August 23, 2020
Without reliable information, we rely on fear or luck.
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations, and Positivity
6. Mortality Rates By Age
7. A new surge in Europe
J. Links to Other Stories
- Hangover Cure Successfully Tested on Drunk Subjects in Finland A group of Finnish researchers believe they’ve discovered what people have spent centuries searching for: a cure for hangovers. A dose of 1,200 milligrams of amino acid L-cysteine was found to reduce alcohol-related nausea and headache. [NOTE: We believe in sharing medical research that might be useful to our readers.]
- Contact tracing apps unlikely to contain C19 spread Contract tracing apps used to reduce the spread of C19 are unlikely to be effective without proper uptake and support from concurrent control measures, finds a new study by UCL researchers.
- UA research finds relationship between COVID-19 deaths and morbid obesity Researchers found a statistically significant relationship between the prevalence of morbid obesity and cases of — and deaths from — C19
- Blood clots and lung injuries found in patients who have died of C19 A new post-mortem study of patients who have died from C19 found severe damage to the lungs and signs of blood clotting in major organs.
- New 3D Imaging Technique to Visualize Lung Tissue Damage in Severe C19 Researchers led by Göttingen University develop new three-dimensional imaging technique to visualize tissue damage in severe C19.
- Your Covid Gray Hair? It’s Here to Stay People are dropping the dye and embracing silver beards and roots. Reactions vary; ‘confusing me with the Unabomber’
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 (8/22)
- Total Cases = 23,370,910 (+1.1%)
- New Cases = 261,622 (+10,344) (+4.1%)
- New Cases (7 day average) = 247,005 (-580) (-0.2%)
- 7 day average of new cases has been trending lower since 8/13
- 7 day average of new cases decreased from 263,281 on 8/13 to 247,005 on 8/22, a decrease of 6.2%
- Almost 1,000,000 new cases every 4 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 5,841,428 (+0.8%)
- New Cases = 43,829 (-6,652) (-13.2%)
- Percentage of New Global Cases = 16.8%
- New Cases (7 day average) = 43,848 (-1,398) (-3.1%)
- Total Number of Tests = 75,475,175
- Percentage of positive tests (7 day average) = 6.7%
- 7 day average of new cases has been trending lower since 7/24
- 7 day average of new cases has decreased from 68,621 on 7/24 to 43,848 on 8/22, a decline of 36.1%
- 7 day average of percentage of positive tests rates continues to decline
- Total Deaths = 807,942 (0.7%)
- New Deaths = 5,343 (-719) (-11.9%)
- New Deaths (7 day average) = 5,642 (-19) (-0.3%)
- 7 day average has been trending lower since 8/13
- 7 day average of new deaths have declined from 5,889 on 8/13 to 5,642 on 8/22, a decrease of 4.2%
- Total Deaths = 180,174 (+0.5%)
- New Deaths = 974 (-196)
- Percentage of Global New Deaths = 18.2%
- New Deaths (7 day average) = 1,002 (-20) (-2.0%)
- 7 day average of new deaths have been trending lower since 8/4
- 7 day average of new deaths have increased from 1,177 on 8/4 to 1,002 on 8/22, a decrease of 14.9%
- As a lagging indication, we expect new deaths to continue to decline as the number of new cases decrease
3. Top 5 States in Cases, Deaths, Hospitalizations, and Positivity (8/22)
Hotspot new cases and hospitalizations have cooled off (FL, CA, TX)
- Peak cases and decline %:
- FL – 15,300 (7/12); cases decline 70%
- CA – 12,137 (7/22); cases decline 58%
- TX – 12,619 (7/15); cases decline 58%
- Peak hospitalizations and decline %:
- FL – 9,520 (7/21); hospitalizations decline 50%
- CA – 8,820 (7/27); hospitalizations decline 33%
- TX – 10,893 (7/27); hospitalizations decline 52%
- Deaths should continue to decline based on peak hospitalizations
4. C19 Fatality Rates Plunge
- The percentage of those dying from C19 is plunging in most states across the country as doctors learn more about the virus and treatments improve.
- Across the U.S., the case fatality rate (CFR) has been dropping for weeks — in some states for months. Despite breathless reports that hospitals have been overflowing and people dying in droves, the data doesn’t support the claims.
- “In Arizona, about 5% of those who tested positive for the coronavirus by the end of May died. The case fatality rate now is about half that figure,” The Hill reported. “In California, the rate stood at 4% in late May, and is now 1.6 percent. In April, 7.5% of those who tested positive in Minnesota died, a rate that has fallen to 2.7%, according to The Hill’s analysis of state data.”
- One reason the CFR is dropping because the people now contracting the virus are younger and healthier, so they’re more able to fight of the virus — which is highly contagious but often brings only mild, flu-like symptoms. Plus, testing for the virus, which is now widespread, is identifying the infected more quickly, which means they can get treatment.
- At the height of the pandemic, which occurred in April, some of the worst affected were put on ventilators. “Now, some doctors said, fewer patients are being intubated, and the sickest patients are being treated with drugs like remdesivir and dexamethasone, treatments that can help lower the risk of death,” The Hill reported.
- Doctors are also using more basic methods like proning, in which patients lay on their stomachs. That method helps them access more of their lung capacity, preventing suffocation that comes with fluid buildup caused by pneumonia.
- “I think we are getting better in treating C19. The experience that’s been acquired over the past few months by those individuals who have been laboring with incredible determination and energy in ICUs have made it possible for the people who we were losing maybe back in March and April in the terrible outbreak in New York are now being saved,” Francis Collins, director of the National Institutes of Health, told The Hill in an interview. “There’s a better understanding now about how to keep people off of ventilators, unless you absolutely have to because of all the complications that ensue at that point.”
- The virus’s main vectors of transmission have shifted, too. In March and April, outbreaks in assisted living facilities targeted older people who were more likely to have the underlying conditions that led to the worst outcomes.
5. The Number Of US Hospitalizations Is Declining By 1% Per Day
- Back on July 14 when a wave of new covid cases was sweeping the sunbelt states prompting many to speculate if a new round of shutdowns was imminent, we took the other side of the argument and said that the pandemic peak had hit, and that in Arizona – an early recent outbreak state, “the worst was over for the COVID breakout.”
- We were right, and as Bank of America writes today, Arizona has seen a 66% decline since its peak on July 14th, while the US excl. the four major recent outbreak states (AZ, CA, FL, TX) experiencing a 13% decline since the peak on July 30th.
- There’s more: as BofA also points out, “we continue to see clear signs the Coronavirus is rolling over in the US as the number of people hospitalized due to C19 declines at a rapid pace of about one percent1% a day (26% in 23 days).“
- Extrapolating, this rate of decline means that there will be zero covid-related hospitalizations around the Nov 3 election day, a feat that if marketed properly, could mean the differnce for Trump between victory and defeat.
- Some more observations from BofA:
- This week saw front page headlines that official C19 statistics can no longer be trusted due to decreasing testing volumes. We agree but are wondering why there were no such headlines when daily new cases were rising due to more testing.
- This is why we rely on statistics for the number of people hospitalized due to C19. Drawback is that hospitalizations are lagged indicators of infections. Let’s assume for this discussion that the lag is three weeks. The recent peak number of hospitalized on July 24th suggests peak daily new C19 infections in the US around Independence Day (July 4th).
- But daily new C19 cases continued to rise sharply in July, which dominated the headlines. It looks like daily new cases and the number of people hospitalized are virtually coincident, as the peaks for both were reached around the same time. This actually makes sense as probably the primary driver of testing is someone going to the hospital with C19 symptoms. We imagine that person gets tested along with the immediate family, friends and colleagues. Because C19 statistics are very persistent, it seems likely that the numbers continue to roll over.
- There is little doubt that all these negative C19 related headlines have weighed on consumer, business and investor confidence. As this now reverses we remain positioned for a re-steepening Treasury curve by expecting bull flattening IG corporate spread curves, compression along the quality curve and outperformance of the most C19 negatively impacted names. Heavy new issuance remains a headwind, but it is mitigated by strong inflows. Next week should be busy and then the window closes in the two weeks before Labor Day.
- It wasn’t just Bank of America that had good news: in its state-level coronavirus tracker, Goldman confirmed that the number of new confirmed coronavirus cases continues to decline in the vast majority of states, yet the bank urged some caution, noting that “although the nationwide downward trajectory is encouraging, state government officials may wait until case levels decline further before moving forward with additional reopening policies.”
- Ironically, there is just one state where there is a tangible number of new cases – the one which was among the first to permit protests (and riots) in late May and early June: as Goldman notes, “Cases are on the rise in the most populous state of California, which has faced technical difficulties in reporting accurate daily case counts.”
6. Mortality Rates By Age
Source: Center for Disease Control & Prevention
7. A new surge in Europe
- Europe is entering a new phase in the pandemic as a fresh wave of infection strikes countries that had initially reined in the virus.
- In the last few days, France, Germany and Italy have experienced their highest daily case counts since the spring, and Spain is in the middle of a major outbreak. Belgium, Croatia, the Netherlands, the United Kingdom have also seen a recent uptick in cases.
- Some of the surge is being driven by young people. The proportion of people age 15 to 24 who are infected in Europe has risen from around 4.5% to 15% in the last five months, according to the World Health Organization.
- This time around, European leaders have not imposed strict lockdowns like those that curbed the virus in the spring, concerned that the public would not tolerate a return to draconian measures. Instead, leaders are relying on localized efforts, targeted restrictions on movement and increased mask requirements.
- There are growing fears that the end of the summer vacation season will spread the virus, at the same time that people move their lives indoors and the fall flu season begins.
Source: NY Times Coronavirus Update
B. New Scientific Findings & Research
1. A “Novel” Breakthrough? New Studies Show Memory T-Cells Offer Long Term And Pre-Existing COVID Immunity
- Much of the talk about the coronavirus over the last couple of months has been about antibodies.
- They are looked at as part of the key to unlocking questions about immunity to the virus. Specifically, researchers have looked at how vaccines induce antibody responses and how long antibody protections last after someone has had the virus. In the answers to those questions lies the answer to another: how and when will we achieve herd immunity?
- There had been worries about coronavirus antibodies over the past few months, as several studies showed they may only last several months. This had led to a litany of questions about how often one would require a vaccination and whether or not we would ever become immune to the “novel” virus.
- But a new study highlighted by Business Insider shifted focus away from antibodies and onto memory T cells – the cells that identify and destroy infected cells and inform B cells how to craft antibodies.
- The study, published in Cell, now suggests that everyone who gets C19 develops T cells that may offer long term immunity by hunting down the coronavirus at later dates. “Memory T cells will likely prove critical for long-term immune protection against C19,” the study says.
- The study looked at blood from 206 people in Sweden who had been exposed to C19 in varying degrees of severity. Regardless of a person’s exposure, they developed a “robust” T cell response, according to the study. And even those who tested negative to antibodies developed memory T cells, the study found.
- Even Dr. Anthony Fauci even called T cell studies like this one “good news” for fighting the virus. “People who don’t seem to have high titers of antibodies, but who are infected or have been infected, have good T-cell responses,” he said during a Facebook interview last Thursday.
- Similarly, a study performed in July found that in 36 C19 patients who recovered, all produced memory T cells that “recognize and are specifically engineered to fight the new coronavirus.” A third study, published in Nature, found that out of 18 people studied, more than 80% developed these T cells.
- These previous studies also found that many people who never had C19 seem to have memory T cells that can recognize the new virus. This, of course, would mean that the virus isn’t a “novel” as we once thought. In the July study, more than half of people already had the T cells and in the Nature study, more than one third already had the T cells.
- Another study published earlier in August showed that 25 people who never had C19 had memory T cells that could recognize it. In other words, they had some form of pre-existing immunity.
- The lifespan of such T cells can be immense. For example, in the July study, T cells in blood samples from 23 people who survived SARS were still there 17 years later. The same T cells “could recognize the new coronavirus”.
- Alessandro Sette, a coauthor of that study, said: “This could help explain why some people show milder symptoms of disease while others get severely sick.”
- “You’re starting with a little bit of an advantage — a head start in the arms race between the virus that wants to reproduce and the immune system wanting to eliminate it,” he concluded.
2. Researchers May Have Discovered the True Cause of Low Oxygen Levels in Severe Cases of C19
- A new pilot study from the Icahn School of Medicine at Mount Sinai suggests that C19 is causing significant dilation of the blood vessels of the lung, specifically the capillaries. This vasodilation is contributing to the very low oxygen levels seen in C19 respiratory failure and also helps explain why the disease behaves differently than classic acute respiratory distress syndrome (ARDS). The study was published in the American Journal of Respiratory and Critical Care Medicine.
- In classical ARDS, pulmonary inflammation leads to leaky pulmonary blood vessels that flood the lungs with fluid, making the lungs stiff and impairing oxygenation. Many patients with C19 pneumonia demonstrate severe hypoxemia that is markedly out of proportion to the degree of lung stiffness. This disconnect between gas exchange and lung mechanics in C19 pneumonia has raised the question of whether the mechanisms of hypoxemia in C19 differ from those in classical ARDS.
- The discovery was serendipitous. Researchers were initially assessing cerebral blood flow in mechanically ventilated C19 patients with altered mental status to look for, among other things, abnormalities consistent with stroke. They used a robotic transcranial Doppler (TCD), the Lucid Robotic System by NovaSignal, to perform a “bubble study,” which is a non-invasive and painless ultrasound technique.
- “It is remarkable that a diagnostic machine used to study the brain could give us insight into the pathophysiology of a pulmonary disease. The benefit of using this particular system was that automated monitoring allowed providers to assess cerebral blood flow while minimizing the potential for exposure to C19,” said Alexandra Reynolds, MD, Assistant Professor of Neurosurgery, and Neurology, at the Icahn School of Medicine at Mount Sinai and Director of TeleNeurocritical Care for the Mount Sinai Health System.
- During this study, agitated saline—saline with tiny microbubbles—is injected into the patient’s vein and TCD is used to determine if those microbubbles appear in the blood vessels of the brain. Under normal circumstances, these microbubbles would travel to the right side of the heart, enter the blood vessels of the lungs, and ultimately get filtered by the pulmonary capillaries, because the diameter of the microbubbles is bigger than the diameter of the pulmonary capillaries. If the microbubbles are detected in the blood vessels of the brain, it implies that either there is a hole in the heart, so that blood can travel from the right to the left side of the heart without going through the lungs, or that the capillaries in the lungs are abnormally dilated, allowing the microbubbles to pass through.
- In the pilot study, 18 mechanically ventilated patients with severe C19 pneumonia underwent TCD with bubble study. Fifteen out of the 18 (83 percent) patients had detectable microbubbles, indicating the presence of abnormally dilated pulmonary blood vessels. The number of microbubbles detected by the TCD correlated with the severity of hypoxemia, indicating that the pulmonary vasodilations may explain the disproportionate hypoxemia seen in many patients with C19 pneumonia. Previous studies have demonstrated that only 26% of patients with classical ARDS have microbubbles during a bubble study; furthermore, the number of these microbubbles does not correlate with the severity of hypoxemia, implying that pulmonary vascular dilations are not a major mechanism of hypoxemia in classical ARDS.
- “It is becoming more evident that the virus wreaks havoc on the pulmonary vasculature in a variety of ways. This study helps explain the strange phenomenon seen in some C19 patients known as ‘happy hypoxia,’ where oxygen levels are very low, but the patients do not appear to be in respiratory distress.
- If these findings are confirmed in larger studies, pulmonary microbubble transit may potentially serve as a marker of disease severity or even a surrogate endpoint in therapeutic trials for C19 pneumonia. Future studies that investigate the use of pulmonary vascular constrictors in this patient population may be warranted,” says senior author Hooman Poor, MD, Assistant Professor of Medicine (Pulmonary, Critical Care and Sleep Medicine) at the Icahn School of Medicine at Mount Sinai and Director of Pulmonary Vascular Disease at the Mount Sinai – National Jewish Health Respiratory Institute.
- The pilot study has since expanded to collect data from approximately 80 patients, including those with less severe disease, and will evaluate the severity of microbubble transit and how it varies during the course of the disease.
3. Early Natural Killer cell-mediated immune response may contribute to severe C19
- Researchers may have come one step closer toward understanding how the immune system contributes to severe C19. In a study published in Science Immunology, researchers at Karolinska Institutet in Sweden show that so-called natural killer (NK) cells were strongly activated early after coronavirus infection but that the type of activation differed in patients with moderate and severe C19. The discovery contributes to our understanding of development of hyperinflammation in some patients.
- Coronavirus infection can in some cases cause severe C19 disease. Although this is thought to be partially driven by a misdirected innate immune response, many aspects of the early immune response to the infection remain elusive.
- Researchers at Karolinska Institutet have now, in collaboration with colleagues at the Karolinska University Hospital, investigated the early response to coronavirus infection of NK cells, a cell type in the immune system known to be important in the control of viral infections.
- The study analyzed blood samples from 27 patients with moderate (10) and severe (17) C19 infection. The researchers also included blood samples from 17 healthy individuals as a control group. The result showed that NK cells were strongly activated in the blood shortly after infection.
- “The type of NK cell activation detected differed considerably in patients with moderate compared to severe disease,” says Niklas Björkström, physician and immunology researcher at the Center for Infectious Medicine, Department of Medicine Huddinge, at Karolinska Institutet, who led the study.
- It is likely that the type of NK cell response observed in coronavirus infected patients with moderate disease is a canonical NK cell response shared between many types of viral infections, according to the researchers.
- However, patients who developed severe C19 had a different composition of responding NK cells. These patients’ NK cells generally had higher expression of the proteins perforin, NKG2C and Ksp37, which according to the researchers reflect a high presence of so-called adaptive NK cells. Adaptive NK cells have an even greater ability to kill target cells compared to other NK cells.
- The researchers are now investigating to what extent the NK cell-mediated immune response observed in the critically ill patients might contribute to C19 severity, and the extent to which other parts of the response may be beneficial.
- “Taken together, our findings provide additional insights into immune reactions in early coronavirus infection and ensuing C19 disease,” Niklas Björkström says. “We hope that these insights will contribute to the improved care and treatment of patients with severe C19 disease.”
- The study is part of the larger Karolinska C19 Immune Atlas project, which aims to increase knowledge about the characteristics of immune cells in patients with C19.
4. Nasal vaccine against C19 prevents infection in mice
- Scientists at Washington University School of Medicine in St. Louis have developed a vaccine that targets the coronavirus, can be given in one dose via the nose and is effective in preventing infection in mice susceptible to the novel coronavirus. The investigators next plan to test the vaccine in nonhuman primates and humans to see if it is safe and effective in preventing C19 infection.
- Unlike other C19 vaccines in development, this one is delivered via the nose, often the initial site of infection. In the new study, the researchers found that the nasal delivery route created a strong immune response throughout the body, but it was particularly effective in the nose and respiratory tract, preventing the infection from taking hold in the body.
- “We were happily surprised to see a strong immune response in the cells of the inner lining of the nose and upper airway — and a profound protection from infection with this virus,” said senior author Michael S. Diamond, MD, PhD, the Herbert S. Gasser Professor of Medicine and a professor of molecular microbiology, and of pathology and immunology. “These mice were well protected from disease. And in some of the mice, we saw evidence of sterilizing immunity, where there is no sign of infection whatsoever after the mouse is challenged with the virus.”
- To develop the vaccine, the researchers inserted the virus’ spike protein, which coronavirus uses to invade cells, inside another virus – called an adenovirus – that causes the common cold. But the scientists tweaked the adenovirus, rendering it unable to cause illness. The harmless adenovirus carries the spike protein into the nose, enabling the body to mount an immune defense against the coronavirus without becoming sick. In another innovation beyond nasal delivery, the new vaccine incorporates two mutations into the spike protein that stabilize it in a specific shape that is most conducive to forming antibodies against it.
- “Adenoviruses are the basis for many investigational vaccines for C19 and other infectious diseases, such as Ebola virus and tuberculosis, and they have good safety and efficacy records, but not much research has been done with nasal delivery of these vaccines,” said co-senior author David T. Curiel, MD, PhD, the Distinguished Professor of Radiation Oncology. “All of the other adenovirus vaccines in development for C19 are delivered by injection into the arm or thigh muscle. The nose is a novel route, so our results are surprising and promising. It’s also important that a single dose produced such a robust immune response. Vaccines that require two doses for full protection are less effective because some people, for various reasons, never receive the second dose.”
- Although there is an influenza vaccine called FluMist that is delivered through the nose, it uses a weakened form of the live influenza virus and can’t be administered to certain groups, including those whose immune systems are compromised by illnesses such as cancer, HIV and diabetes. In contrast, the new C19 intranasal vaccine in this study does not use a live virus capable of replication, presumably making it safer.
- The researchers compared this vaccine administered to the mice in two ways — in the nose and through intramuscular injection. While the injection induced an immune response that prevented pneumonia, it did not prevent infection in the nose and lungs. Such a vaccine might reduce the severity of C19, but it would not totally block infection or prevent infected individuals from spreading the virus. In contrast, the nasal delivery route prevented infection in both the upper and lower respiratory tract — the nose and lungs — suggesting that vaccinated individuals would not spread the virus or develop infections elsewhere in the body.
- The researchers said the study is promising but cautioned that the vaccine so far has only been studied in mice.
- “We will soon begin a study to test this intranasal vaccine in nonhuman primates with a plan to move into human clinical trials as quickly as we can,” Diamond said. “We’re optimistic, but this needs to continue going through the proper evaluation pipelines. In these mouse models, the vaccine is highly protective. We’re looking forward to beginning the next round of studies and ultimately testing it in people to see if we can induce the type of protective immunity that we think not only will prevent infection but also curb pandemic transmission of this virus.”
5. Cells in the Nose Are Key Entry Point for Coronavirus
- Scientists at Johns Hopkins Medicine, experimenting with a small number of human cell samples, report that the “hook” of cells used by coronavirus to latch onto and infect cells is up to 700 times more prevalent in the olfactory supporting cells lining the inside of the upper part of the nose than in the lining cells of the rest of the nose and windpipe that leads to the lungs. These supporting cells are necessary for the function/development of odor-sensing cells.
- The findings, from a preliminary study of cells lining both the nose and trachea, could advance the search for the best target for topical or local antiviral drugs to treat C19, and offers further clues into why people with the virus sometimes lose their sense of smell.
- A summary of the findings appears in a letter published on August 18, 2020, in the European Respiratory Journal.
- “Loss of the sense of smell is associated with C19, generally in the absence of other nasal symptoms, and our research may advance the search for a definitive reason for how and why that happens, and where we might best direct some treatments,” says Andrew Lane, M.D., professor of otolaryngology-head and neck surgery, and director of the Division of Rhinology and Skull Base Surgery at the Johns Hopkins University School of Medicine.
- Lane’s medical practice focuses on people with nasal and sinus problems, who oftentimes, he says, lose their sense of smell — a condition called anosmia.
- Scientists have known that coronavirus latches on to a biological hook on the surface of many types of human cells, called an angiotensin-converting enzyme 2 receptor (ACE2). The receptor reels in essential molecules.
- In a bid to explore the ACE2 link to C19 in more detail, Lane, Mengfei Chen, Ph.D., a research associate in Lane’s lab at the Johns Hopkins University School of Medicine, and others on his team took a close look at ACE2 levels in nasal tissue specimens from 19 adult men and women with chronic rhinosinusitis (inflammation of nasal tissue) and in tissues from a control group of four people who had nasal surgeries for issues other than sinusitis.
- The researchers also studied tissue samples of the trachea from seven people who underwent surgery for abnormal narrowing of the trachea.
- Cells from children were not examined for this study, in part because they tend to have low ACE2 levels in the cells lining the nose, which may contribute to generally less severe illness among children infected with the coronavirus. None of the study participants had been diagnosed with C19.
- The scientists used a high-resolution imaging technique called confocal microscopy to produce very sharp images of cells lining the nasal and tracheal airways. They used fluorescent stains to identify ACE2 receptors.
- They found high levels of ACE2 among nasal cells that give structural support called sustentacular cells. These cells are located in an area called the olfactory neuroepithelium, where odor-sensing neurons are found. The researchers say this area of the nose may be particularly vulnerable to infection and might be the only infected site even when there are no symptoms. Because of this, they urge people to wear masks and wear them correctly.
- For the study, depending on the biopsy sample, cells in the olfactory neuroepithelium had a 200-fold to 700-fold increase in ACE 2 proteins compared with other samples from the nose and trachea. Because the cells with high levels of ACE2 are associated with odor sensing, the researchers suggest that infection of these cells may be the reason some people with C19 experience loss of smell.
- Two of seven trachea specimens had low levels of ACE2 receptors, and the amount of those receptors was similar between study participants with and without chronic rhinosinusitus.
- Because the cells lining the nose may prove to be a key entry point for coronavirus, Lane says there may be ways to target those particular cells with topical antiviral drugs or other therapies directly to that area.
- The researchers plan to advance this research by investigating C19-infected tissue from the noses of humans to confirm if the coronavirus does indeed target support cells in the nose.
6. Hint of C19 immunity: 3 sailors with antibodies spared in outbreak at sea
- Hints of protective immunity against the pandemic coronavirus have surfaced in the wake of a recent COVID-19 outbreak that flooded the crew of a fishing vessel.
- The coronavirus, SARS-CoV-2, infected 104 of the 122 people on board, about 85 percent, during a short voyage. But trawling through data collected before and after the ship set sail, researchers noted that the 18 spared from infection just happened to include the only three people on board that had potent, pre-existing immune responses against SARS-CoV-2. Specifically, the three sailors were the only ones found to have SARS-CoV-2 neutralizing antibodies, which are proteins that circulate in the blood and completely sink the infectious virus.
- The numbers are small and the finding is not definitive. Additionally, the study appeared this month on a pre-print server, meaning it has not been published by a scientific journal or gone through peer review. Still, experts say the study was well done and significant for netting data that hint that potent, pre-existing immune responses from a past infection can indeed protect someone from catching the virus again.
- “While this is a small study, it offers a remarkable, real-life, human experiment at a time when we’ve been short of hardline, formal, proof that neutralizing antibodies genuinely offer protection from re-infection, as predicted by animal models,” Danny Altmann, a professor of immunology at Imperial College London, said in a media statement.
- For the study, researchers in Seattle, Washington were able to test 120 members of the 122-person crew before they set sail. They looked for active infections by probing for SARS-CoV-2 genetic material in noses, and they looked for past infections by probing for antibodies that develop toward the end of an infection. All 120 were negative for SARS-CoV-2 in their nose. Six, however, had antibodies against the pandemic virus.
- On further examination of those six with antibodies, only three had neutralizing antibodies, the researchers found. Though all antibodies suggest past exposure to a virus, not all antibodies can neutralize viruses. And neutralizing antibodies are considered critical for protective immunity.
- The researchers can’t say for sure what was going on with the three who had some antibodies, but not neutralizing antibodies. Their best guess is that they simply had false positive test results and didn’t truly have antibodies against SARS-CoV-2. But it’s also possible that they had waning antibody responses, perhaps from a distant infection at the beginning of the infection, or a burgeoning antibody response during the early stages of an infection. Regardless, after the ship set sail and the COVID-19 outbreak struck, all three were infected with SARS-CoV-2.
- When the ship returned after about 16 days at sea, with sick aboard, the researchers re-tested all the crew members and followed them for up to 32 days. A total of 104 were infected, including one of the two crew members they didn’t initially test.
- As for the three with neutralizing antibodies, initial tests for SARS-CoV-2 genetic material in their noses were all negative. Two of the three tested negative at three different times—from the day they got off the boat to 18 days later. The third crew member tested negative after three and ten days of disembarking. But, in a data wrinkle, this person had very weakly positive tests seven days and 13 days after getting off the boat. The tests didn’t qualify as positive, based on preset criteria. But it does suggest some remnant viral material was lingering in the person’s nose—which has been seen in other studies.
- Despite the limitations of the study and quarks of the data, experts say it’s well done and helpful information. Jonathan Ball, professor of molecular virology at the University of Nottingham, noted in a media statement that although the study was small and leaves questions lingering, it “gives us important insight into the type of immunity that might protect from future infection.”
7. Air-conditioned rooms and low humidity help spread C19
- Dry air and air-conditioned rooms can help spread the coronavirus, according to an Indian-German research team that looked at the role of relative humidity in the transmission of infections.
- For office workers and students worldwide, the findings are important as they head back to their desks after months in lockdown.
- “The role of humidity seems to be extremely important to the airborne spread of C19 in indoor environments,” the researchers reported. on the website of Germany’s Leibniz Institute for Tropospheric Research (TROPOS).
- For more information, read the study here.
- The scientists, who reviewed 10 international studies of swine flu and other infectious diseases such as Middle East Respiratory Syndrome, found humidity affects a virus in three ways: droplet size, how droplets float and how droplets land on surfaces.
- In more humid rooms, virus droplets become heavier and fall faster in higher humidity, “providing less chances for other people to breathe in infectious viral droplets,” the team wrote, according to DW, a German news website.
- Dry air makes the droplets shrink and hang around, becoming what the scientists describe as an “optimal route” for transmission.
- Low humidity also dries out mucous membranes in the nose, making an easier way in for the coronavirus, they wrote.
- Rooms should have a relative humidity of 40% to 60% — open the windows, the researchers urge — to keep a virus from spreading and governments should include the recommendation in any public health guidelines, the team found.
- Besides raising the relative humidity and wearing face masks, the scientists are urging businesses and schools to not pack their rooms with people.
More on Low Humidity
- A study just published in Transboundary and Emerging Diseases confirms an earlier study conducted in the Greater Sydney, Australia area during the early stages of the pandemic that reported a link between low humidity and community spread of C19. The new research led by Dr. Michael Ward in the Sydney School of Veterinary Science adds to the growing body of evidence that low humidity is a key factor in the spread of the Coronavirus. The scientists estimated that for a 1% decrease in relative humidity, C19 cases increase by 7 to 8%. The same link was not found in other weather patterns such as rainfall, temperature or wind.
- According to Ward, dry air favors the spread of the virus: “”When the humidity is lower, the air is drier and it makes the aerosols smaller,” he said, adding that aerosols are smaller than droplets. “When you sneeze and cough those smaller infectious aerosols can stay suspended in the air for longer. That increases the exposure for other people. When the air is humid and the aerosols are larger and heavier, they fall and hit surfaces quicker.” These findings add to a growing body of research that recommends wearing a mask.
- Reference: Ward, M.P., et al., (2020). Humidity is a consistent climatic factor contributing to SARS-CoV-2 transmission. Transboundary And Emerging Diseases, DOI.org/10.1111/tbed.13766
8. Study finds children have high C19 viral load despite mild or no symptoms
- Children with little to no symptoms may spread the coronavirus more easily than severely ill adults, according to a new study published Thursday.
- The Massachusetts General Hospital (MGH) and Mass General Hospital for Children recently studied 192 children suspected of having the coronavirus or who had been in contact with an infected person. [Read the study here]
- Of the 192 participants, 49 tested positive and had significantly higher levels of virus in their airways compared to virus-stricken adults in intensive care units.
- “I was surprised by the high levels of virus we found in children of all ages, especially in the first two days of infection,” Dr. Lael Yonker, director of the MGH Cystic Fibrosis Center and lead author of the study, said. “I was not expecting the viral load to be so high. You think of a hospital, and of all of the precautions taken to treat severely ill adults, but the viral loads of these hospitalized patients are significantly lower than a ‘healthy child’ who is walking around with a high coronavirus viral load.”
- Dr. Alessio Fasano, director of the Mucosal Immunology and Biology Research Center at MGH and senior author of the study, said that health experts have come to the “erroneous conclusion” that adults are the vast majority of those infected because “we have mainly screened symptomatic subjects.”
- “Kids are not immune from this infection, and their symptoms don’t correlate with exposure and infection,” she said. “Our results show that kids are not protected against this virus. We should not discount children as potential spreaders for this virus.”
- Researchers also found only half of the children who tested positive had fevers, calling into question the efficacy of proposed thermal scanners in schools, USA Today reported.
- “How likely are you to pick up every case of COVID? The answer is only 50% of the time,” Dr. Roberta DeBiasi, chief of Pediatric Infectious Diseases at Children’s National Hospital in Washington D.C, said of thermal scanners, according to the newspaper. “You still have to put in all those other measures to try to prevent spread (because) children will be missed from screening methods.”
- The researchers found although children are less likely to get severely ill with the virus, they can easily spread it to vulnerable adults in their lives, especially if they’re in school.
- DeBiasi added that, based on other respiratory illnesses, children are known spreaders.
- The researchers also studied a rare infection that can result in heart problems from the child’s immune response to the virus.
- “This is a severe complication as a result of the immune response to C19 infection, and the number of these patients is growing,” Fasano, who is also a professor of Pediatrics at Harvard Medical School, said. “And, as in adults with these very serious systemic complications, the heart seems to be the favorite organ targeted by post-C19 immune response.”
- She said the immune response complication should factor into vaccine production strategy.
- The researchers recommend wearing masks, social distancing, hand washing, a combination of in-person and remote learning and frequent testing if returning to school in the fall.
- “This study provides much-needed facts for policymakers to make the best decisions possible for schools, daycare centers and other institutions that serve children,” Fasano said. “Kids are a possible source of spreading this virus, and this should be taken into account in the planning stages for reopening schools.”
- The study titled “Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses,” was originally published in the Journal of Pediatrics Thursday.
C. Vaccines & Testing
1. ‘Instant Coffee’ C19 Tests Could Be the Answer to Reopening the U.S.
- With the economy tanking, unemployment skyrocketing, schools slamming their doors and the Big Ten and PAC-12 conferences canceling fall football, America is a country looking for an answer to C19 yesterday. And one might be available—if you can handle instant coffee rather than espresso.
- The coffee analogy is one used by Michael Mina, assistant professor of epidemiology at the Harvard T. H. Chan School of Public Health, and it’s meant to describe the functional difference between two approaches to rapid testing for the virus. In this case, easy and cheap—instant coffee, that is—may very well be better.
- “This is the most important potential tool that could exist today,” Mina said in a recent interview. “We pretty much have a different way…to stop community transmission in the absence of a vaccine—and it is sitting right in front of us.”
- Daily or near-daily testing could be the key to opening our society, and that comes down to making the tests widely available and affordable. If you had the option to test yourself in the morning by spitting into a tube (or swabbing your nose) and waiting 15 minutes for the results, and if it cost you no more than a couple of dollars, wouldn’t you jump at that chance?
- Mina breaks down the existing tests into two camps. “Espresso coffee” tests are reverse transcriptase polymerase chain reaction (RT-PCR) tests or deluxe antigen tests, and several manufacturers, like Mesa Biotech, Quidel and Becton, Dickinson, have already been granted Emergency Use Authorization (EUA) by the Food and Drug Administration (FDA). These tests are highly sensitive, require a machine to churn out the results, and are expensive—anywhere from $30 to $150 per test. They also may have longer turnaround times; even Yale University’s SalivaDirect, which just received EUA on August 15 and costs only about $10, must be submitted to and processed by a central laboratory.
- In sharp contrast lie the “instant coffee” rapid paper antigen tests, including those made by E25Bio and Sherlock Biosciences, and one under development by 3M and MIT. These are fast, simple to use, at-home tests, and some are really inexpensive: about $1 to $5 per test. They are called lateral flow assays, but manifestly they are paper-strip tests that have an antibody embedded on filter paper. If a saliva sample has coronavirus present, the antibody will bind that viral antigen, turning the test positive, much like a pregnancy test works. Though the tests have much lower sensitivity than PCR tests overall, one advantage they have is that they do not detect leftover, inactive viral RNA particles, which may be present days to weeks after a person is infectious.
- Here’s the key: What is more important than a perfect test is one that turns positive during the time period in which an individual can spread the virus to others—and that’s, purportedly, what these cheap tests do well. Generally, disease transmission in C19 is believed to begin early—several days before one becomes symptomatic. Viral load levels peak early and then they gradually decline, with an individual unlikely to be infectious approximately eight to 10 days after showing symptoms.
- Though efficacy needs to be better proven, these antigen tests are efficient at detecting virus at high viral loads. When they are used frequently during this period of infectivity, Mina believes their sensitivity and performance would far exceed that of a single PCR test. At any rate, Mina and his colleagues have demonstrated in their statistical models that public health surveillance depends much more on frequency of testing and rapid reporting of results than it does on the comparative sensitivity of the tests themselves.
- If everyone made use of such an affordable alternative, we could very quickly get this pandemic under control. A positive COVID-19 test would mean the individual stays home; a negative test would mean he/she goes to work, or school or practice, or to shop or dine. Under this approach, the prevalence of the virus in the community would drop considerably—and contact tracing wouldn’t be needed, because everyone would already be doing the testing.
- Like almost everything connected with our effort to control COVID-19, the research related to this rapid-test system is not perfect. Mina and his colleagues acknowledged several important limitations to their study, among them potential manufacturer variations in testing characteristics, improper clinical sampling, possible assumptions made related to viral kinetics and perhaps an erroneous belief that everybody would participate in such a plan.
- But the bigger problem may be finding the tests at all. Why haven’t we seen them in the drug stores? The answer is that the FDA is holding developers of these tests, like E25Bio, to the same high sensitivity standards as those required for molecular grade diagnostics. Without being granted an EUA, the companies are not manufacturing the tests. Mina and others argue that a paradigm shift is needed, so that rapid antigen tests are recognized as a “public health tool,” which when combined with frequent use, will identify infectious individuals.
- It will likely take placing the full weight of the federal government (or someone of influence, like Bill Gates) behind these companies in order to shore things up, further vet the test’s accuracy during the window of infectivity, solve regulatory issues and rapidly ramp up production, so that 50 million to 150 million tests could be performed by Americans each day. Given how low-tech the strips are, such mass production should be feasible.
- This type of frequent, low-cost surveillance testing of people at home—especially while they’re asymptomatic—would go a long way toward helping contain our current outbreak. This could be the key we have all been looking for to unlock our front doors and get back to business—or pleasure.
2. Pfizer and BioNTech’s favored C19 vaccine has fewer side effects than their first
- Pfizer and BioNTech surprised many industry watchers on July 27 when they announced they would conduct a large-scale study of a vaccine for Covid-19. The surprise? The vaccine that would be tested in a 30,000-patient trial wasn’t the one for which the companies had presented data on July 1.
- The reason, the companies said, was that a second vaccine seemed to generate a similar immune response, but fewer side effects. On Thursday, they posted the results from all 332 people who received either vaccine, referred to as vaccines B1 or B2 — and indeed, B2 recipients experienced markedly fewer adverse events tied to the vaccine.
- “Obviously, the better tolerated the vaccine, the more I think it will encourage public acceptance of a broad immunization,” said William Gruber, the senior vice president of vaccine clinical research and development at Pfizer. “Both would have been great candidates. We were fortunate that B2 actually satisfied having both a favorable immune profile and fewer reactions.”
- The study tested doses of each vaccine ranging from 10 micrograms to 100 micrograms. The 30-microgram dose of B2 is being taken forward in clinical trials.
- With the original vaccine, called BNT162b1, or B1 for short, patients between the ages of 18 and 55 had adverse events thought to be related to the vaccine 50% of the time at the 30-microgram dose. Those between the ages of 65 and 85 had related adverse events 16.7% of the time.
- For the second vaccine, BNT162b2, or B2, patients between 18 and 55 had adverse events thought to be related to the vaccine 16.7% of the time, and no adverse effects thought to be related to the vaccine were reported in those between the ages of 65 and 85.
- Both vaccines use mRNA — the genetic messenger the body uses to make the DNA code into proteins — packaged inside a fatty capsule, called a lipid nanoparticle, that allows it to get into cells. The mRNA instructs cells to make a protein, which then triggers the immune system into action. For the B1 vaccine, the mRNA coded for the part of a protein on the coronavirus that binds to a receptor on human cells in order to gain entry to them. The B2 vaccine makes the entirety of this protein, known as the spike protein.
- Using the full spike protein may allow the immune system to figure out more ways to detect and attack the virus. Chemical modifications to the mRNA may also explain some of the difference. Although the same dosage, by weight, was given to patients with each vaccine, the B2 vaccine would include fewer particles, because the full-length mRNA is heavier.
- The side effects tracked were mostly those one would expect from a vaccine injection, including soreness at the injection site, fever, chills, headache, and muscle or joint pain. No older adult who received B2 reported redness or swelling at the injection site.
- The average level of antibodies to the virus in older adults was only 41% that seen in younger participants. However, it was still higher than the level of antibodies seen in recovered patients, the authors said.
- All patients in the study of B2 were white and non-Hispanic, with more older women than older men participating. The younger patients were a median of 37 years old, while the older ones were a median of 69.
- Pfizer has said that some data from its large study of the B2 vaccine could come as early as October and if the vaccine is successful, the companies could seek approval as early as that month.
D. The Road Back?
1. Warding off a ‘Twindemic’
- As fall and winter approach, American public health officials are growing increasingly concerned about the possibility of a resurgence of C19 paired with a severe flu season.
- If large numbers of people do not take the flu shot this year — out of distrust or lack of access — it would increase the risk of a widespread outbreak and possibly overwhelm hospitals as they battle the coronavirus. Doctors believe that the flu can leave people vulnerable to a harsher case of C19, and if patients were to contract both at the same time, it could be disastrous.
- To prevent this nightmare scenario, the Trump administration announced yesterday that pharmacists nationwide would be allowed to administer all scheduled shots to children as young as 3, including the flu vaccine — a convenience for parents. And the CDC said that it was offering flu shots offering protection from 4 flu strains rather than three, including a stronger-than-normal version aimed at protecting people over 65.
- Flu vaccine compliance rates in the U.S. are not great. During the 2018-19 flu season, only 45.3% of adults over 18 got the vaccine, and skepticism continues to run high, particularly in communities of color because of longstanding distrust and experiences of discrimination in public health.
- American public health officials typically look to Australia’s flu season as a predictor of how the flu will play out in the U.S. Australia’s June-to-August winter recorded a 99% drop in flu cases compared with 2019, because lots of people got shots, social distancing was prevalent, and Australians decreased their movement.
- But this year, experts say, Americans can’t put stock in the Australian experience.
- “This situation is of no comfort, as these measures do not apply to the United States, where the populace has never been effectively physical distancing,” said Dr. Paul Van Buynder, a public health professor at Griffith University in Queensland, Australia. “It is likely they will have a significant influenza season this northern winter.”
2. Fear Is More Dangerous Than C19
- Our daily lives are filled with risks — lots of risks. Just look at these examples:
- Every year, 30,000 to 40,000 Americans die in automobile accidents, yet none of us is willing to give up cars to avoid the possibility of dying in a crash.
- Heart disease kills more than 600,000 of our fellow citizens annually, yet we continue to eat fast food and pack on extra pounds.
- Diabetes puts more than 80,000 Americans into their graves each year, yet we do not ban the use of sugar.
- Close to 50,000 Americans take their own lives annually, yet we have instituted C19 policies that have increased the incidence of suicide to the highest levels seen since the Great Depression.
- Millions of children are infected with influenza each year, and hundreds die from the disease. But we have never closed our schools or insisted on masking the population to prevent the spread of flu.
- Child abuse and child sex-trafficking are at record levels in this country, and many specialists believe that it is due, in part, to our schools being closed while adults are unable to go their normal daily routines.
- The CDC estimated that as many as 500,000 people died worldwide from the H1N1 virus in 2009 — the first year that that virus circulated. Overall, 80% of H1N1 virus–related deaths were thought to have occurred in people younger than 65 years of age. Despite this, we didn’t close the schools, mask the population, or shut down the economy.
- In 1968, the Hong Kong Flu killed approximately 4 million people globally. Not only did we not shut down our economy in the face of that staggering number, but the three-day Woodstock Rock Festival in upstate New York was held in the midst of the epidemic.
- Isn’t it time we stopped living our lives and dictating what we can and cannot do based on fear of every new danger? Instead, shouldn’t we let each individual decide what risks he is willing to take?
- The famous declaration in President Franklin D. Roosevelt’s first inaugural address seems as apropos today as it was in 1933: “The only thing we have to fear is fear itself.”
- We are Americans — the freest, most prosperous society in the history of the world. We fought to end slavery, losing over 600,000 Americans in the Civil War. We fought in two world wars and played a dominant role in winning both. Those wars cost the lives of more than 500,00 Americans.
- We take risks to enjoy the freedom they gave us — or at least we used to. We ride motorcycles, skydive, climb mountains, and drive too fast. We eat the wrong foods, drink too much alcohol, and live in ways that are often not healthy — and we cherish our right to do so.
- “Better safe than sorry” has not been elevated to a national motto. It doesn’t appear on any flags; no one is rushing to buy T-shirts emblazoned with those words. But “Live Free or Die”? That’s a different story. It is the motto of the state of New Hampshire and was a colonial rallying cry. The words “and the home of the brave” end the National Anthem. Do we still believe that it is?
- Fear is far deadlier and a more contagious disease than C19. Fear raises our blood pressure to unhealthful levels; fear influences us to make poor decisions. We fear being criticized, we fear exposing our ideas, we fear offending others, and we fear being infected by a virus that is not much more deadly than viruses of the past.
- As a physician with more than 25 years in practice, I will tell you what I tell my patients: you should not fear C19. You should properly prepare and protect the most vulnerable in your homes, your businesses, and society, but you should join everyone else in living your life in maximum liberty with commonsense protections and precautions.
- I can also report that we have an effective treatment when symptoms of C19 are seen early and remain mild. These treatments can also offer protection for the most vulnerable.
- Stop listening to those who want you to stay in a state of chronic fear. Turn off the mainstream media constantly using fear to capture your attention. Don’t let those who want power over our lives to gain more of a foothold in Washington.
- Turn on friendships and optimism and life. Turn on church and community and hope. Live with purpose, and fear fatigue will never become a problem.
E. Back To School?!
1. Trump Administration Declares Teachers Essential Workers
- The Trump administration has designated teachers as essential workers in its effort to encourage schools to reopen for in-person instruction this fall, as some early-opening school districts have been hit with coronavirus outbreaks among students and staff.
- In adding teachers to its list of essential workers, which is only guidance and nonbinding, the government is advising teachers exposed to confirmed cases of C19 but who are not exhibiting symptoms to remain at work and not quarantine.
- Vice President Mike Pence informed governors of the administration’s decision on a phone call this week, according to CNN, which first reported the news.
- Some states have reportedly already given this guidance to school districts, including Tennessee, which has seen a number of confirmed cases in districts that have already opened.
- In Florida’s Martin County, 14 teachers are quarantining along with 292 students just a week after schools opened their doors because of an emergency order from Gov. Ron DeSantis and the state’s education commissioner.
- President Trump throughout the summer has been adamant that schools should reopen for in-person instruction in the fall, falsely claiming that children don’t easily spread the virus.
- Research is still being done on the effects the coronavirus has on children, but a study published in JAMA Pediatrics in July found that children carry as much or more of the infection in their noses and throats compared to adults, and a study on contact tracing in South Korea found that young people were most likely to spread C19 in their households.
- Dr. Anthony Fauci, the government’s top infectious disease official, has encouraged attempting in-person instruction with precautions. Florida’s largest teachers union sued DeSantis and the state’s education commissioner in July over its emergency declaration to reopen schools amid a spike in infections in the state.
- In August, Trump introduced a new adviser to the White House’s coronavirus task force, Dr. Scott Atlas. Board-certified in diagnostic radiology, he is not an infectious disease expert, but his views on the pandemic, particularly around reopening schools, align much closer to Trump’s views than his other health experts Fauci and Dr. Deborah Birx.
2. Schools Have No Good Options for Reopening during C19
- Even as schools have already begun reopening across the United States, debate is still intensifying over whether students should be physically present in classrooms. Children are widely thought to be at relatively low risk of developing severe C19, but a new report from the American Academy of Pediatrics (AAP) indicates that cumulative cases doubled in roughly the past month: between July 9 and August 13, the number increased from about 200,000 to over 406,000. Physically reopening schools might accelerate the increase—potentially raising the number of children with severe symptoms and spurring spread among the community at large.
- Whether children attend classrooms or learn remotely at home, each option carries a risk of harm to students, their families and the adults who work with them. The virus can spread through the enclosed halls and classrooms of a school building; but prolonged reliance on virtual learning alone may disrupt a child’s educational and social development, and can have serious longer-term economic repercussions. In an attempt to minimize damage, individual schools are implementing a variety of different plans, and are prepared to change course if local conditions shift.
The Public Health Risk
- Existing evidence suggests that children—though definitely not immune to C19—are in some ways less vulnerable than adults. A June study in Nature Medicine found that people younger than 20 are half as likely as older adults to contract the disease. The AAP report that indicated increasing cases among children also found this population represents just 9.1 percent of all U.S. C19 cases—and that severe cases of coronavirus are rare among children, resulting in fewer hospitalizations and deaths. “Fortunately, COVID in children, in the vast majority of cases, is a very mild, self-limited illness. Many children are often even asymptomatic,” says Danielle Dooley, a pediatrician and spokesperson for the AAP.
- Although the risk is lower, it is not nonexistent. The AAP report, which includes data from 44 states, notes that a small percentage of this age group—between 0.2 and 8.8 percent of child C19 cases—did require hospitalization. The same report indicates that 19 of the states reported no deaths among children, and the highest rate of pediatric deaths was 0.6 percent of cases. But if the total number of infections in this age group rises, the number that develop a severe case would likely increase as well.
- Children also might pass the coronavirus to adults, who tend to have much more severe symptoms. Teachers, janitors, bus drivers and others must all spend significant amounts of time with students in enclosed spaces, where they are at a relatively high risk of contracting C19 from children (as well as each other). Before students even entered public school buildings in Gwinnett County, Ga., 260 employees who attended planning meetings either tested positive for C19 or had had contact with someone else who had. In Santa Clara, Calif., 40 school officials took part in an indoor meeting; days later, one of the officials received a positive C19 test—and as a result of their exposure, the other attendees had to go into quarantine. Many school employees fear that returning to the classroom will put their lives, and those of their loved ones, at very real risk.
- “The issue we need to worry about is whether or not [children are] vectors,” says Helen Jenkins, an infectious disease epidemiologist at Boston University School of Public Health. The science on how much children transmit the coronavirus is not settled. Some data suggest, Jenkins says, that “those infected are half as likely as adults to transmit to others.” Dooley notes that “We also are seeing increasing data that [children] don’t tend to be spreaders, so they’re not necessarily passing it to other children or other adults in their household or their community—from the data that we have so far.” But other data indicate children older than 10 can act as vectors. A study in Emerging Infectious Diseases, published online in July, analyzed contact-tracing reports for nearly 6,000 coronavirus patients in South Korea, and found those aged 10 to 19 spread the virus as much as adults did. [NOTE: Additional data from the research team now calls that conclusion into question; it is not clear who was infecting whom.]
- Even if transmission rates and serious cases are very low, students physically attending school could carry at least some infections home to family members—who could face far worse health threats and spread the virus more effectively among the general population. This may have contributed to a second wave of coronavirus cases in Israel; in May the country’s numbers were encouragingly low, so schools reopened with few restrictions. But then the number of infections in children quickly spiked, followed by those among older Israelis. In other countries, schools safely reopened by being more cautious and implementing a variety of restrictions—mandating masks, limiting student interaction, or slowly ramping up their plans to begin reopening with only younger children present or for only one day a week.
The Developmental Risk
- There are enormous advantages to having kids in classrooms. “Schools play a really central role in children’s lives, and it’s just not possible to deliver all of the services and benefits of schools when you are in a remote learning situation,” Dooley says. She explains that schools often provide food—more than 30 million children rely on them for nutritious meals—as well as recreation and physical and mental health care. Beyond this, “being around your peers, being around a community of supportive adults—that’s really critical for a child’s development,” she points out. “They need that contact with their peers in order to grow.”
- Of course, all that is on top of the most important service schools provide: education. “Education is a really important determinant of health and lifelong health outcomes,” Dooley says. Students who try to take classes virtually require the equipment and internet connections to do so. Special education students need extra attention that they cannot always receive via videoconference. Younger children require adult engagement, often from a stay-at-home parent or a hired tutor, in order to complete their work. Many students, particularly those from lower-income households, lack these options and are falling behind in their studies as a result. Wealthy families can buy supplies, provide high-speed internet and hire private tutors, allowing their children to avoid such setbacks. Also, the wealth gap between white and minority families means this imbalance in school outcomes may increase the achievement gap between white and minority students, according to reports from the Center for American Progress research institute and the consulting firm McKinsey & Company.
- Many parents and communities also have to rely on school systems for basic child care during working hours. And since online learning itself often requires at least some adult help, even parents who are able to work from home can find themselves in the extremely stressful position of having what amounts to two full-time jobs: paid work, and unpaid child care and teaching. The situation is often described in terms such as “crushing.” This can cause economic problems as well as mental health ones. If schools do not reopen, some parents (many of them mothers) may be forced to leave the workforce—and then be unable to return. On an individual level, families will lose income; on a society-wide level, this could severely damage the economy.
- To avoid this, institutions including the AAP, the CDC, educators’ organizations and the National Academies of Sciences, Engineering, and Medicine have advocated for in-person schooling—if it can be done safely. This means establishing effective and rigorously enforced rules and protocols that will allow students to physically attend school while minimizing risks to their health and that of their communities.
How To Reopen Schools
- There can be no universal, one-size-fits-all rules for reopening physical campuses safely. Community transmission rates vary greatly from region to region, and month to month. Different districts face widely disparate financial realities. Even within the same school system, younger and older students differ in their ability to learn virtually—and in their likelihood of spreading the novel coronavirus. “We have to be prepared and flexible for an ever-changing school year,” Dooley says. “Protocols and procedures put in place at the beginning of the school year may need to change as the level of disease may increase in a community.”
- Many of the measures for keeping school attendees safe are the same as the ones meant to help protect the general population: covering faces, regularly washing or sanitizing hands throughout the day, limiting students to small social “bubbles” (also called “pods” or “cohorts”), improving ventilation in classrooms, and even teaching outdoors when possible. Keeping children and adults at a distance from each other would also help, but this can be difficult because it requires space that is often simply unavailable. Some contend this problem can be addressed by staggering schedules so each student attends classes in person fewer days a week (studying online from home the rest of the time), reducing the number of people in a building at a given time. “Another thing we can do is regular testing,” Jenkins says. “Children are more likely to be asymptomatic,” so rapid testing would allow schools to identify and isolate people with C19 to protect other students and teachers.
- Several of these measures—improving ventilation, having some children attend classes virtually, and providing fast and regular tests—will be inconvenient and require additional funding, potentially from the federal government. Perhaps because of this difficulty (as well as political pressure from some who insist that enforcing pandemic precautions is unnecessary or overly intrusive), many schools have pushed to physically reopen without the requisite precautions. Last month Florida and Iowa announced that schools must provide in-person instruction, despite the fact that C19 cases were rising in both states. In Georgia, photos of mostly maskless high school students crowding a hallway spread on social media; after nine people tested positive for C19, the school had to institute online-only learning while the building was closed for cleaning. Without safety measures—or with sudden spikes in community spread—other schools may reopen only to quickly close campuses as well.
- “One of the best things we can do to keep [schools] safe is to keep local community transmission low,” Jenkins says. To do so, she recommends that authorities take strong action to control the virus—even when that means closing businesses such as gyms and bars. “It’s very tempting to want to reopen as many industries making money as possible, because there’s big pressure to get the economy going,” she says. “But it’s unlikely we can have everything. I hope [governors are] thinking of priorities, and I’d hope schools would come near the top of that.”
F. Nursing Homes
1. An ‘Unprecedented’ Effort to Stop the Coronavirus in Nursing Homes
- The coronavirus crept into Heartland Health Care Center, a nursing home in Moline, Ill., on the last day of July, when a member of the nursing staff tested positive.
- It was an ominous sign: The virus can spread through a nursing home in a flash. Older people — who are often sick and frail and need regular hands-on attention — are uniquely susceptible. Staff members who care for residents are at high risk of infection and of unintentionally spreading the virus.
- Although nursing home residents make up just 1.2 percent of the United States population, they account for about 40 percent of C19 deaths.
- But this time, the nursing home was not defenseless. Heartland was the first facility to participate in a large clinical trial of a drug that might protect residents from the infection in nursing homes and assisted living facilities.
- Drug companies and the federal government often avoid testing drugs in older people, even if they are the ones who need treatment most. The elderly may have a range of complicating conditions that make difficult to tell if the drug is working, and nursing home and extended care facilities are governed by a raft of complex regulations regarding privacy and access.
- Experts say the new research, sponsored by Eli Lilly and the National Institutes of Health, is among the first large clinical trials to involve nursing home residents. And the scientists are delighted.
- “These patients are so underserved,” said Dr. Rebecca Boxer, medical director of clinical trials at the Kaiser Permanente’s Institute for Health Research in Colorado. “They do not get access to innovative new drugs and trials.”
- The experimental drug is a monoclonal antibody, an artificially synthesized version of coronavirus antibodies produced by the body. In this case, the antibody was “cloned” from those found in the blood of a Seattle man, one of the first patients to survive C19, the illness caused by the coronavirus.
- Monoclonal antibodies are one of the great hopes in the war on the coronavirus. They already serve as the basis for effective treatments for arthritis, cancer, lupus — even Ebola. They are difficult to manufacture, however, and expensive.
- Despite the obstacles, two companies, Regeneron and Eli Lilly, have forged ahead with clinical trials. The trial in nursing homes is pivotal to Eli Lilly’s effort to determine whether its version can stop the coronavirus.
- “Some people ask, ‘If we have a vaccine, why do this?’” said Dr. Myron Cohen, a University of North Carolina researcher who proposed the trial. “But a vaccine will take a month to produce antibodies, and some populations need a more emergent intervention.”
- But it is not easy to do a trial in nursing homes. Because the residents cannot be expected to travel to a clinic for an infusion and subsequent testing and monitoring, the clinical trial must to come to them.
- Eli Lilly’s researchers are watching facilities in which a single case of C19 appears after having no active cases for at least 14 days. Once the case is reported, a sort of medical SWAT team scrambles to the facility as quickly as possible.
- A nursing supervisor at Heartland called Eli Lilly as soon as the home learned of the employee’s positive test. The team wasted no time getting to the facility.
- The next day, medical personnel pulled up in two vehicles. One was a moving truck carrying infusion chairs, poles for intravenous infusions, bedside tables, and privacy screens. The other was an R.V. with an interior retrofitted as a mobile lab with infusion materials, a centrifuge, freezers and computers to transmit data.
- The team quickly turned Heartland’s large dining room — which was not being used, because the pandemic had put a stop to communal dining — into an infusion center. The day after the medical team arrived, the first residents and staff who agreed to participate received infusions.
- Participants are randomly assigned to receive one of two infusions: a placebo, or the monoclonal antibody, designed to latch onto the virus and to block it from entering and infecting cells. At Heartland, 25 of the 80 residents who were approached eventually agreed to join the trial.
- The drug should remain in participants’ bodies for at least a month, and possibly as long as three months, the researchers say. Participants and doctors do not know who is getting the antibody and who is not.
- “It’s a little daunting from the patients’ standpoint,” said Dr. Mark Gloth, chief medical officer at ProMedica Senior Care/HCR ManorCare, a nationwide chain of 222 nursing homes and long-term care facilities, including Heartland.
- “We have been restricting visitors for months. Some family members say, ‘I can’t even get in there and hold my loved one’s hand. I want to be sure it’s OK with them.’”
- Lee Rouland was at Heartland Health to recover from a pressure sore and agreed to join the study. “Somebody has to go first,” he said.Credit…Jordan Gale for The New York Times
- Lee Rouland, 45, was in the nursing home recovering from a serious pressure sore when he was asked if he wanted to join the study. He readily agreed.
- A paraplegic since falling from a fire escape when he was 22, Mr. Rouland was unable to leave his room because he cannot sit in his wheelchair. So the investigators came to him. The infusion took an hour.
- For the next two hours, the team monitored Mr. Rouland’s vital signs: heart rate, blood pressure, blood oxygen levels. Because he cannot easily travel to a lab for subsequent tests, investigators plan to visit to his home once he leaves Heartland.
- He’s worried, of course. If he got the drug, it might cause adverse reactions. But “somebody has to go first,” Mr. Rouland said.
- The study is being undertaken at nursing homes and extended care facilities across the United States and will enroll 2,400 residents and staff. Eli Lilly hopes to enlist 500 facilities — so far, about 125 have agreed to join the study — and the company anticipates enrolling 40 to 80 participants at each site.
- There are obvious advantages to testing the drug in nursing homes. Residents are all in one place, making it easy to do contact tracing. And the rocket pace of a nursing home outbreak makes it easier to see if the coronavirus can be halted with this drug.
- Monoclonal antibodies are difficult to make. The drug, if it works, is expected to be expensive — an infusion of a monoclonal antibody can cost thousands of dollars. Eli Lilly has not announced what it will charge for the drug if it is approved for marketing.
- There is no guarantee of success, and previous attempts to do studies in nursing homes have fallen short. Nursing home residents can be difficult participants: Many have dementia, or have difficulty seeing and hearing. Yet they or, in some cases, someone designated to make decisions for them, must provide informed consent.
- “Informed consent is very scripted and can be incredibly challenging, especially with an infused experimental drug,” Dr. Boxer said. Potential participants have to read and understand a form that explains the risks and the adverse side effects that can occur.
- Then, she said, participants usually have to repeat back in their own words what they are being asked to do. The people soliciting informed consent most often are not nursing home staff, since they have to be credentialed by an ethics board that approved the study.
- Yet “they need to understand the limitations of working with the very old and disabled,” Dr. Boxer said.
- Often, residents will want someone else to sign the consent form for them, but states have varying regulations governing who may be authorized. Some residents with dementia might agree one day but forget the next that they agreed to take part, and then reverse their decision.
- Nursing homes are very protective of patient privacy. But research regulations allow investigators, in some circumstances, to review patients’ medical records to identify patients who might be eligible for a study.
- “There just isn’t a culture in nursing homes that is attuned to doing research and clinical trials,” said Dr. Mathew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado.
- When Dr. Cohen, who is working with the National Institute of Allergy and Infectious Diseases to run clinical trials of antibodies, thought of the nursing home trial, he began calling chief executives of nursing home chains.
- “At the end of the calls, I was really shaken up,” he said. “They explained the unbelievable suffering of clients and families.”
- Residents who were infected were dying alone, no visitors allowed, he learned. Staff members were falling ill. Nursing home executives were eager to participate in the study.
- In Citrus Heights, Calif., a staff member at a nursing home tested positive earlier this month. The moving van and R.V. appeared the next day, and Katy Tenner, 37, a staff dietitian, was among those who volunteered for the study.
- The infusion and monitoring took so long she had to get the treatment on her day off. Every day for the next 56 days, she has to have her vital signs checked. Every week she has to have a coronavirus test.
- But she is excited about the study. So often, she said, she drives home from work, listening to news on the radio and “bawling my eyes out, hearing about my fellow health care workers dying from this virus.”
- “This could be a weapon to fight it and maybe outsmart it,” she said.
2. A Novel Way to Combat C19 in Nursing Homes: Strike Teams
- The coronavirus entered Cherry Springs Village quietly, then struck with force. Nearly every staff member and resident of the long-term care facility would become infected.
- They needed help — fast — and the county responded: It sent in a “strike team” of medical workers, emergency responders, clergy and others, in what is becoming a new model for combating C19 in residential care centers.
- Nurses and doctors from hours away came to aid sick residents and replace staff who had contracted the virus. They set up oxygen and IV drips, to avoid sending residents with milder illness to overburdened hospitals.
- Members of the county’s emergency management department conducted rapid testing of all staff and residents. The Henderson County Rescue Squad, a volunteer paramedic group, erected decontamination tents outside for staff to safely remove protective gowns, masks and other equipment after shifts, and educated them on proper use and removal of the garments.
- Chaplains and therapists came from a nearby hospice to provide emotional support to families and staff, who sometimes witnessed several residents die in one day. A public relations employee was dispatched to communicate with family members about ill loved ones and the situation inside.
- Covid strike teams apply an emergency response model traditionally used in natural disasters like hurricanes and wildfires to combating outbreaks in long-term care facilities. Composed of about eight to 10 members from local emergency management departments, health departments, nonprofit organizations, private businesses — and at times, the National Guard — the teams are designed to bring more resources and personnel to a disaster scene.
- “Calling emergency management made sense, because it was a disaster,” said Dr. Anna Hicks, a local geriatrician who helped coordinate the Cherry Springs strike team. “It felt like being in a natural disaster.”
- C19 outbreaks spread like wildfires in long-term care facilities, which house medically vulnerable residents and staff in relatively small spaces. So a growing number of states are treating them like one.
- More than 40% of all coronavirus deaths in the United States have been tied to nursing homes, according to a New York Times analysis.
- “Desperate times, like a pandemic, call for a different way of thinking,” said Dr. Timothy Chizmar, the emergency medical services director for Maryland. “The idea has roots in trauma settings, where it’s just not possible to take everybody off the scene — sometimes you need to take some medical care to them.”
- Though initially coordinated at the top, with governors and state health departments sending the National Guard to the scene, strike teams are now being replicated on a much smaller scale in counties and local jurisdictions, including in states that were hot spots for the virus like North Carolina.
- At least seven other states have sent strike teams to long-term care facilities with outbreaks, including Florida, Texas, Massachusetts, New Jersey, Ohio, Wisconsin and Tennessee. Other states have proposed but not yet adopted them.
- A bill in the House or Representatives, introduced by members of both parties, would allow the secretary of the Department of Health and Human Services to allocate federal funds to the states specifically for the creation of strike teams to manage C19 outbreaks in nursing homes.
- Representative Josh Gottheimer, Democrat of New Jersey, one of the sponsors of the House bill, began coordinating strike teams in his state in April after receiving calls about outbreaks at two nursing homes in his district, where long-term care facilities were particularly hard hit by the virus.
- Police had discovered 17 bodies stuffed into a morgue that was only intended to hold four people inside Andover Subacute and Rehabilitation Center I and II, one of the largest nursing homes in the state. The city’s police chief said facility employees were simply “overwhelmed by the amount of people who were expiring.”
- An outbreak at the New Jersey Veterans Home at Paramus, a state-run home for former military members, had quickly evolved into one of the biggest coronavirus outbreaks in the country. Almost every resident — 98% — contracted the virus, and 81 people died.
- “We quickly learned they had a massive staff outage — 60% of the staff were out sick,” said Mr. Gottheimer, who went on to coordinate strike teams statewide alongside Gov. Phil Murphy, the federal coronavirus task force, Representative William Pascrell, the National Guard and local hospitals.
- “We called the other nursing homes in my district and found similar shortages,” he said. “And that’s when it struck me that we better figure out a way to get more people on the ground to these facilities.”
- The needs of long-term care residents are much greater during an outbreak, as previously healthy people may suddenly require complex medical attention like oxygen concentrators and intravenous drips, or need assistance carrying out basic tasks like eating and drinking.
- The situation can be particularly dire for assisted living facilities, which tend to have fewer on-site medical staff than nursing homes, but are often home to people at-risk for the worst outcomes of the virus, including those with developmental disabilities and dementia.
- “But even nursing homes, in general, are not built for a whole lot of acute care,” Dr. Chizmar said. “They serve a very important role, but that’s just not part of their mission.”
- Members of strike teams can help meet these needs by acting as temporary staff in the initial days of an outbreak.
- In most states, receiving strike team aid is voluntary — a long-term care facility requests the help of a team. The model has proliferated quickly.
- In North Carolina, Buncombe County adopted the strike team model shortly after seeing it implemented in neighboring Henderson County.
- The team conducts regular calls with long term care facilities to aid with testing and infection control, but occasionally, they’ll do “drop in” visits to facilities they haven’t heard from in awhile, said Jennifer Mullendore, medical director at the Buncombe County Health Department.
- “If there’s a facility we have a concern about or we might have gotten a complaint about, or they show up on our radar for whatever reason, we will give the 15 minute heads up, and ask to be let in,” she said.
- Maryland, one of the first states to adopt this model, received more than 130 requests from nursing homes, assisted living facilities and group homes for individuals with development disabilities in the first few months of the pandemic.
- Ten people — about a fifth of the residents — died at Cherry Springs Village over the course of its two-month outbreak. Henderson County officials believe outcomes would have been much worse without the help of the rapid response strike team.
- But more research is needed about this and other strategies for combating C19 outbreaks in nursing homes and congregate care facilities.
- “Anecdotally, we’ve seen that facilities who have had cases since April, when we first started using the strike team, have had slower, more controlled spread within their facilities,” said Dr. Hicks, noting that the county has since sent the team to five other long term care homes with outbreaks. “We have definitely seen improved coordination of care and better control of the spread in these facilities. I don’t think anyone knows 100% that strike teams are the reason for that but I know they’ve been helpful.”
- While there is no solid data how effective these strike teams have been, Sheryl Zimmerman, researcher and director of the Program on Aging, Disability, and Long-term Care at the University of North Carolina, said they make sense.
- “We do know that assisted living communities in particular are understaffed, and lack the medical expertise a nursing home would have. So it’s critical to bring in outside help,” she said. “Taking this as an opportunity to embrace new models to provide support these places need is kind of a slam dunk, no-brainer.”
- Mr. Gottheimer, the New Jersey congressman who introduced the bill to provide federal funds for strike teams, said he wanted the option to be available in states now facing a surge in cases and hospitalizations.
- “Unfortunately, other parts of the country are now experiencing what we did, and having massive shortages overall of health care staff,” said Gottheimer. “We saw how critical strike teams were in the crisis here. You’re always hopeful strike teams won’t be needed — but the point is to have them ready in case we do.”
G. How Effective Are Masks?
1. Sweden Refuses To Mandate Face Masks As Nordic Neighbors Expand Restrictions
- One by one, scientists in Denmark, the Netherlands, Finland and Sweden have raised doubts about the effectiveness of asking citizens to wear masks in every public venue, with many arguing that asking people to wear masks at all hardly makes sense in places where the rate of spread is low. However, over the past few weeks, many have acknowledged that masks may be beneficial in certain circumstances, and policies that focus specifically on these (such as mandatory use on public transit) might be more beneficial.
- As debate is mostly stifled in the US, Sweden’s top epidemiologist and architect of the country’s no-lockdown C19 strategy, Anders Tegnell, is speaking up about Sweden’s decision to stand by its mask policy, which, like most of Sweden’s C19 response, is surprisingly lax.
- Speaking once again to the FT , Tegnell explained his doubts, his hopes and even areas where he suspects masks may be effective. But his final conclusion is that the “science” that American liberals are always boasting about simply isn’t as concrete as the Washington Post, New York Times and others make it out to be.
- “It is very dangerous to believe face masks would change the game when it comes to C19,” Tegnell told the FT. He also shared some evidence to suggest that his neighbors were caving to political whims, and perhaps pressure from Brussels, by widening mask mandates.
- Soren Riis Paludan, a viral infections expert from Aarhus University, said research had suggested that at Denmark’s current infection rate 100,000 people would have to wear face masks properly for a week to avoid one infection. “If there’s very little virus in the community, the effect is limited. But if you’re in the middle of a hotspot, then everything says that they can have an effect. In Denmark, we have compromised and said face masks may be another tool in the toolbox,” Prof Paludan said. Another reason for Swedish reluctance, according to experts, is high trust in the authorities. “When the Swedish health agency says there’s no reason to wear face masks, people don’t wear face masks,” said Prof Ludvigsson. “In other countries, where there’s less trust and they don’t recommend wearing masks, people might do it anyway.”
- The odds of infection in the initial scenario above are staggeringly low, and yet, viral memes shared on Instagram and Facebook for the past few months have posed scenarios where neglecting to wear a mask could practically guarantee that more than a dozen random strangers could be accidentally infected. This is extremely unlikely.
- Most evidence supporting mask involves retrospective analysis of hundreds of studies and data sets used to study other things. The truth is, we truly don’t know how effective wearing a surgical mask might be to stop an infected individual from spreading it to another person (which is why they’re worn in surgery).
- Nordic experts also point to a lack of hard evidence over the effectiveness of face masks. Many countries as well as the World Health Organization have changed their advice on wearing masks as studies have appeared to point to a link between their use and lower infection rates.
- But some Nordic experts are still skeptical. Mr Ludvigsson noted that in a meta-analysis by the WHO of 29 studies that showed face masks were effective, only three concerned their use outside hospitals and of those that did not none involved C19. Still, he said his personal position had changed and he now believed they should recommend their use on public transport in Sweden but for a set period. “It would increase compliance if people know it’s only for three months,” he added.
- Though Tegnell says he is keeping an open mind.
- “Face masks can be a complement to other things when other things are safely in place. But to start with having face masks and then think you can crowd your buses or your shopping malls – that’s definitely a mistake,” he said, adding that countries such as Belgium and Spain with widespread mask use still had rising infection rates. Sweden’s public health agency said on Tuesday that it was working on proposals for the government in the next few weeks and could open up for face mask use in specific circumstances such as visits to hospitals or dentists. Sweden is not the only European country skeptical about face masks. In the Netherlands, they must be worn on public transport and at airports but are not mandatory elsewhere.
H. Practical Tips & Other Useful Information
1. When Should You Get Your Flu Vaccination?
- The world is eagerly awaiting the creation of a C19 vaccine, which is happening at a record-setting pace, but it’s not the only vaccine that may determine how pandemic-centered lives unfold this winter.
- There’s another vaccine that will play a key role. It already exists.
- The flu vaccine feels pedestrian compared to the hopes pinned on the C19 vaccine. Still, getting that vaccine could go a long way to keeping the costs of the C19 pandemic under control, explains Libby Richards, an associate professor at Purdue University’s School of Nursing.
- “Unfortunately, C19 will still be circulating during flu season, which makes getting a flu vaccine more important than ever — especially as schools and our economy continue to re-open,” Richards tells Inverse.
- Historically, our track record on the flu vaccine hasn’t been great. The CDC estimates that only 45.3 percent of adults received the flu vaccine during the 2018-2019 flu season, which was up about 8 percent from the previous year.
- Richards adds that this year C19 complicates the situation; it’s already “led to decreased use of preventative healthcare services, including vaccines.”
- If the flu vaccine is traditionally around 60 percent effective (the flu vaccine varies in effectiveness each year depending on strain — last year it was about 45 percent effective, per the CDC), we would need to have about 83 percent of the population vaccinated to achieve herd immunity. That’s the stage when enough people are immune to a disease, that it’s rare for even unvaccinated people to get sick.
- Getting as close as possible this year to that percentage could have lasting impacts on the ability of the healthcare system to fight C19.
- “Our healthcare system is already stretched thin; I think if it gets stretched much thinner, we could be at a breaking point,” Richards says.
Why Getting the Flu Vaccine is Important
- Flu season usually runs from October to April each year. It varies in severity and its regularity and normalization obscure how devastating the flu can really be.
- The CDC can only estimate the true burden of the flu because of reporting delays or consequences that go unreported. But during the 2019-2020 flu season, the agency estimated that the flu accounted for between 18 million and 26 million medical visits, between 410,000 and 740,000 hospitalizations, and between 24,000 and 62,000 deaths. Those numbers are adjusted to account for the fact that more people may have been tested for the flu fearing those symptoms may have actually been coronavirus.
- These statistics don’t exist to compare coronavirus to the flu, rather they underscore the fact that when the two illnesses meet, the compounded effects could be a “twindemic” – a phrase popularized in an August 16 New York Times story.
- A twindemic might emerge because of the strain that yet another respiratory illness might put on our healthcare system, Richards explains. Getting the flu vaccine could reduce the number of severe flu cases that happen this year – and these severe cases require the same lifesaving equipment that is used to fight severe C19, she says.
- “We have all heard the C19 stories of ICUs filled beyond capacity and shortages of equipment such as ventilators. If we add a bad flu season to that — we won’t be able to handle it,” she says.
When Should You Get the Flu Vaccine?
- The CDC already expects to have 20 million more doses of the flu vaccine on hand this year compared to the 2019-2020 flu season.
- Richards says September is a “great time” to start thinking about the flu vaccine and is when she chooses to get vaccinated. That said, getting a vaccine too early could potentially lead to reduced immunity later in the winter. Regardless, you definitely want to aim to get a vaccine before the flu starts circulating.
- “It takes about two weeks for the body to develop immunity from the vaccine and we tend to see flu cases starting to increase in October so I always try to get myself and my family vaccinated in September,” Richard says.
- It may feel a bit nerve-wracking to think about walking into a clinic to get a flu vaccine during a pandemic. To make things a bit easier, Richards suggests taking basic precautions like wearing a mask, and making sure to sanitize your hands before you go into the doctor’s office and after you leave.
- She says that it’s worth making the trip and that getting coronavirus from the clinic is “very unlikely” especially since healthcare providers take extra precautions like wiping surfaces down between patients.
- It’s far more important to ensure that there’s less disease going around in the outside world. And taking influenza off the table (as much as is possible) could be a huge step towards keeping this winter under control.
- “Getting vaccinated isn’t just about personal health, Richards explains. “It also protects the health of your friends, family, and community.”
2. Fitbit Study Suggests Wearables Can Detect C19 Before Symptoms Appear
- Fitbit has detailed some fascinating early findings of its C19 wearables study, which aims to find an algorithm to identify infections early.
- That it can detect half of coronavirus infections the day before symptoms appear, with 70 per cent specificity, is the most important development here.
- Fitbit Director of Research Conor Heneghan has published an interesting post on the study at the Fitbit blog. It is well worth a read, but let’s take a look at some of the most salient points.
- Heneghan writes fatigue is the most commonly reported symptom. Only 55 percent registered a fever, suggesting “temperature screening alone may not be enough to understand who might be infected.”
- Breathing rate, heart rate variability and resting heart rate are the metrics Fitbit uses to pinpoint an infection early. HRV decreases, and both breathing rate and heart rate increase as the immune system mounts a response to the virus.
- “Those metrics begin to signal changes nearly a week before participants reported symptoms,” writes Heneghan.
- An infection commonly causes a spike in breathing rate and heart rate.
- One obvious question is whether other, more minor, illnesses might cause similar changes to breathing and heart rate, and HRV. However, the Fitbit study continues: these are early observations, not final conclusions.
- Fitbit has submitted its initial research findings for publication in a peer-reviewed journal. Those who want to dig much deeper can read the paper online.
- So far more than 100,000 Fitbit users in the US and Canada have signed up for the study. The 1,000 reported C19 cases in that cohort are the basis for the results.
- The Fitbit study is just one of several to use wearable technology to try to identify coronavirus and study patients’ recovery. King’s College London and the University of California have also launched programs to assess how wearables can help.
I. Johns Hopkins COVID-19 Update
August 21, 2020
1. Numbers & Trends
- The WHO C19 Dashboard reports 22.49 million cases (236,093 new) and 788,503 deaths (6,047 new) as of 4:30am EDT on August 21.
- Globally, there are 7 countries currently reporting test positivity of 20% or greater. As we have discussed previously, high test positivity can indicate that testing capacity or volume may not be sufficient to fully capture the scale of community transmission. The WHO previously set 5% test positivity as one of the key benchmarks for determining if countries have their C19 epidemic under control. Five (5) of the 7 countries in the top tier are in the Central and South America region: Argentina (57.9%), Bolivia (44.6%), Colombia (32.4%), Mexico (63.7%), and Panama (34.8%). The remaining 2 countries are in Asia (including the Eastern Mediterranean region): Bangladesh (20.5%) and Oman (38.9%)*. A number of other countries, spread across all continents, are reporting test positivity greater than 10%. Many countries—including some current hotspots (eg, Brazil, Peru, Suriname), China, and most countries in Africa—do not regularly report test positivity, so there are likely others that are facing similar challenges.
- At the continent level, Asia now represents the most daily incidence, surpassing North America in early July and South America in early August. Both Asia and South America are continuing to report increasing incidence, whereas North America has been on the decline since late July. Notably, Asia’s ascendance is driven primarily by the epidemic in India, and North America’s decline is due in large part to decreasing incidence in the US. Africa’s daily incidence previously exceeded that of Europe; however, Africa’s epidemic has been on the decline since early August, while Europe’s daily incidence is rebounding. Africa’s recent trend is largely driven by South Africa’s epidemic, and numerous countries in Europe are reporting increasing daily incidence. On a per capita basis, South America’s daily incidence (172 daily cases per million population) is considerably higher than all other continents, including more than 70% higher than #2 North America (99). And North America is reporting at least 3-4 times the per capita daily incidence as the remaining continents. Europe is #3 (31), and is Asia #4 (20), followed by Oceania and Africa, which are both reporting fewer than 10 new daily cases per million population.
- The US CDC reported 5.51 million total cases (46,500 new) and 172,416 deaths (1,404 new). In total, 19 states (no change) are reporting more than 100,000 cases, including California with more than 600,000 cases; Florida and Texas with more than 500,000; New York with more than 400,000; and Georgia and Illinois with more than 200,000. For nearly 3 weeks, the US continues to average more than 1,000 deaths per day.
- Several US territories are exhibiting high per capita daily incidence. The US Virgin Islands is reporting 226 new daily cases per million population, which would be #3 globally, between the Maldives and Colombia. Puerto Rico is reporting 185 new daily cases per million population, which would put it at #7 globally in terms of per capita daily incidence, falling between Brazil and Israel. Guam is also reporting 192 new daily cases per million population, which would be #4 globally; however, this appears to be driven largely by a spike of 105 new cases reported today, more than double its previous record daily incidence.
- The Johns Hopkins CSSE dashboard reported 5.60 million US cases and 174,647 deaths as of 1:30pm EDT on August 21.
2. South Korea
- South Korea’s C19 epidemic continues to grow, with the Korean CDC reporting 315 new domestic cases today. Additionally, 2,241 individuals are currently under quarantine, and South Korea’s Vice Health Minister, Kim Gang-lip, described the situation as “grave.” More than 50 of the new cases are associated with the Sarang Jeil Church in Seoul, a place of worship that has recently participated in large protests against South Korean President Moon Jae-in. The emergence of large churches as drivers of transmission in South Korea, both early in the epidemic and the current resurgence, has driven division in South Korean society. In response to epidemic response measures, including investigations and orders to suspend gatherings, as well as public criticism and stigmatization, some congregations have accused the government of manipulating C19 data to reflect poorly on the churches. News media have reported that misinformation, including conspiracy theories, are exacerbating divisions as the C19 response becomes increasingly politicized.
- In addition to these churches, South Korea has reported C19 clusters and outbreaks in a number of other settings. One outbreak, in particular, has been linked to a Starbucks cafe near Seoul, which has prompted the government to strengthen restrictions on cafes and restaurants. As of August 20, 58 cases have been linked to the cafe. Case investigations have identified 4 index patients who infected at least 25 other patrons, and 29 secondary cases have been identified as well. The investigation is ongoing, but health officials reportedly indicated that the index cases were not wearing masks and that the cafe did not have sufficient ventilation. Other outbreak or cluster settings include a variety of businesses, such as life insurance call centers, as well as hospitals and nursing homes.
3. France Mandates Masks
- The French Ministry of Labor, Employment, and Integration recently announced a new mandate requiring that individuals wear masks while at work. The move makes France one of the only countries in the world to require universal mask usage in all workplaces. SARS-CoV-2 transmission in the workplace is a major concern as countries weigh decisions regarding the ability to resume in-person work. Many countries around the world have established some sort of mask mandate or recommendation, with wide variance.
- Earlier this week, JAMA published a commentary that addresses the effectiveness of employees wearing face shields in mitigating transmission risk among community health workers. The researchers describe a small study of C19 incidence among a group of community health workers before and after implementing face shield use. The study involved 62 community health workers in Chennai, India, who provided counseling for individuals and households in the community. Prior to implementing face shield use, the workers wore surgical masks and adhered to other risk mitigation procedures. Over a period of 9 days, 12 health workers were infected. Following these infections, the health workers wore face shields in addition to their masks and existing risk mitigation protocols. Over a 41-day period after instituting this protocol, zero of the remaining 50 health workers tested positive for SARS-CoV-2. Considering the risk of transmission for community health workers, who have close contact with numerous individuals and households on a daily basis, these results offer support for potential effectiveness of face shields in combination with masks in preventing the spread of C19.
- The Venezuelan government has received criticism for extreme measures taken to enforce C19 interventions. Multiple reports have identified a variety of inhumane punishments—including physical abuse, forced exercise, and prolonged detainment—for those caught violating social distancing restrictions or those suspected of being infected. The country’s government has reportedly referred to individuals who come into contact with C19 as “bioterrorists” and used security forces to enforce strict measures. Additionally, the government has imposed strict measures for returning migrants, forcing individuals to remain in isolation, potentially for weeks, as they attempt to cross the border back into Venezuela. Despite these hard-line efforts, opposition leader Juan Guaidó announced earlier this week that Venezuela’s daily incidence could soon exceed the national testing capacity. This could result in a perceived “flattening” of the epi curve; however, it would be due to insufficient testing capacity rather than decreased transmission, which could provide a false sense of confidence that could lead to further increases in transmission. The US government announced that it will unfreeze some funds for Mr. Guaidó—previously frozen under sanctions imposed on Venezuela—to establish a system to financially support medical professionals in the country. The human rights advocacy group, Amnesty International, recently released a report outlining the failure of Venezuelan authorities to protect their health care professionals, including reprisals against whistleblowers or those who have spoken out against the government’s response.
5. India Seroprevalence
- Indian health officials recently published the results of several seroprevalence studies, which found widespread transmission compared to studies previously conducted in other countries. In New Delhi, a new seroprevalence survey suggests that more than 29% of the city’s population may have been exposed to SARS-CoV-2. A previous study conducted in July by India’s National CDC estimated that 23.5% of the New Delhi population was seropositive. The state of Delhi is the fifth most severely affected state in India. In the city of Pune, researchers from the Indian Institute of Science Education and Research conducted a seroprevalence study involving more than 1,600 participants. The researchers estimate that more than 50% of the entire city population is seropositive, including more than 65% in one part of the city. Pune is in Maharashtra, the most severely affected state in India, with more than 450,000 reported cases. If these results are accurate, it could mean millions of additional cases in India. India is currently reporting the highest daily incidence of any country, and it is #3 globally in terms of cumulative incidence, behind only the US and Brazil. Serological studies in other countries have reported much lower rates of seropositivity, typically less than 15% and often less than 10%. Some experts have suggested that herd immunity could be reached at 50-70% seropositivity; however, there is considerable uncertainty around that number, and it could vary from population to population, depending on a number of complex factors.
6. Vaccine Trial in South Africa
- US-based pharmaceutical company Novavax announced that it will conduct a Phase 2b clinical trial for its candidate vaccine in South Africa. The Bill and Melinda Gates Foundation provided funding for the trial, which will include 2 cohorts, a larger group of healthy adults and a smaller group of HIV-positive adults, that will total more than 2,600 participants. Pending successful results from this and other clinical trials, Novavax had previously signed a partnership with The Serum Institute of India to produce the vaccine for countries in Africa. African countries have reported more than 1 million cumulative cases, but recent data suggest that the spread of C19 has slowed. South Africa has reported the highest cumulative incidence in Africa (and #5 globally) at just under 600,000 cases; however, South Africa has reported a steady decrease in daily incidence over the past several weeks.
7. Australia Vaccine Purchase
- Australian Prime Minister Scott Morrison and the Ministers of Health and Industry, Science, and Technology jointly announced that the Australian government finalized an agreement with pharmaceutical manufacturer AstraZeneca to procure enough early doses of its SARS-COV-2 vaccine for every Australian. If AstraZeneca’s vaccine candidate (in collaboration with Oxford University [UK]) successfully demonstrates efficacy in Phase 3 clinical trials, the Australian Government will have priority access to enough vaccine for 25 million Australians, which will be administered free of charge to the public. In addition to the new purchase agreement, the Australian government has invested AU$333 million (~US$238 million) to support medical countermeasures (MCMs) development for C19. Australia also unveiled its new national vaccination and treatment strategy, which emphasizes MCM research and development, MCM purchasing and manufacturing, international partnerships to improve access to MCMs, regulation and safety through clinical trials and oversight, and vaccine administration and monitoring programs. In addition to the agreement with Australia, AstraZeneca has finalized similar deals with other countries, including the US and the whole of the EU. In light of these massive contracts, some on the order of hundreds of millions of doses, have driven WHO Director-General Tedros Adhanom Ghebreyesus to call on national governments to avoid “vaccine nationalism” in order to ensure equitable access for affected populations around the world, including countries that cannot compete financially with larger, high-income countries in order to procure their own doses from among the earliest supply.
8. UK Dismantles Public Health England
- The UK government recently announced that its leading public health agency, Public Health England (PHE), is being dismantled and replaced with a National Institute for Health Protection that is reportedly to be modeled after the Robert Koch Institute in Germany. This new institute will merge PHE response efforts with the National Health Service Test and Trace program and the Joint Biosecurity Centre, and it is expected to formally start operations in early 2021. The decision was made after news that Health Secretary Matt Hancock and other members of UK Prime Minister Boris Johnson’s administration were displeased with how PHE handled SARS-CoV-2 testing and contact tracing efforts. The decision has been met with widespread criticism among news media and public health stakeholders that see it as an attempt by the British government to shift blame for challenges with the country’s C19 response. While the National Institute for Health Protection will reportedly focus principally on addressing the needs of the UK C19 epidemic and future health emergencies, it is unclear how PHE’s work on other public health issues, such as obesity and smoking, will be handled after the transition.
9. Clinical Trials in Children & Pregnant Women
- As vaccine developers rapidly conduct clinical trials for candidate SARS-CoV-2 vaccines, researchers are paying increased attention to priority high-risk populations. Clinical trials have generally focused on testing vaccine safety and efficacy in healthy adults, and have largely excluded children and pregnant women, among other populations. To date, AstraZeneca is the only manufacturer contracted to provide vaccines to the American public that is conducting clinical trials in children, according to a report by STAT News. While children may not be among the highest-priority populations early in a mass vaccination campaign because of their relatively lower risk of severe disease and death, they may be a priority in terms of resuming in-person schooling. To our knowledge, no clinical trials have included pregnant women or those who are breastfeeding. The inclusion of pregnant women, and other high-risk or vulnerable populations, in vaccine clinical trials, particularly early stage trials, has been a longstanding debate, due to concerns about the potential for adverse events. There has been a push in recent years from researchers, bioethicists, and medical professionals to open clinical trials to pregnant women and support their involvement, as it can be crucial for pregnant women to be immunized to protect themselves and the fetus, particularly for emerging pathogens like Zika virus and Ebolavirus that could disproportionately affect pregnant women or the fetus.
10. WHO Updates Quarantine Guidance
- The WHO published an update to its C19 quarantine guidance, specifically for arriving travelers and individuals with known exposure to SARS-CoV-2. The previous iteration of the guidance was published on March 19, and the update includes additional information on maintaining sufficient ventilation in quarantine areas, including standards for minimum ventilation rate and airflow pattern and direction, and providing care for children under quarantine—as well as other updates based on information and analysis since the previous version was published. Notably, the guidance recommends quarantining children at home when possible, and with a parent or caretaker who is at lower risk for severe C19 disease and death. Risk assessment for children under quarantine should be conducted in a holistic manner, accounting for a variety of factors beyond just C19 risk, such as mental wellbeing.
11. Long-Term Effects
- Ed Yong, writing for The Atlantic, continued his in-depth investigation of the long-term health effects of C19. He previously covered C19 “long-haulers”—recovered C19 patients who experience symptoms long after their recovery from the acute stage of the disease—in June. He notes that many of the “long-haulers” are not those typically associated with elevated risk of severe C19 disease or death. Many of those with longer-term health effects are younger, with an average age in the 40s, and “most were formerly fit and healthy.” Additionally, these long-term symptoms are more often observed in women. Notably, a substantial portion of “long-haulers” did not necessarily experience severe disease during the acute infection. As the primary driver of transmission, both in the US and globally, shifts toward younger individuals, the risk of prolonged health effects is concerning. Compared to acute C19 disease, the longer-term health effects have not been as well studied or characterized, and further research will be required as more people are affected, in particular to provide a more accurate picture of the total burden of C19. Long-term health effects could have a major impact on societies’ ability to recover from the pandemic, even after transmission is brought under control.