols in the spread of the flu, SARS and other infectious diseases, joined forces to campaign for greater recognition of aerosol transmission.
- They said that the coronavirus is less contagious through the air than measles but that the risk of transmission goes up the longer air remains stagnant and the longer people continue to breathe it.
- In interviews, they said WHO officials had unfairly set a higher bar for showing aerosol spread than was required for acceptance of the other two pathways. “For them, droplets and touch are so obvious that they’re proven, but airborne is so outlandish that it needs a very high level of evidence,” Jimenez said.
- Proof would require exposing large numbers of healthy people to aerosols emitted by C19 patients, a study that scientists said would be unethical.
- Donald Milton, a University of Maryland environmental health professor and an expert on aerosols who co-wrote the letter, said the average person breathes 10,000 liters of air each day.
- “You only need one infectious dose of the coronavirus in 10,000 liters, and it can be very hard to find it and prove that it’s there, which is one of the problems we’ve had,” he said.
2. How Effective Are Masks?
- While the use of face masks in public has been widely recommended by public health officials during the current C19 pandemic, there are relatively few specific guidelines pertaining to mask materials and designs. A study from Florida Atlantic University, in the Physics of Fluids, from AIP Publishing, looks to better understand which types are best for controlling respiratory droplets that could contain viruses.
- Siddhartha Verma and his team experimented with different choices in material and design to determine how well face masks block droplets as they exit the mouth. Using a laser to detect droplets as they were coughed and sneezed out of a mannequin head, the group was able to map out the paths of droplets and examine how different designs and materials alter that path.
- The authors note the need for further quantitative analysis but were aware of the power of more straightforward visualization.
- “While there are a few prior studies on the effectiveness of medical-grade equipment, we don’t have a lot of information about the cloth-based coverings that are most accessible to us at present,” said Verma. “Our hope is that the visualizations presented in the paper help convey the rationale behind the recommendations for social distancing and using face masks.”
- The approach draws on a laser sheet setup that is a mainstay for those studying fluid mechanics, which Verma compares to seeing dust particles in a beam of sunlight.
- “The main challenge is to represent a cough and sneeze faithfully,” he said. “The setup we have used a simplified cough, which, in reality, is complex and dynamic.”
- The group found that loosely folded face masks and bandanna-style coverings reduced the distance traveled by the droplet jets between 1/8 to 1/2 respectively of that for an uncovered cough.
- However, well-fitted homemade masks with multiple layers of quilting fabric and off-the-shelf cone style masks proved to be the most effective. Some leakage notwithstanding, these masks reduced the number of droplets significantly.
- When without a mask, the mannequins were projecting droplets much farther than the oft-cited 6 feet in social distancing guidelines.
- Verma said the group looks to continue studying the complex interplay that can involve droplet evaporation, ambient airflow and properties of the respiratory fluid ejected that lead to how droplets behave.
- “It is also important to understand that face coverings are not a 100% effective in blocking respiratory pathogens,” he said. “This is why it is imperative that we use a combination of social distancing, face coverings, hand-washing and other recommendations from health care officials until an effective vaccine is released.”
3. Blood cell damage may explain low oxygen levels
- Damage done by the coronavirus to the membranes of red blood cells that carry oxygen may explain why many C19 patients have alarmingly low oxygen levels, according to new research.
- Specifically, the virus attacks the membranes’ most abundant protein, called band 3, said senior researcher Angelo D’Alessandro of the University of Colorado Anschutz Medical Campus.
- The protein is critical to stabilize red cell membrane structures, regulate red cell metabolism and stabilize the cell’s processing of hemoglobin, the substance that transports and then releases the oxygen.
- By disrupting the interaction of band 3 with hemoglobin, the virus could impair red cells’ capacity to deliver oxygen, D’Alessandro said.
- “Since red cells circulate for up to 120 days, this could also help explain why it can take months to recover from the virus … until enough new red cells without this damage are made and circulate,” D’Alessandro told Reuters, adding that he became infected in March.
- “It took me three weeks to heal from the infection, but I am still recovering slowly,” he said. D’Alessandro’s team posted their findings on Tuesday on medRxiv, ahead of peer review. (https://bit.ly/3ikTZLK)
F. Potential Treatments
1. Coronavirus Damages the Endocrine System: Steroids May Offer Vital C19 Treatment Strategy
- People with endocrine disorders may see their condition worsen as a result of C19, according to a new review published in the Journal of the Endocrine Society.
- “We explored the previous SARS outbreak caused by the very similar virus SARS-CoV-1 to advise endocrinologists involved in the care of patients with C19,” said Noel Pratheepan Somasundaram of the National Hospital of Sri Lanka in Colombo, Sri Lanka. “The virus that causes C19 — SARS-CoV-2 — binds to the ACE2 receptor, a protein which is expressed in many tissues. This allows the virus to enter endocrine cells and cause the mayhem associated with the disease.”
- The coronavirus can cause loss of smell and gain entry to the brain. In past coronavirus infections such as the SARS epidemic in 2003, many patients developed a post-viral syndrome with fatigue. This could in part be caused by adrenal insufficiency, a condition where the adrenal glands do not make enough cortisol, as a result of damage to the pituitary system. During the SARS epidemic, patients who developed adrenal insufficiency typically recovered within one year.
- “Testing for cortisol deficiency and treating patients with steroids may become a vital treatment strategy,” Somasundaram said. “Very recent studies have demonstrated lowered mortality in severely-ill patients with C19 treated with the steroid dexamethasone.”
- C19 also could lead to new cases of diabetes and worsening of existing diabetes. The coronavirus attaches to ACE2, the main entry point into cells for coronavirus, and disrupts insulin production, causing high blood glucose levels in some patients. The authors highlight the need for strict glucose monitoring in patients with C19 as a measure to maximize recovery.
- “People with vitamin D deficiency may be more susceptible to coronavirus and supplementation could improve outcomes, though evidence on the subject is mixed,” Somasundaram said.
1. Oxford’s vaccine is leading candidate, but….
- Oxford University, experts think, is the most likely to come up with a viable vaccine candidate for C19, which has caused havoc around the world. Even the World Health Organization has pegged them as the leading candidate for a viable vaccine.
- In a recent online call with the Ministers of Parliament of the House of Commons Science and Technology Committee, Dr. Sarah Gilbert, the lead researcher for Oxford’s C19 vaccine and Professor of Vaccinology at the Jenner Institute & Nuffield Department of Clinical Medicine, spoke about the ongoing trial.
- The coronavirus is a family of viruses and SARS-CoV-2, like SARS and MERS, is part of this one big family, identified in the mid-1960s. Coronaviruses are known to have symptoms like fever, sore throat, headaches, cough, runny nose, etc and are also very common. People who have been infected are thought to be susceptible to getting infected again. This is a major cause for concern with a potential C19 vaccine.
- In order to dispel concerns about re-infections, Gilbert said that the Oxford vaccine should be able to provide ‘a good duration of immunity’ and she is optimistic about it. She also said a vaccine might provide better results than natural immunity acquired when individuals recover from the virus.
- “Vaccines have a different way of engaging with the immune system, and we follow people in our studies using the same type of technology to make the vaccines for several years, and we still see strong immune responses,” said Gilbert.
- “It’s something we have to test and follow over time – we can’t know until we actually have the data – but we’re optimistic based on earlier studies that we will see a good duration of immunity, for several years at least, and probably better than naturally-acquired immunity.”
- The vaccine, which has been given the name AZD1222, is licensed to British biopharmaceutical company AstraZeneca, which will be manufacturing it if trials succeed. The vaccine is currently in Phase III human trials, in which the vaccine is being administered to around 8,000 participants. The trial will assess how the vaccine works in a large number of people over the age of 18, and whether the vaccine works to prevent people from becoming infected with C19.
- Gilbert said, “We’re very happy that we’re seeing the right sort of immune response that will give protection, and not the wrong sort.”
- Oxford University is also slated to conduct human trials in Brazil with 5,000 individuals, in the US with 30,000 participants and another 2,000 in South Africa.
- When asked how long will it be till a vaccine is available, Gilbert said she is confident human trials will be completed by the year-end, by which time AstraZeneca plans to manufacture millions of doses in anticipation of approval.
- However, Kate Bingham, chair of the UK Government Vaccine Taskforce, said that, excluding the Oxford vaccine program that is on track to be completed by August this year, she hopes for a breakthrough in other C19 trials by early 2021.
- “We don’t know coronavirus well. Think of examples like HIV and malaria. We know those diseases well, yet we don’t have vaccines against them,” she told the committee. “So we may never get a vaccine, or we may only get a vaccine that modifies the severity of the disease, or lessens its effects.”
- Oxford University Regius Professor of Medicine Sir John Bell also echoed similar thoughts as Bingham when he said, “This whole epidemic has relied too heavily on assumptions that have turned out not to be true. So my strong advice is to be prepared for the worst.”
2. Cautious Optimism About Imperial College Vaccine
- Prof Robin Shattock would have liked slightly longer to develop the revolutionary approach to vaccines that he is pretty sure will not only save lives in the C19 pandemic but become the norm for vaccine development within five years.
- His team at Imperial College were working on Ebola and Lassa fever vaccines using new technology but had not got as far as human trials when a novel coronavirus started to kill thousands of people in Wuhan, China.
- Animal data told them they were on the right track, but it is now C19 that will prove or disprove whether the approach, using what they call self-amplifying RNA, is a breakthrough.
- He is careful not to over-promise, but it is clear he backs his own horse over 120 other contenders in the effort to develop a coronavirus vaccine. “Of course, or I wouldn’t be doing it,” Shattock told the Guardian.
- “I’m cautiously optimistic that it will work as well as anything else that is being developed because it induces good immune responses in animal models, and we predict it will be the same in humans and it will be very safe because we are using such low doses.
- “What we don’t know is what level of immunity is required to prevent infection. If we only need a tiny bit, the majority of vaccines out there will probably work. That will be fantastic for the world.
- “If we need a certain level of immune response that is high then we may see some vaccines are more successful than others. I would hope ours will be one of the successful ones, but there is no guarantee until we get the data that shows it works.”
- The Imperial vaccine is based on bits of genetic code, rather than bits of the virus itself. The code is inserted in fat droplets into the muscle of the arm, which then makes the spike protein for which the Sars-CoV-2 virus is famous. This induces the immune system to go into action, producing antibodies to fight it and hopefully creating a memory of the virus as an enemy invader to be repelled in case of genuine infection.
- Shattock is aiming for a vaccine that will treat all the billions of people on the planet, however small their country’s GDP. That’s the real beauty of this approach, he believes: it’s very safe, uses very little material and can be scaled up very quickly.
- And it’s going to be cheap, around £2 to £3 a dose, he thinks, which is chips for a brand-new vaccine. The first vaccines for human papillomavirus (HPV) – a group of viruses that can cause some types of cancer – cost around £300 per course.
- If it’s a race, Imperial will not win it. “We are not going to be first unless others fail,” he said. If that matters, it is because all the demand and funding will focus on the first vaccine that works, though there will be issues around affordability and scaling up.
- The vaccines being developed in the US are likely to stay there, with the Trump administration securing every dose that can be produced to protect Americans first. “I suspect if they work, they will be so busy meeting US demand that there are always going to be parts of the world that can’t access them,” Shattock said. “The idea that a single vaccine will be rolled out in a timely fashion around the world I think is very naive.”
- The UK government has put significant funding into Oxford University and Imperial’s attempts. The US has also invested in Oxford, but Shattock is not sorry it hasn’t offered anything to him. “In some ways it makes life easier. They have so much money that it also comes with a kind of pull. I think we would get very distracted if we were in that huge race in the US,” he said.
- It’s unlikely the first vaccines will be 100% effective, and the protection they give may wear off after a time. Shattock said it was quite possible that the Oxford University/Astra Zeneca prototype, which is ahead of the field as the first in large human trials, and the Imperial vaccine could be used together.
- “That’s not a surprise. If you use two different approaches – one to prime the immune system, and change to another to boost it, it often gives you a better response. One of the uncertainties about the AstraZeneca vaccine is whether it could be used for reboosting the immune system if you need an annual or five-yearly booster,” he said.
- Oxford is using a traditional approach, delivering the vaccine through a mild cold virus called an adenovirus. That should teach the immune system to fight the coronavirus, but it’s possible the antibodies may next time reject the cold virus as well, so extra booster doses won’t work so well. The Imperial vaccine, on the other hand, which is two shots to begin with, one month apart, can be given as often as needed.
- So is Shattock’s vaccine better? “I think that’s a difficult judgment call to make,” he said. “If what we see in animals translates to humans, we will have a different quality of immune response. That’s probably because we can give two doses. I think we will see higher levels of antibodies. Whether that makes a difference in protection or not, again, is an unknown.”
- Imperial will start its efficacy trials in humans in October. “We should know whether the vaccine works by the end of the year,” he said. “We have put in place the ability to make 85m doses for the UK.” At two doses each, that could cover 42.5 million adults. “We can make more, but we know we can guarantee we can make that many doses. We can cover the UK without any problem at all.”
- He thinks the more vaccines there are that work, the better, because that will give more coverage around the world. Imperial’s can be produced in very large quantities so quickly because it uses very little material, but Shattock said: “We need to partner with manufacturers around the world to do that.” That could be a huge pharma company such as AstraZeneca, but more likely, he thinks, it will be a variety of smaller companies that currently work on small margins based in different parts of the world, producing it in South America, India, Australia and so on to get global spread.
- The success rate of vaccines at this stage of development is 10%, Shattock says, and there are already probably 10 vaccines in clinical trials, “so that means we will definitely have one”.
- Other vaccines getting big support in the US are Johnson and Johnson’s, which uses an adenovirus like Oxford’s, and Moderna’s, which uses an RNA approach like Imperial’s but with a dose that is 100 times bigger. “I suspect their vaccine and ours will look quite similar in terms of immune response, but we are just using much less material. And they won’t be interested in developing world markets because they are a billion-dollar enterprise and need to make big returns on their investment.” BioNTech in Germany is testing several RNA candidates, one of which looks similar to Imperial’s.
- While Shattock hopes the Imperial vaccine works against C19, his team see it very much as the future. “The next time there is a pandemic, we hope this technology will be ready to be produced in many parts of the world much, much more rapidly. We are at a transition point. In five years’ time probably everybody will be using this sort of technology for outbreak pathogens.”
- It’s fast and it’s cheap. If it works, it may mean vaccines not only against viral outbreaks but also against the endemic neglected diseases that afflict low-income countries, where there has been little incentive in the past for companies to get involved.
H. Concerns & Unknowns
1. US Testing Capacity Stretched to the Limit
- The United States is once again at risk of outstripping its C19 testing capacity, an ominous development that would deny the country a crucial tool to understand its pandemic in real time.
- The American testing supply chain is stretched to the limit, and the ongoing outbreak in the South and West could overwhelm it, according to epidemiologists and testing-company executives. While the country’s laboratories have added tremendous capacity in the past few months—the U.S. now tests about 550,000 people each day, a fivefold increase from early April—demand for viral tests is again outpacing supply.
- If demand continues to accelerate and shortages are not resolved, then turnaround times for test results will rise, tests will effectively be rationed, and the number of infections that are never counted in official statistics will grow. Any plan to contain the virus will depend on fast and accurate testing, which can identify newly infectious people before they set off new outbreaks. Without it, the U.S. is in the dark.
- The delays have already started. Yesterday, Quest Diagnostics, one of the country’s largest medical-testing companies, said that its systems were overwhelmed and that it would now be able to deliver C19 test results in one day only for hospitalized patients, patients facing emergency surgery, and symptomatic health-care workers. Everyone else now must wait three to five days for a test result.
- “Despite the rapid expansion of our testing capacity, demand for testing has been growing faster,” Quest said in a statement last week warning of such a possibility. The company then said that orders for C19 testing had grown by 50 percent in three weeks.
- “This is very bad,” Michael Mina, an epidemiology professor at Harvard, told us. Rapid test-turnaround times are the only way to control the coronavirus without forcing every potentially contagious person—everyone who’s had contact with someone diagnosed with C19—into quarantine, he said: “Our modeling efforts more or less show that if you don’t get results back in a day or so, outbreaks really can’t be stopped without isolating and quarantining all contacts preemptively.”
- Quest is not the only firm to report growing problems. “We hit the wall three weeks ago,” Jon Cohen, the executive chairman of BioReference Laboratories, a lab-services company that is testing patients for the virus in New York, New Jersey, and Florida, told us. “At that point, most laboratories were already running at capacity, as far as I can tell.”
- In mid-June, four changes hit all at once, Cohen said. Large companies began to test their employees en masse, hospitals started to test every patient who needed an elective procedure, and nursing homes started regularly testing their employees and some residents. The American public also seemed to seek out voluntary tests in greater numbers this month. The surge in testing overwhelmed both his testing company’s capacity and its equipment suppliers, he said.
- “We not only hit capacity, but any ability to increase our capacity became limited by the supply side,” he said. “The vendors, the suppliers can’t keep up.”
- LabCorp, another major testing company, also recognized the surging demand for tests in a statement this weekend. “We are doing everything we can to continue delivering results in a timely manner while continually increasing testing capacity,” it said.
- Unlike in the first days of the pandemic, when C19 testing kits themselves were in short supply, now the problem lies with the equipment needed to get test results. The hardest-hit new areas do not have enough machines to process samples, leading to a growing backlog of tests, lab directors told us. Some are also running out of the chemical reagent that must react with a testing specimen.
- Labs in the U.S. use several different types of viral-testing machines to diagnose C19, and each type has its own supply-chain issues and processing challenges, Lauren Sauer, an emergency-medicine professor at Johns Hopkins, told us by text message. With “so many platforms” in use, she said, resolving bottlenecks and shortages nationwide is especially hard.
- “What is currently happening [on testing] is so pocketed and disconnected,” she said.
- The American Clinical Laboratory Association, a trade group that represents testing labs, has also warned of shortages. “While our members are collectively performing hundreds of thousands of tests each day, the anticipated demand for C19 testing over the coming weeks will likely exceed members’ testing capacities,” said Julie Khani, its president, in a statement. The group’s members conduct about half of the country’s daily coronavirus tests, according to information in her statement.
- The problems have not been felt everywhere. Dina Greene, the director of laboratory services for the health-care group Kaiser Permanente in Washington State, told us that supply-chain problems have not yet disrupted the group’s ability to work. But demand for tests was increasing, she confirmed, and she “wouldn’t be surprised” if shortages hit her team soon.
- Testing has hobbled the American response since the earliest days of the pandemic. As our reporting revealed, the U.S. had tested fewer than 3,000 people for the coronavirus by March 5, even though community spread of the virus had been detected more than a week earlier. In the following weeks, states and hospitals rationed access to tests, granting them only to health-care workers and the sickest patients. This meant that many people who may have had the virus, especially in the Northeast, were never tested for it.
- Even after the initial crunch in March, the country’s testing apparatus continued to be beset by problems. For much of April, as the virus killed tens of thousands of Americans, testing plateaued at roughly 150,000 tests a day. Since then, the number of daily tests has increased, but not as fast as experts once hoped. Only in the past two weeks has the U.S. succeeded in testing more than 500,000 people a day, which the Harvard Global Health Institute once said would be a good goal for mid-May. The institute said today that the U.S. must test at least 1.2 million people a day to control the outbreak and at least 4.3 million people a day to eliminate it.
- In all that time, the federal government never solved the testing problem. In early April, for instance, researchers at Duke University and the American Enterprise Institute, a conservative think tank, called for the government to take charge of the crisis by establishing a task force that would consolidate information about testing and help states and companies understand what was possible. Such a task force could manage emerging shortages, and it could help the country understand how much testing capacity might be attainable by July, August, or September.
- But such an effort never took shape. “If this work has been done, I have not seen it, and I fear that neither have the governors and other state and local leaders who are having to make decisions about how and when to reopen,” Caitlin Rivers, an author of the report and a professor at Johns Hopkins University, told Congress last month.
- “We basically need a Manhattan Project for testing,” Sauer said. “A nationwide, systematic strategy with a clear agency lead is desperately needed. But it’s not happening and I think we all fear significant access issues and supply-chain disruptions in the near future.”
- The U.S. is seeing a new surge of cases in the South and West that threatens to overwhelm its health system anew. The country reported more new confirmed C19 cases last week than in any other week of the pandemic so far. While the administration’s focus has drifted elsewhere, demand for tests is only growing. Alex Greninger, a laboratory-medicine professor at the University of Washington, told us that it was little wonder the testing companies were overwhelmed.
- “The testing supply chain wasn’t meant for this kind of onslaught of volume across the world at the same time,” he said.
2. Researchers find neurological damage in four children with coronavirus inflammatory syndrome
- Children diagnosed with C19 pediatric multisystem inflammatory syndrome, or PMIS, may develop new neurological problems without any of the respiratory issues commonly associated with the virus, according to a study published Wednesday in the Journal of the American Medical Association.
- Researchers examined 27 children with C19 PMIS, who were previously healthy, between March 1 and May 8 at Great Ormond Street Hospital for Children in London, England. They found that of the 27 patients, four experienced new neurological symptoms.
- Symptoms included impaired brain function, headaches, brainstem and cerebellar issues, muscle weakness and reduced reflexes. All four patients required admission to the intensive care unit for treatment.
- Although the study is small, researchers say the results show the coronavirus can also cause neurological damage in children — not just adults — without any of the respiratory symptoms that have become a hallmark indicator of C19.
- Neurological issues have been previously reported in adults with the coronavirus. The paper cites a different study published in May on the Wiley Online Library that examined 214 coronavirus patients in Wuhan, China. Of those patients, 78 experienced neurological symptoms, which included dizziness, headache, impaired consciousness, acute cerebrovascular disease, seizures and ataxia, which mimics being drunk, with slurred speech and stumbling.
- Researchers of the pediatric study observed splenium signal changes in the corpus callosum area of the brain, or lesions on the brain, in the four patients. They said although these findings are not specific to SARS-CoV-2, clinicians should consider the virus when diagnosing children who have new neurological symptoms.
- Moreover, scientists emphasized that since respiratory symptoms were uncommon among PMIS patients, clinicians should suspect C19 in children who show new neurological problems without any other symptoms.
- In April, health officials first observed a rise in coronavirus cases in children who developed a rare inflammatory condition. Symptoms of PMIS were similar to that of Kawasaki syndrome, which causes swelling of the heart’s blood vessels and mainly affects children under the age of 5.
- The World Health Organization had announced that it would investigate whether there is a relationship between C19 and the inflammatory conditions. Since then, no new symptoms or inflammatory disease have been reported in children infected with the coronavirus.
- Scientists have said that young adults are less likely to become severely ill than older adults, according to early findings on the virus. However, this new study shows that despite the typically mild acute infection, children may be at a high risk of a secondary inflammatory syndrome.
I. Projections & Our (Possible) Future
1. Hospitalizations Have Been A Good Predictor of Deaths . . . Until June, When Deaths Continued to Decline as Hospitalizations Increased
- Hospitalization data can help us understand the severity of C19 outbreaks in the United States, and even see a little bit of what’s to come. Until very recently, we didn’t have a national summary figure—now we can finally piece together a national statistic from states that provide it, and estimate the rest.
- The data we use to follow the C19 pandemic in the United States is unwieldy. Cases alone are only a partial indicator of the severity of regional outbreaks. More testing discovers more cases, so we have to look at test positivity to see if testing results indicate worsening outbreaks. (In a recent post, we explored how tests-per-positive may be a more useful indicator than the percent-positive rate—we use both.) Some media accounts treat deaths as the ultimate measure of whether a state’s response is succeeding or failing, but it takes a long time to die of C19—nearly three weeks from the date of infection, on average, and another week beyond that for the states to report the deaths. This means that reported death numbers are often a measure of an outbreak’s severity up to a month in the past.
- And deaths aren’t the only profound outcome of C19. We don’t yet know the long-term effects of surviving C19, but there’s evidence it could cause permanent lung damage, diabetes, and brain damage. Science writer Ed Yong spoke with several survivors who experienced symptoms weeks and months after contracting C19. None of the people Yong profiled were admitted to an ICU, and their collective experiences revealed that some so-called “mild” cases of C19 can be “hellish,” with lingering symptoms that include shortness of breath, hallucinations, delirium, even feelings of a heart attack despite normal EKG readings.
- That’s what makes the number of C19 hospitalizations such a useful data point. It complements case counts because it’s a measure of severity, conveying C19’s effects on both people and healthcare systems. Like every other C19 metric, hospitalization data has a built-in lag—when someone contracts C19 and is eventually admitted to the hospital, it takes about six days after infection for them to begin to feel symptoms, and another week before they’re admitted. Still, this means that hospitalizations may be almost two weeks ahead of reported deaths as a way for us to understand outbreaks.
- And while we won’t know what effect non-fatal cases of C19 will have on survivors, health insurance, or healthcare for months, or even years and decades, today’s hospitalization numbers are a place to begin for tomorrow’s planning. In short, it’s a number that sits at the center of a lot of what we want to know about the pandemic and its effects.
Hospitalization and the mysteries of the C19 death curve
- In the shorter term, hospitalizations can help us predict whether the death curve in the United States, which has been declining for months, will begin to increase or plateau. A systematic review of 14 studies published in the Journal of Medical Virology found that across the studies, about 25% of hospitalized patients died. In an early study of 5,700 hospitalized patients in New York City, the mortality rate among the 2,634 with known outcomes was 21%. A smaller study in the Bronx borough of New York City found a 24% in-hospital mortality rate.
- Many US states are showing C19 hospitalization increases—some quite sharp—so these are worrisome numbers.
- But there’s reason to hope that hospital mortality rates are declining. That’s the news from Milan, where hospital fatality rates fell from 24% to 2% from March to May (and the percentage of hospitalized patients who needed to be admitted to intensive care units also dropped). In England, the hospital fatality rate fell from 6% in April to 1.5% in June.
- Researchers have suggested a variety of reasons for this decline in hospital deaths. The authors of the Milan paper suggested several factors, including a better understanding of the disease’s effects, a reduction in the severity of the local outbreak, and a decline in simultaneous infections with seasonal illnesses. “Patients with C19 in late March and early April included a significant proportion of patients who caught the infection in hospital,” the authors of the British Medical Journal report on the decline in hospital mortality rate in England wrote. “These patients, because they were in hospital, were more likely to be sicker and more vulnerable than patients who acquired infection in the community and so more likely to die from C19.”
- But as the share of patients with infections from community transmission increases, the mortality rate has still declined. Several factors might explain this: Current patients are younger and less likely to die, hospitals are admitting less severe cases because more beds are available, and doctors and nurses have learned from experience.
- Bob Wachter, chair of the University of California-San Francisco Department of Medicine, posted a list of “Things We’ve Gotten Better At Since March”; it includes a number of improvements that could affect in-hospital mortality, such as better monitoring of vital signs and a more effective use of prone (face-down) positioning, which has been observed to improve oxygen levels in severely ill C19 patients. [NOTE: The Twitter post is below]
- We still don’t know how the death curve will respond to increasing hospitalizations in the United States. In certain states, the rise in hospitalizations has been very sharp. Between June 2 and July 2 in Arizona, the number of people hospitalized with C19 rose from 1009 to 2,938. During the same period in California, C19 hospitalizations rose from 4,393 to 6,812. For the same dates In Texas, C19 hospitalizations jumped from 1,773 to 7,382.
The patchy history of US C19 hospitalization data
- In the early months of the pandemic, it was impossible to know how many people in the United States were hospitalized with C19. On April 5th, when we began compiling hospitalization data, only 13 states reported how many people were in the hospital with C19. Twenty-five other states reported the cumulative number of people who had been hospitalized.
- Current hospitalization numbers go up when C19 patients are admitted or when already admitted patients are diagnosed with C19, and down when C19 patients die or are released from the hospital, or when patients considered to be probable cases receive negative confirmatory test results. Cumulative hospitalization numbers are intended to capture all C19 patients admitted to hospitals, but this number also changes as patients are diagnosed with C19, or when probable cases of C19 are ruled out by negative confirmatory test results.
- Because the two hospitalization metrics are fundamentally different kinds of quantities, we could not merge them into a single number that answered the most pressing question: how many people were in the hospital with C19?
- More than two months from when we started compiling hospitalization data, 47 states, 2 territories, and the District of Columbia now report the number of people currently hospitalized. This has allowed us to create useful national summary statistics about this crucial metric of disease severity.
- One state with worrying case and test positivity trends that doesn’t show up in the hospitalization data is Florida. Its seven-day average for daily new case counts was under 1,000 at the beginning of June; by July 2, the average was over 7,800. Test positivity rose from 5.5% in the first week of June to 16.6% in the last week. Given those trends, hospitalizations would be expected to climb—but the state hasn’t reported C19–specific hospitalization data except in a single week in May.
- Hawaii, Idaho, and Kansas also don’t report how many C19 patients are currently hospitalized, but none are as populous as Florida. While case counts are rising in Idaho and Kansas, the case counts are lower and the rise in new cases is still shallower than in Florida.
- The South Florida Sun-Sentinel tracked down hospitalization data from three counties in its region that runs through June 24. As of that date, Miami-Dade County had 981 hospitalized C19 patients, a high since April and up from 787 since June 1. Hospitalizations in Broward County doubled in that timeframe; they were up from 245 to 394 in Palm Beach County. Those are the three largest counties in Florida. In Hillsborough, the fourth-largest, hospitalized patients increased from 196 to 267 from June 18-25 (as positive cases rose 61 percent to over 7,000). In the fifth-largest, Orange County, the Orlando Sentinel reports that 185 patients were hospitalized on June 26. That’s up from 73 on June 15, and a low of 27 on May 10.
Estimating the true extent of C19 hospitalizations in the US
- Because Florida isn’t reporting statewide totals, our regional hospitalization data for the South is considerably lower than the true count. And even without Florida, the trends there are the worst of any US region. The chart below shows estimates of the true hospitalization count for each region with non-reporting states included; the trend in the South is the same with and without Florida’s estimate. C19 hospitalizations in the West are also rising, though not as drastically.
- To derive the estimates in the chart, we take the number of cases reported in a given region over the prior two weeks and calculate the share of those cases that came from states that are not reporting current C19 hospitalizations. We then estimate current hospitalizations for non-reporting states, so that these states have hospitalization estimates proportional to their share of cases. For these states, we assume that the relationship between new cases and hospitalizations is the same as the region as a whole.
- As the chart shows, the national C19 death curve has been closely related to the hospitalization curve until early June. But there’s no reason to think deaths won’t go up again in regions and states where hospitalizations are currently increasing, especially in places where C19 hospitalizations have risen sharply, like Arizona and Texas. [Note: We believe that this statement is incorrect. There are reasons to think that the fatality rate is declining and, as a result, the number of new deaths may not increase nearly as much as increases in new hospitalizations (or new cases).] What remains to be seen is how steeply death counts will rise. It’s possible the rise in deaths will not be as dramatic, given the changing demographics of the infected, the precedent of Milan and England, and lessons learned about treatment since the beginning of the pandemic. But even if a greater percentage of hospitalized C19 patients survive, they could face considerable health problems that we still know very little about.
- [NOTE: In the chart above, Estimated Hospitalizations is the gray-dotted line, which trends above the red-dotted line (Reported Hospitalizations). What the chart shows is that around June 1, the 7-day Average Death line (solid black) breaks from the Hospitalization lines, and has been trending down for more than one month. This trend would seem to support the observations that the overall death rate is declining.]
J. The Road Back?
1. A Cheap, Simple Way to Control the Coronavirus
By Laurence J. Kotlikoff and Michael Mina
- Simple at-home tests for the coronavirus, some that involve spitting into a small tube of solution, could be the key to expanding testing and impeding the spread of the pandemic. The FDA should encourage their development and then fast track approval.
- One variety, paper-strip tests, are inexpensive and easy enough to make that Americans could test themselves every day. You would simply spit into a tube of saline solution and insert a small piece of paper embedded with a strip of protein. If you are infected with enough of the virus, the strip will change color within 15 minutes.
- Your next step would be to self-quarantine, notify your doctor and confirm the result with a standard swab test — the polymerase chain reaction nasal swab. Confirmation would give public health officials key information on the virus’s spread and confirm that you should remain in quarantine until your daily test turned negative.
- E25Bio, Sherlock Biosciences, Mammoth Biosciences, and an increasing number of academic research laboratories are in the late stages of developing paper-strip and other simple, daily C19 tests. Some of the daily tests are in trials and proving highly effective.
- The strips could be mass produced in a matter of weeks and freely supplied by the government to everyone in the country. The price per person would be from $1 to $5 a day, a considerable sum for the entire population, but remarkably cost effective.
- Screening the population for infection, however, is different from determining whether someone is infected.
- The FDA has recently approved group P.C.R. testing to screen large numbers of people. (Group testing, which is used in other countries, assays multiple swab samples at once and if the virus is found, individuals are tested.) So there is reason to hope that the FDA will also approve paper-strip tests as a way to find out where the virus has spread.
- Hope needs to be replaced with surety. Biotech companies are reluctant to take these tests to market for fear that the FDA will disparage them for being less sensitive than the nasal swab tests. The nasal swab test can detect extremely small quantities of viral particles.
- But the problem with the nasal swab tests is their cost, which ranges from $50 to $150. They also require laboratory assessment, which can take days. That is why, the CDC reports, nine of 10 infected Americans never get tested. It’s also why those who do get tested, generally are tested only once.
- Clearly, if you’re infected and never tested, you can unwittingly spread the virus. And if you are tested, but just once, and the test comes back negative, you may still later become infectious. Finally, if your polymerase chain reaction swab is positive, but it takes five days to learn the result, you may spend those days transmitting the disease.
- Group testing can dramatically lower nasal-swab-testing costs for universities and large companies. But absent federal coordination, it can’t be used routinely to test all Americans.
- We need the best means of detecting and containing the virus, not a perfect test that no one can use. That is where paper-strip testing would have the advantage. Their ability to be used more frequently would trump the nasal swab test’s higher sensitivity. Paper-strip testing would also sharply improve diagnosis as those with a positive paper-strip test would still be given a nasal swab test.
- Would everyone take a paper-strip test every day? Here market incentives will surely help. Once they are provided to all, employers would likely require their workers to take time-dated pictures of their negative test results before coming to work. Colleges would require students to do the same before coming to class. Restaurants could accept reservations only if accompanied by negative-test pictures. In short, everyone will have an incentive to test themselves daily to participate fully in the economy and return to normal life.
- Once paper strips’ efficacy is definitively proved and they are cleared by the FDA, Congress can quickly authorize the production and distribution, for free, of a year’s supply to all Americans. Then we’ll have not only a true day-to-day sense of C19’s path. We’ll also have a far better means to quickly contain and end this terrible plague.
2. Lab Made Antibodies Can Be the Bridge to a Vaccine
Opinion by Luciana Borio and Scott Gottlieb
- America’s coronavirus epidemic has taken a turn for the worse, with many more states showing sharp increases in daily cases compared with two weeks ago. How long will it take for researchers to catch up and develop more effective therapies against C19?
- The federal government’s Operation Warp Speed is working with drugmakers to accelerate the development and manufacturing of vaccines. Five candidates are in clinical trials, including one from Pfizer (on whose board one of us, Dr. Gottlieb, sits). More vaccines are expected to enter such trials soon. A safe and effective vaccine is the best hope for ending the pandemic and fully restoring the economy. Everyone is hoping for success—and quickly.
- But the path to a vaccine can be long and complex. Enrolling patients in clinical trials, ramping up factories, and producing sufficient supply is an intricate process that can take many months. Distributing vaccines also takes time, and so does encouraging Americans to take them. With so many uncertainties, vaccines aren’t likely to be available widely until next year. That means we need to pursue other potential antidotes.
- One promising option is monoclonal antibodies—lab-produced molecules engineered to mimic antibodies that occur naturally in response to an infection or vaccine. Like natural antibodies, the lab versions bind to the virus and prevent its spread. Regeneron, Vir, Eli Lilly and others are developing this class of drugs for Covid. Several are in clinical trials.
- The trick will be producing them at scale. For a cautionary tale, consider the antiviral drug remdesivir, which has shown benefits against Covid and is authorized for use by the FDA. Supply wasn’t ramped up enough in advance, so there may be shortages as the epidemic worsens. It’s important not to repeat that mistake with antibodies.
- Antibody drugs have a record of treating viral diseases such as Ebola and might be a bridge to a vaccine. These treatments can be administered to those exposed to coronavirus and used as a prophylaxis to prevent them from developing the disease. Antibodies can also reduce the severity of the disease in infected patients.
- Moreover, antibodies are a hedge against the risk that the virus mutates in ways that evade other drugs or vaccines. Antibodies can be administered as a mixture of different molecules that target different parts of the virus. Drugmakers can engineer the antibodies to stay in the body for months, which offers lasting protection the way a vaccine does. As important, antibodies can protect the elderly and the immunocompromised, whose immune systems often fail to mount an effective response to vaccines. Best of all, these drugs can be available as soon as this fall.
- The problem is the limited capacity to make enough product to meet demand during a pandemic. A recent report by the Duke Margolis Center for Health Policy estimates that it would take at least 25 million doses of antibodies to give the therapies to symptomatic people and their close contacts over the next year, assuming the number of cases holds roughly steady to the levels of mid-June. That’s about half as many antibodies as the U.S. produces each year in supplying the 100 different antibody products approved for a range of other diseases.
- Operation Warp Speed focuses on finding and making vaccines. The government should set up a parallel effort for antibodies, as even a limited supply could save many lives. Government should work with drugmakers to free up domestic manufacturing plants to start making more of these antibody drugs even before the FDA approves them. That way America can have a large supply on hand if one or more prove safe and effective. To avoid disruption to the supply of other antibody drugs, companies could be asked to quickly make and stockpile extra doses of their existing medicines.
- Ultimately, the hope is crushing C19 with a vaccine. But the epidemics raging in the Sun Belt suggest that the virus’s wrath will be a threat through the summer, fall and winter. Combining public-health measures, such as face masks and distancing, with technology like monoclonal antibodies is the best hope for faster progress.
3. Rapid testing will allow Americans to attend sporting events this fall
- Rapid coronavirus testing, which can produce results in under an hour, will allow Americans to attend crowded sports events in time for the fall football season, a top U.S. health official said Thursday.
- “We want to see Americans have a chance to have some normal experiences of enjoying life,” National Institutes of Health Director Dr. Francis Collins said during a coronavirus hearing with the U.S. Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies. “I do believe this should be possible.”
- Sports fans and athletes across the world have been frustrated by canceled games as public health officials urge event-based businesses to temporarily close due to the coronavirus rapidly spreading across the globe.
- Collins told lawmakers that U.S. health officials are putting together a point-of-care coronavirus test that can give results within an hour and be administered at sporting events.
- “And I think the general sense is for athletic teams, you really need to know that, otherwise you’re going to have an outbreak that will wipe out the entire team,” he said.
- The comment by Collins came weeks after White House coronavirus advisor Dr. Anthony Fauci expressed doubt over the National Football League playing this year.
- The NFL is reportedly optimistic it can begin its season in 2020 amid the pandemic.
- “Unless players are essentially in a bubble — insulated from the community and they are tested nearly every day — it would be very hard to see how football is able to be played this fall,” Fauci told CNN last month. “If there is a second wave, which is certainly a possibility and which would be complicated by the predictable flu season, football may not happen this year.”
K. Technology vs. Coronavirus
1. New technologies to keep offices clear of coronavirus
- Employers are looking at a range of innovations aimed at making workplaces safe
- As economies emerge from hibernation, employers are rushing to make workplaces safe with rudimentary tools such as hand sanitiser, face masks and the use of stairs rather than lifts. But engineers are developing more radical technologies to keep the virus out of offices.
- The big challenges posed by the virus indoors are the collection of particles on surfaces and the flow of air between individuals. “Pandemics like this can provide fertile ground for creative minds to think about how to do things differently,” said Shaun Fitzgerald, visiting professor at the University of Cambridge.
- Many of the innovations, however, will not come cheap. Here are some of the emerging options:
- Viruses and bacteria can survive for a long time on surfaces and can be stubbornly resistant to cleaning. On plastics and steel, for example, the novel coronavirus can live for up to 72 hours.
- Silver and copper, by contrast, are known to kill viruses and bacteria within four hours. But “the timeframe we need is seconds to minutes, and it needs to be built into the materials”, says Felicity de Cogan, research fellow at the University of Birmingham.
- She is also founder of NitroPep, a company that is developing layers of material with tiny spikelike particles that puncture and kill viruses within minutes.
- NitroPep’s spikes are tiny antimicrobial agents that can be added to desks, walls and other surfaces and rupture anything with a membrane that lands on them.
- “It doesn’t require a change in behavior, it just sits there and kills whatever lands on it,” said Ms de Cogan. The spikes cannot be felt by anyone running their hand across the surface.
- The technology is untested for coronavirus, but when it was piloted for a year on a Royal Navy ship it removed more than 95% of bacteria such as E.coli and MRSA, which is resistant to many forms of antibiotics. How effective the technology is at killing viruses such as Sars-Cov-2, which causes C19, remains to be seen.
- If deemed to be effective for the novel coronavirus, Ms de Cogan says she will look to apply the microscopic spikes to handles and seating on public transport and use them for self-cleaning protective equipment.
- Although exact pricing has not been determined, the technology has been designed to be “very economical so that it can be used as widely as possible”, Ms de Cogan said.
- Some experts have reservations. “We’re not going to be able to cover every product and material we touch with self-cleaning surfaces,” said Joseph Gardner Allen, assistant professor at the Harvard TH Chan School of Public Health.
Germicidal ultraviolet Irradiation
- Coronavirus has brought a new lease of life to a decades-old technology known as “germicidal ultraviolet” — beams of UV light that kill micro-organisms by mangling RNA in viruses and DNA in bacteria and fungi.
- It already has a track record: during a series of drug-resistant tuberculosis outbreaks in the 1980s researchers found that placing UV lamps on the ceiling of large rooms effectively stopped transmission of the disease.
- It is particularly recommended in crowded and poorly ventilated environments such as food manufacturing facilities, warehouses and airports.
- Coronavirus has even turbocharged demand for UV disinfecting robots. Danish company UVD Robots was the first company to invent these machines, which travel around buildings emitting UV light that leaves bacteria and viruses too damaged to function. The robots, which sell for roughly €60,000, can already be found at hospitals, hotels, offices and airports around the world, including London’s Heathrow.
- However, there are real concerns about UV radiation causing skin and eye damage to humans. That means it has to be placed high up and encased in light fixtures or air conditioning systems, while the robots are programmed to operate only at night when no one is around.
Monitoring a building’s pulse
- Real-time environmental monitors that “check the pulse” of a building already exist to assess things like CO2 levels and could be retuned to focus on the virus.
- Some researchers in Switzerland are trying to develop sensors that detect the virus itself. Researchers at the Swiss Federal Institute of Technology (ETH Zurich) and Swiss Federal Laboratories for Materials Science and Technology (Empa) have developed a sensor set inside a chamber that emits a light signal if it comes into contact with the virus’s RNA.
- Testing in real life environments — including hospitals, train stations and shopping malls — will start in the next few months.
Ventilation is key
- While high tech solutions may show promise, some engineers argue that the cost of implementation and speed of delivery mean that the focus now should be on simpler upgrades to existing systems. Chief among them are heating, ventilation and air conditioning (HVAC) systems.
- They can play a key role in preventing the accumulation of tiny airborne microdroplets known as “aerosols”, but in many cases there is room for improvement. The minimum ventilation flow rate is typically 5-10 litres of fresh air per person per second, but some buildings can have just 1 litre per person per second.
- Many ventilation systems also circulate air from one indoor space to another, increasing the risk of airborne infection. Instead, each room needs to be pumped full of 100% outdoor air wherever possible, engineers say.
- “You always want the air to move from clean to dirty and then out. In the bathroom, you want it to move from indoor, to bathroom and then out through the exhaust,” said Mr Allen.
- Wirth Research, based in Oxford and set up by Nick Wirth, a former Formula One technical director, is developing a system to destroy airborne particles from some of the least ventilated spaces — notably passenger lifts (elevators) and aeroplanes.
- Cool indoor air is circulated out of the space into a “viral furnace” where it is heated to more than 95C to kill any pathogens and then cooled and filtered back in. Mr Wirth estimates that installing the system in a small space such as a lift would cost several thousand pounds.
- The process of heating and then cooling air is fairly energy intensive but Mr Wirth argues that it will be essential to ensure the safety of some of the most stagnant environments.