September 24, 2020
Without reliable information, we rely on fear or luck.
“Everyone had a fear there would be explosive outbreaks of transmission in the schools. In colleges, there have been. We have to say that, to date, we have not seen those in the younger kids, and that is a really important observation.”Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota
“To those who argue that the lockdown flattened the curve in New York and New Jersey, the evidence argues otherwise. New York, New Jersey wound up with the sharpest spike or highest death rate in the world … In contrast, Sweden had a relatively softer touch, few mandates and mostly voluntary guidelines and had 18% of New York’s fatalities.”US Senator Rand Paul
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity
4. Trends in the Midwest/Plains Hotspots
5. Is the Fall Surge Here
1. Statins reduce C19 severity by 50% (!) (*)
1. Who’s Most At Risk in the C19 Mental Health Crisis (*)
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A. The Pandemic As Seen Through Headlines
(In no particular order)
- Trump moves more money to ‘Operation Warp Speed’
- Johnson & Johnson Project Becomes 4th US COVID-19 Vaccine To Enter ‘Phase 3’ Trials
- Head of FDA advisory committee recuses herself from COVID vaccine review
- European Union Reaches Agreement with Sanofi, GSK for Up to 300 Million Doses of COVID-19 Vaccine
- Russia Strikes Deals to Sell Its Coronavirus Vaccine Internationally
- Russia offers United Nations staff free virus vaccines
- Experts Worry As Leading COVID-19 Vaccines Adopt Trial Shortcuts In “Rush For Results”
- FDA boss, Dr. Fauci assure public that COVID-19 vaccines will be safe
- FDA mulls tougher rules that could delay COVID-19 vaccine
- Beware of covid-19 vaccine trials designed to succeed from the start
- CDC director hints at new guidance on aerosols
- “No Medical Justification For Emergency Measures” – Open Letter From 100s Of Doctors, Health Pros Urges End To Lockdowns
- The fall surge is here
- Airlines Beg To Relax Quarantine Rules, Support Mandatory Testing Instead, In Push To Spur Demand
- Missouri governor who was critical of mask mandates tests positive for coronavirus
- Pandemic limbo pushes New Yorkers to test out other places to live
- Walmart starts pilot project to deliver COVID-19 test kits by drone
- Trump says China must be held accountable for spread of COVID-19 in UN speech
- Xi Jinping downplays China’s handling of coronavirus in UN address
- US Secretary of State Pompeo warns lawmakers about China’s alleged tactics to dodge COVID-19 blame
- UK Prime Minister Johnson Unveils New National COVID-19 Restrictions As Cases Surge, Warns They Could Last For Up To 6 Months
- New Lockdowns Could Lead Europe To Economic Depression
- As Europe faces second coronavirus wave, tracing apps lack impact
- Latin America’s relentless outbreak
- The 10 countries with the highest deaths per capita were all in Latin America or the Caribbean
- Ministers in Israel have decided on a full lockdown to begin this Friday that is much stricter than the country’s first one in March
- As rich nations struggle, Africa’s coronavirus response is praised
- France orders bars and restaurants shut in Marseilles, Paris on “high alert”
- Paris to ban gatherings of more than 10 people
- France to announce new COVID restrictions
- Belgium eased some coronavirus restrictions with the hope that the looser rules will increase compliance
- Irish outbreak worsens
- 90% of those who died with COVID-19 in Norway also had a chronic disease
- NYC warns of new hotspots that require “urgent action”
- Japan on track to approve new COVID drug
- Indonesia reports another daily record
- Bank of America analysts warn spike in US cases driven by testing
- Canadian Prime Minister Trudeau may unveil new covid restrictions
- Study shows colleges caused huge spike in cases
- Colleges become ‘breeding grounds’ for outbreaks
- India sees cases slow to just 75,000
- Munich mandates outdoor facemasks
- Hong Kong Disney set to reopen again on Friday
- China, Japan to ease travel restrictions on foreigners
- Ottawa’s top doctor orders up to $5,000 fine for breaking COVID-19 rules
- Only one person has been fined in the NYC’s mass transit mask crackdown
- 80% Of Americans Say Post-Pandemic Food Inflation Is Impacting Their Budgets
- UBS CEO Joins JPMorgan In Push For ‘A Return To The Office’ For Staff
- CEOs Start to Place Big Bets as Pandemic Grinds On
- No Job, Loads of Debt: Covid Upends Middle-Class Family Finances
- Feds to give tobacco farmers up to $100 million in COVID-19 aid
- Global Trade Returns Faster Than Expected
- UN labor agency warns of rising global wealth inequality amid COVD-19
- “I Was Truly Alone”: Florida Waiter Laid Off Due To COVID Winds Up Homeless, Living In A Tent
- $138 Billion Bridgewater Set Up 50 “Tent Offices” In The Woods Outside Of Its HQ For Its Traders
- Littered face mask found inside stomach of dead penguin in Brazil
- Italian airline offers ‘COVID-tested flights’ to oversee coronavirus cases
- With a new coronavirus lockdown possible in Scotland, people are once again on the hunt for toilet paper
- ‘Swedish Fauci’ blames mild flu season for COVID-19 deaths
- A survey found that 90% of restaurants and bars in New York City can’t pay full rent
- Japanese firm develops first UV lamp that safely kills coronavirus
- Substitute teacher shortages loom as the school year begins
- People with ‘silent’ COVID-19 have as much coronavirus as those with symptoms
- Proud Boys denied Portland rally permit over COVID-19 concerns
- Four NYC areas, including Brooklyn ‘cluster,’ have 20% of city C19 cases
- Fast, Low-cost Testing is Essential for Averting a Second Wave of Covid-19
- Parents are hellbent on bringing Halloween back from the dead amid C19
- Parents charged for allowing teen rager that forced high school into remote learning
- ‘West Side Story,’ ‘Black Widow,’ more films stalled by COVID-19
- Metropolitan Opera to remain closed through 2021 due to COVID-19
- New research found that young Americans age 18 to 25 are more likely to believe misinformation about the virus than those over 65
- NHL bubbles made players feel ‘like an animal’
- NFL punishes more coaches for mask violation
- Notre Dame’s coronavirus outbreak halts promising season
- The death of a college football player from Covid-19 is raising questions for his university, and is prompting more athletes to think about their risks
- One More Symptom of COVID-19: Conspiracy Theories
- More than 100 teachers in Kenosha, Wis., have called in sick this week to protest their district’s decision to hold in-person classes, forcing some schools to switch to virtual learning
- Almost 90,0000 pre-K students and children with disabilities in New York City returned to classrooms
- Virus cases are reported in 100 New York City school buildings
- Maskless Wuhan clubbers party like it’s COVID-19-ninety-nine
- Why so many Americans have started their holiday shopping even earlier than usual
- As some U.S. college students party, others blow the whistle
- After 48,299 COVID-19 Cases at 37 US Universities – Only 2 Hospitalizations and ZERO Deaths — More Likely to Be Killed By a Dog
- “This Kind Of Thing Is Enough To Make One Go To The Pub. Oh, We Can’t: It’s Past 10pm…”
B. Numbers & Trends
Note: Unless otherwise noted, (i) all cases/deaths are confirmed cases/deaths that have been reported, (ii) all numbers reported in this update are as of the end of the most recent reporting period, and (iii) all changes reflect changes since the preceding day.
1. Cases & Tests (9/24)
- Total Cases = 32,085,788
- New Cases = 315,717
- New Cases (7 day average) = 285,776 (+1,863) (+0.7%)
- 2nd highest number of new cases
- 7 day average of new deaths is a record high
- 1,000,000+ cases every 4 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 7,139,553
- New Cases = 41,616
- Percentage of New Global Cases = 13.2%
- New Cases (7 day average) = 41,293 (+188) (+0.5%)
- Total Number of Tests = 100,582,090
- Percentage of positive tests (7 day average) = 5.3%
- 7 day average of new cases has been mostly trending down since 2nd peak on 7/25, with increases from 9/13 to 9/20
- 7 day average of new cases is 40.7% less than 2nd peak
- Total tests exceed 100 million
- 7 day average of percentage of positive tests, which has been trending lower, is approaching 5%
- Total Deaths = 981,228
- New Deaths = 6,273
- New Deaths (7 day average) = 5,225 (+35) (+0.7%)
- 7 day average has mostly been trending down since 2nd peak on 8/13
- 7 day average is 11.8% less than 2nd peak
- Total Deaths = 206,593
- New Deaths = 1,122
- Percentage of Global New Deaths = 17.9%
- New Deaths (7 day average) = 751 (+14) (1.9%)
- Number of new deaths is 29 less than last week
- Number of new deaths in US fall to 3rd highest, behind India and Brazil
- 7 day average of new deaths declined for the first times since recent rise in daily deaths began on 7/5, which may indicate that the rise in daily deaths has peaked
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity (9/24)
4. Trends in the Midwest/Plains Hotspots
- Positivity rates in North Dakota, South Dakota, Idaho, Missouri, and Wisconsin have nearly doubled over the last 30 days
- While the number of cases have increased and a greater number of people are testing positive (indicating a high rate of spread), the number of hospitalizations and the number of deaths are still low
|State||Cases 1||Hospitalizations||Daily Deaths 1||Positivity Rate %1|
5. Is the Fall Surge Here?
- Public health experts have long been worried that the end of the summer — as some students returned to school and the weather cooled — would bring a surge in coronavirus cases.
- That surge appears to have begun.
- The number of new daily confirmed cases in the U.S. has jumped more than 15% in the past 10 days. It is the sharpest increase since the late spring, and it has arrived just before the official start of autumn.
- Unlike the earlier summer surge in the U.S., this spike also coincides with a rising number of cases in other affluent countries, like Canada and much of Europe. The increases appeared to play a role in yesterday’s stock-market decline, as investors feared the need for new lockdowns.
- In Britain today, Prime Minister Boris Johnson plans to announce new restrictions on nightlife. In the Czech Republic yesterday, the health minister resigned. In Madrid, the authorities imposed new restrictions on almost one million residents. Across Europe, officials are hoping that these targeted restrictions will reduce new cases — and allow them to avoid imposing full lockdowns again.
- In Britain today, Prime Minister Boris Johnson plans to to announce new restrictions on nightlife. In the Czech Republic yesterday, the health minister resigned. In Madrid, the authorities imposed new restrictions on almost one million residents. Across Europe, officials are hoping that these targeted restrictions will reduce new cases — and allow them to avoid imposing full lockdowns again.
- Coming weeks may bring new problems, too: The cooler fall weather will start to complicate outdoor socializing. “And if pandemic-fatigued families travel to spend the holidays together, it will get worse in late fall and winter,” The Times’s Jeneen Interlandi wrote in an article previewing the rest of the year.
- There has been one big piece of good news. People infected today are roughly 30% to 50% less likely to die than those in the early spring, Ashish Jha, the dean of Brown University’s School of Public Health, estimates.
Source: New York Times Coronavirus Update
C. New Scientific Findings & Research
1. Only 20% infected with C19 remain asymptomatic
- Most people infected with the new coronavirus will have symptoms, according to researchers who reviewed data from nearly 80 studies of individuals with positive PCR tests for C19.
- Overall, just 20% remained asymptomatic. Five of the studies provided enough data for the researchers to examine the spread of the disease.
- Compared to C19 patients with symptoms, patients who never developed symptoms were 65% less likely to transmit the virus to others, the researchers reported on Tuesday in the journal PloS Medicine.
- “A minority of people has truly asymptomatic coronavirus infection and, if they are less infectious than people with symptoms, they probably account for a relatively small proportion of all transmission,” coauthor Dr. Nicola Low of the University of Bern told Reuters.
- “Most people will go on to develop symptoms and there is a substantial amount of transmission during the pre-symptomatic phase,” Low said.
- That means prevention measures to reduce transmission, including face covering, social distancing, physical barriers and widespread testing and contact tracing to find and isolate contagious people remains necessary.
[Note: The CDC has previously estimated that 40% of infections were asymptomatic. See https://www.wildcat.arizona.edu/article/2020/07/sc-cdc-40-percent%5D
2. Viral load has declined as pandemic progressed
- A US study from the city of Detroit, presented at this week’s ESCMID Conference on Coronavirus Disease (ECCMID, online 23-25 September) shows that the initial coronavirus viral load in nasopharyngeal samples has been decreasing as the pandemic progressed. The authors also observed that the decline in viral load was associated with a decrease in death rate. The study is by Dr Said El Zein, Wayne State University/ Detroit Medical Center, Detroit, MI, USA, and colleagues.
- The dynamics of the coronavirus viral load (VL) on a population level remain poorly characterised. In this study, the authors present data describing the downward trend in the initial coronavirus VL in nasopharyngeal swab samples of hospitalized patients in Detroit, Michigan during the period of April 4- June 5, 2020.
- They conducted a retrospective study that included all hospitalized patients who had initial nasopharyngeal swab samples analyzed at the Detroit Medical Center, that returned positive for the coronavirus by PCR testing between April 4 and June 5, 2020. To estimate the viral load, the authors used the so-called cycle threshold (Ct) value provided by the test for each sample – a higher Ct indicates a lower viral load. Based on their studies, the authors designated high, intermediate, and low VL samples to have a Ct value of 25 or under, 26-36, and 37 or over, respectively.
- During the first week of the study (week of April 4, 2020), 49% of the initial VL samples were in the intermediate group, compared to 25.5% each in the low and high VL categories respectively. Thereafter, there was a progressive decline in the percentage of samples in the high and intermediate VL categories with a concomitant rise in the percentage of samples in the low VL category.
- By week five of the study, 70% of the positive samples had an initial low VL. This trend in initial VL coincided with a decrease in the percent of deaths (see figure 1 in abstract). Almost half of the patients in the high VL group died (45%) compared to 32% and 14 % of the intermediate and low VL categories respectively (Figure 2).
- The authors conclude: : “During the April-June 2020 period of the C19 pandemic, the initial coronavirus load steadily declined among hospitalized patients with a corresponding decrease in the percent of deaths over time.Though confounding variables have not been evaluated, this suggests an association between initial viral load and mortality.”
- Dr El Zein adds: “Exact reasons for a decrease in initial viral load over time are unclear. A downward trend in the initial VL may reflect a reduction in the severity of the pandemic and trends in the viral load values over time may represent a marker to assess the progress of the pandemic. Rapid implementation of social distancing measures, lockdown and widespread use of facemasks may have contributed to a decrease in the exposure to the virus.”
3. As many as 90% of C19 infections may not be infectious at all
- A growing body of research suggests that a significant number of confirmed C19 infections in the U.S. — perhaps as many as 9 out of every 10 — may not be infectious at all, with much of the country’s testing equipment possibly picking up mere fragments of the disease rather than full-blown infections.
- Confirmed cases of the disease have been the focal point of public health authorities and governments worldwide for many months, with countries across the globe working frantically to shore up their testing infrastructure and ensure that most citizens who want a C19 test can obtain one with relative ease.
- Many politicians, meanwhile — including most state governors in the U.S. — have tied reopening policies to the number of cases detected in the local community, with regions and localities often being permitted to reopen in staggered “phases” only when they have reached successively lower benchmarks of average new daily cases in the area.
- Numerous institutions, meanwhile, have adopted testing protocols in an attempt to preempt the spread of the virus. American colleges and universities, for instance, have turned to mass testing in order to closely monitor incidences of the disease among students, particularly residential students living on campus.
- Yet a burgeoning line of scientific inquiry suggests that many confirmed infections of C19 may actually be just residual traces of the virus itself, a contention that — if true — may suggest both that current high levels of positive viruses are clinically insignificant and that the mitigation measures used to suppress them may be excessive.
‘Cycle threshold’ set very high for many tests
- At issue is the method by which many C19 tests detect a patient’s viral load within a given sample. Polymerase chain reaction tests, which have been widely deployed to determine if individuals are infected with the disease, function by amplifying DNA samples to the point that an antigen can be detected and classified.
- The “cycle threshold” is the number of amplification cycles a PCR test goes through before a target pathogen is detected. A lower cycle threshold means that a higher amount of the virus was present in the sample; a higher threshold means the machine had to work harder to detect the virus in the sample, indicating a lower viral load and more likely a non-infectious patient.
- According to a rundown of PCR tests compiled by the Foundation for Innovative New Diagnostics, many manufacturers of PCR tests set the cycle threshold cutoff for a positive sample at up to around 40 cycles, a level numerous public health officials believe is guaranteed to return what are effectively false positive results that have detected fragments of the virus.
- “I’m shocked that people would think that 40 could represent a positive,” Juliet Morrison, a virology professor at the University of California, Riverside, told the New York Times in August.
- Health authorities elsewhere have indicated similar skepticism of high-threshold tests. A spokeswoman for Taiwan’s Central Epidemic Command Center said in June that the agency only assigns positive cases to samples with Cts of 35 or less, with authorities there believing that any samples with Cts of more than 32 are likely (though not definitely) non-infectious.
- A team of researchers at Oxford, meanwhile, wrote in a preprint paper last week that, based on a review of various sample collections, swabs requiring more than 30 cycles were “associated with non-infectious samples.”
- Binary positive-negative test results — in which cycle thresholds are not considered — will “result in false positives with segregation of large numbers of people who are no longer infectious and hence not a threat to public health,” they wrote.
- Preprint papers have not yet been through the peer review process, so their results and conclusions can be changed prior to full publication. Yet several other research projects have indicated similar results. One, published in April by public health authorities out of France, found that “patients with Ct values equal or above 34 do not excrete infectious viral particles.”
- Similarly, a study out of Ireland seeking to determine “the duration of infectivity” of C19 patients found that, of numerous samples subject to PCR testing, scientists were unable to achieve positive culture growth in any that required more than 34.3 cycles.
- Both of those thresholds are notably smaller than the maximum number of cycles instituted by many test manufacturers, suggesting that there may be many nominally positive C19 cases that are innocuous far as infectiousness and illness are concerned.
- Echoing those concerns, researchers at Harvard in May argued that “the Ct value from positive test results, when interpreted in context, can help to refine clinical decision making,” and that a cycle threshold of around 34 may be a useful tool for determining when a patient is truly infectious and when he or she is merely carrying remnants of the virus.
- Such a policy, if implemented, could have momentous implications for public health policy in the U.S. and elsewhere. Presently, in many industries and at many institutions, a single positive C19 case can result in a complete shutdown of the affected company or university or elementary school, followed by a rush to have everyone tested out of concern that the virus may have spread.
- A greater emphasis on the cycle threshold of positive tests may preempt such disruptive policies by signaling which positive test results are truly infectious and which are detecting low viral loads at much less threat of infectivity.
- Early indications suggest the number of clinically trivial positive cases in the U.S. might be startlingly high. The NY Times said last month that a review of the cycle thresholds of positive cases in Nevada, New York and Massachusetts indicated that “up to 90% of people testing positive carried barely any virus.”
- Those numbers, if extrapolated nationwide, could suggest that a significant proportion of the mitigation and preparation measures currently in place across the U.S. might be excessive relative to the actual level of infectious cases around the country.
- Ultimately it can be difficult to determine the cycle thresholds used at laboratories across the country, making that kind of extrapolation difficult. A spokeswoman for LabCorp — one of the largest clinical laboratory groups in the world — said the company “does not include the CT value in result reporting.”
- “Our CT cutoff is based on extensive validation,” she said, “and is within the accepted range to accurately identify individuals currently infected with SARS-CoV-2.” The company on its website says it has performed 13.5 million C19 tests, about 15% of the country’s total number of tests.
- At the Center for Evidence-Based Medicine at Oxford University, researchers stressed last month that “PCR detection of viruses is helpful so long as its limitations are understood; while it detects RNA in minute quantities, caution needs to be applied to the results as it often does not detect infectious virus.”
- “If this is not understood, PCR results may lead to restrictions for large groups of people who do not present an infection risk,” they wrote.
D. Improved & Potential Treatments
1. Statins reduce C19 severity by 50%
- There are no FDA-approved treatments for C19. While several therapies are being tested in clinical trials, current standard of care involves providing patients with fluids and fever-reducing medications. To speed the search for new C19 therapies, researchers are testing repurposed drugs — medicines already known to be safe for human use because they are FDA-approved for other conditions — for their abilities to mitigate the virus.
- UC San Diego Health researchers recently reported that statins — widely used cholesterol-lowering medications — are associated with reduced risk of developing severe C19 disease, as well as faster recovery times. A second research team at UC San Diego School of Medicine has uncovered evidence that helps explains why: In short, removing cholesterol from cell membranes prevents the coronavirus from getting in.
- The clinical study, published September 15, 2020 in American Journal of Cardiology, was led by Lori Daniels, MD, professor and director of the Cardiovascular Intensive Care Unit at UC San Diego Health, and Karen Messer, PhD, professor and chief of the Division of Biostatics and Bioinformatics in the Department of Family Medicine and Public Health.
- The mechanistic study, published September 18, 2020 in The EMBO Journal, was led by Tariq Rana, PhD, professor and chief of the Division of Genetics in the Department of Pediatrics at UC San Diego School of Medicine and Moores Cancer Center.
Patients with C19 who took statins fared better
- A molecule known as ACE2 sits like a doorknob on the outer surfaces of many human cells, where it helps regulate and lower blood pressure. ACE2 can be affected by prescription statins and other medications used for cardiovascular disease.
- But, in January 2020, researchers discovered a new role for ACE2: the coronavirus primarily uses the receptor to enter lung cells and establish respiratory infections.
- “When faced with this novel virus at the beginning of the pandemic, there was a lot of speculation surrounding certain medications that affect ACE2, including statins, and if they may influence C19 risk,” Daniels said. “We needed to confirm whether or not the use of statins has an impact on a person’s severity of coronavirus infection and determine if it was safe for our patients to continue with their medications.”
- To do this, Daniels, Messer and team retrospectively analyzed the electronic medical records of 170 patients with C19 and 5,281 COVID-negative control patients hospitalized at UC San Diego Health between February and June 2020. They collected anonymized data that included the patients’ disease severity, length of hospital stay, outcome, and use of statins, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) within 30 days prior to hospital admission.
- Among the patients with C19, 27 percent were actively taking statins on admission, while 21% were on an ACE inhibitor and 12% on an ARB. The median length of hospital stay was 9.7 days for patients with C19.
- The researchers found that statin use prior to hospital admission for C19 was associated with a more than 50% reduction in risk of developing severe C19, compared to those with C19 but not taking statins. Patients with C19 who were taking statins prior to hospitalization also recovered faster than those not taking the cholesterol-lowering medication.
- “We found that statins are not only safe but potentially protective against a severe C19 infection,” said Daniels. “Statins specifically may inhibit coronavirus infection through its known anti-inflammatory effects and binding capabilities as that could potentially stop progression of the virus.”
- This initial study was relatively small and focused on a single health system. Moving forward, Daniels is partnering with the American Heart Association to analyze thousands of patients all over the country to corroborate the data she’s developed locally.
- “I tell my patients who are on statins, ACE inhibitors or other ARBs to keep taking them,” she said. “Fears of C19 should not be a reason to stop, if anything our research findings should be incentive to continue with their medication.”
Draining cholesterol from cell membranes blocks coronavirus entry
- Statins weren’t yet on Rana’s radar when they began their EMBO Journal study approximately six months ago. At first, his team was simply curious to see which genes are switched “on” in human lung cells in response to coronavirus infection.
- A gene called CH25H was “blazing hot,” Rana said. CH25H encodes an enzyme that modifies cholesterol. “I got excited because with HIV, Zika, and a few others, we know that CH25H blocks the virus’ ability to enter human cells.”
- Here’s what’s happening inside our cells: CH25H’s enzymatic activity produces a modified form of cholesterol called 25-hydroxycholesterol (25HC). In turn, 25HC activates another enzyme called ACAT, found inside cells in the endoplasmic reticulum. ACAT then depletes accessible cholesterol on the cell’s membrane. It’s a normally occurring process that gets kicked into high gear during some viral infections.
- The team quickly got to work examining 25HC in the context of coronavirus from several angles. They explored what happens to human lung cells in the lab with and without 25HC treatment when they are exposed to first a noninfectious virus that carries the coronavirus spike protein (its key to cell entry) or to live coronavirus itself.
- No matter which way they came at it, added 25HC inhibited the ability of the virus to enter cells — blocking infection almost completely.
- “The difference between untreated cells and those treated with 25HC was like day and night,” Rana said.
- While the coronavirus uses the ACE2 receptor to initially dock on a cell, Rana’s study suggests that the virus also needs cholesterol (normally found in cell membranes) in order to fuse with and enter the cell. 25HC takes away a lot of that membrane cholesterol, preventing viral entry.
- In a similar way, statins are likely beneficial in preventing or reducing the severity of coronavirus infection because, while intended to remove cholesterol from blood vessels, they are also removing cholesterol from cell membranes. As a result, the coronavirus can’t get in.
- “This is already happening in our bodies on a regular basis, so perhaps we just need to give it a boost, with statins or by other means, to better resist some viruses,” Rana said. “It’s not unlike cancer immunotherapy — the idea that sometimes instead of attacking a tumor directly, it’s better to arm a patient’s immune system to do a better job of clearing away tumors on its own.”
- If it can be developed into a therapeutic, 25HC might work even better as an antiviral than statins, Rana said. That’s because it works specifically on cholesterol in cell membranes, rather than cholesterol throughout the body. Like all medications, statins can cause negative side effects, including digestive problems and muscle pains, and may not be an option for many people with C19. What’s more, while some previous studies suggested statins may also elevate ACE2 levels, which could allow more viral entry, Rana’s team did not see an increase in the receptor in response to 25HC.
- Statins are FDA-approved for human use, but 25HC is a natural product currently available only for laboratory work. Rana and team plan to continue optimizing 25HC as a potential antiviral agent. Many steps remain before it might be tested in human clinical trials.
E. Concerns & Unknowns
1. Who’s Most At Risk in the C19 Mental Health Crisis
- It doesn’t take a scientific study to know that the coronavirus pandemic is taking a tremendous toll on the mental health of people around the world. Maybe you’re feeling it yourself, your brain and body buckling under unprecedented levels of prolonged stress.
- But scientific research is capturing the scale of the mental health crisis in numbers, helping reveal its full scope and the factors underlying it. This information is crucial for public health experts to develop a public mental health response to the pandemic. A paper published in the journal Science on Friday shows the link between psychological symptoms and the C19 pandemic between March and April in the U.S. Empirical studies on the mental health effects of C19, the University of California, Irvine researchers note, are rare — making up just 3% of the published literature on the coronavirus.
- Between March 18 and April 18 of this year, which the authors describe as an “escalating period of illness and death in the United States,” acute stress and depressive symptoms significantly increased among Americans. The researchers based their analysis on survey data from a nationally representative group of 6,514 people who were asked not only about their experience of stress and depression during the pandemic but also about coronavirus-related job loss, social media exposure, and personal loss.
- In addition to showing evidence for the link between worsening mental health and the worsening pandemic, the study identifies the people who are most likely to experience worsening mental health. The survey data allowed the researchers to identify “predictors” — factors that suggest someone is more likely to suffer mental health issues due to C19.
- People who have preexisting mental or physical health conditions, for example, are more likely to have both acute stress and depressive symptoms related to the coronavirus. In particular, having a preexisting psychiatric condition is the strongest predictor of depressive symptoms. Prior victimization, like being bullied, was also linked with the emotional responses of young adults during the pandemic. Another strong predictor of acute stress and depression is losing one’s job or wages and experiencing shortages of necessities. And a particularly eye-opening finding is that one of the strongest predictors of pandemic-related acute stress is extensive exposure to C19-related media — which includes exposure to conflicting information in the news.
- The survey data also revealed that more young people experienced acute stress and depression related to the coronavirus; that psychological symptoms didn’t abate after lockdown; and, interestingly, that people who continued to work during the early part of the pandemic were less depressed than people who didn’t, even though they were at higher risk of getting C19. One explanation for the latter observation might be that people who lost their jobs were more depressed, but an alternative explanation is that people who continued working in “essential” services had found renewed meaning in their jobs.
So, how can this information help?
- Public health officials can use these learnings to target the people who are most at risk and support them accordingly, the researchers write. Clearly, people with preexisting mental and physical health conditions must be a priority when allocating mental health services. Those who have lost their jobs or are struggling to make ends meet are likewise in crucial need of mental health support, as well as help mitigating their economic losses so they don’t enter a “loss spiral” in which their financial stress causes psychological distress. And public health messaging needs to be crystal clear — no more flip-flopping guidance on whether to wear masks, for example (you should definitely wear a mask). Young people, facing uncertainty, are also in need of mental health support.
- One factor this study doesn’t specifically look into is the role of race, although the data the researchers used is meant to be a representative snapshot of the entire U.S. population. People of color, especially Black Americans, have been hit especially hard by the coronavirus; Black, Hispanic, and other people of color are not only dying at higher rates than white Americans but also experiencing disproportionate job loss. A few studies have shown that their mental health is disproportionately suffering, too. These people must also be taken into account by public health officials when deciding whose mental health to prioritize.
- The spread of C19 should end with the development and distribution of a vaccine, if all goes accordingly. But it’s time that our leaders understand that the psychological trauma of living through the pandemic — especially for the vulnerable people identified by this study and others — may continue far into the future if nothing is done to help them now.
2. There’s Growing Concern C19 Could Spark a Wave of Parkinson’s Disease
- As the world struggles with the ongoing crisis of the coronavirus pandemic, scientists warn that the infection may pose yet another serious threat to human health, in the form of a “silent wave” of neurological consequences that could follow in the wake of the virus.
- While the specific risks remain hypothetical at this point, the concerns are very real. In fact, a similar long-term effect was seen after the Spanish Flu pandemic last century.
- We already know that C19 has links to brain damage, neurological symptoms, and memory loss. What’s less clear is how the infection can bring about these crippling symptoms, in what volume, and to what ultimate effect.
- “Although scientists are still learning how the coronavirus is able to invade the brain and central nervous system, the fact that it’s getting in there is clear,” says neuroscientist Kevin Barnham from the Florey Institute of Neuroscience & Mental Health in Australia.
- “Our best understanding is that the virus can cause insult to brain cells, with potential for neurodegeneration to follow on from there.”
How to measure that potential is the big question
- In a new study, Barnham and his co-authors propose that the “third wave” of the C19 pandemic might not be a resurgence in coronavirus infections, but a subsequent increase in viral-associated cases of Parkinson’s disease, seeded by neuroinflammation, triggered in the brain as an immune response to the virus.
- There’s no hard evidence yet to confirm such a surge in parkinsonism will ultimately result, it’s worth noting.
- But something very much like this did happen once before, during the last and most comparable pandemic to grip the world: the 1918 Spanish Flu, where a form of brain inflammation called encephalitis lethargica tied to the pandemic increased the risk of parkinsonism by two to three times.
- “We can take insight from the neurological consequences that followed the Spanish Flu pandemic in 1918,” Barnham says.
- “Given that the world’s population has been hit again by a viral pandemic, it is very worrying indeed to consider the potential global increase of neurological diseases that could unfold down track. The world was caught off guard the first-time, but it doesn’t need to be again.”
- While the researchers acknowledge there is currently insufficient data to quantify the increased risk of developing Parkinson’s disease in relation to C19 infections, they suggest the best way of identifying future cases early would be long-term screening of SARS-CoV-2 cases post-recovery, monitoring for expressions of neurodegenerative disease.
- As it happens, the new research coincides with the publication of a case report from Israel highlighting the kinds of risks Barnham and his colleagues are anticipating, even if the episode itself remains far from clear.
- In what appears to be the first documented case of a patient developing Parkinson’s disease after an earlier SARS-CoV-2 infection, doctors recount how a 45-year-old man was hospitalised in March with C19 symptoms, experiencing cough, muscle pain, and a loss of smell.
- During a following period of isolation in a C19 facility, he began to experience difficulties communicating, both speaking and writing, and also showed signs of tremor and impaired walking, with subsequent testing indicating a diagnosis of Parkinson’s disease.
- While the man’s doctors acknowledge that the mechanism bringing about his neurodegeneration is unclear, they say it’s hypothetically possible his condition was triggered somehow by inflammation in the brain caused by the virus, after the infection took hold in his central nervous system.
- That said, the short time window between his C19 infection and the development of Parkinson’s symptoms make the hypothesis unlikely, they admit, calling the temporal association “intriguing”, even if we can’t conclude much for certain from this isolated case.
- In this case, the man had no family history of Parkinson’s disease or obvious genetic signs of predisposition, but it’s possible, some think, that the infection might exacerbate or accelerate the development of latent Parkinson’s that hasn’t yet revealed itself.
- “C19 infection may have been a stressor that brings previously subtle, unrecognised symptoms to a point of awareness,” neurologist Alberto Espay from the University of Cincinnati, who was not involved with the case, told MedPage Today.
- “It’s not that those exposures caused Parkinson’s but, rather they acted as precipitants, exacerbating subtle Parkinson’s symptoms to a threshold of severity making them noticeable for the first time to patients and physicians.”
- While that’s largely speculative, for now at least, it emphasises the possibility that future cases of Parkinson’s after C19 might be capable of detection early, if we just know what to look out for, and recognise them before the condition has fully developed, at which point mitigation is no longer an option.
- “By waiting until this stage of Parkinson’s disease to diagnose and treat, you’ve already missed the window for neuroprotective therapies to have their intended effect,” Barnham says.
- “Alongside a strategised public health approach, tools for early diagnosis and better treatments are going to be key.”
- The findings are reported in the Journal of Parkinson’s Disease.
3. Heart attack treatment has slowed during pandemic
- The average time from when a heart attack starts to when treatment begins has gotten longer during the pandemic, and researchers attribute most of the delay to patients’ fears of contracting C19 if they go to a hospital.
- In a study published in the American Journal of Emergency Medicine, doctors in China found the average time from symptom onset to first contact with a healthcare provider was about an hour longer in January to April 2020 than during the same period in 2019.
- And this year, after arrival at the hospital, the time until a blocked artery was reopened was 22 minutes longer – and more heart attack patients died, the authors say.
- Coauthor Dr. Ming-Wei Wang from Affiliated Hospital of Hangzhou Normal University told Reuters patients need to understand the importance of getting to a hospital quickly, and C19 screening at hospitals should be hastened for patients with chest pain.
- Dr. Aditya Kapoor from India’s Sanjay Gandhi Postgraduate Institute of Medical Sciences, who was not involved in the study, said other studies have found similar delays. “Resource and manpower allocation to C19 treatment, lockdown restrictions, and patient apprehensions related to hospital visits all play an important role,” he said.
1. Silk Offers Homemade Solution for C19 Prevention – More Protection Than Cotton Face Masks
- With personal protective equipment still in short supply, researchers at the University of Cincinnati examined what common household fabrics might work best as a face covering.
- Next to a single-use N95 respirator or surgical mask, UC found the best alternative could be made by a hungry little caterpillar. Silk face masks are comfortable, breathable, and repel moisture, which is a desirable trait in fighting an airborne virus.
- Perhaps best of all, silk contains natural antimicrobial, antibacterial and antiviral properties that could help ward off the virus, said Patrick Guerra, assistant professor of biology in UC’s College of Arts and Sciences.
- Studies have shown that copper, in particular, can kill bacteria and viruses on contact. And that’s where the little caterpillars have their own superpower, Guerra said.
- “Copper is the big craze now. Silk has copper in it. Domesticated silk moths eat mulberry leaves. They incorporate copper from their diet into the silk,” Guerra said.
- Many health care providers wear a surgical mask in combination with an N95 respirator. The outer covering helps prolong the life of the N95 respirator by keeping it clean. Guerra, whose wife, Evelyn, is a medical doctor, said silk might be an especially good choice for this outer cover as they perform similarly to surgical masks that are in short supply.
- “Cotton traps moisture like a sponge. But silk is breathable. It’s thinner than cotton and dries really fast,” Guerra said.
- With C19 surging in parts of the United States, face masks have become a focal point of prevention.
- In the UC biology lab, researchers tested cotton and polyester fabric along with multiple types of silk to see how effective a barrier each is for repelling water, representing respiratory droplets containing the virus. They found that silk worked far better as a moisture barrier than either polyester or cotton, both of which absorb water droplets quickly.
- UC’s study concluded that silk performs similarly to surgical masks when used in conjunction with respirators but has the added advantages of being washable and repelling water, which would translate to helping to keep a person safer from the airborne virus.
- “The ongoing hypothesis is that coronavirus is transmitted through respiratory droplets,” Guerra said. “If you wore layers of silk, it would prevent the droplets from penetrating and from being absorbed. Recent work by other researchers also found that increasing layers of silk improves filtration efficiency. This means that silk material can repel and filter droplets. And this function improves with the number of layers.”
- The study was published this month in the journal Plos One.
2. Most KN95 masks fall short of U.S. standards for effectiveness
- Up to 70% of KN95 masks manufactured in China do not meet U.S. standards for effectiveness, an analysis by ECRI found.
- ECRI, a patient safety organization, said it found 60% to 70% of imported KN95 masks do not filter 95% of aerosol particulates despite the standard the KN95 mask name suggests. ECRI tested nearly 200 masks from 15 different manufacturer models purchased by some of the largest health systems in the U.S.
- The testing was conducted by ECRI’s quality assurance researchers at the organization’s independent medical device laboratory.
- The finding raises concerns for the safety of both patients and providers in the midst of the C19 pandemic.
- “Because of the dire situation, U.S. hospitals bought hundreds of thousands of masks produced in China over the past six months and we’re finding that many aren’t safe and effective against the spread of C19,” said Marcus Schabacker, M.D., Ph.D., ECRI’s president and CEO, in a statement.
- There are still mixed reports of a lack of adequate personal protective equipment supplies at hospitals nationwide. Last week, Centers for Medicare & Medicaid Services Administrator Seema Verma told Fierce Healthcare that federal authorities assured the White House’s coronavirus task force that hospitals had their necessary supplies. However, in some areas of the country, healthcare workers continue to protest a lack of adequate protection.
- In the early days of the pandemic, many providers even purchased their own PPE amid widespread shortages and reports hospitals were competing against the U.S. government for supplies.
- ECRI recommends healthcare providers do more due diligence before purchasing masks that aren’t made or certified in the U.S. It also recommends noncertified KN95 masks be reserved for use in healthcare settings in non-C19 circumstances.
3. Plastic face shields do not stop spread of C19
- Plastic face shields are all but useless when it comes to defeating the spread of the coronavirus, according to a new Japanese study.
- The clear coverings were tested in a simulation by Fugaku, the world’s fastest supercomputer, which found that nearly 100 percent of airborne droplets less than 5 micrometers in size escaped through the shields, the Guardian reported Tuesday.
- One micrometer is the equivalent of one-millionth of a meter.
- The shields, typically used by workers in the restaurant industry, were also ineffective at trapping larger droplets measuring 50 micrometers — about half of which were also able to escape.
- The study was conducted by Riken, a government-backed researcher center in Kobe, Japan.
- In order to reach its results, the Fugaku simulation combined airflow with thousands of particles of various sizes.
- Makoto Tsubokura, a team leader at Riken, said regular face masks should be used instead of face shields.
- “Judging from the results of the simulation, unfortunately the effectiveness of face guards in preventing droplets from spreading from an infected person’s mouth is limited compared with masks,” he told the Guardian.
- Tsubokura said people who are not recommended to wear face masks could resort to donning shields — but only if they were outdoors or in indoor settings with proper ventilation.
- Fugaku has conducted other simulations, recently finding that face masks made out of non-woven fabric are more effective at preventing the spread of C19 than those made of cotton and polyester, the outlet noted.
- Researchers at Duke University made similar findings last month, concluding that N95 masks are most effective but three-layer surgical masks and cotton masks are good stand-ins as well.
G. The Road Back?
1. Thousands of American Troops to Take Part in C19 Early-Detection Study
- Thousands of Defense Department personnel are slated to take part in a C19 early-detection study that looks to identify troops with barely perceptible symptoms and quarantine them early.
- If successful, the study, which will collect data on the troops, could point the way to a widely used, noninvasive method of detecting C19 symptoms even before a patient feels sick. Researchers said they hope to learn more through the study about what it means to be asymptomatic.
- Officials plan for more than 5,000 largely U.S.-based troops in coming weeks to join a joint study between the Defense Department and Koninklijke Philips NV, a global health technology company, to use bio-measuring devices like smartwatches that identify people infected with C19, quarantine them and treat the illness.
- For more than two years, Department of Defense research units have been collaborating on software developed by Philips that closely monitors a variety of biomarkers like pulse, temperature and oxygen saturation to look for barely recognizable symptoms of illness, sometimes before a person sees any changes.
- The research began as a way to non-invasively monitor troops to see when they might be coming down with something like seasonal flu and to quarantine them before they get the rest of their team or platoon sick. The program has been fast-tracked in light of the coronavirus pandemic.
- The program can’t diagnose an illness, but it can show that there might be a problem.
- “We compare it to the check engine light in your car,” said Christian Whitchurch, human systems director at the Defense Department’s Defense Innovation Unit. “When something goes wrong, you’re told to go see the mechanic.”
- Among the markers of someone who is an asymptomatic carrier of C19 might be small changes in blood oxygen levels or heartbeat and respiratory patterns, said John Hannan, a top official at the Defense Threat Reduction Agency, which is part of the Defense Department.
- “There are subtle changes in physiology that aren’t easy to detect under regular clinical means. You can see these changes before they become symptomatic,” said Dr. Joseph Frassica, head of Philips research in the Americas.
- There are limitations to the data collection because troops are younger and healthier than the general population. As of Monday, there have been 43,419 C19 cases among U.S. service members, according to the Pentagon, and seven related deaths.
- It isn’t clear whether the demographics of the study participants could alter how the detection technology should be used with the general population.
- About 1,000 troops have already begun wearing smart rings or smartwatches connected to the Philips RATE system, which tracks key biomarkers and compares them to millions of cases of patients who have been monitored previously. Troops send real-time biodata to the RATE system—which is in use in some hospitals—and are told if their bodies show signs of illness that require consultation with a physician.
- Defense officials said this pilot study has already flagged multiple cases where troops later tested positive for C19.
- Apart from C19, the technology can be useful for perennially problematic infectious diseases like the flu, especially in concentrated troop populations or settings like college dormitories where people live in close proximity and diseases can quickly run rampant.
- Mr. Whitchurch said data uploaded to the cloud doesn’t include GPS or location data and personal data is protected. Years ago, concerns arose when some tracking apps were shown to give away troop locations.
- Military and medical advancements have long been intertwined, often because progressions have come via lessons learned from war injuries. Perhaps most famously, U.S. Army surgeon Maj. Walter Reed made advancements in the understanding of yellow fever after troops were exposed to illnesses in battle.
- But the use of troops for medical testing is more fraught, particularly in instances when the military has exposed troops to little-known or understood ailments or chemicals, such as mustard gas. Troops have sued the military in the past, citing the long-term effects of the experiments.
- The C19 detection study poses fewer risks than some past medical studies involving U.S. troops, though could lead the military to lean more on technology to determine readiness, said Jonathan Moreno, a professor of bioethics at the University of Pennsylvania. While the data may help predict C19 now, some worry it could lead to more pressure for intrusive information gathering in the future.
- “Should we ask for consent if it reveals medical issues that a person in uniform may not want revealed and is not relevant to job performance? What else can be learned in theory that could be damaging to them?” said Mr. Moreno.
2. There’s a New Weapon Against C19. And It’s Dogs
- No one is going to feel safe traveling during this pandemic—especially as the cramped quarters of airplanes and cruise ships make social distancing more or less impossible. But since we can’t redesign travel, many airports have taken a different tack: limiting who is allowed to. At airports such as LAX, temperature screenings attempt to catch sick travelers before they pass through security.
- But now, the Helsinki Airport is doing one better: It’s hiring a team of dogs, trained to sniff out C19, to screen passengers.
- Dogs have already proven their ability to sniff out diseases ranging from cancer to malaria. While we don’t always know exactly what they are detecting to ferret out specific illnesses, the clues are likely tied to a dog’s ability to smell volatile organic compounds—the metabolic junk our bodies produce all the time, which can vary with illness.
- With 220 million scent receptors, versus the 5 million receptors that humans have, they have a sense of smell that’s 10,000 times more accurate than our own. They can sniff substances that are diluted to a point of just one part per trillion, or the equivalent of smelling one drop of liquid in the combined volume of 20 Olympic swimming pools.
- Researchers at the Veterinary Faculty of the University of Helsinki have been training dogs to be able to detect C19 since early 2020. In May, the research group reported that it had successfully trained dogs to detect C19 in urine samples. But progress has happened fast. Now, the dogs have been trained to detect C19 from sweat on our skin and have started trial testing at the Helsinki Airport.
- According to International Airport Review, these canines need as little as 10 molecules to detect C19, while current test equipment requires 18,000,000. And there’s no comparison of speed. Abbot Labs has a 15-minute test that costs $5 to administer. Dogs can detect C19 more or less instantly, and without an uncomfortable nasal swab.
- The screening process won’t be as simple as letting passengers walk by while a dog casually sniffs, however. Instead, passengers will be instructed to rub their skin with a wipe, then drop the wipe into a cup. The dog will sniff this cup inside an isolated booth. This arrangement allows for anonymous processing that protects a person’s privacy, while shielding the handler from direct contact with a potentially infected passenger. Any passenger who is suspected of having C19 will be directed to the airport’s health information area.
- The Helsinki program will soon employ four dogs but could expand to as many as 22 as enough canines are trained for the task. And while it’s unclear if the idea will scale beyond one airport—nursing homes would be another excellent use case of such dogs, according to researchers—it makes for a fascinating case study on how we don’t necessarily need more technology to screen for C19 when 130,000 years of domesticated canine evolution is already on our side.
H. Back to School!?
1. Feared coronavirus outbreaks in schools yet to arrive
- Thousands of students and teachers have become sick with the coronavirus since schools began opening last month, but public health experts have found little evidence that the virus is spreading inside buildings, and the rates of infection are far below what is found in the surrounding communities.
- This early evidence, experts say, suggests that opening schools may not be as risky as many have feared and could guide administrators as they chart the rest of what is already an unprecedented school year.
- “Everyone had a fear there would be explosive outbreaks of transmission in the schools. In colleges, there have been. We have to say that, to date, we have not seen those in the younger kids, and that is a really important observation,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
- This does not mean the risk of contracting the coronavirus is zero. Poor and inconsistent reporting in many parts of the country means that experts do not yet have a full view of the situation, and most schools have been open for only a few weeks. It’s also unclear how closely the incidence of the coronavirus in schools is tied to policies in schools such as mandatory mask-wearing.
- Most of the nation’s largest districts opened with fully remote teaching, so the data are largely from smaller communities. And the pandemic may grow worse as flu season and winter approaches.
- But the fact that large swaths of the country opened for in-person school while others did not offers the more cautious districts a chance to observe how things have gone elsewhere in charting their next steps.
- On Wednesday, researchers at Brown University, working with school administrators, released their first set of data from a new National C19 School Response Data Dashboard, created to track coronavirus cases. It found low levels of infection among students and teachers.
- Tracking infections over a two-week period beginning Aug. 31, it found that 0.23% of students had a confirmed or suspected case of the coronavirus. Among teachers, it was 0.49%. Looking only at confirmed cases, the rates were even lower: 0.078% for students and 0.15% for teachers.
- “These numbers will be, for some people, reassuring and suggest that school openings may be less risky than they expected,” said Emily Oster, an economics professor at Brown University who helped create the tracker. She noted that the school coronavirus rates are “much lower” than those in the surrounding community.
- Still, she said: “I don’t think that these numbers say all places should open schools with no restrictions or anything that comes close to that. Ultimately, school districts are going to have different attitudes toward risk.”
- The information for her dashboard is voluntarily reported by schools and school districts, both public and private, including schools that offer in-person classes and those that are fully remote. As of Wednesday morning, the project had data from more than 550 schools, including more than 300 that have some in-person classes. Organizers are working to add more schools as they go.
- Separately, the early data from Texas also shows low levels of infection. Since the start of school, 3,445 Texas students reported positive coronavirus tests — or about 0.31 percent of the 1.1 million students attending school in person, according to data released Wednesday. An additional 2,850 school employees tested positive, although a rate could not be calculated because it was not clear how many of the state’s more than 800,000 school staff members were working in school buildings.
- Teacher’s unions in Texas that keep track of infections say they have been surprised by how low it was. In many parts of the country, teacher’s unions have resisted school systems’ efforts to return to classes, saying sufficient safeguards were not in place.
- “I am not seeing at this particular point the rate I had expected,” said Zeph Capo, president of the Texas branch of the American Federation of Teachers.
- He said this is partly because parents in communities most affected by the coronavirus are less willing to send their children back to school. And he predicted that the numbers will rise as more students return to buildings and if the pandemic worsens this winter, as experts are expecting.
- There’s also evidence from the Northeast. The Network for Public Education, a nonprofit advocacy organization that supports traditional public school districts, has been tracking 37 school districts in Connecticut, New York and Pennsylvania.
- In the weeks since school started, there have been 23 confirmed cases of the coronavirus across 20 schools and no indication that the virus was spread in schools, said Carol Burris, the network’s executive director.
- The districts studied were in counties with low coronavirus rates and all required wearing masks.
- “So far, in the schools that we are following . . . outbreaks have not occurred, even when someone tests positive for C19,” Burris said.
- “We’re not seeing schools as crucibles for onward transmission,” said Sara Johnson, associate professor of pediatrics at the Johns Hopkins University School of Medicine. “It’s reasonable to say that it looks promising at this point.”
- She added that data suggest that schools should bring students back “slowly and carefully” and with safeguards to protect teachers and staff members. “These data are promising but covid is still a very big threat to people,” she said.
- These findings were underscored by an analysis this week in Science magazine, a leading academic journal. It found that children and adolescents are at a “much lower risk” for the coronavirus and said assumptions that schoolchildren would be a “key component” of the transmission chain are “most likely” wrong.
- “Relative to their risk of contracting disease, children and adolescents have been disproportionately affected by lockdown measures,” it contended.
- The early data are emerging as school officials continue to evaluate their plans and consider whether they want to change course. Many districts that began with entirely remote education are considering whether they want to introduce in-person options for some students or on certain days.
- The data are helpful but superintendents will want more detail, such as information about districts similar to their own, and what covid mitigation strategies seem to have worked, said Noelle Ellerson Ng, an associate director at AASA, the School Superintendents Association, which is a co-sponsor of the new dashboard reporting tool.
- She called the early data “potentially optimistic” but said it is premature for districts to change course and decide to open their buildings.
- Much of the concern is focused on teachers and other adults in the building, because data shows that C19, the disease caused by the coronavirus, is far more deadly to older patients.
- According to the American Federation of Teachers, 14 active teachers, principals and counselors have died of C19 since the school year started, although it is not possible to conclude that any one of them contracted the coronavirus at school.
- Some experts, including teacher’s union officials, say it appears that coronavirus rates are lower in school districts where face coverings are required and polices are enforced to keep distance between students in the building, although there is scant data to prove the correlation.
- Randi Weingarten, president of the American Federation of Teachers, said the “science worked” in districts that took adequate precautions.
- “We don’t have all the information, that’s true, but I’m not surprised that things were okay,” she said. She posited that early pictures of Georgia schools that went viral showing students packed into hallways without masks “scared people enough” to institute mask and physical distancing policies.
- Nationwide, though, these policies vary widely. The new dashboard asked about covid mitigation strategies and found that about 7 in 10 schools required staff members and students to wear masks. About half limited gatherings to 25 people or fewer. About four in 10 kept students in one classroom, with about the same portion checking temperatures upon arrival.
- In suburban Atlanta, the Cherokee County School District encourages but does not require masks for students in most circumstances and requires them for teachers and staff members only when they are not able to keep a distance. Officials have tried to reduce crowds in hallways by staggering bell schedules and eliminated large gatherings such as assemblies.
- The schools opened for in-person learning in early August, when coronavirus caseloads in the area were high, and since then, at least 381 positive cases had been identified, each one triggering a two-week quarantine of teachers and classmates who may have been exposed. At one point, more than 2,329 people were in quarantine and three of six high schools were temporarily closed.
- District spokeswoman Barbara Jacoby said that none of the cases had been definitively linked to in-school exposure, although it had not been rules out in about a dozen.
- “Our community is entirely open,” she said. “You can go to not only school but youth sports, houses of worship, scouts, swimming pools. You can go anywhere. So it’s hard for public health officials to determine where transmission happens. A lot of these students interact outside school together.”
- Last week, the number of students and staff members in the district in quarantine was down to about 400, with 67 positive cases identified. The district has about 42,000 students. [an infection rate of 0.16%]
- Jacoby said that, overall, things had gone “better than expected.”
- One problem in evaluating school programs is not every school and not every state is providing useful data. Some districts in the country, such as Cherokee, are reporting every case to the public. But others report nothing.
- In Florida, where Gov. Ron DeSantis (R) has pushed schools to open even in areas with high coronavirus positivity rates, some counties have been pressured not to release school-specific coronavirus information, citing privacy concerns.
- A promised state school coronavirus dashboard has not yet been produced, although there is a “pediatric report” that shows some data, by county, of cases for Floridians younger than 18. According to the latest report, as of Tuesday, there is 13.7 percent rate of positive cases among children ages 1 to 17.
- Andrew Spar, president of the Florida Education Association, the state’s teacher’s union, said it’s hard to discern the true situation.
- “There is no real reporting of cases going on in the state,” he said. “There is no mechanism for consistent and fair reporting, so there is no way to analyze what is really happening in our schools.”
2. Temperature Isn’t a Good Litmus Test Children’s Entry Into School
- Across the country, the litmus test for many children’s entry into school, athletics and extracurricular activities, is their temperature. But experts and medical groups increasingly say that isn’t a good gauge of C19 as many infected children and adults don’t get fevers. Furthermore, variability in individual temperatures as well as questions about the accuracy of body-temperature scanners and infrared contact-free thermometers put such checks at risk of potential error.
- In some cases parents are taking their children’s temperatures so often that doctors say they are diagnosing more cases of periodic fever syndrome than usual. Periodic fever syndromes are autoinflammatory disorders in which children have recurrent episodes of fever and other symptoms. Though the genetic conditions are considered rare, doctors say they often go undiagnosed.
- In other cases doctors have been stumped by parents who say their otherwise healthy children have had low-grade temperatures for months, unclear if it is connected to an undiagnosed, asymptomatic C19 case or not.
- A U.S. Centers of Disease Control and Prevention study of nearly 300 children with C19 found that 56% had a fever. Its current guidance for school reopenings recommends against symptom screening for C19. The American Academy of Pediatrics’ interim guidance on school reopenings similarly doesn’t recommend universal temperature checks.
- “Thinking that you have done enough by simply screening a child for a temperature is one of those things that we felt created potentially a false sense of security for schools,” says Nathaniel Beers, a pediatrician at Children’s National Hospital in Washington, who co-chaired the committee that drafted the guidance.
- Doctors say baseline temperature varies depending on age, gender and other factors. Temperatures also fluctuate throughout the day based on a person’s circadian rhythm.
- Doctors define a normal temperature as 98.6 degrees Fahrenheit and a fever as 100.4 degrees Fahrenheit or higher based on an 1868 study by German researcher Carl Reinhold August Wunderlich. But researchers such as Philip Mackowiak, an emeritus professor of medicine at the University of Maryland School of Medicine, have questioned the research and published studies showing the average human temperature may be slightly lower and vary based on gender, age and time of day. Wunderlich “had a massive database but he didn’t publish his calculations,” Dr. Mackowiak says. “His thermometers calibrated higher than current thermometers. And yet that’s a number we still look to as a definition of the lower limits of the febrile range.”
- An adult’s temperature varies by on average one degree Fahrenheit over the course of a day, though for some it can be several degrees, says Dr. Mackowiak who published a 1992 study in JAMA demonstrating this. Similar findings have been published by researchers at Stanford and Harvard.
- Dr. Mackowiak’s study found from a population-level standpoint that oral temperatures peak in the evening at 99.9 degrees.
- Similarly, a 2018 study in the Journal of General Internal Medicine crowdsourced oral temperatures from 329 participants using a smartphone app and found that average oral temperatues were 97.7 degrees and a fever was defined as 99.5 or higher. Temperatures varied throughout the day and were affected by gender and age.
- Most studies have focused on adults, not children, so the normal range of temperature in children remains unknown, says Julie Parsonnet, who specializes in infectious diseases at Stanford University. Dr. Parsonnet was the senior author of a study published this year that found the average adult’s body temperature is about 97.5 degrees.
- Every morning Jenny Martin takes her daughter Sloane’s temperature and types the number into a health survey on her phone. Before Sloane enters her second-grade classroom, she is checked again by a teacher using a contactless forehead thermometer.
- “We just keep a thermometer right by her toothbrush and it’s part of the daily routine now,” Ms. Martin says. Sloane, who is 8 years old, returned to her private school in Boca Raton, Fla., three weeks ago. “We’re aware that a fever is no longer the first indicator of Covid or the be-all and end-all, but it’s something.”
- Dr. Mackowiak says infrared thermometers usually held near the forehead are problematic because they aren’t standardized and their temperature readings can be affected by sweat, makeup on the forehead or even the time of day.
- The focus on temperature has led to two perplexing phenomena, say some pediatric rheumatologists in the Northeast. They say they are seeing an uptick in children with recurrent low-grade fevers and those with new diagnoses of periodic fever syndromes.
- Jonathan S. Hausmann, a pediatric and adult rheumatologist at Boston Children’s Hospital and Beth Israel Deaconess Medical Center, runs an auto-inflammatory disease clinic that is seeing more patients. He says people are more closely monitoring changes in temperature due to fears of C19, so previously undiagnosed children with periodic fever syndrome are surfacing. Before the pandemic, parents may have attributed fevers to other viral infections. But with children exposed to fewer other people now, parents are noticing periodic fevers more.
- “It’s not that these are becoming more frequent,” Dr. Hausmann says. “We’re recognizing them more readily because everyone’s concerned about fevers.”
- Beth Gottlieb, head of pediatric rheumatology at Cohen Children’s Medical Center in New Hyde Park, N.Y., says she has observed the same, particularly for PFAPA—Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis—a type of periodic fever syndrome that often affects children under age 5. “We’re seeing a sudden surge of these kids,” Dr. Gottlieb says. “Typically we don’t see a lot of them, maybe once a month. I’ve had six of them in the last month or two.”
- For many genetic syndromes, people have an underlying predisposition for the condition but an environmental factor—which could be anything from a virus to stress—may trigger the disease.
- Separately Dr. Gottlieb says she has seen more parents coming in with children who have consistent low-grade fevers. If a child is otherwise normal and happy she advises parents to stop taking their temperature. “This may be their normal body temperature based on the rhythm of the day,” she says.
- Philip Kahn, an associate professor and pediatric rheumatologist at NYU Langone Medical Center, also has observed a number of otherwise healthy children who have a daily recurrent fever. “Previously I might have seen a kid like this once every three or four years,” he says. He has seen 13 since May. None of the children reported having C19 though they may have had asymptomatic cases. They had negative antibody tests though such checks aren’t always reliable. One possibility is that the elevated temperatures are an aftereffect of C19. Another possibility, says Dr. Kahn, is that the shutdown—which meant more time indoors and less outside—led to changes in some children’s bodies.
- While touchless thermometers are handy, the most accurate thermometers are oral ones, experts say, which should be used at home.
- Ear thermometers are at greater risk of user error—and wax or other blockages may affect their accuracy, says Nathaniel Beers, a pediatrician at Children’s National Hospital in Washington. Readings from a forehead thermometer that touches the skin can be thrown off by a person’s activity or blood flow to the forehead.
- Axillary temperatures, which are taken in the armpit, are generally a degree lower so one degree should be added to the reading. Temperatures taken with a rectal thermometer are slightly higher than oral temperatures but typically used only with infants.
- Dr. Beers says thermometers’ accuracy decreases with use and different thermometers have different lifespans. People should regularly check the accuracy of their thermometers and not assume they still work.
3. CDC says no Trick-or-treating, haunted houses or hayrides
- Ironically, this is the one time you shouldn’t wear a mask.
- Halloween won’t be canceled over the coronavirus pandemic. However, the CDC is warning revelers against participating in certain holiday traditions to help slow the spread of disease. The group has released their 2020 Halloween guidelines for the C19 era.
- “Many traditional Halloween activities can be high-risk for spreading viruses,” the agency wrote in the advisory posted Monday.
- “High-risk activities” entailed “crowded costume parties held indoors,” haunted houses, hayrides and tractor rides with people from outside of one’s household and, sadly, door-to-door trick-or-treating, per the notice. This includes “trunk-or-treat, where treats are handed out from trunks of cars lined up in large parking lots.”
- “Traveling to a rural fall festival that is not in your community if you live in an area with community spread of C19,” should be avoided as well, per the guidelines.
- The CDC also cautioned against donning a costume mask unless “it is made of two or more layers of breathable fabric that covers your mouth and nose and doesn’t leave gaps around your face.” And don’t slap a plastic mask over a coronavirus cover as that can make it hard to breathe, per the warning.
- Fortunately, they’ve provided a handy list of “low-risk” Halloween pursuits, which include socially distanced pumpkin carving, virtual Halloween costume competitions and Halloween movie nights. Socially distanced outdoor scavenger hunts are also encouraged.
- Too watered down for Halloween die-hards? Fortunately, they’ve provided some “moderate-risk” alternatives as well.
- In lieu of door-to-door trick-or-treating, the CDC suggests “one-way trick-or-treating where individually wrapped goodie bags are lined up for families to grab and go while continuing to social distance (such as at the end of a driveway or at the edge of a yard).” One enterprising Halloween dad went viral recently after dispensing treats via a COVID-safe “candy chute.”
- And if you must attend a Halloween party or costume parade, make sure it occurs outdoors and that participants wear masks and stay 6 feet apart at all times. Meanwhile, a Halloween-themed cloth mask ensures that revelers can celebrate the holiday in style while mitigating the spread of disease. Fittingly enough, it appears that the now-viral “Karen” mask — which lampoons white women who throw public tantrums over mask mandates — doesn’t serve this purpose.
- No haunted house, no problem. Hit up an “open-air, one-way, walk-through haunted forest,” that adheres to all the aforementioned precautions. “If screaming will likely occur, greater distancing is advised,” according to the guidelines.
- While organizing a Hallow’s Eve party, the CDC urges hosts to assess “current C19 levels in your community to determine whether to postpone, cancel, or limit the number of attendees.”
- The CDC stresses that the alternatives are not meant to replace local or state mandates on the coronavirus pandemic.
- Unfortunately, the coronavirus pandemic has put a major damper on nationwide Halloween celebrations of late. New York City recently suspended their annual holiday parade over COVID concerns, while Los Angeles banned trick-or-treating outright before subsequently reversing their decision.
4. The Moral Case for Opening Schools — Without Masks!
- If you’re a public-minded student or teacher committed to reducing the death toll from C19, what is the morally correct way to behave?
- According to the epidemiologist Sunetra Gupta, you should do just about the opposite of what’s being preached by college presidents, teachers’ unions, political leaders, and the scientific and media establishment. Unless you’re elderly or particularly vulnerable, you shouldn’t be wearing a mask all day, or shaming others for going unmasked. You should be careful not to endanger the vulnerable, but otherwise you should be exposing yourself to the virus in order to promote herd immunity.
- Gupta, 55, wants to teach her classes at Oxford in person, without a mask, and she is appalled at her colleagues’ reluctance to go back to the classroom.
- “It’s such a disservice to this generation of students,” she says. “Teachers and students who are vulnerable should have the option to go online, but for the rest of us this virus is no bigger than other risks we take in daily life. It’s not rational, and certainly not communitarian, to avoid being infected with a pathogen that carries such a low risk to you when there’s a high benefit to the community by helping to create herd immunity.”
- Gupta’s strategy is heresy to the public-health establishment, but it seems to be paying off in Sweden, and her research team at Oxford has a far better track record on C19 than the scientists whose work inspired the widespread lockdowns and mask mandates in the first place. In March, when Neil Ferguson’s team at Imperial College London terrified politicians and the public with its projections of Covid deaths—more than 500,000 in Britain and 2 million in the United States—Gupta’s team warned that this scenario was based on dubious assumptions about the virus’s spread and lethality.
- The Imperial computer model assumed that most of the population had not yet been exposed to an exceptionally lethal virus, so lockdowns were the only way to avoid mass casualties. Gupta’s model, by contrast, assumed that many people had already been exposed without suffering serious consequences. That meant that the virus wasn’t so lethal and that the United Kingdom and other places were already developing herd immunity, making lockdowns unnecessary. Gupta was dubbed “Professor Reopen”—as opposed to Imperial’s “Professor Lockdown”—and she was pilloried along with the few others who shared her views.
- Officials at the World Health Organization and the National Institutes of Health condemned the strategy of relying on herd immunity. Anthony Fauci, the White House advisor, said that it would lead to a “completely unacceptable” number of deaths—perhaps more than 10 million Americans, by one calculation published by scientists in the New York Times. A group of Swedish doctors and scientists denounced their country for keeping day-care centers, primary schools, bars, restaurants, and stores open, declaring in late July that the policy was leading to needless “death, grief and suffering” because Sweden was “nowhere near herd immunity.”
- In fact, though, this strategy now seems to have fostered herd immunity in Sweden and other places. The number of daily Covid deaths in Sweden, which peaked at 115 in April, has averaged just two since the beginning of August. Fewer than 6,000 Swedes have died, a far cry from the nearly 100,000 deaths projected by the Imperial model. Per capita, the United States and Britain have suffered more Covid deaths than Sweden, and the fatality rates in the states of New York and New Jersey are three times higher than Sweden’s.
- It’s true, as lockdown proponents often point out, that the fatality rate is higher in Sweden than in neighboring Nordic countries. But most of that disparity, according to a recent analysis by George Mason University economist Daniel Klein and colleagues from Scandinavia, is due to factors unrelated to those neighbors’ lockdowns, which were actually quite light and short-lived compared with those in Britain and the northeastern United States. (In Norway and Finland, for instance, schools reopened in May, and bars and restaurants reopened in early June.) Even before any of the lockdowns, Sweden was harder hit than its neighbors, partly because it had relatively more immigrants and international travelers, but mainly because of its larger proportion of highly vulnerable old people, particularly in nursing homes.
- During the summer, Sweden’s critics pointed to seroprevalence surveys showing that fewer than 20 percent of Swedes had developed antibodies to the virus, well below the level of 60 percent to 70 percent assumed to be the threshold for herd immunity. But that was likely another mistaken assumption, Gupta’s team and other researchers believe, because the antibody tests miss so many people who are effectively immune to the virus.
- Some of these people are immune because they have antibodies not detected by the tests, and many others—perhaps 20 percent to 50 percent of the population—have developed resistance through previous exposure to other coronaviruses. Once these people are accounted for, herd immunity could be reached even if the antibody tests show a prevalence as low as 10 to 20 percent.
- That means that many places besides Sweden could have reached or approached herd immunity. In New York City, nearly a quarter of the residents tested positive for antibodies in the state’s survey in April. The city’s graph of Covid deaths maps a curve much like the one recorded in Sweden without a lockdown: a peak in April, falling to a straight line barely above zero since July, despite the city’s gradual reopening of restaurants and businesses. After looking at the data, one team of researchers recently concluded that New York City has likely crossed the herd-immunity threshold, meaning that a lockdown would not be necessary to protect the city against a much-feared strong second wave.
- Herd immunity cannot eliminate deaths; like ordinary flu viruses, C19 will remain endemic even if a vaccine arrives. But herd immunity ends the epidemic by greatly slowing the spread. The elderly and other high-risk people still need to be careful—and Gupta favors continuing policies to shield them from the virus—but the best long-term strategy for protecting them is letting low-risk people build up herd immunity right now.
- That means reopening schools and allowing young people to study and congregate without masks. Martin Kulldorff, a Harvard epidemiologist and one of Gupta’s few allies, noted that not a single child in Sweden has died from Covid, and that Swedish teachers did not suffer unusually high rates of infection, even though the country never closed schools for those under 16 and didn’t force students to wear masks.
- For American children under 14, the risk of dying from Covid is lower than the risk of dying from the flu or pneumonia, according to the calculations of Avik Roy, president of the Foundation for Research on Equal Opportunity. For teenagers and young adults, it’s much lower than the risk of being murdered. For anyone under 55, it’s lower than the risk of dying from accidents, from cancer, or from heart disease. If college students are willing to get in a car, why should they be terrified of sitting in a lecture hall? And why should they be reviled—much less expelled—for fraternizing with other students and helping to build up herd immunity?
- “The Covid isolation strategies are accompanied by a lot of virtue-signaling and self-righteousness,” Gupta says, “but the costs are very high on the poor around the world as well as the young.
- I find it intolerable for teachers to ask youth to give up this important phase of their development—and to slow the development of herd immunity. If we really care about the common good and protecting the vulnerable, the rest of us should be willing to take a very small personal risk.”
I. Herd Immunity
1. What happens when a major city allows the coronavirus to rage unchecked?
- If the Brazilian city of Manaus is any answer, it means about two-thirds of the population could get infected and one person in 500 could die before the epidemic winds down.
- During May, as the virus spread rapidly in Manaus, the equatorial capital of the state of Amazonas, dire reports described overwhelmed hospitals and freshly dug graves. Demand for coffins ran at four to five times figures for the previous year. But since hitting a peak four months ago, new coronavirus cases and deaths in the city of 1.8 million have undergone a rapid and unexplained decline.
- Now a group of researchers from Brazil and the United Kingdom say they know why—so many people got infected that the virus is running out of hosts.
- In a report posted to the preprint server medRxiv, a group led by Ester Sabino, of the Institute of Tropical Medicine at the University of São Paulo, says it tested banked blood for antibodies to the virus and estimates that between 44 and 66% of the population of Manaus has been infected since the city detected its first case in March.
- “From what we learned this is probably the highest prevalence in the world,” Sabino said in a phone interview. “Deaths have dropped very rapidly, and what we’re saying is that it’s related.”
- In the US, President Donald Trump has attracted ridicule for saying the virus “will go away” on its own. His comments may be a reference to the fact that if enough people get infected by a virus and develop antibodies to fight it off, so-called herd immunity starts to build in the population: As more people gain immunity, it becomes harder for the virus to infect new people and continue its spread.
- That’s exactly what’s happening in Manaus, the authors believe. “Although nonpharmaceutical interventions, plus a change in population behavior, may have helped to limit coronavirus transmission in Manaus, the unusually high infection rate suggests that herd immunity played a significant role in determining the size of the epidemic,” they wrote.
- The Amazon region has seen the virus at its worst, with people dying at home and infections hitting indigenous groups. However, by mid-August, the Washington Post was documenting a sudden turnaround in Manaus. From a peak of 79 deaths on one day in May, the rate in the city is down to two or three a day in September, according to its health department.
- It remains unclear why the virus spread so quickly in Manaus, where mobility data shows people did begin social distancing in March. Sabino and her colleagues think the outbreak may have been accelerated by dense housing, poor water supplies, and crowding on boats that serve as local transportation.
- According to the authors, the infection fatality rate in Manaus was about 0.28%, or one death in every 350 people infected by the virus. Considering that not everyone has caught the virus in Manaus, the city-wide C19 death rate would be between one in 500 and one in 800 people overall. [Note: an Infection Fatality Rate of between 0.125% to 0.2%]
- Florian Krammer, an immunologist at Mt. Sinai Hospital in New York, says it was expected that some regions would reach levels of immunity high enough to interrupt local outbreaks, but that such events should be considered public health failures, not successes.
- “Community immunity via natural infection is not a strategy, it’s a sign that government failed to control an outbreak and is paying for that in lives lost,” Krammer tweeted.
- Other cities should be cautious about drawing conclusions from Manaus since, among other factors, it has a fairly young population. Just 6% of citizens there are over 60, according to Brazil’s Institute of Geography and Statistics. In New York City, that figure is around 16% and for the US overall, it’s 20%. Elderly people have a much, much higher risk of dying if they catch the virus than younger people.
- The Brazilian figures do suggest just how many people in one place could get infected as the virus spreads—a concept known as the attack rate. Were two-thirds of the US population to be infected, the virus could easily claim more than 500,000 American lives, mostly among the elderly. That’s in line with early projections for worst-case scenarios and with recent events on the ground. The US today surpassed the grim record of more than 200,000 deaths attributed to the virus. Tens of thousands of people are still being infected daily.
- In Brazil, Sabino’s team was well placed to study the trajectory of the pandemic because the group was previously involved with checking blood donations for transmissible pathogens. Since Brazilian blood banks retain samples of donated blood, they were able to go back and look for coronavirus antibodies at several points in time—a technique known as serial sampling.
- “Very few people have the capacity to do serial sampling, but in Brazil it’s mandatory to save samples, so we could,” says Sabino. During the month of June, a high of 40% of new blood donors were positive for coronavirus antibodies, though the number has decreased since then as antibodies tend to wane over time.
- Gabriela Gomes, a mathematical modeler at the University of Strathclyde, says the new report finds that twice as many people in Manaus had coronavirus antibodies as a previous study had suggested; there could be ongoing discussion among immunologists over which finding is more accurate. Sabino says her team used an improved antibody test developed by Abbott Laboratories for their analysis, which she says is more sensitive than the test used for the earlier study and misses fewer cases.
- Going forward, the Amazonian capital could now help public health officials better understand how long immunity to C19 lasts and how often the virus reinfects people. The blood survey clearly showed that with time, people’s antibodies become harder to detect. That could mean individual immunity to the virus is not permanent. “Manaus may act as a sentinel to determine the longevity of population immunity and frequency of reinfections,” the authors wrote in their preprint.
2. Sweden has achieved herd immunity
By Sebastian Rushworth, M.D.
- At the beginning of August I wrote an article about my experiences working as an emergency physician in Stockholm, Sweden during the covid pandemic. For those who are unaware, Sweden never went in to full lockdown. Instead, the country imposed a partial lockdown that was almost entirely voluntary. People with office jobs were recommended to work from home, and people in general were recommended to avoid public transport unless necessary. Those who were over 70 years old, or who had serious underlying conditions, were recommended to limit social contacts.
- The only forcible restriction imposed by the government from the start was a requirement that people not gather in groups of more than 50 at a time. After it became clear that covid was above all dangerous to people in nursing homes, an additional restriction was placed on nursing home visits. At no time has there been any requirement on people to wear face masks in public. Restaurants, cafés, hairdressers, and shops have stayed open throughout the pandemic. Pre-schools and schools for children up to the age of 16 have stayed open, while schools for children ages 16-19 switched to distance learning.
- My personal experience is that people followed the voluntary restrictions pretty well at the beginning, but that they have become increasingly lax as time has gone on. As a personal example, my mother and my parents-in-law stayed locked up in their homes for the first six weeks or so of the pandemic. After that they couldn’t bear to be away from their grandchildren any longer.
- In my earlier article in August, I mentioned that after an initial peak that lasted for a month or so, from March to April, visits to the Emergency Room due to covid had been declining continuously, and deaths in Sweden had dropped from over 100 a day at the peak in April, to around five per day in August.
- At the point in August when I wrote that article, I hadn’t seen a single covid patient in over a month. I speculated that Sweden had developed herd immunity, since the huge and continuous drop was happening in spite of the fact that Sweden wasn’t really taking any serious measures to prevent spread of the infection.
- So, how have things developed in the six weeks since that first article?
- Well, as things stand now, I haven’t seen a single covid patient in the Emergency Room in over two and a half months.
- People have continued to become ever more relaxed in their behavior, which is noticeable in increasing volumes in the Emergency Room. At the peak of the pandemic in April, I was seeing about half as many patients per shift as usual, probably because lots of people were afraid to go the ER for fear of catching covid. Now volumes are back to normal.
- When I sit in the tube on the way to and from work, it is packed with people. Maybe one in a hundred people is choosing to wear a face mask in public. In Stockholm, life is largely back to normal. If you look at the front pages of the tabloids, on many days there isn’t a single mention of covid anywhere. As I write this (19th September 2020) the front pages of the two main tabloids have big spreads about arthritis and pensions. Apparently arthritis and pensions are currently more exciting than C19 in Sweden.
- In spite of this relaxed attitude, the death rate has continued to drop. When I wrote the first article, I wrote that covid had killed under 6,000 people. How many people have died now, six weeks later? Actually, we’re still at under 6,000 deaths. On average, one to two people per day are dying of covid in Sweden at present, and that number continues to drop.
- In the hospital where I work, there isn’t a single person currently being treated for covid. In fact, in the whole of Stockholm, a county with 2,4 million inhabitants, there are currently only 28 people being treated for covid in all the hospitals combined. At the peak, in April, that number was over 1,000. If 28 people are currently in hospital, out of 2,4 million who live in Stockholm, that means the odds of having a case of covid so severe that it requires in-hospital treatment are at the moment about one in 86,000.
- Since March, the Emergency Room where I work has been divided in to a “covid” section and a “non-covid” section. Anyone with a fever, cough, or sore throat has ended up in the covid section, and we’ve been required to wear full personal protective equipment when interacting with patients in that section. Last week the hospital shut down the covid section. So few true cases of covid are coming through the Emergency Room that it no longer makes sense to have a separate section for covid.
- What about the few formal restrictions that were imposed early in the pandemic? The restriction on visits to nursing homes is going to be lifted from October 1st. The older children, ages 16-19, who were engaging in distance learning during part of the spring, are now back in school, seeing each other and their teachers face to face. The Swedish public health authority has recommended that the government lift the restriction on gatherings from 50 people to 500 people.
- When I wrote my first article, I engaged in speculation that the reason Sweden seemed to be developing herd immunity, in spite of the fact that only a minority had antibodies, was due to T-cells. Since I wrote that article, studies have appeared which support that argument. This is good, because T-cells tend to last longer than antibodies. In fact, studies of people who were infected with SARS-CoV-1 back in 2003 have found that they still have T-cells seventeen years after being infected. This suggests that immunity is long lasting, and probably explains why there have only been a handful of reported cases of re-infection with covid, even though the virus has spent the last nine months bouncing around the planet infecting many millions of people.
- As to the handful of people who have been reported to have been re-infected. Almost all those cases have been completely asymptomatic. That is not a sign of waning immunity, as some claim. In fact it is the opposite. It shows that people develop a functioning immunity after the first infection, which allows them to fight off the second infection without ever developing any symptoms.
- So, if Sweden already has herd immunity, what about other countries? How close are they to herd immunity? The places that have experienced a lot of covid infections, like England and Italy, have mortality curves that are very similar to Sweden’s, in spite of the fact that they went in to lockdown. My interpretation is that they went in to lockdown too late for it to have any noticeable impact on the spread of the disease. If that is the case, then they have likely also developed herd immunity by now. Which would make the ongoing lockdowns in those countries bizarre.
- What about the vaccine? Will it arrive in time to make a difference? As I mentioned in my first article, lockdown only makes sense if you are willing to stay in lockdown until there is an effective vaccine. Otherwise you are merely postponing the inevitable.
- At the earliest, a vaccine will be widely available at some point in the middle of next year. How many governments are willing to keep their populations in lockdown until then? And what if the vaccine is only 30% effective? Or 50%? Will governments decide that is good enough for them to end lockdown? Or will they want to stay in lockdown until there is a vaccine that is at least 90% effective? How many years will that take?
- So, to conclude: Covid is over in Sweden. We have herd immunity. Most likely, many other parts of the world do too, including England, Italy, and parts of the US, like New York. And the countries that have successfully contained the spread of the disease, like Germany, Denmark, New Zealand, and Australia, are going to have to stay in lockdown for at least another year, and possibly several years, if they don’t want to develop herd immunity the natural way.
3. Why Has Sweden escaped a second coronavirus wave so far?
- A train pulls into the Odenplan subway station in central Stockholm, where morning commuters without masks get off or board before settling in to read their smartphones.
- Whether on trains or trams, in supermarkets or shopping malls — places where face masks are commonly worn in much of the world — Swedes go about their lives without them.
- When most of Europe locked down their populations early in the C19 pandemic by closing schools, restaurants, gyms and even borders, Swedes kept enjoying many freedoms. The government’s relatively low-key approach to imposing restrictions captured the world’s attention, but it also coincided with a per capita death rate that was much higher other Nordic countries’.
- Now, as coronavirus infection numbers surge again in much of Europe, Sweden — a country of 10 million people — has some of the lowest numbers of new cases and only 14 C19 patients in intensive care.
- Whether this is due to the Swedish government’s strategy, however, is still uncertain.
- Its health authorities — and, in particular, its chief epidemiologist, Dr. Anders Tegnell — keep repeating a familiar warning: It’s too early to tell, and all countries are in a different phase of the pandemic.
- That has not stopped a World Health Organization official from saying the continent could learn broader lessons from Sweden that could help the battle against the coronavirus elsewhere.
- “We must recognize that Sweden, at the moment, has avoided the increase that has been seen in some of the other countries in Western Europe,” Catherine Smallwood, the WHO’s senior emergency officer for Europe, said. “I think there are lessons for that. We will be very keen on working and hearing more from the Swedish approach.”
- According to the European Center for Disease Control, Sweden has reported 30.3 new C19 cases per 100,000 inhabitants in the last 14 days, compared with 292.2 in Spain, 172.1 in France, 61.8 in the U.K. and 69.2 in Denmark, all of which imposed strict lockdowns early in the pandemic.
- Overall, Sweden has 88,237 reported infections and 5,864 fatalities from the virus, or 57.5 deaths per 100,000 inhabitants, since the beginning of the crisis.
- The way Sweden’s strategy was viewed outside the country seems to depend largely on what stage of the pandemic the observer was experiencing at the time. Initially, many abroad were incredulous at images of Swedes dining with friends in restaurants or sipping cocktails on the Stockholm waterfront. Some were envious that Swedish businesses were not forced to close.
- Then came shock as the coronavirus ripped through the country’s nursing homes and hospices.
- By mid-April, more than 100 deaths were reported each day in Sweden, while mortality rates were falling elsewhere in Europe.
- Today, as fears of a second wave grow across Europe, it’s fashionable in some quarters to praise Sweden, with reporters from France, Britain and elsewhere traveling to Stockholm to ask about its success.
- But a Swedish government commission investigating the handling of the pandemic will have hard questions to answer: Did authorities wait too long to limit access to nursing homes, where about half of the C19 deaths occurred? Were they too slow to provide personal protective equipment to staff in those homes when shortcomings in the elder-care sector had long been known? Why did it take so long to set up wide-scale testing?
- Tegnell also refuses to rule out a second wave of coronavirus infections in Sweden. A particular concern is the return of students to high schools for the first time since March.
- “We need to be very careful and find the first sign that something is going on so that we can do as much as possible to prevent it from escalating,” he told the Associated Press.
- Localized outbreaks are expected, but rather than fight them with nationwide rules, officials plan to use targeted actions based on testing, contact tracing and isolating patients rapidly.
- “It’s very important that we have quick and local response to hit down the virus without making restrictions for the whole country,” Health Minister Lena Hallengren said last week.
- From the beginning, health officials argued that Sweden was pursuing a sustainable approach toward the coronavirus that the population could adopt — for years, if necessary. “This is a marathon, not a sprint” became a slogan repeated by ministers at every opportunity, given that neither a vaccine nor a cure yet exist.
- While the rest of the world watched with envy at the freedoms that Swedes enjoyed amid lockdowns elsewhere, there were not as many as people have assumed. Gatherings were capped at 50, and congregating at bars was banned.
- Most of the changes involved voluntary actions by residents, rather than rules imposed by the government.
- The trust in the population to exercise personal responsibility put Sweden at odds with countries that used coercive measures such as fines to force compliance with lockdown restrictions.
- This is often attributed to a Swedish model of governance, where large public authorities composed of experts develop and recommend measures that smaller ministries are expected to follow. In other words, the people trust the experts and scientists to develop reasonable policies, and the government trusts the people to follow the guidelines.
- Swedes were asked to work from home when possible and maintain social distance, and most willingly complied. While people now ride public transportation without masks, there are also far fewer people commuting than before.
- Unlike most European countries that have mandated wearing masks in public spaces, Sweden does not recommend their broad use, and people largely follow that recommendation.
- Health officials say face masks used outside healthcare facilities by untrained personnel can provide a false sense of safety that could see sick people leave home and ignore social distancing. Instead, they believe simple but non-negotiable guidelines provide clear rules that can stay in place for long periods of time: staying home when showing symptoms of C19, maintaining good hand-washing hygiene and keeping social distance.
- In a country the size of California but with only a quarter of the state’s population of 41 million, and with low levels of transmission, most Swedes believe that wearing masks makes little sense.
- Carol Rosengard, 61, who runs a center for disabled youth, has seen people wear masks improperly or take them off to smoke a cigarette or drink water.
- “That’s not how they should be handled,” Rosengard said, explaining her support for not imposing face mask rules on the population.
- That view is echoed by Hallengren, the health minister, who doesn’t totally dismiss the effectiveness of masks and sees their usefulness in cases of severe local outbreaks. At the same time, she rejects blanket rules for the entire country.
- “People will not wear masks for years,” she said.
1. Unwarranted Fear Has Won The Covid Narrative… At An Enormous Cost to the Country
- Today we live in a nation where nearly half of all U.S. citizens deeply believe they will get the Covid virus and die. This fear is pervasive, and it is false.
- Data on who is infected, who becomes ill, and who has died from Covid isn’t subject to many questions; it is objective, available and knowable data. So how can there be such a wide gap between data and fear?
- It has been half a century since existential events pierced the psyche of the American mind with such abject fear. The possibility of a global atomic attack sent children to protective bunkers in the basements of schools. Polio outbreaks terrorized minds with the profound angst, “My entire family can be paralyzed, especially our children.” A century ago, the Spanish Flu was a virus everyone feared with good reason as it was both indiscriminate and lethal. Covid19 has now earned its stripes as a fear-inducing menace, and yet the data across America is quite different from other historical threats to public health and safety.
- With the advent of 24-hour cable and social media news feeds, the infection and death count rolls on from 50,000 deaths to 150,000 and soon 200,000 — harrowing statistics bombarding Americans and inducing and reinforcing fear while barking at Federal and State officials, “Do something to save us.”
- C19 is compared to the movie Contagion, where a virus born from bats and pigs in a Chinese wet market infects swiftly, broadly, and with extreme lethality laying to waste the U.S. and other nations until a vaccine arrives. Calls are loud to test universally, lockdown every business, close colleges, stadiums, and arenas, mandate masks even outdoors, and undertake a new Manhattan Project to find the vaccine. But the movie bears little resemblance because, in reality, the C19 death data tells a very different story.
- Recriminations of the government focus principally on the Trump administration and (primarily) Red State governors for not moving swiftly enough and sufficiently enforcing new social distancing norms. The governors of Florida and Texas had to begin daily news conferences to keep up with the Governor of New York to pursue the award for most hours on T.V. (far more than the President). All of the criticism of having not deployed enough masks and testing resources will give way (or be redoubled) after November’s election cycle. But all of that media has come at a high cost: it has unleashed profound and irrational fear among the American public, which is the most potent emotion in humans and now very hard to contain.
- Polling by Gallup indicates approximately 45% of Americans are “very worried” or “Somewhat worried,” they will contract Covid. Pew Research reveals 51% of adults having “high” or “medium” psychological distress from their fear of Covid. The American Psychiatric Association’s research indicates that 40% of Americans believe they could become seriously ill and die from Covid.
- The death data, readily available, tells us the statistical average (and averages are deceiving) would be nearer to a .06% chance of dying when you apply the death stats across America. We call this the ‘Data-Fear Gap,’ and it is reinforced by a relentless media barrage supporting fear-based policy reactions having far-reaching and long-lasting consequences more deadly than the virus itself on both people and our economy.
- The death data on Covid reveals this: in every state in America and indeed every country worldwide, this virus attacks and kills primarily older persons who suffer from one or more co-morbid conditions of obesity, hypertension, diabetes, or other pulmonary and immune system conditions. More than 84% of all deaths in the United States from the virus are of persons older than 65, and according to the official death data available from all 50 State Health departments, among those who died, more than 90% already suffered from one or more of these co-morbid conditions at the time of their Covid illness. So what does that mean for the rest of America?
- Using the inverse data tells us ~16% of all deaths or about 31,200 (.16 x 195,000) persons outside of the most vulnerable group have also died (i.e., not older and not suffering from these conditions). This set of deaths is a more diverse, random group — but, notably, almost no one under age 35. In a country of 331,000,000 of whom approximately 46,000,000 are persons over 65, that means the virus has taken the lives of about .01% of the younger-than-65 population ((331,000,000–46,000,000 = 285,000,000) -> 31,200/285,000,000 = .0001)). It is doubtful you have heard a whisper of these dry statistics on the national evening news or read it in your local paper. This is not to be insensitive to any death — every Covid death is an American tragedy. But this dry data is foundational when formulating an appropriate policy response to this virus, and it all has been buried with the dead.
- My fearful friends scoff at this wonkish approach saying, “Maybe that’s the math, but the virus could change. Stay safe, and for God’s sake, keep your kids at home!” Yet the curves of new cases, hospitalizations, and deaths have been remarkably consistent for months, state by state, warm or cold weather, Blue-State Lockdowns, or Red-State Lockdowns.
- Of the thousands of college students who caught the virus, how many hospitalized? Zero. Not one. So we present here all the available death data from each State at: Covid Stats – Methuselah Advisors
J. Projections & Our (Possible) Future
1. Former FDA Director Expects “At Least One More Cycle” Of C19 Before Vaccine Approval
- Former FDA Director Dr. Scott Gottlieb has been one of the most prominent ‘expert’ voices since the start of the C19 epidemic, writing op-eds about how the FDA can safely speed up approval of a vaccine, and appearing daily on CNBC’s “Squawk Box”.
- On Sunday, Gottlieb appeared on CBS News’ Face the Nation, where he shared that he expects the US to experience one more round of C19 before a vaccine becomes widely available.
- “Well I think we have at least one more cycle with this virus heading into the fall and winter…if you look around the country right now there’s an unmistakable spike in new cases and the declines in hospitalizations that we were achieving have started to level off.”
- It’s possible it could be a “post-Labor Day bump,” and Saturday’s Sunday’s numbers could suggest that perhaps US cases are already leveling off again. But it’s clear that “we’re seeing a resurgence in infections,” Gottlieb said, adding that “there’s a lot of risk” heading into the fall season because that’s when “respiratory illnesses” like to spread.”
- Gottlieb also weighed in on President Trump’s latest claim on vaccine timing – that a vaccine will be widely available by April. Gottlieb, who is on the board of Pfizer, said that he doesn’t expect a vaccine will be approved for general use until the end of the 2nd quarter, or perhaps even the beginning of the third quarter, of next year.
- Whether the vaccine is approved in April or June of next year, ultimately, shouldn’t make much difference, Gottlieb added. The outbreak should have mostly tapered off by then. But there will always be a risk of a comeback heading into the fall in the US.
- While there’s a possibility that the vaccine could be made available to “select groups” who are particularly vulnerable to the virus, such exceptions will only be made “on a very limited basis”.
2. Charting the C19 pandemic over the next 12 months — and beyond
- What does the future of the pandemic in the U.S. look like? It’s the question everyone —from people trying to plan vacations to experts trying to issue public health guidance — has been trying to answer for the past seven months. In a sweeping new project, STAT’s Andrew Joseph takes a look at 30 turning points that could change the pandemic’s trajectory or offer a barometer of the response, from how Trump talks about C19 during the first presidential debate this month to what the late-stage data from vaccine trials will look like if they emerge in December. This road map is informed by interviews with dozens of experts, including public leaders like Anthony Fauci, frontline workers in hospitals and schools, and epidemiologists.
- The road map is available at: Stat News Road Map
J. Practical Tips & Other Useful Information
1. How to Ventilate Your Home to Fight Coronavirus, Wildfire Smoke
- Healthy air in homes is a bigger concern than ever. Evidence that C19 spreads through the air means that those spending time indoors—even at home—might be at risk of exposure. The virus, along with added threats from wildfire emissions in the Western U.S., are prompting calls for new ventilation measures in dwellings.
- Using filters, fans, air purifiers and open windows can help. Here, experts weigh in on ways to improve your home’s ventilation to combat viruses as well as outdoor and indoor pollutants.
What are the basic ways homes are ventilated?
- The main methods are through mechanical ventilation, with heating and air-conditioning systems that use filters; portable air cleaners or purifiers; natural ventilation with outdoor air; and hybrids that combine several of these, says Jianshun Zhang, professor of mechanical and aerospace engineering at Syracuse University.
How important is it to bring fresh air into the home?
- If your building allows it, letting in outside air is one of the best ways to dilute the coronavirus. For effective natural ventilation, create a cross flow by opening windows or doors on either side of the home, if you have that option, Prof. Zhang advises.
- To fight C19, “you need as much outdoor air as you can get and still feel comfortable,” he says. One caveat: Pollutants might mean you will need to filter the air once it’s inside the home.
Are portable air purifiers a good option?
- Air purifiers with a high-efficiency particulate-air filter, known as a HEPA filter, are effective against C19 and wildfire smoke. Some devices offer additional air-cleaning technology including bipolar ionization, UV light and plasma, but they aren’t yet recommended and are still considered emerging technologies, says Max Sherman, the residential team leader of the Epidemic Task Force at the American Society of Heating, Refrigerating and Air-Conditioning Engineers.
Are bathroom and kitchen exhaust fans helpful?
- Exhaust fans bring in outdoor air while expelling indoor air. Running an exhaust fan near an open window can be a simple way to bring clean air into the home while diluting aerosols that may carry the virus, says Joseph Allen, director of the Healthy Buildings Program at the Harvard T.H. Chan School of Public Health. This is especially useful in apartments without central heating or air-conditioning systems.
Should you run your central-air system on fan-only when not heating or cooling?
- That’s a good idea, if you have that option. Most HVAC units have a fan-only option that can run when heating or cooling isn’t necessary. The fan allows the filter that is part of the unit to keep working and is especially useful for those working from home during wildfires or trying to limit virus exposure in the home. “You would want that to run all the time, when it’s not heating and cooling,” Dr. Sherman says.
- To get smoky air out of the house, try using a HEPA air purifier in each room while running the HVAC fan throughout the day, Dr. Zhang advises.
How Droplets Move
- Droplets of all sizes are emitted when a person coughs, talks or sneezes. How they travel depends on many factors. Some research has found that droplets will be carried by a moist gas cloud, which a Massachusetts Institute of Technology researcher has said can travel up to about 26 feet after a sneeze. Some of the droplets will fall as the cloud moves. Others ultimately evaporate, producing aerosols that can linger in the air and travel with airflow patterns, a March article by the researcher published in the Journal of the American Medical Association said.
What kind of filter should you use in your central air-conditioning and heating system?
- For HVAC filters, ratings known as MERV, or minimum efficiency reporting value, are usually the key to determining quality. (Though some manufacturers have their own rating systems.) A filter with a rating of MERV-13 or greater is recommended for fighting C19, Dr. Sherman says. Filters with a lower MERV rating, the type that are often installed in HVAC units, are good at catching pet hair, but not viruses, he warns. Call your HVAC installer to ask about expanding or adding a filter slot so a higher-rated filter can be used.
What should you keep in mind about ventilation in common areas when living in an apartment building?
- The building’s shared areas, including the laundry room, elevator and lobby, are often poorly ventilated but still can be considered low risk if you are masked and spend only short periods of time in those areas, says Jeffrey Siegel a professor of civil engineering at the University of Toronto who studies indoor-air quality. The time spent around people in highly trafficked areas is important to keep in mind. For instance, you may not want to wait for an empty elevator if the lobby is full of people. It’s much more complicated than saying, ‘Wait for the next car,’ ” he says.
If you share walls with neighbors, what do you need to know about ventilation?
- You need to be extra-aware of ventilation when living in any kind of attached dwelling, though the risks are often still low, Prof. Siegel says. Known C19 exposure in the building may warrant use of an air purifier in your apartment. About 20% of your air can transfer for each shared wall, he says. A rule of thumb: “If you smell your neighbors cooking, it means the air is transferred.”
Is it important to track air quality in your home?
- Most people don’t need to track the quality of air inside their home, and tools are still expensive, says Prof. Siegel, who advises trusting your own senses: “If you walk into a room and it’s stuffy, that’s a good indication of bad ventilation.”
K. Johns Hopkins COVID-19 Update
September 24, 2020
1. Cases & Trends
- The WHO C19 Dashboard reports 31.43 million cases and 967,164 deaths as of 6:30am EDT on September 23. At 35-40,000 deaths per week, the global mortality could surpass 1 million deaths in the next week.
- The US CDC reported 6.83 million total cases and 199,462 deaths. The US is averaging 41,141 new cases and 767 deaths per day. We expect the US to surpass 200,000 cumulative deaths in the CDC’s afternoon update. In total, 22 states (no change) are reporting more than 100,000 cases, including California with more than 700,000 cases; Florida and Texas with more than 600,000; New York with more than 400,000; Georgia with more than 300,000; and Arizona, Illinois, and New Jersey with more than 200,000.
- The Midwest region of the US is now reporting its highest average daily incidence to date. The increase began in mid-June, around the time incidence began to increase in the South, Southwest, and West; however, the Midwest incidence plateaued when other regions steadily declined. Over the past several weeks, the Midwest incidence has increased again. The timing of the recent surge coincides with the return to school, including in-person classes in some areas, and much of the increased incidence is among younger adults. The Midwest is now reporting its highest average incidence to date.
- According to data compiled by researchers at COVID Exit Strategy, Wisconsin’s daily incidence has more than doubled over the past 2 weeks, and the incidence in Nebraska and South Dakota has increased by 40% or more. Several Midwest states are also reporting concerning trends in terms of testing. Arkansas, Iowa, Kansas, Missouri, Nebraska, South Dakota, and Wisconsin are all reporting test positivity greater than 15% over the past 2 weeks, and Nebraska and Wisconsin have increased by more than 3 percentage points over that time.
- The Johns Hopkins CSSE dashboard reported 6.91 million US cases and 201,204 deaths as of 12:30pm EDT on September 23.
2. US CDC DROPLET VS AIRBORNE/AEROSOL GUIDANCE
- When we covered the inadvertent changes to US CDC guidance on SARS-CoV-2 transmission on Monday, archived versions of the site captured Friday-Sunday had not yet been posted. You can now view archived versions via the Internet Archive and compare them to the current version. We will continue to monitor CDC guidance for any changes, particularly any associated with the draft version that was published on Friday and then removed.
3. WEDDING RECEPTION OUTBREAK
- An August wedding in Maine has been linked to more than 175 associated cases and 8 deaths, including many who did not attend the wedding. Notably, none of the associated deaths attended the wedding. Six of the 8 deaths were residents of a nearby long-term care facility, where an employee who lives with someone who attended the wedding is believed to have introduced the virus.
- Associated cases have been identified in multiple long-term care facilities and the county jail. The outbreak at the jail has been attributed to an employee who attended the wedding, and it has resulted in at least 84 cases, including nearly half of the incarcerated population and employees as well as 17 household contacts of employees.
- The wedding reportedly had 62-65 attendees and an indoor ceremony and reception, which violated the state prohibition on gatherings of more than 50 people, and attendees reportedly did not adhere to recommendations regarding physical distancing or mask use. All attendees had their temperatures checked before entering; however, this failed to identify infectious individuals.
- The Maine CDC issued an “imminent health hazard” citation to the event facility where the reception was held for failing to maintain social distancing measures, allowing too many people to congregate, and neglecting to collect contact information from wedding guests. The facility reportedly suspended all operations due to the outbreak. This case study highlights the potential for transmission at individual events to spill over into the community as well as the limitations of temperature or symptom monitoring to identify infectious individuals.
4. K-12 SCHOOLS
- With no federal reporting guidelines, school C19 reports continue to be fragmented. The New York Times has compiled information on the public availability of school-level C19 data. Currently, 11 states have no public reporting for school-associated C19 cases. Some states that do report C19 cases do not do so clearly or explicitly, and data can be difficult to identify among other C19 reporting. The level of reporting also varies by state, ranging from school- and district-level data to aggregated state-level data.
- Lawsuits continue to be a mechanism for forcing school reopenings or closures. Several teachers in Palm Beach, Florida, filed a lawsuit against the local school board to keep classes online. Conversely, a local school board in Oregon filed a lawsuit against state health and education officials to allow them to resume in-person instruction, despite the county having one of the highest incidence rates in the state.
- In New Mexico, a lawsuit has been filed claiming that differences in state C19 requirements for public and private schools is unconstitutional. A spokesperson for the governor’s office argued that the differences in requirements for public and private schools are a result of private schools having “more flexibility” to respond during the pandemic. Private schools in New Mexico are only permitted to return to 25% capacity, whereas public schools can operate at up to 50% capacity for in-person classes. Notably, however, private schools can resume in-person classes for all grades K-12, but public schools are currently limited to grades K-5.
5. MIDWEST RESURGENCE
- C19 incidence is once again on the rise in the Midwest region of the US*. Analysis conducted by researchers at Harvard University identified 6 Midwest states as being at a “tipping point”—Arkansas, Missouri, Oklahoma, North and South Dakota, and Wisconsin—signaling the potential for increased transmission over the coming weeks if not quickly brought under control. Notably, Wisconsin Governor Tony Evers issued a new public health emergency declaration for the state and extended the statewide mask mandate as a result of the recent surge in C19 incidence. As we covered previously, the Big Ten Conference, which largely consists of schools from Midwest states, announced that it will resume athletic competition, including football. Of note, the counties where 9 of the 14 schools** are located are reporting increasing C19 incidence, including 2 that doubled compared to the previous week. As a whole, counties with Big Ten schools are reporting per capita incidence that is more than double the national average, including 4 that are approximately 3 times the national average or higher.
6. HALLOWEEN & DÍA DE LOS MUERTOS
- As the weather cools, many are looking ahead to fall holidays. Halloween, widely celebrated throughout the US, and Día de los Muertos, an important Mexican cultural holiday, typically involve both family gatherings and community events. To mitigate the SARS-CoV-2 transmission risk linked to these holidays, the CDC published guidance on ways to safely participate in these celebrations. The guidance breaks down certain holiday-related activities for both Halloween and Día de los Muertos into low-, moderate-, and high-risk categories.
- Traditional trick-or-treating, in which children go house-to-house and adults give them candy, is considered a high-risk activity since it involves direct contact between numerous children and adults as well as the widespread movement of children around the community. Instead, the CDC suggests that families prepare individually packaged candy and place it outside the home in a way that children can take it with no contact necessary. For Día de los Muertos, the CDC suggests that families perform traditional activities only with members of their own households or meet with extended family members in outdoor settings with appropriate physical distancing to mitigate transmission risk.
7. OCCUPATIONAL SAFETY
- Since the beginning of the pandemic, worker safety has been a primary concern, especially as many workers were quickly designated as “essential” and unable to work from home. While employers are required by law to minimize workplace hazards, the Occupational Safety and Health Administration (OSHA) is tasked with enforcing the implementation of worker safety laws.
- A commentary published in JAMA asserts that the federal government has not taken full advantage of OSHA’s authority to improve worker safety in the midst of C19. While many businesses have taken steps to protect their employees, specific practices and the degree of implementation vary considerably across businesses and localities.
- The authors assert that a stronger federal presence and more stringent oversight of OSHA compliance would compel employers to take stronger actions to protect their employees against workplace C19 hazards. They call on OSHA to implement an Emergency Temporary Standard (ETS) that would require all employers to create and implement an infection prevention and control plan during the pandemic. Some states have issued state-level ETSs, and a federal ETS mandate is currently being proposed to the US Senate.
8. AIR TRAVEL TRANSMISSION
- As social distancing policies are relaxed and air travel is increasing around the world, airlines are implementing measures to reduce transmission risk, particularly onboard aircraft. Two recently published case studies address the risk of SARS-CoV-2 transmission related to air travel. Both studies were published in the US CDC’s Emerging Infectious Diseases journal, and both document suspected transmission between passengers and crew onboard commercial aircraft.
- Both case studies evaluate transmission dynamics onboard long-haul flights. In the first study, researchers used genomic analysis of clinical specimens to link 4 cases onboard a flight arriving in Hong Kong. The researchers hypothesize that 1 or 2 passengers (traveling together) infected 2 flight attendants during the flight. The other study investigated a cluster of 16 cases on the same flight arriving in Vietnam.
- The index patient is believed to have flown in business class, and 12 other business class passengers were infected—as well as 2 passengers and 1 flight attendant in economy class. The attack rate in business class was 62%, and it was 92% among passengers seated within 2 seats (approximately 2 meters) of the index patient.
- The prolonged exposure and close proximity of the passengers in business class suggests that the infections occurred during travel, whether during the flight or before the flight (eg, in business class lounge areas or standing in line during boarding). Researchers are still trying to understand the exact mechanisms and risk of in-flight transmission (eg, droplet/airborne versus fomite transmission).
- The US CDC has reportedly identified approximately 1,600 confirmed C19 cases who flew while infectious and more than 11,000 contacts who may have been exposed during travel. Despite collaborating with airlines, health officials face a variety of barriers to conducting contact tracing for airline passengers, including testing insufficiencies and inaccurate or outdated contact information (particularly for international flights).
- Additionally, CDC guidance defines a close contact as anyone seated within 6 feet of a known case or anyone on a flight without assigned seating, which can overlook at-risk passengers seated farther away or those who may have had other forms of contact (e.g., using the onboard lavatories). Current CDC guidance to mitigate transmission risk during air travel suggests physical distancing, mask use, and frequent handwashing, but it also notes that avoiding travel is the best way to minimize risk. CDC officials stated that they have not yet confirmed SARS-CoV-2 transmission onboard a domestic flight; however, they emphasize that this does not mean that it has not happened or is not occurring.
- Many countries around the world continue to restrict American travelers, due in part to the current state of the US epidemic. Notably, restrictions on US travelers entering Canada and Mexico have been extended through at least October 21.
9. VACCINE CLINICAL TRIALS
- Johnson & Johnson (J&J) announced that it commenced Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine. Similar to other vaccines in Phase 3 trials, the J&J vaccine is built on an adenovirus vector to deliver the vaccine—the same platform used for its Ebola vaccine that was recently licensed in Europe. The J&J vaccine, developed by Janssen Pharmaceuticals, does offer several advantages over other vaccines in Phase 3 trials that could be particularly useful in terms of implementing vaccination campaigns.
- Unlike some other leading candidates, the vaccine is designed to require only 1 dose, and while it must remain refrigerated, it does not need to be frozen. The clinical trials will include 60,000 participants in Argentina, Brazil, Chile, Colombia, Mexico, Peru, South Africa, the United Kingdom, and the United States. In a press release from J&J, the company committed to publishing Phase 1/2 trial data in the near future.
- As concern persists regarding the potential for a vaccine to be authorized for use before Phase 3 trials are complete, the US FDA is expected to announce standards for issuing an Emergency Use Authorization (EUA) for a candidate vaccine. Amid ongoing political statements regarding the timeline for vaccine availability, the FDA guidance could increase transparency regarding how the candidate vaccines will be evaluated, including the metrics that must be met during clinical trials to receive the preliminary authorization.
- The standards are expected to be more stringent than those used for convalescent plasma and hydroxychloroquine, and reportedly, FDA officials have indicated that the standards for an EUA will be close to those required for a full authorization. By outlining the standards for an EUA, the FDA aims to build confidence that scientific evidence will drive the evaluation of candidate vaccines, rather than political influence.
10. PEER REVIEW OF SARS-CoV-2 SYNTHETIC ORIGIN PREPRINT
- Perhaps more so than any event in history, preprint manuscripts and other publications outside of the traditional peer review process (e.g., press release) have been particularly impactful over the course of the C19 pandemic. Considering the pace of discovery and the potential for analysis to inform pandemic response operations and policies, preprint manuscripts can disseminate information much more quickly than the peer review process would allow. However, peer review provides an independent check on publications and research, and bypassing this process can allow research that does not meet acceptable standards to be widely circulated.
- A recent preprint manuscript presents genomic analysis of the SARS-CoV-2 virus and concludes that the viral genome suggests that it is synthetic in origin, as opposed to a naturally occurring virus. The sensational claims and conclusions in the manuscript have the potential to garner significant public and media attention, and the nature of the conclusions could potentially impact global geopolitics and international C19 response.
- The study and conclusions, however, have not been subjected to independent expert scrutiny. Several experts at the Johns Hopkins Center for Health Security endeavored to provide an analogue to the peer review process for this article and put the analysis in context for elected and appointed government officials, the media, and the public. The Center’s experts identified a number of flaws throughout the manuscript that call into question the validity of the analysis and findings.
- As Americans, and presumably citizens in countries around the world, stay home as part of social distancing efforts, they are generating more garbage. According to a report by NPR, garbage volume “spiked as much as 25%” in the spring, when most Americans were under some form of “stay at home” order or other social distancing policy. In addition to increased volume, the distribution of garbage is shifting from businesses to homes, and the trucks designed to empty large dumpsters are not necessarily able to be repurposed to collect residential garbage that may require navigating narrower streets or alleys. In some countries, such as Japan, existing garbage collection practices are being updated to reduce the risk of exposure for sanitation workers.
- Additionally, some cities are facing shortages of sanitation workers, which further challenges trash collection efforts. Sanitation workers are certainly essential, but it can be difficult to provide them with the same level of protection that other essential workers have. The CDC has published guidance for waste collectors and recyclers that includes recommendations for C19 risk mitigation measures.
- In addition to general recommendations that are applicable to most businesses (eg, mask use, physical separation), the CDC recommends that sanitation workers practice enhanced hygiene, and it emphasizes the importance of personal protective equipment, including eye protection, gloves, and coveralls or uniforms. In particular, the CDC recommends avoiding contact with bodily fluids or items/surfaces contaminated with them; however, garbage often contains these items. In many cases, sanitation workers may not be able to avoid contact with garbage, which could potentially pose a transmission risk.