July 11, 2020
Reliable information is the best tool available to protect your family from the pandemic and its shockwaves
“States with major outbreaks should seriously look at shutting down again.”Dr. Fauci
“We all want to avoid whole countries going back into total lockdown, that is not a desire that anybody has. But there may be situations in which that is the only option.”Dr. Michael Ryan, executive director of WHO’s Health Emergencies Program
“The wearer of the mask, even the standard rectangular surgical masks … will decrease the risk of infection by the person wearing the mask by about 65%.”Dean Blumberg, chief of pediatric infectious diseases at UC Davis Children’s Hospital
A. The Pandemic As Seen Through Headlines
B. Numbers & Trends
C. Assessing & Reducing Risk
- Are You Ready for a Second Wave? It’s Not Too Early to Start Preparing.
- Factors that put you at higher risk of dying from C19
- Wearing a mask cuts your risk of becoming infected by 65%
D. New Scientific Findings & Research
- Pathophysiology, Transmission, Diagnosis, and Treatment of C19
- Preliminary study suggests tuberculosis vaccine may reduce C19 deaths
- Researchers propose novel approach to limit organ damage for patients with severe C19
- A plasma shot could prevent coronavirus, but is not a priority for the government or industry
- Single-cell RNA sequencing outlines the immune landscape of severe C19
- Neutralizing antibodies in the battle against C19
- Supercomputer Finds Existing Drug With Potential for Treating C19
E. Improved & Potential Treatments
- Remdesivir reduces risk of death in severely sick patients by 62%
- New study supports remdesivir as C-19 treatment
- Doctors are Better at Treating C19 Patients Than They Were in March
F. Concerns & Unknowns
- Self-isolation may increase susceptibility to C19
- China Points to Shrimp as Virus Carrier
- ‘Unknown pneumonia’ deadlier than coronavirus sweeping Kazakhstan
G. Conflicting Findings & Information
H. Back to School!?
- Children don’t transmit C19, schools should reopen in fall
- School openings across globe suggest ways to keep coronavirus at bay, despite outbreaks
- Students Will Pay a High Price for School Closures
- Coronavirus Is Blowing Up America’s Higher Education System
I. The Road Back?
J. Projections & Our (Possible) Future
- Are C19 Polls Leading to Poor Policy Decisions?
- Hard Hit Neighborhoods May Be Close to Herd Immunity
K. Practical Tips & Other Useful Information
L. Johns Hopkins COVID-19 Update
M. Links to Other Stories
A. The Pandemic As Seen Through Headlines
(In no particular order)
- A new surge in virus deaths
- US deaths near 1,000 for 4th day
- Six US states see record surges in COVID-19 cases, Florida becomes epicenter
- The death toll is edging up in several states, which may end a long period in which the national toll has steadily declined
- Patients Swamp Sun Belt Hospitals With Covid-19 on a Rampage
- Testing Bottlenecks Keep States From Tamping Down Virus
- Cases in the U.S. military have more than doubled over the last month, reaching a total of 16,637, according to Pentagon data
- Black and Hispanic Americans dying at younger ages from Covid-19
- Time to shut down again? As coronavirus cases surge, a growing chorus makes the case
- Trump says Fauci has ‘made a lot of mistakes’ on coronavirus
- CDC feels pressure from Trump as rift grows over coronavirus response
- Chinese Virologist Flees Hong Kong, Accuses Beijing Of COVID-19 Cover-Up
- Mississippi’s five largest medical centers out of ICU beds
- Michigan Gov. Whitmer signed an order requiring residents to wear masks in indoor public spaces and in crowded outdoor areas. Violators may be punished by a $500 fine.
- Kentucky Gov. Beshear announced that masks will be mandatory in many public settings starting today
- In a rollback, Nevada Gov. Sisolak said the state will close bars in some counties and limit indoor and outdoor dining to parties of up to 6 people
- Atlanta Mayor Set To Reimpose Lockdown As Cases Surge, Defying Gov. Kemp
- In South Carolina, selling alcoholic drinks in restaurants and bars will be banned over concerns about the virus’s spread among young people.
- Top Pediatrician Says States Shouldn’t Force Schools To Reopen If Virus Is Surging
- The Los Angeles teachers union called on the LA Unified School District to keep campuses closed when school resumes in August
- Virus Ravaging Historic Prison Spirals Into Health Crisis
- Georgia reopens convention center in Atlanta to treat COVID patients
- Phoenix mayor says hospital running out of morgue space
- California positivity rate ticks higher
- Trump says Fauci “A nice man”, but “he’s made a lot of mistakes”
- Dr. Fauci says ‘divisiveness’ not helping pandemic
- Arizona sees ICU beds steady at 89%, reports 4,221 new cases
- Florida sees 2nd day of 11k+ positivity rate drops to 12.4%
- UK cases creep higher, deaths flat
- In Sweden, only 70 COVID deaths involved people under 49
- Kudlow says Trump will not tolerate US shutdown
- US sees deaths top 800 for fourth straight day
- Philippines reports daily record
- Arizona Gov. orders indoor dining at max 50% capacity
- Tokyo reports another daily record
- Texas Gov. warns outbreak going to get worse, pleads with people to wear masks
- India cases top 400,000
- Japan sees record 430 new cases
- Victoria reports 216 new cases
- Australian official: vaccine may be 2 years away still
- Clinicians brace for mental health impact of coronavirus reopening reversals
- NJ Gov. Murphy: Giants, Jets won’t have to quarantine before training camp
- Gov. Cuomo predicts COVID-19 bump for NY amid surge in other states
- Cuomo shipping remdesivir to Florida to help fight COVID-19
- California will release 8,000 prisoners to stop spread of COVID-19
- Florida governor says if Walmart is open, schools should be too
- NY allowing family nursing home visits for first time since pandemic
- Herd immunity played no role in decreasing COVID-19 cases: NYC’s top doctor
- Republicans look into holding their convention outdoors
- Gilead Says Remdesivir Linked to a Reduction in Mortality Risk
- German Biotech Sees Its Coronavirus Vaccine Ready for Approval by December
- Who Gets a Vaccine First? U.S. Considers Race in Coronavirus Plans
- New pharma-led fund aims to boost antibiotic development
- Senators introduce bill that would require plan for pandemic testing
- Universal Coronavirus & Influenza Vaccines: Osivax secures funding COVID-19 can be transmitted in the womb, reports pediatric infectious disease journal
- It’s time to begin a national wastewater testing program for Covid-19
- TSA head orders new virus safety measures after meeting whistleblower
- FDA official casts doubt on ‘challenge trials’ for Covid-19 vaccine
- NIH launches clinical trials network to test COVID-19 vaccines and other prevention tools
- Americans Are Bewildered by Patchwork of Social-Distancing Rules
- People are just fatigued. They are tired of staying inside.
- Simple daily life tasks have become risk assessment fraught with the weight of life or death decisions
- Mayor of Alabama city since 1984 dies of COVID-19
- WHO promises ‘honest evaluation’ of how world handled COVID-19
- Several Disney parks will reopen on Saturday for a limited number of visitors
- Disney World ripped over indoor, mask-free ‘relaxation zones’
- A New World Order for the Coronavirus Era Is Emerging
- The U.K. goes (slowly) back to the pub
- British PM Boris Johnson tells country to ‘go back to work’
- Coronavirus spikes could mean return to lockdowns, WHO warns
- Looks Like Sweden Was Right After All
- Major Tax Increases Are About To Slam America As Cities & States Want You To Pay For COVID Fallout
- Hong Kong, facing a third wave of the virus driven by locally transmitted infections, shut down its school system today
- Japan Pushes Re-Opening as New Virus Cases Reach Record in Tokyo
- Virus Unrest Turns Violent As Serbs Protest Being “Lied To For Political Ends”
- EU Says U.K.’s Brexit Stance Will Add to Virus Damage for Firms
- Singaporeans Head to the Polls as the City Grapples With the Virus
- Masks Key to Reopening Australia’s Victoria, Officials Say
- China Buying ‘Practically Zero’ Chile Salmon After Covid Scare
- Countries around the world are hoping to recoup some of their tourism losses by enticing people to spend money at home
- ‘They could have stopped the plague’: Trump says China trade deal unlikely after coronavirus
- Economy Won’t Recover Until At Best 2023
- Our itch to share helps spread COVID-19 misinformation
- Masked Fans Return to Stadiums as Baseball Inches Back in Japan
- On Some Planes, Empty Rows While Passengers Crowd Together
- As Trump Pushes for Reopenings, Congregations Choose Safety Over Haste
- Churches Were Eager to Reopen. Now They Are Confronting Coronavirus Cases
- “It’s Going To Be A Mess” – Quarter of NYC Renters Haven’t Paid Since March
- Lou Holtz rails against canceling college sports: ‘What has happened to our way of life?’
- NHL and players union officially reach agreement to resume play
- Jail won’t issue inmates face masks because ‘they’re going to eat them’
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 = 12,616,579 (+1.9%)
- New Cases = 237,320 (+13,664)
- Growth Rate of New Cases (7 day average) = 2.2%
- New Cases (7 day average) = 204,974 (+4,363)
- Number of new cases on 7/10 was a record high
- Number of new cases has increased for 4 consecutive days
- 7 day average of new cases on 7/10 was a record high
- 7 day average of new cases has increased every day since 5/26
US Cases & Testing:
- Total Cases = 3,291,786 (+2.2%)
- New Cases = 71,787 (+10,720)
- Percentage of New Global Cases = 30.2%
- Growth Rate of New Cases (7 day average) = 3.4%
- New Cases (7 day average) = 56,549 (+1,839)
- Total Number of Tests = 41,010,213
- Percentage of positive tests (7 day average) = 8.3%
- Number of new cases on 7/10 was a record high
- Number of new cases have been rising rapidly since 6/10
- 7 day average growth rate is high (and increasing)
- 7 day average of new cases on 7/10 was a record high
- 7 day average of new cases have increased every day since 6/9
- Percentage of positive tests has been steadily increasing since 6/21
- Total Deaths = 562,039 (+1.0%)
- New Deaths = 5,530 (+13)
- Growth Rate of New Deaths (7 day average) = 0.8%
- New Deaths (7 day average) = 4,804 (+37)
- Number of new deaths has been relatively stable since 7/4
- Number of new deaths is 34.8% less than the peak (8,485) on 4/17
- 7 day average of new deaths has increased slightly since 7/4
- 7 day average of new deaths is 31.7% less than peak (7,036) on 4/18
- Total Deaths = 136,671 (+0.6%)
- New Deaths = 849 (-111)
- Percentage of Global New Deaths = 15.4%
- Growth Rate of New Deaths (7 day average) = 5.1%
- New Deaths (7 day average) = 657 (+32)
- The number of new deaths is lowest in 4 days, but remains high
- 7 day average growth rate of new deaths is very high
- 7 day average of new deaths has increased 27.4% since 7/5
- Spike in new deaths began on 7/7, approx. 2 weeks after new cases began to rapidly increase
3. Top 5 States in Cases & Deaths (7/10)
C. Assessing & Reducing Risk
1. Are You Ready for a Second Wave? It’s Not Too Early to Start Preparing.
- In evaluating our risk, we have to evaluate whether there will be a Second Wave. While no one can know for sure, the history of past pandemics indicates that there is a very good chance that there will be a Second Wave. Let’s assign at least a 50% risk of a Second Wave occurring this fall/winter.
- We also have to evaluate whether a Second Wave will be worse than the First Wave? Same answer. While no one can know for sure, the history of past pandemics indicates that there is a very good chance that a Second Wave will be worse than the First Wave, and possibly a lot worse. So, let’s assign at least a 50% risk of a Second Wave being worse than a First Wave.
- Under this analysis, there is a 25% risk of a severe Second Wave. Even if you do not agree with the risk assessment, the risk is unquestionably more than 0% — a lot more in our view. Regardless of your assessment of the percentage risk of a Second Wave, can you risk being unprepared for a severe Second Wave?
- In order to answer that question, we need to identify the implications of a Second Wave? First, supply chains are likely to become more stressed than the First Wave. So, everything in short supply in the First Wave will be in short supply again – including toilet paper, paper towels, sanitizers, N95 masks, meat, drugs, etc. And, if supply chains have not fully recovered at the start of a Second Wave, supply disruptions may be more severe than during the First Wave. Moreover, if a Second Wave is worse, then supply disruptions may be more extensive than during the First Wave.
- In addition, if there is a Second Wave, then there is a high risk that there will be more lockdowns, resulting in disruptions in earnings and life activities such as schools, gatherings and travel. Increased social unrest would also be a possibility.
- Things will only get worse if the Second Wave is worse than the First Wave.
- Using a risk-benefit analysis, we believe that the low cost of preparing versus the potentially very high cost of being unprepared makes the decision pretty simple. Preparing for a Second Wave is low cost insurance against a potentially disruptive and catastrophic event that could have a material adverse effect on your family.
- As preparing for a Second Wave is prudent, what should we do and when. We will be talking about these two topics in future Updates, but we note once the risk is perceived by a large number of people, it will be more difficult if not impossible to adequately prepare as rapid increases in demand could easily overwhelm the supply chain as we saw occur during the First Wave. So, the sooner you prepare, the better.
- If anyone believes that there is no need to prepare for a Second Wave, we would very much like to hear and share your point of view.
2. Factors that put you at higher risk of dying from C19
- A study of more than 17,000,000 people in England has confirmed the various factors that are linked with an increase in a person’s risk of dying from C19: age; being male, Black, or from an ethnic minority background; or having underlying health conditions. It confirms a lot of previous research, but it’s by far the largest study yet. It was published in Nature yesterday.
- The researchers used pseudonymized health records from about 40% of England’s population—17,278,392 adults—of whom 10,926 were recorded as dying from C19 or related complications. They plugged this data into a health analytics platform they’d built, called OpenSAFELY. The team has said it will keep adding to the platform as more patients’ records become available.
What they found:
- As we knew, age is the single biggest indicator of whether someone is likely to die from the coronavirus, and the risk increases sharply among those over 80. People older than 80 were hundreds of times more likely to die than people under 40, and more than 90% of deaths in England were in people over 60.
- Men were more likely to die than women of the same age: Men accounted for 60% of all deaths.
- People with underlying medical conditions like obesity, diabetes, severe asthma, and cardiovascular disease were at higher risk, as were people with lower incomes.
- The study confirmed that Black and South Asian people, as well as those from other ethnic minority groups, were more likely to die than white patients. The researchers could not establish why there is such a big ethnic disparity, saying that “only a small part of the excess risk is explained by higher prevalence of medical problems such as cardiovascular disease or diabetes among BME people, or higher deprivation.”
- In the US, Black and Latino people are almost twice as likely to die as white people, according to data obtained from the CDC.
- Read the Nature study here: OpenSAFELY: factors associated with COVID-19 death in 17 million patients
3. Wearing a mask cuts your risk of becoming infected by 65%
- Health experts have stressed the importance of wearing a mask to limit the possibility of infecting others with C19, but a range of new research now suggests they also protect the wearer, according to a report Monday.
- With many states implementing policies to make face coverings mandatory in both indoor and outdoor spaces, one doctor says that masks also reduce the risk of infection to the wearer by 65%.
- “We’ve learned more due to research and additional scientific evidence and now we know [that] not only wearing a mask prevents the person wearing the mask to transmit to others, but wearing the mask protects the person who’s wearing it,” said Dean Blumberg, chief of pediatric infectious diseases at UC Davis Children’s Hospital.
- “So the wearer of the mask, even the standard rectangular surgical masks … will decrease the risk of infection by the person wearing the mask by about 65%.”
- He added that N95 masks do an even better job at protecting people from the virus, but they are in short supply and are needed for healthcare professionals.
- Blumberg and William Ristenpart, a professor of chemical engineering at UC Davis, appeared on UC Davis Live: Coronavirus Edition to discuss the topic of transmission. Ristenpart’s lab at UC Davis has studied how people emit small droplets while breathing or talking that could carry the virus.
- The pair highlighted two primary methods of transmission. The first being visible droplets a carrier expels, which are roughly one-third the size of a human hair. They said masks create an effective barrier against those types of droplets.
- “Everyone should wear a mask,” Blumberg said. “People who say, ‘I don’t believe masks work,’ are ignoring scientific evidence. It’s not a belief system. It’s like saying, ‘I don’t believe in gravity.’”
- The second is via the aerosol particles we expel when we talk. They are about 1/100th the size of a human hair and are more difficult to defend against. He said that’s because the smaller particles could still sneak through a gap in rectangular or homemade cloth masks.
- Social distancing and staying outdoors are helpful for staying clear of the small particles because there is more airflow, Blumberg and Ristenpart said.
- “Studies in laboratory conditions now show the virus stays alive in aerosol form with a half-life on the scale of hours. It persists in the air,” Ristenpart added. “That’s why you want to be outdoors for any social situations if possible. The good airflow will disperse the virus. If you are indoors, think about opening the windows. You want as much fresh air as possible.”
- He said that’s why enclosed areas like bars — seen as hotspots for contracting the virus — are particularly dangerous: “The louder you speak, the more expiratory aerosols you put out.”
- “So we don’t know who might spread it,” Blumberg said. “We do know social distancing reduces the risk of transmitting the virus by 90 percent, and wearing masks decreases the risk by 65 percent.
D. New Scientific Findings & Research
1. Pathophysiology, Transmission, Diagnosis, and Treatment of C19
- The coronavirus is spread primarily via respiratory droplets during close face-to-face contact.
- Infection can be spread by asymptomatic, presymptomatic, and symptomatic carriers. The average time from exposure to symptom onset is 5 days, and 97.5% of people who develop symptoms do so within 11.5 days.
- The most common symptoms are fever, dry cough, and shortness of breath. Radiographic and laboratory abnormalities, such as lymphopenia and elevated lactate dehydrogenase, are common, but nonspecific.
- Diagnosis is made by detection of the coronavirus via reverse transcription polymerase chain reaction testing, although false-negative test results may occur in up to 20% to 67% of patients; however, this is dependent on the quality and timing of testing.
- Manifestations of C19 include asymptomatic carriers and fulminant disease characterized by sepsis and acute respiratory failure. Approximately 5% of patients with C19, and 20% of those hospitalized, experience severe symptoms necessitating intensive care. More than 75% of patients hospitalized with C19 require supplemental oxygen.
- Treatment for individuals with C19 includes best practices for supportive management of acute hypoxic respiratory failure.
- Emerging data indicate that dexamethasone therapy reduces 28-day mortality in patients requiring supplemental oxygen compared with usual care (21.6% vs 24.6%; age-adjusted rate ratio, 0.83 [95% CI, 0.74-0.92]) and that remdesivir improves time to recovery (hospital discharge or no supplemental oxygen requirement) from 15 to 11 days.
- In a randomized trial of 103 patients with C19, convalescent plasma did not shorten time to recovery.
- Ongoing trials are testing antiviral therapies, immune modulators, and anticoagulants.
- The case-fatality rate for C19 varies markedly by age, ranging from 0.3 deaths per 1000 cases among patients aged 5 to 17 years to 304.9 deaths per 1000 cases among patients aged 85 years or older in the US.
- Among patients hospitalized in the intensive care unit, the case fatality is up to 40%.
- At least 120 coronavirus vaccines are under development.
- Until an effective vaccine is available, the primary methods to reduce spread are face masks, social distancing, and contact tracing.
- Monoclonal antibodies and hyperimmune globulin may provide additional preventive strategies.
2. Preliminary study suggests tuberculosis vaccine may reduce C19 deaths
- One of the emerging questions about the coronavirus that scientists are working to understand is why developing countries are showing markedly lower rates of mortality in C19 cases than expected.
- Research by Assistant Professor Luis Escobar of the College of Natural Resources and Environment and two colleagues at the National Institutes of Health suggests that Bacille Calmette-Guérin (BCG), a tuberculosis vaccine routinely given to children in countries with high rates of tuberculosis infection, might play a significant role in mitigating mortality rates from C19. Their findings have been published in the Proceedings of the National Academy of Sciences.
- “In our initial research, we found that countries with high rates of BCG vaccinations had lower rates of mortality,” explained Escobar, a faculty member in the Department of Fish and Wildlife Conservation and an affiliate of the Global Change Center housed in the Fralin Life Sciences Institute. “But all countries are different: Guatemala has a younger population than, say, Italy, so we had to make adjustments to the data to accommodate those differences.”
- Escobar, working with NIH researchers Alvaro Molina-Cruz and Carolina Barillas-Mury, collected coronavirus mortality data from around the world. From that data, the team adjusted for variables, such as income, access to education and health services, population size and densities, and age distribution. Through all of the variables, a correlation held showing that countries with higher rates of BCG vaccinations had lower peak mortality rates from C19.
- One sample that stood out was Germany, which had different vaccine plans prior to the country’s unification in 1990. While West Germany provided BCG vaccines to infants from 1961 to 1998, East Germany started their BCG vaccinations a decade earlier, but stopped in 1975. This means that older Germans — the population most at risk from C19 — in the country’s eastern states would have more protection from the current pandemic than their peers in western German states. Recent data shows this to be the case: western German states have experienced mortality rates that are 2.9 times higher than those in eastern Germany.
- “The purpose of using the BCG vaccine to protect from severe C19 would be to stimulate a broad, innate, rapid-response immunity,” said Escobar, who noted that the BCG vaccines have already been shown to provide broad cross-protections for a number of viral respiratory illnesses in addition to tuberculosis.
- Escobar stresses that the team’s findings are preliminary, and that further research is needed to support their results and determine what the next steps should be for researchers. The World Health Organization noted that there is no current evidence that the BCG vaccine can protect people from C19 infections, and stated that it does not currently recommend BCG vaccinations for the prevention of C19. There are currently clinical trials underway to establish whether BCG vaccination in adults confers protection from severe C19.
- “We’re not looking to advise policy with this paper,” Escobar said. “This is, instead, a call for more research. We need to see if we can replicate this in experiments and, potentially, in clinical trials. We also need to come back to the data as we get more information, so we can reevaluate our understanding of the coronavirus pandemic.”
- Barillas-Mury, a chief researcher who specializes in mosquito-borne disease vectors, noted that establishing a link between BCG vaccines and C19 case severity could result in attempts to stockpile doses of the BCG vaccine, placing countries with high tuberculosis rates at risk.
- “If the BCG vaccine is protective, production would have to increase to meet the sudden spike in vaccine demand in order to prevent a delay in distribution to countries that very much need it to fight tuberculosis,” she said.
- While a direct correlation between BCG vaccinations and a reduction in coronavirus mortalities still needs to be understood more fully, researchers hold hope that the BCG vaccine might be able to provide at least short-term protections against severe C19, particularly for front-line medical workers or high-risk patients. And, if BCG does provide short-term protection, there are longer term considerations about how countries could best utilize BCG vaccines to reduce mortality rates for future viral outbreaks that target the human respiratory system.
3. Researchers propose novel approach to limit organ damage for patients with severe C19
- Patients with severe C19 frequently experience a life-threatening immune reaction, sometimes called a cytokine storm, which can lead to respiratory failure, organ damage and potentially death. With no FDA-approved treatment currently available for the coronavirus, researchers are racing to find ways to stop the virus or the inflammatory overreaction it provokes in its tracks.
- In a paper published in Cancer and Metastasis Reviews and selected by the journal as the featured publication, a team of researchers from Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital propose that controlling the local and systemic inflammatory response in C19 may be as important as anti-viral and other therapies.
- Led by Dipak Panigrahy, MD, of the Cancer Center at BIDMC, and Charles N. Serhan, PhD, DSc, director of the Center of Experimental Therapeutics and a member of the Department of Anesthesiology, Perioperative and Pain Medicine at Brigham and Women’s Hospital, the researchers suggest that a family of molecules naturally produced by the human body may be harnessed to resolve inflammation in patients with severe C19, thereby reducing the acute respiratory distress and other life-threatening complications associated with the viral infection.
- “Controlling the body’s inflammatory response is key to the management of C19 and may be as important to managing the pandemic as anti-viral therapies or a vaccine,” Panigrahy said. “Our team proposes using molecules made by the body called pro-resolution lipid mediators — which are currently in clinical trials for other inflammatory diseases — as a novel approach to turning off the inflammation and preventing the cytokine storm caused by C19.”
- Cytokines are released by the body as part of its normal immune response to injured or infected tissues. Typically, the body also releases chemicals to put an end to — or resolve — the inflammatory response. But in a significant percentage of patients with severe C19, the cytokines unleashed to kill the virus also do damage to infected lung cells. In turn, this injury to the lung tissues triggers additional inflammation, and the so-called “cytokine storm” begins to spiral out of control.
- Naturally occurring molecules called resolvins — discovered by Serhan and colleagues at BWH in 2002 — actively turn off inflammation. Panigrahy, Serhan and colleagues have previously demonstrated that resolvins and related pro-resolution molecules could play a role in preventing cancer metastasis and progression. This class of molecules are also currently in clinical trials investigating their use against other inflammatory diseases, such as ocular, periodontal, and inflammatory bowel disease. Now, the scientists suggest, they could be re-deployed for the management of C19.
- “A paradigm shift is emerging in our understanding of the resolution of inflammation as an active biochemical process,” said Serhan. “Activating the body’s own resolution pathways with the use of resolvins and related pro-resolution molecules –which, importantly, promote blog clot removal– may complement current treatment strategies while limiting severe organ damage and improving outcomes in C19 patients.”
4. A plasma shot could prevent coronavirus, but is not a priority for the government or industry
- It might be the next best thing to a coronavirus vaccine.
- Scientists have devised a way to use the antibody-rich blood plasma of C19 survivors for an upper-arm injection that they say could inoculate people against the virus for months.
- Using technology that’s been proven effective in preventing other diseases such as hepatitis A, the injections would be administered to high-risk healthcare workers, nursing home patients, or even at public drive-through sites — potentially protecting millions of lives, the doctors and other experts say.
- The two scientists who spearheaded the proposal have garnered widespread support from leading blood and immunology specialists, including those at the center of the nation’s C19 plasma research.
- But the idea exists only on paper. Federal officials have twice rejected requests to discuss the proposal, and pharmaceutical companies — even acknowledging the likely efficacy of the plan — have declined to design or manufacture the shots, according to a Times investigation.
- There is little disagreement that the idea holds promise; the dispute is over the timing. Federal health officials and industry groups say the development of plasma-based therapies should focus on treating people who are already sick, not on preventing infections in those who are still healthy.
- Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the NIH, said an upper-arm injection that would function like a vaccine “is a very attractive concept.”
- However, he said, scientists should first demonstrate that the coronavirus antibodies that are currently delivered to patients intravenously in hospital wards across the country actually work. “Once you show the efficacy, then the obvious next step is to convert it into an intramuscular” shot.
- But scientists who question the delay argue that the immunity shots are easy to scale up and should enter clinical trials immediately. They say that until there’s a vaccine, the shots offer the only plausible method for preventing potentially millions of infections at a critical moment in the pandemic.
- “Beyond being a lost opportunity, this is a real head-scratcher,” said Dr. Michael Joyner, a Mayo Clinic researcher who leads a program sponsored by the Food and Drug Administration to capitalize on coronavirus antibodies from C19 survivors. “It seems obvious.”
- The use of so-called convalescent plasma has already become widespread. More than 28,000 patients have already received the IV treatment, and preliminary data suggest that the method is safe. Researchers are also looking at whether the IV drip products would prevent new infections from taking root.
- The antibodies in plasma can be concentrated and delivered to patients through a type of drug called immune globulin, or Ig, which can be given through either an IV drip or a shot. Ig shots have for decades been used to prevent an array of diseases; the Ig shot that prevents hepatitis A was first licensed in 1944. They are available to treat patients who have recently been exposed to hepatitis B, tetanus, varicella and rabies.
- Yet for the coronavirus, manufacturers are only developing an intravenous solution of Ig.
- Joyner told The Times that 600 C19 survivors donating their plasma each day could, depending on donation volumes and concentrations, generate up to 5,000 Ig shots. With millions of probable survivors in the United States, he said, capacity isn’t a problem.
- Plasma companies said they’ve focused their efforts on an intervention for the sickest patients. Grifols, for example, said it has not developed a shot because it is pursuing a federally supported IV formula “to treat patients already infected with a serious case of C19,” but the company acknowledged that an antibody injection would be a good choice for prevention.
- Advocates for the immunity shots say businesses are reluctant to invest in a product that could soon be replaced by a vaccine, so the government should offer financial incentives to offset that risk. Billions of federal dollars are already being spent on vaccine research through Operation Warp Speed, and funding for an Ig shot that could serve as a bridge to a vaccine would come with a relatively modest price tag, they say.
- “Antibodies are the most precious resource on the planet right now, next to air. We have the industry, the technology, and the know-how to produce a proven product,” said Patrick Schmidt, the chief executive of FFF Enterprises, a major distributor of Ig products in the United States.
- “The amount of money and resources going into a vaccine, with no guarantee it will work — this could have saved lives by now.”
- The proposal for an injection approach to coronavirus prevention came from an immunization researcher who drew his inspiration from history.
- Dr. Michael Oxman knew that, even during the 1918 flu pandemic, the blood of recovered patients appeared to help treat others. Since then, convalescent plasma has been used to fight measles and severe acute respiratory syndrome, or SARS, among other diseases.
- Like other doctors, Oxman surmised that, for a limited time, the blood coursing through the veins of coronavirus survivors probably contains immune-rich antibodies that could prevent — or help treat — an infection.
- On March 27, he and Dr. John Zaia, the director of City of Hope’s Center for Gene Therapy, submitted a proposal to the federal Biomedical Advanced Research and Development Authority, or BARDA, urging the rollout of Ig shots for first responders and members of other high-risk groups.
- The agency granted $12.5 million to Grifols and $14.5 million to Emergent BioSolutions to produce plasma-based C19 medicines in IV form drips, among more than 50 different biomedical partnerships to fight the pandemic. But the immunity shot proposal was rejected.
- The pair followed up with a detailed proposal to conduct a clinical trial at UC San Diego. They believed injectable five-milliliter vials of Ig could be given quickly by minimally trained healthcare workers, offering at least two months of immunity to doctors and nurses, as well as residents of nursing homes, college dormitories and military submarines.
- The submission was backed by four other infectious disease researchers and statisticians, but it was also rejected, records show.
- A spokeswoman for BARDA told The Times that the agency had received thousands of submissions, and that “while we are interested in the potential of (Ig) for treatment and prevention, we are focused intently on treatments for hospitalized patients to save lives.”
- The strategy baffled Oxman and Zaia, who said the Ig shots are a far more efficient delivery system that can potentially reach many more people.
- What’s more, prophylactic shots would probably require far fewer antibodies than IV treatments, Joyner said. With Ig shots, plasma donations could possibly go twice — or even five times — as far, he said.
- If a second wave were to arrive before an effective vaccine, that stockpile would be all the more essential.
- Oxman started focusing his attention on the key players in the industry — the manufacturers who dominate the development of plasma drugs. He held weekly phone calls with Schmidt, the distributor; together, the two tried to convince 7 different companies to produce the shots themselves and bring them to health agencies for testing. They were unsuccessful.
- Takeda and CSL Behring, two large companies who co-lead the new CoVIg-19 Plasma Alliance to develop an Ig product for IV drips, said their efforts are trained on the sickest. The IV formula “represents the fastest path to reach patients, assuming the trial is successful,” said Julie Kim, the head of the plasma-derived therapies business unit at Takeda.
- Financial calculations may be another factor for companies. Intravenous plasma products are traditionally the main economic driver for the industry, supply experts said, in part because vaccines have replaced many short-term immunity shots over the years. The money-making antibodies are also far more diluted in intravenous drugs than in injectable ones, which boosts profit margins.
- “They charge a fortune off of intravenous drugs in the hospital. They don’t want to devote the manufacturing plant to something that won’t make oodles of money,” said one infectious disease expert, who has advocated for coronavirus Ig shots but asked not to be publicly identified.
- Researchers also said industry executives have little incentive to produce the immunity shots for the coronavirus, given the possibility that a longer-lasting vaccine could replace it within a year.
- Representatives for CSL, Takeda and Grifols all challenged that assertion.
- “The choice of one delivery method or another has no connection with the potential financial or pricing implications,” a Grifols spokesman told The Times.
- Throughout May, researchers and doctors at Yale, Harvard, Johns Hopkins, Duke and four different University of California schools sent a barrage of letters to dozens of lawmakers. They held virtual meetings with health policy directors on Capitol Hill, but say they have heard no follow-up to date.
- Dr. Arturo Casadevall, the chair of the National C19 Convalescent Plasma Project, said he spoke to FDA officials who told him they do not instruct companies on what to produce. Casadevall told The Times that the leaders of the national project were “very supportive of the need to develop” an Ig shot rapidly and that he believed it would be “very helpful in stemming the epidemic.”
- Joyner, of the Mayo Clinic, said there are probably 10 million to 20 million people in the U.S. carrying coronavirus antibodies — and the number keeps climbing. If just 2% of them were to donate a standard 800 ml of plasma on three separate occasions, their plasma alone could generate millions of Ig shots for high-risk Americans.
- The antibody injections, for now, do not appear to be a high priority for the government or the industry.
5. Single-cell RNA sequencing outlines the immune landscape of severe C19
- A new single-cell RNA sequencing analysis of more than 59,000 cells from three different patient cohorts provides a detailed look at patients’ immune responses to severe cases of C19. The results suggest that patients with severe C19 experience increased regulation of the type I interferon (IFN-I) inflammation-triggering pathway – a signature that the researchers also observed in patients hospitalized with severe cases of influenza.
- Their findings suggest that anti-inflammatory treatment strategies for C19 should also be aimed toward the IFN-I signaling pathway, in addition to targeting inflammatory molecules such as TNF, IL-1?, and IL-6 that have been implicated in C19.
- Seong Seok Lee and colleagues sequenced the RNA from a total of 59,572 blood cells obtained from four healthy donors, eight patients with mild or severe C19, and five patients with severe influenza.
- Patients in both the mild and severe C19 cohorts all showed increased regulation of the TNF/IL-1ß-driven inflammatory response, while patients with severe C19 also exhibited an increased IFN-I response.
- By comparison, patients with severe flu showed increased expression of various IFN-stimulated genes, but did not experience TNF/IL-1ß responses as seen in C19 patients.
- Unlike the flu cohort, patients in the severe C19 cohort exhibited the IFN-I signature concurrently with TNF/IL-1ß-driven inflammation – a combination also not seen in patients with milder cases of C19.
- Based on their results, the scientists propose that the IFN-I response exacerbates inflammation in patients with severe C19.
- Their results, along with past mouse studies that highlight how the timing of IFN-I expression is critical to determining the outcome of C19, support targeting IFN-I as a potential treatment strategy for severe C19.
6. Neutralizing antibodies in the battle against C19
- An important line of defense in the fight against the coronavirus is the formation of neutralizing antibodies. These can eliminate the intruders and have great potential to be used for prevention and treatment of C19. A team of researchers led by Prof. Florian Klein (Cologne University Hospital) and the German Center for Infection Research (DZIF) has further elucidated how these antibodies develop and has isolated potent coronavirus neutralizing antibodies. Together with Boehringer Ingelheim, these antibodies are currently being further characterized and developed. It is expected that they will enter the stage of clinical development later this year. The results were published today (July 07, 2020) in the journal Cell.
- “Our goal was to better understand the immune response to the coronavirus and to identify highly potent antibodies that could be used to prevent and treat C19,” explained Prof. Klein, Director of the Institute of Virology at the Cologne University Hospital and Principal Investigator at the DZIF. “We assume that such antibodies are effective for several weeks and may protect against C19 during this period,” added Dr. Christoph Kreer, who conducted the work together with Dr. Matthias Zehner in Cologne.
- In close collaboration with scientists from Marburg, Frankfurt, Munich, Tübingen and Israel, the researchers investigated the coronavirus antibody response in twelve individuals recovered from C19. They examined more than 4000 SARS-CoV-2-specific B cells on a single cell level and were able to partly decode the humoral immune response to coronavirus. They reconstructed 255 antibodies in the laboratory, which were examined by Prof. Stephan Becker’s laboratory in Marburg for their ability to neutralize the novel coronavirus SARS-CoV-2. In total, 28 neutralizing antibodies were found.
- “Interestingly, many antibodies showed only a small number of mutations. This means that only minor changes were necessary to effectively recognize and neutralize the virus” says Dr. Zehner. In fact, in blood samples collected before the pandemic, the scientists found B cells carrying similar antibody characteristics to those of coronavirus neutralizing antibodies. This may suggest that the coronavirus antibodies can be readily formed and that an active vaccine may provide rapid protection.
- The antibodies have been developed for protecting against and treating C19. In addition, these antibodies could be used for ‘post-exposure prophylaxis.
- Here antibodies would be applied after contact with an infected individual. “This form of intervention could be of particularly interest for stopping localized outbreaks and for preventing disease progression in people at risk,” said Prof. Klein. The scientists expect that first clinical trials will be performed at the end of 2020.
- There are a significant number of studies focusing on potential treatments for C19, including existing drugs that are being trialed. Some progress has been made, too.
- A private-public consortium funded by the EXSCALATE4CoV project has announced promising results for the fight against the coronavirus. According to the announcement, “an already registered generic drug used to treat osteoporosis, Raloxifene, could be an effective treatment for C19 patients with mildly symptomatic infection,” as stated by the European Commission.
- The EXSCALATE4CoV platform brings together supercomputing centers in Germany, Spain and Italy, pharmaceutical companies, large research centers and biological institutes across Europe. It uses “a unique combination of high-performance computing power and AI with biological processing,” as noted in the same press release. “The platform has around 120 Petaflops computing power, allowing research into the behaviors of molecules with the aim of identifying an effective treatment against coronavirus.” Petaflop refers to one thousand trillion, or one quadrillion, floating-point operations per second.
- The European Commission press release adds: “The consortium has already virtually tested 400,000 molecules using its supercomputers. 7 000 molecules were preselected and further tested ‘in vitro’. Raloxifene emerged as a promising molecule: according to the project, it could be effective in blocking the replication of the virus in cells, and could thus hold up the progression of the disease.” According to the project partners, Raloxifene “is well-tolerated with a known safety profile.” The EXSCALATE4CoV consortium is in discussions with the European Medicines Agency for establishing “the fastest path to clinical trials in humans.”
Screening procedure takes weeks, not years
- The EXSCALATE4CoV platform can “perform in weeks a screening process that with traditional techniques would take many years. In a first step it has so far identified 6 out of 25 different protein models of the coronavirus that are constantly evolving, with various mutations received weekly, which are translated into a digital form for use in the next step.”
- The European Commission adds that the second stage “is to match the digital structure of coronavirus proteins against the available library of molecules. In the third and final step, the identified molecules undergo several additional biological screening operations in laboratories located in Belgium and Germany to understand how an identified molecule interacts with the virus model and to assess the degree to which it can stop its activity.”
- Project partners hope that in the next phase, the EXSCALATE4CoV platform will enlarge the current tests, taking into account an extended library of 5 million molecules out of 500 billion in its chemical library. These massive virtual screening activities will be supported and empowered by three of the most powerful computer centers in Europe: CINECA, Barcelona Supercomputing Center, and Jülich Research Centre. The EXSCALATE4CoV (EXaSCale smArt pLatform Against paThogEns for Corona Virus) project will run until September 2021.
E. Improved & Potential Treatments
1. Remdesivir reduces risk of death in severely sick patients by 62%
- Gilead Sciences published new data Friday on its antiviral drug remdesivir that shows it reduced the risk of death for severely sick coronavirus patients by 62% compared with standard care alone.
- The company said its analysis also found that remdesivir treatment was associated with “significantly improved clinical recovery.” The findings are being presented at the Virtual C19 Conference as part of the 23rd International AIDS Conference, the company said.
- Gilead said it analyzed data from 312 patients enrolled in its phase three trial and compared it with that of 818 patients in “a real-world retrospective cohort” with similar characteristics and disease severity who received standard care alone during the same time period as the phase three trial.
- “While not as vigorous as a randomized controlled trial, this analysis importantly draws from a real world setting and serves as an important adjunct to clinical trial data, adding to our collective understanding of this virus and reflecting the extraordinary pace of the ongoing pandemic,” Dr. Susan Olender of Columbia University Irving Medical Center said in a statement.
- The findings show that 7.6% of patients treated with remdesivir died compared with 12.5% of patients in the analysis who did not receive remdesivir treatment. The analysis also found that 74.4% of patients who received treatment with remdesivir recovered by day 14 compared with 59% of patients who received standard care alone.
- Gilead said its findings warrant more study in additional trials.
- “We are working to broaden our understanding of the full utility of remdesivir,” Gilead’s Chief Medical Officer Dr. Merdad Parsey said in a statement. “To address the urgency of the continuing pandemic, we are sharing data with the research community as quickly as possible with the goal of providing transparent and timely updates on new developments with remdesivir.”
- In late April, the National Institute of Allergy and Infectious Diseases released preliminary results from its own study of remdesivir that showed patients who took remdesivir usually recovered after 11 days, four days faster than those who didn’t take the drug. However, the study did not find any statistically significant reduction in the risk of death among patients treated with remdesivir.
2. New study supports remdesivir as C-19 treatment
- The news about remdesivir, the investigational anti-viral drug that has shown early promise in the fight against C19, keeps getting better.
- This week researchers at Vanderbilt University Medical Center (VUMC), the University of North Carolina at Chapel Hill and Gilead Sciences reported that remdesivir potently inhibited the coronavirus in human lung cell cultures and that it improved lung function in mice infected with the virus.
- These preclinical findings help explain the clinical effect the drug has had in treating C19 patients. Remdesivir has been given to patients hospitalized with C19 on a compassionate use basis since late January and through clinical trials since February.
- In April, a preliminary report from the multicenter Adaptive C19 Treatment Trial (which included VUMC) suggested that patients who received the drug recovered more quickly.
- “All of the results with remdesivir have been very encouraging, even more so than we would have hoped, but it is still investigational, so it was important to directly demonstrate its activity against the coronavirus in the lab and in an animal model of disease,” said VUMC’s Andrea Pruijssers, PhD.
- The researchers were the first to perform detailed studies to demonstrate that the drug, which was developed by Gilead Sciences to combat hepatitis C and respiratory syncytial virus, and later the Ebola virus, also showed broad and highly potent activity against coronaviruses in laboratory tests.
- The current findings, reported this week in the journal Cell Reports, provide “the first rigorous demonstration of potent inhibition of the coronavirus in continuous and primary human lung cultures.” The study is also the first to suggest that remdesivir can block the virus in a mouse model.
- Ongoing clinical trials will determine precisely how much it benefits patients in different stages of C19 disease.
- Meanwhile in the laboratory, Pruijssers said, “We also are focusing on how to use remdesivir and other drugs in combinations to increase their effectiveness during C19 and to be able to treat at different times of infection.”
- C19 is at least the third instance since 2003 in which a coronavirus originally transmitted from bats has caused serious illness in humans.
- Thus there is an urgent need to identify and evaluate broadly efficacious and robust therapies that can limit and prevent coronavirus infections. “Broad-spectrum antiviral drugs, antibodies, and vaccines are needed to combat the current pandemic and those that will emerge in the future,” the researchers said.
- In addition to the coronavirus, studies in the Denison and Baric labs have shown that remdesivir is effective against a vast array of coronaviruses, including other bat viruses that could emerge in the future in humans.
- “We hope that will never happen, but just as we were working to characterize remdesivir over the past six years to be ready for a virus like the coronavirus, we are working and investing now to prepare for any future coronavirus,” Denison said. “We want remdesivir and other drugs to be useful both now and in the future.”
3. Drug Derived From Plasma of C19 Patients to Be Tested as Preventive Measure
- Drugmaker Emergent Biosolutions Inc. plans to work with Mount Sinai Health System in New York City to test whether a drug derived from the blood plasma of recovered C19 patients can prevent infections in doctors, nurses and military forces.
- The proposed study, which the partners announced Wednesday, would add to efforts evaluating the coronavirus-fighting potential of experimental drugs made from plasma donated by recovered patients.
- If the drug proves to work safely, it could help protect health-care workers and other people working in essential jobs who are at high risk of infection until a vaccine is ready and perhaps even after.
- Some people don’t tolerate vaccines, said Judith Aberg, chief of the division of infectious diseases and immunology at Mount Sinai. “This offers another avenue of prevention.”
- The trial is being funded with $34.6 million from the Defense Department, which is looking for drugs that could help military units finding it difficult to do their work while maintaining social distance.
- The partners are still working out the details, including the number of subjects and the start date. They must also get permission from the Food and Drug Administration to conduct the study.
- Investigators said they would draw from previous work using hyperimmune globulin products in the prevention of diseases such as hepatitis B to set up the study. The researchers said they hope to meet with the FDA soon to discuss the design of the trial.
- Convalescent plasma, as the plasma taken from recovered patients is known, has emerged as a promising, though unproven, treatment for C19.
- Recently published results from an expanded-access study of the therapy involving 20,000 patients found that the transfusions resulted in few serious side effects and that there wasn’t an excessive mortality rate. But investigators can’t determine whether plasma improved outcomes because every patient in the study received it.
- Researchers want to see whether drugs made by purifying antibodies taken from the donated blood could work better than the convalescent plasma. The drugs are known as C19 hyperimmune globulin, or Covid-HIG.
- The first of two trials sponsored by the National Institute of Allergy and Infectious Diseases testing Covid-HIG as a treatment will begin in seriously ill hospitalized patients later this summer.
- The study by Emergent and Mount Sinai would explore whether such a drug could protect against infection.
- Under the terms, ImmunoTek Bio Centers LLC, which manages and operates plasma-collection centers, would provide Mount Sinai with the machines to collect plasma from recovered C19 patients at the hospital. ImmunoTek’s FDA-approved license would be extended to Mount Sinai to set up plasma collection on site.
- Mount Sinai would ship the plasma to Emergent, of Gaithersberg, Md., which would manufacture the Covid-HIG drug to be studied in the trial.
- There are many advantages to using a Covid hyperimmune product over convalescent plasma, said Mount Sinai’s Dr. Aberg.
- “It is a consistent amount of antibody in every lot number, rather than depending on whatever the antibodies of one particular donor is with convalescent plasma,” Dr. Aberg said.
- Yet researchers must explore what antibody level would provide protection to people and what the duration of that protection would be, she added.
- In April, the U.S. Department of Health and Human Services awarded Emergent $14.5 million to develop Covid-HIG as a potential treatment to be tested in hospitalized patients and a second trial involving patients who are at high risk of progressing to severe disease.
- The product Emergent makes from the plasma collected at Mount Sinai would be used both in the prophylaxis trials and the treatment trials, for which Mount Sinai is also one of the study sites. Emergent is one of several companies working with the NIAID on the treatment trials.
4. Doctors are Better at Treating C19 Patients Than They Were in March
- In early March, most doctors in the United States had never seen a person sick with C19. Four months later, nearly every emergency room and intensive care physician in the country is intimately familiar with the disease. In that time, they’ve learned a lot about how best to treat patients. But in some cases, they’re still taking the same approach they did in the spring.
- “There’s so much that’s different, and so much that’s the same,” says Megan Ranney, an emergency physician and associate professor at the Brown University Department of Emergency Medicine.
- For the first few months of the pandemic, recommendations for every incremental decision made in a hospital were changing faster than they ever have before. “You almost couldn’t keep up — from one day to the next, your practice would change and your protocols would change. It was really disorienting for doctors and nurses,” Ranney says.
- Information spread between colleagues, through medical education blogs and podcasts, and on social media. Doctors talked about new research on Twitter and shared new strategies in Facebook groups and on WhatsApp. If a suggestion that floated by a doctor in a Facebook group was low-risk and seemed like it might be helpful, it could be put into practice immediately. “If it’s a small change, they could start using it the next day,” she says.
- That’s how the now-common practice of asking patients with C19 to flip onto their stomachs spread: through word-of-mouth and on social media. When someone is on their back, their organs squish their lungs and make it harder for their airways to fully expand. When someone is on their stomach, their lungs have more room to fill up with air. The advice started circulating through the medical community before there was a formal, published study on the practice.
- Testing it out wouldn’t have many downsides (it wasn’t dangerous to patients), and it was easy to do. “There’s this possibility that it could be positive, and there were a lot of stories about it having a positive effect,” Ranney says. “So, it spread in a much more organic and quick way, because it was something that we could do, but we weren’t worried it would hurt patients.”
- Doctors like Seth Trueger, an assistant professor of emergency medicine at Northwestern University, saw the position help patients get enough oxygen to avoid needing a ventilator. “I started jokingly call it ‘tummy time,’” he says. Studies are starting to validate those observations, finding that patients who spent time on their stomachs were, in fact, better off.
- Since March, physicians have also figured out other ways to help severely ill patients avoid ventilation. “We appreciate that it’s probably not a great thing for these patients, and we’ve developed other ways to get people high levels of oxygen,” says James Hudspeth, the COVID response inpatient floor lead at Boston Medical Center. For example, doctors are turning to nasal cannulas, which are noninvasive prongs that blow oxygen into the nose, before a ventilator.
- They have better medications for hospitalized patients now, too. Since March, doctors have cycled through a few different options — like hydroxychloroquine, which turned out not to be effective. Now, they’re primarily using remdesivir, an antiviral drug that appears to help C19 patients recover more quickly, and the steroid dexamethasone, which helps improve the survival rate for patients on ventilators. “Many intensive care units and many hospitals have created their own standard order sets, or standard therapies, for people with C19,” Ranney says. Those shift as new evidence comes out around different medications.
- That’s not unusual, Ranney says. Hospitals regularly change the drugs they use for conditions like flu and pneumonia as new data comes out. “What’s unusual is to change practice so quickly,” she says. “That’s just the reality of a global pandemic, with a disease we’ve never seen before.”
- Most of the changes in doctors’ strategies over the past few months have been in patients who are severely ill. If someone is sick enough to be hospitalized with C19 but doesn’t need to be in intensive care, there still isn’t much doctors can do for them. They’ll get fluids to make sure they stay hydrated and are given oxygen if they need it. Doctors will try to keep their fever down and monitor them to see if they get sicker, but that’s about it.
- “It’s just those basic things,” Ranney says. Doctors now are more vigilant to the threat from blood clots, which have appeared in many C19 patients over the past months. Because testing is more available in hospitals than it was earlier this year, they’ll also confirm that a moderately ill patient actually does have C19 — and avoid giving them unnecessary treatments. But active interventions for patients with less severe symptoms are still around the same as they were back in March. “We’re still kind of in this watchful waiting,” she says.
- One lingering question, Hudspeth says, is figuring out how to keep those moderately ill patients from becoming severely ill. Steroids may be helpful earlier on, he says, as could artificial antibody treatments that block the virus, though those strategies are still under investigation. “Part of the challenge we face at the present moment is that the moderate patients are often where we would want to intervene,” he says.
- Changes to treatment strategies for patients who are not severely sick have been harder to come by — in part because it’s riskier to try something new in that group. If someone isn’t dangerously sick, there isn’t as much to gain from using an experimental treatment that may have a chance of causing harm, so doctors are less likely to take risks. “We’re more likely to try stuff with sicker patients,” Ranney says. “And their families are more likely to consent to a clinical trial.”
- Despite the open issues around C19 treatments, the rate of new information is slowing down. Doctors aren’t shifting their practices as quickly as they were back in March and April, and Trueger says he thinks the next few months may be relatively stable. Doctors might get new information about which medications are more or less helpful, but other common best practices might be more entrenched. “I don’t think things are going to change as rapidly as the changes we had up front, when we were really flying half blind,” he says.
F. Concerns & Unknowns
1. Self-isolation may increase susceptibility to C19
- Months of self-isolation and social distancing have taken their toll. Sheldon Cohen, the Robert E. Doherty Professor of Psychology at Carnegie Mellon University, has produced a body of research that suggests that interpersonal stressors many are experiencing during quarantine are associated with an increased vulnerability to upper respiratory viruses and perhaps coronavirus. A summary of his work is available online in the July 8 issue of Perspectives on Psychological Science.
- “We know little about why some of the people exposed to the coronavirus are more likely to develop C19 than others. However, our research on psychological factors that predict susceptibility to other respiratory viruses may provide clues to help identify factors that matter for C19,” said Cohen.
- Cohen has spent his career examining the impact of different behavioral, social and psychological factors on the development of upper respiratory illnesses. Through a series of viral challenge studies, he examined how such factors can affect whether or not healthy adults exposed to respiratory viruses become ill. His work has focused on eight viral strains that cause a common cold (rhinovirus types 2, 9, 14, 21, 39 and Hanks, as well as respiratory syncytial virus and corona virus 229E) and two that cause influenza (A/Kawasaki/86 H1N1; and A/Texas/36/91).
- “The focus on the pandemic up until now has been changing behaviors to avoid exposure to the virus,” said Cohen. “In our work, we intentionally exposed people to cold and influenza viruses and studied whether psychological and social factors predict how effective the immune system is in suppressing infection, or preventing or mitigating the severity of illness.”
- Cohen’s work has pointed to the importance of social and psychological factors in the development of infection and illness. This work may hold clues to the health implications of the on-going quarantine.
- To slow the spread of coronavirus, many communities issued stay-at-home measures, increasing interpersonal stressors, like loneliness, loss of employment and familial conflict. According to Cohen, these stressors may be powerful predictors of how a person will respond if exposed to coronavirus.
- In a series of studies, he found participants experiencing interpersonal stressors had a greater chance of developing an upper respiratory illnesses when exposed to cold viruses. Cohen believes interpersonal stressors might play a similar role in response to the coronavirus causing C19, increasing a person’s vulnerability to infection and illness.
- In addition, both social and psychological stressors increased the production of cytokines, molecules that promote inflammation in response to infection. In Cohen’s work, psychological and social stressors were associated with an overproduction of pro-inflammatory cytokines in response to cold and influenza viruses. In turn, this excess of inflammation was associated with an increased risk of becoming ill.
- Similarly, research on C19 has shown that producing an excess of pro-inflammatory cytokines is associated with more severe C19 infections suggesting the hypothesis that a stress-triggered excessive cytokine response might similarly contribute to excessive inflammation and symptoms in C19.
- While social and psychological stressors increase susceptibility, Cohen’s work also indicates that social integration and social support offer a protective shield against respiratory infection and illness.
- “If you have a diverse social network (social integration), you tend to take better care of yourself (no smoking, moderate drinking, more sleep and exercise),” said Cohen. “Also if people perceive that those in their social network will help them during a period of stress or adversity (social support) then it attenuates the effect of the stressor and is less impactful on their health.”
2. China Points to Shrimp as Virus Carrier
- China said samples of imported shrimp tested positive for the coronavirus, raising questions again over whether the pathogen can spread through food or frozen products.
- The virus tested positive on both the inside and outside of the shrimp packaging, said China’s General Administration of Customs. The samples were from three Ecuadorian plants, and imports from those processors will be halted, it said.
- “The test result doesn’t mean the virus is contagious, but reflects the loopholes in companies’ food safety regulations,” said Bi Kexin, director of the food import and export safety bureau in the customs department. “Customs will further strengthen control of the origins of imported cold-chain food.”
- China last month pointed to imported salmon as a possible culprit for Beijing’s fresh C19 outbreak, sparking a boycott of the fish as supermarkets took the produce off their shelves. China also began mass testing of cold food imports at ports, and blocked shipments from meat plants abroad that reported infections among workers.
- Evidence suggests that it’s extremely unlikely for the virus to be transmitted through food, said Gorjan Nikolik, associate director of seafood at Rabobank.
- Chinese officials have also agreed with global experts that imported food poses a low risk of transmitting the virus. That’s led to confusion overseas over why China is continuing to test and halt shipments.
- The tests are “an important measure to prevent the risk of the virus being transmitted from imported cold chain food channels,” Bi said. “This is a necessary measure taken to protect the health of the people and does not interrupt normal international trade.”
- China’s customs authorities also tested a total of 227,934 samples and the rest of the samples were negative, it said. The shrimps that tested positive were delivered to ports in Dalian and Xiamen and have been destroyed, it said.
3. ‘Unknown pneumonia’ deadlier than coronavirus sweeping Kazakhstan
- The Chinese embassy in Kazakhstan has warned of a deadly “unknown pneumonia” after the former Soviet republic reported a spike in pneumonia cases since June.
- “The death rate of this disease is much higher than the novel coronavirus. The country’s health departments are conducting comparative research into the pneumonia virus, but have yet to identify the virus,” the embassy said in a warning to Chinese citizens in the country.
- While the Chinese embassy described the illness as an “unknown pneumonia”, Kazakhstani officials and media have only said it is pneumonia.
- It was not clear why the Chinese embassy had described the illness as “unknown” or what information it had about the pneumonia.
- The embassy’s website, citing local media reports, said the provinces of Atyrau and Aktobe and the city of Shymkent have reported significant spikes in pneumonia cases since the middle of June.
- The Chinese embassy said that so far there have been nearly 500 pneumonia cases in the three places, with over 30 people in a critical condition.
- The country as a whole saw 1,772 pneumonia deaths in the first part of the year, 628 of which happened in June, including some Chinese nationals, the embassy continued.
- Saule Kisikova, the health care department chief in the capital Nur-Sultan, told the news agency Kazinform: “Some 300 people diagnosed with pneumonia are being hospitalised every day.”
- The agency also said there had been 1,700 pneumonia cases nationwide in June – more than two times the number in the same month last year.
- Kazakhstan announced a state of emergency on March 16 to tackle the spread of C19. The lockdown was lifted on May 11, but restrictions and quarantine measures have been reimposed in some areas following the surge in pneumonia cases.
- Kazakhstan’s President Kassym-Jomart Tokayev said in a televised address on Wednesday that the situation was still serious and it was too early to relax restrictions.
- He added the country was “in fact facing the second coronavirus wave coupled with a huge uptick in pneumonia cases”, according to the Russian news agency Tass.
- Late last month officials warned about the rise in pneumonia cases. Kisikova said that doctors were finding 600 people a day with pneumonia symptoms, compared with 80 a day before the start of the C19 outbreak, the Singapore-based website CNA reported.
- “Every day, 350 to 400 patients are hospitalized in the city with either C19 or pneumonia,” she said.
G. Conflicting Findings & Information
1. Why lopinavir and hydroxychloroquine do not work on C19
- Lopinavir is a drug against HIV, hydroxychloroquine is used to treat malaria and rheumatism. Until recently, both drugs were regarded as potential agents in the fight against the coronavirus. A research group from the University of Basel and the University Hospital has now discovered that the concentration of the two drugs in the lungs of C19 patients is not sufficient to fight the virus.
- In February 2020, a C19 patient cohort was established at the University and the University Hospital in Basel to prospectively monitor a range of diagnostic means and potential treatments for C19, including the off-label use of hydroxychloroquine and lopinavir/ritonavir.
- A research group prospectively monitored lopinavir plasma levels in C19 patients. “Considering that substantial inflammation was observed in these patients, and previous studies have shown the inhibition of drug metabolism by systemic inflammation, we had the rationale to investigate the effect of inflammation on lopinavir and hydroxychloroquine plasma levels,” states Professor Catia Marzolini, first author of the study and professor for experimental medicine at the University of Basel.
- The authors included 92 patients in their study. Professor Parham Sendi, who is the co-leader of this study summarizes the main findings as follows:
- First, lopinavir plasma levels were more than two to threefold higher than typically observed in HIV patients. Hydroxychloroquine levels were with normal range.
- Second, there was a significant correlation between the inflammation marker levels in the blood and lopinavir plasma levels.
- Third, when the inflammation was blocked with the Interleukin-6 inhibitor Tocilizumab, lopinavir plasma levels were significantly lower than the ones in patients without Tozulizumab treatment.
- These results clearly indicate that drug metabolism enzymes (cytochrome P450 3A) are inhibited by systemic inflammation. “Caution is advised when prescribing CYP3A4 substrates such as Lopinavir/ritonavir or any other drug with a narrow therapeutic index to C19 patients because of the risk of elevated drug levels and related toxicities,” the authors state.
- Importantly, from the lopinavir and hydroxychloroquine concentrations in the plasma, the study group calculated the corresponding concentration in the lung compartment – the anatomic site of coronavirus infection. The results strongly suggest that it is unlikely that both drugs reach sufficient concentrations to inhibit the virus replication in the lung.
- WHO accepted the recommendation from the Solidarity Trial’s International Steering Committee to discontinue the trial’s hydroxychloroquine and lopinavir/ritonavir arms on 4 July 2020. Professor Manuel Battegay – co-leader of this study and head of the Division of Infectious Diseases and Hospital Epidemiology at the University Hospital in Basel – mentioned that the results provide important pharmacological and antiviral insights to the rationale of discontinuing the lopinavir/ritonavir arm. In fact, they add scientific reasoning why hydroxychloroquine and lopinavir are not effective against the coronavirus.
Note: Other studies have come to a different conclusion. For example, a clinical trial by the Ford Medical System recently found that hydroxychloroquine reduced mortality rates by 50%.
H. Back to School?!
1. Children don’t transmit C19, schools should reopen in fall
- A commentary published in the journal Pediatrics, the official peer-reviewed journal of the American Academy of Pediatrics, concludes that:
- children infrequently transmit C19 to each other or to adults, and
- many schools, provided they follow appropriate social distancing guidelines and take into account rates of transmission in their community, can and should reopen in the fall.
- The authors, Benjamin Lee, M.D. and William V. Raszka, Jr., M.D., are both pediatric infectious disease specialists on the faculty of the University of Vermont’s Larner College of Medicine. Dr. Raszka is an associate editor of Pediatrics.
- The authors of the commentary, titled “C19 Transmission and Children: The Child Is Not to Blame,” base their conclusions on a new study published in the current issue of Pediatrics, “C19 in Children and the Dynamics of Infection in Families,” and four other recent studies that examine C19 transmission by and among children.
- In the new Pediatrics study, Klara M. Posfay-Barbe, M.D., a faculty member at University of Geneva’s medical school, and her colleagues studied the households of 39 Swiss children infected with C19. Contact tracing revealed that in only three (8%) was a child the suspected index case, with symptom onset preceding illness in adult household contacts.
- In a recent study in China, contact tracing demonstrated that, of the 68 children with C19 admitted to Qingdao Women’s and Children’s Hospital from January 20 to February 27, 2020, 96% were household contacts of previously infected adults. In another study of Chinese children, nine of 10 children admitted to several provincial hospitals outside Wuhan contracted C19 from an adult, with only one possible child-to-child transmission, based on the timing of disease onset.
- In a French study, a boy with C19 exposed over 80 classmates at three schools to the disease. None contracted it. Transmission of other respiratory diseases, including influenza transmission, was common at the schools.
- In a study in New South Wales, nine infected students and nine staff across 15 schools exposed a total of 735 students and 128 staff to C19. Only two secondary infections resulted, one transmitted by an adult to a child.
- “The data are striking,” said Dr. Raszka. “The key takeaway is that children are not driving the pandemic. After six months, we have a wealth of accumulating data showing that children are less likely to become infected and seem less infectious; it is congregating adults who aren’t following safety protocols who are responsible for driving the upward curve.”
- Rising cases among adults and children in Texas childcare facilities, which have seen 894 C19 cases among staff members and 441 among children in 883 child care facilities across the state, have the potential to be misinterpreted, Dr. Raszka said. He has not studied the details of the outbreak.
- “There is widespread transmission of C19 in Texas today, with many adults congregating without observing social distancing or wearing masks,” he said. “While we don’t yet know the dynamics of the outbreak, it is unlikely that infants and children in daycare are driving the surge. Based on the evidence, it’s more plausible that adults are passing the infection to the children in the vast majority of cases.”
- Additional support for the notion that children are not significant vectors of the disease comes from mathematical modeling, the authors say. Models show that community-wide social distancing and widespread adoption of facial cloth coverings are far better strategies for curtailing disease spread, and that closing schools adds little. The fact that schools have reopened in many Western European countries and in Japan without seeing a rise in community transmissions bears out the accuracy of the modeling.
- Reopening schools in a safe manner this fall is important for the healthy development of children, the authors say. “By doing so, we could minimize the potentially profound adverse social, developmental, and health costs that our children will continue to suffer until an effective treatment or vaccine can be developed and distributed, or failing that, until we reach herd immunity,” the paper concludes.
2. School openings across globe suggest ways to keep coronavirus at bay, despite outbreaks
- Early this spring, school gates around the world slammed shut. By early April, an astonishing 1.5 billion young people were staying home as part of broader shutdowns to protect people from the novel coronavirus. The drastic measures worked in many places, dramatically slowing the spread of SARS-CoV-2, the virus that causes C19.
- However, as weeks turned into months, pediatricians and educators began to voice concern that school closures were doing more harm than good, especially as evidence mounted that children rarely develop severe symptoms from C19. (An inflammatory condition first recognized in April, which seems to follow infection in some children, appears uncommon and generally treatable, although scientists continue to study the virus’ effect on youngsters.)
- Continued closures risk “scarring the life chances of a generation of young people,” according to an open letter published this month and signed by more than 1500 members of the United Kingdom’s Royal College of Paediatrics and Child Health (RCPCH). Virtual education is often a pale shadow of the real thing and left many parents juggling jobs and childcare. Lower-income children who depend on school meals were going hungry. And there were hints that children were suffering increased abuse, now that school staff could no longer spot and report early signs of it. It was time, a growing chorus said, to bring children back to school.
- By early June, more than 20 countries had done just that. (Some others, including Taiwan, Nicaragua, and Sweden, never closed their schools.) It was a vast, uncontrolled experiment.
- Some schools imposed strict limits on contact between children, while others let them play freely. Some required masks, while others made them optional. Some closed temporarily if just one student was diagnosed with C19; others stayed open even when multiple children or staff were affected, sending only ill people and direct contacts into quarantine.
- Data about the outcomes are scarce. “I just find it so frustrating,” says Kathryn Edwards, a pediatric infectious disease specialist at the Vanderbilt University School of Medicine who is advising the Nashville school system, which serves more than 86,000 students, on how to reopen. Her research assistant spent 30 hours hunting for data—for example on whether younger students are less adept at spreading the virus than older ones, and whether outbreaks followed reopenings—and found little that addressed the risk of contagion in schools.
- When Science looked at reopening strategies from South Africa to Finland to Israel, some encouraging patterns emerged. Together, they suggest a combination of keeping student groups small and requiring masks and some social distancing helps keep schools and communities safe, and that younger children rarely spread the virus to one another or bring it home. But opening safely, experts agree, isn’t just about the adjustments a school makes. It’s also about how much virus is circulating in the community, which affects the likelihood that students and staff will bring C19 into their classrooms.
- “Outbreaks in schools are inevitable,” says Otto Helve, a pediatric infectious disease specialist at the Finnish Institute for Health and Welfare. “But there is good news.” So far, with some changes to schools’ daily routines, he says, the benefits of attending school seem to outweigh the risks—at least where community infection rates are low and officials are standing by to identify and isolate cases and close contacts.
How likely are children to catch and transmit the virus?
- Several studies have found that overall, people under age 18 are between one-third and one-half as likely as adults to contract the virus, and the risk appears lowest for the youngest children. The reason remains the subject of intense study. But the town of Crépy-en-Valois, home to 15,000 people on the northern outskirts of Paris, provides some confirmation that younger age reduces risk of infection—and transmission.
- When two high school teachers developed minor respiratory symptoms in early February, no one suspected C19. It was cold and flu season, and health officials still assumed the novel coronavirus was mostly confined to China. It wasn’t until 25 February, after one of their contacts was hospitalized in Paris, that the teachers realized they had been infected with SARS-CoV-2. For at least 12 days before the start of winter break on 14 February, and before France instituted precautionary measures, the virus had been spreading freely at the school.
- Arnaud Fontanet, an epidemiologist at the Pasteur Institute, and his colleagues started an investigation in Crépy-en-Valois in late March to see whether they could piece together the virus’ reach in the town and its schools. In high school, antibody testing showed that 38% of pupils, 43% of teachers, and 59% of nonteaching staff had been infected. (By then, several people associated with the school had been hospitalized with C19 complications.) In six elementary schools, they found a total of three children who had caught the virus, likely from family members, and then attended school while infected. But, as far as the researchers could tell, those younger children didn’t pass the virus on to any close contacts.
- “It’s still a bit speculative,” says Fontanet, who shared results from the high school on 23 April and from the elementary schools on 29 June, both on the preprint server medRxiv. But high school students “have to be very careful. They have mild disease, but they are contagious.” Children younger than 11 or 12, on the other hand, “probably don’t transmit very well. They are close to each other in schools, but that is not enough” to fuel spread. At the same time, scientists note that children have more contacts than adults, especially at school, which could offset the lower odds they will spread the pathogen.
- Other outbreaks also suggest that elementary school pupils pose a smaller threat than older students. Among the worst schoolwide outbreaks was at Gymnasium Rehavia, a middle and high school in Jerusalem, where 153 students and 25 staff were infected in late May and early June. An outbreak at a New Zealand high school before that country’s shutdown infected 96 people, including students, teachers, staff, and parents. In contrast, a neighboring elementary school saw few cases.
- But the picture is still blurry. Another Israeli outbreak was in an elementary school in Jaffa, with 33 students and five staff members affected. Across the globe, an elementary school classroom in Trois-Rivières, Canada, had nine of 11 students infected after one contracted the virus in the community.
- Other data come from day care centers: In many countries, they stayed open for children of essential workers, and outbreaks appeared rare. Two flares in Canadian day cares—one in Toronto, and one outside of Montreal—led to temporary closures. In Texas, where overall cases have skyrocketed, at least 894 preschool staff and 441 children across 883 facilities have tested positive, according to news reports. That’s up from 210 total cases just a few weeks ago.
- Tracing transmission through schools, one student at a time—as Fontanet and his colleagues did—should help elucidate whether the virus tracks differently in children of different ages. Another clue about age-based spread came from Crépy-en-Valois’s timeline of new infections. Among high school students and staff, new infections dropped off sharply once winter break started. But in the elementary schools, the (already low) rate of new cases held steady. Fontanet says that pattern suggests that while high schoolers were catching the virus at school, the younger pupils caught it from family members and not their classmates.
Should children play together?
- The scenes hardly resemble typical school: Preschool children instructed to spend recess playing alone inside a chalk square. Eight-year-olds told not to speak to their friends. Middle schoolers are reminded to steer clear of classmates when entering or leaving the building.
- As schools reopened, many embraced physical distancing for students to prevent viral spread. But although the strategy is effective, it is leaving more and more scientists, pediatricians, and parents deeply uncomfortable. They hunger for a compromise that protects communities from C19 while supporting the mental health of young people. “There has to be a level of risk that we’re willing to take if a child’s in school” says Kate Zinszer, an epidemiologist at the University of Montreal.
- Schools are “where our children run around, play and laugh and argue with each other. They need to return to that sort of a healthy normality as soon as possible,” Russell Viner, RCPCH’s president said in a statement last month.
- From the start, some countries bet on strands of research suggesting young children are unlikely to spread the virus: schools in the Netherlands cut class sizes in half but didn’t enforce distancing among students under age 12 when they reopened in April. Other schools adopted a “pod” model as a compromise. Denmark, the first country in Europe to reopen schools, assigned children to small groups that could congregate at recess. It also found creative ways to give those groups as much space and fresh air as possible, even teaching classes in a graveyard. Some classes in Belgium met in churches to keep students spread out. Finland has kept normal class sizes, but prevents classes from mixing with one another.
- As spring wore on, many other countries began rethinking distancing in schools. The Canadian province of Quebec, which reopened many elementary schools in May with strict distancing, has announced fall plans that allow children to socialize freely in groups of six; each group must stay 1 meter away from other groups of students and 2 meters away from teachers. Although French preschoolers were photographed sitting inside their own recess squares in May, day cares there have now abandoned all distancing rules for children ages 5 and under. Older students are advised to stay at least 1 meter away from others while inside. But outside they can play freely with others in their class. The Netherlands recently announced that anyone under age 17 does not need to distance.
- The change is driven not just by pediatricians’ advice but also by practicalities: A full school building leaves little room for distancing. In Israel, pressure to return everyone to school after a partial reopening on 3 May was intense. Two weeks later, classrooms welcomed back all students, housing their usual 30 to 40 pupils. Distancing in class was impossible, says Efrat Aflalo of Israel’s Ministry of Health. So the country embraced another protective strategy: masks.
Should kids wear masks?
- Masks likely blunt spread at school, but children—even more than adults—find them uncomfortable to wear for hours and may lack the self-discipline to wear them without touching their faces or freeing their noses. Does discomfort override a potential public health benefit?
- “For me, masks are part of the equation” for slowing the spread of C19 in schools, especially when distancing is difficult, says Susan Coffin, an infectious disease physician at the Children’s Hospital of Philadelphia. “Respiratory droplets are a major mode of [virus] transmission,” she says, and wearing a mask places an obstacle in those droplets’ path.
- In China, South Korea, Japan, and Vietnam—where masks are already widely accepted and worn by many during flu season—schools require them for almost all students and their teachers. China allows students to remove masks only for lunch, when children are separated by glass or plastic partitions. Israel requires masks for children older than age 7 outside the classroom, and for children in fourth grade and above all day—and they comply, says Aflalo, who has 8- and 11-year-old boys. On the bus ride to school, “all the kids are sitting with masks on,” she says. “They don’t take them off. They listen to the orders.”
- Elsewhere, masks are less central. In some schools in Germany, students wear them in hallways or bathrooms, but can remove them when seated at their (distantly spaced) desks. Austria reopened with this approach, but abandoned masks for students a few weeks later, when officials observed little spread within schools. In Canada, Denmark, Norway, the United Kingdom, and Sweden, mask wearing was optional for both students and staff.
- Not all countries have the luxury of instituting a mask policy driven by science and comfort. Benin requires masks in public spaces, but because the cost can be prohibitive for families, schools do not turn maskless students away. Students in Ghana returned to school in May wearing masks—if they had them. South Africa, which faces a rising C19 caseload, is racing to provide free masks to all students who need them.
- For Aflalo, the potential value of masks was underscored after a record-setting heat wave struck Israel in mid-May. As temperatures rose to 40°C, masks became intolerable, and with the health ministry’s blessing, students and teachers largely put them aside for almost a week.
- For 2 weeks—the typical C19 incubation period—things seemed fine. Aflalo left to go camping in the desert with her family. But then, a crisis: While on vacation, “I started getting calls about the Gymnasium,” says Aflalo, referring to Gymnasium Rehavia, the school in Jerusalem with the large outbreak. Aflalo can’t say for sure that the outbreak was fueled by a lack of masks, but she believes the timing is suggestive.
What should schools do when someone tests positive?
- The short answer: No one knows. That’s largely because of a lack of data about how many silent cases might be brewing when an illness or two comes to light. “How do we best deal with infection?” Edwards wonders. “Do we just close the classroom” or shutter the whole school?
- Some schools have favored isolating only close contacts. In Germany, for example, classmates and teachers of an infected student are sent home for 2 weeks, but other classes continue. Until summer break, Quebec generally did the same; at least 53 students and teachers tested positive after many schools reopened in May, according to news reports, but officials believed many of those infections were contracted in the community.
- Elsewhere, officials are more cautious. Taiwan, which has largely suppressed the virus, kept schools open after one case but said it would close them for two or more, a situation it hasn’t yet faced. In Israel, schools closed for a single case, and close contacts of every infected individual were tested and quarantined, Aflalo says. By mid-June, 503 students and 167 staff had been infected, and 355 schools had closed temporarily. (That number is a small fraction of the 5000 schools across Israel.)
- Widespread testing in schools, including of children without symptoms, could help officials choose the most effective policy. The U.K. government recently began a study of as many schools as it can recruit across England. The project will test students and staff at preschools, primary schools, and secondary schools several times over at least 6 months for both the virus and antibodies to it, in an effort to map transmission patterns and viral prevalence. In Berlin, researchers from Charité University Hospital launched a study in 24 schools on 15 June—2 weeks before summer break—that will test a cohort of 20 to 40 pupils and five to 10 staff members from each school every 3 months for at least 1 year. The researchers will look for both active infections and antibodies, to map the extent of silent infections and the threat they pose to students and staff. A similar study started this week in 138 preschools and elementary schools across the state of Bavaria.
Do schools spread the virus to the wider community?
- Because children so rarely develop severe symptoms, experts have cautioned that open schools might pose a much greater risk to teachers, family members, and the wider community than to students themselves. Many teachers and other school staff are understandably nervous about returning to the classroom. In surveys of U.S. school districts, as many as one-third of staff say they prefer to stay away. Science could find few reports of deaths or serious illnesses from C19 among school staff, but information is sparse. Several teachers have died of C19 complications in Sweden, where schools did not modify class sizes or make other substantive adjustments.
- Early data from European countries suggest the risk to the wider community is small. At least when local infection rates are low, opening schools with some precautions does not seem to cause a significant jump in infections elsewhere.
- It’s hard to be sure, because in most places, schools reopened in concert with other aspects of public life. But in Denmark, nationwide case numbers continued to decline after day care centers and elementary schools opened on 15 April, and middle and high schools followed in May. In the Netherlands, new cases stayed flat and then dropped after elementary schools opened part-time on 11 May and high schools opened on 2 June. In Finland, Belgium, and Austria, too, officials say they found no evidence of increased spread of the novel coronavirus after schools reopened.
- In a broader study of C19 clusters worldwide, epidemiologist Gwen Knight at the London School of Hygiene & Tropical Medicine and her colleagues collected data before most school closings took effect. If schools were a major driver of viral spread, she says, “We would have expected to find more clusters linked to schools. That’s not what we found.” Still, she adds, without widespread testing of young people, who often don’t have symptoms, it’s hard to know for sure what role schools might play.
- At the same time, open schools can change the overall balance of who becomes infected by adding cases among children. In Germany, the proportion of all new infections that were in children under age 19 ticked upward from about 10% in early May, when schools reopened, to nearly 20% in late June. But wider testing and a decline in cases among the elderly could also explain the increase. In Israel, infections among children increased steadily after schools opened. That paralleled a rise in cases nationwide, but it’s not clear whether the country’s rising caseload contributed to the increase within schools or vice versa.
- “We try to focus the epidemiologic research and find the source but it’s hard,” Aflalo says. “We cannot say right now this is because of this or that.”
What lies ahead?
- In much of the world, schools that closed in March remained closed through the summer break, and autumn will see a wave of reopenings. For millions of especially vulnerable children, however, the break may continue indefinitely. Many low-income countries lack the resources to shrink class sizes or provide everyone with masks and so are hesitant to reopen in the midst of a pandemic. In June, Bangladeshi Prime Minister Sheikh Hasina said schools will likely stay shut until the danger of C19 has passed. Similarly, officials in the Philippines said in-person schooling will not resume until there is a vaccine to protect against C19.
- In other places, ranging from Mexico to Afghanistan to the United States, planning for fall 2020 is underway. In the United States, school districts are releasing a patchwork of plans, which often include hybrid models that alternate distance learning with small in-person classes. Whether those plans sufficiently protect children, staff, and communities from C19 will depend on how case numbers look as opening day approaches. This reality was thrown into stark relief late last month, when Arizona’s governor announced he would delay the state’s school reopening by at least 2 weeks, to 17 August, because of a surge in cases.
- The experiment will continue. Yet scientists lament that as before, it may not generate the details they crave about infection patterns and paths of transmission. “There just isn’t really a culture of research” in schools, Edwards says. Gathering data from schoolchildren comes with layers of complexity beyond those of traditional pediatric research. In addition to seeking consent from parents and children, it often requires buy-in from teachers and school administrators who are already overwhelmed by their new reality. Integrating research—the only sure way to gauge the success of their varied strategies—may be more than they can handle.
3. Students Will Pay a High Price For School Closures
- In mid-April, UNESCO reported 192 countries had closed all schools and universities, affecting more than 90% of the world’s learners: almost 1.6 billion children and young people. While some governments are starting to order teachers and students back to work, education—one of the most important drivers in human capital investment—continues to be largely closed for business.
- How long schools will remain closed, how student learning will be affected, and how greatly this will affect the poorest and most vulnerable populations remain difficult to say. We do not yet know enough about what happens next: Questions range from whether it is possible for recovered patients to be reinfected to how long it will take to develop, license, and distribute a viable vaccine. But we do know that learning will indeed be lost, and that those losses will not likely be evenly distributed.
- When children lose out on education, they lose out on future opportunities including economic benefits, such as additional earnings, with far-reaching consequences. Some modeling suggests that the loss of learning during the extraordinary systemic crisis of World War II still had a negative impact on former students’ lives some 40 years later. And neither is the impact of lost learning confined to the individual level: For whole societies closing down education today, there will likely be significant consequences tomorrow.
- With this in mind, we have developed preliminary evidence to estimate projected potential losses of future earnings as a result of the current school closures. We present this as a starting point to help governments make increasingly informed choices about school closures, and to start a global debate on controlling and mitigating the economic downward spiral that C19 is already creating.
Projected Future Earning Losses On Students and the Economy
- In presenting these findings, we emphasize their status as the start, rather than the culmination, of an analytical process. There are complicating considerations we have identified, including the uneven quality of learning, differences in provision of effective distance learning, and other pressures that will come to bear on some children, such as the need to find work to help support their families. There are likely more we have not yet considered, but we anticipate others will provide them through comments and discussion around this blog. For now, we simply seek to sound the alarm about the scale of the sacrifice young people are being forced to make.
- We begin by assuming that every additional year of schooling equates to 10% in additional future earnings. We then use the number of months of education closures to estimate the loss in marginal future earnings. For example, if Country X closes its schools and universities for four months, the loss in marginal future earnings would be 2.5% per year over a student’s working life. We apply this assumption to the world’s largest economy, the United States of America and its 76 million students, as our starting point. We model on a 45-year working life, a discount rate of 3 percent, and mean annual earnings of $53,490.
- This quick estimate suggests lost earnings of $1,337 per year per student: a present value loss of earnings of $33,464 (63 percent of a year’s salary at current average wage rates). While this may not sound like too much of an individual price for young people to pay in the fight against C19, a look at the impact on the whole of the country is much more sobering.
- In this model, the cost to the United States in future earnings of four months of lost education is $2.5 trillion—12.7% of annual GDP. And with well over half the country’s states deciding to keep schools and universities closed until the fall at the earliest, much of this loss may well materialize. Extrapolating to the global level, on the basis that the U.S. economy represents about one-quarter of global output, these data suggest the world could lose as much as $10 trillion over the coming generation as a result of school closures today.
- These figures are preliminary, and the current model is simple. But they raise important questions for further investigation, including these three we hope to shed further light on in the coming weeks:
- How does the projected loss of future earnings and the severity of its impact on young people’s prospects differ between rich and poor countries?
- Within countries, which groups of children and young people are likely to suffer most from the economic impact of lost learning and access to education?
- How does the sacrifice being made by young people as a result of lost education compare with that being made by other parts of the population?
- The scale of economic damage likely already stored up due to lost learning indicates the care with which governments should plan their next policy moves. Like so many aspects of this pandemic, the impact on children and young people seems more likely to take the form of a long crisis rather than a short, sharp shock.
4. Coronavirus Is Blowing Up America’s Higher Education System
- When Kashuan Hopkins walked into his weekly IT staff meeting at the University of Oklahoma on March 9, he was largely unprepared for what would follow. He had heard of coronavirus, but at the time, Oklahoma was still virtually untouched—only one case of C19 had been confirmed in the state, and the first death wouldn’t be reported for almost a week. His boss, however, instructed Hopkins to accelerate training for Canvas, the online learning management system used by the university. Puzzled, Hopkins offered to schedule a couple extra sessions later that week, but was instead told to start scheduling “as many as you can.” Within 48 hours, Hopkins was conducting Canvas training for faculty virtually around the clock. On March 12, the university announced a suspension of in-person classes on its main campus—a suspension that would soon turn into a complete transition to online learning.
- OU’s frantic effort to train hundreds of teachers and transition thousands of students on the fly was seen at colleges and universities around the world. Steps that would typically have been implemented over the course of years were telescoped into weeks and sometimes even days. The City University of Hong Kong, for instance, moved all its coursework onto digital platforms in just eight days, according to Canvas. This relative success belies an underlying failure: for years, elite schools have advocated for the value of in-person teaching. When the pandemic hit, they were forced into crisis mode.
- With the coronavirus upending the service model and the economics of universities across the country, it is not at all clear how flexible America’s higher education system will be in the face of high costs, institutional barriers to change, and a longstanding belief in the value of the way things are traditionally done. A professor at Columbia Business School once told me that “all businesses will be disrupted in the digital age,” but added with a self-satisfied smile, “except for us, of course.” The American affection for the residential model is understandable, but as Mitchell Stevens, a professor at the Stanford Graduate School of Education, told me, it also comes with an astronomical price tag: student costs significantly higher than those in other countries; oppressive student debt; and exclusion from top universities for a wide range of students who can’t afford to leave behind family commitments to spend years on campus.
- Some of the support for the residential model reflects a belief in the value of in-person teaching and the rites of passage associated with going away to college. But it also reflects economic self-interest. Postsecondary education in the United States is an almost $700-billion-a-year business, and tuition and fees associated with residential colleges are a primary and critical pillar of this educational economy. Administrators, faculty, staff, and housing providers, to name just a few, all have a stake in this enterprise. Scott Galloway, a professor at New York University’s Stern School of Business, has predicted that more schools would begin to announce they’ll go online-only in the fall—after they receive a wave of tuition and housing deposits.
- Despite the institutional biases against online learning, the hasty, unplanned transition online has seen some real success among university students. In a recent Longevity Project and Morning Consult poll, 33% of respondents said that they were “very satisfied” in their online version of college, and another 43% said they were “somewhat satisfied”—relatively strong numbers for something cobbled together in a matter of days. Terri Cullen, a professor at the College of Education at OU, told me that once teachers “began to think outside the construct of time,” they started to take advantage of unique features of digital learning. Even in the courses that rely on in-person activities, teachers found interesting workarounds. Cullen described a biology class that replaced field studies with 360-degree photos from the field, then shipped $25 microscopes to every student so they could take samples at home and analyze them with virtual lab partners.
- Those successes, however, are balanced against ongoing challenges that come with the fact that elite schools have failed to embrace online learning. Sydney Maggin, a rising sophomore who’s planning to major in illustration at Parsons School of Design, praised the flexibility and responsiveness of faculty in this new environment, but also lamented the loss of access to the Making Center, a three-story lab of cutting-edge design and production technologies. Some faculty members have struggled with the technology and with the fact that what works in the classroom does not always translate online. And some students have faced similar struggles. 11% of respondents to the Longevity Project and Morning Consult poll said that technical issues were the biggest online-learning challenge they faced, and a very large group of respondents, 38%, reported that their biggest challenge was staying focused and on track with assignments, likely a systemic challenge that online educators would have to deal with.
- Universities also have to contend with their own success in mythologizing in-person education. Even though a high percentage of students were satisfied with their online experiences, in the Longevity Project and Morning Consult poll, only 11% of respondents said they were now more likely to take online classes than before the pandemic, even if in-person instruction was available, and an equal number said they were now less likely to do so. And few are happy with the new economic equation. In a College Pulse survey, more than 90% of respondents said they should pay less in tuition if classes are online—an offer that few colleges have so far made. Maggin, the Parsons student, told me that while she recognizes the school needs a consistent revenue stream to pay faculty, administrators, and maintenance staff, she still didn’t think it was fair to charge full tuition because she “relies on the resources [at the school] and the value of the New York experience.”
- This all comes at a perilous financial time for schools and students alike. “On March 1, the financial infrastructure of higher education was by no means secure,” said Stevens, the Stanford professor. “State legislatures had been cutting budgets for public higher education for a generation. Public universities were increasingly relying on full-paid out-of-state and international students to support their basic operations. Student loan debt had exceeded $1.6 trillion, such that Americans owed more in education loans than they did on their credit cards.” The events of the past three months have only exposed these problems further, as schools face the disappearance of full-fare international students and declining government support. Virtually every state is facing a budget gap in 2020, and higher education will likely be one of the first victims of reduced state spending. In early July, for instance, the state of Maryland slashed $131 million from its higher education budget. Meanwhile, Immigration and Customs Enforcement has announced that international students won’t be able to stay in the U.S. if their school goes online-only.
- The massive money crunch driven by C19 could well lead schools to seek more cost-effective ways to do business. A professor at the University of Virginia told me he had pre-recorded all his lectures for a large survey class, and noted ruefully that this meant it would be hard for schools to continue to justify hiring faculty, like him, to teach the course fresh every time. But the fast-moving nature of the crisis and the deep-seated roots of the residential model may blunt the opportunity. Stevens told me that most schools are “very much in short-term crisis-management mode” and seem focused on returning to “normal,” regardless of the consequences. The fear is that colleges may create broad public risk—Stevens colorfully likened reopening Stanford or the University of Michigan to reopening beaches in South Florida—but they will miss out on an opportunity to rethink elite education to be more agile and inclusive. “I think the commitment to return students to campus is misguided and reckless,” he told me, and “makes no pedagogical or public health sense.”
I. The Road Back?
1. How Japan Beat Coronavirus Without Lockdowns
- While the numbers of infected are subsiding in some regions, the C19 pandemic still rages in others. The world is likely to be dealing with the effects of the novel coronavirus until an effective vaccine or treatment is developed. As many governments work to reopen travel and commerce, it has become clear that this is a global crisis, and nation-by-nation approaches alone are proving insufficient. It’s essential for nations to share their experiences and learn from each other.
- By following the science developed by world-renowned experts, Japan has been able to avoid the worst effects of the pandemic without mandatory lockdowns. How have we done it?
- High-quality medical care—accessible to all thanks to universal health insurance—no doubt helps. Social and cultural factors might be at play, too. The Japanese routinely wear masks to ward off hay fever and colds.
- However, the core insight that has helped us in our fight against C19 is the notion of transmission clusters.
- Early on, our health experts noticed that the disease spreads in a peculiar way. Although the coronavirus is highly contagious, it is not uniformly contagious.
- Most who are infected by it—about 80%—never pass it on to anyone else. The bulk of infections can be traced to a small number of “super-spreading events.” Just as striking, a person with mild symptoms, or even none at all, could easily cause a super-spreading event, or a cluster.
- Because C19 is a disease that spreads along relatively small numbers of super-spreading transmission chains, if you can isolate these chains or prevent them from forming, transmission of the virus isn’t sustainable.
- Guided by such knowledge, we employed two techniques to contain and prevent clusters.
- First, Japanese health experts recommended a special kind of contact tracing called “retrospective tracing.” This approach differs from standard methods that focus mainly on the period after a patient contracted the disease. With retrospective tracing, health workers try to ascertain a patient’s movements and interactions before they became infected. By mapping them and cross-referencing them with those of other infected people, tracers can identify common sources of infection—the people and places behind an infection cluster.
- Second, we developed a guide for avoiding high-risk situations. We call them the “three Cs”: closed spaces, crowded places and close-contact settings, especially those involving loud talking. These settings all pose a major risk of infection. Today, thanks to extensive public-awareness campaigns, even children in Japan know to avoid them.
- “Cluster-busting” isn’t a panacea. For one thing, it works best when outbreaks are relatively small. While Japan managed to detect the first wave early, some clusters inevitably formed, prompting the government to declare a state of emergency on April 7. The voluntary business closures and other restrictions succeeded in reducing in-person contact by as much as 80%, and were lifted after less than two months.
- Although these measures were effective in suppressing the virus expansion in Japan, the reduction in person-to-person contacts came with heavy economic costs. After new cases fell back to a small number, the cluster-based approach, in particular avoiding the three Cs, has remained central to suppressing transmission of the virus while allowing social and economic activities to resume. In Japan, with the advice of experts, more than 100 industrial sectors—including the supermarket, restaurant and entertainment industries—have established guidelines for conducting business while avoiding the three Cs.
- Keeping C19 under control as the world edges back out of its shell will require innovative approaches and new technologies. Japan has been promoting digitization throughout society. Our “Digital New Deal” has made working from home easier by aggressively promoting telework technology, freeing people from Tokyo’s packed commuter trains.
- Avoiding the three Cs isn’t always possible, so we are increasing and enhancing our testing capacity through the introduction of new technologies such as saliva-based tests and ultrafast antigen testing. Local health centers have played an important role in contact tracing, and voluntary app-based monitoring is helping to ease their burden.
- Using “Fugaku,” Japan’s newly developed supercomputer that recently ranked as the most powerful in the world, artificial-intelligence researchers are working with medical experts to develop ways to mitigate C19 transmission. They have already developed simulations of droplet spread and contagion in restaurants. I am hoping they may also help us find better ways to contain the spread of the virus.
- Humanity isn’t out of the woods yet. Defeating C19 will take time, resources and global goodwill. All countries must move forward together, in a spirit of openness and cooperation.
J. Projections & Our (Possible) Future
1. Are C19 Polls Leading to Poor Policy Decisions?
- America is in an election year, but public opinion surveys these days seem to focus as much on C19 as on who should be the next president. Pollsters use their survey data as a fuzzy form of viral tracking—noting, for example, that in March just 4% of Americans said they knew someone who had tested positive, versus 36% in June. Or they riddle us with findings like the one that says 65% of adults wear a mask in stores but only 44% report seeing others do the same. There’s even mashup polls that analyze pandemic partisanship: One from May announced that 74% of Republicans guessed they’d soon be back to a hair or nail salon, as opposed to 43% of Democrats and 55% of Independents. In short, while everyone was out buying pulse oximeters, the pollsters have been busy taking the nation’s pulse on the ever-changing public health emergency.
- This endless surveying has gotten out of hand, and it needs to be reined in.
- The Covid surveys aren’t simply grist for news reports; they appear to be a source of public health prescriptions at the highest levels of government. Just last week, New York City mayor Bill de Blasio nodded to the polls when he explained why the city’s schools would reopen. A survey of more than 300,000 public school parents by the city had found that around three-quarters wanted their kids back in the classroom this fall. “They feel ready now,” de Blasio said. “They know that’s what they want to do. So we’re full steam ahead for September.”
- It’s as if we’re living in a game show where the public health option that gets the most applause wins. But this pandemic isn’t a game, and we need scientific expertise, not vox populi, to guide us. It may indeed be wise—and better for New York City’s public health—if schools reopen in the fall. To make that decision on the basis of a parent survey, though, as opposed to studies detailing how viral transmission can be curbed in classroom settings, suggests that the nation’s “leaders” are simply followers of their constituents.
- Statewide policies on wearing masks seem to be similarly, and catastrophically, in thrall to public polling. Republican governors, such as Georgia’s Brian Kemp and Florida’s Ron DeSantis, may know of surveys showing that their voters are more reluctant to mask up. Gallup polls now find a 32-point gap, the largest that it has ever been, between the higher usage rates for Democrats and the lower ones for Republicans. In late June, Kemp explained why he wouldn’t issue a mandate: That “is a bridge too far for me right now. We have to have the public buy-in.” Around the same time, Florida governor Ron DeSantis said that, even though a mandate “could make an impact,” enforcing penalties “would backfire.” Wearing masks is no panacea, but in the aftermath of DeSantis’ comments, his state recorded 10,000 new coronavirus cases in a single day—marking the most significant jump in cases there since the pandemic began.
- There is an argument to be made that surveys of public opinion on health measures can help policymakers manage outbreaks and communicate their messages more effectively. Polls of attitudes toward potential C19 vaccines, for instance, could be used to plan for a massive immunization campaign. According to recent data from the Associated Press-NORC Center for Public Affairs Research, only 49% of Americans said they would take a vaccine against the new coronavirus, were one to become available, and one-fourth of surveyed Black Americans said they would. Public health officials can now unpack why that racial difference might exist and try to address it down the road.
- But small differences in these kinds of polls can make a big difference in the headlines they generate—and the decision making they inform. Whereas the Associated Press-NORC Center poll gave respondents the options of answering “yes,” “not sure” or “no” to receiving a hypothetical C19 vaccine, a Pew Research Center study asked if they would “definitely” or “probably” take one, or not. As a result, coverage of the former poll—“Only half of Americans …”—implied that the US is a nation of self-destructive antivaxxers. But coverage of the latter—“72% of Americans say …”—lumped together the certain with the somewhat trepidatious, and came out sounding much more optimistic.
- It’s garbage data, but it’s also data that the leader of the United States used to delegitimize a leading scientist during the worst pandemic humankind has seen in a century.
- America is a giant country with a giant C19 problem. Its long-standing, “insane addiction” to polls is so unhealthy that it ends up as a risk factor for poor decision making. For one thing, polls only give us a snapshot in time. They suffer from “short-termism,” as public opinion analyst Karlyn Bowman noted in National Affairs. “Pollsters ask questions about a controversial news event to secure coverage, only to move onto the next topic, making it difficult to determine how public attitudes are changing over time.”
- Opinion surveys may also be inaccurate. The same errors that arise in political polling from low response rates, for example, might also plague public health research. “Those not participating in election polls may also not be inclined to participate in public health surveys,” wrote the Dutch social epidemiologist Frank van Lenthe. “Those who experience financial problems, poor housing circumstances, and work-related stress may give participation in research or interventions a much lower priority than those who do not.” If that is true then there’s reason to think that the very people who would be least likely to respond to a Covid-related poll would be among the most vulnerable to the pandemic’s ravages.
- Another risk arises from the so-called bandwagon effect, whereby public polls end up altering the very beliefs they’re meant to measure. This concern—that the mere act of reporting on a majority opinion encourages people to conform to it—goes back as far as the 1930s and 1940s, as historian Jill Lepore noted in 2015 for The New Yorker. Lawmakers back then regularly introduced motions in Congress “calling for an investigation into the influence of public-opinion polling on the political process.” It only makes this problem worse, Lepore writes, that “a sizable number of people polled either know nothing about the matters those polls purport to measure or hold no opinion about them.” Covid polling could end up spreading the opinion that it’s safe to open bars, for example, despite warnings from public health officials.
- People are particularly sensitive to social cues about emerging health behaviors, says Damon Centola, a professor at the Annenberg School for Communications at the University of Pennsylvania. He points to mask wearing as one example of this in the US. “It’s so conspicuous because it’s new, and it’s shifting underneath our feet,” he says. People have looked to their peers to decide whether to wear a mask, and the practice has become emblematic of local community values—and even political partisanship. It’s not too hard to imagine how those pandemic-politics mashup polls would encourage this kind of division, by continually highlighting the different attitudes among different groups.
- We’ve now been through so many news cycles about masks, for example, and so many polling data dumps on the same topic, that basic public health measures can be easily recast and distorted through a political lens. “Mask-wearing has become a totem, a secular religious symbol,” one Republican strategist told The Washington Post. “Christians wear crosses, Muslims wear a hijab, and members of the Church of Secular Science bow to the Gods of Data by wearing a mask as their symbol, demonstrating that they are the elite; smarter, more rational, and morally superior to everyone else.”
- Ohid Yaqub, a health-policy researcher at the University of Sussex in Brighton, UK, says that we need to elevate the voice of public health experts with “consistent messaging,” not poll outcomes. It will be an uphill battle, though. Last week, Donald Trump retweeted to his 83 million followers an online poll by the anti-Muslim organization Act for America, which asked whether they had more trust in the president or Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases. More than 90% of the poll’s respondents had selected Trump. Given that it was a Twitter poll, many of the respondents were likely followers of Act for America, but the president doesn’t seem to care about things like sampling bias. It’s garbage data, but it’s also data that the leader of the United States used to delegitimize a leading scientist during the worst pandemic humankind has seen in a century. If we don’t put an end to this polling madness, we will be on an accelerated path to Idiocracy.
- The framers of the US Constitution aimed for a government system that would not be at the constant mercy of the short-sighted whims of the people. But the growing dominance of polling undermines this goal. You only need to look back as far as February to see that twice as many Americans were worried about catching the flu versus coronavirus, even though there were plenty of reasons to fear the latter and it proved to be worse. Now is not the time to keep taking the temperature of the country with incessant polls; we’ve already had enough questionable temperature-taking in this pandemic.
2. Hard Hit Neighborhoods May Be Close to Herd Immunity
- At a clinic in Corona, a working-class neighborhood in Queens, more than 68% of people tested positive for antibodies to the new coronavirus. At another clinic in Jackson Heights, Queens, that number was 56%. But at a clinic in Cobble Hill, a mostly white and wealthy neighborhood in Brooklyn, only 13% of people tested positive for antibodies.
- As it has swept through New York, the coronavirus has exposed stark inequalities in nearly every aspect of city life, from who has been most affected to how the health care system cared for those patients. Many lower-income neighborhoods, where Black and Latino residents make up a large part of the population, were hard hit, while many wealthy neighborhoods suffered much less.
- But now, as the city braces for a possible second wave of the virus, some of those vulnerabilities may flip, with the affluent neighborhoods becoming most at risk of a surge. According to antibody test results from CityMD that were shared with The New York Times, some neighborhoods were so exposed to the virus during the peak of the epidemic in March and April that they might have some protection during a second wave.
- “Some communities might have herd immunity,” said Dr. Daniel Frogel, a senior vice president for operations at CityMD, which plays a key role in the city’s testing program.
- The CityMD statistics — which Dr. Frogel provided during an interview and which reflect tests done between late April and late June — appear to present the starkest picture yet of how infection rates have diverged across neighborhoods in the city.
- As of June 26, CityMD had administered about 314,000 antibody tests in New York City. Citywide, 26% of the tests came back positive.
- But Dr. Frogel said the testing results in Jackson Heights and Corona seemed to “jump off the map.”
- While stopping short of predicting that those neighborhoods would be protected against a major new outbreak of the virus — a phenomenon known as herd immunity — several epidemiologists said that the different levels of antibody prevalence across the city are likely to play a role in what happens next, assuming that antibodies do in fact offer significant protection against future infection.
- “In the future, the infection rate should really be lower in minority communities,” said Kitaw Demissie, an epidemiologist and the dean of the School of Public Health at SUNY Downstate Medical Center in Brooklyn.
- Dr. Ted Long, the executive director of the city’s contact-tracing program, said that while much remained unknown about the strength and duration of the protection that antibodies offer, he was hopeful that hard-hit communities like Corona would have some degree of protection because of their high rate of positive tests. “We hope that that will confer greater herd immunity,” he said.
- Neighborhoods that had relatively low infection rates — and where few residents have antibodies — are especially vulnerable going forward. There could be some degree of “catch up” among neighborhoods, said Prof. Denis Nash, an epidemiology professor at the CUNY School of Public Health.
- But he added that even if infection rate were to climb in wealthier neighborhoods, “there are advantages to being in the neighborhoods that are hit later.” For one, doctors have become somewhat more adept at treating severe cases.
- Some epidemiologists and virologists cautioned that not enough data exists to conclude that any areas have herd immunity. For starters, the fact that 68.4% of tests taken at an urgent care center in Corona came back positive does not mean that 68.4% of residents had been infected.
- “For sure, the persons who are seeking antibody testing probably have a higher likelihood of being positive than the general population,” said Professor Nash. “If you went out in Corona and tested a representative sample, it wouldn’t be 68%.”
- So far, the federal government has released relatively little data from antibody testing — making the CityMD data all the more striking. The Centers for Disease Control and Prevention, for instance, has published limited data that suggested that 6.93% of residents in New York City and part of Long Island had antibodies. But that survey was based on samples collected mainly in March, before many infected New Yorkers might have developed antibodies.
- New York State conducted a more comprehensive survey on antibody rates, which involved testing some 28,419 people across the state. That survey suggested that roughly 21.6% of New York City residents had antibodies. But it also revealed a much higher rate in some neighborhoods. While the state has released little data from Queens, its numbers showed that in Flatbush, Brooklyn, for example, about 45% of those tested had antibodies.
- The CityMD data provides similar conclusions. At a location in Bushwick, a Brooklyn neighborhood which has a large Hispanic population and where the median household income is below the citywide average, some 35% of antibody tests were positive, according to Dr. Frogel.
- Dr. Frogel said that across the Bronx, which has had the city’s highest death rate from C19, about 37% of antibody tests were turning up positive.
- The CityMD in Corona, on Junction Boulevard, serves a predominantly Hispanic neighborhood whose residents include many construction workers and restaurant employees. Many had to work throughout the pandemic, raising their risk of infection.
- Angela Rasmussen, a virologist at Columbia University, called the high positive rate in Corona “a stunning finding.” Epidemiologists said the rate showed the limits of New York’s strategy in curtailing the virus: While public health measures may have slowed the spread in some neighborhoods, they did far less for others.
- There are reasons parts of Queens were hit so hard. Homes in Elmhurst and parts of Corona are especially crowded — the highest rate of household crowding in the city, according to census bureau data from 2014. Given that transmission among family members is a leading driver of the disease’s spread, it is unsurprising that crowded households have been associated with higher risk of infection.
- For residents of Corona, the main sources of employment are jobs in hospitality, including restaurants, as well as construction and manufacturing, according to a 2019 report by the Citizens’ Committee for Children of New York. Many construction workers and restaurant employees showed up to work throughout the pandemic, elevating their risk of infection.
- “Our plan did not really accommodate essential workers as it did people privileged enough — for lack of a better word — to socially distance themselves,” Professor Nash said. He said that one lesson of the past few months was that the city needed to better protect essential workers — everyone from grocery store employees to pharmacy cashiers — and make sure they had sufficient protective equipment.
- Epidemiologists have estimated that at least 60% of a population — and perhaps as much as 80% — would need immunity before “herd immunity” is reached, and the virus can no longer spread widely in that community.
- But scientists say it would be a mistake to base public health decisions off antibody rates across a population.
- “Just looking at seroprevalence alone can’t really be used to make actionable public health decisions,” Dr. Rasmussen, the virologist at Columbia, said.
- One reason is that the accuracy of the antibody tests is not fully known, nor is the extent of immunity conferred by antibodies or how long that immunity lasts. Dr. Rasmussen noted that the “magical number of 60% for herd immunity” assumes that everyone infected has complete protection from a second infection. “But what about people with partial protection?” she asked. “They may not get sick, but they can get infected and pass it along.”
- “It is premature to discuss herd immunity, since we are still learning what the presence of C19 antibodies means to an individual and whether, or for how long, that conveys immunity; and we don’t know how the level of immunity in a single community translates into herd immunity,” said Jonah Bruno, a spokesman for the state Department of Health.
- He said he was unsurprised by the high rate in Corona, and senior officials with the city’s contact-tracing program and public hospital system agree. “We know this area was disproportionately affected,” said Dr. Andrew Wallach, a senior official in the city’s public hospital system, “so this just confirms what we’ve seen clinically.”
K. Practical Tips & Other Useful Information
1. The best (and worst) materials for masks
- It’s intuitive and scientifically shown that wearing a face covering can help reduce the spread of the novel coronavirus that causes C19. But not all masks are created equal, according to new University of Arizona-led research.
- Amanda Wilson, an environmental health sciences doctoral candidate in the Department of Community, Environment and Policy in the Mel and Enid Zuckerman College of Public Health, is lead author on a recent study published in the Journal of Hospital Infection that assessed the ability of a variety of nontraditional mask materials to protect a person from infection after 30 seconds and after 20 minutes of exposure in a highly contaminated environment.
- When the researchers compared wearing masks to wearing no protection during 20-minute and 30-second exposures to the virus, they found that infection risks were reduced by 24-94% or by 44-99% depending on the mask and exposure duration. Risk reduction decreased as exposure duration increased, they found.
- “N99 masks, which are even more efficient at filtering airborne particles than N95 masks, are obviously one of the best options for blocking the virus, as they can reduce average risk by 94-99% for 20-minute and 30-second exposures, but they can be hard to come by, and there are ethical considerations such as leaving those available for medical professionals,” Wilson said.
- The next best options, according to the research, are N95 and surgical masks and, perhaps surprisingly, vacuum cleaner filters, which can be inserted into filter pockets in cloth masks. The vacuum filters reduced infection risk by 83% for a 30-second exposure and 58% for a 20-minute exposure. Of the other nontraditional materials evaluated by the researchers, tea towels, cotton-blend fabrics and antimicrobial pillowcases were the next best for protection.
- Scarves, which reduced infection risk by 44% after 30 seconds and 24% after 20 minutes, and similarly effective cotton t-shirts are only slightly better than wearing no mask at all, they found.
- “We knew that masks work, but we wanted to know how well and compare different materials’ effects on health outcomes,” said Wilson, who specializes in quantitative microbial risk assessment.
- Wilson and her team collected data from various studies of mask efficacy and created a computer model to simulate infection risk, taking various factors into consideration.
- “One big component of risk is how long you’re exposed. We compared risk of infection at both 30 seconds and 20 minutes in a highly contaminated environment,” she said.
- Other conditions that impact risk of infection are the number of people around you and their distance from you, she said.
- The size of virus-transporting droplets from sneezes, coughs or even speech is also a very important factor. Larger, heavier droplets carrying the virus drop out of the air faster than smaller, lighter ones. That’s one reason distance helps reduce exposure.
- “Aerosol size can also be affected by humidity,” Wilson said. “If the air is drier, then aerosols become smaller faster. If humidity is higher, then aerosols will stay larger for a longer period of time, dropping out faster. That might sound good at first, but then those aerosols fall on surfaces, and that object becomes another potential exposure route.”
- The study also showed that the more time a person spends in an environment where the virus is present, the less effective a mask becomes.
- “That doesn’t mean take your mask off after 20 minutes,” Wilson said, “but it does mean that a mask can’t reduce your risk to zero. Don’t go to a bar for four hours and think you’re risk free because you’re wearing a mask. Stay home as much as possible, wash your hands often, wear a mask when you’re out and don’t touch your face.”
- Masks protect the wearer and others in a number of different ways. Wilson said there are two “intuitive ways” that masks filter larger aerosols: mechanical interception and inertial impaction.
- “The denser the fibers of a material, the better it is at filtering. That’s why higher thread counts lead to higher efficacy. There’s just more to block the virus,” she said. “But some masks (such as those made from silk) also have electrostatic properties, which can attract smaller particles and keep them from passing through the mask as well.”
- The model developed by Wilson and her colleagues included parameters such as inhalation rate – the volume of air inhaled over time – and virus concentration in the air.
- “We took a lot of research data, put it into a mathematical model and related those data points to each other,” Wilson said. “For example, if we know people’s inhalation rates vary by this much and know this much virus is in the air and these materials offer this much efficiency in terms of filtration, what does that mean for infection risk? We provide a range, in part, because everyone is different, such as in how much air we breathe over time.”
- Wilson also said it’s important for a mask to have a good seal that pinches at nose, and she noted that people shouldn’t wear a mask beneath the nose or tuck it under the chin when not in use.
- “Proper use of masks is so important,” Wilson said. “Also, we were focusing on masks protecting the wearer, but they’re most important to protect others around you if you’re infected. If you put less virus out into the air, you’re creating a less contaminated environment around you. As our model shows, the amount of infectious virus you’re exposed to has a big impact on your infection risk and the potential for others’ masks to protect them as well.”
L. Johns Hopkins C19 Update
July 10, 2020
1. Cases & Trends
- The WHO C19 Situation Report for July 9 reports 11.87 million cases (204,967 new) and 545,481 deaths (5,575 new). The WHO has reported more than 200,000 new cases for 4 of the last 6 days. The pandemic has been ongoing for more than 6 months and continues to accelerate.
India, Pakistan & Bangladesh
- India reported its highest daily incidence to date, with 26,506 new cases. India remains #3 globally in terms of daily incidence.
- Pakistan continues to report decreasing incidence since its peak in mid-June, and its total active cases continues to decline, dropping below 90,000 for the first time since June 15. Pakistan fell to #12 globally in terms of daily incidence.
- Bangladesh continues to report decreased daily incidence as well, reporting 2,949 new cases. This is only the second time since June 12 that Bangladesh reported fewer than 3,000 new cases. Notably, Bangladesh’s test positivity remains slightly greater than 20%, and the number of daily tests performed has decreased steadily since early July. This could indicate that Bangladesh’s decreased incidence could be driven more by reduced testing than slowing transmission. Bangladesh is now #10 globally in terms of daily incidence.
Central & South America
- Brazil reported 42,619 new cases, its fifth highest daily incidence to date. Brazil has not yet set a new high daily incidence this week, which could potentially indicate that its epidemic is approaching a peak or plateau. Brazil remains #2 globally in terms of daily incidence, following only the US. Mexico reported 7,280 new cases, its highest daily incidence to date and its first day with more than 7,000 new cases.
- Mexico surpassed Russia to become #5 globally in terms of daily incidence. Broadly, the Central and South American regions are still a major C19 hotspot.
- Including Brazil and Mexico, the region represents 6 of the top 13 countries globally in terms of daily incidence:
- Additionally, Bolivia is reporting more than 1,000 new cases per day. Central and South America also represent 5 of the top 13 countries in terms of per capita daily incidence—Panama (#3), Brazil (#4), Chile (#11), Peru (#12), and Bolivia (#13).
Eastern Mediterranean Region
- Israel reported its highest and third highest daily incidence to date over the past 2 days—1,335 and 1,268 new cases, respectively. Israel’s epidemic continues to exhibit a concerning acceleration, after the country appeared to bring it under control for several weeks. Israel is now #10 globally in terms of per capita daily incidence.
- Overall, the Eastern Mediterranean Region remains a global hotspot, representing 5 of the top 10 countries in terms of per capita incidence: Bahrain (#1), Oman (#2), Qatar (#5), Kuwait (#8), and Israel. Additionally, nearby Armenia is #9. Saudi Arabia fell below 100 new cases per million, dropping it out of the top tier of countries.
- The region also includes several notable countries in terms of total daily incidence. In addition to Pakistan, Saudi Arabia is #11, and several other countries in the region are reporting more than 1,000 new cases per day.
- Kosovo has recently reported rapidly increasing daily C19 incidence, up to 214 new cases in its most recent update. While not necessarily a large number in and of itself, this now puts Kosovo at #14 globally on a per capita basis. Kosovo’s cumulative incidence is 4,100 cases, including 86 deaths.
- South Africa remains among the top countries globally in terms of both per capita (#6) and total daily incidence (#4). South Africa reported 13,674 new cases, its highest daily incidence to date and more than 25% above the previous record.
- After several weeks of maintaining low levels of transmission, several countries around the world are beginning to report increasing C19 incidence once again. Australia, Israel, and Japan have reported increasing C19 incidence since early-to-mid June as well as multiple European countries—including Austria, Luxembourg, Iceland, and Serbia. In contrast to the US, which failed to bring its epidemic under control before its resurgence, these countries appear to be facing legitimate “second waves” of C19, illustrating the challenge of maintaining containment while relaxing social distancing measures. In the absence of a vaccine, it is likely that any increased social interaction (eg, from easing social distancing measures) will result in increased transmission, and we will continue to observe this pattern as countries try to balance economic activity against C19 risk.
- The US CDC reported 3.05 million total cases (64,771 new) and 132,056 deaths (991 new). This is the United States’ highest daily total to date, and the US has reported more than 50,000 new cases for 6 of the last 8 days. This is also the second consecutive day that the US reported more than 900 new deaths. In total, 22 states (increase of 1) and New York City reported more than 40,000 total cases, including California with more than 275,000 cases; Florida, New York City, and Texas with more than 200,000 cases; and 6 additional states with more than 100,000. The current daily incidence in the US is more than 50% higher than the first peak in mid-April, and it has increased by 165% since June 9, up from 20,338 new cases per day to 53,795 yesterday (7-day average).
- Regional analysis of state-level C19 data illustrates several concerning trends in the US epidemic. While nationally, US C19 deaths have decreased steadily over the past several weeks—before rebounding substantially in the days since the Independence Days holiday weekend—this trend is not consistent across all regions. New England, the Mid-Atlantic region, and the Midwest are all exhibiting marked declines in C19 mortality, but both the South and Southwest regions are reporting increased daily deaths since early-to-mid June. Additionally, test positivity is increasing nearly nationwide, indicating that increased transmission may be outpacing the growing testing capacity. New England and the Mid-Atlantic are reporting relatively steady or slight increases in test positivity, but test positivity is increasing significantly in the Midwest, South, Southwest, and West regions, where many states are currently facing C19 surges.
- The Johns Hopkins CSSE dashboard reported 3.14 million US cases and 133,542 deaths as of 1:00pm on July 10.
2. Disney Reopening
- Disney is planning to begin its phased reopening of Walt Disney World in Orlando, Florida, tomorrow. Not all areas of Disney World will reopen at the same time. Tomorrow, Disney will reopen the main Magic Kingdom park and Animal Kingdom, followed by Epcot and Hollywood Studios on July 15. Some Disney hotels and campgrounds have already begun their reopening procedures in advance of the parks.
- Disney will limit the number of guests allowed in the parks per day and implement enhanced screening and hygiene measures. Temperature checks will be performed on visitors upon entry. Individuals with fevers of 100.4°F or higher will not be permitted to enter the parks. Face masks will also be required for guests over 2 years old, as well as park staff, at all times except for eating, drinking, and swimming. Notably, Disney provides specific guidance for allowable face masks, requiring a minimum of 2 layers, and neck gaiters or bandanas will not qualify as face masks at the Disney parks. Despite these and other precautions, there are many that feel Disney should not move forward with reopening the parks, particularly in light of surging C19 incidence in Florida and other areas of the country. Previously, some employees signed a petition asking Disney to delay its reopening procedures.
3. Incarcerated Population Outbreak
- Experts have been concerned over the potential for rapid SARS-CoV-2 transmission in congregate settings such as correctional facilities. Crowded conditions, poor ventilation, poor healthcare infrastructure, and large populations with underlying conditions put incarcerated populations at elevated risk for C19. San Quentin State Prison in California (US) is now experiencing exactly this situation. More than one-third of the prison population, including inmates and staff, has tested positive in the past 5 weeks. Health experts have called for correctional facilities to release inmates who pose little risk to public safety or those who have nearly completed their sentences and to implement regular testing for all inmates and staff. Notably, local researchers offered free SARS-CoV-2 testing to the facility for several months, but the prison reportedly declined.
- The outbreak appears to have originated with several high-risk individuals who were transferred from another facility that was experiencing its own outbreak. The individuals were not tested within a week of their transfer, and several developed symptoms after arriving at the San Quentin facility. At least 62 inmates from the facility have been hospitalized, and 6 have died. The facility has established tents to house inmates who need to be treated or isolated. The outbreak finally garnered the attention of state legislators, who are now working to identify measures to mitigate the risk of this scenario repeating in other California correctional facilities.
4. Serbia Protests
- Thousands of Serbs protested in Belgrade, Serbia following an announcement that the national government intended to re-institute C19 “lockdown” measures. Serbian President Aleksandar Vucic previously lifted many social distancing restrictions after C19 incidence initially declined, which permitted activities such as sporting events to resume and business to reopen, more rapidly than many other European countries. C19 incidence in Serbia has more than tripled since June 24, however, nearly returning Serbia to where it was at its first peak. Reportedly, the protesters indicated that they were more upset by the policy decisions that facilitated the resurgence of C19 than they were about reinstituting the restrictions. In response to the protests, President Vucic announced that the government would not implement highly restrictive “lockdown” measures; however, the government prohibited gatherings of more than 10 people and implemented other social distancing restrictions in an effort to once again contain the epidemic.
5. US Schools
- Following a White House event addressing plans for schools to reopen this fall, in which US President Donald Trump indicated that he would pressure states to resume in-person classes, President Trump criticized the existing US CDC C19 guidance for schools. He described the CDC guidance as “very tough & expensive” and called for updated guidance that would be easier for schools to follow. Subsequently, Vice President Mike Pence stated that the CDC would issue revised guidance in the coming days. Numerous experts argue that softening the CDC guidance based on factors other than the available scientific evidence will inherently increase transmission risk in school settings. In contrast to the statements by the President and Vice President, US CDC Director Dr. Robert Redfield stated yesterday that the CDC will not issue updated guidance for schools. He emphasized that the guidance is a set of recommendations, not requirements, and that states and schools are responsible for making decisions regarding whether and how to implement protective measures. He also noted that the CDC will issue additional guidance documents, but they will include supplemental information as opposed to revised guidance.
- While US schools have yet to resume after most closed in March, some summer camps are operating in various parts of the country. Several camps—which, much like schools, involve prolonged close contact between children and instructors—have already reported C19 outbreaks, with dozens of students and camp staff testing positive, either while at the camp or shortly after returning home. Several of these camps have closed operations as a result of the outbreaks. Camps may not necessarily adhere to the same physical distancing, hygiene and sanitation, and other C19 recommendations as schools will; however, these outbreaks provide some indication that C19 can spread rapidly among children and staff and potentially result in further spread in the community.
- Similarly, some sports programs, including college and professional, have resumed practices, and some have been forced to alter plans due to transmission of SARS-CoV-2 among players and coaches. Multiple universities, including the University of North Carolina and Ohio State University, reportedly suspended voluntary workouts following positive SARS-CoV-2 tests among players, coaches, and staff. The Ivy League conference announced the cancellation of all fall collegiate sports for 2020, which could potentially have far-reaching impact on other conferences and universities across the country. Following that announcement, the Big Ten Conference announced that it is removing all non-conference competitions from the schedule for all fall sports. It is unclear if or how this could affect post-season tournaments, championships, and football bowl games. Additionally, Stanford University announced that it is discontinuing 11 sports programs due to financial challenges exacerbated by the C19 pandemic.
6. US C19 Resurgence
- Many parts of the US continue to battle surging SARS-CoV-2 transmission. Numerous states are reporting increasing—and in some instances, record-breaking—C19 incidence, hospitalizations, test positivity, and now deaths. This recent trend has driven some to re-institute various forms of social distancing that were previously lifted or implement new policies, such as mandatory mask use. While many states have paused their recovery plans or reversed course to some degree, it may not be sufficient to contain the current level of community transmission in the most severely affected areas. Dr. Anthony Fauci recently commented that “any state that is having a serious problem…should seriously look at shutting down,” although he acknowledged that a “complete shutdown” would be an “extreme” option. So far governors have resisted re-issuing “stay at home” orders that were implemented widely earlier in the epidemic. As we move toward the scheduled start of school in the fall, state officials will likely need to make difficult decisions regarding social distancing orders, particularly considering the interdependence between children returning to school, parents returning to work, and risks of community transmission.
- Reports continue to emerge of hospitals and health systems in severely affected areas struggling to cope with C19 patient surge, particularly in intensive care units. States are taking a variety of approaches to mitigate stress on health systems, including ordering hospitals to implement surge capacity plans, prohibiting elective procedures, and deploying supplemental personnel to affected hospitals.
- The US continues to scale up testing, but test positivity in many states continues to increase as well, indicating that existing capacity is not sufficient compared to the current level of transmission. One analysis—published in The New York Times, using data from the COVID Tracking Project—indicates that the US is only conducting 39% of the testing needed for the current scale of transmission. Notably, 22 states are conducting fewer than 50% of the necessary tests, including Arizona at 10% and 3 other states below 20%. Yesterday, Democrats on the US Senate Committee on Health, Education, Labor, and Pensions published a report on their investigation into US government efforts to scale up SARS-CoV-2 testing capacity. The senators argue that challenges with testing capacity, now and early in the US epidemic, stem from a failure of leadership and coordination at the most senior levels of government.
7. UK Expected to Opt Out of EU Vaccine Effort
- The UK government is expected to announce that it will not participate in the EU’s vaccine development effort. Reportedly, the UK government has determined that joining the effort would result in minimal gains for the UK while potentially introducing delays in distribution due to allocation issues. Some Members of Parliament have criticized the decision, especially in the wake of the UK’s departure from the EU; however, the UK has its own vaccine development strategy already underway. In an agreement with Oxford and AstraZeneca, the UK would be among the first recipients of any vaccine that emerges from those efforts. The US has similar agreements with various pharmaceutical companies, leading some world leaders to criticize the two countries for lack of collaboration and practicing “vaccine sovereignty.”
8. WHO C19 Response Review
- The WHO is establishing an independent panel to review its handling of the C19 pandemic response. The effort will reportedly be led by former New Zealand Prime Minister Helen Clark and former Liberian President Ellen Johnson Sirleaf. The review is in response to an unanimous resolution passed by WHO Member States at the 2020 World Health Assembly calling for an evaluation of the global pandemic response. The resolution calls for an “impartial, independent, and comprehensive evaluation” of the WHO-coordinated international response to the pandemic. Representatives of EU countries and others, including Australia and the UK, indicate that the purpose of the review is not to assign blame, but rather, to address key epidemiological questions relevant to the response. The WHO also announced that it is sending a team of experts to China to collaborate with Chinese officials in the development of a program to identify the zoonotic origin of SARS-CoV-2. The program will ultimately be implemented by a “WHO-led international mission.”
9. PPE Shortages
- The US is once again experiencing increasing shortages of crucial personal protective equipment (PPE)—including masks, gowns, and face shields—as C19 incidence and hospitalizations incidence continue to rise in many parts of the country. Several media outlets have reported that unions and associations representing nurses and doctors across the country have raised concerns about the lack of PPE and its implications for operations in a variety of healthcare settings, including hospitals and doctors’ offices. Democratic lawmakers have called on President Trump to develop a national strategy for acquiring and distributing PPE, particularly in anticipation of further increases in transmission. The President of the National Nurses United union states that calls for action from March regarding PPE supply chain limitations have still not been addressed. She also criticized President Trump for the decision to make state and local governments principally responsible for addressing PPE shortages rather than implementing a centralized and coordinated federal program. Despite statements from numerous US government officials that PPE supply is not an issue, Vice President Pence stated that guidance will be issued soon that encourages healthcare workers to reuse PPE.
10. Airborne Transmission
- Following the publication of a letter signed by more than 200 researchers and experts calling for the WHO to acknowledge the role of airborne or aerosol transmission during the C19 pandemic, the WHO published updated briefing information that outlines its current understanding of SARS-CoV-2 transmission routes. The new document updates WHO guidance from late March and includes detail regarding various types of transmission, including via respiratory droplets, aerosols (also referred to as “droplet nuclei”), and fomites. The WHO continues to emphasize that respiratory droplets are the primary route of transmission Additionally, airborne/aerosol transmission is a risk during aerosol-generating medical procedures (e.g., intubation), and fomites are a potential route of transmission as well.
- With respect to airborne/aerosol transmission, the WHO describes some of the available evidence supporting the role of airborne transmission; however, there is not sufficient evidence to support to suggest that it is a primary transmission route outside of aerosol-generating procedures. It remains possible that some exhaled respiratory droplets can form infectious droplet nuclei/aerosols via evaporation; however, the extent to which these contribute to transmission is unclear. While research has been conducted for other pathogens, additional investigation is needed for SARS-CoV-2 in order to more fully characterize the potential for airborne transmission. The report also includes an overview of the available evidence for other types of transmission—including from animals, vertically from mother to fetus, and via other bodily fluids such as urine or feces—and the timing of the infectious period relative to infection and symptom onset.
11. Masks Up At Starbucks
- The United States’ most ubiquitous coffee chain, Starbucks, is now requiring customers to wear masks at all of its US locations, starting July 15. Mask use mandates in the US continue to vary by state; however, the new Starbucks policy will be applied consistently, regardless of the state’s policy. Customers who do not wish to wear masks may be able to purchase coffee and other products via drive-through windows, curbside pickup, or delivery. Several other national business chains have implemented similar mask mandates at all locations, including Costco, and other national chains have called on governors to mandate mask use statewide, following high-profile conflicts and incidents at stores across the country.
12. Public’s Role in Vaccination
- While many technical and logistical challenges remain in order to develop, distribute, and administer SARS-CoV-2 vaccinations on a global scale, these are far from the only outstanding barriers. Human factors—”including understandings of disease, perceptions of risk, and social factors affecting access”—will likely affect the public’s willingness and ability to adhere to vaccine recommendations. Experts and researchers around the world are already studying factors associated with individuals’ willingness to be vaccinated, even though a vaccine is still months away at the very earliest. The Johns Hopkins Center for Health Security, in collaboration with experts from Texas State University, published a report outlining analysis and recommendations from the Working Group on Readying Populations for C19 Vaccine.
- The recommendations focus on establishing trust with the public and providing reliable and factual information—including on “vaccine risks, benefits, and supply”—so that they can make informed decisions regarding protective actions like vaccination. Equitable allocation and distribution and transparency about associated decisions also builds trust, and officials must implement efforts to ensure that the vaccine is available at times and in locations that are reasonably convenient for everyone to mitigate barriers to accessing the vaccine. Like existing vaccination programs, misinformation will remain a major challenge for experts, officials, and communicators. Effective oversight and transparent review of vaccination data, including for adverse events, will be critical to maintaining trust and demonstrating positive benefit for individuals and communities in the face of misinformation and opposition.
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