August 15, 2020
Without reliable information, we rely on fear or luck.
A. Numbers & Trends
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations, and Positivity
4. First Wave vs. Second Wave (US)
B. Airborne Transmission
C. New Scientific Findings & Research
D. Improved & Potential Treatments
E. Herd Immunity
F. Vaccines & Testing
G. Concerns & Unknowns
4. New reports shed further light on how nursing homes have been affected by C19
H. Back to School!?
I. Practical Tips & Other Useful Information
J. The Road Back?
K. Projections & Our (Possible) Future
L. Johns Hopkins COVID-19 Update (8/14)
M. Links to Other Stories
- Serum Institute of India Is Ready to Produce a Coronavirus Vaccine The Serum Institute of India is preparing to crank out a billion doses. And that’s just the beginning.
- Malaria discovery could expedite antiviral treatment for C19 The study, conducted by an international team and led by RMIT University’s Professor Christian Doerig, outlines a strategy that could save years of drug discovery research and millions of dollars in drug development by repurposing existing treatments designed for other diseases such as cancer.
- NIH-Moderna Investigational C19 Vaccine Shows Promise Vaccine shows promise in mouse studies and is currently being evaluated in Phase 3 clinical testing.
- Excess Deaths in New York City During the C19 and 1918 Influenza Pandemics The C19 pandemic is often compared to the 1918 flu pandemic, in which 675,000 people in the U.S. died. A new study quantifies the impact that the two pandemics had on New York City, which was hard-hit during the 1918 crisis and was until recently the epicenter of the current pandemic. Nearly 288 people died for every 100,000 person-months — which denotes death over time — in the city during the 1918 pandemic, compared to 202 out of every 100,000 person-months between early March and early May this year. While the overall incidence of the disease may be comparable, the increase in death rate compared to control periods was higher during the current pandemic: The first two months of the C19 pandemic saw more than four times the death rate as was seen during 2017-2019, whereas the 1918 pandemic death rate was 2.8 times the rate observed between 1914-1917.
- What C19-related smell loss reveals about how the mind works It took medical experts months to agree that loss of smell was a C19 symptom, yet another sign of outdated opinions about the importance of this sense.
- Herd Immunity to C19 Fails to Materialize in Sweden Sweden’s policy of allowing the controlled spread of Covid-19 viral infection among the population has so far failed to deliver the country’s previously stated goal of herd immunity.
- The Covid Tracking Project
- See How All 50 States Are Reopening (and Closing Again)
- City Health Dashboard
- Coronavirus Vaccine Tracker
- Could My Symptoms Be Covid-19?
- US Travel & Retail Supply Chain Updates
A. 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 prior day. Green highlights indicate a decrease or no change and yellow highlights indicate an increase.
1. Cases & Tests (8/14)
- Total Cases = 21,345,271 (+1.4%)
- New Cases = 285,994 (+508) (+0.2%)
- New Cases (7 day average) = 261,331 (+536) (+0.2%)
- 7 day average of new cases began rising again on 8/8 (after declining from 8/1 to 8/7)
- 7 day average of new cases was a record high on 8/14
- 1,000,000+ new cases every 4 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 5,476,266 (+1.1%)
- New Cases = 60,600 (+5,236) (+9.5%)
- Percentage of New Global Cases = 21.2%
- New Cases (7 day average) = 54,102 (-401) (-0.7%)
- Total Number of Tests = 69,362,009
- Percentage of positive tests (7 day average) = 7.4%
- 7 day average of new cases has been trending down since 7/25
- 7 day average of new cases has decreased from 69,190 on 7/25 to 54,102 on 8/14, a decline of 21.8%
- 7 day average of percentage of positive tests continues to trend downward
- Total Deaths = 762,664 (0.8%)
- New Deaths = 5,946 (-593) (-9.1%)
- New Deaths (7 day average) = 5,807 (-64) (-1.1%)
- 7 day average has been trending higher since 7/5
- 7 day average of new deaths have increased from 4,146 on 5/26 to 5,807 on 7/25, an increase of 40.1%
- Total Deaths = 171,535 (+0.7%)
- New Deaths = 1,120 (-164) (-12.8%)
- Percentage of Global New Deaths = 18.1%
- New Deaths (7 day average) = 1,054 (-26) (-2.4%)
- After declining from 8/4 to 8/8, the 7 day average of new deaths has been moving up and down within a 5% range
- 7 day average of new deaths on 8/15 was 75 less than the second peak of 1,129 on 8/4, a decline of approx. 7%
3. Top 5 States in Cases, Deaths, Hospitalizations, and Positivity (8/14)
4. First Wave vs. Second Wave (US)
- Highest 7 day average of new cases during 2nd Peak is more than double 1st Peak
- Highest 7 day average of new deaths during 2nd Peak is approx. 50% less than the 1st Peak
- Fatality/Case Rate During 1st Wave was 6.7%
- Fatality/Case Rate During 2nd Wave is 1.0%
- So far, 1st Wave was 6.7x more lethal than 2nd Wave (or, in other words, 2nd Wave is approx. 15% as lethal as the First Wave)
[Note: As the 2nd Wave is continuing, these numbers will change, but we currently estimate that 1st Wave will be least 4x more lethal than 2nd Wave]
B. Airborne Transmission
1. ‘A Smoking Gun’: Infectious Coronavirus Retrieved From Hospital Air
Many experts believe airborne virus plays a significant role in community transmission. A new study fills in the missing piece: Floating virus can infect cells.
- Skeptics of the notion that the coronavirus spreads through the air — including many expert advisers to the WHO — have held out for one missing piece of evidence: proof that floating respiratory droplets called aerosols contain live virus, and not just fragments of genetic material.
- Now a team of virologists and aerosol scientists has produced exactly that: confirmation of infectious virus in the air. (Read the study here: https://www.medrxiv.org/content/10.1101/2020.08.03.20167395v1)
- “This is what people have been clamoring for,” said Linsey Marr, an expert in airborne spread of viruses who was not involved in the work. “It’s unambiguous evidence that there is infectious virus in aerosols.”
- A research team at the University of Florida succeeded in isolating live virus from aerosols collected at a distance of seven to 16 feet from patients hospitalized with C19 — farther than the six feet recommended in social distancing guidelines.
- The findings, posted online last week, have not yet been vetted by peer review, but have already caused something of a stir among scientists. “If this isn’t a smoking gun, then I don’t know what is,” Dr. Marr tweeted last week.
- But some experts said it still was not clear that the amount of virus recovered was sufficient to cause infection.
- The research was exacting. Aerosols are minute by definition, measuring only up to five micrometers across; evaporation can make them even smaller. Attempts to capture these delicate droplets usually damage the virus they contain.
- “It’s very hard to sample biological material from the air and have it be viable,” said Shelly Miller, an environmental engineer at the University of Colorado Boulder who studies air quality and airborne diseases.
- “We have to be clever about sampling biological material so that it is more similar to how you might inhale it.”
- Previous attempts were stymied at one step or another in the process. For example, one team tried using a rotating drum to suspend aerosols, and showed that the virus remained infectious for up to three hours. But critics argued that those conditions were experimental and unrealistic.
- Other scientists used gelatin filters or plastic or glass tubes to collect aerosols over time. But the force of the air shrank the aerosols and sheared the virus. Another group succeeded in isolating the live virus, but did not show that the isolated virus could infect cells.
- In the new study, researchers devised a sampler that uses pure water vapor to enlarge the aerosols enough that they can be collected easily from the air. Rather than leave these aerosols sitting, the equipment immediately transfers them into a liquid rich with salts, sugar and protein, which preserves the pathogen.
- “I’m impressed,” said Robyn Schofield, an atmospheric chemist at Melbourne University in Australia, who measures aerosols over the ocean. “It’s a very clever measurement technique.”
- As editor of the journal Atmospheric Measurement Techniques, Dr. Schofield is familiar with the options available, but said she had not seen any that could match the new one.
- The researchers had previously used this method to sample air from hospital rooms. But in those attempts, other floating respiratory viruses grew faster, making it difficult to isolate the coronavirus.
- This time, the team collected air samples from a room in a ward dedicated to C19 patients at the University of Florida Health Shands Hospital. Neither patient in the room was subject to medical procedures known to generate aerosols, which the WHO and others have contended are the primary source of airborne virus in a hospital setting.
- The team used two samplers, one about seven feet from the patients and the other about 16 feet from them. The scientists were able to collect virus at both distances and then to show that the virus they had plucked from the air could infect cells in a lab dish.
- The genome sequence of the isolated virus was identical to that from a swab of a newly admitted symptomatic patient in the room.
- The room had six air changes per hour and was fitted with efficient filters, ultraviolet irradiation and other safety measures to inactivate the virus before the air was reintroduced into the room.
- That may explain why the researchers found only 74 virus particles per liter of air, said John Lednicky, the team’s lead virologist at the University of Florida. Indoor spaces without good ventilation — such as schools — might accumulate much more airborne virus, he said.
- But other experts said it was difficult to extrapolate from the findings to estimate an individual’s infection risk.
- “I’m just not sure that these numbers are high enough to cause an infection in somebody,” said Angela Rasmussen, a virologist at Columbia University in New York.
- “The only conclusion I can take from this paper is you can culture viable viruses out of the air,” she said. “But that’s not a small thing.”
- Several experts noted that the distance at which the team found the virus is much farther than the six feet recommended for physical distancing.
- “We know that indoors, those distance rules don’t matter anymore,” Dr. Schofield said. It takes about five minutes for small aerosols to traverse the room even in still air, she added.
- The six-foot minimum is “misleading, because people think they are protected indoors and they’re really not,” she said.
- That recommendation was based on the notion that “large ballistic cannonball-type droplets” were the only vehicles for the virus, Dr. Marr said. The more distance people can maintain, the better, she added.
- The findings should also push people to heed precautions for airborne transmission like improved ventilation, said Seema Lakdawala, a respiratory virus expert at the University of Pittsburgh.
- “We all know that this virus can transmit by all these modes, but we’re only focusing on a small subset,” Dr. Lakdawala said.
- She and other experts noted one strange aspect of the new study. The team reported finding just as much viral RNA as they did infectious virus, but other methods generally found about 100-fold more genetic matter.
- “When you do nasal swabs or clinical samples, there is a lot more RNA than infectious virus,” Dr. Lakdawala said.
- Dr. Lednicky has received emails and phone calls from researchers worldwide asking about that finding. He said he would check his numbers again to be sure.
- But ultimately, he added, the exact figures may not matter. “We can grow the virus from air — I think that should be the important take-home lesson,” he said.
C. New Scientific Findings & Research
1. Antibody drugs could be one of the best weapons against C19. But will they matter?
- From the moment C19 emerged as a threat, one approach to making drugs to treat or prevent the disease seemed to hold the most promise: They’re known as monoclonal antibodies.
- Now, scientists are on the brink of getting important data that may indicate whether these desperately needed therapies could be safe and effective. Clinical trials involving a pair of antibodies developed by Regeneron Pharmaceuticals will read out early results in September. A separate effort from Eli Lilly could yield data later in the fall.
- Despite experts’ eagerness to see the data, however, there remains a debate over just how significant a role any antibody treatment might play in changing the course of the pandemic.
- “A lot of smart people who understand immunology and virology think antibodies will work,” said Robert Nelsen, an investor at ARCH Venture Partners who is invested in Vir Biotechnology, which will start tests of its own C19 antibody study this month.
- Scott Gottlieb, the former commissioner of the FDA, is less sure antibody treatments will be significant factors in bringing the pandemic under control. Even though the development efforts have been proceeding extraordinarily fast by normal standards, the U.S. has spent billions of dollars purchasing vaccines in advance, but has done far less to shore up capacity for antibody drugs.
- “We may have missed a window to scale the manufacturing of antibody drugs that could have been an important bridge to a vaccine and a hedge in the event vaccines are delayed or don’t work,” Gottlieb, a fellow at the American Enterprise Institute and board member for Pfizer and other health care companies, told STAT. “These drugs had the ability to perhaps meaningfully change the contours of this epidemic, and we just won’t have enough doses to realize that goal.”
- Monoclonal antibodies are antibodies — the kind that the body produces to neutralize invading viruses — that have been genetically engineered into new medicines.
- In 1975, two researchers, Georges J.F. Köhler and César Milstein, developed the method for mass-producing them by fusing antibody-producing cells from mice with cancer cells. They shared the Nobel Prize in physiology or medicine in 1984. The first monoclonal antibody drug, for kidney transplant patients, was approved in 1986. Today, Humira, an antibody from AbbVie that treats a host of immune-related diseases, is the pharmaceutical industry’s top-selling product, generating $15 billion in sales last year.
- Regeneron has produced several monoclonal antibodies since being founded in 1988, including Praluent for high cholesterol, Libtayo for a type of cancer, and Dupixent for severe eczema. In 2014, the technology was also used to develop an effective treatment for Ebola.
- As the Covid pandemic hit, Regeneron’s chief scientific officer, George Yancopoulos, assigned Christos Kyratsous, a confident, Porsche-driving scientist with a dry sense of humor, to lead a team that would search for an antibody. In early February, a non-infectious fragment of genetic code of the novel coronavirus arrived at the company’s research laboratories in Tarrytown, N.Y., from China, and the company has used this starting material to produce hundreds of virus-neutralizing antibodies using genetically engineered mice, along with blood taken from survivors of C19.
- But getting antibodies into people has taken time. “I tragically right now have a 91-year-old aunt who’s trapped in a nursing home where right now there’s a coronavirus outbreak,” Yancopoulos said in April. “And I just wish I could get them our [drug] today. It’s just not ready.”
- Other companies are advancing their own efforts. For years, AbCellera, a Vancouver-based biotech, had been working with the National Institutes of Health and the U.S. Department of Defense to game out the response to future pandemics. In February, the NIH’s National Institute of Allergy and Infectious Diseases sent the company a sample of blood from a patient who had recovered from C19. AbCellera inserted the sample into a credit-card-sized device that isolates the B cells that make antibodies, and used it to find more than 550 antibodies that might work against the virus.
- Regeneron’s antibodies — REGN10933 and REGN10987 — both target the “spike” protein on the virus’ surface that helps it invade cells, but individually, each drug binds to the protein at a different, non-overlapping location. This “cocktail” approach aims to increase the chance that the virus can be neutralized without escaping. It’s the same multidrug strategy used successfully to treat other viral diseases such as HIV and hepatitis C. Regeneron refers to the dual antibody regimen as REGN-COV2.
- The first look at Regeneron’s data will provide results on the ability of REGN-COV2 to reduce the amount of coronavirus in patients compared to placebo. Safety and other data will also be announced.
- Outcomes data will come later. For the study of hospitalized C19 patients, Regeneron hopes to show that the treatment can improve clinical status based on a seven-point scale ranging from hospital discharge to death. In between, the scoring system measures changes in the use of supplemental oxygen or mechanical ventilation. In the study of ambulatory C19 patients, REGN-COV2 is designed to speed recovery and prevent the disease from getting worse. Unlike Regeneron, Eli Lilly and AbCellera have chosen not to use a cocktail approach, starting instead by testing a single antibody. Data from its study, however, being conducted with the NIH, aren’t expected to be released until October or November.
- “Reducing the theoretical risk of escape mutations has a real cost, and the real cost is manufacturing, meaning you will have less doses available, meaning fewer people will be treated in this critical time period,” Lilly Chief Scientific Officer Daniel Skovronsky told STAT during a recent event. “So my view is we go for a single antibody, which means that we can treat twice as many people if it works.”
- The Lilly antibody, called LY-CoV555, will be investigated in a placebo-controlled clinical trial of approximately 300 patients hospitalized with mild to moderate C19. An initial efficacy assessment based on symptoms improvement, including the need for supplemental oxygen, will be conducted five days following the injections of LY-CoV555 or placebo. If these initial results show a benefit for the Lilly antibody, the study will be expanded to enroll another 700 patients, including people with severe cases of C19.
- Recently published animal data suggest these antibody treatments may work in humans. Monkeys exposed to coronavirus followed one day later with injections of the Regeneron cocktail cleared the virus faster than monkeys treated with a placebo. Damage to the lungs, including cases of pneumonia, was reduced but not eliminated in the monkeys treated with the cocktail compared to the placebo group. The monkey study was released via a preprint server, meaning the data had not yet been peer-reviewed or published in a journal.
- In a research note, SVB Leerink analyst Geoff Porges called the monkey data “quite encouraging,” but he also cautioned it may not be curative in humans on its own, citing the inconclusive pneumonia results and the challenge of treating patients early, before they might have symptoms.
- “If clinical development for the antibody cocktails is successful, we believe it would be most likely to complement the existing standard of care and antiviral therapies such as remdesivir, rather than displacing antivirals,” said Porges.
- Nelsen, the investor at ARCH Venture Partners, said: “If you treat people who are very sick, you may not see anything. If you treat people earlier, you will probably see what you saw in the monkeys: a significant reduction in virus, which doesn’t necessarily mean a reduction in morbidity and mortality, but it should. What you really want to do is prevent the progression of the disease.”
- Vir, the biotech firm that Nelsen backed, will start a clinical trial of its lead antibody candidate VIR-7831 later this month, seeking to show that it can prevent hospitalization due to C19. A second antibody candidate, VIR-7832, will advance into a clinical trial later this year. Both drugs are designed to bind to a location on the spike protein that creates a high barrier to resistance. In preclinical studies, the antibodies also recruit immune cells to help kill other cells already infected by the virus, Vir said.
- Similar to vaccines, antibody treatments are also being developed to prevent C19 infection, particularly in people who are at high risk and who might have been exposed to the virus through close contact with an already infected person.
- “Once someone has come into contact with some of the disease, it’s too late for an active vaccine,” Lilly’s Skovronsky said. “But a passive immunization like our antibody could be valuable. When you think about the populations that are suffering the most, it’s the elderly, it’s the immunocompromised, it’s patients in nursing homes and long-term care facilities.”
- Lilly and NIAID are conducting a 2,400-patient Phase 3 study to test whether its treatment can keep nursing home patients from developing C19. The antibody will be given to patients and staff at places where there has been an infection to see if it can stop them from developing the disease. To conduct the study, Lilly is deploying a fleet of recreational vehicles that can be used prepare study drug and do lab work, as well as pull trailers that can be used as on-site infusion clinics.
- Regeneron and NIAID are also conducting a prevention study in 2,000 healthy adults who are household contacts with an individual with a positive C19 test. Will it be possible to manufacture enough antibody? Regeneron said it is “in active discussions with other parties” that can add additional manufacturing capacity.
- The big determinant of how fast answers will emerge will be the speed at which doctors can enroll patients in these studies, said Anita Kohli, the director of clinical research at Arizona Clinical Trials and an investigator for both Regeneron and Eli Lilly. This, she said, is harder than it sounds, especially for patients who are not so sick that they are in the hospital. “I think some of the recruitment is more difficult, because you’re recruiting sick people,” she said. “Sick people want to eat chicken soup and stay at home and not go to the clinical trials center.”
- One problem is that diagnostic tests are taking a long time to come back. Doctors are supposed to enroll patients in the studies within five or six days of the onset of symptoms. If testing takes two weeks to come back, patients often recover before they are enrolled. Kohli’s center has begun to test patients for Covid in the hopes that some will volunteer to be in studies.
- “Vaccines are not going to work for everybody,” she said. “People are still going to get sick, there’s no two ways about it. And we’ve got to have a treatment.”
- The problem, she said, is that patients are not being made aware of clinical trials for therapeutics soon enough.
- “People have not been directed toward clinical trials, or are not thinking about them,” she said.” I think that’s what we need to change here. It’s not that they aren’t very exciting, they are very exciting. They just aren’t talked about enough.”
2. Antiviral Treatment for C19 Could Come Much Sooner Thanks to Malaria Breakthrough
- The study, conducted by an international team and led by RMIT University’s Professor Christian Doerig, outlines a strategy that could save years of drug discovery research and millions of dollars in drug development by repurposing existing treatments designed for other diseases such as cancer.
- The approach shows so much promise it has received government funding for its potential application in the fight against C19.
- The study, published in Nature Communications, demonstrated that the parasites that cause malaria are heavily dependent on enzymes in red blood cells where the parasites hide and proliferate.
- It also revealed that drugs developed for cancer, and which inactivate these human enzymes, known as protein kinases, are highly effective in killing the parasite and represent an alternative to drugs that target the parasite itself.
- Lead author, RMIT’s Dr. Jack Adderley, said the analysis revealed which of the host cell enzymes were activated during infection, revealing novel points of reliance of the parasite on its human host.
- “This approach has the potential to considerably reduce the cost and accelerate the deployment of new and urgently needed antimalarials,” he said.
- “These host enzymes are in many instances the same as those activated in cancer cells, so we can now jump on the back of existing cancer drug discovery and look to repurpose a drug that is already available or close to completion of the drug development process.”
- As well as enabling the repurposing of drugs, the approach is likely to reduce the emergence of drug resistance, as the pathogen cannot escape by simply mutating the target of the drug, as is the case for most currently available antimalarials.
- Doerig, Associate Dean for the Biomedical Sciences Cluster at RMIT and senior author of the paper, said the findings were exciting, as drug resistance is one of the biggest challenges in modern healthcare, not only in the case of malaria, but with most infectious agents, including a large number of highly pathogenic bacterial species.
- “We are at risk of returning to the pre-antibiotic era if we don’t solve this resistance problem, which constitutes a clear and present danger for global public health. We need innovative ways to address this issue,” he said.
- “By targeting the host and not the pathogen itself, we remove the possibility for the pathogen to rapidly become resistant by mutating the target of the drug, as the target is made by the human host, not the pathogen.”
- Doerig’s team will now collaborate with the Peter Doherty Institute for Infection and Immunity (Doherty Institute) to investigate potential C19 treatments using this approach, supported by funding from the Victorian Medical Research Acceleration Fund in partnership with the Bio Capital Impact Fund (BCIF).
- Co-investigator on the grant, Royal Melbourne Hospital’s Dr. Julian Druce, from the Victorian Infectious Diseases Reference Laboratory (VIDRL) at the Doherty Institute, was part of the team that were first to grow and share the virus that causes C19, and said the research was an important contribution to efforts to defeat the pandemic.
- Royal Melbourne Hospital’s Professor Peter Revill, Senior Medical Scientist at the Doherty Institute and a leader on Hepatitis B research, said the approach developed by the RMIT team was truly exciting.
- “This has proven successful for other human pathogens including malaria and Hepatitis C virus, and there are now very real prospects to use it to discover novel drug targets for Hepatitis B and C19,” he said.
3. These are the COVID symptoms you’ll likely get first
- New research has boiled down the most probable order in which C19 symptoms first appear.
- The earliest sign of the coronavirus will most likely be a fever in infected patients, followed by a cough and muscle pain, according to the study conducted by the University of Southern California published in the Frontiers in Public Health journal Thursday.
- People will then experience nausea or vomiting and diarrhea.
- The latest findings are a major breakthrough in studying the coronavirus, since patients will now be able to more quickly identify and treat the disease.
- “This order is especially important to know when we have overlapping cycles of illnesses like the flu that coincide with infections of C19,” Peter Kuhn, a professor of biological sciences and medicine who worked on the study, said in a statement. “Doctors can determine what steps to take to care for the patient, and they may prevent the patient’s condition from worsening.”
- Establishing a diagnosis early is key to stopping the virus before it gets more serious.
- “Given that there are now better approaches to treatments for C19, identifying patients earlier could reduce hospitalization time,” said Joseph Larsen, a doctoral candidate and the lead researcher on the study. “The order of the symptoms matter. Knowing that each illness progresses differently means that doctors can identify sooner whether someone likely has C19, or another illness, which can help them make better treatment decisions.”
- The initial symptoms of the coronavirus are very similar to other respiratory illnesses such as MERS and SARS, but it’s the timing of gastrointestinal issues that makes C19 easier to single out.
- “The upper GI tract (i.e., nausea/vomiting) seems to be affected before the lower GI tract (i.e., diarrhea) in C19, which is the opposite from MERS and SARS,” the scientists wrote in the study.
- Larsen, along with faculty advisers Kuhn and James Hicks, conducted the study at the USC Michelson Center for Convergent Bioscience’s Convergent Science Institute in Cancer.
- The USC researchers analyzed data collected by the World Health Organization in China between Feb. 16 and 24 from more than 55,000 confirmed coronavirus cases. The scientists also took a look at nearly 1,100 cases gathered from Dec. 11 to Jan. 29 by the China Medical Treatment Expert Group via the National Health Commission of China.
- They then compared the numbers to influenza symptom data of 2,470 cases in North America, Europe and the Southern Hemisphere that were reported to health authorities from 1994 to 1998.
4. Mouthwash Could Reduce the Risk of Coronavirus Transmission
- The coronavirus can be inactivated using certain commercially available mouthwashes. This was demonstrated in cell culture experiments by virologists from Ruhr-Universität Bochum together with colleagues from Jena, Ulm, Duisburg-Essen, Nuremberg, and Bremen. High viral loads can be detected in the oral cavity and throat of some C19 patients.
- The use of mouthwashes that are effective against the coronavirus could thus help to reduce the viral load and possibly the risk of coronavirus transmission over the short term. This could be useful, for example, prior to dental treatments. However, mouth rinses are not suitable for treating C19 infections or protecting yourself against catching the virus.
- The results of the study are described by the team headed by Toni Meister, Professor Stephanie Pfänder and Professor Eike Steinmann from the Bochum-based Molecular and Medical Virology research group in the Journal of Infectious Diseases, published online on July 29, 2020. A review of laboratory results in clinical trials is pending.
Eight mouthwashes in a cell culture test
- The researchers tested eight mouthwashes with different ingredients that are available in pharmacies or drugstores in Germany. They mixed each mouthwash with virus particles and an interfering substance, which was intended to recreate the effect of saliva in the mouth. The mixture was then shaken for 30 seconds to simulate the effect of gargling. They then used Vero E6 cells, which are particularly receptive to the coronavirus, to determine the virus titer. In order to assess the efficacy of the mouthwashes, the researchers also treated the virus suspensions with cell culture medium instead of the mouthwash before adding them to the cell culture.
- All of the tested preparations reduced the initial virus titer. Three mouthwashes reduced it to such an extent that no virus could be detected after an exposure time of 30 seconds. Whether this effect is confirmed in clinical practice and how long it lasts must be investigated in further studies.
- The authors point out that mouthwashes are not suitable for treating C19. “Gargling with a mouthwash cannot inhibit the production of viruses in the cells,” explains Toni Meister, “but could reduce the viral load in the short term where the greatest potential for infection comes from, namely in the oral cavity and throat – and this could be useful in certain situations, such as at the dentist or during the medical care of C19 patients.”
Clinical studies in progress
- The Bochum group is examining the possibilities of a clinical study on the efficacy of mouthwashes on coronaviruses, during which the scientists want to test whether the effect can also be detected in patients and how long it lasts. Similar studies are already underway in San Francisco; the Bochum team is in contact with the American researchers.
D. Improved & Potential Treatments
1. Inspired by llamas’ unique antibodies, scientists create a potent anti-coronavirus molecule
- Inspired by a unique kind of infection-fighting antibody found in llamas, alpacas, and other camelids, a research team at the University of California, San Francisco, has synthesized a molecule that they say is among the most potent anti-coronavirus compounds tested in a lab to date.
- Called nanobodies because they are about a quarter of the size of antibodies found in people and most other animals, these molecules can nestle into the nooks and crannies of proteins to block viruses from attaching to and infecting cells.
- The lab-made one created by the UCSF team is so stable it can be converted into a dry powder and aerosolized, meaning it would be much easier to administer than C19 treatments being developed using human monoclonal antibodies. While the work is still very preliminary, the goal is to deliver the synthetic nanobody via simple inhaled sprays to the nose or lungs, allowing it to potentially be self-administered and used prophylactically against C19 — if it’s shown safe and effective in both animal tests and clinical trials.
- After four months of working nearly around the clock, the team posted the results Monday to the bioRxiv preprint server (here). The paper has not yet been peer-reviewed, but the researchers said they are already in talks to find a partner that can quickly test, manufacture, and distribute the new compound in hopes it can prevent new infections and mitigate disease in those who are already infected. “Every day, 5,000 people die of this disease. We’d like as soon and as fast as possible to find a partner to make this,” said Peter Walter, a veteran biochemist who permanently resides on many short lists of those expected to win a Nobel Prize and who co-led the project with structural biologist Aashish Manglik.
- Well-aware of the furor over early announcements for coronavirus therapies, the duo do not want to oversell their findings and acknowledge the nanobody, called Aeronab 6, needs to be tested in clinical trials. But they are enthusiastic because of both how stable the compound is and how well it has responded in lab tests where it inhibits the infection of cells by binding ferociously to the infamous spike proteins that allow coronavirus particles to enter and infect cells. “It’s almost like a mousetrap that never lets go,” said Walter.
- While the lab results look promising, experts in the field advise caution because important work has not been done to test the compound in animals. “The critical thing is animal data. We’ve found things that are very potent in vitro that do nothing in vivo,” said Dimiter Stanchev Dimitrov, a professor of medicine who directs the Center for Antibody Therapeutics at the University of Pittsburgh and has created antibody-based therapeutics for numerous viruses including SARS and MERS, two other coronaviruses. He said it can take months to collect the needed data in animals. “Once these are tested in animal models, then I can get excited.”
- Dimitrov said that while administering an antibody therapy through an inhaler was an exciting idea that other groups are also investigating, there could be difficulties getting a drug delivered uniformly within the lung. “It’s tricky to deliver antibodies to the lung,” he said.
- The nanobody’s potency against coronavirus was tested at the Institut Pasteur in Paris by Veronica Rezelj, a postdoctoral researcher in the institute’s viral populations and pathogens unit. When Rezelj mixed coronavirus and small amounts of the nanobody on cell plates, the Vero-E6 cells (derived from the kidney cells of African green monkeys and commonly used in lab work) were protected from infection and stayed alive.
- “Within four days from the day the package from the U.S. arrived, we knew we had a very potent nanobody,” she said. “Very little nanobody was needed to completely abolish virus infectivity.” She said the nanobody’s effectiveness was much higher than that in published data about neutralizing antibodies taken from the blood of C19 patients, or other synthetically made nanobodies.
- Rezelj has tested many antivirals against the coronavirus in recent months; many won’t even work in cell culture or animal models, let alone humans. The nanobodies, she said, are more promising: “We are very confident that they could work from a therapeutic standpoint after human clinical trials are completed.”
- Dozens of related therapies using human monoclonal antibodies are being developed for use against the coronavirus, with some already in clinical trials, but Walter and Manglik are skeptical about how widespread and practical those approaches will be: They’re expensive to manufacture in mammalian cells, must be administered intravenously by medical personnel, and require high doses because they travel through the bloodstream before reaching the lungs. The UCSF researchers think an effective approach may be to target nasal passages, where the virus may first become established before it is seeded into the lungs.
- Their compound, they say, could be cheaply made in enormous quantities using bacteria or yeast, and would require low doses because it is so potent against the virus and can be administered directly to the lungs and or nasal passages. “We’d like this to be made available to developing countries,” Walter said. “This is possible because it can be shipped as a dry powder and it should be very inexpensive to produce.”
- Other labs around the world, including at the University of Oxford and the Rosalind Franklin Institute, have recently published work on synthetic nanobodies. In May, a University of Texas group showed true llama antibodies that were engineered in the lab helped prevent coronavirus infection in lab studies. And this week, a team from China reported in bioRxiv that it produced camel nanobodies active against the C19 virus.
- Markus Seeger, an assistant professor at the Institute for Medical Microbiology at the University of Zurich, was among the first to publish work on synthetic nanobodies, or sybodies as he calls them, for use against coronavirus, and he recently signed a partnership with Absolute Antibody to make the compounds available for research. Seeger said many labs are at work on the compounds because they are cheap to manufacture, simpler to optimize than human antibodies, and potentially powerful for therapeutics, prophylactics, and even use on masks and surfaces to curb viral spread.
- “We’re just at the tip of the iceberg,” he said. “I think with many companies there will be a lot of activity.”
- While he noted that there was a big difference between having a potent nanobody and an actual drug, Seeger said he thought the new compound looked promising because it not only blocked the virus from binding to cells but actually changed the conformation of the spike protein, locking down the receptor binding domains that allow it to attach to cells.
- The UCSF team members, who normally work on research like deciphering the shape of receptors on cell membranes and understanding how proteins unfold, jumped at the chance to work on coronavirus therapies in March. “When UCSF shut down all research operations with the exception of coronavirus work, we stopped our regular work and really pivoted,” Manglik said.
- The project took advantage of a massive library of synthetic nanobodies manufactured in yeast that Manglik had helped create a few years ago, long before the pandemic, to better understand the structure of proteins to aid in drug design and further basic research. “The library would not have been there without the drive for basic research,” said Walter.
- It took Walter and his graduate student Michael Schoof to press Manglik to use the library to hunt for a weapon against the coronavirus. Manglik, who is also an M.D., had recently started his lab at UCSF and said he saw the tools he was developing to engineer and optimize proteins for basic research as uniquely positioned “to directly tackle the pandemic death toll.”
- They rapidly screened the library’s collection of 2 billion nanobodies for ones that might work against the C19 coronavirus by using its spike protein to fish out nanobodies that bound to it. They then culled that group to about 20 nanobodies that worked especially well in preventing the virus from entering and infecting cells. Aeronab 6 rose to the top because it bound to the spike protein in a really strong and unique manner and because it was so stable. Walter, Manglik, and Schoof hold a patent on the compound.
- Even though the nanobody worked well from the start, Manglik led an effort to optimize the molecule so it would be even more effective. The team created a version that both prevented the coronavirus spike proteins from binding to the cell and locked the spikes down so they remain in a position that makes them unavailable for binding. They also “humanized” the nanobody so it closely resembled a human protein and thus would be less likely to create an allergic or immune response.
- Manglik is not a fan of working with actual llamas; there is the hassle and veterinary bills, not to mention the fact it takes months of waiting for an animal to produce nanobodies after they are infected with a pathogen. But he does give the animals credit: “We’ve been dealing with the challenge of building molecules that are as beautiful as those produced in nature and we take deep inspiration from the kind of antibodies that exist in camels, alpacas, and llamas.”
- He said the work was only possible because of the drive of the many trainees on the project, some of them routinely working until 3 or 4 in the morning. The trainees, Manglik said, lacked experience but made up for it in enthusiasm and by “working at the limits of their physical capacity.”
- Those trainees say they were inspired by Manglik’s willingness to work endless hours in the lab on routine bench work, even pipetting during Zoom meetings. “Here’s a full-fledged professor, coming in, gloving up, and purifying proteins,” Schoof said.
- The UCSF scientists envision Aeronab 6 as something that could be offered to people who have recently tested positive for coronavirus to prevent disease progression. It could also be offered to people who have been exposed to the disease to prevent infection, or used as a daily prophylactic for those at high risk of infection, such as health care workers, first responders, and prison guards.
2. Large study suggests blood plasma can help treat C19, with caveats
- Infusing hospitalized C19 patients with blood plasma from people who recovered from the disease appeared to show a benefit in a nationwide study, but the study’s lack of a placebo group left several experts struggling to interpret the data.
- The study, which enrolled more than 35,000 patients, found that quickly administering so-called convalescent plasma had a marked effect on mortality for patients with severe cases of C19. Those who received transfusions within three days of diagnosis had a seven-day death rate of 8.7%, while patients who got plasma after four or more days had a mortality rate of 11.9%. The difference met the standard for statistical significance.
- But without a placebo group for comparison, it’s unclear just how valuable the treatment might be. The study, run by the Mayo Clinic and sponsored by the National Institutes of Health, was meant to broaden access to convalescent plasma. It was part of what is known as an “expanded access program,” not designed to definitively test how well the treatment works but to get it to patients while collecting data.
- In a statement, the Mayo Clinic said that the Food and Drug Administration has advised it that the expanded access program will continue “while planning is under way to transition smoothly to Emergency Use Authorization of convalescent plasma.”
- Peter Bach, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes, said there’s no way to be sure about the ultimate benefit of convalescent plasma, but the study “checks a few boxes.” For one, it supports the overall theory that convalescent plasma might help some patients, he said. He noted that researchers also found that the quality of the plasma infusion had an effect on patient outcomes, as those who got infusions that were particularly rich with antibodies fared better overall.
- “If we had just done the randomized controlled trials, we would know the answers we are still guessing at,” Bach said, noting the authors of the study were “appropriately cautious.”
- The results of the study were published Thursday on a preprint server, meaning they have not yet been peer-reviewed.
- The study enrolled a high proportion of critically ill patients, with about 52% in intensive care units and 28% requiring mechanical help to breathe. About 60% of the study participants were male. Roughly half the patients were white, while 38% were Hispanic, 19% were Black, and 4% were Asian. The study classified more than a quarter of patients as “other or unknown.”
- The concept behind convalescent plasma, which dates back more than a century, is that blood from patients who have recovered from an infection will be rich with antibodies against it, making their plasma an effective treatment. A host of pharmaceutical companies are developing lab-grown C19 antibodies that would work much the same way, and the many vaccines in development are meant to spur the production of similar antibodies that would prevent infection in the first place.
- As doctors around the world scramble to find effective therapies for C19, studies like this one present enticing data but do little to address the clinical guesswork physicians face when treating the disease.
- “It raises the question of what strength of evidence is necessary to treat during a pandemic,” said Harlan Krumholz, director of the Center for Outcomes Research and Evaluation at Yale New Haven Hospital. “The problem is we have yet to resolve what is sufficient evidence to change the treatment paradigm.”
- Steven Nissen, a noted clinical trialist at the Cleveland Clinic, agreed: “The lack of high-quality trials in making clinical decisions about how to treat patients with coronavirus infection is a national embarrassment. Here we have another non-randomized study, NIH-funded, and uninterpretable.”
- Randomized, placebo-control studies of convalescent plasma are ongoing.
E. Herd Immunity
1. Population immunity is slowing down the pandemic in parts of the US
- The large number of people already infected with the coronavirus in the US has begun to act as a brake on the spread of the disease in hard-hit states.
- Millions of US residents have been infected by the virus that causes C19, and at least 160,000 are dead. One effect is that the pool of susceptible individuals has been depleted in many areas. After infection, it’s believed, people become immune (at least for months), so they don’t transmit the virus to others. This slows the pandemic down.
- “I believe the substantial epidemics in Arizona, Florida and Texas will leave enough immunity to assist in keeping C19 controlled,” Trevor Bedford, a pandemic analyst at the University of Washington, said on Friday, in a series of tweets. “However, this level of immunity is not compatible with a full return to societal behavior as existed before the pandemic.”
- The exact extent to which acquired immunity is slowing the rate of transmission is unknown, but major questions like school reopening and air travel may eventually hinge on the answer.
- What is known is that after rising at an alarming pace starting in May, new cases of C19 in Sun Belt states like Florida have started to fall. Some of that may be due to social distancing behavior, but rising rates of immunity are also a factor, according to Youyang Gu, a computer scientist whose C19 Projections is among 34 pandemic models tracked by the US Centers for Disease Control and Prevention.
- “Immunity may play a significant part in the regions that are declining,” says Gu. At least until the fall, which is how far his models look forward, he says, “I don’t think there is going to be another spike” of infections in southern states.
- The US has been recording more than 1,000 C19 deaths and 45,000 confirmed cases a day. The flip side of the rapid spread, however, is there are progressively fewer vulnerable people to catch and spread the virus again. Researchers say they hope to determine how great a role the rise of this population immunity can play in managing the pandemic.
- “Clearly, as susceptibility drops, disease spreading drops. No one can say different,” says Tom Britton, a statistician who models the pandemic at the University of Stockholm. “The question is to what degree is the effect because of interventions or because of immunity? In regions with very large outbreaks—New York, Milan, Madrid, and London—I am convinced it’s a combination.”
- A virus outbreak will cease to grow, even without any control measures, when a threshold called herd immunity is achieved. That’s when so many people are immune that the virus can’t find new hosts quickly enough.
- For the new coronavirus, the threshold for reaching herd immunity is unknown. Estimates vary widely: anywhere from 10% to 80% of the population might have to be infected, depending on how well the virus spreads but also on social factors like how much people ordinarily mix with one another.
- Once an obscure inflection point known only to epidemiologists, herd immunity has gained what Francois Balloux, a systems biologist at University College London, calls “Kardashian-like” fame and become a lightning rod in politically polarized debates over economic reopening.
- On social media, some commenters insist that herd immunity has already arrived, meaning lockdowns and school closures are not necessary. Others find reason to doubt that immunity will ever accumulate without a vaccine and say counting on it can only lead to millions of deaths.
- “It seems there is the ‘herd immunity is already reached’ team and the ‘we are all going to die’ team. The good thing is, that there is a third ‘let’s get the data and let’s look at what this all means team’ out there,” tweeted Florian Krammer, an immunologist at the Icahn School of Medicine in New York City.
- What is certain is that in the US, with a raging epidemic, natural immunity is building fast. During June and July, Gu estimates, 450,000 people a day were being infected by the coronavirus in the US, the highest figures since the disease arrived in February.
- That number is higher than the official case count because it includes an estimate of infections that go unseen, unfelt, or unreported. In June, CDC director Robert Redfield told reporters that the real number of infections could be many times the official tally. For instance, Gu has estimated that about 35 million Americans have now been infected—roughly 10% of the nation’s population.
- Natural infection also turns out to be extremely efficient at reducing virus transmission—even more effective than an equal number of people getting a vaccine. The reason is that the virus has been finding and infecting precisely those people who—whether because of behavior, circumstances, or biology—are most likely to be part of transmission chains.
- Perhaps they are college students on spring break, or hospital nurses, or people who touch their face all the time. Whatever the reason, once these individuals become infected and are removed from the equation through death or immunity, the effect on the pandemic is outsized. By contrast, vaccinating a sheltered older person might protect that individual but does relatively less to stop transmission.
- “When the disease itself causes herd immunity, it does so more efficiently than when we give out vaccine at random,” Marc Lipsitch, a public health modeler at Harvard University, told the political pundit Bill Kristol last week during a podcast interview. As a result, “there is discussion” about whether viral transmission could be reduced more quickly than generally believed, he says.
Lessons from Sweden
- Outside the US, researchers are also closely tracking the role of population immunity in national responses. Sweden, for example, did not impose a strict lockdown, and saw a large number of deaths starting in April. Since then, however, the number of new infections has declined. The nation’s leaders said last week that children would go back to school unmasked.
- “I would say in Sweden there is no doubt that immunity plays an important role, more than in other countries,” says Britton. “Now this epidemic is slowly stopping.”
- Britton says a better understanding of how population immunity is shaping outbreaks could help guide the level and intensity of social interventions. He says the goal is to keep the virus’s reproduction number, called R, below 1, meaning every person with the virus infects fewer than one other. Under those conditions, an outbreak dwindles.
- “Herd immunity is when all restrictions can be relaxed and you are still below 1,” he says. “But immunity doesn’t have to be at that level to have an effect.”
- In some cities, like New York and Miami, blood tests show that 20% or more of the population has had the virus. But in regions still little affected, like small towns or rural areas, the population remains more susceptible. That means the virus can and will continue to cause new outbreaks. For instance, Louisiana saw a large spike in infections, followed by a lull and then a second spike. This occurred as the virus first hit New Orleans and later reached the rest of the state.
- The geographic unevenness of the pandemic is one reason Britton does not think Sweden is able to get back to normal yet. “Are we protected from big outbreaks if all the restrictions are released? The answer is no,” he says. “On a national scale the immunity is not that high—it might be 20%. But in Stockholm it’s maybe 30 or 40%. We may be close to herd immunity [there], so they could relax restrictions a bit more.”
2. A mathematical model reveals the influence of population heterogeneity on herd immunity to C19
- A recent study in the Journal Science proposes that herd immunity can be achieved at a lower rate (~43%) when age and activity of the population are taken into consideration. Below is a summary of the study.
Heterogeneity and herd immunity
- In response to C19, some politicians have been keen to exploit the idea of achieving herd immunity. Countering this possibility are estimates derived from work on historical vaccination studies, which suggest that herd immunity may only be achieved at an unacceptable cost of lives. Because human populations are far from homogeneous, Britton et al. show that by introducing age and activity heterogeneities into population models for C19, herd immunity can be achieved at a population-wide infection rate of ∼40%, considerably lower than previous estimates. This shift is because transmission and immunity are concentrated among the most active members of a population, who are often younger and less vulnerable. If nonpharmaceutical interventions are very strict, no herd immunity is achieved, and infections will then resurge if they are eased too quickly.
- Despite various levels of preventive measures, in 2020, many countries have suffered severely from C19.
- Using a model, we show that population heterogeneity can affect disease-induced immunity considerably because the proportion of infected individuals in groups with the highest contact rates is greater than that in groups with low contact rates.
- We estimate that if R0 = 2.5 in an age-structured community with mixing rates fitted to social activity, then the disease-induced herd immunity level can be ~43%, which is substantially less than the classical herd immunity level of 60% obtained through homogeneous immunization of the population. Our estimates should be interpreted as an illustration of how population heterogeneity affects herd immunity rather than as an exact value or even a best estimate.
F. Vaccines & Testing
1. Rapid-Response C19 Test Makers Face Outsize Demand
- Doctors, nursing homes and federal officials are scrambling to get rapid-response C19 antigen testing supplies from the two companies that secured emergency approval to produce them, as cases continue to rise in the U.S.
- Rapid-response antigen tests make up a small but growing area of C19 testing in the U.S. and are seen as helpful in tamping down outbreaks because they offer faster results than many molecular tests that must be sent to labs for processing. The tests search for virus proteins while other tests look for the virus’s genetic material.
- Quidel Corp. and Becton Dickinson & Co., the only companies that so far have federal emergency authorization to supply such diagnostic tests, also make machines that process them. The boxlike test-analyzers, which before the pandemic processed tests for ailments such as the flu, are found in doctors’ offices and nursing homes, allowing facilities to avoid shipping samples to commercial labs for processing. They can deliver results in about 15 minutes and process dozens of samples an hour.
- Quidel is struggling to produce enough analyzers to meet demand, while Becton Dickinson’s challenge is making enough tests, the companies say.
- In July, people waited two weeks or longer for results of diagnostic tests in the U.S. The delays underscored the importance of immediate results that individuals can quickly act on.
- CVS Health Corp., which says it performs about 5% of U.S. testing, is planning to expand so-called point-of-care C19 testing because it offers a solution to delays, the company said last week.
- Some small practices say they have struggled to obtain the rapid antigen tests and processing equipment they need. Katie Schafer, a pediatrician at Bloom Pediatrics in Birmingham, Mich., had a Becton Dickinson analyzer that the practice used for flu tests. Last month, she ordered 1,000 C19 tests to run on the machine. So far, only 120 tests have arrived.
- “I consider ourselves lucky that we got any at all,” said Dr. Schafer, who tries to save the tests for patients with symptoms and has about half of the initial delivery left. “There’s no good news coming out of the reps that sell these tests,” she added.
- Quidel and Becton Dickinson are each ramping up production to meet demand but are grappling with challenges including sourcing sample-collection swabs and additional manufacturing plant capacity.
- Quidel said it currently makes about 2,000 analyzers a month and can make up to 1.8 million tests weekly if it is able to secure all the supplies it needs.
- A Quidel board member’s personal physician asked for help acquiring one of the company’s analyzers, but Quidel refused because the practice planned to test only five people a day, said Douglas Bryant, Quidel’s chief executive.
- Becton Dickinson has enough analyzers to meet demand and is ramping up production, though it faces a shortage of testing kits, a spokeswoman said.
- The federal government has been given priority over other customers for the tests and analyzers Quidel and Becton Dickinson have made recently. The equipment is largely being deployed to nursing homes where the coronavirus has taken a severe toll. Mr. Bryant said he was told by the U.S. Defense Department that it was preparing a mass order.
- Public health officials have raised some concerns that rapid antigen tests deliver false-negative results at a higher rate than other tests. But federal officials have said that, as these tests become more widespread, they appear equal in sensitivity to the more broadly used polymerase chain reaction diagnostic tests.
- There are no rules on how C19 testing instruments or tests should be prioritized, said a spokeswoman for the Department of Health and Human Services, though the agency asks that test makers follow the distribution of cases in the country.
- Becton Dickinson sells most of its devices through distributors and leaves sales policies and allocation to their discretion, the company spokeswoman said. It allows buyers to purchase its machines outright without also requiring them to order a minimum number of tests to run on them.
- Quidel said it initially had a process for prioritizing who was able to buy its machines and ensured the units went mostly to health providers capable of testing large numbers of people, Mr. Bryant said. Now, he said, aside from mass sales to government entities, the company mostly leaves such decisions to its network of external distributors but wants analyzers to go to places that can run the most tests.
- “There are going to be people who are disappointed, and I personally feel bad about that,” Mr. Bryant said.
- Quidel and its distributors either sell the analyzers for $1,200 each or give the analyzer free to a buyer if they agree to purchase a certain number of tests for C19 and other illnesses, an arrangement referred to as leasing.
- Some small practices say they haven’t been able to buy a Quidel machine outright and can’t afford the number of tests required under the lease arrangement. Quidel distributors have at times steered customers toward larger orders, some primary care and pediatric practices said.
- In a July email to Mission, Texas-based Family Medicine Associates from distributor CLIA Waived Inc. that was reviewed by The Wall Street Journal, an account manager said the practice would have to wait until September to buy a device outright but could get one under a lease if it committed to buying at least 200 flu and 200 strep tests a year for the next three years.
- The Quidel tests cost roughly twice as much as the practice’s normal kits for those tests, and the arrangement would cost it an additional $6,000, said Kayla Tezcucano, Family Medicine’s office manager.
- “I get upset because we are in the middle of a pandemic and they are able to supply these tests that give us answers we need,” Ms. Tezcucano said.
- CLIA Waived operating chief Bryan Andrus said the account manager’s assertion that Quidel would lease but not sell a machine was based on his experience with past orders. Mr. Bryant said Quidel doesn’t prioritize leases over sales but acknowledged some distributors may steer clients toward larger-ticket deals.
G. Concerns & Unknowns
1. C19 “long haulers” are organizing online to study themselves
- Gina Assaf was running in Washington, DC, on March 19 when she suddenly couldn’t take another step. “I was so out of breath I had to stop,” she says. Five days earlier, she’d hung out with a friend; within a day, that friend had started showing three classic signs of C19: fever, cough, and shortness of breath.
- Assaf had those symptoms too, and then some. By the second week, which she describes as “the scariest and hardest on my body,” her chest was burning and she was dizzy. Her friend recovered, but Assaf was still “utterly exhausted.” A full month after falling ill, she attempted to go to grocery shopping and ended up in bed for days.
- She was never tested for the coronavirus, and doctors who saw her virtually suggested she was experiencing anxiety, psychosomatic illness, or maybe allergies. “I felt very alone and confused, and doctors had no answers or help for me,” says Assaf, whose symptoms persist to this day.
- In those first few months, Assaf found a legion of people in situations similar to her own in a Slack support group for C19 patients, including hundreds who self-identified as “long-haulers,” the term most commonly used to describe those who remain sick long after being infected.
- There, she noticed, long-haulers were trying to figure themselves out: Did they have similar blood types? Get tested at a certain time? Have a common geographic or demographic denominator?
- So Assaf, a technology design consultant, launched a channel called #research-group. A team of 23 people, led by six scientists and survey designers, began aggregating questions in a Google form. In April, they shared it within the Slack group and on other social-media groups for long-haulers like them.
- In May, this group, which now calls itself Patient-Led Research for C19, released its first report. Based on 640 responses, it provides perhaps the most in-depth look at long-haulers to date and offers a window into what life is like for certain coronavirus patients who are taking longer—much longer—to recover.
- Until recently, the idea that a person could have the coronavirus for a long time was foreign. Doctors still don’t know what to do with these patients. At the beginning of the pandemic, those who got sick followed one of two paths: either they recovered or they died. Long-haulers don’t fit in either bucket.
- The existence of a third path is only now being acknowledged. It wasn’t until late July that the US Centers for Disease Control published a paper recognizing that as many as one-third of coronavirus patients not sick enough to be admitted to the hospital don’t fully recover.
- Zijian Chen, the medical director at Mount Sinai’s Center for Post-Covid Care in New York, says he and his colleagues noticed by late April that some patients weren’t recovering. “That is when we realized that patients will need further care,” he says.
- What that care entails, however, remains fuzzy. Part of the problem is there isn’t a definition for what constitutes a long-hauler. Chen says Mount Sinai’s program includes “patients with a positive test result for C19 and [whose] symptoms persist for more than one month after the initial infection.”
- The Patient-Led Research team’s survey targeted patients who felt symptoms for longer than two weeks; importantly, some respondents who reported symptoms were not able to get tested, which would have disqualified them from Chen’s program. The CDC’s paper was based on interviews with subjects conducted 14 to 21 days after they received a positive test result.
- Chen hopes to conduct clinical care and research to better understand long-haulers’ symptoms. But he says it’s difficult to devote time or personnel to the task in the midst of a pandemic.
- Susannah Fox, who researches online movements within chronic-disease communities, says patient-led research groups such as the one Assaf started will increasingly command the attention of medical researchers, particularly during crises when doctors and scientists are overwhelmed.
- “The future of health care and technology is being built in these patient communities,” she says, noting that many early adopters of online bulletin boards and virtual communities were people with rare or chronic diseases who wanted to meet other people like them.
- Today, the Patient-Led Research team has new digital tools at its disposal that allow its members to connect and carry out their own research while isolated at home. One resource in particular—the Slack support group, which was created by a company called Body Politic—has been crucial to the team’s efforts.
- When the coronavirus struck New York, Body Politic was an emerging media company based in New York City that aimed to highlight underrepresented voices. Then the pandemic hit. Within days of one another, three Body Politic employees got sick with what they all suspect was the disease. “Our priorities shifted,” says Fiona Lowenstein, founder and editor in chief, who tested positive.
- The company’s first support group for covid patients wasn’t on Slack, says Sabrina Bleich, Body Politic’s creative director, who was among those to fall ill. The group initially gathered followers on Instagram, but when that became too overwhelming, they started a WhatsApp chat group. Within a couple of days, though, the group had exceeded the WhatsApp group limit of 256. She says Slack “felt like the right option to house a large group of people, be adaptable as we grew, and allow for many different communities and conversation streams to occur simultaneously.”
- That Slack group has ballooned to more than 7,000 active members. “There was a huge group of patients who felt alone,” Lowenstein says. “They had no idea that they were not alone.”
- There are subgroups based on geography (“The UK group is very active,” Lowenstein says) and symptoms (neurological symptoms are a popular topic). Members are from all over the world, though Lowenstein suspects the fact that it’s on Slack might bias its participation toward those who know how to use the software.
- Despite its limits, the Slack group allowed the coronavirus long-haulers in the Patient-Led Research group to find one another. It made it possible for them to coordinate their efforts and launch a study of their own symptoms. For many, the group has both provided a way to draw medical attention to their condition and served as a form of community during months of quarantine.
- The organizers—all millennial women—have bonded through working together on this project. Assaf leads the group. Hannah Wei, a qualitative researcher based in Canada, handles survey design; Lisa McCorkell, a policy analyst in California, has taken on data analysis; and Athena Akrami, a neuroscientist in London, provides medical guidance. They can all name the exact moment when symptoms set in and precisely what day and time they got worse or better.
- Hannah Davis, who helps with press and administrative tasks, remembers when she realized she was sick. It was March 25, and she was struggling to read a text message. “We were trying to arrange a video call with a friend, but I couldn’t understand what it was saying,” she says.
- She soon developed a persistent low fever and began having difficulty breathing—symptoms typical of the coronavirus. She was told to stay home and was unable to get a test. But Davis calls those issues “mild” compared with those that came later. She had a hard time reading and started to notice phantom smells. She had gastrointestinal issues, and after 103 days she developed a skin rash characteristic of C19.
- Davis felt isolated. At the time, she was stuck in her Brooklyn apartment—alone, sick, and wishing she could connect with someone who understood what she was going through. The Body Politic Slack group was “a lifesaver,” she says. “I don’t know I could have [kept going] without it.”
- When I spoke to her 135 days after she initially fell ill, Davis was still sick, with daily fevers, joint pain, cognitive issues, and more. But she feels a renewed sense of purpose thanks to the Patient-Led Research team.
- Many in the group were doing their own research even before they joined forces. Wei, a long-hauler who tested positive, was frustrated at the lack of information and resources available for people like her. So she created covidhomecare.ca, which includes Google Doc templates for tracking symptoms (and a log of her own symptoms as a guide).
- Wei’s expertise in survey design helped the Patient-Led Research group figure out the best way to go about studying themselves. She notes that the group’s survey results are biased—72% of respondents in the first survey are American, and the respondents are predominantly English-speaking. Seventy-six percent of respondents are white, and most are cisgender females.
- Akrami, who gets noticeably breathless as she speaks, ran a statistical analysis to help the group interpret its results. “We asked about 62 different symptoms,” she says. “We invited people who have been tested or not tested and asked if they were negative or positive, then compared the symptoms.”
- They found that 60 of those symptoms were as likely to show up in long-haulers who tested positive as those who were never tested for the coronavirus. This result seems to indicate that official tallies of cases may be overlooking a large number of patients.
- McCorkell, a long-hauler who’s never been tested, says that nearly half of survey respondents—all of whom have self-reported coronavirus symptoms—were never tested either.
- Of those who were eventually tested, many were found negative but still believe they have the virus, on the basis of their own symptoms or a physician’s diagnosis. False negatives are common in coronavirus testing, particularly for people who are tested too soon or too long after being infected.
- Still, the survey captured data particular to how long-haul patients experience the disease and its symptoms. “Even when controlling for the time of test, the only difference in symptoms between those who tested positive and those who tested negative is that those who tested positive reported loss of smell and loss of taste more often,” says McCorkell.
- The timing of certain symptoms among long-haulers also seems to fluctuate in a kind of pattern. According to the survey, neurological and gastrointestinal symptoms tend to appear around the second week, then dip, and then rise again around the third or fourth month.
- Davis was grateful when a fellow long-hauler warned her that days 90 through 120 were the hardest. “It’s crowdsourced recovery,” she says. The survey’s results suggest that neurological symptoms are common for long-haulers: nearly two-thirds of patients described debilitating dizziness, while blurry vision, trouble concentrating, and “brain fog” were also cited frequently. More than a fifth of patients described memory loss and hallucinations.
- McCorkell says that with the next survey, due out in the next few weeks, the group will attempt to reach more respondents from Black, Hispanic/Latino, and indigenous communities—groups that have been hit hardest by the coronavirus. And Akrami hopes she can pull in the bigger Body Politic community to help translate survey results into other languages and disseminate the information.
- But the long-haulers are now outgrowing their own group. Davis says the Patient-Led Research team is raising money to pay for more Slack users as their numbers grow. “I was lucky to have this experience that I hope is accessible for all long-haulers,” she says. Within the group, “it’s singularly most people’s resource for medical guidance.”
- During a time of extreme isolation and uncertainty, Davis and the other organizers are grateful for their Slack group, and to have found each other. “This support group has been one of the biggest gifts of my life,” she says.
2. Vaping linked to higher risk of C19 in teens and young adults
- Teens and young adults who vape are far more likely to be diagnosed with C19 than those who don’t, a new study by Stanford researchers found. A young person who has vaped and smoked cigarettes was seven times more likely to be diagnosed with C19, according to the study published today in the Journal of Adolescent Health. Someone who only vaped was five times as likely to be diagnosed. (Read the study here: https://www.sciencedirect.com/science/article/pii/S1054139X20303992)
- Public health officials should be concerned about vaping as they try to get the ongoing pandemic under control and as the number of younger people testing positive grows, experts tell The Verge. Not only that, but young vapers’ vulnerability to C19 should inform how regulators address the popularity of e-cigarettes, say the new paper’s authors.
- “When I first started seeing the stories come out that adolescents and young adults were suddenly being diagnosed with C19 and actually getting sick from it, one of the thoughts I had was, ‘wow, could this study partly explain that?’” says Bonnie Halpern-Felsher, senior author of the study.
- The proportion of young people getting infected with C19 has recently risen dramatically, the World Health Organization found this month. Out of the 6 million people with the disease globally for whom the WHO had data on age, the percentage of those aged 15 to 24 tripled from 4.5 percent on February 24th to 15 percent on July 12th.
- Halpern-Felsher’s research doesn’t reveal exactly how vaping increases a young person’s likelihood of getting sick. It might be because of the way vaping affects the lungs or immune system — or vapers may be more exposed to C19 for other reasons. People who vape tend to share devices and touch their faces more as they puff, the paper notes. [NOTE: In our opinion, sharing a device requires someone to be with one or more friends and may occur in a bar]
- Yet, after outbreaks of vaping-associated lung injuries last year, “This is yet one more sign that e-cigarettes are unhealthy,” Halpern-Felsher says. “Look, this is a pandemic … this is the time for you to quit and not start vaping,” she says.
- “I don’t think anybody will be shocked at the results. I think people [will say] we saw this coming,” says Ana María Rule, an assistant professor at Johns Hopkins’ Department of Environmental Health and Engineering, who was not involved in the study. She notes that C19 and electronic cigarettes affect the same parts of the lungs.
- While the results may not be surprising, it’s an important study, according to Rule. Researchers have suspected that vaping would lead to long-term health effects. “What this [study] changes, is that we’re now seeing that it actually could have short term health effects,” she says.
- The new paper’s findings are based on an online survey conducted in May of 4,351 US residents between the ages of 13 and 24. The sample reflects roughly equal numbers of people of different ages, races, and genders, and the results were adjusted for confounding variables like the number of C19 cases in survey participants’ states and whether participants followed shelter-in-place orders.
- It’s also significant that unlike similar studies looking into links between cigarette smoking and C19 outcomes, the new research is population-based. Previous research studied C19 patients, whereas the new study includes more people than just those who have already tested positive. That makes it more of an unbiased sample, Halpern-Felsher explains.
- The new paper calls for the Food and Drug Administration to regulate e-cigarettes and do outreach with teens on the link between vaping and C19 as the pandemic continues to wreak havoc in the US. On top of that, health care providers should ask patients whether they have a history of vaping or smoking, Halpern-Felsher and her co-authors write in the paper. Ultimately, that could give doctors a better understanding of how at-risk their young patients are during the pandemic.
3. 40% of adults reported dealing with mental health problems during lockdown
- As America’s coronavirus epidemic persists, CDC researchers between June 24 and June 30 surveyed 5,412 U.S. adults to gauge how the crisis has affected Americans’ mental health—and they discovered some striking and concerning statistics.
- According to the report, over 40% of those surveyed said they had experienced a mental or behavioral health condition related to the coronavirus epidemic. Overall, 25.5% of respondents said they had experienced symptoms of anxiety disorder, while 24.3% said they had experienced symptoms of depression. Further, the researchers found that 10.7% of all respondents said they had considered suicide at some point during the 30 days leading up to the survey. [NOTE: 25.5% of young adults between 18-24 seriously considered suicide within the last 30 days]
- The researchers also found that reports of anxiety, depression, and suicidal ideation were up significantly this year when compared with previous years. For example, the reported prevalence of anxiety disorder symptoms was about three times higher this June when compared with reported prevalence of anxiety disorder symptoms during the second quarter of 2019, while the reported prevalence of depression symptoms was about four times higher this June when compared with the second quarter of 2019.
- In addition, about twice as many respondents in June said they had considered suicide in the preceding 30 days when compared with the number of U.S. adults who in 2018 said they had considered suicide in the preceding 12 months, according to the report.
- Moreover, data from the separate, online Household Pulse Survey conducted by CDC’s National Center for Health Statistics, which surveyed nearly 996,000 U.S. adults from April 23 through July 21, shows that reported rates of anxiety and depression have been rising since America’s coronavirus epidemic reached its first peak in April.
- The epidemic has disproportionately affected the mental wellbeing of Americans ages 18 to 24, with more than half of adults in that age group who responded to CDC’s June survey reporting symptoms of depression, just under half reporting symptoms of anxiety disorder, and more than a quarter reporting that they had considered suicide within the preceding 30 days.
- The epidemic also has taken a heavier toll on Hispanic and Black Americans’ mental health, with more than a third of Hispanic respondents saying they had experienced symptoms of depression or anxiety and nearly 20% saying they had considered suicide in the preceding 30 days. Meanwhile, just under a quarter of Black respondents said they had experienced symptoms of depression or anxiety and around 15% said they had considered suicide in the preceding 30 days.
- In addition, unpaid caregivers and essential workers reported comparatively higher rates of anxiety disorder and depressive symptoms, as well as suicide ideation. For instance, 31% of respondents who reported being unpaid caregivers said they had considered suicide in the preceding 30 days, compared with 3.6% among respondents who did not report being an unpaid caregiver. Likewise, 22% of respondents who reported being an essential worker said they had considered suicide in the preceding 30 days, compared with 7.8% of respondents who reported being nonessential workers, 4.7% among unemployed respondents, and 2.5% among retired respondents.
- Researchers also found that 13.3% of all respondents said they had begun or increased substance use to cope with stress related to the epidemic. For the survey, substance use was defined as using “alcohol, legal or illegal drugs, or prescriptions drugs that are taken in a way not recommended by your doctor.”
- Ken Duckworth, CMO of the National Alliance on Mental Illness, said CDC’s findings represent “a virtually real-time biopsy of the American mental health experience.” He added, “[Y]ou can criticize this study for being internet-based. You can criticize this study for not having formal diagnostic interviews. But you can conclusively say the adults are not [all right] in America.”
- Anna Mueller, a professor of sociology at the Indiana University Bloomington who conducts research on suicide, said CDC’s report shows that the “breakdown in our society, the breakdown of the safety net, the breakdown of economic security is taking a massive toll. These breakdowns really show how crucial economic stability and economic security are to an individual’s well-being.”
- In addition, Mueller said uncertainty may be a contributing factor to the proportion of 18- to 24-year-olds who reported suicide ideation. “They’re watching their world crumble, and probably struggling to imagine a future,” she explained. “I mean, we all are. What is the world going to look like? What is college going to look [like]? What is employment going to look like if they were hoping to enter the labor force?”
- Nadine Kaslow, a professor of psychiatry at the Emory University School of Medicine, said, “We need to recognize the profound effects of the [epidemic], of racial injustice, of economic instability. Those people whose symptoms of anxiety or depression, or substance use or suicidal ideations are really interfering with their functioning, where the symptoms are extreme, those people need help.”
- Kaslow added that access to affordable mental health care will be vital to addressing the ongoing mental health crisis, as will compassion.
- “No matter how tired and burnt out we each are, we need to check in with people, to see how they’re doing, to let people know that we care,” she said. “People did a lot of that at the beginning. … As we get into this phase that people sort of call the disillusionment phase, I personally think we’re seeing a lot less of that. We have to be in this for the long haul. We have to take care of each other for the long haul”
4. New reports shed further light on how nursing homes have been affected by C19
- New CDC data underscore how nursing homes have been among the hardest-hit places during the C19 pandemic. In one report, based on an outbreak at a Maryland facility, investigators found that around 1 in 5 residents at a 200-person nursing home tested positive for the coronavirus. Those who were on dialysis had worse outcomes: Nearly half of them tested positive versus 16% of those who weren’t on dialysis. Those on dialysis were also more likely to be hospitalized and to die from C19.
- In another report based on data from seven health departments across the U.S., scientists found that delaying facility-wide testing could lead to more cases. In an analysis of 88 nursing homes that waited to implement facility-wide testing until a C19 case was identified led to an additional case being identified per day after the first case was diagnosed.
Source: Stat News
H. Back To School!?
1. Half of U.S. elementary and high school students will study virtually only this fall
- A little more than half of U.S. elementary and high school students will attend school only virtually this fall, according to a new study, as education officials struggle with an unprecedented and wrenching decision amid the coronavirus pandemic.
- The study by Burbio, which aggregates school and community calendars nationwide, found that 52% of students will go to school virtually only and just 25% will attend every day. The remaining 19% will have some form of hybrid schooling, combining online and in-person learning. Four percent of districts remain undecided.
- The situation is fluid, with new decisions announced daily and school districts often changing their minds as the virus spreads or comes under control, and as parents, teachers and politicians debate what is safest for kids, teachers and the broader community. But Burbio found a decided trend toward more virtual learning.
- “We have seen a dramatic shift to online only learning in the past three weeks,” said Burbio co-founder Julie Roche in a news release. “Large districts such as Chicago, and Sun Belt cities such as Houston and Miami along with large suburban districts such as Fairfax County Virginia were all setting plans to return with in-person learning and shifted to fully remote.”
- Burbio found the largest 200 districts were two-thirds virtual despite a decision by New York Gov. Andrew Cuomo last week that looks set to open New York City schools.
- Burbio sampled 1,200 of the nation’s 13,500 school districts, representing about 35% of the nation’s schools to arrive at its estimate. The estimate has a margin of error of plus or minus 2.7.
- It found vast differences between regions and states, between counties in the same state and even between school districts in the same county. Texas, a recent hot spot for the virus, is a patch-work quilt of divergent choices. Schools in the Panhandle, largely rural, are nearly all in-person. Equally rural southern Texas schools look to have opted for virtual learning. Houston is virtual, but some schools in Harris County, where the city is located, are in person.
- “We expect this situation to stay fluid for the entire academic year and we will continue to measure it,” said Roche. “Many districts have thresholds for C19 levels that could result in converting back to remote learning. Other districts are planning to revisit the ‘on-line’ decision as soon as September and could convert to in-person models.”
- Burbio School Tracker is here: https://cai.burbio.com/school-opening-tracker/
2. The No-Win School Reopening
- Schools superintendent Michael Hinojosa stepped on a land mine while laying plans to reopen his 153,000-student district amid the coronavirus pandemic. He wanted teachers instructing from classrooms, even if students were at home, to make sure they stayed focused.
- “It is better for us if they come in,” Dr. Hinojosa said from his office at Dallas Independent School District headquarters late last month. “It is unprofessional if kids are yelling in the background, dogs barking and husbands walking back and forth.”
- The teachers’ response was swift and clear: His approach would gamble with their lives as C19 runs rampant in the area, citing an Arizona teacher’s recent death as an example.
- After consulting a county leader, Dr. Hinojosa changed his stance. He would now allow teachers to apply to work from home if they had reliable internet and minimal distractions. He asked a staffer to write new language. “I don’t want to have a firestorm,” he said.
- Dr. Hinojosa’s experience shows the heart-wrenching decisions facing superintendents throughout America as they try to educate children while navigating an array of opposing forces, few of them stable.
- They must balance rapidly changing statistics that project the potential loss of learning—and potential loss of lives. Government directives are shifting. A plan for the fall may face teacher-union backlash. Change the plan, and some parents object. Reopen and a student gets C19—and the district has to roll out another plan.
- ‘Things are changing in real time, sometimes by the hour,’ says Dr. Hinojosa.
- A superintendent’s decisions can affect the economy, determining if parents can head back to work or need to be home helping their children learn.
- “Flexibility is the name of the game,” Dr. Hinojosa said, “because things are changing in real time, sometimes by the hour.” He is among holdouts: He hasn’t given up on offering both in-person and remote learning, despite more districts locally and nationally announcing they will start online-only.
- Issues over reopening have split the U.S., with some people wanting campuses open to in-person learning while some unions haven’t ruled out so-called safety strikes over reopening. Some school districts have already started the new school year, with many offering remote learning and some opening doors to students.
- Large districts such as Chicago and Los Angeles have scrapped in-person learning plans for now. As C19 flares across the country, many districts are focusing on improving remote learning.
- The Dallas district released its reopening plan last month, but said there could be changes based on input from parents, teachers and circumstances with the virus. The plan mostly centers on safety procedures, such as wearing masks, social distancing and cleaning buildings. The district has delayed the school start date to Sept. 8 from Aug. 17.
- The student body in Dr. Hinojosa’s district is about 70% Hispanic, 22% Black and 6% white. He fears losing academic gains made under his watch in the district, which state data show went from having 37 low-performing schools in 2015 to eight in 2019. He feels his students are defeating the odds like he did as an immigrant boy in the district, where at least 90% of students qualify for free or reduced-priced lunches.
- It has been about five months since his students learned in classrooms, and remote learning was less than stellar after a fast spring rollout, he said: “We cannot afford to get further behind.”
- Dr. Hinojosa is listening to parents as he continues to fine-tune the plan. Some want schools reopened, as they can’t stay home to help educate their children. Others demand flexibility in switching to in-person learning if they are called back to work, instead of waiting until the end of the nine-week period as the district prefers.
- “If I have to go back to work, they have to go back to school,” said Dallas parent Kendall McKimmey. “I can’t lose my job over it.”
- A district spokeswoman said there would be some flexibility for parents needing to switch to in-person learning.
- ‘Flexibility is the name of the game,’ says Dr. Hinojosa.
- Dr. Hinojosa faces backlash from teachers like Diane Birdwell, 59. “I don’t want to die, and I don’t want to get sick,” she said. “But I can’t retire yet. So if the schools reopen, I really don’t have a choice but to go back. I know the superintendent is doing what he can to keep us all safe, but the virus doesn’t care.”
- Some Dallas teachers cite the situation in Arizona’s Hayden-Winkelman Unified School District, where three teachers shared a classroom during virtual summer school. One got sick the first week of class. All three tested positive for C19, despite precautions such as masks, temperature checks, social distancing and cleaning. The teacher showing the first symptoms died, and eight employees in all—13% of employees—got infected in the 300-student district, said the district’s superintendent, Jeff Gregorich.
- “I have no idea right now what it is that I could have done differently,” Mr. Gregorich said. One of the three teachers, Angela Skillings, 43, said she and the other two “were very careful,” adding, “We’re not sure who had it first, who gave it to who. It was scary.”
- Dallas’s Alliance-AFT teachers union wants only online learning until January, or at a minimum the first eight weeks of school, and under a steady decline in confirmed C19 cases and hospitalizations. Union President Rena Honea has asked her 5,000 members to contact board members to urge them to support the request. “The teachers are the very people that are having to do the work, that are having to risk their lives,” Ms. Honea said.
- Dr. Hinojosa said that teachers have a valid concern about contracting the virus in classrooms and that the district is relying on medical experts to advise it as it makes reopening decisions.
- While Texas teachers unions don’t have the legal right to strike, he said they can make life rough, so he works with them. “They’re very organized,” he said. “If they get mad and you just diss them, then they can make a lot of noise. They can make your life miserable.”
- The Dallas district’s reopening plan, released July 21, requires students and staff to wear protective face coverings and encourages social distancing at 6 feet. Schools will separate students with plexiglass when in classrooms or lunchrooms, won’t allow volunteers inside, and will confine parents to the front office.
- A video accompanying the plan shows masked students getting mandatory temperature checks before entering school. At classrooms, they slip off masks and slide on face shields, or wear both if parents choose. All students receive a refillable bottle of hand sanitizer. School buildings are cleaned daily and disinfected weekly.
- The video’s orderly scenario likely won’t last as people get lax, said Dallas teacher Leslie Daroche, 47. “When a parent drops their kids off at school, they trust that the school will keep them safe,” she said. “I don’t want that safety plan to be me, making sure kids keep their masks on and don’t breathe on each other. Every teacher wants to go back to school and be with their kids, but you want to go back safe.”
- Dr. Hinojosa came to the U.S. from Mexico as a young boy with his family, attending schools in the Dallas district. He started his career in the district as a teacher and coach. He is now in a second stint as superintendent, with an education career spanning 40 years, about 26 of them spent leading school districts, including in Cobb County in suburban Atlanta.
- On the workday late last month, stretching past 15 hours, Dr. Hinojosa attended a board meeting where he heard from dozens of speakers, via a live feed, including teachers not wanting to teach in person. “We can catch up on learning, but we cannot replace lives,” one teacher said. Another said: “This has been one of my greatest life challenges.”
- On the agenda: his proposal that Dallas push its reopening date back three weeks, giving him more time to prepare. A board member noted his constituents’ concern with the proposal, which would also delay school’s end to June 18, saying it would interfere with summer activities like camps and vacation.
- Board member Joyce Foreman questioned why the district hadn’t involved teachers more with the conversation surrounding reopening plans.
- “Can I get some kind of commitment that the teachers will be brought to the table?” she said.
- Dr. Hinojosa apologized, saying he made decisions in the speed of the moment. “I accept your request,” he told Ms. Foreman.
- Shortly after the board voted unanimously to delay the school year’s start to Sept. 8, he dashed across the hall for a news conference. “We’re going to listen to the parents, we’re going to listen to the teachers,” he said, answering questions in English and Spanish. “And we’re going to especially listen to the science.”
- But the science, too, is shifting over theories on children’s role in the pandemic, complicating planning. Some health experts say children who get infected tend to do very well, but others don’t, and children can pass it on to adults. A recent study in South Korea found children between ages 10 and 19 spread the new coronavirus much more than those under 10.
- In writing a plan, the district has watched the Centers for Disease Control and Prevention, which encourages schools to reopen for in-person learning this fall but says school officials should make decisions based on levels of community transmission and the capacity to mitigate spread in schools. The CDC advises reopened schools to increase physical distance between students, keeping students in small groups and wearing masks or cloth face coverings.
- ‘This thing may go on for a while,’ says Dr. Hinojosa.
- Even as Dr. Hinojosa hopes to get students in class, he is preparing to roll out what he says will be a robust remote-learning program, which he expects also to be a fallback for anyone needing quarantine. Many districts, including Dallas, say remote learning will be more rigorous this time around and similar to what a student would receive on campus. Dallas teachers will give students zeros for undone work, unlike before.
- Dr. Hinojosa is painfully aware of problems nationally in the spring, when schools rolled out remote learning quickly to millions of students. Many students didn’t have internet access, some parents weren’t available to teach their children, and many teachers lacked training to deliver instruction remotely.
- It has been a balancing act for Dr. Hinojosa, trying not to get crosswise with spirited parents, teachers and politicians in a district sitting in heavily Democratic Dallas in a Republican-controlled state.
- Dr. Hinojosa expects to have to deal with positive C19 cases when schools reopen, judging from cases in other U.S. school districts.
- In Gwinnett County Public Schools, Georgia’s largest district, staff returned to school July 29. By the next day, officials reported about 260 employees had tested positive for coronavirus or been in contact with someone who had. School is scheduled to start in Gwinnett on Aug. 12 with teachers required to instruct from classrooms with students returning on a staggered basis despite their objections.
- “There have been no changes in the district’s expectation that teachers report to schools,” the district said in a statement.
- The Dallas district plans to have students who start in-person send in assignments by laptop, to become familiar with the online platform, said Dr. Stephanie Elizalde, the district’s chief of school leadership. That way, she said, “At any given time, if we have a situation, they can learn at home.”
- ‘If we have a situation, they can learn at home,’ says Dr. Elizalde, in red mask at the board meeting.
- Dallas will isolate students with C19 symptoms until their parents can get them. For positive cases, Dallas County’s health department will aid in contact-tracing to determine who needs to quarantine or if a school needs to close.
- Students who purposely cough, sneeze or spit on another student with the intention of spreading the virus face repercussions. The Dallas district guidelines require that, for intentional incidents, a police or security officer be called to determine the violation for possible consequences.
- Dr. Hinojosa said he is making decisions for the long haul. “This thing may go on for a while,” he said. “The kids have got to keep on learning.”
3. What Should College Students Pack to Fight C19?
- What anti-Covid supplies should college students pack?
The Bottom Line
- Amid the stress about colleges reopening, students heading to campus face an added concern: What to bring to the dorm during a pandemic. Parent Facebook pages, usually filled with posts about room decorations and clothing suggestions, are now focused on quarantine supplies and safety.
- Epidemiologists say the items students can bring to help protect them from C19 are the same ones they are advised to use at home: masks, soap, hand sanitizers, disinfectants and gloves.
- “The most important thing to bring is common sense,” says Brad Pollock, who is chairman of the Department of Public Health Sciences and associate dean for Public Health Sciences at the University of California Davis School of Medicine.
- One recommendation making the rounds: packing an emergency “Covid bag” in case a student tests positive and has to quarantine, just as a pregnant woman might pack a “go bag” in case she has to rush to the hospital. Other suggestions include ultraviolet-light sterilization boxes, HEPA air purifiers, zinc tablets and oxygen-saturation monitors.
- While many of these supplies might not stop Covid, doctors say, they may help prevent other illnesses, which could make Covid worse. For example, taking vitamin D helps the immune system and is safe. “There’s no harm to it,” says Ehsan Ali, an internal medicine physician with Beverly Hills Concierge Doctor in California.
- UV light disinfector: Dr. Ali recommends a standing UV lamp, which he says will disinfect and kill bacteria and viruses throughout a room. He says boxes or bags that disinfect with UV light can be used to sterilize small items like keys and cellphones, but are less effective, because their sanitizing light might not penetrate every crevice in a room.
- Portable air purifier: Dr. Pollock warns that air purifiers are unlikely to prevent C19 because the virus is most often transmitted through respiratory droplets from an infected person speaking, coughing or sneezing. The droplets are fairly heavy and don’t travel that far in the air, so transmission is believed to occur mostly through close contact, meaning within 6 feet of an infected person. However, such purifiers can help clean the air and thus prevent students from getting sick from other hazards, he says. In addition, the World Health Organization revised its guidelines, saying people talking or singing may expel the virus through tiny airborne particles, which could be trapped by filters. [NOTE: Recent research indicates that proper ventilation may be an even greater way to prevent the spread of C19. Experts recommend a H13 HEPA Filter machine. Read more here: https://www.nytimes.com/wirecutter/blog/can-hepa-air-purifiers-capture-coronavirus/]
- Lunch box and ice pack: Many colleges letting students back on campus are offering only takeout food service. Insulated bags and reusable ice packs might help if classes are far from the dining hall and a student doesn’t want to travel back and forth to eat.
- Oxygen saturation monitor: Dr. Pollock says these devices, which measure the blood-oxygen level, aren’t necessary unless someone has contracted C19 and is monitoring whether to go to a hospital. Only elderly patients who might not notice that their breathing is impaired would benefit from a monitor, he says, but if a college student wants one, it wouldn’t hurt. [NOTE: As noted in our prior Coronavirus Updates, a Pulse Oximeter can be a warning sign that you need to go to the hospital if you have C19. Read more here: https://www.yalemedicine.org/stories/covid-pulse-oximeter/]
- Disinfectant and wipes: Use these in dorm rooms and bathrooms, Dr. Ali says. The C19 virus can last up to 72 hours on plastic and stainless steel, up to 24 hours on cardboard and four hours on copper, according to a study in the New England Journal of Medicine by U.S. government and academic scientists.
- Masks: Even though health experts say only N95 respirator masks, properly worn, can guard fully against the virus, disposable surgical masks and cloth masks can provide some protection. Dr. Pollock says ideally, cloth masks should be washed between uses but students also can rinse them in warm, soapy water or rotate use every few days.
- Tylenol or Advil: There have been reports that using painkillers from a class known as nonsteroidal anti-inflammatory drugs, containing ingredients like ibuprofen, might worsen C19 infections. Even though the World Health Organization says it doesn’t recommend against the use of ibuprofen, some parents say they are packing Tylenol instead of Advil just in case.
- Vitamin D: Some research shows that vitamin D deficiency can weaken the immune system. Because vitamin D deficiency is relatively common, experts recommend supplementing if levels are low. [NOTE: Spend up to 15 minutes in the sun]
I. Practical Tips & Other Useful Information
1. The 14 face masks tested in Duke University study, ranked from best to worst
- We all need to wear masks in public spaces to prevent the spread of C19 — but not all of them are created equal.
- And little was known about how effective each one was at stopping respiratory droplets.
- That is, until Duke University researcher Dr. Martin Fischer came up with a simple test to measure it.
- The experiment, published Friday in the journal Science Advances, tested 14 different types of masks and was inspired by a request from Fischer’s co-worker Dr. Eric Westman, who works with Cover Durham, an initiative to distribute reusable face coverings to those in need. Westman asked if someone at the school could assure him that the masks he received as donations were effective.
- To test the coverings, scientists outfitted a black box with a laser and a cellphone camera and had four testers try out the 14 donated options. Wearing each mask, A tester would speak in the direction of the laser beam inside the box, saying the phrase “Stay healthy, people” five times. A camera recorded the amount of respiratory droplets set off by the speech, and an algorithm determined how many droplets had leaked through the face covering.
- “The was about setting up a simple measurement technique that can be reproduced,” Fischer told The Post.
- And while he doesn’t advocate for any specific mask, Fischer — who wears a basic cotton version himself — says the overarching point of the study is that many of the varieties are pretty effective. But you’re better off wearing a real mask than something that makes you look like a bandit trying to stick up a bank in the Wild West.
- Here’s a breakdown of face coverings Fischer and his team put through the paces, from the strong sealed medical N95 mask to the flimsy neck gaiter.
|1||N95 Medical||No wonder the fitted “3M 1860 Surgical Mask and Particulate Respirator” is worn by health-care workers: It was the most effective of the bunch on the study’s logarithmic scale.|
|2||Surgical mask||This disposable surgical mask was the second most effective variety, ranging from zero to 0.1 in terms of the particles spread from speaking while wearing one.|
|3||Polypropylene and cotton||The synthetic material polypropylene, laid in between two layers of cotton, was the third best.|
|4||Polypropylene apron mask||This mask made with two layers of the synthetic material was just marginally worse than the one made with both cotton and polypropylene.|
|5||Cotton mask with ties||The next six cotton masks all performed around the same level, which Fischer said shows variables matter. “It depends how loud you speak, and how well it fits around your face,” or if facial hair causes a looser fit, he said.|
|6||Two-layer cotton with ties||Right behind the green tie mask was another cotton version with two layers, and straps that went across the bottom and tied behind the ears.|
|7||Valved n95||N95 masks with exhalation valves are designed to protect the user from breathing in harmful materials not necessarily the other way around, which could have contributed to its performance. [NOTE: The CDC now says valve N95 masks are not safe]|
|8||Hand-sewn cotton||This cotton mask was sewn using the popular “Olson” pattern, which is available online.|
|9||‘MAXIMA AT’ mask||A pleated cotton variety from North Carolina-based company Hudson’s Hill was essentially tied with the similar-looking single-layer cotton mask to the left.|
|10||Single-layer cotton||This one-layer mask performed better than one with two layers, which should serve as a reminder of the variables in the experiment and in life, said Fisher.|
|11||Pleated two-layer cotton||This two layered cotton pleated style mask, performed just slightly worse than its other similar styles.|
|12||Knitted||A mask made from what appears to be a tee-shirt knit (Fisher was keen to point out the researchers are not textile experts) had more variability of droplet projection than other styles.|
|13||Bandana||Adored by celebrities such as Johnny Depp and Kristen Stewart, the folded bandana has become a chic covering option, but it’s basically useless, multiple studies — including Duke’s — have found.|
|14||Neck gaiter||The stretchy gaiter tested here (a style beloved by runners) was worse than forgoing a mask completely, and was shown to break the larger particles into smaller ones, allowing them to slip out of the sides more easily.|
2. The best ways to reduce the risk of C19 indoors
- The vast majority of coronavirus transmission occurs indoors, most of it from the inhalation of airborne particles that contain the coronavirus. The best way to prevent the virus from spreading in a home or business would be to simply keep infected people away. But this is hard to do when an estimated 40 percent of cases are asymptomatic and asymptomatic people can still spread the coronavirus to others.
- Masks do a decent job at keeping the virus from spreading into the environment, but if an infected person is inside a building, inevitably some virus will escape into the air.
- I’m a professor of mechanical engineering at the University of Colorado Boulder. Much of my work has focused on how to control the transmission of airborne infectious diseases indoors, and I’ve been asked by my own university, my kids’ schools and even the Alaska State Legislature for advice on how to make indoor spaces safe during this pandemic.
- Once the virus escapes into the air inside a building, you have two options: bring in fresh air from outside or remove the virus from the air inside the building.
It’s all about fresh, outside air
- The safest indoor space is one that constantly has lots of outside air replacing the stale air inside.
- In commercial buildings, outside air is usually pumped in through heating, ventilating, and air-conditioning (HVAC) systems. In homes, outside air gets in through open windows and doors, in addition to seeping in through various nooks and crannies.
- Simply put, the more fresh, outside air inside a building, the better. Bringing in this air dilutes any contaminant in a building, whether a virus or something else, and reduces the exposure of anyone inside. Environmental engineers like me quantify how much outside air is getting into a building using a measure called the air exchange rate. This number quantifies the number of times the air inside a building gets replaced with air from outside in an hour.
- While the exact rate depends on the number of people and size of the room, most experts consider roughly six air changes an hour to be good for a 10-foot-by-10-foot room with three to four people in it. In a pandemic this should be higher, with one study from 2016 suggesting that an exchange rate of nine times per hour reduced the spread of SARS, MERS, and H1N1 in a Hong Kong hospital.
- Many buildings in the US, especially schools, do not meet recommended ventilation rates. Thankfully, it can be pretty easy to get more outside air into a building. Keeping windows and doors open is a good start. Putting a box fan in a window blowing out can greatly increase air exchange too. In buildings that don’t have operable windows, you can change the mechanical ventilation system to increase how much air it is pumping. But in any room, the more people inside, the faster the air should be replaced.
Using CO2 to measure air circulation
- So how do you know if the room you’re in has enough air exchange? It’s actually a pretty hard number to calculate. But there’s an easy-to-measure proxy that can help. Every time you exhale, you release CO2 into the air. Since the coronavirus is most often spread by breathing, coughing or talking, you can use CO2 levels to see if the room is filling up with potentially infectious exhalations. The CO2 level lets you estimate if enough fresh outside air is getting in.
- Outdoors, CO2 levels are just above 400 parts per million (ppm). A well ventilated room will have around 800 ppm of CO2. Any higher than that and it is a sign the room might need more ventilation.
- Last year, researchers in Taiwan reported on the effect of ventilation on a tuberculosis outbreak at Taipei University. Many of the rooms in the school were underventilated and had CO2 levels above 3,000 ppm. When engineers improved air circulation and got CO2 levels under 600 ppm, the outbreak completely stopped. According to the research, the increase in ventilation was responsible for 97 percent of the decrease in transmission.
- Since the coronavirus is spread through the air, higher CO2 levels in a room likely mean there is a higher chance of transmission if an infected person is inside. Based on the study above, I recommend trying to keep the CO2 levels below 600 ppm. You can buy good CO2 meters for around $100 online; just make sure that they are accurate to within 50 ppm.
The word on air cleaners
- If you are in a room that can’t get enough outside air for dilution, consider an air cleaner, also commonly called air purifiers. These machines remove particles from the air, usually using a filter made of tightly woven fibers. They can capture particles containing bacteria and viruses and can help reduce disease transmission.
- The U.S. Environmental Protection Agency says that air cleaners can do this for the coronavirus, but not all air cleaners are equal. Before you go out and buy one, there are few things to keep in mind.
- The first thing to consider is how effective an air cleaner’s filter is. Your best option is a cleaner that uses a high-efficiency particulate air (HEPA) filter, as these remove more than 99.97 percent of all particle sizes.
- The second thing to consider is how powerful the cleaner is. The bigger the room–or the more people in it–the more air needs to be cleaned. I worked with some colleagues at Harvard to put together a tool to help teachers and schools determine how powerful of an air cleaner you need for different classroom sizes.
- The last thing to consider is the validity of the claims made by the company producing the air cleaner.
- The Association of Home Appliance Manufacturers certifies air cleaners, so the AHAM Verifide seal is a good place to start. Additionally, the California Air Resources Board has a list of air cleaners that are certified as safe and effective, though not all of them use HEPA filters.
Keep air fresh or get outside
- Both the World Health Organization and U.S. Centers for Disease Control and Prevention say that poor ventilation increases the risk of transmitting the coronavirus.
- If you are in control of your indoor environment, make sure you are getting enough fresh air from outside circulating into the building. A CO2 monitor can help give you a clue if there is enough ventilation, and if CO2 levels start going up, open some windows and take a break outside. If you can’t get enough fresh air into a room, an air cleaner might be a good idea. If you do get an air cleaner, be aware that they don’t remove CO2, so even though the air might be safer, CO2 levels could still be high in the room.
- If you walk into a building and it feels hot, stuffy, and crowded, chances are that there is not enough ventilation. Turn around and leave.
- By paying attention to air circulation and filtration, improving them where you can and staying away from places where you can’t, you can add another powerful tool to your anti-coronavirus toolkit.
J. The Road Back?
1. Forced Isolation May Be the Only Way to Stop Resurgence of Virus
- Flare-ups from Australia to Japan show the world hasn’t learned an early lesson from the coronavirus crisis: to stop the spread, those with mild or symptom-free coronavirus infections must be forced to isolate, both from their communities and family.
- In Australia, where Victoria state has been reporting record deaths, some 3,000 checks last month on people who should have been isolating at home found 800 were out and about. In Japan, where the virus has roared back, people are staying home but aren’t in isolation: 40% of elderly patients are getting sick from family members in the same apartments.
- The failure to effectively manage contagious people with mild or no symptoms is a driving factor behind some of the world’s worst resurgences. But lessons from Italy, South Korea and others that have successfully contained large-scale outbreaks show that there’s a tried-and-tested approach to cutting off transmission: move them out of their homes into centralized facilities while they get over their infections, which usually doesn’t require longer than a few weeks.
- “A laissez-faire approach naively trusting everyone to be responsible has been shown to be ineffective, as there will always be a proportion who will breach the terms of the isolation,” said Jeremy Lim, adjunct professor at the National University of Singapore’s Saw Swee Hock School of Public Health.
- Faced with a new cluster this week after 102 days without a locally transmitted case, New Zealand has quickly enacted this strategy, placing around 30 people — including at least two children below the age of 10 — into centralized quarantine.
- But other countries facing sustained spread like Australia and the U.S. are not broadly enacting the policy despite its proven track record. Their unwillingness — or inability — to do so underscores the challenges faced by liberal democracies whose populations are less likely to tolerate measures that require individual sacrifice for the greater good.
Not at Home
- The existence of a large group of carriers who hardly feel sick is a unique feature of the coronavirus crisis, and a major factor that has driven its rapid spread across the globe. Unlike in previous outbreaks like the 2003 SARS epidemic, many infected people don’t feel ill enough to stay home, and so spread the pathogen widely as they go about their daily lives.
- The CDC has estimated that 40% of C19 infections are asymptomatic.
- In Wuhan, the Chinese city where the coronavirus first emerged last year, mildly sick patients were originally turned away from hospitals and told to rest at home, given that the overwhelmed health-care system needed to tend to the most severe cases. But health experts soon found that these people would infect their family members and others as they moved around in the community, precipitating a deluge of cases.
- Bringing mild or asymptomatic patients to designated facilities — re-purposed convention centers, hotels and stadiums — for basic medical care marked a turning point in the city’s fight against the coronavirus. Simply separating them from healthy people halted the pathogen’s silent spread through the community.
- The strategy has since been used in Italy, Singapore and South Korea at the height of their own coronavirus outbreaks earlier this year. Faced with a resurgence last month, Hong Kong converted an exhibition center to accommodate mild C19 patients and is building more such facilities.
- In New Zealand, the government put “a lot of thought” into enacting the policy, and is asking family members of confirmed cases to go into centralized quarantine with them if they require care, said director general of health Ashley Bloomfield.
- The approach is effective firstly because it prevents people from infecting family members in the same household — over 80% of cluster infections in China cities were in households after mild patients were allowed to stay home, said a Lancet study. In Europe, the surge of household infections drove Italy’s Milan to start putting such cases in hotels, enabling the country to gain control over its outbreak in early May.
- Beyond household spread, the strategy is necessitated by a facet of human nature that’s been seen time and again across countries and cultures: left to their own devices, some people just won’t follow the rules.
- In Australia and Japan, infected people who’ve been told to stay home have gone out for a variety of reasons — some can’t work from home and need the income, while others want to pick up groceries and supplies. One woman in Tokyo traveled cross country by bus after having her infection confirmed.
- “It is far better to be more aggressive in the short term with even mild cases than it is to allow such cases to slip under the radar,” said Nicholas Thomas, associate professor in health security at the City University of Hong Kong.
- But forcibly moving mild or asymptomatic patients into centralized facilities has been met with backlash in some countries where citizens are not as accepting of government directives. Some people might lose their jobs if they disappear for two weeks, or have caretaking responsibilities for young children or older parents where it’s unfeasible to be separated.
- “People would be wondering what on earth they’re doing locked up in a hospital,” said Stephen Leeder, emeritus professor of public health and community medicine at the University of Sydney. “From what I know about the Australian psyche, I don’t think it would go down all that well.”
- In places like Venezuela and India where conditions in quarantine facilities are poor, the prospect of being taken away has caused some to avoid being tested or to lie to contact-tracers for fear of being found positive, making the work of health officials more challenging.
- In an emailed response to Bloomberg News queries, the Department of Health and Human Services in Victoria said the government provides alternative accommodation for quarantine, but that these are for health workers “who may not be able to safely live at their normal address” and other vulnerable groups.
- Rather than forcing isolation on mild cases, authorities have locked down 5 million residents in Melbourne and are tightening restrictions until new cases come under control.
- Officials are using a combination of stepped-up checks and fines of A$4,957 ($3,550) to convince infected people to stay home, while repeat offenders risk a A$20,000 penalty in court. More than 500 military personnel are helping the police conduct checks on 4,000 households every day to ensure those who are supposed to be staying home are there.
- To be sure, aggressive and thorough contact-tracing and case follow-up have successfully contained outbreaks in countries like Germany without a centralized quarantine strategy. But these places relied on an army of efficient workers hunting down every chain of transmission, a resource not many governments have had time to build up.
- “The classic practice in public health is to identify, trace and quarantine,” said Yang Gonghuan, former deputy director of the Chinese Center for Disease Control and Prevention. “But how that is carried out depends on popular sentiment and the country’s resources.”
K. Projections & Our (Possible) Future
1. C19 Shaping Up to Be Battle for Years Even With Vaccine
- The coronavirus pandemic is likely to be a challenge for years to come even with a vaccine, according to pharmaceutical and public-health experts.
- While a vaccine will provide some measure of protection to societies around the globe, the virus is likely to flare up from time to time and be constantly battled, much like the flu and other pathogens.
- “We know this virus is not going away any time soon. It’s established itself and is going to keep on transmitting wherever it’s able to do so,” Soumya Swaminathan, chief scientist for the World Health Organization, at the “How C19 Is Reshaping the Global Healthcare Ecosystem” event hosted by Bloomberg Prognosis. “We know we have to live with this.”
- Humanity’s record against viruses is poor. Only one virus has been fully driven out of existence in humans – smallpox. The rest are managed, with brushfires stomped out when they flare up.
- “I think what’s realistic to expect is that with a combination of drugs and vaccines we can get to a stable place where the pandemic is manageable,” said Novartis Chief Executive Officer Vas Narasimhan. He called the actual elimination of the virus “unlikely.”
- There are 29 different vaccines in human trials around the world, according to a WHO report released Thursday. More than 20 million people have been confirmed infected around the globe, with at least 751,000 killed by the virus.
- While the rush to rapidly test vaccines has potentially cut years off of the time before one will be ready, a first round of inoculations will likely go only to health workers and high-risk populations, with the general public having to wait until sometime next year to get a shot.
- “The longer you wait, the more knowledge you’re going to have on the vaccine,” Narasimhan said. ”With reasonable confidence, we could have a safe and effective vaccine before the end of next year that could be used broadly.”
- Two of the furthest along vaccines are being developed by Pfizer Inc. and by the University of Oxford, which is working with drugmaker AstraZeneca Plc. But scientists working on the trials said it was important to collect a robust set of data rather than rush to look at early results.
- The Oxford vaccine is being tested in the United Kingdom in a 10,000-person trial that has signed up most of its participants. It’s set to run for as long as a year gathering results, potentially with an earlier look.
- “We don’t yet have clarity on the timelines for those trials,” said Sarah Gilbert, the Oxford professor who has led development of the vaccine. She warned against early looks into the trial — a process called unblinding — that can taint the results. “We can’t have multiple looks at the data,” she said.
- Pfizer said it, too, would not rush into an early look.
- “We won’t unblind the study too early,” said Kathrin Jansen, Pfizer’s head of vaccine research and development. “If we are successful, yeah, we can declare success early.”
- With vaccines, which are given to healthy people, longer sets of data are crucial to find out how safe they are in the long term and how long protection lasts.
- “We won’t know until we follow patients in clinical trials, in particular the vaccine trials, for six months to a year,” said Novartis’s Narasimhan.
- Pandemics like C19 are rare, occurring perhaps as infrequently as once in 200 years, said Neil Ferguson, a professor at Imperial College London who advised the U.K. government on its early-stage response. Yet more new viruses and outbreaks are likely to appear as urbanization and deforestation bring humans and animals into closer contact.
- Over the past decade there have been an “increasing number of viruses and bacterial infections spilling over into humans,” said Devi Sridhar, chair of global public health at the University of Edinburgh. “As long as we have close contact between animals and humans we will continue to have spillover events. And we’re seeing that through urbanization, deforestation, having wet markets.”
- There are steps that can be taken to reduce the risks of future pandemics, mainly involving the reduction of human interaction with wildlife, Ferguson said. One of the big risks is killing game for food, along with sales in markets in Asia and Africa.
- “Frankly, stopping those we could reduce the risk, but not completely,” he said.
- While hundreds of vaccines are in development that could slow or even halt the coronavirus, that’s just one step along the way to protection. Covid has wreaked havoc in rich and poor countries alike, suggesting that public health systems have been found lacking even in countries with strong systems of care, according to Soumya Swaminathan, chief scientist at the World Health Organization.
- The WHO has been heavily criticized by U.S. President Donald Trump, who has said the group failed the prevent the outbreak and is too politically close to China. The U.S. currently has one of the world’s worst ongoing outbreaks.
- “We haven’t invested in public health responses,” said Swaminathan. “The countries that have really responded well have done so because the political leadership took it seriously, took early note of what was happening, and relied on scientific expertise.”
L. Johns Hopkins COVID-19 Update
August 14, 2020
1. Numbers & Trends
- The WHO C19 Situation Report for August 13 reports 20.44 million cases (276,398 new) and 744,385 deaths (6,933 new). We expect the global mortality to surpass 750,000 deaths in this afternoon’s or tomorrow’s Situation Report.
Central & South America
- The Central and South America region remains the primary global C19 hotspot, with 5 of the top 10 countries in terms of total daily incidence and 6 of the top 10 for per capita daily incidence. Brazil’s daily incidence continues to hold relatively steady at 43-46,000 new cases per day, and it remains #3 globally in terms of daily incidence. Following a slight increase earlier this week, Colombia’s daily incidence remains elevated at 10,870 new cases per day, down slightly from its record high yesterday (10,972). Colombia remains #4 globally in terms of daily incidence. Peru has reported steadily increasing daily incidence since late June. With 7,513 new cases per day, Peru remains #5 globally with respect to daily incidence. Argentina’s C19 epidemic continues to accelerate steadily as well, up to 6,841 new cases per day, its highest average to date. Argentina remains #6 globally in terms of daily incidence. Mexico is reporting 6,152 new cases per day, climbing to #7 globally. Multiple other countries in the region are also reporting more than 1,000 new cases per day. Suriname climbed into the global top 10 in terms of per capita daily incidence, jumping to #7. Additionally, Panama fell to #2, Peru remained #3, Colombia fell to #5, Brazil fell to #6, and Argentina fell to #10. Several other countries in the region are reporting more than 100 new daily cases per million population as well.
- India is reporting more than 62,000 new cases per day and still increasing, and it remains #1 globally with respect to daily incidence. The global record for average daily incidence is 67,374 new cases per day, set by the US on July 23, and India could soon surpass this mark if it continues along its current trajectory.
- The Philippines’s daily incidence appears to have leveled off, holding steady at approximately 4,000 new cases per day since August 5. The Philippines remains #10 in terms of daily incidence. After decreasing 25% from its peak, the Maldives’ daily incidence increased again, and it climbed to #4 globally in terms of per capita daily incidence.
- South Africa has reported steadily decreasing daily incidence since its peak on July 20 (12,584 new cases per day). South Africa is currently reporting 4,954 new cases per day, its lowest average since June 26, and it fell to #9 in terms of daily incidence.
- After consistent decreases in daily incidence since late June, Bahrain reported increasing daily totals over the past several days, climbing again to #1 globally in terms of per capita daily incidence. Kuwait fell out of the top 10 again, but only just. Qatar also continues to report more than 100 new daily cases per million population. Nearby Israel, in the WHO’s European region, fell to #8 in terms of per capita daily incidence.
- While Europe does not have any countries in the top 10 in terms of total or per capita daily incidence (with the exception of Israel), a number of countries are reporting more than 1,000 new cases per day. Additionally, Spain is reporting more than 3,900 new cases per day, which puts it just outside the top 10 for total daily incidence.
- The US CDC reported 5.18 million total cases (56,307 new) and 165,148 deaths (1,497 new). Following steady declines since July 24, the average daily incidence in the US increased slightly over the past 2 days, up from 52,193 new cases per day to 53,361. Additionally, the US continues to average more than 1,000 new deaths per day, a trend that has persisted for more than 2 weeks. Numerous states that were severely affected during the summer C19 resurgence—including Arizona, California, Florida, and Texas—appear to be at or past their peak in terms of daily C19 mortality, but others are still reporting increasing mortality or still approaching a peak. Considering that the national daily incidence peaked 3 weeks ago, we expect to start seeing an associated decline in national C19 deaths in the near future.
- In total, 17 states are reporting more than 100,000 cases, including California, Florida, and Texas with more than 500,000 cases; New York with more than 400,000; and Georgia with more than 200,000. We expect Illinois to surpass 200,000 cases in the next update. Additionally, Puerto Rico is currently reporting more than 225 daily cases per million population and increasing steadily. It is a US territory, but its current per capita daily incidence would be #4 globally, falling between Peru and the Maldives—up 2 spots since our last briefing.
- The US remains #2 globally in terms of total daily incidence, and it fell to #9 in terms of per capita daily incidence.
- The Johns Hopkins CSSE dashboard reported 5.27 million US cases and 167,528 deaths as of 1:30pm on August 14.
2. UN Schools Reports
- More than 1 billion children worldwide have been affected by school closures due to the C19 pandemic. The UN has provided educational resources, including for virtual or remote learning options, for children around the world, but educational disruption remains a major challenge in many parts of the world. The UN published a policy brief on schooling in the context of the C19 pandemic, which discusses the substantial ways in which the pandemic has disrupted education, particularly in low-income settings where remote learning is not feasible on a wide scale. In many settings, school closures were occurring even before the pandemic began, due to political or social instability. The pandemic has exacerbated these disruptions, leading UN Secretary-General António Guterres to warn of a “generational catastrophe” that could “undermine decades of progress…and exacerbate entrenched inequalities.”
- The UN report highlights that these disruptions in education widen social disparities for vulnerable populations and reduce access to valuable resources typically provided by schools. Additionally, disruptions in education have downstream effects on national economies, as parents, particularly women, may not be able to return to work. The report provides high-level recommendations, including calling on stakeholders to plan extensively for how schooling can resume in ways that mitigate transmission risk, ensure sustainable financial support for educational systems, and re-imagine education to foster resilience and innovation.
- The UN Educational, Scientific, and Cultural Organisation (UNESCO) published guidance that addresses strategies for catch-up learning to support students for whom educational disruptions have put their learning behind schedule. The recommendations include teaching only what must be learned at a certain grade level and utilizing “microschools” or “microlearning” in smaller groups. Appropriate strategies will likely be context- and setting-specific.
- UNICEF and the WHO Joint Monitoring Programme published a report on the availability of drinking water, sanitation, and hygiene (WASH) resources in schools around the world. Substantial gaps remain in the availability of WASH resources, with only 57% of the world’s schools having basic hygiene services (including soap for handwashing) in 2019. As the world considers ways to reopen schools safely, careful consideration will need to be provided to ensure that students have the WASH resources they need to return safely, especially in light of enhanced hygiene and sanitization mechanisms needed to mitigate SARS-CoV-2 transmission risk.
3. Rwanda Pool Testing
- Rwanda has implemented a novel “pooled” testing strategy in order to make more efficient use of limited testing supplies and capacity. Like many countries, including the US, Rwanda is facing challenges to scaling up testing capacity. Pooled testing combines specimens from multiple people into a single sample for testing. If the pooled sample tests positive, then all individuals in that sample are tested individually. A single infected individual among the pool should result in a positive test, so a negative test means that nobody in that pool is positive. By testing multiple people with a single test and only testing individual specimens when necessary, pooled testing can increase testing capacity, as long as the expected prevalence of active infection is sufficiently low.
- Rwanda is reportedly taking the pooled testing concept a step further by implementing an adaptive algorithm to further increase testing efficiency, developed by Dr. Wilfred Ndifon, “a mathematical epidemiologist and director of research at the African Institute for Mathematical Sciences Global Network” in Rwanda. Following a positive test in a pooled sample, the algorithm determines the most efficient way to conduct tests on smaller, overlapping pooled samples from among the affected individuals, rather than testing each specimen individually. This novel approach further reduces the number of tests required (and money needed to purchase the tests) as well as the time necessary to return accurate results without sacrificing accuracy. In a recent publication (preprint), Dr. Ndifon and his colleagues describe the algorithm and the potential impact on tests, time, and financial costs. Other African countries, including South Africa, have expressed interest in utilizing the algorithm.
4. UK Seroprevalence
- Researchers at Imperial College London reported findings from a large seroprevalence study involving more than 100,000 participants in the UK, using a self-administered lateral flow immunoassay (LFIA) to detect SARS-CoV-2 antibodies. The LFIA selected for this study previously demonstrated sensitivity of 84.4% and specificity of 98.6% using finger-prick blood specimens. Analysis of multiple LFIAs, recently published in BMJ: Thorax, determined that these performance characteristics make this assay “suitable for seroprevalence studies.” The seroprevalence study, conducted under the UK’s REal-time Assessment of Community Transmission-2 (REACT-2) program, was implemented after the UK’s epidemic peak. It estimates the overall UK seroprevalence to be 6.0%, which translates to approximately 3.36 million adult infections through June 20. For comparison, the UK has reported 313,798 cumulative cases to date, which corresponds to approximately 0.6% of the total UK adult population.
- Seroprevalence was found to be the highest among individuals aged 18-24 years (7.9%), compared to other age groups. The study identified racial and ethnic disparities as well, with seroprevalence of 17.3% and 11.9% among those of “Black or Asian (mainly South Asian) ethnicity,” respectively, compared to only 5.0% among Whites. Seroprevalence also varied geographically, with the highest rate reported in London (13.0%). Nearly one-third of those with detectable antibodies reported experiencing no symptoms. The study also reports seroprevalence among various professions, including essential workers and healthcare personnel.
- These results align relatively closely with previous seroprevalence studies in the UK. A study conducted by the UK Biobank, published July 30, involved 20,000 participants. This study found that 7.1% of participants had detectable antibodies. Seropositivity was higher among individuals under 30 years old (10.8%), racial and ethnic minorities (11.3% among Black participants and 9.0% among South Asian participants), and individuals living in London (10.4%).
5. Spain Resurgence
- Spain faced one of the most severe C19 epidemics early in the pandemic. After extended “lockdowns” brought community transmission under control, Spain is reporting increasing incidence that could potentially signal the beginning of a “second wave” of transmission. In May and June, Spain reported only 1 day for which daily incidence exceeded 1,000 new cases. Over the last 2 weeks, however, Spain reported 3 days with more than 5,000 new cases. Last week, The Lancet published a commentary that called for an independent investigation into Spain’s handling of the C19 epidemic, including at both the national and regional levels, in order to identify lessons with respect to governmental decision-making, healthcare and public health operations, and the public’s response that could inform efforts to prepare for subsequent waves of transmission. The authors stressed that this investigation should not be an effort to assign blame, but rather, an opportunity to identify and strengthen weaknesses in the system.
6. “Contaminated” Food Products
- Chinese officials issued a warning that frozen chicken wings originating in Brazil and frozen shrimp originating in Ecuador tested positive for SARS-CoV-2. Following the positive tests, Chinese officials conducted contact tracing to identify individuals who may have come into contact with the frozen food products, and no one has yet tested positive. Additionally, authorities disinfected the area where the products were stored. The positive tests were reportedly from “the surface of frozen chicken wings” and “the packaging of frozen shrimp,” but it is unclear when or where these items were originally contaminated. Additionally, it is unclear if the virus detected on the products was viable (ie, capable of infecting a human) or if the test detected dead virus or portions of dead virus.
- While scientists and health officials—including at the US CDC, US FDA, and WHO—believe that the risk of foodborne transmission is low, the announcement prompted concerns that food packaging could potentially play a role in virus transmission. Fomite transmission is possible, particularly if people touch their face without washing their hands thoroughly, but it is not expected to be the primary mode of transmission. Handling food packaging that may contain virus particles is currently not expected to be a substantial contributor to SARS-CoV-2 transmission; however, it remains important to wash hands thoroughly and regularly, including before eating or handling food. The US FDA has issued guidance on safe food handling in the context of C19. In response to these reports, senior WHO officials—including Dr. Mike Ryan, Executive Director of the WHO Health Emergencies Programme—emphasized that “people should not fear food or food packaging or the processing or delivery of food.”
7. US C19 Reporting
- Last month, the US government announced the creation of a new C19 reporting system for hospitals, which would require direct reporting to the US Department of Health and Human Services (HHS), rather than via state health departments and the US CDC. The effort was initiated to expedite the provision of relevant C19 data to the federal task force; however, numerous health officials and experts called attention to the risk of bypassing the CDC and added burden on hospitals. Multiple reports indicate that data reporting from the federal level has lagged significantly since transitioning to the new system, which is hindering state and local officials from implementing effective response activities and policies. In fact, some key data are lagging by more than a week, which impairs the ability to understand the current state of SARS-CoV-2 transmission and the epidemic’s impact on health systems. HHS officials argue that the delays are an inevitable part of quality control checks to ensure the system is working properly and that the data reported provides more detail and includes more facilities than the previous method, providing improved awareness of the current C19 situation. A myriad of experts and government officials have emphasized the potential damage caused by an interruption in the availability of critical data, particularly as the country attempts to gain control of a major resurgence in transmission.
- The New York Times published an open letter from more than 30 current and former members of the federal Healthcare Infection Control Practices Advisory Committee (HICPAC), which cites the dangers of the new HHS C19 reporting system. The authors argue that the transition endangers the integrity of national C19 data and that new reporting requirements put increased stress on the national healthcare system. They also note that the CDC maintains robust and established disease reporting systems, including the National Healthcare Safety Network (NHSN) that was previously used to report C19 data, and that the new system is unnecessary. The letter was reportedly written as an unpublished document following the announcement of the new reporting system last month, but it was only made public earlier this week.
8. US Schools
- Many school systems in the US have begun their transition to the 2020-21 school year, with some moving forward with in-person classes and others adopting virtual/remote or hybrid models. The results have been mixed, with some in-person attempts leading to sizable exposures. Reportedly, more than 2,000 individuals—including students, teachers, and other staff—across multiple states have been quarantined following exposures at schools, and at least 230 positive cases have been identified. In numerous instances, schools that resumed in-person classes have been forced to shift to virtual/remote models following the detection of C19 cases. In one example, Cherokee County School District—outside of Atlanta, Georgia—has reportedly quarantined at least 1,193 individuals after starting the school year with in-person classes, and multiple schools in the district suspended in-person classes after opening for less than a week. In other examples, schools have provided parents and the students the option of attending in-person or remote classes, and C19 cases detected in the schools have reportedly driven some students to shift from in-person to remote classes. Most schools are just starting to resume classes, so any effect on incidence, within schools or in the community, may not be evident for several more weeks.
- As these types of reports continue to raise questions about the feasibility of having safe, in-person schooling during the C19 pandemic, some school districts are beginning to invest in what seems like an inevitable continuation of distance learning that most schools utilized in the spring. In Harris County, Texas—which hosts one of the largest school districts in the country—the local government announced that it is investing US$32 million to increase access to computers and wifi for students in order to improve their ability to take part in virtual/remote learning options. The county will utilize emergency C19 funding provided under the CARES Act to implement the program. The effort will reportedly provide more than 200,000 computers and 80,000 wifi hotspots.
9. US Mask Mandate
- Yesterday, US Presidential candidate Joe Biden called on state governors to implement mask mandates nationwide to mitigate C19 transmission risk. He framed mask use as an issue of individual responsibility instead of individual rights, noting that wearing a mask to protect others is the patriotic thing to do. Similarly, experts from Georgetown, Harvard, and Emory Universities published a commentary in JAMA calling for universal mask use in the US. They highlight the need for state governments to implement mask mandates, as a uniform approach is critical to combating a health emergency like C19 that can “spill over to adjoining states [or] even the entire country.” Researchers have conducted a number of studies to model the impact of mask use, and several indicate that universal masking could potentially save tens of thousands of lives in the US over the course of several months. As of August 4, 35 states have implemented some form of mask mandate, although the details vary from state to state. Mandates have also been implemented by local governments where statewide mandates do not exist; however, some states, like Georgia, have prohibited local officials from instituting their own mask policies. Mask use is not wholly sufficient for containing the US epidemic, but it is a “minimally invasive” tool that nearly everyone can utilize to reduce transmission risk in the community.
10. New Zealand Domestic Transmission
- New Zealand extended its Alert Level 3 “lockdown” of Auckland, the country’s most populous city, through August 26 as a result of an ongoing C19 outbreak. Since the first case tested positive on Tuesday, New Zealand has identified 29 cases linked to the Auckland cluster, including 13 in the past 24 hours. One additional case is suspected to be linked to the cluster, and 38 individuals are currently under quarantine. An ongoing epidemiological investigation has identified cases with symptom onset as early as July 31, but it is not yet clear if this corresponds to the index case for this outbreak.
- In addition to enhanced social distancing measures in Auckland, Alert Level 3 restricts travel into and out of the affected area, and checkpoints have been established around the city. The checkpoints are principally aimed at education and awareness efforts regarding the new restrictions; however, law enforcement officers are also screening travelers. While New Zealand had largely lifted all C19-related social distancing measures in June, following the interruption of domestic transmission, it maintained travel restrictions and border screening for arriving travelers. Genomic analysis indicates that the current outbreak is not directly linked to the strain that previously circulated in New Zealand, suggesting that it could be the result of a recent importation, as opposed to ongoing undetected circulation; however, the investigation has not yet identified a link to international travel.
11. Brussels Mask Mandate
- Earlier this week, the city council of Brussels, Belgium’s capital city, mandated mask use in public spaces. The order was issued in the hopes of curbing a surge of C19 cases over the past several weeks. The daily incidence in Brussels is approximately 50 cases per 100,000 population, which is more than double the highest national per capita daily incidence globally (Bahrain; 23.8 daily cases per 100,000 population). The city has approximately 1.2 million residents, and masks were previously only required in indoor or crowded public spaces.