September 29, 2020
Without reliable information, we rely on fear or luck.
CDC Publishes Survival Rates
- Age 0-19 — 99.997%
- Age 20-49 — 99.98%
- Age 50-69 — 99.5%
- Age 70+ — 94.6%
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity
6. Social distancing is more effective than travel bans (Link Only)
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A. The Pandemic As Seen Through Headlines
(In no particular order)
- Global coronavirus death toll surpasses 1 million people
- The floundering global response to the pandemic puts the most vulnerable at dire risk, an aid group warns
- U.S. Continues Gradual Recovery Though Risks Remain
- Coronavirus cases up in 21 states as new model predicts ‘huge surge’
- New study finds US is nowhere near COVID-19 herd immunity
- The pandemic is far from over, experts say, despite Trump allies’ claims
- Dr. Fauci says US ‘not in a good place’ with over 205,000 coronavirus deaths
- UK professor warns COVID-19 lockdowns ‘defer the problem’
- New cases in Sweden, which became a lightning rod over its lax pandemic response early on, remain surprisingly low
- Trump announces distribution of 150,000,000 rapid coronavirus tests
- New document reveals scope and structure of Operation Warp Speed and underscores vast military involvement
- China pushes emergency COVID-19 vaccine to thousands despite safety concerns
- Putin To Be Among First To Receive ‘Controversial’ Sputnik Vaccine Ahead Of S.Korea Visit
- Elon Musk says he won’t take coronavirus vaccine, calls Bill Gates a ‘knucklehead’
- 1 in 3 parents don’t intend to have their child get the flu shot this year
- More than 1,700 health care workers have died of COVID-19 and related complications
- Military suicides up as much as 20% during COVID-19 pandemic
- Facing the pandemic’s economic fallout, some U.S. employers are cutting health coverage, potentially leaving tens of millions of workers without insurance by the end of the year
- As insurers move this week to stop waiving telehealth copays, patients may have to pay more for virtual care
- Sales of zinc have surged during the pandemic, but while the supplement may shorten a cold, there’s no definitive evidence suggesting that it can help with the coronavirus
- UK Government poised to amend regulations to allow use of unlicensed vaccine
- UK Parliament sets curfew for its own bars after loophole outrage
- Beijing unveils new protections for health emergency whistleblowers
- Florida’s Governor Lifts All COVID-19 Restrictions On Businesses Statewide
- Florida bars packed after state lifts COVID-19 restrictions
- NY COVID-19 infection rate hits highest level since mid-July
- NYC’s mayor calls an uptick in the city’s daily positivity rate ‘cause for real concern,’ as more schools reopen
- The virus is surging in one of the most rural states, Montana, where new daily cases have more than doubled in the past two weeks to an average of 250 a day
- Large groups of maskless people gather in Brooklyn COVID-19 hot zones
- NYC threatens lockdown for COVID-19 hot spots
- A new analysis by the CDC shows that the virus is more common in teenagers than younger children
- Regeneron new therapeutic proves effective a treating mild to moderate symptoms
- NYC positivity rate tops 3% for first time in months
- NYC Mayor De Blasio imposes fines for refusing to wear masks
- Texas, California see fewest new deaths in three months
- Cities in Northern England urge rollback of local lockdown measures
- India’s hardest hit state prepares to reopen restaurants, bars
- Growing numbers of people in Europe are dismissing the threat of the virus as a hoax and have protested restrictions in cities like London, Paris and Berlin despite mounting cases
- Turkey cracks down on doctors who doubt official figures
- Tory rebellion to curb UK ministers’ Covid powers advances
- COVID-19 restrictions tighten in France as cases spike
- The French government ordered bars, cafes and restaurants in Marseille and Aix-en-Provence to close for 15 days starting Sunday evening, prompting fury in the region
- Thailand extends emergency ahead of easing ban on tourists
- Colombia surpassed 800,000 cases over the weekend, just as social life had begun to return to Bogotá, the capital and epicenter of the country’s crisis
- Israel’s second lockdown could last a while
- Kenya extends nationwide curfew for two months
- With cases rapidly rising, the Netherlands adds new restrictions
- Madrid Erupts As Citizens Clash With Police During Anti-Lockdown Riots
- G20 gathering of world leaders to be virtual
- “Supply Has Been Decimated”: California Mask Shortage Has Worsened Due To Wildfire Smoke
- NYC elementary schools reopen in key test of resuming learning during coronavirus pandemic
- De Blasio may nix on-site learning at NYC schools amid soaring COVID-19 rate
- NYC principals call on State to take over their schools
- Students are traveling thousands of miles to take SAT amid COVID-19 cancellations
- Democrats unveil new COVID relief plan that includes another round of checks
- US retailers set record for closures as pandemic fuels crisis
- MTA pensions ‘decimated’ by COVID-19 market crash, lawsuit says
- United Airlines pilots reach deal to avoid thousands of furloughs
- Tesla’s Nevada Gigafactory Has The County’s Highest COVID-19 Case-Count Since June
- Pregnant and lactating women should not be excluded from Covid-19 drug, vaccine trials
- CDC releases Thanksgiving guidelines amid COVID-19 pandemic
- Answer the phone, officials beg the public: It could be a contact tracer
- First cruise ship to sail post-coronavirus docks after 12 crew test positive
- US travelers can currently visit Mexico for $144 round trip
- Majority of Gen Z women say they experienced a wake-up call during self-isolation
- Nearly 70% of Americans say they’re done with coffee shops after becoming at-home baristas
- Molar meltdown: Pandemic panic is causing people to crack their teeth
- After urging mask mandates for airports, Senator Diana Feinstein spotted at airport without mask
- COVID-19 pandemic pushes back NASA’s search for life on Saturn’s moon
- NFL’s first COVID-19 outbreak is here: Eight members of Titans test positive
- Cops bust up off-campus student party with over 1,000 people
- Desk shortage forces parents, students to get creative at home
- Plastic surgery on the rise as patients use COVID-19 masks to hide
- Man builds candy-shooting cannon, robot to keep trick-or-treating alive
- Luxury fashion brands like Prada are focusing on “waist-up” designs and relaxed bottoms for the era of video conference calls
B. Numbers & Trends (9/28)
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
- Total Cases = 33,545,333
- New Cases = 230,919
- New Cases (7 day average) = 285,288 (-237) (-0.1%)
- Record high 7 day average of new cases occurred on 9/19 at 289,653
- Since 9/19, 7 day average has been relatively stable slightly below peak number
- 1,000,000+ cases every 4 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 7,361,611
- New Cases = 37,418
- Percentage of New Global Cases = 16.2%
- New Cases (7 day average) = 41,499 (+295) (+0.7%)
- Total Number of Tests = 105,749,110
- Percentage of positive tests (7 day average) = 5.2%
- 7 day average of new cases has been relatively stable since 9/19, ranging between 41,497 and 41,217
- Since 2nd peak on 7/25, 7 day average has declined from 69,724 to 41,499 cases, a decrease of 40.5%
- 7 day average of the percentage of positive tests has declined 0.5% over last month
- 100,000+ cases every 3 days (based on 7 day average)
- Total Deaths = 1,006,138
- New Deaths = 3,841
- New Deaths (7 day average) = 5,269 (-42) (-0.8%)
- 7 day average of new deaths has been relatively stable since 9/16, ranging between 5,347 and 5,192 (no directional trend)
- 7 day average has mostly been trending lower since 2nd peak of 5,921 new deaths on 8/13, a decrease of 11%
- Total Deaths = 209,808
- New Deaths = 355
- Percentage of Global New Deaths = 9.2%
- New Deaths (7 day average) = 755 (-4) (-0.5%)
- 7 day average of new deaths has been relatively stable since 9/22, ranging between 761 and 738
- Since 2nd peak on 8/4, 7 day average has declined from 1,178 to 755 deaths, a decrease of 35.9%
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity (9/28)
- A total of 32 states have 7-day average positivity rates above the 5% threshold recommended by the WHO. ND leads the nation in positivity rate with more than 31% of its tests coming back positive
- Four states (SD, IA, ID and GA) have 7-day average positivity rates between 20-30%
- A total of 11 states have 7-day average positivity rates 10%-20% (MO, WI, KS, NE, UT, NV, AL, MS, IN, FL, and TX)
- There are 16 states between 5%-10% (MT, AR, MN, WA, NC, WY, CO, OK, DE, PA, SC, OR, TN, AZ, HI, MD)
- Despite the growth in positivity rates, only WI and KS have jumped into the top 5 states, albeit at much lower number of total cases, which have been dominated by TX, CA, FL, GA and IL since July
- FL reported only 738 new positive cases and only 5 deaths, the first time it has had less than 1,000 new cases since June 8
- New York reported 1,005 new virus cases on Saturday — the largest single-day uptick since early June
4. Positive C19 test rates top 25% in some Midwest states
- The number of C19 cases in the US rose by at least 10 percent in 21 states last week — while a new model predicts a “huge surge” is expected to impact more Americans as early as next month.
- New infections accelerated mainly in the West, according to a CNN analysis of Johns Hopkins University data, although some Eastern outliers like North Carolina and New Jersey also saw upticks.
- The states where infections are rising include Alabama, Alaska, Colorado, Idaho, Maine, Michigan, Minnesota, Montana, Nevada, New Jersey, New Mexico, North Carolina, North Dakota, Oregon, South Carolina, South Dakota, Texas, Utah, Washington state, Wisconsin and Wyoming.
- Another 18 states saw their rates hold steady, while just 11 — including Florida, Connecticut and New Hampshire — saw new cases of C19 decrease by more than 10 percent from a week earlier, according to the report.
- Meanwhile, the country could see a “huge surge” in cases starting in October — and increasing through November and December — as people spend more time inside, where there’s a higher likelihood of transmitting the bug, Dr. Chris Murray, director of the University of Washington’s Institute for Health and Metrics and Evaluation, told CNN.
- The US is tallying roughly 765 coronavirus deaths per day — but that figure could nearly quadruple to 3,000 daily fatalities by December, according to the IHME’s model.
- The bleak analysis also comes just days after a study found that less than 10 percent of Americans have C19 antibodies, suggesting the nation is further away from herd immunity than researchers initially thought, the New York Times reports.
- The study, which was published Friday in The Lancet, analyzed blood samples from 28,500 patients on dialysis in 46 states and found that 9.3 percent had antibodies to the virus.
- The findings roughly match those in a CDC analysis to be released this week that found about 10 percent of blood samples from sites nationwide had antibodies to the virus, the Times reports.
- However, The Lancet research showed antibody levels across the country varied greatly. In the New York metropolitan area, which includes New Jersey, the levels exceeded 25 percent of samples tested, while antibody levels dipped below 5 percent in the West, the Times reports.
- Meanwhile, New York reported 1,005 new virus cases on Saturday — the largest single-day uptick since early June.
- And in California, state health officials are warning that hospitalizations could skyrocket by up to 89 percent if the state’s current rate of C19 infections continues, the Mercury News reports.
- “As we see these trend lines, which have been coming down and flattening, look like they’re coming up … we want to sound that bell for all of you,” California Health and Human Services Secretary Dr. Mark Ghlay told reporters Friday.
- “We want to see us respond as a state to those slight increases.”
- California’s rate of new infections and fatalities, however, remained lower last week than those of two weeks ago — at just over 3,500 cases per day and just below 84 deaths per day, the newspaper reports.
5. Wisconsin Is on the Brink of a Major Outbreak
- In New York, the decisive moment came in March. In Arizona and other Sun Belt states, it struck as the spring turned to summer. In every state that has so far seen a large spike of C19 cases, there has been a moment when the early signs of an uptick are detectable—but a monstrous outbreak is not yet assured. Can a state realize what’s happening, and stop a surge in time? Wisconsin is about to find out.
- In the past week, Wisconsin has crashed through its own coronavirus records, reporting more cases and more C19 hospitalizations than it has at any time since the pandemic began, according to the COVID Tracking Project at The Atlantic. It now ranks among the top states in new cases per capita, according to the Centers for Disease Control and Prevention, and it is reporting more new cases, in absolute terms, than all states but California, Texas, and Florida.
- Wisconsin’s outlook was deteriorating into the weekend. Yesterday, it reported more than 2,620 new cases of C19, an all-time high. More than 540 people are hospitalized with the virus statewide.
- The outbreak started about a month ago. It seemed, at first, like a product of students returning to college campuses. The University of Wisconsin at Madison brought back tens of thousands of students to campus in August. Within a week of classes starting, more than 1,000 of them tested positive, and the university shut down all in-person instruction. Other states in the Midwest saw similar spikes after colleges and universities restarted for the fall.
- But those states are not seeing what Wisconsin is now. Cases are popping up in too many places, and among too many different age groups, to be blamed on college kids. In fact, every age group except 18-to-24-year-olds has seen cases rise this week, according to official data. “There’s a surge happening in cases across the state, for the most part,” Ajay Sethi, an epidemiology professor at the University of Wisconsin, told me.
- Any coronavirus outbreak is bad news, but a surge in Wisconsin, at this moment, would be particularly awful. The problem is one of both political geography and poor timing. Wisconsin could determine the outcome of the presidential election: The state went for President Donald Trump in 2016 by only 22,748 votes, and both Trump and former Vice President Joe Biden have campaigned there this month. The election is little more than a month away, and if the threat of infection scares Wisconsinites away from polling places, the outbreak could play a role in who wins the state.
- But this is also a bad time for any state to have an outbreak. As my colleague Alexis C. Madrigal and I wrote this month, the pandemic has become harder to track in the United States. Nationwide, the results of some new types of C19 tests are not being consistently reported to local governments. In Wisconsin, testing has declined from its peak: The state reports fewer coronavirus tests a day now than it did in late July. This means that metrics that proved useful during the Sun Belt surge this summer, such as the percentage of tests that come back positive, have become less reliable. And this, in turn, has made it harder for officials and experts to forecast how large of an outbreak a state might be facing before the corresponding spikes in cases and hospitalizations.
- In Wisconsin, neither of those numbers looks good. The Badger State is seeing an explosive rise in cases: On September 1, it reported an average of about 750 new coronavirus cases a day; now it reports more than 2,000 a day. Wisconsin has reported nearly as many new cases per capita this week as Texas and Georgia did at the peak of their outbreaks this summer, according to the CDC.
- At the same time, the number of people hospitalized with C19 in Wisconsin has more than doubled since the month began. “The surges are in Green Bay, in northeastern Wisconsin, and there’s a little evidence of an uptick in Milwaukee,” Sethi said. “A lot of these counties are where older individuals live, on average.”
- But the state is not doomed to becoming the next Arizona, and it has already had some success halting the spread of the virus. After the University of Wisconsin at Madison shut down in-person classes earlier this month, case counts plummeted across the state. (The school is now loosening those restrictions.) Nationwide, many colleges and universities have successfully kept the virus in check through frequent testing and mask requirements.
- But those tools aren’t as easy to deploy in a fractious state. This week, Governor Tony Evers, a Democrat, announced that the rising case counts forced him to extend a statewide mask mandate through November. Mask mandates are supported by public-health officials in the Trump administration and the White House Coronavirus Task Force. Yet the state’s top Republican legislators immediately attacked the move. “Moot, illegal, invalid, and almost assuredly headed for litigation,” Scott Fitzgerald, the state’s Senate majority leader, said in a statement. If the mask mandate is overturned in the state legislature, as Fitzgerald has repeatedly threatened, then Wisconsin’s odds of a deadly surge will worsen.
- Leaders in Wisconsin should recognize that they hold the entire region’s fate in their hands, because their reckless action could set off a much larger blaze. The Midwest now reports more C19 cases per capita than any other region. It is the only part of the country to have escaped a large-scale outbreak so far, but a major spike could prove especially devastating, because the residents of many midwestern states skew older.
- The next few months will prove decisive in the Midwest. Infections didn’t really start going in the Southwest until the summer arrived, when the searing daytime heat drove people indoors, where the coronavirus seems to spread most easily. In the Midwest, indoor season arrives in late autumn. It is nearly 80 degrees Fahrenheit in Green Bay today. The weather in December probably won’t be as favorable.
6. Six reasons C19 death rates are improving
- The sickest coronavirus patients can live for weeks with a gripping headache, profound nausea, burning lungs, malaise, cough and waves of pain in their bones. They may be tethered to a breathing machine.
- But eight months into the pandemic, fewer are dying.
- New data reveals that while patients are still being rushed to intensive care units, a greater proportion are coming out alive. Since the pandemic began, the cumulative death rate for Californians with C19 has fallen by more than half in the past three months. In early June, it was 5.87%; by Sept. 13, it was down to 2.14%.
What’s going on?
- Some of the decline simply reflects a shift in testing, as infections in younger and healthier people are diagnosed. But that doesn’t explain all of it. There also have been fundamental improvements in how we prepare and care for the sickest patients, according to interviews with top medical experts.
- “These declines in the case fatality ratios are striking,” said Dr. George Lemp, an epidemiologist and former director of the HIV/AIDS Research Program at UC’s Office of the President, who analyzed death rates using state data.
- “We should applaud and appreciate the medical community for being able to find rapid ways to improve the outcome of this life-threatening illness,” he said.
Here are six major reasons why the death rate is falling:
More testing, younger patients
- When the pandemic first hit, only people with severe symptoms were tested. Now expanded testing is detecting milder and earlier cases, so the prognosis is better, said UCSF epidemiologist Dr. George Rutherford.
- We’re also diagnosing more infections in younger people, who fare better. Early on, we focused a lot of testing on outbreaks in nursing care facilities, where the sick and elderly face slimmer odds of survival. Now, fewer of this vulnerable population is getting sick.
- As the patient mix has changed, so has the math, explained Rutherford. The denominator — the total number of cases — has grown faster than the numerator — total deaths. So the overall mortality rate is falling.
- The declines have occurred across all age groups, during the four-month period between May and August 2020, according to Lemp’s analysis. This means everyone is doing better.
- The phenomenon is driven by more than statistics, said Rutherford. “As we gain greater experience with novel infections, mortality goes down.”
- Hospitals cite “the four S’s” needed for effective ‘surge’ planning: staff, supplies, space and systems. Managing a patient on a ventilator, in particular, is a labor-intensive and delicate task.
- During a surge of cases, hospitals in Southern California fell short on all four of these metrics, nearly hitting capacity. Some patients were intubated in emergency rooms instead of the intensive care units. Hospitals were forced to use older equipment, as well as doctors and nurses from outside hospitals who were less familiar with procedures and life-saving devices.
- In the San Francisco Bay Area, hospitals were better prepared. And this planning has improved, over time.
- The death rates of the regions are a study in contrast. For example, Los Angeles reports 57 deaths per 100,000 residents, while San Francisco has only one-tenth as many, with about 6 deaths per 100,000 residents, according to data presented at UCSF’s Grand Rounds last week.
- “None of our hospitals were flooded,” said UCSF infectious disease expert Dr. Monica Gandhi. Preparation “allows an organized response. You have enough nurses. You’re only doing your job, not other people’s jobs. You’re not running around. Rooms are ready. You have PPE.”
- “It is the chaos that can occur when hospitals are not ready that absolutely contributes to mortality,” she said.
Improved use of ventilators
- Doctors now have a better understanding of how to manage breathing in severely ill patients, said Dr. Andra Blomkalns, chair of the Department of Emergency Medicine at Stanford Medicine.
- Initially seen as a last-ditch measure — and a sign of impending death — doctors now recognize the value of putting people on mechanical ventilation early, if needed, she said.
- “We used to say ‘someone doesn’t quite need it yet, let’s see how they do in the hospital.’ That hasn’t worked well,” she said. “We’ve resolved that if they have to be on it, it’s better to put them on it earlier rather than wait until too late.”
- We’ve also gotten better at fine-tuning ventilation, understanding the optimal amount of oxygen, pressure and time between breaths, she said. We’ve learned to be very gentle on the lungs.
- Clinicians are also more skilled at deploying other tactics.
- We’ve enlisted “proning,” where a team of caregivers gently roll a patient from their back onto their abdomen, said Dr. Alan Chausow, chair of Pulmonary Medicine at Palo Alto Medical Foundation and medical director of the Critical Care Unit at Mountain View’s El Camino Hospital. When the patient is lying face down, it’s easier for the back of their lungs to expand.
- “It’s not comfortable to lay on your tummy. But it definitely helps,” he said. “We’ve been proning people for other diseases for 10 years. We’re just taking that experience and adding onto it.”
- We’ve also learned to be especially vigilant in the prevention of other infections, Chausow said. In the ICU, for instance, use of a urinary catheter boosts the risk of deadly infection.
- And now that research shows C19 boosts the risk of lethal blood clots, doctors monitor blood more closely, and increase the use of preventive blood thinners, experts said.
- “With every novel infection, as we gain greater experience and as we use better and better tools, the mortality goes done,” said UCSF’s Rutherford. “It was true of Ebola, HIV and a bunch of others. Now it’s also true of C19.”
- Use of drugs such as remdesivir and the steroid dexamethasone may be helping.
- Remdesivir, authorized on May 1, shortens the recovery time for some of the sickest patients. While it blocks the virus from replicating, it’s unclear whether it’s actually keeping more people alive. In clinical trials, death rates are slightly lower — 7.1% vs. 11.9% — but this difference was not statistically significant.
- The common steroid called dexamethasone, authorized in mid-July, has been proven to reduce deaths of patients on ventilators by one-third; in patients receiving supplemental oxygen, but not on ventilators, it cut deaths by one-fifth.
- One drug is more appropriate for some patients; the second is better for others. Sometimes both are used.
- “At the beginning, people were very ill and we had simply nothing to offer them,” said UCSF’s Gandhi.
- This week, drug maker Eli Lilly announced that a single infusion of its experimental monoclonal antibody — a manufactured copy of the body’s natural protective antibody — reduced hospitalizations by 72 percent. The research has not yet been published or reviewed by independent scientists.
- Some patients may also be benefiting from participation in clinical trials for experimental drugs that subdue a lethal immune response, called a “cytokine storm.” There’s preliminary evidence that patients given the drug Tocilizumab, originally designed for rheumatoid arthritis, were 45% less likely to die. Blood pressure drugs may mute the chemical signals that precede cytokines. The FDA has authorized the use of a cartridge that continually filters excess cytokines from the blood.
- What will make the biggest difference, said Lemp, is a future “‘home run’ drug, that can dramatically shut down the virus — killing it, by stopping replication.”
Better information-sharing between doctors
- Clinicians aren’t waiting to get their news through formal channels; instead, they’re talking to each other, in hospital Grand Rounds and other forums. There’s more communication and collaboration, said Stanford’s Blomkalns.
- “Initially, everything was rumor,” said El Camino’s Chausow. “Now we’re practicing more evidence-based medicine.”
- “It’s a tough, tough disease, which nobody thinks will go away. It will be a part of our lives, long term,” he said. “So getting answers will really involve good data.”
- The best way to reduce death, he said, is to prevent infection altogether, through mask-wearing and social distancing.
- “The goal is to not get sick in the first place,” he said. “We save more lives by keeping people out of the ICU.”
C. New Scientific Findings & Research
1. Sufficient Levels of Vitamin D Significantly Reduces Complications, Death Among C19 Patients
- Hospitalized C19 patients who were vitamin D sufficient, with a blood level of 25-hydroxyvitamin D of at least 30 ng/mL (a measure of vitamin D status), had a significant decreased risk for adverse clinical outcomes including becoming unconscious, hypoxia (body starved for oxygen) and death. In addition, they had lower blood levels of an inflammatory marker (C-reactive protein) and higher blood levels of lymphocytes (a type of immune cell to help fight infection).
- “This study provides direct evidence that vitamin D sufficiency can reduce the complications, including the cytokine storm (release of too many proteins into the blood too quickly) and ultimately death from C19,” explained corresponding author Michael F. Holick, PhD, MD, professor of medicine, physiology and biophysics and molecular medicine at Boston University School of Medicine.
- A blood sample to measure vitamin D status (measured serum level of 25-hydroxyvitamin D) was taken from 235 patients were admitted to the hospital with C19. These patients were followed for clinical outcomes including clinical severity of the infection, becoming unconscious, having difficulty in breathing resulting in hypoxia and death. The blood was also analyzed for an inflammatory marker (C-reactive protein) and for numbers of lymphocytes. The researchers then compared all of these parameters in patients who were vitamin D deficient to those who were vitamin D sufficient.
- In patients older than 40 years they observed that those patients who were vitamin D sufficient were 51.5% less likely to die from the infection compared to patients who were vitamin D deficient or insufficient with a blood level of 25-hydroxyvitamin D less than 30 ng/mL.
- Holick, who most recently published a study which found that a sufficient amount of vitamin D can reduce the risk of catching coronavirus by 54 percent, believes that being vitamin D sufficient helps to fight consequences from being infected not only with the coronavirus but also other viruses causing upper respiratory tract illnesses including influenza. “There is great concern that the combination of an influenza infection and a coronal viral infection could substantially increase hospitalizations and death due to complications from these viral infections.”
- According to Holick this study provides a simple and cost-effective strategy to improve one’s ability to fight the coronavirus and reduce C19’s adverse clinical outcomes, including requiring ventilator support, overactive immune response leading to cytokine storm and death.
- “Because vitamin D deficiency and insufficiency is so widespread in children and adults in the United States and worldwide, especially in the winter months, it is prudent for everyone to take a vitamin D supplement to reduce risk of being infected and having complications from C19.”
2. C19 may deplete testosterone, helping to explain male patients’ poorer prognosis
- For the first time, data from a study with patients hospitalized due to C19 suggest that the disease might deteriorate men’s testosterone levels.
- Publishing their results in the peer-reviewed journal The Aging Male, experts from the University of Mersin and the Mersin City Education And Research Hospital in Turkey found as men’s testosterone level at baseline decreases, the probability for them to be in the intensive care unit (ICU) significantly increases.
- Lead author Selahittin Çayan, Professor of Urology, states that while it has already been reported that low testosterone levels could be a cause for poor prognosis following a positive coronavirus test, this is the first study to show that C19 itself depletes testosterone.
- It is hoped that the development could help to explain why so many studies have found that male prognosis is worse than those females with C19, and therefore to discover possible improvement in clinical outcomes using testosterone-based treatments.
- “Testosterone is associated with the immune system of respiratory organs, and low levels of testosterone might increase the risk of respiratory infections. Low testosterone is also associated with infection-related hospitalization and all-cause mortality in male in ICU patients, so testosterone treatment may also have benefits beyond improving outcomes for C19,” Professor Çayan explains.
- “In our study, the mean total testosterone decreased, as the severity of the C19 increased. The mean total testosterone level was significantly lower in the ICU group than in the asymptomatic group. In addition, the mean total testosterone level was significantly lower in the ICU group than in the Intermediate Care Unit group. The mean serum follicle stimulating hormone level was significantly higher in the ICU group than in the asymptomatic group.
- “We found, Hypogonadism – a condition in which the body doesn’t produce enough testosterone -in 113 (51.1%) of the male patients.
- “The patients who died, had significantly lower mean total testosterone than the patients who were alive.
- “However, even 65.2% of the 46 male patients who were asymptomatic had a loss of libido.”
- Commenting on the results of the study, Professor Çayan added: “It could be recommended that at the time of C19 diagnosis, testosterone levels are also tested. In men with low levels of sex hormones who test positive for C19, testosterone treatment could improve their prognosis. More research is needed on this.”
3. C19 spike protein morphs into 10 different shapes to invade cells
- The novel coronavirus uses its “spike proteins” to latch onto and invade human cells. But to do so, the spikes morph into at least 10 different shapes, according to a new study.
- At the start of the pandemic, scientists rapidly identified the structure of the spike protein, paving the way to target it with vaccines and other drugs. But there’s still so much scientists don’t know about the interaction between the spike protein and the “doorknob” on the outsides of human cells — called the ACE2 protein. For instance, they aren’t sure what intermediate steps the protein takes to kickstart the process of fusing to, and then opening the cell, ultimately dumping viral material into the cell.
- “The spike protein is the focus of so much research at the minute,” said co-lead author Donald Benton, a postdoctoral research fellow at the Francis Crick Institute’s Structural Biology of Disease Processes Laboratory in the United Kingdom. Understanding how it functions “is very important because it’s the target of most of the vaccination attempts and a lot of diagnostic work as well.”
- To understand the process of infection, Benton and his team mixed human ACE2 proteins with spike proteins in the lab. They then used a very cold liquid ethane to rapidly freeze the proteins such that they became “suspended in a special form of ice,” Benton told Live Science. They then put these samples under a cryo-electron microscope and obtained tens of thousands of high-resolution images of the spike proteins frozen at different stages of binding to the ACE2 receptors.
- They found that the spike protein undergoes shape changes as it binds to the ACE2 receptor. After the spike protein first binds, its structure becomes more open to allow for more binding (imagine how much easier it would be to hug someone if they opened up their arms). The spike protein eventually binds to ACE2 at all three of its binding sites, revealing it’s “central core,” according to a statement. This final structure likely allows the virus to fuse to cell membranes.
- “It’s a very complicated receptor binding process compared to most virus spike proteins,” Benton said. “Flu and HIV have a more simple activation process.” The coronavirus is covered in spike proteins, and it’s likely only a small fraction of them go through these conformational changes, bind to human cells and infect them, Benton said.
- “We know that the spike can adopt all these states that we were talking about,” said co-lead author Antoni Wrobel, who is also a postdoctoral research fellow at the Francis Crick Institute’s Structural Biology of Disease Processes Laboratory. “But whether each of the spikes adopts all of them we can’t say because we can see only kind of snapshots.”
- The spike protein is very quick to change. In the lab, the spike can morph into all of these different conformations in less than 60 seconds, Wrobel told Live Science. But “this will be very different in a real infection; everything will be slower because the receptor will be stuck on the surface of a cell so you have to allow time for the virus to diffuse to this receptor,” Benton said.
- Why does the spike protein go through this many conformational changes to infect a cell? It “may be a way of the virus protecting itself from recognition by antibodies,” Benton said. When the spike protein is in its closed states, it hides the site that binds with the receptor, maybe to avoid antibodies coming in and binding to that site instead, he said.
- But “it’s very hard to know,” Wrobel said. In any case, this research reveals more surfaces on the spike protein that are exposed during infection — as different shapes reveal surfaces once thought hidden. Researchers can then potentially develop vaccines to target these surfaces. “We can then start to think about therapeutics that would fit somewhere either in the receptor surface or somewhere in the spike itself that then act as drugs,” Wrobel told Live Science.
- Wrobel and Benton hope to figure out why the coronavirus goes through so many conformational changes, how that compares to other coronaviruses and if these changes might help explain why this new virus spreads so easily.
- The findings were published Sept. 17 in the journal Nature.
4. Strong activation of anti-bacterial T cells linked to severe C19
- A type of anti-bacterial T cells, so-called MAIT cells, are strongly activated in people with moderate to severe C19 disease, according to a study by researchers at Karolinska Institutet in Sweden that is published in the journal Science Immunology. The findings contribute to increased understanding about how our immune system responds against C19 infection.
- “To find potential treatments against C19, it is important to understand in detail how our immune system reacts and, in some cases, perhaps contribute to worsening the disease,” says Johan Sandberg, professor at the Department of Medicine, Huddinge, at Karolinska Institutet and the study’s corresponding author.
- T cells are a type of white blood cells that are specialized in recognizing infected cells, and are an essential part of the immune system. About 1 to 5 percent of T cells in the blood of healthy people consist of so-called MAIT cells (mucosa-associated invariant T cells), which are primarily important for controlling bacteria but can also be recruited by the immune system to fight some viral infections.
- In this study, the researchers wanted to find out which role MAIT cells play in C19 disease pathogenesis. They examined the presence and character of MAIT cells in blood samples from 24 patients admitted to Karolinska University Hospital with moderate to severe C19 disease and compared these with blood samples from 14 healthy controls and 45 individuals who had recovered from C19. Four of the patients died in the hospital.
- The results show that the number of MAIT cells in the blood decline sharply in patients with moderate or severe C19 and that the remaining cells in circulation are highly activated, which suggests they are engaged in the immune response against the coronavirus. This pattern of reduced number and activation in the blood is stronger for MAIT cells than for other T cells. The researchers also noted that pro-inflammatory MAIT cells accumulated in the airways of C19 patients to a larger degree than in healthy people.
- “Taken together, these analyses indicate that the reduced number of MAIT cells in the blood of C19 patients is at least partly due increased accumulation in the airways,” Johan Sandberg says.
- In convalescent patients, the number of MAIT cells in the blood recovered at least partially in the weeks after disease, which can be important for managing bacterial infections in individuals who have had C19, according to the researchers. In the patients who died, the researchers noted that the MAIT cells tended to be extremely activated with lower expression of the receptor CXCR3 than in those who survived.
- “The findings of our study show that the MAIT cells are highly engaged in the immunological response against C19,” Johan Sandberg says. “A likely interpretation is that the characteristics of MAIT cells make them engaged early on in both the systemic immune response and in the local immune response in the airways to which they are recruited from the blood by inflammatory signals. There, they are likely to contribute to the fast, innate immune response against the virus. In some people with C19, the activation of MAIT cells becomes excessive and this correlates with severe disease.”
D. Vaccines & Testing
1. Virus in the Blood Can Predict Severe C19 – Blood Test on Hospital Admission Can Show if Good Chance of Rapid Recovery
- A blood test on hospital admission showing the presence or absence of the coronavirus can identify patients at a high risk of severe C19. Admitted patients without virus in their blood have a good chance of rapid recovery. This according to researchers at Karolinska Institutet and Danderyd Hospital in a new study published in the scientific journal Clinical Infectious Diseases.
- Blood samples were taken from patients with a confirmed C19 infection within three days of admission to the Department of Infectious Diseases, Danderyd Hospital, Sweden. Patients with measurable levels of coronavirus in their blood were 7 times more likely to develop critical symptoms and eight times more likely to die within 28 days.
- “This readily available test allows us to identify patient groups at high or low risk of severe C19, which enables us to better guide the treatment and monitoring of these patients”, says the study’s lead author Karl Hagman, infectious diseases consultant at Danderyd Hospital and doctoral student at Karolinska Institutet’s Department of Clinical Sciences at the same hospital.
2. A guide to how — and when — a C19 vaccine could be cleared
- In a U.S. pandemic response dominated by missteps, the effort to develop vaccines to prevent C19 has so far been a triumph. Vaccines against the coronavirus that causes the disease are now racing through giant clinical trials as a result.
- The process of deciding when a vaccine appears to be safe and effective isn’t as straightforward as the general public might believe. But it’s important to understand it if we are to have confidence in these critical tools for helping to curb the pandemic.
- Here, then, is a rundown of the science that goes into the decision-making process, what it tells us about when results could realistically be available, and when vaccines could start to be administered. This story is based on interviews as well as on documents the drug makers have released detailing their clinical trial plans.
When will vaccine makers have enough data?
- A clinical trial is typically sponsored by a company making a vaccine candidate or an academic institution, or a partnership of both. But it is actually monitored by what is known as a data and safety monitoring board, or DSMB, a group of independent experts hired to make sure volunteers in the study are safe. In many studies, the DSMB has the ability to recommend stopping a study not only if a treatment is unsafe, but also if it is so clearly effective that continuing just wouldn’t be ethical.
- In the case of the vaccine trials, the studies being run by Moderna, AstraZeneca, and Johnson & Johnson with the National Institutes of Health share a common DSMB. The study being run by Pfizer and its partner BioNTech has its own.
- The DSMBs will conduct what’s called an interim analysis after a certain number of people have been infected with C19 and shown symptoms. Each of these cases is considered an “event,” and each vaccine maker has set a different number of events as a threshold to conduct an interim analysis as part of their trial protocols.
- The study being run by Pfizer and its partner BioNTech, frontrunners in the race for a vaccine, is conducting its first interim analysis after 32 events, and would consider the vaccine effective if 26 people in the placebo group and six in its vaccine group had Covid. A study of Moderna’s vaccine, another frontrunner, is waiting until there are 53 cases of Covid.
- In the case of Pfizer and BioNTech, an interim analysis could happen in October.
- Should a vaccine be approved, potentially for millions of people, after its efficacy has been shown based on 32 cases of C19?
- Some experts say no. Eric Topol, the director of the Scripps Research Translational Institute, has been fervently saying that all the trials should continue beyond even their designed ends — when there are about 150 cases of Covid — saying that even the 150 number “may make statistical sense, but it defies common sense.” This could be particularly true if efficacy is limited, given that all the vaccines frequently cause side effects like fever.
- Others say that while making a decision based on an interim analysis is fine, the first Pfizer analysis, in particular, seems to set a relatively low bar for efficacy given the small number of events.
- The numbers are in line with past vaccine studies. Prevnar 13 was approved to prevent pneumonia in adults based on a study of 84,000 people that detected 139 cases of pneumonia, 90 of them in the placebo group.
- But there’s also a precedent for keeping such studies going to collect more safety data. Researchers studying RotaTeq, a vaccine to prevent a virus that causes childhood diarrhea, collected data from 70,000 patients to rule out a potential side effect which had been seen with a previous vaccine.
The rules of approval
- If and when a company believes its vaccine is safe and effective, it will then submit its data to the Food and Drug Administration.
- No C19 vaccine is likely to be fully approved by the FDA in the near term, because of requirements for manufacturing and follow-up that could take years. The FDA is expected instead to use a different authority by granting what is known as an emergency use authorization, or EUA.
- The bar for an EUA is low, and past EUAs have seemed unwise in hindsight. A drug, peramivir, was authorized on an emergency basis to treat hospitalized patients during the H1N1 swine flu in 2009; the drug later failed to be shown effective in a clinical trial of such patients. Hydroxychloroquine was given an EUA to treat C19 in hospitalized patients; that authorization was later rescinded once further study showed the drug did not benefit them. The EUA for convalescent plasma involved data that would never pass muster for an approval. These later examples are precisely why many experts are so worried that the FDA’s decision-making is politicized.
- The challenge for the FDA will be to make sure that it brings its usual standards for a vaccine to the much more flexible emergency use authorization process.
- Reviewing data on a drug candidate normally takes a year, six months if it is fast, and three months at the fastest. Even a truncated review should take weeks. So even if data on Pfizer’s vaccine are available in mid-October, an emergency authorization by Election Day is difficult to imagine. The same is true if data emerge from one of the studies of AstraZeneca’s vaccine being conducted outside the U.S.
Will the trials march on?
- In the interim analyses that most people who follow medicine are used to, as soon as there is a clear result, the trial stops. But the plan for C19 vaccines is different: Data from an interim analysis may be released if a vaccine is deemed inarguably effective — but volunteers may not be immediately told whether they are receiving vaccine or placebo. In other words, the study will remain “blinded.” Participants receiving a placebo will not be switched immediately to the vaccine.
- “The protocol is designed in a way that even if we would be able to file after an interim analysis, the protocol is designed to move on, at least for a certain amount of time,” said Kathrin Jansen, Pfizer’s head of vaccine research, on a recent call with reporters. The reason is that there is a need to assess efficacy in smaller groups, such as teenagers, the elderly, and people with HIV, she said. Jansen said that Pfizer and BioNTech hope to gather information about severe infection, too.
- Keeping a trial going after an interim analysis can be difficult, so much so that Thomas Fleming, one of the top minds in clinical trial statistics, co-authored a 2008 paper on why it should be avoided.
- In a conference call with reporters to discuss the start of the study for Johnson & Johnson’s vaccine, Anthony Fauci, who heads research on infectious disease at the NIH, said that the other trials will continue in a blinded fashion until half the volunteers in the study have been followed for at least two months, in order to collect more data on efficacy and safety.
- The J&J study requires only 20 cases of C19 before an interim analysis is conducted. But Paul Stoffels, Johnson & Johnson’s chief scientific officer, told STAT that his company will wait to even conduct an interim analysis until after half the participants in its 60,000-volunteer study, started this month, have been followed for two months. Such an analysis will also require enough data in other populations, including the elderly. After the data are interpreted, the DSMB might recommend stopping the study.
- “Generating enough data is also where we take our responsibility, because in the end we will be liable for the product getting into the market,” Stoffels said.
- “You know, we go from a thousand people, to 60,000, to probably 100 million to 500 million people,” Stoffels said. “The information we generate has to be very solid.”
- That’s the point that regulators and, especially, politicians need to remember no matter how eager they are to have a vaccine in hand.
E. Improved & Potential Treatments
1. Nasal spray reduces coronavirus level in blood by up to 96%
- Australian biotech company Ena Respiratory said on Monday that a nasal spray it is developing to improve the human immune system to fight common cold and flu significantly reduced the growth of the coronavirus in a recent study on animals.
- A study on ferrets showed the product dubbed INNA-051, which could be used complementary to vaccines, lowered the levels of the virus that causes C19 by up to 96%, the company said. The study was led by British government agency Public Health England.
- Ena Respiratory said it would be ready to test INNA-051 in human trials in less than four months, subject to successful toxicity studies and regulatory approval.
2. Mother’s milk could help fight coronavirus
- A research team in Beijing tested the effect of human breast milk on cells exposed to the coronavirus. The milk was collected in 2017, well before the start of the pandemic, and the cell types tested varied from animal kidney cells to young human lung and gut cells.
- The results were the same: most living virus strains were killed by the milk.
- The breast milk was “blocking viral attachment, entry and even post-entry viral replication,” the team led by Professor Tong Yigang from the Beijing University of Chemical Technology wrote in two non-peer-reviewed papers posted on biorxiv.org on Friday.
- Breastfeeding has previously been seen as increasing the risk of viral transmission.
- In Wuhan, where the virus was first detected, newborns were separated from mothers who tested positive and fed exclusively by formula, according to Chinese media reports from February.
- The CDC also warns that babies being breastfed by mothers suspected or confirmed to be carrying C19 should be seen as “suspect” carriers too.
- But the latest study supports the World Health Organization’s official stance that mothers should continue to breastfeed even if they have C19.
- The global health body tracked 46 C19 breastfeeding their children in several countries through June.
- Viral genes were detected in the milk of three mothers but there was no evidence of infection. Only one child tested positive and transmission through other means could not be ruled out.
- Tong and colleagues mixed some healthy cells in human breast milk, then washed the milk off and exposed the cells to the virus.
- They observed there was almost no viral binding or entry to these cells, and the treatment also halted viral replication in cells already infected.
- They concluded that the infection could be inhibited by breast milk, which is already known to have suppressive effects on bacteria and viruses such as HIV.
- Tong and colleagues suspected the coronavirus was sensitive to some well known antiviral proteins in milk, such as lactoferrin, but found none of the proteins worked as expected.
- Instead, they said the most likely ingredient for inhibiting the virus was whey, which contains several different proteins.
- Cow and goat whey, was able to suppress the living viral strains by about 70 per cent, according to Tong‘s study. In comparison, the efficacy of human whey reached nearly 100 per cent.
- Human milk was able to eliminate the virus in a broader range of cell types, but the researchers said it was unclear what had caused the difference.
- Tong and colleagues said they had not found any sign of harm caused by human milk, which “promoted cell proliferation” while killing the virus.
- Some parents are known to use donated breast milk to feed their babies, which is often pasteurised to eliminate potential contamination.
- However, the Chinese team found that heating the milk to 90 degrees for 10 minutes inactivates the whey protein, causing the protection rate against the coronavirus would drop to under 20 per cent.
- “It is worth identifying the key factors for further antiviral drug development,” they concluded.
3. Phase III clinical trial assessing if dual-antibody injection prevents C19 illness
- A combination antibody treatment for preventing C19 illness in individuals who have had sustained exposure to someone with the virus is being studied by researchers in a clinical trial.
- The Phase III, randomized, double-blinded, placebo-controlled trial will help researchers determine if the laboratory-made dual-antibody treatment, REGN-COV2, can prevent coronavirus infection in individuals who share a home with someone with a confirmed infection.
- “If this trial demonstrates that this treatment is effective, it could be used in various settings where exposure risk is heightened, such as health care, airlines, meatpacking factories, nursing homes, and among first responders,” said Roberto C. Arduino, MD, the study’s lead investigator and professor of infectious disease with McGovern Medical School at UTHealth. “It is crucial that we discover treatment options that can not only prevent severe illness, but also stop the spread of C19 within our communities.”
- The study team is seeking to enroll asymptomatic individuals who have had at least 48 hours of sustained exposure to a person with a confirmed coronavirus infection, known as an index case. Participants must be randomized within 96 hours of the index case’s diagnosis. Trial participants must live in the same household as the index case patient for 29 days during the study.
- REGN-COV2 is a combination of two monoclonal (laboratory-made) antibodies that target two different sites of the spike protein found on the surface of the coronavirus. Antibodies are proteins created by the immune system to fight a pathogen or infection. The targeted surface spike protein gives the virus a crown-like appearance and allows it to attach to and enter cells.
- The REGN-COV2 antibody cocktail is a combination of antibodies originally isolated from patients who have recovered from C19 and produced by mice that have been genetically modified to have human immune systems.
3. Ultrapotent Antibody Mix Blocks Coronavirus From Entering Cells – Protects Against the Pandemic Coronavirus
- A mix of ultrapotent antibodies from recovered C19 patients has been shown to recognize and lock down the infection machinery of the pandemic coronavirus and keep it from entering cells. Each of the antibody types performs these overlapping tasks in a slightly different way.
- Low doses of these antibodies, individually or as a cocktail, were also shown to protect hamsters from infection when exposed to the coronavirus by preventing it from replicating in their lungs.
- An advantage of such cocktails is that they might also prevent the natural mutant forms of the virus that arose during this pandemic to escape treatment. As some variants in the infection machinery have already been discovered during the coronavirus pandemic, using a mix of antibodies allows for neutralization of a broad spectrum of such viral variants.
- In addition to preventing virus entry into host cells, the presence of the antibodies also seems to set off the infection-fighting actions of other immune cells, which arrive to clear out the virus.
- “We believe that leveraging multiple, distinct, complementary mechanisms of action could provide additional benefits for clinical applications,” the researchers noted.
- The researchers determined how the antibodies worked on a molecular level through cryo-electron microscopy studies of the resulting changes in the configuration of the virus infection machinery. Besides directly preventing interactions with the host receptor, one of the two discovered antibodies locks the infection machinery in an inactive conformation, meaning it could not fuse with the host membrane on the surface of the cell. If unable to fuse, the coronavirus cannot break in and deliver its RNA to commandeer the cell.
- The findings of this research were reported on September 24, 2020, in a rapid release paper in Science.
- While the world awaits approved vaccines, pharmaceuticals to prevent or treat infections from the pandemic coronavirus are being sought that might be quicker to develop and test. These might both address the gap until vaccines are widely distributed, and still be needed for use after vaccines are available.
- “Our results pave the way to implement antibody cocktails for prophylaxis or therapy that might have the advantage of circumventing or limiting the emergence of viral escape mutants,” the researchers noted. The antibody cocktail in their study needs to undergo trials in humans to determine safety and effectiveness.
5. Wanted in C19 Fight: ‘Superdonors’ of Convalescent Plasma
- Blood banks and researchers are mobilizing to find recovered C19 patients who could be blood plasma “superdonors,” people who have high levels of antibodies against the disease and are willing to donate regularly.
- The hunt has intensified in the past month, after the Food and Drug Administration authorized the use of convalescent plasma, derived from patients who have survived the virus, as a potential therapy for hospitalized patients.
- Sara Goldberg, 35 years old, of Fanwood, N.J., got sick a few days after taking a dance class in March and later learned that several other people in the class were diagnosed with C19 infections. She suffered from symptoms including fever, shortness of breath and headaches.
- Once she felt better, she volunteered to be a plasma donor at Mount Sinai Health System, where she was tested for antibodies and told she had high levels. Ms. Goldberg said she received an email request last month from Mount Sinai saying it was collecting plasma from people with high antibody levels to develop concentrated products that might help prevent or treat C19. She also joined a research study of antibody levels in recovered patients.
- Many scientists think that recovered patients’ antibody levels could wane, generally after three months. But Ms. Goldberg’s levels remain high. One of the researchers reached out to her to tell her they hope to figure out why. “I think it could be interesting to understand why I am different,” she said.
- There is new determination in the search for high-antibody plasma because under FDA guidelines issued earlier this month, all donated plasma units will soon have to be labeled either “high titer” or “low titer,” referring to the concentration of antibodies. The FDA, in documents issued as part of the emergency-use authorization, said data suggest transfusions of high-titer plasma might be effective in reducing mortality in some hospitalized patients.
- The emergency-use authorization covers both high- and low-titer plasma. Blood banks, unsurprisingly, expect greater demand for plasma with high levels.
- “We expect hospitals will want high-titer plasma,” said Cliff Numark, senior vice president of Vitalant, a network of nearly a dozen community blood centers. “We don’t know if we will have enough.”
- Right now, demand for plasma overall is flat, said Dr. Claudia Cohn, chief medical officer for AABB, a group representing the transfusion medicine and cellular therapy community. She said it could reflect reservations about the strength of existing data, the waning of the pandemic in certain areas of the country, or concerns that the authorization was issued under political pressure from the White House—a suggestion the FDA has pushed back on but that continues to generate debate.
- Doctors said an expected upturn in demand for convalescent plasma didn’t materialize after the authorization, although they are prepared for one should infections surge later this year.
- The expectation that both hospitals and clinicians will opt for high-titer plasma has led at least one researcher to consider whether vaccinating patients who have recovered from a C19 infection might boost their level of neutralizing antibodies, which scientists believe are critical for attacking the virus.
- “We want to take a person who has recovered from Covid and make them a superdonor with very high antibody levels,” said Dr. Philip J. Norris, director of laboratory science at Vitalant Research Institute, part of the blood-center network that supports research into blood and blood safety. High-antibody plasma from such donors could be tested to see if it is more effective in helping others fight off the disease.
- The American Red Cross is working on strategies for identifying and recruiting high-titer donors. Between June 15 and Sept. 12, the Red Cross said it tested more than 1.2 million donations. Approximately 2% showed positive for C19 antibodies, the Red Cross said. The organization is still determining how to label the plasma.
- “It is still a point of debate and discussion on what to call high-titer,” said Dr. Pampee Young, chief medical officer of biomedical services at the Red Cross.
- The FDA said emergency-use authorization isn’t intended to replace randomized controlled trials, which remain necessary to conclude definitively that convalescent plasma is safe and effective.
- The agency has authorized a specific antibody test and the threshold above which plasma may be designated “high titer.” Researchers say one challenge is that, with different antibody tests in use, blood banks and labs may differ in how they determine which plasma is high titer.
- The FDA has said “low titer” units also may be used, leaving it up to health-care providers to decide on an individual basis. “I don’t know how clinicians will decide,” said Dr. Todd W. Rice of Vanderbilt University Medical Center in Nashville, Tenn., a co-principal investigator of a large randomized controlled trial of convalescent plasma that is seeking to enroll people at sites across the country. “There isn’t much data for low-titer plasma out there.” He said people randomized to receive plasma in the trial will get only high-titer units.
- Investigators at the University of California, San Francisco, said they are using only high-titer plasma for a 50-person randomized clinical trial.
- Dr. Jonathan H. Esensten, medical director of the blood bank and transfusion service at Zuckerberg San Francisco General Hospital and Trauma Center, said the investigators’ definition of high-titer plasma differs from the FDA’s, and antibody concentrations used in their trial are well above the levels the FDA considers high. “I do not think the FDA designation of ‘high titer’ is particularly useful for us,” he said.
- A spokeswoman for the FDA said the agency’s definition of high-titer plasma is based on an analysis of clinical outcomes in a large, expanded-access study that compared subjects treated with different levels of neutralizing antibodies. The spokeswoman added that the agency encourages gathering more data on convalescent plasma with different levels of antibodies in a variety of C19 patient populations.
- In March, at the start of the pandemic in New York City, Mount Sinai Health System started screening people for SARS-CoV-2 antibodies and recruiting volunteer plasma donors. By July, they had screened more than 51,000 people using an antibody test they developed.
- From the start, researchers went beyond simply telling people whether they had antibodies, said Dr. Carlos Cordon-Cardo, professor and chair of the department of pathology. They also gave them a score corresponding to low, medium, or high levels of antibody titers. The score is generated by the number of times a scientist can dilute a patient’s serum and still be able to detect the presence of antibodies.
- As the screening continued and they learned more, they decided that only the highest concentrations of antibody levels—representing around 70% of donors identified as positive for antibodies, according to the investigators’ data—should be encouraged to donate.
- Dr. Ania Wajnberg, an associate professor of medicine at Mount Sinai who set up the donor-identification program, said when she told people their antibody scores, those with higher scores considered them a point of pride. “Some of them would brag about it to each other, including husbands and wives,” she said.
- Mount Sinai is planning to track antibody levels over time in recovered C19 patients. Elizabeth Tallman, 58, of Brooklyn, N.Y., who is participating in the research, said six months after having Covid, her antibody level remains high. “I am happy I have a high antibody score,” she said. “I feel fortunate.” But so far, researchers she talks to can’t explain why.
- Liz Weidhorn of Fair Lawn, N.J., got sick in March after performing in a community-theater production, with symptoms including fever, dizziness and fatigue. A few months after recovering, she took an antibody test at a walk-in clinic and was told she had antibodies, but not whether the levels were high or low. Later, when she volunteered to donate plasma, doctors ran another antibody test.
- “The doctor told me my antibodies were robust,” she said. She found the news comforting, she said. “Finding out I have robust antibodies, I felt vindicated,” she said.
F. Concerns & Unknowns
1. Shorter time from symptom onset to hospitalization is associated with worse outcome in patients with C19
- New research presented at this week’s ESCMID Conference on Coronavirus Disease (ECCVID, held online) shows that a shorter time from symptom onset to hospitalisation is associated with more serious disease and death in patients with C19. The study is by Dr Annie Wong-Beringer and colleagues, University of Southern California (USC) School of Pharmacy, Los Angeles, CA, USA, and presented at ECCVID by co-author Amanda Chron.
- Patients with C19 assessed in this study presented to the Huntington Memorial Hospital, Pasadena, CA, USA, for care after varying duration of symptom onset. In this study, the authors evaluated patient characteristics and the relationship between the timeline of symptoms prior to hospitalisation and the resultant outcomes.
- All patients who were hospitalised from home due to C19 between March 14, 2020 to May 14, 2020 with a positive PCR result for SARS-CoV-2 were evaluated via retrospective review of electronic medical records to obtain pertinent demographic, laboratory, and clinical information. Patients were grouped based on the time from onset of symptoms to hospitalisation and compared for clinical characteristics, treatment, and outcomes.
- The study included 252 patients; 33% presented within 3 days while 27% were after 1 week from onset of symptoms. Patients presenting shortly (within 3 days) after symptom onset tended to be older (65 vs 58 years) and were more likely to have hypertension (59% vs 41%) and chronic kidney disease (14% vs 3%) than those admitted after one week.
- However, this group that presented within 3 days also presented with fewer symptoms overall such as fever (55% vs 66%), shortness of breath (48% vs 66%), non-productive cough (40% vs 66%,) and muscle/joint pain (12% vs 26%) but had higher levels of organ failure and a worse overall assessment based on a severity score called APACHE II, which factors in physiology, age and chronic conditions. This quicker-presenting group also ultimately were more likely to develop acute respiratory distress syndrome (13% vs 6%) and have higher mortality (15% vs 3%) than those presenting at hospital more than one week after symptom onset.
- Further analysis of the study groups revealed that just over half of the patients (55%) received antiviral therapy, and it was more likely to be given to those who presented with fever with shortness of breath and/or septic shock. Despite receipt of antiviral therapy, mortality rate remained high at 23% in those presenting within 3 days compared to 5% in those presenting after one week. By comparison, among those who did not receive antiviral therapy, mortality was 7% in the quicker-presenting group whereas none died in the group presenting after 7 days.
- The authors conclude: “Our findings suggest that patients with C19 who had significant comorbidities became acutely ill with severe presentation shortly (within 3 days) following onset of symptoms and were at significant risk for complications and death despite receipt of antiviral therapy. Aggressive management and vaccine prioritisation should be directed at this patient population.”
G. The Road Back?
1. CDC Releases Thanksgiving Guidelines Amid C19
- The CDCl and Prevention has released its guidance on how to safely celebrate Thanksgiving amid the coronavirus pandemic — recommending that gatherings remain small and bargain-hunters stick to online shopping.
- The federal health agency advised that the safest way to celebrate Turkey Day would be to stay home and avoid unnecessary travel.
- “Thanksgiving is a time when many families travel long distances to celebrate together. Travel increases the chance of getting and spreading the virus that causes C19,” the CDC posted on its website.
- “Staying home is the best way to protect yourself and others.”
- The agency then ranked a series of holiday activities from low-risk to higher-risk.
Low-risk Thanksgiving activities include:
- Having a small dinner with only the people who live in your household
- Having a virtual dinner and sharing recipes with friends and family
- Shopping online rather than in person on the day after Thanksgiving or the next Monday
- Watching sports events, parades, and movies from home
Moderate-risk activities include:
- Having a small outdoor dinner with family and friends who live in your community
- Visiting pumpkin patches or orchards where people use hand sanitizer before touching pumpkins or picking apples, wearing masks is encouraged or enforced, and people are able to maintain social distancing
- Attending a small outdoor sports events with safety precautions in place
The higher-risk activities for the holiday include:
- Going shopping in crowded stores just before, on, or after Thanksgiving
- Participating in or being a spectator at a crowded race
- Attending crowded parades
- Using alcohol or drugs, which the agency says can cloud judgment and increase risky behaviors
- Attending large indoor gatherings with people from outside of your household
- The CDC urged Americans to avoid higher-risk activities like Black Friday shopping at stores or attending parades.
H. Back to School!?
1. The Students Left Behind by Remote Learning
- Shemar, a twelve-year-old from East Baltimore, is good at math, and Karen Ngosso, his fourth-grade math teacher, at Abbottston Elementary School, is one reason why. “I would try to pump him up and tell him, ‘You’re a good student,’ ” she said. But she knew that he didn’t get enough sleep, and he was often absent. His home situation, like those of many of her students, was unstable: his mother suffered from drug addiction, and they moved frequently.
- Ngosso kept an eye on Shemar even after he started fifth grade, which is when I met him, in late 2018, at First & Franklin Presbyterian Church, a few blocks from the transitional housing where he and his mother were living. I volunteered to tutor Shemar, and once a week I picked him up from school and we’d do homework at a coffee shop.
- Shemar has a remarkably good sense of direction, which came in handy when he had to catch multiple buses and the light rail to get to school from wherever home happened to be. He has a knack for impish one-liners, often prefaced by “Can I just say something?” He is the only kid I’ve tutored who will, without fail, stop mid-text to ask about a word he doesn’t recognize. “Personification?” he’ll ask. “What’s that?” His own vocabulary is charmingly esoteric—once, he said that an older sister had “bamboozled” him into going to the store; another time, he asked me to tighten his swim goggles “just a smidgen.”
- His mother takes Suboxone every day at a clinic, but stability is elusive. She and Shemar often stay up late watching TV, and when Shemar made it to school he was often drowsy in class. But being around teachers and other kids revived him. I continued to see him when he entered sixth grade, and on days when I picked him up he was typically tearing around the jungle gym with friends, with an unself-consciousness that, together with his slight frame, made him seem younger than twelve. Sometimes he’d help his social-studies teacher, a young woman in her first year on the job, straighten up her classroom.
- One day, when I arrived, Shemar (this is his middle name) looked disconsolate. He thrust a sheet of paper at me—the social-studies teacher had quit. There was a tear running down Shemar’s cheek. “She was my favorite teacher,” he said.
- By early March, there was a new social-studies teacher. Shemar’s English class was reading “Farewell to Manzanar,” a young-adult novel about the internment camps for Japanese-Americans during the Second World War. The hallways were decorated with posters for Black History Month. Shemar had made one about Bisi Ezerioha, the Nigerian-American engineer and race-car driver.
- Then, on March 16th, as the coronavirus pandemic took hold in the United States, Maryland closed its schools.
- Like districts across the country, Baltimore’s was unprepared. Initially, teachers made worksheets for each grade level, which parents had to pick up at school. Shemar’s school was three miles from his grandmother’s house, where he was living at the time, so I picked up the packet, along with one of the boxes of sliced-apple snacks that the school was handing out.
- Remote learning started in earnest on April 6th. For Shemar, that meant just four hours per week of live online instruction—an hour for each of the main subjects once a week, with nothing on Fridays. Shemar had an Xbox but no computer, so the pastor at our church, Rob Hoch, said that it would reimburse me for buying Shemar a laptop. I dropped it off at his grandmother’s house, and helped his mother load onto her phone the app, called Remind, that Shemar’s teachers used for communicating with families. It required finding links and codes from weeks earlier. I felt slightly frantic, knowing that, in the early pandemic period, every minute spent together in the house brought greater risk.
- It soon became clear that, even with the computer, this form of schooling wasn’t going to work for Shemar. He had a wireless connection at his grandmother’s house, but he spent some of his days at a row house, a mile to the southwest, that his mother had moved into, in one of her repeated efforts to establish a home for them. A few weeks earlier, a twenty-one-year-old man had been killed a block away. There was no Internet, and when his mother called Comcast to ask about the free Wi-Fi it was offering to the families of Baltimore schoolchildren, she was told that a previous tenant had applied, so she couldn’t do so herself. It was a familiar situation for her: so often, when she made an effort on her son’s behalf, it foundered quickly in a bureaucratic dead end.
- The Remind app was another problem. Shemar downloaded it on his phone, which had no cellular service but could be used with Wi-Fi. But, when his mother lost or broke her phone, she borrowed Shemar’s. He often missed the reminders about his daily classes or the links to access them, which might change from week to week. I had the app on my phone, and every few days I got a message from him, asking me to send him the link and the schedule.
- The biggest challenge was not technological. No one made sure that Shemar logged on to his daily class or completed the assignments that were piling up in his Google Classroom account. His grandmother, who is in her seventies, is a steady presence, but she attended little school while growing up, in a sharecropping family in South Carolina. She was also losing her eyesight. One day, she explained to me the family’s struggles to assist Shemar: though three of his four older siblings lived in the house, too, they had jobs or attended vocational school, and one of them had a baby to care for; Shemar’s mother was often absent; and his great-uncle, who also lived in the house, had dropped out of school in South Carolina around the age of eight, and was illiterate.
- Shemar’s teachers worried about him but had a hard time reaching him, given his mother’s frequent changes of phone number. One time, his English teacher drove to his house and visited with him on the small front porch.
- I checked on Shemar a couple of times during the spring, but, in hindsight, I was too willing to let the lockdown serve as an excuse to hunker down with my own kids, who were doing online learning at other Baltimore public schools. So I was startled when I received a text message in May from Shemar’s fourth sibling, who worked at an Amazon warehouse and lived with his girlfriend and baby, asking for the link to the day’s class. Shemar had moved in with them.
- The following Sunday, I dropped by the house with some groceries. Shemar’s mother, who had been evicted from her row house, was there, too, and Shemar was in good spirits. But, the next afternoon, he was alone in the living room, the lights off, the blinds drawn, and the TV on. He had stayed up very late the night before, watching TV with his mother, and had slept past noon, missing that day’s class. For breakfast, he had eaten some Nutella that I had brought by the day before. I asked what he would have for dinner, assuming he would eat with his brother’s family. In fact, they usually ate on their own, upstairs. “Nutella,” he said.
- One day, I wrote to him on Instagram to ask if he was in his English class, and was cheered when he responded that he was. But he and one other student were the only ones there. The link for the class had changed at the last moment and he hadn’t received the message. He and his classmate had been sitting in their virtual space for twenty minutes, waiting for the teacher.
- I have chosen to tell the story of Shemar’s remote-learning difficulties, with his family’s permission, because it was his plight that alerted me to the fact that remote learning was proving disastrous. As the spring went on, I grew increasingly distressed by the lack of public alarm over students like Shemar, who were sitting in countless dark rooms, safe from C19, perhaps, but adrift and alone. Society’s attention to them has always been spotty, but they had at least been visible—one saw them on the way to school, in their blue or burgundy uniforms, or in the park and the playground afterward. Now they were behind closed doors, and so were we, with full license to turn inward. While we dutifully stayed home to flatten the curve, children like Shemar were invisible.
- Ryan Hooper, who teaches social studies at Joseph C. Briscoe Academy, a middle and high school for high-needs kids, told me that, of his typical class of between five and ten students, only one or two generally logged on for his sessions. Often, no one showed up.
- Hooper, a twenty-eight-year-old native of Cleveland, became a teacher after serving in the Army. The kids at Briscoe, he said, were “very challenging students that come from awful situations.” Many are so emotionally troubled that, even with such small class sizes, each teacher is assigned a paraprofessional to help out in the room. But Hooper liked the challenge and the close bonds that came with the intensive interaction.
- With the shift to remote instruction, he felt a “loss of purpose,” he said. “All the gratifying, purpose-driven reward benefits of being a teacher were stripped.” At first, he and his colleagues called to check on the students who weren’t logging on, but the calls only further overwhelmed their parents and guardians, roughly half of whom are foster parents. Some districts in Massachusetts alerted child-protection agencies about students who did not log on, but Baltimore did not take that step.
- Another young teacher in Baltimore, who taught reading to a middle-school special-education class, told me that three of his ten kids never showed up online. One boy told him that his mother had just lost her job. “I don’t want to do it,” he said, of remote learning. “I don’t care if I fail. I’m fourteen, in seventh grade—I don’t think they’re going to fail me again.” He was right. Students in Baltimore were not penalized for failing to do the work—their third-quarter grade would carry over into the fourth quarter, though they could get bonus points for making an effort.
- The school alerted parents that they could get free laptops, but only one of the special-ed teacher’s students made an appointment to get one. The other six students who sometimes logged on did so with smartphones, which made it more difficult to use Google Docs, the program used for most assignments. The students rarely turned their cameras on. “None of them like showing their faces,” the teacher said. “You don’t know if they’re there or not.” One time, a girl did turn her camera on, and he saw paint peeling off the walls behind her.
- The teacher was driving downtown one weekday when he saw one of his students from a summer-school class last year washing windshields at an intersection. When the boy saw his former teacher, he panicked and ran away.
- The United States was a pioneer in universal education. In 1797, Samuel Harrison Smith, a Washington newspaper editor, won an essay contest with a piece making the case for why it was essential to the country’s success. “An enlightened nation is always most tenacious of its rights,” he wrote. The new nation was strikingly free of the British upper-class fear that educating the working class would give it dangerous ideas—with the major exception of slaveowners, who withheld schooling for that very reason. Those in power in the North and the Midwest, as Carl Kaestle notes in “Pillars of the Republic,” his 1983 history of schooling in the early U.S., saw education as a means of alleviating poverty and squalor in rapidly growing cities and helping to assimilate immigrants.
- In the early decades of the nineteenth century, a patchwork of schooling spread across the U.S. In small-town New England, and eventually in the Midwest as well, “district schools” mixed children of all ages, including “trundle-bed trash,” as people called kids barely past toddlerhood. Students showed up with whatever primer they could obtain, and corporal punishment was so prevalent that schools often employed women as teachers only in the summer, when the older boys that they would have trouble physically subjugating worked in the fields.
- Coastal cities had a few “charity schools” for the urban poor, supported by churches and philanthropists who wanted to break the generational cycle of poverty. “One of the central goals of charity-school workers was to rescue children from an allegedly harmful family environment,” Kaestle writes.
- Increasing numbers of state and local governments in the North and the Midwest began authorizing taxation to pay for public schools. Reformers recognized that the way to build support for taxes was to create a school system that would be used by all. “If taxation was going to work, it could not only be for the benefit of ‘other people’s children,’ ” Jack Schneider, a professor of education at the University of Massachusetts, Lowell, told me. “It had to benefit everyone.”
- By mid-century, more than ninety-five per cent of adults in New England could read and write, and three-quarters of children between the ages of five and nineteen were enrolled in school; the rest of the North was not far behind. “In no country in the world is the taste for reading so diffused among the people as in America,” a Swedish visitor wrote, in 1853. Public schools, the New York governor, William Seward, said, were “the great levelling institutions of the age . . . not by levelling all to the condition of the base, but by elevating all to the association of the wise and good.”
- In the South, however, slaveowners denied instruction to nearly all the Black children they claimed as property, and local and state governments lagged behind in building public schools. Even in the North, Horace Mann and other reformers were reluctant to push for integrating the new systems, and the children of free Black families mostly remained in separate schools.
- It took decades more to realize truly universal education. Episodes in this country and elsewhere have shown the consequences of failing to provide that basic good. The destruction caused by the Second World War, for example, affected a generation of children. One researcher found “significant, long-lasting detrimental effects” on German children, with those in the most heavily bombed cities completing 1.2 years less of school and seeing their future earnings decrease by an average of six per cent. Other studies found similar effects among children who were evacuated from London—as the authors of one study put it, “Participants describe a whole different life they believe they could have had if they had had the opportunities they feel they lost.”
- Research conducted six months after Hurricane Katrina found that about twenty per cent of students in New Orleans were either not enrolled in school or had missed more than ten days a month. One study reportedly found that, five years after the storm, roughly a third of the city’s children had been held back, nearly double the average in the South; another study reportedly found that the average seven-year-old in New Orleans at the time of the hurricane was, a decade later, more likely than his or her counterparts in all but two cities in the country to be neither employed nor attending school.
- Prince Edward County, in Virginia, is one of the most wrenching examples of such disruptions. In 1954, when the Supreme Court, in Brown v. Board of Education, ruled against school segregation, districts across the South threatened to close their public schools to avoid integrating them. But only one place actually did so for an extended period: Prince Edward County, west of Richmond. In 1959, the county board of supervisors eliminated the entire school budget, for some twenty-one schools and an estimated three thousand students. White families raised tens of thousands of dollars for a new private high school, and received offers of temporary space from, among others, the Presbyterian Church, the Moose Lodge, and the Woman’s Club House. Textbook suppliers donated books, other districts donated buses, and leaders of the new academy stripped the public schools of books, desks, and football goalposts.
- The county’s Black community lacked the resources to establish private schools for the roughly fifteen hundred Black students. About sixty-one of them were taken in by Kittrell College, a Black institution in North Carolina. Other children went to live with relatives in Philadelphia, Boston, and New York; in some cases, siblings were dispersed permanently.
- Many kids simply went without school. Ricky Brown, who would have been in kindergarten that year, spent his days idly, occasionally joining some seventy-five students who attended “training centers” set up in the basement of the Reverend L. Francis Griffin’s church. “The only thing I got out of that was how to spell my name and the alphabet,” Brown told Kristen Green, in “Something Must Be Done About Prince Edward County,” her 2015 book on the shutdown. That was more education, though, than McCarthy Eanes received: Green recounts that Eanes and his fifteen or so school-aged siblings stayed home on their family’s tobacco farm.
- The closure lasted five years, until the Supreme Court ordered the county schools to reopen and desegregate. When they did open, in the fall of 1964, as few as eight of the roughly fifteen hundred students were white. The Michigan State University researcher Robert L. Green estimated that thirteen hundred Black children in the county received no formal education during the closure. He also found that the illiteracy rates for Black students under twenty-two went from three per cent to twenty-three per cent. Years later, Doug Vaughan, who became a garment worker, tried to teach himself to read using Harlequin romances. “I always wondered, ‘Where would I be if I had gone to school, completed it, and gotten an education?’ ” he told Kristen Green. “Where would I be in life?”
- Sonja Santelises’s parents went to segregated Black high schools in the Deep South during the fights over Brown v. Board and the white flight to “segregation academies.” They raised her in Massachusetts, after her father got a job as a chemist for Eastman Kodak. In 2016, having spent several decades as a school administrator in New York, Boston, and Baltimore, Santelises became the head of the Baltimore school system. She insisted on high expectations for Black and brown children, who make up ninety per cent of the district’s seventy-nine thousand students. This led her to conclude that the academic costs for Baltimore’s children of keeping schools closed this fall needed to weigh heavily in any calculation.
- As a trial run for opening, and to provide catch-up for at least some of the students who’d lost ground in the spring, the city offered in-person summer-school instruction at six schools. About two hundred children attended. It was one of only a few in-person summer schools around the country.
- The Baltimore schools are perpetually strapped for resources: among other deficits, sixty buildings lack air-conditioning, which forces frequent closures in hot weather. But administrators were getting advice from experts at the local college, Johns Hopkins University, which is home to one of the country’s largest schools of public health and which had created a leading coronavirus database. Among Hopkins’s experts is Jennifer Nuzzo, an epidemiologist whose work focuses on outbreak detection and response. Nuzzo had supported lockdowns to slow the spread of the coronavirus in the spring, but by the summer she was arguing that schools should plan to reopen in much of the country. In an Op-Ed in the Times on July 1st, Nuzzo and Joshua Sharfstein, a pediatrician who has served as Baltimore’s health commissioner and Maryland’s health secretary, wrote that the coronavirus had mostly spared young people: children made up nearly a quarter of the American population but accounted for just two per cent of known C19 cases; they had been hospitalized at a rate of 0.1 per hundred thousand, compared with 7.4 per hundred thousand in adults between the ages of fifty and sixty-four. The authors mentioned studies from France and Australia suggesting that children were not major transmitters of the virus. And they noted that the American Academy of Pediatrics favored school reopening. “The disruption of learning can have lifetime effects on students’ income and health,” they wrote.
- A number of experts were beginning to agree with Nuzzo and Sharfstein. According to reports, the rate of infection among teachers in Sweden, which as part of its less restrictive response to the virus had left most of its schools open, was no greater than it was in neighboring Finland, which had closed all its schools. “They found that teachers had the same risk of covid as the average of other professions,” said Martin Kulldorff, a professor at Harvard Medical School who develops statistical and epidemiological methods for disease surveillance.
- In July, Meira Levinson, a professor of education at Harvard, co-authored an article in The New England Journal of Medicine laying out how to reopen primary schools. Levinson told me that she worried about what students would lose without in-person instruction. “Education is about learning to trust others and being vulnerable with others. If you are learning, you are doing something—at least for a while—you don’t know how to do,” she said. “That’s a vulnerable position to be in, and as human beings we need to have relationships with some level of trust to be able to do that.”
- Joseph Allen, the director of the Healthy Buildings program at Harvard’s school of public health, wrote a sixty-two-page plan with a dozen colleagues listing steps that schools could take to reduce transmission risk. To improve ventilation and air quality, schools with air-conditioning could upgrade their air filters, while schools without it could make sure that their windows opened and set up fans to circulate fresh air from outdoors; when it got too cold for that, they could install portable air purifiers. Notably, the recommendations did not include a hybrid model, with students in school a limited number of days per week to allow for social distancing—students did not need to be spaced out much more than usual, Allen said, as long as they wore masks. “There’s certainly no such thing as zero risk in anything we do, and that is certainly the case during a pandemic,” he said in a conference call to present the plan. But, he added, “there are devastating costs of keeping kids out of school. When we have this discussion about sending kids back to school, we have to have it in the context of the massive individual and societal costs of keeping kids at home.”
- Santelises found many of the claims persuasive. Baltimore worked on a plan to bring students into school two days a week, while allowing families the option of full remote learning if they preferred. Teachers with health concerns would do online instruction for kids who stayed home. As the Harvard report recommended, the schools would upgrade air-conditioners with better filters; schools lacking them would finally get windows that could be opened.
- On July 7th, President Trump held a series of events at the White House with Betsy DeVos, his Secretary of Education, to demand that schools open. “We’re very much going to put pressure on governors and everybody else to open the schools,” he said. “It’s very important for our country. It’s very important for the well-being of the student and the parents. So we’re going to be putting a lot of pressure on: open your schools in the fall.”
- The effect of Trump’s declaration was instantaneous. Teachers who had been responsive to the idea of returning to the classroom suddenly regarded the prospect much more warily. “Our teachers were ready to go back as long as it was safe,” Randi Weingarten, the longtime president of the American Federation of Teachers, told me. “Then Trump and DeVos played their political bullshit.” Ryan Hooper, the former soldier, saw the effect on his colleagues. “It was really unhelpful,” he said.
- A week later, the Baltimore Teachers Union and the Maryland State Education Association sent a four-page letter to the Maryland governor, Larry Hogan, a Republican, and the state superintendent of schools, Karen Salmon, calling on them to bar any in-person instruction for the first semester. They noted that, by one count, nearly a quarter of teachers nationwide were considered especially susceptible to the virus, and cited the lack of funding for personal protective equipment and testing. They questioned whether students could be counted on to wear masks, wash their hands, and maintain social distancing.
- Most strikingly, they argued that reopening schools would be riskiest for the families of precisely those disadvantaged students whom proponents of reopening said they were most concerned about: “the significant numbers of Black and Brown students . . . and their families who unjustly face healthcare disparities that have made them more likely to be infected and killed by the coronavirus.” In Detroit, where protesters tried to halt summer school by blocking school buses and filing a lawsuit, a white progressive activist compared requiring Black children’s attendance at school to the Tuskegee Study, in the nineteen-thirties, in which hundreds of Black men with syphilis went deliberately untreated.
- Some of the unions’ concerns were hard to dispute. The Trump Administration offered little funding for P.P.E. or building upgrades, and Governor Hogan and Superintendent Salmon did not do much more to help. “There was a concerning lack of robust leadership from the superintendent’s office,” Leslie Margolis, a managing attorney for Disability Rights Maryland, which advocates for people with special needs, told me. “A lot of school systems were looking for guidance.” (A spokesperson for Hogan said that his hands-off approach was intentional: “The Governor was one of the most outspoken advocates for ensuring that these decisions were made locally.”)
- Four days after the unions sent their letter, the Times ran an article with an alarming headline: “Older Children Spread the Coronavirus Just as Much as Adults, Large Study Finds.” The subheading read “The study of nearly 65,000 people in South Korea suggests that school reopenings will trigger more outbreaks.” Contact tracing from more than five thousand C19 cases in South Korea, the piece noted, had found a dramatic difference in how the virus moved among younger and older children. “Children younger than 10 transmit to others much less often than adults do, but the risk is not zero,” it stated. “And those between the ages of 10 and 19 can spread the virus at least as well as adults do.”
- Previously, the debate about reopening had consisted of people offering examples of success and failure in a handful of countries: advocates cited France, Australia, and Sweden, among others; opponents cited Israel, where the hasty reopening of schools, along with a broader ending of lockdowns, had led to a resurgence of cases. But the South Korean findings seemed to be based on a much larger set of data.
- Some researchers immediately found problems with the study’s conclusions, pointing out that the sample of children who had become sick was exceedingly small. Also, noted Alasdair Munro, a clinical-research fellow in pediatric infectious diseases at University Hospital Southampton, in the United Kingdom, it was not clear whether older children had passed the virus to adults or had got it at the same time and shown symptoms earlier.
- “That study had methodological flaws that several of us pointed out,” Allen, the Harvard public-health professor, said. “But the headline took off.” Zeynep Tufekci, a sociologist who has become an influential voice on the pandemic response, tweeted, “I personally know parents who changed their whole next year because of the article. . . . The takeaway people got was 10-year-olds can transmit as much as adults.”
- In July, at the first of a series of weekly online forums, the Baltimore school system updated parents on its plans for the fall. Santelises told the several thousand people listening that the district was still soliciting input and hadn’t finalized anything, but she made clear her enthusiasm for having at least some in-person instruction. She told parents that the in-person summer school was going very well—in the end, zero covid cases were traced to it—and that the ideal was to provide in-person instruction to families who wanted it.
- As she was speaking, comments began popping up in the margins of the Facebook Live page that was hosting the forum. “How is this possible? This is a death sentence for these kids.” “How many dead students is considered an acceptable risk?” “This is crazy my children are more important y’all are trying to make these babies go back . . . because of Trump.”
- The direct risks to children were, in fact, blessedly limited. By mid-July, of the roughly thirty-two hundred people known to have died of C19 in Maryland, only one was under the age of nineteen. Nationwide, fewer than a hundred children had died of the virus, roughly comparable to the number of those who die of the flu, which children are also far more likely to transmit than they are covid.
- But it was not hard to see how parents could have got the impression that children were at great risk. Towns and cities had closed playgrounds, wrapping police tape around them. People in heavily Democratic areas were wearing masks even on empty streets. There may have been an implicitly political dynamic at work: the greater the threat posed by C19, the greater Trump’s failure in not containing it. (Joe Biden’s campaign aired an ad in early September that read “Our Kids Not Safe in School.”) In early July, Anthony Fauci, a trusted guide on coronavirus prevention, told the Washington Post that he still left his mail to sit for up to two days before opening it.
- Public-health officials who had spent months scaring people into taking proper precautions were now struggling to un-scare them enough to contemplate a return to school. “The messaging never evolved,” Jennifer Nuzzo, the Hopkins epidemiologist, told me.
- As the school system deliberated, Baltimore, which had seen lower numbers of cases early in the pandemic than many cities on the East Coast, started to see an increase. As elsewhere, the virus was taking a disproportionate toll on Black and Hispanic people, though to a less dramatic degree than in some states.
- At another online parent forum, on July 16th, the district released the results of informal surveys it had conducted. Of the more than five thousand parents who responded, forty-seven per cent preferred all-remote learning, forty-one per cent preferred a mix, and twelve per cent preferred all in-person. A survey of faculty and staff found that seventy-two per cent preferred remote instruction, while a quarter preferred a mixture and only three per cent preferred all in-person. “The voices we don’t hear are the ones who are shut up at home,” Levinson, the education professor, told me. “We have no mechanism to hear from them. There are no polls of six-year-olds.”
- A few days later, I stopped by Shemar’s grandmother’s house, where he was again living. He had barely left the house all summer—he slept late most days, and spent the majority of his waking hours in the living room, the blinds drawn, playing video games. I asked his grandmother what she thought the schools should do and she answered without hesitation: they should reopen. “There’s too many kids that need to go to school,” she said. “That homeschooling is not going to get it.” She went on, “I can’t even see, so I can’t help him, and most of the time the rest of them are gone. What do you want to do, teach him online? I don’t even know how to get online, so I can’t be no help to nobody.” Shemar, she said, “is not one of those kids who says, ‘I’ve got to do this’ and do it. You’ve got to sit right there with him.”
- She told me that, as a girl in South Carolina, she often had to stay home from school to watch her younger siblings or help with the crops. She repeated what she often told Shemar: “All I wanted to do when I was your age was go to school, and couldn’t.”
- On July 20th, Santelises held a conference call with reporters to announce that Baltimore’s schools would be fully remote, with a reassessment in mid-October. “The fact is, folks, that we are at a time when there is a lot of concern about returning to school generally across the country and across the state,” she said. “We heard loud and clear that many staff are just not comfortable.”
- Other major districts followed—Fairfax County, Virginia (where the district now sends bus drivers on their regular routes twice a week, with empty buses, to keep them on the payroll); Philadelphia; Chicago; Washington, D.C. (where some teachers heaped “body bags”—stuffed black trash bags—outside the headquarters of D.C. public schools, to warn against reopening). By late August, every single county in Maryland had chosen full remote learning, even though the state’s test-positivity rate had fallen to near three per cent, two per cent below the World Health Organization’s and the Centers for Disease Control’s recommended threshold for reopening schools. Across the country, some thirty-five of the fifty largest districts opted for a fully remote opening, as did most large cities, with the notable exception of New York, which announced a hybrid approach and a delayed start. A study by the Brookings Institution found that districts’ school-opening decisions correlated much more strongly with levels of support for Trump in the 2016 election than with local coronavirus case levels. “It almost feels like folly now to speak about data,” Nuzzo told me. “The decision was going to be made not on data but on politics.”
- On August 7th, I met Shemar’s fourth-grade teacher, Karen Ngosso, and her two children for a walk in Druid Hill Park, Baltimore’s vast green jewel. I had met Ngosso in early 2019: Shemar’s mother thought he had gone missing one night, and Ngosso, who hadn’t had him as a student for a year, came to help us look for him. (He was fine.)
- As we set off, she told me that a cousin of hers, a woman in her early sixties who had diabetes and high blood pressure and had recently completed cancer treatment, had just died from C19 in Missouri. Ngosso’s husband had also been infected. The experience left her feeling resentful of others in the neighborhood who seemed not to be taking the threat of the virus seriously.
- Ngosso, who is Black, grew up in Kansas City, one of seven children. When she was ten, her mother died in childbirth. As Ngosso recounts it, she and her siblings essentially raised themselves, drawing on what their mother had instilled in them—they even got themselves to church on Sundays. “We’d say, ‘Mama wouldn’t want us doing this,’ ” she told me. “Even though Mama was dead, we knew how to handle ourselves, because of things she said to us.”
- All her siblings now lead successful lives—the eldest retired from the military, one became a nurse, one ran a catering business. Ngosso’s upbringing left her with a strong belief in the power of self-reliance, and with little tolerance for what she perceived as the lack of initiative and responsibility on display around her, both in the neighborhood where she lived and in the schools where she taught. “It’s this learned helplessness,” she told me.
- She had moved to a different school last year, Hazelwood Elementary, and she told me that, after schools closed in the spring, of her forty-two third graders, only fifteen had shown up for online sessions. She had been heartened by how well some of her students took to remote learning—one girl flourished in the role of class moderator, overseeing the online chat box. But many other kids had simply vanished, even after the school distributed laptops and she held special sessions to show parents how to negotiate the Blackboard program.
- I had thought that Ngosso would oppose the decision to keep the schools closed, since her insistence on rigor and high expectations for students and families echoed Santelises’s. But Ngosso did not trust other families. “When you drive around Baltimore, you see all these grown people walking around, no masks,” she said. “Those people’s kids will come to school. It’s like a snowball effect.” She doubted that younger kids could be trusted to keep masks on in class. “Just in general, kids are a snotty, messy mess,” she said.
- She put little stock in the data showing that the virus had far less effect on children. She noted the subset of children with C19 who had got seriously sick with inflammation of the skin, eyes, blood vessels, and heart, which received a lot of media attention in the late spring. She cited the findings from the South Korean study. (A week after our walk, the Times reported that additional data from South Korea was casting doubt on the initial findings.) “They’re carriers,” she said, referring to children. “They’re supercarriers.”
- She was worried about students like Shemar. “You have kids like him that need some type of stability, which school provides,” she said. But she also questioned whether his online education was that different. “The fundamental problem for him isn’t if the school is open or not, it’s that adults around him are supporting his education,” she said. “It doesn’t matter if school is virtual or in real life, he’s going to have the same issues.”
- Ryan Hooper, the former soldier, saw it differently. On July 29th, he had published an op-ed in the Baltimore Sun saying, “I’m distraught at the thought of our kids in the city missing more school.” He told me that he didn’t understand why schools couldn’t open at least for younger students, who were assumed to pose less of a risk of contagion and who were especially unsuited to online learning, or for high-needs students, like the ones he worked with, who were in small classes that would be easy to space out. “My biggest concern is that we’re going to lose these kids,” he said. “They might never come back.”
- Christopher Morphew, the dean of the Johns Hopkins School of Education, which operates a public school in the city, told me, “The costs of this are going to be huge.” In many homes, children as young as ten were going to be trying to do their online classes while babysitting younger siblings. “The failure to plan now, to spend the money now, is going to cost us in human resources, in violence, in other ways, for a long time,” he said. He estimated that the closure could result in eighteen months of “summer melt,” the term for the educational regression caused by long breaks in schooling. “Eighteen months of summer melt when you’re already three grades behind is virtually impossible to come back from.”
- I recently talked with Diamonté Brown, the head of the Baltimore Teachers Union, which is affiliated with the American Federation of Teachers. Brown grew up in Baltimore and attended the University of Michigan before becoming a teacher. She has worked at some of the city’s highest-poverty middle and high schools. Last year, she defeated the incumbent in the union’s presidential election, by appealing to the activist ethos of the burgeoning political left. She told me that the union had been adamant about keeping schools fully remote in the fall, and that she took no encouragement from the fact that summer school had not produced any known infections: “Just because someone didn’t contract covid doesn’t mean it went great.” She said that secretaries who had recently been sent back into schools hadn’t received adequate P.P.E. The union opposed even allowing teachers to conduct their online courses from their classrooms. “We think they should not go in—we can’t protect them, we don’t have anything that holds the district accountable,” she said. If teachers return to the buildings now, she added, “Why would the district negotiate on anything?”
- Brown chided those advocating reopening. As she saw it, they were professing a concern for disadvantaged urban children whom they had previously done little to support. “When it comes at a time that benefits other people, suddenly those kids become the apple of everyone’s eye,” she said. “I won’t allow people to use my schoolchildren as pawns.”
- The young special-education teacher told me that the buildings loomed large in teacher discussions in another way, too. Many of his colleagues, he said, had expressed relief at not having to go back to their schools. With remote learning, “my life is a lot calmer and less stressed,” he told me. “Now we don’t have to suspend anyone or send anyone to the office.”
- On Labor Day, the day before school started, I went over to Shemar’s grandmother’s house. His mother was in the dark living room, lying on the couch she and Shemar share as a bed, watching her favorite TV show, “Merlin.” Shemar was at the dining-room table, playing Minecraft on his laptop.
- When I had seen him a couple of weeks earlier, he had been startled to learn that he was going into the seventh grade; he had assumed that, because the spring semester had been truncated, he and his classmates would still be in the sixth grade. We went out on the porch with the laptop and made sure he was logged in to Google Classroom, Remind, and Clever, another program his school would be using. According to the Baltimore Sun, the district had handed out thirty thousand laptops to students and negotiated to buy as many as twenty thousand Internet hot spots. It had also paid Comcast six hundred and fifty thousand dollars to keep providing Wi-Fi to fourteen thousand children who lacked it.
- I asked Shemar and his mother how they felt about the school year starting online. She said that she thought it was for the best, given the risks of C19. Shemar shrugged. “It was annoying,” he said. “School was getting annoying.” The use of the past tense was striking, as if “school” were something that was behind him.
- The next day was beautiful, made eerie by the absence of the activity that usually pervades the first day of school in any city. Shemar’s troubles started immediately. His social-studies teacher was absent, which hadn’t been announced until the night before, and he hadn’t received the Zoom link for the substitute. The teacher for his next class, science, which would start the year with a unit on melting points, had put the Zoom link in Remind, which Shemar didn’t have the password for. “How do I log in to my classroom for class?” he wrote me at 10:30 a.m. He got into math class, where they would be catching up on long division with decimals and fractions, but there was no code sent for his first class after lunch, which the schedule said would be Spanish but which was changed at the last minute to library.
- By the end of the day, he had logged on to two of his five classes. I started looking into alternatives, such as the “learning centers” that the district was setting up at a handful of schools, with Recreation and Parks staffers supervising while kids did their online classes. Other districts were also offering such in-school supervision, in many cases requiring families to pay extra for sending their kids (raising the question of why the schools were safe for this purpose but not for actual instruction). But the Baltimore learning centers were available only to younger students.
- That afternoon, I talked with Weingarten, of the American Federation of Teachers. She asked how the first day of school was going in Baltimore and, when I told her, she offered sympathy for Shemar’s difficulties. “There are no good choices right now,” she said.
- Yet many places had made a different choice. Schools were opening all across Europe, including in towns and cities whose test-positivity rates were well above those in Maryland and many other parts of the U.S. that were keeping schools closed. “Not everything should be destroyed by the health situation,” Jean-Michel Blanquer, France’s education minister, said. “We must be vigilant, but not forget the educational and social imperatives, nor deviate from our two objectives: improving the educational level of each child and reducing inequalities.”
- Schools were also opening in roughly half of all districts in the U.S., and so far there was little evidence of the virus spreading inside school buildings. In Connecticut, many small towns and suburbs were offering in-person instruction—but not New Haven, which is heavily Black and Hispanic. In Texas, Florida, and Georgia, where many schools had been open since mid-August, C19 case numbers and hospitalization rates generally continued to decline from their summer highs, despite reported outbreaks at some schools. In Wisconsin, where teachers’ unions had been hollowed out by Governor Scott Walker, schools were opening in much of the state (though not in Milwaukee). A middle-school teacher in Sheboygan told me that kids were spending the whole day in the same classroom, and the smell of sanitizer was overpowering. But so far there had been no confirmed cases at the school.
- In Baltimore, where the midsummer rise in cases had ebbed, some of the city’s élite private schools were already open, while others were preparing to do so. They had hired extra teachers to shrink class sizes, set up tents for outdoor instruction, and installed expensive audio-visual systems in classrooms to allow teachers to simultaneously teach students in class and at home, for additional spacing. Many parents around the country were dubious about young kids sitting through hours of online instruction, and were removing them from the public-school system: in Los Angeles, kindergarten enrollment was down by about fourteen per cent; in Chapel Hill, North Carolina, by seventeen per cent. Jon Hale, a professor of education at the University of Illinois, worried about the flight of middle- and upper-class students. “Anytime they see the system as unstable and they pull out of it, it has a lasting effect,” he said. “In this system, the dollars follow the student, and the consequences could be tragic. It will decimate the system for those who rely on it.”
- There has always been a gulf between public education and private. But the new disparity is stark: in many cities, children in private schools are going to school, and children in public schools are not. (Among such places is Prince Edward County.) A nationwide survey by the education-news network Chalkbeat found that roughly half of white students had the option of in-person instruction, while only about a quarter of Black and Hispanic students did. After a summer of renewed attention on the disparities facing Black people, millions of Black children would not be getting in-person education.
- Weingarten said that this came down to “trust.” “If parents and teachers aren’t confident that the safety measures are in place, then you’re not going to be able to stand it up in the middle of a pandemic,” she said. Contending that the virus was more harmful to kids than first realized, she cited the South Korean data—she was not aware of the revision, she said—and then another recent Times story on cases rising among kids, which had also been challenged for lacking context and scale. I noted the disagreements with her citations. She replied, “In the absence of trusted information, people have fear right now.”
- I asked if she worried that there might be a backlash against public education and teachers’ unions if opening goes fairly well in private schools and public schools that have opened. “I’m hoping not,” she said. Ideally, successful opening in some places—notably the big test case of New York City—would give other districts confidence to follow suit. And, she said, she did not put much stock in predictions that the closures would cause a sustained unravelling of public education. “At the end of the day, kids need to be together in the community,” she said.
- Becky Pringle, the president of the other national teachers’ union, the National Education Association, was also confident that parents now leaving the public schools for homeschooling or private schools would return. “Our parents and communities still believe in our schools, that they are a foundation of democracy,” she said when we spoke, on the second day of school in Baltimore. “I don’t think they’re going to abandon schools.” I asked Pringle why her union, like others, had put such emphasis on the virus’s health risks to children, and she said, “When we look at the data and they say only .1 per cent of kids will contract it and get seriously ill and die, that’s actually around fifty thousand children.” I noted that the number of children known to have died of C19 nationwide was around a hundred. She said her estimate was what could happen if kids did go back to school.
- As we were talking, my phone buzzed. Shemar hadn’t realized that the link for that day’s first class, still with a substitute, had arrived at the last minute in the Remind app, so he had missed that period. He then had trouble finding the link for math class. That afternoon, he again lacked a link for a class: physical education, taught remotely. Citywide, about eighty per cent of students had logged on, but only sixty-five per cent were reliably present, according to the district. Before the pandemic, the attendance rate was eighty-seven per cent.
- For the foreseeable future, Shemar would be spending his days as he had spent the spring and the summer: in a dark room, in front of a screen, with virtually no direct interaction with kids anywhere close to his own age. Sometimes the screen would hold Minecraft and Fortnite; sometimes, if he got the hang of the log-ins, it would hold Zoom.
- Schools in cities such as Baltimore, though deeply imperfect, had long given children a break from such isolation—the key, as the supporters of nineteenth-century charity schools argued, was to get disadvantaged children out of the home and into school, every day. For the time being, in Baltimore and many other American cities, that function was on hold.
- I kept thinking of something Karen Ngosso had told me about Shemar. “His story, it could be any number of kids,” she said. “There’s thousands of him. There’s millions of him.”
2. CDC Study Bolsters Case For Elementary School Reopening
- Children under the age of 12 are much less likely than teenagers to contract the coronavirus, according to a study by the Centers for Disease Control and Prevention published on Monday. The study adds nuance to prior findings that the risk of contracting and dying of C19, the disease caused by the coronavirus, increases with age. The reasons for the correlation are not yet entirely understood.
- The new study also found that Hispanic children were hit hardest by the coronavirus, composing 42% of all cases for which ethnic data was available. That highlighted another uncomfortable truth about the pandemic: People of color have been disproportionately affected by both its medical and economic ravages.
- The new study does, however, appear to bolster the arguments of those who say that children should return to school instead of continuing with what has been, according to many accounts, a disastrous national experiment in distance learning. New York City has returned some children to school buildings and is expected to ramp up in-person instruction by the end of the week.
- Officials in Washington, D.C. — where the president has been loudly calling for schools to reopen — have also told principals to prepare for reopening school doors in November.
- CDC researchers analyzed data from early March, when schools across the country began to shut down, to mid-September, by which time many states had opened schools either partially or fully for in-person instruction. The researchers found that of the roughly 280,000 children who tested positive for C19 during that time, 63 percent were between the ages of 12 and 17. Thirty-seven percent were ages 5 to 11.
- “Incidence among adolescents was approximately double that among young children,” the study concludes. That seems to bolster the case for in-person instruction for elementary schoolchildren, who appear to struggle the most with computer-based remote learning. High school students, who are better equipped to utilize online learning platforms and less likely to require adult supervision, could presumably delay returning to classrooms longer because they are at a higher risk of becoming ill.
- Kids were most likely to be infected by the coronavirus in the Southeast and the West, regions where some governors were slow to impose lockdown measures and quick to lift them.
- Children for the most part had mild infections, with only 1.2 percent hospitalized and 0.1 percent requiring intensive care. During the six months accounted for by the study, 51 children died of C19, making for a fatality rate of 0.018 percent. About a quarter of both ICU admissions and fatalities were for children who had underlying medical conditions, such as diabetes, obesity and breathing problems.
- The report did not speculate on why Hispanic children, who make up 25 percent of the nation’s population of children between the ages of 5 and 17, would suffer at a rate — 42 percent — much higher than their share of the population. Black children represented 17 percent of coronavirus cases and 14 percent of the relevant population. White children, about 50 percent of the population studied, accounted for 32 percent of the cases.
- Public health experts have suggested several reasons for these disparities, including the dearth of green space, adequate preventive health care and unhealthful food options in many communities of color. Hispanic adults, in particular, are likely to hold essential jobs that put them and their families at greater risk.
- The prevalence of multigenerational households, whether for cultural or economic reasons, could also be a factor in facilitating viral spread.
- The study calls for monitoring and mitigation strategies as communities across the country seek safe ways to reopen schools — and keep them open. A CDC guidance initially published in July said that “in-person schooling is in the best interest of students.” The bevy of studies published since then have not fundamentally challenged that assertion.
I. Practical Tips & Other Useful Information
1. CDC: How to Select, Wear, and Clean Your Mask
- CDC recommends that you wear masks in public settings around people who don’t live in your household and when you can’t stay 6 feet away from others. Masks help stop the spread of C19 to others.
- Wear masks with two or more layers to stop the spread of C19
- Wear the mask over your nose and mouth and secure it under your chin
- Masks should be worn by people two years and older
- Masks should NOT be worn by children younger than two, people who have trouble breathing, or people who cannot remove the mask without assistance
- Do NOT wear masks intended for healthcare workers, for example, N95 respirators
- CDC does not recommend the use of gaiters or face shields. Evaluation of these face covers is on-going but effectiveness is unknown at this time.
How to Select
- When selecting a mask, there are many choices. Here are some do’s and don’ts.
How to Wear
- Wear a mask correctly and consistently for the best protection.
- Be sure to wash your hands before putting on a mask
- Do NOT touch the mask when wearing it
- Do wear a mask that:
- Covers your nose and mouth and secure it under your chin
- Fits snugly against the sides of your face
- Do NOT wear a mask:
- How to take off a mask
How to Clean
- Masks should be washed regularly. Always remove masks correctly and wash your hands after handling or touching a used mask.
- Include your mask with your regular laundry
- Use regular laundry detergent and the warmest appropriate water setting for the cloth used to make the mask
- Use the highest heat setting and leave in the dryer until completely dry
- For more information, visit our How to Wash Masks web page.
- For more information, see our Masks web site. For information on the sources for our mask guidance, see Recent Studies.
2. Dreading a dark winter lockdown? Think like a Norwegian
- When Kari Leibowitz first arrived in the Norwegian city of Tromsø, she was both intrigued by, and fearful of, the approaching winter. Two hundred miles north of the Arctic Circle, the city does not see the sun from mid-November to mid-January. It was a far cry from the state of New Jersey, where she had grown up, or Stanford, California, where she had been studying before travelling to Norway.
- As a health psychologist, Leibowitz’s aim was to understand the ways that Tromsø’s citizens coped with the long “polar night”. In many countries, the short days of winter are thought to cause lethargy and low mood, resulting in “seasonal affective disorder” (SAD). This is sometimes assumed to have a purely biological basis – levels of mood-regulating neurotransmitters such as serotonin are generally lower in winter than in summer, and last week a study suggested that people with more neurotic personalities are particularly susceptible to low winter moods. SAD is often treated using standard antidepressant drugs, as well as psychotherapies.
- During the darkest periods of the polar night, Tromsø only receives two to three hours of indirect sunlight, shining into the sky from below the horizon. Yet its inhabitants do not show the kind of wintertime depression you might expect of a city cast in darkness. One study by May Trude Johnsen at the University of Tromsø found that the citizens’ wellbeing barely changed across the year. Their sleep was a bit more disturbed without the daily rhythm of the rising and setting sun, but they reported no increase in mental distress during the winter.
- So what’s their secret? Of the many potential explanations, Leibowitz’s work suggests that one vital component may be a particular “mindset” that arms the citizens against the stresses of the long polar night.
- These lessons could not be more timely. We may not live in the far north, but many of us in Europe and the US find winter to be the cruellest of all seasons – and that’s without the shadow of a global pandemic. Last week the Observer reported that as we face the daunting prospect of a second lockdown in cold dark conditions Brits have been stocking up on patio heaters and fire pits but, consumerism aside, what might we learn from the Norwegians’ psychological resilience?
- Leibowitz’s findings build on decades of previous research showing that the mental framing of stressful events can powerfully influence the ways we are affected by them. People who see stressful events as “challenges”, with an opportunity to learn and adapt, tend to cope much better than those who focus more on the threatening aspects – like the possibility of failure, embarrassment or illness. These differences in mindset not only influence people’s mood, but also their physiological responses, such as changes in blood pressure and heart rate, and how quickly they recover after the event. And the impact can be long-lasting, even during major transitions: one Israeli study found that immigrants’ stress appraisals can predict how well they adjust to their new country. They also seem to determine how well police officers in Australia cope with the stresses of their work.
- Needless to say, our appraisal of whether an event feels like a threat, or an opportunity, will depend on our circumstances and our resources to handle the problems we encounter. But it is sometimes possible to change our appraisal of a situation consciously. In one memorable experiment, Alison Wood Brooks, an associate professor at Harvard Business School, asked participants to face their fears of public speaking. Brooks found that simply asking the participants to repeat the phrase “I am excited” helped to reduce their anxious feelings and led to a better overall performance, since it encouraged them to view the situation as a new challenge rather than a threat. Many psychotherapies, such as cognitive behavioural therapy and acceptance and commitment therapy, have also been found to increase our resilience by helping us to reframe stressful events in more constructive ways.
- To test whether a difference in outlook could also explain the resilience of Tromsø’s residents, Leibowitz designed the “wintertime mindset scale”, which asked participants to rate how much they agreed or disagreed with statements such as
- There are many things to enjoy about the winter
- I love the cosiness of the winter months
- Winter brings many wonderful seasonal changes
- Winter is boring
- Winter is a limiting time of year
- There are many things to dislike about winter
- Sure enough, she found that participants’ answers predicted their wellbeing over the coming months; the more they saw the winter as an exciting opportunity to enjoy a glacial climate, the better they fared, with high levels of life satisfaction and overall mental health.
- Amazingly, Leibowitz found that these attitudes actually increase with latitude, in the regions where the winters will be even harsher. People in Svalbard (at 78 deg north) had a more positive mindset than the people in Tromsø (69 deg north), who took a more optimistic view than people in Oslo (60 deg north). In other words, the positive wintertime mindset is most common where it’s most needed.
- Most people don’t realise their beliefs about winter are subjective. They feel there’s nothing they can do about it
- These positive attitudes were apparent in Leibowitz’s casual conversations; indeed, she says that many of her friends struggled to understand why you would not enjoy winter. They embraced the possibility of skiing or hiking in the mountains, and savoured the chance to practice koselig – a Norwegian version of Denmark’s hygge – which might involve snuggling under blankets with a warm drink in the candlelight. Far from dwindling in the dark, Tromsø’s community flourished in the long polar night. “There is this interaction between the culture that you’re part of, and the mentality or mindset that grows out of it,” says Prof Joar Vittersø, Leibowitz’s collaborator at the Arctic University of Tromsø.
- Surrounded by Norwegian positivity, Leibowitz soon found her own mindset shifting; she learned to love long walks with a headlamp to guide her path. And rather than yearning for sunlight, she came to appreciate the “soft, peaceful” appearance of the city in the darkness. “When it was snowing, I would always try to go out and enjoy the fresh snowfall.”
- She suspects that many other people could follow suit, once they find out about this research. “Most people don’t realise that their beliefs about winter are subjective,” says Leibowitz, whose research is currently under peer review. “They feel like they’re just someone who hates the winter and there’s nothing they can do about it… But once you put it in people’s heads that mindsets exist, and that you have control over your mindset – I think that that’s tremendously powerful.”
- Leibowitz conducted her initial studies long before the new coronavirus left Wuhan – and she is realistic about the challenges of trying to see the positive in the pandemic. “A change in mindset is not a cure-all for everything,” she emphasises. It can’t simply eliminate our anxieties about the job insecurity or the fear of losing a loved one, and we should not attempt to suppress those emotions.
- Even so, she suspects that adopting the positive wintertime mindset could make a second lockdown a little less daunting for those who worry about keeping their mood buoyed in the bad weather. We might recognise, for instance, that it’s a time for baking comfort food or cosy evenings curled up under a blanket in front of a box set – practising a little bit of the Norwegian koselig. And if we normally exercise on a running machine, we might try to find value in a bracing jog in the elements. Since the risk of contagion is much lower outside, we might also adapt to the Scandinavian way of outdoor socialising (lockdown regulations permitting). Tromsø, for example, has an open-air cinema, so residents can enjoy atmospheric film screenings in the eerie Arctic darkness. As the Norwegians say: “There is no such thing as bad weather, only bad clothes.”
- This time, we do at least have the advantage of knowing what did and didn’t work during the first lockdown, so we can be more realistic in our expectations of what we can and can’t achieve, focusing our efforts on the small actions that bring the most comfort, rather than aiming to write a bestselling novel, say.
- A recent study by Prof Hannes Zacher, a psychologist at Leipzig University, shows that our personal framing of the pandemic has already had a small but significant effect on our responses during the crisis so far.
- The survey, which was set up before the crisis, ran from December 2019 to May this year – and as you might expect, there was a significant drop in life satisfaction and positive mood after the pandemic hit Europe. But certain psychological characteristics and coping strategies seemed to protect some people from the worst effects. This included “active coping” – such as setting up a proper office at home, scheduling home-schooling times for the children, and making sure to eat well, sleep well, and exercise, Zacher says. As the previous research predicted, the most resilient participants also managed to recognise the potential opportunities in the crisis – such as “learning something from the experience, or trying to grow as a person as a result from the experience,” Zacher explains.
- Like Leibowitz, Zacher emphasises that the aim is not to sugar-coat the situation or to deny the difficulties that we will face; we can’t hide from the shadow cast by the pandemic, any more than the citizens of Tromsø can pretend that the sun is still rising. By recognising our own capacity to control our responses to the lockdown and the changing seasons, however, we may all find some hidden reserves of strength and resilience to see us through the days ahead.
J. Johns Hopkins COVID-19 Update
September 28, 2020
1. Cases & Trends
- The WHO C19 Dashboard reports 32.97 million cases and 995,836 deaths as of 10:00am EDT on September 28. The global weekly incidence remained greater than 2 million new cases last week, but it decreased slightly (1.45%) compared to the previous week. At approximately 36,000 deaths per week (~5,142 deaths per day), the global cumulative C19 mortality could reach 1 million by tomorrow.
- Total Daily Incidence (change in average incidence; change in rank, if applicable)
- Per Capita Daily Incidence (change in average incidence; change in rank, if applicable)
- India’s daily incidence continues to decline from its peak in mid-September, down 10% over the past 2 weeks. Peru fell out of the top 10 in terms of total daily incidence, and it was replaced by Indonesia. Israel set a new record for per capita incidence over the weekend, with 718 daily cases per million population. The Bahamas fell out of the top 10 in terms of per capita daily incidence, and it was replaced by France.
- The US CDC reported 7.06 million total cases and 204,033 deaths. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
- 1 million to 2 million: 44 days
- 2 million to 3 million: 27 days
- 3 million to 4 million: 15 days
- 4 million to 5 million: 17 days
- 5 million to 6 million: 22 days
- 6 million to 7 million: 25 days
- The US is averaging 44,307 new cases and 755 deaths per day. This is the highest average daily incidence since August 21 and nearly 30% greater than the low reported on September 12. We are now 3 weeks past the Labor Day holiday—which is also typically the latest that US schools begin the school year—and the US is exhibiting another increase in incidence at the national level.
- In total, 22 states (no change) are reporting more than 100,000 cases, including California and Texas with more than 700,000 cases; Florida with more than 600,000; New York with more than 400,000; Georgia with more than 300,000; and Arizona, Illinois, New Jersey, and North Carolina with more than 200,000. California’s state C19 website is currently reporting more than 800,000 cases, and Florida’s C19 website is reporting more than 700,000 cases. We expect both of those to be reflected in the CDC data in the coming days.
- The Johns Hopkins CSSE dashboard reported 7.12 million US cases and 204,790 deaths as of 11:30pm EDT on September 28.
- On Friday, Florida Governor Ron DeSantis announced that the state would enter Phase 3 of Florida’s C19 recovery plan, which would essentially lift all C19-related restrictions on businesses, including measures that restricted capacity for bars and restaurants. Local governments are permitted to institute their own C19 restrictions on restaurants; however, they must “quantify the economic impact of each limitation” and justify “why each limitation…is necessary for public health.” Governor DeSantis’ executive order also suspends fines or other penalties for individuals who do not comply with C19 restrictions. Businesses are still free to set and enforce their own policies for employees and patrons. The announcement comes as Florida surpasses 700,000 cumulative cases, and C19 incidence is increasing in many parts of the country.
3. VACCINE CLINICAL TRIAL
- Johnson & Johnson (J&J) published (preprint) preliminary findings from the Phase 1/2a clinical trials for its candidate SARS-CoV-2 vaccine (Ad26.COV.S). The studies included nearly 800 participants, who were split into 3 cohorts for the randomized, double-blinded, placebo-controlled study. The first 2 cohorts were made up of 402 healthy adults aged 18-55 years, and the third cohort included 394 healthy adults over the age of 65. The vaccine was given as a single dose or 2 doses administered 56 days apart. The vaccine was generally well tolerated, and the researchers reported 2 serious adverse events. One of the serious adverse events was determined to be unrelated to the vaccine, and the other was a fever that resolved within 12 hours.
- Neutralizing antibody activity was observed in 98% of participants aged 18-55 years, and 99% of participants in those cohorts also demonstrated seroconversion following the vaccination. The younger adult cohorts also had strong T cell, antibody, and a Th1 cytokine response. Only 15 participants from the older cohort had immunogenicity data available, although the researchers reported that initial data are promising. Last week, J&J announced that it will commence Phase 3 clinical trials involving 60,000 participants across approximately 215 sites to test the single-dose vaccine formulation. The J&J candidate vaccine is the only vaccine in Phase 3 trials utilizing only 1 dose, which may expedite results of the trial.
4. SUSCEPTIBILITY IN CHILDREN & ADOLESCENTS
- A systematic review and meta-analysis published in JAMA: Pediatrics describes findings from 32 contact tracing studies and population screening studies to compare susceptibility to SARS-CoV-2 infection among children and adolescents to susceptibility among adults. The researchers—from Australia, the Netherlands, and the UK—evaluated studies representing 41,640 children and 268,945 adults. They determined that individuals under 20 years old had 44% lower odds of infection compared to older adults, a statistically significant difference. Notably, they determined that this association appeared to be largely attributable to younger children—under the age of 10-14 years—and that adolescents appeared to have similar infection risk as adults.
- The younger children also exhibited lower seroprevalence compared to adults, but adolescents and adults exhibited similar seroprevalence. Many of the included studies were conducted at a time when highly restrictive social distancing measures were in place, including school closings, which could have affected children’s exposure both inside and outside the home. Additionally, contact tracing efforts and community-level seroprevalence studies had lower participation for children compared to adults. The researchers were unable to determine the risk of community transmission by children, and further research is necessary to better characterize the role of pediatric cases in the C19 pandemic. This study does provide evidence that older children and adolescents may be similarly susceptible to SARS-CoV-2 as adults.
5. DRIED BLOOD SPOT TESTING
- A study published in the US CDC’s Emerging Infectious Diseases journal demonstrates that dried blood spot (DBS) samples could be used to detect SARS-CoV-2 antibodies. Compared to blood serum, which must be obtained by venipuncture, DBS specimens are much easier to collect, including at home by the general public; ship/transport; and process. A study of 80 participants in the UK tested 87 DBS specimens against matched blood serum specimens from the same participant. The DBS test exhibited 98% sensitivity and 100% specificity compared to the serum samples. DBS testing is used to test for antibodies for a variety of other pathogens, and this capability could reduce the cost, difficulty, and logistical burden of expanding community-level seroprevalence efforts, particularly in lower- and middle-income countries. Additional study is needed to fully characterize the capabilities of DBS testing for SARS-CoV-2, but this initial data provides promising indication that DBS could be a useful tool during the C19 pandemic.
6. FACE COVERINGS
- The use and availability of face coverings, including for the general public and for healthcare workers, has been one of the major ongoing storylines over the course of the pandemic. Researchers continue to evaluate the role of masks and other face coverings in mitigating SARS-CoV-2 transmission, and hospitals and health systems in the US (and likely elsewhere) continue to struggle to maintain sufficient supply of respirators and surgical masks that are critical for protecting healthcare workers and patients.
- Researchers from the University of California Davis and the Icahn School of Medicine at Mount Sinai (New York) published findings from a study to evaluate the ability of various mask types in reducing exhaled respiratory droplets. The study, published in Scientific Reports (a Nature journal), evaluated several different mask types, including N95 and KN95 respirators (vented and unvented; not fit-tested), surgical masks, and homemade cloth masks (single and double-layer). Measurements for respiratory droplets were taken while participants breathed, spoke, coughed, and chewed, and additional measurements were taken before and after washing cloth masks.
- The respirators and surgical masks exhibited a statistically significant decrease in respiratory droplets, whereas the homemade t-shirt masks did not. Notably, the cloth masks resulted in an increase in droplets in some instances, similar to results from a previous study that found increased droplets for neck gaiters. The researchers determined that cloth masks have the potential to shed cloth particles as the material breaks down, which could contribute to the volume of airborne particles. The current study only evaluated paper towel and t-shirt material for the homemade masks, and further research is needed to better characterize the effects of different types of cloth and mask construction. The researchers also note that the sampling methodology did not account for droplets that escape around the edges of the masks.
- An investigation conducted by ECRI—”an independent, nonprofit organization improving the safety, quality, and cost-effectiveness of care across all healthcare settings”—found that KN95 respirators originating in China may not provide sufficient protection for healthcare workers. During the pandemic, KN95 respirators have been used to supplement limited supply of NIOSH-certified N95 respirators, including in healthcare settings. In theory, KN95 respirators should provide similar filtration capabilities as the certified N95 respirators; however, ECRI found that some KN95 respirators do not meet the same filtering standards. The researchers tested 200 respirators across 15 different models, and 60-70% of the KN95 masks imported from China did not filter 95% of airborne particles like they should.
- Notably, it may be difficult to distinguish between KN95 and N95 respirators visually; however, many of the tested KN95 respirators utilize ear loops, as opposed to elastic straps that go around the head and neck, which do not provide an adequate seal between the respirator and the wearer’s face. ECRI recommended that hospitals and health systems purchasing KN95 respirators conduct tests to ensure the products are providing appropriate protection. In April, the US FDA issued an Emergency Use Authorization (EUA) for non-NIOSH-certified respirators, and it has issued several updates since then to address quality control issues with imported products, including a list of products no longer authorized under the EUA due to inadequate performance.
7. DISEASE SEVERITY INDICATORS
- Last week, two studies published in Science provide evidence that type 1 interferon may play an important role in fighting SARS-CoV-2 infection. The first article, researchers conducted whole-genome or exome sequencing for for 659 patients with life-threatening pneumonia due to C19 and compared the results against sequencing from 534 participants with asymptomatic infection or mild disease. The researchers evaluated the genomes for 13 rare mutations associated with decreased interferon production. Among the patients with severe C19 infection, 3.5% had loss of function in one of these genes, representing 8 of the 13 mutations evaluated. Notably, no members of the control group (asymptomatic/mild) had any of these mutations.
- The second study found the body’s immune response could also inhibit interferon activity in patients who are able to produce their own in sufficient quantities. Among 987 patients with severe C19 pneumonia, the researchers identified “rogue antibodies” (auto-Abs) that attacked interferon in 101 patients. These antibodies were not observed in 663 individuals with asymptomatic infection or mild disease, and only 4 of 1,227 healthy individuals had the rogue antibodies. Interestingly, 94% of the patients with the rogue antibodies were male.
- These studies may help identify individual risk factors for developing severe C19 disease. The authors indicate that these 2 conditions could account for 14% of severe C19 cases. They suggest that convalescent plasma donors be screened for rogue antibodies prior to donation to reduce the chance that they could attack interferon in patients receiving the treatment and that synthetic interferons could be a potential area of investigation in terms of developing additional treatment options.
8. RELIGIOUS PRACTICES
- As Israel’s C19 epidemic continues to surge, setting new records in terms of per capita daily incidence, Jewish rabbis, particularly those serving ultra-Orthodox communities, are addressing a myriad of questions to help their followers safely worship during the High Holiday season. Social distancing restrictions have had significant impacts on religious services around the world, in particular on the role of large gatherings for many religious holidays and celebrations. The questions posed to ultra-Orthodox rabbis range from how to best lead prayers and services remotely (eg, via Zoom) to the role of blessing food for those who lost their senses of taste and smell due to C19. There has been some opposition to social distancing measures in some ultra-Orthodox communities, including keeping schools open during national “lockdowns,” but the Israeli government is working to engage with local religious leaders and promote lower-risk alternatives or adaptations for religious services and celebrations, particularly for the High Holiday season.