October 2, 2020
Without reliable information, we rely on fear or luck.
“Today, all of the European countries are more or less following the Swedish model, combined with the testing, tracing and quarantine procedures the Germans have introduced, but none will admit it. Instead, they made a caricature out of the Swedish strategy. Almost everyone has called it inhumane and a failure.”Antoine Flahault, director of the Institute of Global Health
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity
4. Sunbelt and Midwest Review of Cases and Hospitalizations
5. Coronavirus cases are rising in 25 states
6. Unexpected findings from India
7. A Native American health crisis
6. Study finds 100% death rate in C19 patients after CPR (Link Only)
3. Experts Say C19 Vaccine Rollout Unlikely Before Fall 2021 (Link Only)
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A. The Pandemic As Seen Through Headlines
(In no particular order)
- President Donald Trump, First Lady Melania Trump Test Positive for Coronavirus
- President Donald Trump, First Lady Melania Trump Test Positive for Coronavirus
- Mississippi becomes first State to lift mask mandate
- Tulsa is now requiring anyone age 10 and up to wear a mask in public spaces
- Bars, movie theaters and amusement parks in North Carolina can open with restrictions
- A major spike in Wisconsin is swamping hospitals, testing and tracing capacity
- Pfizer has hinted that its vaccine might be ready by October, contrary to most scientific predictions
- Moderna says its coronavirus vaccine won’t be ready until 2021
- FDA widens U.S. safety inquiry into AstraZeneca coronavirus vaccine
- Moderna says coronavirus vaccine boosts immune system response in older adults
- Regeneron says antibody ‘cocktail’ helps COVID-19 patients recover quickly
- An Urgent Call for Vaccine Volunteers
- Russia moves closer to approving its second vaccine
- 15-minute coronavirus test cleared for use in Europe
- World Bank announces $12 billion plan for poor countries to buy Covid vaccines
- Trump administration lays out national distribution plan for Abbott BinaxNOW Ag Card rapid COVID-19 test
- COVID-19 cases rising among US adolescents
- Hydroxychloroquine doesn’t stop spread of COVID-19 in health workers: study
- Coronavirus face masks made with silk are better than cotton
- Tennessee governor ending all statewide restrictions on businesses, gatherings
- College restarts tied to COVID-19 rises in young adults
- The Czech Republic and Slovakia have declared states of emergency to deal with rising case numbers
- Italy to extend COVID state of emergency to end of January
- In Madrid, a virus resurgence is hitting the most economically vulnerable districts of the capital disproportionately, dividing the rich and poor
- Ukraine’s Parliament canceled plenary sessions until Oct. 20 because of rising infections
- South Africa is allowing international flights for first time in more than 6 months
- 63 million people in India may have gotten coronavirus, survey finds
- Amid a surge in cases, India plans to reopen cinemas, entertainment parks and some schools
- Israel reportedly leads world in new COVID-19 infections per capita
- Moscow orders restrictions as new cases mount
- After 6 months, Germany lifts blanket world travel warning
- NY Gov. Cuomo slams NYC’s response to spike in coronavirus cases
- Cuomo unveils app that alerts users when they’re near someone with COVID-19
- New York City’s seven-day average of positive test results ticked up slightly, to 1.46%
- New York City’s Indoor Dining Reopens After Six-Month Shutdown
- NYC is the first major U.S. city to reopen all its public schools for in-person learning
- First NYC school closes due to coronavirus concerns
- Startling number of kids in NYC have lost a parent to COVID-19, study finds
- Half of New York City’s Restaurants, Bars Could Permanently Close Due to Coronavirus, State Audit Finds
- 17 people died this year from methanol-tainted hand sanitizer
- Federal prisons will allow relatives in to visit inmates again starting Saturday
- Almost 20,000 frontline Amazon workers have been infected
- In a new survey, more than 60% of US households with children reported serious money problems, but Black and Latino people bore brunt of the pain
- Disney laid off 28,000 employees at its theme parks in the U.S., or about 25% of its domestic resort work force
- Thousands of airline employees are retiring early and taking buyouts and leaves in anticipation of a slow recovery for the airline industry
- Two airlines start furloughs of 32,000 workers as aid runs dry
- The Pandemic Recession Isn’t Over—and it Could Get Worse
- Most Americans Plan to Vote in Person
- New study links reduced air pollution with better outcomes from COVID-19
- CDC’s ‘no-sail order’ extension blocked by White House, set to expire in October
- 102-year-old Chicago teacher wears hazmat suit to cast mail-in ballot
- Seattle patient third in world to be reinfected with COVID-19
- Rare brain fluid leak in woman’s nose linked to COVID-19 test detailed in case study
- Obese patients seeking weight loss surgery to combat severe coronavirus risk
- Tampa Airport becomes first to offer COVID-19 testing to all passengers
- Notre Dame let coronavirus ‘spread like wildfire’
- NFL indefinitely postpones Steelers-Titans game after new virus cases
- FSU cancels spring break after 1,000-person party
- Most people say they’ve become more frugal during the pandemic
- Creepy coronavirus Halloween masks facing backlash
- US families say their houses are dirtier than they’ve ever been
- Hotels are offering ‘schoolcation’ packages to desperate parents
B. Numbers & Trends
Note: Unless otherwise noted, (i) all cases/deaths are confirmed cases/deaths that have been reported, (ii) all numbers reported in this update are as of the end of the most recent reporting period, and (iii) all changes reflect changes since the preceding day.
1. Cases & Tests
- Total Cases = 34,469,967
- New Cases = 319,406
- New Cases (7 day average) = 290,301 (+1,578) (+0.6%)
- 2nd highest number of new cases
- 7 day average is a record high
- 1,000,000 cases every 3.4 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 7,494,671
- New Cases = 47,389
- Percentage of New Global Cases = 14.8%
- New Cases (7 day average) = 42,952 (+266) (+0.6%)
- Total Number of Tests = 108,431,960
- Percentage of positive tests (7 day average) = 5.2%
- 7 day average has been trending higher since 9/12
- Since 9/12, the 7 day average has increased from 35,517 to 42,952, an increase of 7,435, or 20.9%, which is a concerning trend
- Total Deaths = 1,027,133
- New Deaths = 8,922
- New Deaths (7 day average) = 5,708 (+438) (+8.3%)
- Number of new deaths is a record high
- 7 day average increased more than 8% in one day, which is a very steep increase (while this may be a reporting anomaly, the fact that it is the highest during the pandemic is striking, particularly with the US 7 day average declining)
- Total Deaths = 212,660
- New Deaths = 920
- Percentage of Global New Deaths = 10.3%
- New Deaths (7 day average) = 731 (-24) (-3.2%)
- 7 day average has been trending lower since 2nd peak on 8/4
- Since 2nd peak, 7 day average has decreased from 1,178 to 731, a decline of 37.9%
- 7 day average lowest since 7/11
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity (10/1)
4. Sunbelt and Midwest Review of Cases and Hospitalizations
Sunbelt States (AZ, CA, FL, GA, TX)
- All of the Sunbelt states peaked in cases and hospitalization in mid-July.
- CA, FL, GA and AZ are all approaching levels seen in mid-June and are approaching levels prior to the ending of shelter-in-place rules
- TX new cases have leveled off and is a potential concern
Midwest States (ND, SD, ID, IL, WI)
- ID, SD and ND have all seen cases rise and are among the highest in terms of percentage increases; however, the total number of cases is low compared to higher populated states.
- WI has seen a rapid increase in the number of daily cases rise from 707 on 9/1 to 3,000 new cases as of 10/1, a 324% increase in daily cases. During the same period, hospitalizations increased 127% from 295 on 9/1 to 669 on 10/1
- IL had 1,492 daily cases on 9/1 and 2,166 cases on 10/1, an increase of 45%
5. Coronavirus cases are rising in 25 states
- Nationwide, the U.S. averaged roughly 43,000 cases per day during the past week — essentially unchanged from the week before.
- The number of new daily infections rose in 25 states, spanning every region of the country. New Mexico recorded the biggest spike, at over 50%.
- That broad, nationwide increase was offset by continued progress in pockets of the southern U.S. Only eight states saw their new infections decline over the past week, but that group includes several former Hotspot states in the Sunbelt: Arizona, Florida, Georgia, and Texas.
- Testing was up almost 9% over the same period. The U.S. is now conducting about 935,000 tests per day.
- Texas and North Carolina both reported big data dumps recently that encompassed large backlogs of cases. We have excluded both of those reports from this analysis.
6. Unexpected findings from India
- A vast study in India of nearly 85,000 coronavirus cases and almost 600,000 of their contacts offers some surprising findings and important insights.
- Our colleague Apoorva Mandavilli, who covers science, was born in India and lived in both Tamil Nadu and Andhra Pradesh, the two southern states that were the focus of the study — one of the largest to employ contact tracing anywhere to date.
- “I was blown away by the extent of the contact tracing that they were able to do because India is a very crowded place,” Apoorva told us. “There are so many markets and jam-packed streets and buildings. Tracing the contacts of a person is hard to do anywhere, but especially in India — it’s really impressive.”
- Here are some of the findings she found most surprising:
- Children of all ages can become infected with the virus and can spread it to others — offering solid evidence on one of the most divisive questions of the virus.
- A small number of people were responsible for seeding a majority of new infections, confirming past research. Overall, 5% of people were responsible for 80% of infections detected by contact tracing. Most people, 71%, did not seem to pass the virus on to anyone else.
- Initial infections — known as index cases — were more likely to be among men who were older than their contacts. “I think that says something about who gets to go out and about, and who is more likely to respond to contact tracers,” Apoorva said.
- Deaths increased with age but seemed to drop off after age 65, perhaps because life expectancy in India is 69 years, and Indians who live past 65 tend to be relatively wealthy and have access to good health care.
- The median stay for C19 patients who died in the hospital was only five days, compared with two weeks in the United States. “That really speaks to a system that abandons its people until they are so sick that they are almost at death’s door,” Apoorva said.
- Apoorva also told us that the location of the study should be understood in context.
- “These two Indian states have a really rich history of activism and public health, so they are probably best positioned to tackle something like the pandemic,” she said. “This is probably the best-case scenario, and the situation is much more dire in the rest of India — many fewer hospitals, many fewer skilled personnel, many fewer ventilators and I.C.U. units and everything else you need to take care of C19 patients.”
Source: New York Times Coronavirus Briefing
7. A Native American health crisis
- The Indian Health Service, a Maryland-based government program that provides health care to more than two million members of U.S. tribal communities, has long struggled with mismanagement and shortages in funding, supplies and doctors. Then the pandemic hit.
- The virus tore through native communities, claiming lives at disproportionate rates. Native Americans account for 5 percent of the population of Arizona, and 11 percent of the state’s virus deaths. New Mexico’s population is 11 percent Native American, but they represent nearly 30 percent of its caseload.
- Indian Health Service hospitals waited months for protective equipment from the government, some of which arrived already expired. A severe lack of hospital beds inhibited the I.H.S.’s ability to handle the flood of C19 patients. Tribal officials had to take matters into their own hands, spending millions of dollars to bolster the response.
- The I.H.S. goes back to 1868, when tribes agreed to exchange land and natural resources for health care and other services from the U.S. government as part of the Fort Laramie Treaty. The agency’s defenders say it has always been woefully underfunded, and they blame Congress and previous presidential administrations just as much as they blame President Trump for the agency’s mismanagement.
- At one point during the outbreak, Esther Lucero, the chief executive officer of the Seattle Indian Health Board, said she requested more coronavirus tests from the government but instead received body bags.
- “I feel like it is common practice that we are always getting the bottom of the barrel, the leftover,” Ms. Lucero said.
Source: New York Times Coronavirus Briefing
C. New Scientific Findings & Research
1. Common Cold May Help Protect You From C19, And Immunity is Likely To Last a Long Time – Maybe Even a Lifetime
- Seasonal colds are by all accounts no fun, but new research suggests the colds you’ve had in the past may provide some protection from C19. The study, authored by infectious disease experts at the University of Rochester Medical Center, also suggests that immunity to C19 is likely to last a long time — maybe even a lifetime.
- The study, published in mBio, is the first to show that the coronavirus induces memory B cells, long-lived immune cells that detect pathogens, create antibodies to destroy them and remember them for the future. The next time that pathogen tries to enter the body, those memory B cells can hop into action even faster to clear the infection before it starts.
- Because memory B cells can survive for decades, they could protect C19 survivors from subsequent infections for a long time, but further research will have to bear that out.
- The study is also the first to report cross-reactivity of memory B cells — meaning B cells that once attacked cold-causing coronaviruses appeared to also recognize SARS-CoV-2. Study authors believe this could mean that anyone who has been infected by a common coronavirus — which is nearly everyone — may have some degree of pre-existing immunity to C19.
- “When we looked at blood samples from people who were recovering from C19, it looked like many of them had a pre-existing pool of memory B cells that could recognize the coronavirus and rapidly produce antibodies that could attack it,” said lead study author Mark Sangster, Ph.D., research professor of Microbiology and Immunology at URMC.
- Sangster’s findings are based on a comparison of blood samples from 26 people who were recovering from mild to moderate C19 and 21 healthy donors whose samples were collected six to 10 years ago — long before they could have been exposed to C19. From those samples, study authors measured levels of memory B cells and antibodies that target specific parts of the Spike protein, which exists in all coronaviruses and is crucial for helping the viruses infect cells.
- The Spike protein looks and acts a little different in each coronavirus, but one of its components, the S2 subunit, stays pretty much the same across all of the viruses. Memory B cells can’t tell the difference between the Spike S2 subunits of the different coronaviruses, and attack indiscriminately. At least, the study found that was true for betacoronaviruses, a subclass that includes two cold-causing viruses as well as SARS, MERS and SARS-CoV-2.
- What this study doesn’t show is the level of protection provided by cross-reactive memory B cells and how it impacts patient outcomes.
- “That’s next,” said David Topham, Ph.D., the Marie Curran Wilson and Joseph Chamberlain Wilson Professor of Microbiology and Immunology at URMC, who runs the lab that conducted this work. “Now we need to see if having this pool of pre-existing memory B cells correlates with milder symptoms and shorter disease course — or if it helps boost the effectiveness of C19 vaccines.”
2. Breaking C19’s “Clutch” to Stop Its Spread: Small Molecule Targets Coronavirus RNA for Destruction
- Scripps Research chemist Matthew Disney, PhD, and colleagues have created drug-like compounds that, in human cell studies, bind and destroy the pandemic coronavirus’ so-called “frameshifting element” to stop the virus from replicating. The frameshifter is a clutch-like device the virus needs to generate new copies of itself after infecting cells.
- “Our concept was to develop lead medicines capable of breaking C19’s clutch,” Disney says. “It doesn’t allow the shifting of gears.”
- Viruses spread by entering cells and then using the cells’ protein-building machinery to churn out new infectious copies. Their genetic material must be compact and efficient to make it into the cells.
- The pandemic coronavirus stays small by having one string of genetic material encode multiple proteins needed to assemble new virus. A clutch-like frameshifting element forces the cells’ protein-building engines, called ribosomes, to pause, slip to a different gear, or reading frame, and then restart protein assembly anew, thus producing different protein from the same sequence.
- But making a medicine able to stop the process is far from simple. The virus that causes C19 encodes its genetic sequence in RNA, chemical cousin of DNA. It has historically been very difficult to bind RNA with orally administered medicines, but Disney’s group has been developing and refining tools to do so over more than a decade.
- The scientists’ report, titled “Targeting the SARS-CoV-2 RNA Genome with Small Molecule Binders and Ribonuclease Targeting Chimera (RIBOTAC) Degraders,” appears in the journal ACS Central Science (9/30/20).
- Disney emphasizes this is a first step in a long process of refinement and research that lies ahead. Even so, the results demonstrate the feasibility of directly targeting viral RNA with small-molecule drugs, Disney says. Their study suggests other RNA viral diseases may eventually be treated through this strategy, he adds.
- “This is a proof-of-concept study,” Disney says. “We put the frameshifting element into cells and showed that our compound binds the element and degrades it. The next step will be to do this with the whole COVID virus, and then optimize the compound.”
- “By coupling our predictive modeling approaches to the tools and technologies developed in the Disney lab, we can rapidly discover druggable elements in RNA,” Moss says. “We’re using these tools not only to accelerate progress toward treatments for C19, but a host of other diseases, as well.”
- The scientists zeroed in on the virus’ frameshifting element, in part, because it features a stable hairpin-shaped segment, one that acts like a joystick to control protein-building. Binding the joystick with a drug-like compound should disable its ability to control frameshifting, they predicted. The virus needs all of its proteins to make complete copies, so disturbing the shifter and distorting even one of the proteins should, in theory, stop the virus altogether.
- Using a database of RNA-binding chemical entities developed by Disney, they found 26 candidate compounds. Further testing with different variants of the frameshifting structure revealed three candidates that bound them all well, Disney says.
- Disney’s team in Jupiter, Florida quickly set about testing the compounds in human cells carrying C19’s frameshifting element. Those tests revealed that one, C5, had the most pronounced effect, in a dose-dependent manner, and did not bind unintended RNA.
- They then went further, engineering the C5 compound to carry an RNA editing signal that causes the cell to specifically destroy the viral RNA. With the addition of the RNA editor, “these compounds are designed to basically remove the virus,” Disney says.
- Cells need RNA to read DNA and build proteins. Cells have natural process to rid cells of RNA after they are done using them. Disney has chemically harnessed this waste-disposal system to chew up C19 RNA. His system is called RIBOTAC, short for “Ribonuclease Targeting Chimera.”
- Adding a RIBOTAC to the C5 anti-COVID compound increases its potency by tenfold, Disney says. Much more work lies ahead for this to become a medicine that makes it to clinical trials. Because it’s a totally new way of attacking a virus, there remains much to learn, he says.
- “We wanted to publish it as soon as possible to show the scientific community that the COVID RNA genome is a druggable target. We have encountered many skeptics who thought one cannot target any RNA with a small molecule,” Disney says. “This is another example that we hope puts RNA at the forefront of modern medicinal science as a drug target.”
3. Largest C19 contact-tracing finds children key to spread, evidence of superspreaders
- A study of more than a half-million people in India who were exposed to the coronavirus suggests that the virus’ continued spread is driven by only a small percentage of those who become infected.
- Furthermore, children and young adults were found to be potentially much more important to transmitting the virus — especially within households — than previous studies have identified, according to a paper by researchers from the United States and India published Sept. 30 in the journal Science.
- Researchers from the Princeton Environmental Institute (PEI), Johns Hopkins University and the University of California-Berkeley worked with public health officials in the southeast Indian states of Tamil Nadu and Andhra Pradesh to track the infection pathways and mortality rate of 575,071 individuals who were exposed to 84,965 confirmed cases of the coronavirus. It is the largest contact-tracing study — which is the process of identifying people who came into contact with an infected person — conducted in the world for any disease.
- Lead researcher Ramanan Laxminarayan, a senior research scholar in PEI, said that the paper is the first large study to capture the extraordinary extent to which C19 hinges on “superspreading,” in which a small percentage of the infected population passes the virus on to more people. The researchers found that 71% of infected individuals did not infect any of their contacts, while a mere 8% of infected individuals accounted for 60% of new infections.
- “Our study presents the largest empirical demonstration of superspreading that we are aware of in any infectious disease,” Laxminarayan said. “Superspreading events are the rule rather than the exception when one is looking at the spread of C19, both in India and likely in all affected places.”
- The findings provide extensive insight into the spread and deadliness of C19 in countries such as India — which has experienced more than 96,000 deaths from C19 — that have a high incidence of resource-limited populations, the researchers reported. They found that coronavirus-related deaths in India occurred, on average, six days after hospitalization compared to an average of 13 days in the United States. Also, deaths from coronavirus in India have been concentrated among people aged 50-64, which is slightly younger than the 60-plus at-risk population in the United States.
- The researchers also reported, however, the first large-scale evidence that the implementation of a country-wide shutdown in India led to substantial reductions in coronavirus transmission.
- The researchers found that the chances of a person with coronavirus, regardless of their age, passing it on to a close contact ranged from 2.6% in the community to 9% in the household. The researchers found that children and young adults — who made up one-third of COVID cases — were especially key to transmitting the virus in resource-limited populations.
- “Kids are very efficient transmitters in this setting, which is something that hasn’t been firmly established in previous studies,” Laxminarayan said. “We found that reported cases and deaths have been more concentrated in younger cohorts than we expected based on observations in higher-income countries.”
- Children and young adults were much more likely to contract coronavirus from patients their own age, the study found. In general, same-age contacts across all age groups greatly increased the chance of infection, with the probability of catching coronavirus from low- to high-risk contacts ranging from 4.7-10.7%, respectively.
D. Vaccines & Testing
1. One number could help reveal how infectious a C19 patient is. Should test results include it?
- Ever since the coronavirus pandemic began, battles have raged over testing: Which tests should be given, to whom, and how often? Now, epidemiologists and public health experts are opening a new debate. They say testing centers should report not just whether a person is positive, but also a number known as the cycle threshold (CT) value, which indicates how much virus an infected person harbors.
- Advocates point to new research indicating that CT values could help doctors flag patients at high risk for serious disease. Recent findings also suggest the numbers could help officials determine who is infectious and should therefore be isolated and have their contacts tracked down. CT value is an imperfect measure, advocates concede. But whether to add it to test results “is one of the most pressing questions out there,” says Michael Mina, a physician and epidemiologist at Harvard University’s T.H. Chan School of Public Health
- Standard tests identify coronavirus infections by isolating and amplifying viral RNA using a procedure known as the polymerase chain reaction (PCR), which relies on multiple cycles of amplification to produce a detectable amount of RNA. The CT value is the number of cycles necessary to spot the virus; PCR machines stop running at that point. If a positive signal isn’t seen after 37 to 40 cycles, the test is negative. But samples that turn out positive can start out with vastly different amounts of virus, for which the CT value provides an inverse measure. A test that registers a positive result after 12 rounds, for a CT value of 12, starts out with more than 10 million times as much viral genetic material as a sample with a CT value of 35.
- But the same sample can give different CT values on different testing machines, and different swabs from the same person can give different results. “The CT value isn’t an absolute scale,” says Marta Gaglia, a virologist at Tufts University. That makes many clinicians wary, Mina says. “Clinicians are cautious by nature,” Mina says. “They say, ‘If we can’t rely on it, it’s not reliable.’” In an August letter in Clinical Infectious Diseases, members of the College of American
- Nevertheless, Mina, Gaglia, and others argue that knowing whether CT values are high or low can be highly informative. “Even with all the imperfections, knowing the viral load can be extremely powerful,” Mina says.
- Early studies showed that patients in the first days of infection have CT values below 30, and often below 20, indicating a high level of virus; as the body clears the coronavirus, CT values rise gradually. More recent studies have shown that a higher viral load can profoundly impact a person’s contagiousness and reflect the severity of disease.
- In a study published this week in Clinical Infectious Diseases, researchers led by Bernard La Scola, an infectious diseases expert at IHU-Méditerranée Infection, examined 3790 positive samples with known CT values to see whether they harbored viable virus, indicating the patients were likely infectious. La Scola and his colleagues found that 70% of samples with CT values of 25 or below could be cultured, compared with less than 3% of the cases with CT values above 35. “It’s fair to say that having a higher viral load is associated with being more infectious,” says Monica Gandhi, an infectious diseases specialist at the University of California, San Francisco.
- Conversely, people often test positive for weeks or even months after they recover but have high CT values, suggesting the PCR has identified genetic material from noninfectious viral debris. Current guidelines from the CDC and WHO, which call for patients to isolate themselves for 10 days after onset of symptoms, recognize they are not likely to be infectious after that period. But Mina and others say the recent findings also suggest that a patient who has undergone multiple tests with high CT values is likely at the tail end of their infection and need not isolate themselves. He adds that contact tracers should triage their efforts based on CT values. “If 100 files land on my desk [as a contact tracer], I will prioritize the highest viral loads first, because they are the most infectious,” Mina says.
- Broad access to CT values could also help epidemiologists track outbreaks, Mina says. If researchers see many low CT values, they could conclude an outbreak is expanding. But if nearly all CT values are high, an outbreak is likely waning. “We have to stop thinking of people as positive or negative, and ask how positive?” Mina says.
- CT values could also help clinicians flag patients most at risk for severe disease and death. A report in June from researchers at Weill Cornell Medicine found that among 678 hospitalized patients, 35% of those with a CT value of 25 or less died, compared with 17.6% with a CT value of 25 to 30 and 6.2% with a CT value above 30. In August, researchers in Brazil found that among 875 patients, those with a CT value of 25 or below were more likely to have severe disease or die.
- Gandhi agrees that having access to CT values could help clinicians identify people at high risk for developing symptoms. Nevertheless, she and others note that a high viral load doesn’t necessarily lead to disease; some 40% of people who contract the coronavirus stay healthy even though they have a similar amount of virus to patients who fall ill. “As a physician, having the CT value is not the only thing I will use” to diagnose and track patients, says Chanu Rhee, a hospital epidemiologist at Brigham and Women’s Hospital. “But I do still find it helpful.”
2. Can The U.S. Use Its Growing Supply Of Rapid Tests To Stop The Virus?
- A new generation of faster, cheaper coronavirus tests is starting to hit the market. And some experts say these technologies could finally give the U.S. the ability to adopt a new, more effective testing strategy.
- “On the horizon — the not too distant horizon — there are a whole series of testing modalities coming on line,” says Dr. Ashish Jha, dean of the Brown School of Public Health. “And that gives us hope we can really expand our testing capacity in the nation.”
- Until now, testing has been primarily used to diagnose people who may have C19 and any of their close contacts who may also be infected. But a stubborn shortage of the molecular tests most commonly used — and slow turnaround time for results — has hobbled the nation’s ability to stop outbreaks and contain the pandemic.
- That could change, argue Jha and other public health researchers, as new rapid tests — primarily antigen tests — become more widely available, enabling communities to start widespread screening of the highest-risk people.
- “It is a paradigm shift,” Jha says. “What I think new testing capacity allows us to do is actually play offense — go and hunt for the disease before it spreads to identify asymptomatic people before they spread it to others. It really becomes about preventing outbreaks — not just capturing them after they’ve occurred.”
- Jha and a team at the Harvard Global Health Institute have periodically evaluated how much testing the country and individual states need to effectively fight the spread of the virus.
- In a new analysis the group completed for NPR, researchers developed daily testing targets, showing what would be needed to routinely screen large numbers of asymptomatic people. The researchers factored in the growing availability of the rapid coronavirus tests.
- The U.S. would need 4.4 million tests every day, the analysis concludes, to reach what Jha calls “a basic level of proactive testing.” The idea is to do regular testing of some of the highest risk groups — stopping outbreaks before they can spill over to the rest of the community.
- This scenario calls for screening all nursing home residents and staff twice a week and weekly testing of every prison inmate and guard, firefighter, police officer and emergency medical technician, as well as teachers and staff in K-12 schools, and all university students.
- Using the older molecular test technology, the U.S. has never managed to perform more than about 1 million tests per day. But the companies that make the new antigen tests are ramping up production and additional tests are in the pipeline. As a result, Jha and others estimate that there could be enough capacity to hit 4.4 million daily tests by the end of the year or early 2021.
- But Jha and his collaborators say that far more testing is needed to really enable the economy to reopen safely. The analysis concludes that ideally, the U.S. would need just over 14 million tests a day.
- That ideal scenario would allow communities to expand regular testing to most K-12 students that are in school (excluding those in communities with a high rate of infection, where schools would be closed) as well as health care workers, food service employees, cashiers and retail store clerks.
- “We’ve been holding our breath as a country for the last months — waiting for a new technology, waiting for more capacity for testing,” says Dr. Thomas Tsai, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health who collaborated with Jha in developing the screening targets.
- “This is a moment for us to capitalize on the technology and lets us reopen parts of the economy and schools with confidence,” Tsai says.
- Other public health experts agree.
- “We’re really at a critical inflection point,” says Dr. Jonathan Quick, managing director of pandemic response preparedness and prevention at the Rockefeller Foundation. “We’re on the verge of a dramatic scale-up of the rapid, point-of-care antigen tests that are vital for screening asymptomatic and presymptomatic people.”
- The foundation — which researched production capacity in the industry — projected that there could be capacity to perform more than 70 million tests a month by October, close to 200 million by January and more than 228 million a month by April. (That April figure would add up to about 7.6 million tests per day.)
- “It’ll let us open schools, keep them open and pick up outbreaks early in workplaces, and it will help keep our economy going, keep our education system going,” Quick says.
Deciding who gets screened
- The federal Department of Health and Human Services is buying at least 150 million antigen tests and recently detailed plans for how it plans to distribute them to states. At the same time, some states have started teaming up to buy large numbers on their own.
- The key, however, will be to deploy the tests strategically to ensure that the people most at risk get them, Jha and his colleagues say. This is how they become an effective tool for preventing widespread community outbreaks.
- “But what we’re seeing, of course, is this is not necessarily how these tests are being used,” Jha says, noting that professional athletes have been among the first to get access to the new antigen tests.
- “Now, I love football. I think it would be great to have Big Ten football playing,” Jha says. “But I would prioritize nursing homes and schoolteachers over Big Ten football.”
- This is why groups like Jha’s have developed tools to help state or local leaders think through the tradeoffs involved in distributing tests.
- Brown University School of Public Health and the Harvard Global Health Institute released a calculator tool Thursday that allows leaders to assess which groups they want to prioritize — and see how many daily tests they’d need to screen those groups regularly. The tool offers five scenarios: the base and ideal options shown below, as well as three intermediate options that focus on schools, health care or the economy.
Will there really be enough tests?
- Some say the federal government should be doing far more to more quickly increase the availability of antigen tests, including even simpler versions — not yet on the market — that people could use at home like home pregnancy tests.
- “They look a lot like the chlorine test you might dip in your pool or the test strips that you might test your water with in your kitchen,” says Michael Mina, an infectious disease expert at the Harvard School of Public Health.
- Mina has been urging the Food and Drug Administration to make it easier to get these tests approved, even if they’re less accurate. And Mina argues that the Trump administration should invoke the Defense Production Act to take over production of these tests.
- “If a foreign enemy was dropping bombs on the United States, they wouldn’t just wait until the private sector came up with a new fighter jet. They do things very proactively,” Mina says. “That’s how we should be dealing with this virus.”
- But even if the tests become available in sufficient quantities and are deployed through a comprehensive strategy — two big uncertainties — there are many questions and deep skepticism among some public health experts.
- “I don’t see a monumental shift,” says Jennifer Nuzzo, a senior scholar at the Johns Hopkins Bloomberg School of Public Health Center for Health Security who has been studying testing.
- Nuzzo says it remains far from clear how quickly the companies making the new tests will expand capacity.
- “The new tests are potentially useful, but they’re still not available in enough of a quantity and at a low enough cost to blanket the country and be used in ways that some have suggested,” Nuzzo says.
Concerns about accuracy and reporting
- In addition, there are troubling questions about how reliable the new antigen tests are when used to screen large numbers of people. They tend to produce more false negatives and false positives than the existing molecular tests. And the tests have never really been carefully evaluated to screen large numbers of people without symptoms.
- “We really don’t yet know how these tests perform in people without symptoms. So there are cautions about using them in those populations,” Nuzzo says. “We need to better understand how they work.”
- Supporters of widespread use of rapid tests acknowledge they may be less accurate in some ways. But the tests tend to be more effective at spotting infected people when they are most infectious, which is what’s most important, the supporters say. And the tests’ shortcomings could be outweighed by their potential to enable frequent, repeated testing, which means more positive cases can be identified overall, they say.
- But another problem is many states are failing to capture and report the results of antigen tests, in part because many places using them, such as nursing homes and universities, often don’t have efficient ways to transmit the results to public health authorities.
- “There’s a whole question swirling around that. There’s a real worry there,” Nuzzo says, because that could lead to some communities dramatically undercounting the spread of the virus.
- “I don’t think it’s helpful to oversell optimism. I don’t want to leave people with the belief that all the hard challenges are behind us. No one tool is going to lead us out of this pandemic,” Nuzzo says.
- Some public health officials say the lack of clear guidelines from the federal government about how best to use the tests has caused confusion.
- “There are no clear guidelines on how to use these rapid antigen tests,” says Dr. Jeffrey Engel, the senior adviser for the C19 response for the Council of State and Territorial Epidemiologists. “What we’re seeing is a hodgepodge of different usages across the country.”
- “It seems to be that HHS is concerned more about logistics and getting tests out the door and increasing testing numbers and less concerned about quality control and public health reporting,” Engel adds. “It has the potential to be a big mess.”
E. Improved & Potential Treatments
1. Common Low-Cost Antioxidant Enzyme Is Potential Treatment for C19
Simple diagram showing catalase kick starting reaction that converts hydrogen peroxide into water and oxygen.
- Researchers from UCLA and China have found that catalase, a naturally occurring enzyme, holds potential as a low-cost therapeutic drug to treat C19 symptoms and suppress the replication of coronavirus inside the body. A study detailing the research was published in Advanced Materials.
- Catalase is produced naturally and used by humans, animals, and plants. Inside cells, the antioxidant enzyme kick starts the breakdown of hydrogen peroxide, which can be toxic, into water and oxygen. The enzyme is also commonly used worldwide in food production and as a dietary supplement.
- “There is a lot of focus on vaccines and antiviral drugs, and rightly so,” said Yunfeng Lu, a UCLA Samueli School of Engineering professor of chemical and biomolecular engineering and a senior author on the study. “In the meantime, our research suggests this enzyme could offer a very effective therapeutic solution for treatment of hyperinflammation that occurs due to coronavirus, as well as hyperinflammation generally.”
- Lu’s group developed the drug-delivery technology used in the experiments. Three types of tests were conducted, each addressing a different symptom of C19.
Diagrams showing (left) how catalase acts on symptoms of C19, and a diagram showing what the enzyme does, converting hydrogen peroxide into water and oxygen.
- First, they demonstrated the enzyme’s anti-inflammatory effects and its ability to regulate the production of cytokines, a protein that is produced in white blood cells. Cytokines are an important part of the human immune system, but they can also signal the immune system to attack the body’s own cells if too many are made — a so-called “cytokine storm” that is reported in some patients diagnosed with C19.
- Second, the team showed that catalase can protect alveolar cells, which line the human lungs, from damage due to oxidation.
- Finally, the experiments showed that catalase can repress the replication of coronavirus in rhesus macaques, a type of monkey, without noticeable toxicity.
- “This work has far-reaching implications beyond the treatment of C19. Cytokine storm is a lethal condition that can complicate other infections, such as influenza, as well as non-infectious conditions, like autoimmune disease,” said Dr. Gregory Fishbein, an author on the study and a pathologist at the UCLA David Geffen School of Medicine.
F. Concerns & Unknowns
1. Why people with diabetes are being hit so hard by C19
- Data from the CDC show more than 75% of people who died from C19 had at least one preexisting condition. Overall, diabetes was noted as an underlying condition for approximately 40% of patients. Among people younger than 65 who died from the infection, about 50% had diabetes.
- Juliana Chan, director of the Hong Kong Institute of Diabetes and Obesity, said the pandemic has intertwined with and exposed two other widespread problems: diabetes and disparities triggered by social determinants of health.
- “What we are seeing is nothing new, but it is really just on a massive and global scale,” she said in an interview. “I hope that there is something positive out of this, that people understand that we are hit by three epidemics.”
- While urging prevention as the first and best course, doctors and scientists are testing hypotheses to understand the biology behind the collision of a new infectious disease with an old metabolic one. The exact molecular mechanisms make for an emerging story, and there is disagreement about why, as case reports from around the world suggest, some people develop type 1 diabetes after their coronavirus infection clears. But clinicians and scientists told STAT there is no question that unless people with diabetes have their glucose under control, C19 poses much more danger to them than to other people.
- In people with type 1 diabetes, the insulin-producing pancreatic islet cells have been destroyed, meaning they cannot process the glucose their bodies need for fuel and the sugar accumulates in the blood. In type 2 diabetes, people can’t make enough insulin to convert glucose into energy, or they grow insensitive to the insulin they do make.
- Over a lifetime, problems with too much or too little glucose inflict widespread damage in the kidney, heart, and liver, as well as around nerves. Stroke, heart attack, kidney failure, eye disease, and limb amputations can be the legacy of poor glucose control. The linings of blood vessels throughout the body become so fragile they can’t ferry needed nutrients as well as they should. Inflammation rises and the immune system does not perform well. Obesity, which is more common in type 2 diabetes but can also occur in type 1, makes all these conditions worse.
- “Once someone with diabetes or obesity became infected with C19, then their outcomes were generally not as good,” said Daniel Drucker, of the Lunenfeld-Tanenbaum Research Institute at Mt. Sinai Hospital in Toronto. “They were more likely to be hospitalized, more likely to be intubated, more likely to have higher rates of death.”
- People with obesity as a rule have lower cardiorespiratory fitness, meaning they can’t move as well due to poorer lung function, possibly severe sleep apnea, and blood vessel disease.
- “All of these things are important for when you become ill. You need to be able to breathe. You need to have optimal circulatory function,” Drucker said. “When we develop obesity, we have excess energy storage and the presence of that fat is inflammatory. And so once we get coronavirus infection, we are less able to mount an appropriate immune response because our immune system is already being set off in an inappropriate manner by the presence of obesity.”
- Some studies add support to the idea that it’s not just obesity, but also the downstream hypertension and other cardiovascular diseases that pose greater risk. Drucker said. “It’s those comorbidities that seem to be affecting the increased risk or poor outcomes.”
- It isn’t clear at what point those comorbidities take their toll. Does the course of disease become severe because of those comorbidities, or is there a difference in the biology of early infection, which may lead to increased viral burden in patients with both uncontrolled glucose and obesity?
- For years doctors, patients, and scientists have known from epidemiologic data that infections of any kind — viral, bacterial, or fungal — can do more harm to people with diabetes because their bodies do not process glucose as well during illness, their immune response is weaker, and their circulation is impaired.
- C19’s impact on people with diabetes fits that pattern. Janelle Ayres, a professor at the Salk institute in La Jolla, Calif., points to what diabetes and C19 have in common.
- “The organ systems that the virus targets are the same organ systems that are compromised in diabetic patients, so having both may have synergistic effects that push patients down a more severe disease trajectory,” she said. “This makes it incredibly difficult to parse out the cause and effect of what’s going on in these patients.”
- People with diabetes tend to live in a chronic inflammatory state, setting them up for a more severe inflammatory response to C19 that can culminate in a life-threatening cytokine storm. That immune overreaction is thought to harm some people more through organ damage than via the actual viral infection. But diabetes can also weaken how well the immune system fights viruses. People with type 2 diabetes also have more ACE2 receptors in many tissues, including those lining blood vessels, Ayres pointed out, opening many more doors to C19 invasion. ACE2 is one receptor that the coronavirus’s spike protein uses to gain entry into cells.
- There is only one target to control in hospitalized C19 patients with diabetes, Drucker and others said: glucose.
- “People who have really poorly controlled diabetes are more susceptible to more severe infection, whether it’s influenza or tuberculosis,” he said. “Elevated blood sugar directly impairs our immune function.”
- Age and poor glucose control are the two major drivers of poor outcomes in C19. Someone under 65, not obese, and whose glucose control is good is unlikely to have as much increased risk.
- “It’s very difficult to reverse obesity or to meaningfully lose a sufficient amount of weight during the pandemic. It’s very difficult for me to take away your coronary artery disease — same thing with hypertension,” Drucker said. “But if you have poorly controlled diabetes, I can fix that in days to weeks if I had the resources.”
- Not every person with diabetes and C19 needs to be hospitalized, but if they do require that level of care, controlling — and monitoring — glucose levels are key. There aren’t any results from controlled clinical trials yet, Joslin’s Patti pointed out, but lowering glucose safely to as normal a range as possible is the goal she and other doctors pursue. That can be challenging in the hospital, where typically glucose levels are measured in drops of blood obtained from patients’ fingertips.
- “You don’t want to ask nursing staff to go in repeatedly to be doing fingerstick glucoses for someone who’s severely ill and having to use more PPE,” Patti said. “So there’s more and more use of what’s called continuous glucose monitors, which allow frequent — every five minutes — remote monitoring of glucose levels from outside the room.”
- Vaccines promise prevention in a shot (or two), but clinical trials will have to answer questions about how well they work in people with diabetes, given differences in immune function. There is some evidence in the scientific literature that flu vaccination is not quite as effective in older people with diabetes, or in people of any age with poorly controlled diabetes.
- “Will the vaccines that are being developed [provide] equal immunity and equal protection to people with diabetes and obesity?” Drucker asked. ”When you have the added complication of a preexisting abnormal state of inflammation and immune response in people with diabetes and obesity who are not very healthy, that’s an additional unknown.”
- Tight glucose control is number one, but healthy people with diabetes must also remain vigilant about masks and social distancing. That’s been more effective in Hong Kong than in Western countries, Chan said.
- “Seventeen years ago, when Hong Kong and China were first hit by the SARS-1 virus, we already knew that people with diabetes were three times more likely to die,” she said. “That’s a painful memory for us. We have 100% compliance on masks now. … We never really had a lockdown.”
- Even with such caution, and even in countries that offer citizens universal health care, disparities driving the social determinants of health persist, she said. Income will always divide those who are homeless, live in crowded conditions, or work in jobs that place them at risk, even if C19 subsides. That makes prevention essential, especially for those who don’t have the luxury of protecting themselves.
- “Currently a lot of the care is focused on acute care, not on educating patients, protecting them, supporting them so that they never come to the hospital,” she said about C19.
- “We must not forget. We have to learn from this.”
2. People with Parkinson’s disease have a higher risk of dying from C19
- A new study of approximately 80,000 patients shows that people with Parkinson’s disease (PD) have a 30% higher risk of dying from C19 than people without the neurodegenerative condition.
- The new analysis conducted by researchers with University of Iowa Health Care based on patient data in the TriNetX C19 research network suggests that Parkinson’s disease is an independent risk factor for dying from C19.
- The UI research team led by neurologists Qiang Zhang, MD, and Nandakumar Narayanan, MD, PhD, identified the C19 patient cohort as of July 15 and analyzed the mortality data eight weeks later. They found that 5.5% (4,290 out of 78,355) of C19 patients without PD died compared to 21.3% (148 of 694) C19 patients who also had PD.
- However, the patients with PD were generally older, more likely to be male, and less likely to be African American than the patients without PD. All of these factors also increase the risk of death from C19.
- So, the UI team used two approaches to account for these differences: logistic regression with age, sex, and race as covariates, and matching each PD patient with five non-PD patients with the exact age, sex, and race, and performing a conditional logistic regression. In both cases, the researchers found that the risk of dying from C19 was 30% higher for patients with PD. The findings are published in the journal Movement Disorders.
- “We recognize the limitations of this study; it is retrospective data from a single database, but we are confident that these data show that Parkinson’s disease is independent risk factor for death in C19,” says Narayanan, UI associate professor of neurology and a member of the Iowa Neuroscience Institute. “We believe this observation will be of interest to clinicians treating patients with Parkinson’s disease, and public health officials.”
- The researchers say the findings should also inform patients with PD, and their physicians, of the increased importance of preventing C19 infection in these patients.
- “For our own patients, we can give advice that it’s important that you wear a mask. It’s important that you socially distance,” says Zhang, an associate in the UI Department of Neurology.
- Zhang adds that physicians should also weigh the increased risk of death from C19 when considering how to care for PD patients in person during the pandemic.
- A potential reason why PD patients have an increased risk of death from C19 may be related to the fact that COVID can cause pneumonia and pneumonia is a leading cause of death in patients with PD. This is partly because Parkinson’s patients can have trouble swallowing or choking that can cause aspiration.
- “We are all focused on COVID right now, but this is a clear example of a respiratory illness that leads to increased mortality [in PD patients]. These findings may also have implications for understanding risks for PD patients from other diseases, including influenza,” Narayanan says. “I would recommend a flu vaccine and pneumonia vaccine to try to prevent these problems in patients with PD.”
2. These laboratory-made antibodies are a best bet for a coronavirus treatment, but there won’t be enough
- In two-story-high stainless steel vats, a drug is brewing in trillions of hamster ovary cells. Many experts think this could be the best bet to defang the coronavirus and transform it from a potentially lethal infection into a treatable illness.
- Current treatments for the coronavirus aim to help the sickest patients survive. But this drug, called a monoclonal antibody cocktail, aims to keep people out of the hospital altogether. The experimental shot of lab-generated antibodies imitates the body’s own disease-fighting force. The goal is to boost a person’s immune defense, instead of waiting for human biology to muster its own response — and possibly lose to the virus.
- Predictions about coronavirus vaccines have become almost deafening in recent weeks, but whether or not the first doses of a vaccine arrive this year, some people will continue to get sick. A medication that could prevent people from progressing to the point that they need a hospital bed or ventilator could be a bridge to a vaccine, or it could be the lifeline that could give people confidence to return to normal life even once vaccines are developed.
- Promising but preliminary data has bolstered the chorus of hope around monoclonals from top health officials.
- They are “a real best chance of being a game changer,” according to Francis S. Collins, director of the National Institutes of Health.
- “We’re looking for big impacts on disease, not the small incremental impacts we often see in ordinary drug development,” said Janet Woodcock, who is leading therapeutics development for Operation Warp Speed, the Trump administration’s initiative to provide treatments and vaccines for C19, the disease caused by the coronavirus.
- One thing is certain about monoclonal antibodies: If the pandemic keeps raging, there won’t be enough. Unlike conventional pills, these are expensive, injectable drugs synthesized by living organisms in specialized reactors, at a biological cadence that can’t be rushed. A worldwide scramble to find capacity to make the drugs is afoot, with companies striking deals with competitors to increase their manufacturing capabilities.
- Even then, to create enough antibody medication to treat all the people diagnosed with C19 so far, the entire global capacity for making monoclonals would have to be switched over for a year, according to an analysis conducted for The Washington Post by the BioProcess Technology Group at global accounting firm BDO, which advises the pharmaceutical industry. Now, the reactors that make monoclonal antibodies are mostly occupied, making essential drugs for people with cancer and autoimmune diseases.
- “I pray to God these therapies work,” said Howard Levine, national leader of BDO’s BioProcess Technology Group. “But in the short term, there is going to be a problem, I think, in making enough to treat every single patient.”
Creating a drug recipe
- When a deadly pneumonia was identified in China in January, scientists at Regeneron Pharmaceuticals knew the drill. As with Zika, Ebola and Middle East respiratory syndrome, the new coronavirus’s close cousin, scientists started work on a therapy, using the company’s proprietary platform — what their chief executive Leonard S. Schleifer calls “magical mice.” These rodents, genetically engineered to have humanized immune systems, can muster human antibodies that serve as the template for a new drug.
- On Jan. 21, a week after the scientific work began, Christos Kyratsous, vice president of research, made an unusual call, asking his colleagues to get ready to manufacture a drug that didn’t exist yet.
- “It’s probably going to move fast,” he told Hanne Bak, senior vice president of preclinical manufacturing, who develops the initial recipes to turn science experiments into a repeatable process. “How fast can you move?”
- Bak’s colleague Daniel Van Plew, who oversees industrial operations and product supply — including a global team of 4,000 people and a massive facility filled with giant tanks connected by steel arteries of pipes — happened to be visiting Bak that day. Together, they sketched out the first timelines for scaling up production of a drug.
- Many of the steps had a natural speed limit — scientists had to expose the mice to a form of the virus, wait for their immune systems to respond and then study the antibodies. Scientists also examined antibodies from people who recovered from the virus. They needed to test which ones were most potent, and then engineer hamster ovary cells to produce those antibodies. They would have to feed and nourish those cells for a month — with scientists seeking the laboratory equivalent of Goldilocks.
- “You’re dealing with a living system. …The amount of oxygen, the food, the way [cells are] agitated [in the vat], little things can disrupt it,” Van Plew said. “For all intents and purposes, it has a memory — if you do something bad to it at the beginning of production, it might not produce as well at the end.”
- The scientists tried to move everything else forward as fast as possible, pretending there were no evenings and no weekends. Regeneron split its employees into pods in March, so that if one person got sick, it wouldn’t take out the whole team on a two-week quarantine.
- That meant upending how people usually worked. Instead of one person owning a project from beginning to end, pods on tap to come in Monday would do all the science they could and then hand off their work to the pod that came in on Tuesday, which would pick up where they left off.
- Once the cocktail — a combination of two antibodies — had been selected, Bak’s group began to brew the cells in early April. Normally, her team would meticulously develop a complete recipe for creating a batch of the drug and then hand it off to Van Plew’s team, which would bring it up to the large scale needed to supply clinical trials and, eventually, patients.
- It’s the difference between cooking dinner for two people and preparing that same meal for a giant banquet, when suddenly what worked on a small scale may go awry — the vegetables don’t heat evenly, the cake doesn’t rise or the sauce doesn’t reduce the same way.
- But the pandemic meant Van Plew’s team started just two weeks after Bak’s team, when the recipe they were following was still full of blank spaces. Bak’s team would, with two weeks lead time, have to figure out the steps and then send it to Van Plew’s team, which would translate it for an industrial scale.
- “It was almost like a relay race — you’ve got to stick that handoff of the baton and have nobody drop it,” Bak said.
- Once the cells had been growing for about a month, the scientists had to separate out the antibodies. The process takes four days, according to Taylor Houghtaling, an associate manager who dons protective gear for the clean room conditions and uses specialized techniques to purify the drug during 12-hour shifts.
- Houghtaling recalled that the day the first harvest of antibodies finished, she arrived in the morning and stayed until after midnight. She had done the same thing many times for other drugs during her six years working at Regeneron, but no moment proved more exhilarating. Many members of teams that worked on the drug remained on the floor that night to see the first harvest go into a special bag of medicine that could be given to patients.
- “At that last stage, we don’t necessarily know how well this treatment is going to work yet, but we could be making history right in this moment,” Houghtaling said. “The excitement in the room — we were wearing face masks so you can’t see anyone’s mouth. But everyone was beaming.”
Scaling it up
- To turn that moment of triumph into a viable treatment, ongoing clinical trials will have to show that monoclonal antibodies are safe and effective, and determine the best dose. The drugs are being tested on three fronts: to see whether they can prevent disease in people who have been exposed to the virus, help people early in the illness get better sooner or treat patients who are hospitalized.
- A dose for treatment will require much more drug than a prevention dose, so the capacity to treat people will depend largely on what the trials show. Many experts are hopeful the drugs could prevent disease, providing crucial protection to elderly people whose immune systems may not respond robustly to vaccines.
- Data is beginning to trickle out. Regeneron announced Tuesday that its drug appeared to knock back the virus, reducing levels and relieving symptoms when given to people recently diagnosed with C19 who weren’t in the hospital — particularly in people whose bodies had not mounted a robust immune response.
- Eli Lilly announced in September “proof of concept” interim data that its monoclonal antibody shows signs of reducing hospitalizations when given to people in outpatient settings. The data are preliminary and not yet peer-reviewed, and both trials are ongoing.
- To prepare for making the drug at scale, Regeneron transferred its other products to its facility in Ireland. It recently struck a deal with a competitor, Roche, to rapidly increase production.
- “This is quite unusual, because we’re giving a competitor a lot of our know-how, our technology,” said Schleifer, the Regeneron CEO. “They’re going to get to drive our cars, so to speak.”
- With the partnership, the companies can manufacture between 650,000 and 2 million treatment doses in a year, or 4 million to 8 million prevention doses. The United States has placed an order for $450 million worth of medicine — enough for 70,000 to 300,000 treatments, depending on how much of the drug is in each dose. But with the Centers for Disease Control and Prevention forecasting 1,500 to 5,000 hospitalized patients a day by late October, that supply could be rapidly consumed.
- That has put companies in the unusual position of hoping competitors succeed and thinking about how to make an effective drug and to increase the yield. Eli Lilly is initially testing a single monoclonal antibody, which could allow the company to make twice as much drug as a cocktail approach.
- “In terms of efficiency of manufacturing, of generating as much as possible to help as many as possible, it’s simpler and easier if you have one antibody,” said Andrew Adams, vice president of new therapeutic modalities at Lilly, which plans to make at least 1 million doses by the end of the year.
- Scientists at the California company Vir Biotechnology are developing an antibody designed to be effective at very low doses, with the hope they could manufacture 10 million doses in a year.
- “Vaccines can be mass-produced for billions of people. Antibodies will be for millions of people,” said Phil Pang, chief medical officer for Vir.
- Many experts think that although demand will outstrip supply, there won’t be a single silver bullet to end the pandemic but a convergence of cutting-edge technologies and old-fashioned public health measures. Monoclonal antibodies — potentially from many companies — will start to make the disease less dangerous. First-generation vaccines will start to tamp down the spread of the virus.
- “We can’t treat the whole country,” Schleifer said. “But I do think if something was out there, that if you know that if your wife got sick or your husband got sick, you’d get a shot that would prevent you from getting it — or if you did get sick [you could be treated], that would change a lot of people’s attitudes.”
1. Alexa, do I have C19?
- Vocalis, a voice-analysis company with offices in Israel and the United States, had previously built a smartphone app that could detect flare-ups of chronic obstructive pulmonary disease by listening for signs that users were short of breath when speaking.
- The firm wanted to do the same thing with C19. People who had tested positive for the coronavirus could participate simply by downloading a Vocalis research app. Once a day, they fired up the app and spoke into their phones, describing an image aloud and counting from 50 to 70.
- Then Vocalis began processing these recordings with its machine-learning system, alongside the voices of people who had tested negative for the disease, in an attempt to identify a voiceprint for the illness. By mid-summer, the firm had more than 1,500 voice samples and a pilot version of a digital C19 screening tool. The tool, which the company is currently testing around the world, is not intended to provide a definitive diagnosis, but to help clinicians triage potential cases, identifying people who might be most in need of testing, quarantine or in-person medical care. “Can we help with our AI algorithm?” asks Tal Wenderow, the president and chief executive of Vocalis. “This is not invasive, it’s not a drug, we’re not changing anything. All you need to do is speak.”
- They’re not the only ones racing to find vocal biomarkers of C19 — at least three other research groups are working on similar projects. Other teams are analysing audio recordings of C19 coughs and developing voice-analysis algorithms designed to detect when someone is wearing a face mask.
- It’s a sign of how hungry the young field of vocal diagnostics is to make its mark. Over the past decade, scientists have used artificial intelligence (AI) and machine-learning systems to identify potential vocal biomarkers of a wide variety of conditions, including dementia, depression, autism spectrum disorder and even heart disease. The technologies they have developed are capable of picking out subtle differences in how people with certain conditions speak, and companies around the world are beginning to commercialize them.
- For now, most teams are taking a slow, stepwise approach, designing tailored tools for use in doctors’ offices or clinical trials. But many dream of deploying this technology more widely, harnessing microphones that are ubiquitous in consumer products to identify diseases and disorders. These systems could one day allow epidemiologists to use smartphones to track the spread of disease, and turn smart speakers into in-home medical devices. “In the future, your robot, your Siri, your Alexa will simply say, ‘Oh you’ve got a cold,’” says Björn Schuller, a specialist in speech and emotion recognition with a joint position at the University of Augsburg in Germany and Imperial College London, who is leading one of the C19 studies.
- But automated vocal analysis is still a new field, and has a number of potential pitfalls, from erroneous diagnoses to the invasion of personal and medical privacy. Many studies remain small and preliminary, and moving from proof-of-concept to product won’t be easy. “We are at the early hour of this,” Schuller says.
- Some ailments cause obvious vocal distortions; consider the telltale stuffiness of someone afflicted by allergies. But many scientists think that vocal analysis could help to identify an enormous range of disorders, thanks to the complexity of human speech.
- Speaking requires the coordination of numerous anatomical structures and systems. The lungs send air through the vocal cords, which produce sounds that are shaped by the tongue, lips and nasal cavities, among other structures. The brain, along with other parts of the nervous system, helps to regulate all these processes and determine the words someone is saying. A disease that affects any one of these systems might leave diagnostic clues in a person’s speech.
- Machine learning has given scientists a way to detect aberrations, quickly and at scale. Researchers can now feed hundreds or thousands of voice samples into a computer to search for features that distinguish people with various medical conditions from those without them.
- Much of the early work in the field focused on Parkinson’s disease, which has well-known effects on speech — and for which there is no definitive diagnostic test. The disorder causes a variety of motor symptoms, including tremors, muscle stiffness and problems with balance and coordination. The loss of control extends to the muscles involved in speech; as a result, many people with Parkinson’s have weak, soft voices. “It’s one of those things that you can hear with the human ear,” says Reza Hosseini Ghomi, a neuropsychiatrist at EvergreenHealth in Kirkland, Washington, who has identified vocal features associated with several neurodegenerative diseases. “But if you can get 10,000 samples and a computer, you can get much more accurate.”
- More than a decade ago, Max Little, a researcher in machine learning and signal processing now at the University of Birmingham, UK, began to investigate whether voice analysis might help doctors to make difficult diagnoses. In one study, Little and his colleagues used audio recordings of 43 adults, 33 of whom had Parkinson’s disease, saying the syllable “ahhh”. They used speech-processing algorithms to analyse 132 acoustic features of each recording, ultimately identifying 10 — including characteristics such as breathiness and tremulous oscillations in pitch and timbre — that seemed to be most predictive of Parkinson’s. Using just these 10 features, the system could identify the speech samples that came from people with the disease with nearly 99% accuracy1.
- Little and others in the field have also demonstrated that certain vocal features correlate with the severity of Parkinson’s symptoms. The systems are not yet robust enough for routine use in clinical practice, Little says, but there are many potential applications. Vocal analysis might provide a quick, low-cost way to monitor individuals who are at high risk of the disease; to screen large populations; or possibly even to create a telephone service that could remotely diagnose people who don’t have access to a neurologist. Patients could use the technology at home — in the form of a smartphone app, say — to track their own symptoms and monitor their response to medication. “This kind of technology can allow a high-speed snapshot, an almost continuous snapshot of how someone’s symptoms are changing,” Little says.
- Researchers are now working to identify speech-based biomarkers for other kinds of neurodegenerative disease. For instance, a trio of scientists in Toronto, Canada, used voice samples and transcripts from more than 250 people to identify dozens of differences between the speech of people with possible or probable Alzheimer’s disease and that of people without it2. Among the participants, those with Alzheimer’s tended to use shorter words, smaller vocabularies and more sentence fragments. They also repeated themselves and used a higher ratio of pronouns, such as ‘it’ or ‘this’, to proper nouns. “It can be a sign that they’re just not remembering the names of things so they have to use pronouns instead,” says Frank Rudzicz, a computer scientist at the University of Toronto, who led the study.
- When the system considered 35 of these vocal features together, it was able to identify people with Alzheimer’s with 82% accuracy. (This has since improved to roughly 92%, Rudzicz says, noting that the errors tend to be more or less evenly split between false negatives and false positives.) “Those features add up to sort of a fingerprint of dementia,” Rudzicz says. “It’s a very intricate hidden pattern that’s hard for us to see on the surface, but machine learning can pick it out, given enough data.”
- Because some of these vocal changes occur in the early stages of neurodegenerative diseases, researchers hope that voice-analysis tools could eventually help clinicians to diagnose such conditions earlier and potentially intervene before other symptoms become obvious.
- For now, however, this idea remains largely theoretical; scientists still need to do large, long-term, longitudinal trials to demonstrate that voice analysis can actually detect disease earlier than standard diagnostic methods can.
- And some clinicians note that voice analysis alone will rarely yield definitive diagnoses. “I learn a lot by listening to someone’s voice,” says Norman Hogikyan, a laryngologist at the University of Michigan in Ann Arbor. “I do it for a living. But I put it together with a history and then my exam. All three parts of that assessment are important.”
- Researchers in the field stress that the goal is not to replace doctors or create standalone diagnostic devices. Instead, they see voice analysis as a tool physicians can use to inform their decisions, as another ‘vital sign’ they can monitor or test they can order. “My vision is that collecting speech samples will become as common as a blood test,” says Isabel Trancoso, a researcher in spoken-language processing at the University of Lisbon.
- A number of voice-analysis start-ups — including Winterlight Labs, a Toronto firm co-founded by Rudzicz, and Aural Analytics in Scottsdale, Arizona — are now providing their software to pharmaceutical companies. Many are using the technology to help assess whether people enrolled in their clinical trials are responding to experimental treatments. “Using speech as a more subtle proxy for changes in neurological health, you can help push drugs across the finish line or at the very least identify those that are not promising early on,” says Visar Berisha, the co-founder and chief analytics officer at Aural Analytics.
- Neurodegenerative disorders are just the beginning. Scientists have identified distinct speech patterns in children with neurodevelopmental disorders. In one small 2017 study, Schuller and his colleagues determined that algorithms that analysed the babbling of ten-month-old infants could identify with some accuracy which children would go on to be diagnosed with autism spectrum disorder3. The system correctly classified roughly 80% of children with autism and 70% of neurotypical children.
- Researchers have also found that many children with attention deficit hyperactivity disorder speak louder and faster than their neurotypical peers, and show more signs of vocal strain. The firm PeakProfiling in Berlin is now developing a clinical speech-analysis tool that it hopes can help doctors to diagnose the condition.
- But some clinicians are sceptical about how much useful information such systems will really provide. “Some of it is a little overblown,” says Rhea Paul, a specialist in communication disorders at Sacred Heart University in Fairfield, Connecticut. Children with neurodevelopmental disorders often have many easily observable behavioural symptoms, she notes.
- Moreover, it’s not yet clear whether the algorithms are really identifying specific markers for, say, autism spectrum disorder, or just picking up on general signs of atypical brain development — or even just transient aberrations in speech. “Development is a meandering path and not every kid who starts out looking like they have autism grows up to be an adult with autism,” Paul says. Even if scientists do identify a highly reliable, specific vocal biomarker, she adds, it should only be used to identify children who might benefit from a more thorough evaluation. “It shouldn’t be sufficient in and of itself to label a child, especially so early in life.”
- Scientists are also turning the technology to mental illnesses. Numerous teams around the world have developed systems that can pick up on the slow, pause-heavy, monotonous speech that tends to characterize depression, and others have identified vocal biomarkers associated with psychosis, suicidality and bipolar disorder.
- “Voice is enormously rich in terms of carrying our emotion signals,” says Charles Marmar, a psychiatrist at New York University. “The rate, the rhythm, the volume, the pitch, the prosody [stress and intonation] — those features, they tell you whether a patient is down and discouraged, whether they’re agitated and anxious, or whether they’re dysphoric and manic.”
- In his own work, Marmar has used machine learning to identify 18 vocal features associated with post-traumatic stress disorder (PTSD) in 129 male military veterans. By analysing these features — which were mainly indicators of slow, flat, monotonous speech — the system could identify, with nearly 90% accuracy, which of the veterans had PTSD.
- Marmar and his colleagues are now expanding their research to women and civilians; if the team can generalize the findings, Marmar thinks that the technology could be a useful way to quickly identify people who might need a more thorough psychiatric assessment. “The first real-world application would be for high-throughput screening of PTSD,” he says. “You can do 4,000 voice screens in a matter of hours.”
- Similar consumer applications are already beginning to make their way into the world. The US Department of Veterans Affairs is studying whether an app that monitors mental health can identify service members experiencing psychological distress. The smartphone app, developed by Cogito, a conversational guidance and analytics company in Boston, Massachusetts, collects metadata on users’ habits — such as how frequently they call or text other people — and analyses voice memos they leave on their phones.
- There might even be vocal biomarkers for conditions that seem to have nothing to do with speech. In one study from 2018, scientists analysing speech samples from 101 people who were scheduled to undergo coronary angiograms discovered that certain vocal frequency patterns were associated with more severe coronary artery disease.
- It’s not clear what explains these differences. “We struggle with the mechanism because it’s not obvious,” says Amir Lerman, a cardiologist at the Mayo Clinic in Rochester, Minnesota, who led the research. Coronary artery disease could theoretically change the voice by reducing blood flow, he says. But it’s also possible that it’s not the disease itself that causes the vocal changes, but other associated risk factors, such as stress or depression.
- That study demonstrates both the promise and the limitations of this technology. It’s one thing for a computer to pick out vocal patterns, but it’s another, harder task to understand what they mean and whether they’re clinically meaningful. Are they fundamental characteristics of the disease in question? Or merely markers of some other difference between groups, such as age, sex, body size, education or fatigue, any of which could be a confounding factor? “We’re trying to move away from just shoving data into an algorithm, and really diving into the data sets, coming up with a model of the disease first and then testing that with machine learning,” Ghomi says.
- Most studies so far have identified potential biomarkers in just a small, single population of patients. “Reproducibility is still a question,” Lerman says. “Is my voice today and tomorrow and the day after tomorrow the same?” To ensure that the results can be generalized — and to reduce the possibility of bias, a problem known to plague medical algorithms — researchers will need to test their classification systems in larger, more diverse samples and in a variety of languages. “We don’t want to validate a speech model just with 300 patients,” says Jim Schwoebel, vice-president of data and research at Sonde Health, a Boston-based voice-analysis company. “We think we need 10,000 or more.”
- The company runs SurveyLex, an online platform that allows researchers to easily create and distribute voice surveys, as well as the Voiceome project, an effort to collect voice samples and health information from up to 100,000 people, across a wide variety of speech tasks, locations and accents. “You might be depressed in New York, and sound differently depressed in Houston, Texas,” Schwoebel says.
- For many of the applications that researchers have in mind, voice-analysis systems will have to not only distinguish sick people from healthy controls, but also differentiate between a variety of illnesses and conditions. And they’ll need to do this outside the lab, in uncontrolled everyday situations and on a wide variety of consumer devices. “You’ve got smartphones which have a limited range of sensors, and people are using them everywhere in very uncontrolled environments,” says Julien Epps, a researcher who studies speech-signal processing at the University of New South Wales in Sydney, Australia.
- When Epps and his colleagues, including a researcher at Sonde Health, analysed voice samples recorded with high-quality microphones in a lab, they were able to detect depression with roughly 94% accuracy (see ‘Depressed tones’). When using speech samples that people recorded in their own environments on their smartphones, the accuracy dropped to less than 75%, the researchers reported in a 2019 paper.
- And just because the technology is non-invasive doesn’t mean that it is without risks. It poses serious privacy concerns, including the possibility that individuals could be identified from anonymous speech samples, that the systems might inadvertently capture private conversations, and that sensitive medical information could be sold, shared, hacked or misused.
- If the technology isn’t regulated properly, there’s a danger that insurers or employers could use these systems to analyse speech samples without explicit consent or to obtain personal health information, and potentially discriminate against their customers or employees.
- And then there’s the perennial risk of false positives and overdiagnosis. “We have to be real and realize that a lot of this is still research,” Rudzicz says. “And we need to start thinking about what’s going to happen when we put it into practice.”
Source: Alexa, do I have COVID-19?
H. The Road Back?
1. A QR code could decide whether you go back to work
- Abbott, the company that will supply the US government with 150 million rapid coronavirus tests over the next few months, wants to create a system that will allow schools, businesses, airlines, and event venues to reopen—but only for people who have tested negative for C19.
- In August, Abbott rolled out an app called Navica alongside its card-based diagnostic test, which returns results in 15 minutes without relying on specialized lab equipment. The app records users’ test results and generates a QR code, which Abbott hopes to market as a “digital health pass,” according to a company spokesperson. Abbott envisions that businesses will scan customers’ QR codes at the door before letting them in.
- “We believe workplaces, schools, and other organizations could use the app along with the test to help ensure safer access to facilities and make the return to daily life activities smoother and more confident,” a company spokesperson said in an emailed statement.
- If it catches on, Navica would be the first widespread coronavirus pass in the US. But much like so-called immunity passports, which would allow those with coronavirus antibodies to traipse freely while the rest of the world hunkers down, Abbott’s app faces two big obstacles: low testing volumes and unequal access.
- “If we were able to do repeat testing for everyone that needed it regardless of their ability to pay, and then use the app, that would actually be a really good idea,” said Brooke Nichols, an assistant professor of global health at Boston University. “But with 150 million rapid tests, probably not. There are more than 150 million people in this country.”
- White House officials said that Abbott will deliver 6.5 million tests this week, and the company said it will ramp its production up to 50 million tests per month by the beginning of October. Because Abbott’s tests are cheaper and simpler than standard PCR tests, US president Donald Trump has encouraged states to use them to monitor students and teachers and reopen schools. Still, at Abbott’s ramped-up rate it would take a month and a half to test all K-12 students and teachers once—and an app like Navica would rely on routine testing to be effective.
- “A test is just a snapshot,” said Gigi Gronvall, an immunologist and associate professor of public health at John Hopkins University. “An airline might want you to show proof that you’ve tested negative a couple of days before flying, but you could get infected the next day.”
- Abbott says negative test results stay valid in Navica for seven days. If the country wanted all workers and consumers to get results on a weekly basis, it would have to produce over a billion tests per month. Given the current testing scarcity—and the fact that 19% of Americans don’t own smartphones—Nichols said business and government leaders would need to be careful about how to implement a system of health passes.
- “We see massive inequalities in our society that are just getting worse by the day,” she said. “This is one thing that will contribute to that, unless we make [testing] widely available.”
2.` New York City Subway Is Low Risk for Coronavirus Transmission
- A study of transit systems world-wide suggests New York City subway and bus riders are at low risk of being infected with the new coronavirus during their commutes.
- The report, released Tuesday by a national association of transit agencies, found no correlation between the spread of coronavirus and mass-transit systems. As long as trains and buses are well-ventilated and riders wear masks, public transit is safe, the authors of the report found.
- They also found that infection rates are more closely related to prevalence of the virus in a community than the size and density of its transit system.
- Several academic papers published during the pandemic suggested that transit systems, such as New York City’s often packed subway, contributed to the virus’s spread.
- Sam Schwartz, whose transit-consulting firm published Tuesday’s report for the American Public Transportation Association, said he and his team found that modes of transportation that keep people in the same space over a long period, such as a tour bus or an airplane, could spread the virus. But in spaces where people spend a short period and tend not to talk, risks are low.
- The authors, mainly transit and transportation planners, said they had found no correlation between public-transit use and the virus’s spread anywhere in the world and suggested that employees were more likely to catch the virus at work than in transit.
- “Everything has a risk to it,” Mr. Schwartz said in an interview. “But your risks are probably greater at your place of employment or if you are going out to a restaurant.”
- New York’s Metropolitan Transportation Authority, which runs two commuter railroads as well as the city’s subway and bus systems, is going to great lengths to reassure riders that transit is safe.
- Abbey Collins, a spokeswoman for the state-controlled MTA, said in a statement: “This report adds to the growing body of evidence that mass transit is safe with the proper public health safeguards in place.”
- The authority is spending hundreds of millions of dollars cleaning and disinfecting trains, buses and frequently touched surfaces in stations. It recently imposed a $50 fine on riders who refuse to wear a face covering.
- Jeffrey Harris, who published a paper in April arguing that the subway spread the virus, said those actions hadn’t been taken during the early days of the pandemic, which hit New York City in March.
- Dr. Harris, a physician and an emeritus professor at MIT’s Department of Economics, said in an email that analyses of Covid-19 cases and location data from smartphones were sufficient to show that the subway spread the virus.
- “There is strong evidence that New York City’s unique, massive subway system served as a vehicle to propagate the virus rapidly throughout the city’s five boroughs within days of arriving from abroad,” Mr. Harris said.
- Steve N. Chillrud, a research scientist at Columbia University, said that without good contact tracing, in which health officials track the movement of a virus among people, it wasn’t possible to say definitively where people caught the virus.
- Before the pandemic, the subway carried 5.5 million people on an average weekday. Fear of the virus is hindering the MTA’s efforts to attract people back to trains and buses. Internal surveys taken at firms across the city this summer revealed that mass transit was among the top concerns deterring workers from returning to the office.
- While mass transit ridership remains between 50% and 80% below pre-pandemic levels, traffic at the region’s major bridges and tunnels is almost back to where it was before the region shut down in the spring, suggesting that some people might have switched from mass transit to cars.
- Mr. Schwartz’s team reviewed studies on Covid-19 and mass transit around the world, conducted its own data analysis and interviewed public health specialists.
- They noted that although transit usage has remained relatively strong in East Asian cities, such as Hong Kong, Seoul and Tokyo, virus transmission there hasn’t been linked to ridership, in part because of mask compliance.
- “I think the risk is very low and the MTA is doing everything they can,” said William N. Rom, a research scientist at New York University’s School of Global Public Health, who was interviewed for the report.
- Dr. Rom specializes in tuberculosis, which is also transmitted through the air. Dr. Rom said that he had felt comfortable taking trips lasting 15 minutes or less on the subway, bus and Metro-North Railroad during the pandemic while ridership has been low.
- He said that a longer trip in a more crowded car or bus might make him more cautious, but that as long as he wore a properly fitted N-95 mask he felt safe.
3. Vilified Early Over Lax Virus Strategy, Sweden Seems to Have Scourge Controlled
- The scene at Norrsken House Stockholm, a co-working space, oozed with radical normalcy: Young, turtleneck-wearing hipsters schmoozed in the coffee corner. Others chatted freely away, at times quite near each other, in cozy conference rooms. Face masks were nowhere to be seen.
- It seemed very last January, before the spread of C19 in Europe, but it was actually last week, as many European nations were tightening restrictions amid a surge of new coronavirus cases. In Sweden, new infections, if tipping upward slightly, still remained surprisingly low.
- “I have potentially hundreds of tiny interactions when working here,” said Thom Feeney, a Briton who manages the co-working space. “Our work lives should not be reduced to just the screen in front of us,” he said. “Ultimately, we are social animals.”
- Normalcy has never been more contentious than in Sweden. Almost alone in the Western world, the Swedes refused to impose a coronavirus lockdown last spring, as the country’s leading health officials argued that limited restrictions were sufficient and would better protect against economic collapse.
- It was an approach that transformed Sweden into an unlikely ideological lightning rod. Many scientists blamed it for a spike in deaths, even as many libertarians critical of lockdowns portrayed Sweden as a model. During a recent Senate hearing in Washington, Dr. Anthony S. Fauci, the leading U.S. infectious disease specialist, and Senator Rand Paul, Republican of Kentucky, angrily clashed over Sweden.
- For their part, the Swedes admit to making some mistakes, particularly in nursing homes, where the death toll was staggering. Indeed, comparative analyses show that Sweden’s death rate at the height of the pandemic in the spring far surpassed the rates in neighboring countries and was more protracted. (Others point out that Sweden’s overall death rate is comparable to that of the United States.)
- Now, though, the question is whether the country’s current low caseload, compared with sharp increases elsewhere, shows that it has found a sustainable balance, something that all Western countries are seeking eight months into the pandemic — or whether the recent numbers are just a temporary aberration.
- “It looks positive,” said Anders Tegnell, Sweden’s state epidemiologist, who gained global fame and notoriety for having kept Sweden out of lockdown in March.
- With a population of 10.1 million, Sweden averaged just over 200 new cases a day for several weeks, though in recent days that number has jumped to about 380. The per capita rate is far lower than nearby Denmark or the Netherlands (if higher than the negligible rates in Norway and Finland). Sweden is also doing far better, for the moment, than Spain, with 10,000 cases a day, and France, with 12,000.
- Critics say Sweden does not test for the virus as thoroughly as many other nations — with 142,000 tests for the week ending Sept. 13. Britain, with about six times the population, tested only 587,000 people in the most recent week, far less per capita than Sweden. And Britain conducted far more tests than France, Germany or Spain in that period.
- In early September, 1.2 percent of tests in Sweden were positive, compared with about 7 percent currently in Northwest England, Britain’s hardest-hit area.
- “Our work lives should not be reduced to just the screen in front of us,” said Thom Feeney, center, manager of the Norrsken co-working space, where masks are nowhere to be seen. (picture above)
- In response to the recent outbreaks, many European countries are imposing new restrictions. But political leaders, anxious to avoid unpopular and economically disastrous lockdowns, are relying mostly on social-distancing measures, while trying to preserve a degree of normalcy, with schools, shops, restaurants and even bars open.
- In essence, some experts say, they are quietly adopting the Swedish approach.
- “Today, all of the European countries are more or less following the Swedish model, combined with the testing, tracing and quarantine procedures the Germans have introduced, but none will admit it,” said Antoine Flahault, director of the Institute of Global Health, in Geneva. “Instead, they made a caricature out of the Swedish strategy. Almost everyone has called it inhumane and a failure.”
- Back in the spring, when other nations were clamping down, Sweden was often vilified for having gone its own way. Its borders stayed open, as did bars, restaurants and schools. Hairdressers, yoga studios, gyms and even some cinemas remained open, as did public transportation and parks.
- Gatherings of more than 50 people were banned, museums closed and sporting events canceled. But that was the extent of the measures, with officials saying they would trust in the good sense of Swedes to keep their distance and wash their hands.
- Mr. Flahault lauded Sweden’s government for that part of its approach. “The Swedes went into self-lockdown,” he said. “They trusted in their people to self-apply social distancing measures without punishing them.”
A high school in Stockholm in September, with no distancing and no masks. Back in the spring, Sweden was vilified for keeping bars, restaurants and schools open. (picture above)
- But Mr. Flahault also warned about what he called a major flaw in the Swedish approach. “They continue not to wear masks,” he said. “That can be a big drawback in the Swedish strategy if masks prove effective and key in fighting the pandemic.”
- Sweden might also just be enjoying a lull between peaks of infection. The public face of the country’s coronavirus policies, Mr. Tegnell, agrees, saying the numbers can always go up, as they just have. That said, however, “Sweden has gone from being one of the countries in Europe with the most spread to one that has some of the fewest cases in Europe,” he said in a recent interview.
- Mr. Tegnell said that Sweden would in certain cases prescribe face masks, particularly to contain local outbreaks. And in a break from the past, he told the Dagens Nyheter newspaper that he would now even consider limited, local restrictions on movement and school closures.
- But he still insists that distancing provided overall better protection than masks, which he says could give people a false sense of security.
- Mr. Tegnell stressed, as he has many times before, that Sweden did not set out to achieve “herd immunity,” calling it a “myth that has been created.”
- “We are happy that the number of cases is going down rapidly and we do believe immunity in the population has something to do with that,” he said in the interview, conducted just before the case numbers rose slightly. “And we hope that the immunity in the population will help us get thought this fall with cases at a low level.”
- The streets and restaurants of Stockholm have been full of people. (picture above)
- When the pandemic struck in the spring, the Norrsken House Stockholm, in a former tram depot, looked abandoned, as many of its 450 members stayed home. But by mid-August the place seemed normal. People mixed without visible worries or fears. Some minimal precautions were taken: Workstations designed for six were restricted to four; hand sanitizer stations were everywhere; and most people were social distancing.
- “These limitations are going to be in place for a little while, I think, but it doesn’t feel like a big restriction on your day-to-day life,” said Mr. Feeney, the manager. “There’s a yearning for wanting to get back to normal. Finally people feel, ‘OK, we can do this again now. We’ve got through this.’”
- The changes are just as noticeable in Sweden’s hospitals. At the Sodersjukhuset hospital in Stockholm in the spring, ambulances were constantly unloading C19 patients. “In April it seemed as if almost everybody had Covid,” said Karin Hildebrand, a cardiologist in the intensive care unit. “Even those brought in for heart failure were positive as well.”
- Now, Dr. Hildebrand was enjoying a cappuccino before her shift, casually greeting colleagues who seemed just as relaxed. “We don’t see any Covid positive patients anymore,” she said. “How many are there now on our ward?” she called out to her colleague. “One,” he replied. Dr. Hildebrand smiled.
- “In April it seemed as if almost everybody had Covid,” said Karin Hildebrand. She has seen few patients with the coronavirus recently. (picture above)
- She was disturbed during the first wave by how many of her friends were lax about social distancing and other precautions. In April, she went on national television, to warn Swedes that the situation was grave.
- Now, however, Dr. Hildebrand says Sweden is well prepared for a potential resurgence. “We changed behavior. I don’t see anybody shaking hands, for example,” she said. Recently, she vacationed in the north of Sweden, rock climbing and hiking. “Life is back to normal. But of course there can be a second wave.”
- Some experts believe Sweden is now almost fully in control of the virus.
- “There are indications that the Swedes have gained an element of immunity to the disease, which, together with everything else they are doing to prevent the infection from spreading, is enough to keep the disease down,” Kim Sneppen, professor of biocomplexity at the Niels Bohr Institute in Copenhagen, said in an interview.
- He stressed that the country could have avoided the high death toll in the beginning, but said that Sweden had regained control from mid-April, when deaths declined steadily.
- While the Swedes are far from having achieved herd immunity, he said, “we can conclude that their social distancing rules have proven essential.”
H. Back to School!?
1. To Prevent C19 Spread, Colleges Should Beef Up Precautions
- Federal and state health authorities warned about the threat posed when younger people are infected with the new coronavirus, and recommended universities and colleges strengthen measures to limit transmission.
- Colleges across the country have struggled with Covid-19 outbreaks, including campuses in Georgia, Texas and Iowa. The University of North Carolina at Chapel Hill, which faced a number of outbreaks last month, is among the schools that decided to send students home, alarming health officials who say they could spread the infection to those in their communities.
- Young people tend to be at lower risk of having a severe case of Covid-19, but they can infect older people they come into contact with in their families and communities who are more vulnerable to severe disease due to age or health-related conditions, public-health officials from the U.S. Centers for Disease Control and Prevention wrote in two separate studies published Tuesday in the CDC’s Morbidity and Mortality Weekly Report.
- Young adults are also less likely than other age groups to adhere to Covid-19 prevention measures, CDC officials said in one study, posing a challenge to school administrators and public-health officials.
- Given the risks, CDC officials recommended stronger, more comprehensive safety strategies, including using social media to communicate to younger people the importance of mask wearing, social distancing and hand washing.
- In the second study, CDC and North Carolina health officials, along with University of North Carolina researchers, also called for greater enforcement of mask requirements and increased testing, and suggested reducing the density of on-campus housing.
- “This does not mean that colleges and universities can’t open for in-person instruction,” said Ashish Jha, dean of Brown University’s School of Public Health, who wasn’t involved in either study. Rather, he said, schools need to implement measures that research suggests could keep transmission at bay.
- Brown University is testing its students twice a week, which he said is the kind of surveillance required to identify those who are infected but aren’t showing symptoms before they can spread the virus widely.
- Some supporters of school and university reopenings point to the low risk of young people who are infected developing severe cases. In the new studies, the health officials and researchers raised the broader risks to contacts and community members that college students pose.
- Seventy-one percent of young adults ages 18 to 22 years reside with a parent, one of the studies said. Around 50% attend colleges and universities, and among those, 33% live with a parent.
- Weekly cases among people ages 18 to 22 years rose 55% across the U.S. between Aug. 2 and Sept. 5, according to the study.
- “It is likely that some of this increase is linked to resumption of in-person attendance at some colleges and universities,” the authors wrote.
- The authors, who work for the CDC, said more testing can’t account for the increasing case numbers. The percentage of cases among college-aged students more than doubled in August, while testing rose by 1½ -fold, the authors said.
- In the second study, researchers from the CDC, North Carolina’s health department and the University of North Carolina looked at a university in North Carolina that recorded 670 laboratory-confirmed cases of Covid-19 within three weeks of the campus opening. Also, 18 clusters of five or more cases popped up within 14 days of each other.
- The authors didn’t name the university but its details match those of the University of North Carolina at Chapel Hill, where six of the authors work.
- The rapid increase in cases “underscores the urgent need to implement comprehensive mitigation strategies,” the authors wrote. That means, they added, enforcing masking requirements, reducing the density of on-campus housing, discouraging student gatherings and increasing testing.
I. Projections & Our (Possible) Future
1. Alarming Data Show a Third Wave of C19 Is About to Hit the US
- There are few things as powerful as avoidance learning. Touch a hot stove once and you’re not likely to do it again. Cross against the light and almost get hit by a car and you’re going to be a lot more careful the next time. But when it comes to the U.S. response to C19? Not so much.
- You’d have thought that the sight of overflow hospital tents and refrigerated trucks to hold victims’ bodies in New York would have been enough to scare us all straight in mid-March and early April, when infection rates peaked at 32,000 new cases a day, or nearly 10 cases per 100,000 residents—making social distancing, mask-wearing and hand-washing all universal practices. But shortly after that peak, the warm weather arrived and several states cautiously reopened some public spaces for Memorial Day.
- That, as we wrote at the time, quickly led to distressing signs of upticks in several states, pushing the national rate marginally north again. By the end of June, the rolling average of new cases per day had far exceeded the April peak, prompting some states to pull back their reopening plans. But the damage had been done. By mid-July, a second wave peaked at over twice the value of the first, exceeding 67,000 cases per day—more than 20 cases per capita. There was good news buried in that bad news, however: after the peak was reached, the decline was at least quicker and more precipitous than it was the first time.
- But now for the worse news: Heading into the fall and winter, there are clear signs of a third resurgence bearing a close resemblance to what we saw in early June. Since the most recent nadir on Sept. 9, when the national rate was at 34,300 cases a day—still a notch above the April peak—cases have risen to 45,300 a day, a 32% increase. The numbers paint an alarmingly familiar picture that spells trouble ahead—despite President Donald Trump’s repeated but false assertions that the country is “rounding the final turn” on the pandemic.
- “The latest information is that 90% of the country has not yet been exposed to the virus,” says Dr. Tom Inglesby, director of the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health. “The virus hasn’t changed and has the capacity to spread rapidly if given a chance.”
- It’s now getting that chance. The politicization of mask-wearing; conflicting guidelines from the White House, the Centers for Disease Control and Prevention and the Food and Drug Administration; and state and local policies that contribute to viral transmission are helping to do the disease’s work for it.
- “A single and coordinated strategy might have brought us to a different place,” says Dr. Jon Samet, dean of the Colorado School of Public Health. “Even within some states, counties may proceed independently. There is wide variation in the credence given to misinformation.”
- Samet’s own state offers a vivid example of the rise of the third wave, with its graph since spring forming a stark, three-peaked mountain range, not unlike a view you might find while hiking in the Colorado Rockies:.
- In some ways, however, Colorado is an outlier in the new wave—or at least lies at its very vanguard. The first wave hit hardest in the Northeast; the second in the South and the West. Now, even as cases balloon in the South again (driven in large part by Texas and Florida), the Midwest has surpassed the West in cases, with dramatic spikes from Wisconsin and Minnesota to the Dakotas and down to Utah and Wyoming.
- At a more granular level, the geographic trends become even clearer. There are more than 3,000 counties (or county-equivalents, like parishes) in the U.S., almost all of which report individual daily figures for new C19 positive tests. Breaking them down into three categories—small, medium and large, each with about a third of the U.S. population—reveals that the 62 largest counties, which are home to 110 million people, were responsible for more cases than either of the other two categories through mid-August. Now the story has flipped, with the bloc of smallest counties—encompassing the same number of total people but distributed across a much larger, more rural geography—contributing the most new cases.
- “Given that these are rural areas, behaviors of individuals are likely to be a dominant driver: not adhering to distancing and not wearing masks,” says Samet. “Checking across mask orders in these states, there is a wide range. I suspect adherence to use of masks is lower in these rural counties than in urban areas, as in Colorado by anecdotal reports.”
- There has also been a shift in C19 age demographics that in turn affect the regional situation. “In part of the Midwest, the rise is being driven by young adults who seem to have gotten the coronavirus in universities,” says Inglesby. It doesn’t help that college students—who are by nature less risk-averse than older people—are being enabled in their heedlessness by a lack of guidance from adults who ought to know better. It’s also worth noting that many young Americans hold jobs that increase exposure risk, like retail or restaurant work.
- Whatever the manifold causes of the third wave, there is reason to worry that it will prove worse than the first two. The arrival of colder weather in some states means more time spent indoors, where viruses are more easily transmitted by aerosols produced when people sneeze, cough or merely speak. With the pandemic still raging, many people will likely scrap seasonal travel and family get-togethers for Thanksgiving, Christmas and so on—but many are likely to press ahead regardless, meaning minimal social distancing in crowded planes and trains and around holiday dinner tables.
- “We are concerned that there could be a holiday spike with severity depending on where the epidemic curve is positioned before the start of the season in later November,” says Samet.
- Whether the third wave will be followed by a fourth is, paradoxically, both impossible to say and entirely within our control. Hopefully, greater policy coherence from Washington, uniform national rules around masking and distancing, and broad public acceptance of an eventual vaccine—once it is proven to be safe and effective—will all, at last, stuff the C19 genie back into its bottle. Until then, the U.S., which represents only 4% of the world’s population yet has reported more than 20% of its C19 cases and deaths, will continue to struggle. It is up to all of us, working together, to bring that suffering to an end.
2. Coronavirus cases up in 21 states as new model predicts ‘huge surge’
- The number of C19 cases in the US rose by at least 10% 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% 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% 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% 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% of samples tested, while antibody levels dipped below 5% 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% 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.
J. Herd Immunity
1. New Research Finds Herd Immunity to C19 Is an Impractical Strategy
- Achieving herd immunity to C19 is an impractical public health strategy, according to a new model developed by University of Georgia scientists. The study recently appeared in Proceedings of the National Academy of Sciences.
- Controlling C19 has presented public health policymakers with a conundrum: how to prevent overwhelming their health care infrastructure, while avoiding major societal disruption?
- Debate has revolved around two proposed strategies. One school of thought aims for “suppression,” eliminating transmission in communities through drastic social distancing measures, while another strategy is “mitigation,” aiming to achieve herd immunity by permitting the infection of a sufficiently large proportion of the population while not exceeding health care capacity.
- “The herd immunity concept is tantalizing because it spells the end of the threat of C19,” said Toby Brett, a postdoctoral associate at the Odum School of Ecology and the study’s lead author. “However, because this approach aims to avoid disease elimination, it would need a constant adjustment of lockdown measures to ensure enough—but not too many—people are being infected at a particular point in time. Because of these challenges, the herd immunity strategy is actually more like attempting to walk a barely visible tightrope.”
- This study carried out by Brett and Pejman Rohani at the University of Georgia’s Center for the Ecology of Infectious Diseases, investigates the suppression and mitigation approaches for controlling the spread of the coronavirus.
- While recent studies have explored the impacts of both suppression and mitigation strategies in several countries, Brett and Rohani sought to determine if and how countries could achieve herd immunity without overburdening the health care system, and to define the control efforts that would be required to do so.
- They developed an age-stratified disease transmission model to simulate coronavirus transmission in the United Kingdom, with spread controlled by the self-isolation of symptomatic individuals and various levels of social distancing.
- Their simulations found that in the absence of any control measures, the U.K. would experience as many as 410,000 deaths related to C19, with 350,000 of those being from individuals aged 60-plus.
- They found that using the suppression strategy, far fewer fatalities were predicted: 62,000 among individuals aged 60-plus and 43,000 among individuals under 60.
- If self-isolation engagement is high (defined as at least 70% reduction in transmission), suppression can be achieved in two months regardless of social distancing measures, and potentially sooner should school, work and social gathering places close.
- When examining strategies that seek to build herd immunity through mitigation, their model found that if social distancing is maintained at a fixed level, hospital capacity would need to greatly increase to prevent the health care system from being overwhelmed.
- To instead achieve herd immunity given currently available hospital resources, the U.K. would need to adjust levels of social distancing in real time to ensure that the number of sick individuals is equal to, but not beyond, hospital capacity. If the virus spreads too quickly, hospitals will be overwhelmed, but if it spreads too slowly, the epidemic will be suppressed without achieving herd immunity.
- Brett and Rohani further noted that much is unknown about the nature, duration and effectiveness of C19 immunity, and that their model assumes perfect long-lasting immunity. They cautioned that if immunity is not perfect, and there is a significant chance of reinfection, achieving herd immunity through widespread exposure is very unlikely.
- “We recognize there remains much for us to learn about C19 transmission and immunity, but believe that such modeling can be invaluable in so-called ‘situational analyses,’” said Rohani. “Models allow stakeholders to think through the consequences of alternative courses of action.”
K. Practical Tips & Other Useful Information
1. Coronavirus is in the air. Here’s how to get it out.
- The coronavirus can float in the air. In particular, it can linger in poorly ventilated indoor spaces, spreading farther than 6 feet from its source. These indoor public spaces are high risk and should be avoided while the virus is still spreading.
- But, increasingly, people are returning to those spaces: Bars and restaurants are operating in limited capacity in some places, and are fully reopened in others. Some schools and universities have resumed in-person classes, and mayors are allowing some live entertainment venues to host events.
- With the weather growing colder, experts fear indoor gatherings in these and private spaces could spark new outbreaks. Already, cases are increasing nationwide, and experts are growing more concerned about a potential fall-winter C19 surge.
- To make indoor communal spaces safer, experts keep stressing that they need to be “well-ventilated.” But what does that mean? In conversations with several air quality experts and engineers, I found ventilation to be simple in concept and potentially fraught in execution.
- “It’s a huge engineering problem,” Shelly Miller, an environmental engineer at the University of Colorado Boulder, says. “We don’t have the systems in place for many buildings to be operated appropriately during a pandemic.”
- As Derek Thompson observes in the Atlantic, a lot of places have put on a big show about cleaning surfaces — what he calls “hygiene theater” — though surface contamination is not thought to be a large source of C19 transmission.
- Making places safer, instead, should mean improving air quality. But “have you ever heard a restaurant reopening announce they’ve improved ventilation or increased ventilation?” Lidia Morawska, an engineer and the director of the International Laboratory for Air Quality and Health at Queensland University of Technology, recently told me. “No.”
- Ventilation concerns are not limited to restaurants and schools. Recently, a report from the University of California San Francisco noted “exceedingly poor ventilation” at the San Quentin State Prison, which saw a huge outbreak of more than 2,200 cases.
- Ventilation efforts could easily fall into the “hygiene theater” trap if not done well. So here’s a guide for how to think about safer — but not necessarily “safe” — indoor air, and all the hurdles that may get in the way. We need to think about controlling the source of the virus indoors, about mixing more outdoor air with indoor air, and about air filtration and cleaning devices.
- The experts I spoke with agreed: We can’t ventilate and air purify our way out of the need to wear masks, reduce occupancy in indoor spaces (or just avoid many of them all together), and physically distance. The indoor space that can’t enforce these measures, or allow activities that involve mask removal — like bars and restaurants — probably shouldn’t be open. And, still, the most important way to make indoor spaces safer is to decrease community C19 spread as much as possible. It may not be easy for all spaces to achieve ideal ventilation.
- There are no perfectly safe indoor environments during the pandemic, but there are clear goals to have in mind when trying to make them safer with ventilation. Here’s where to start.
First: Limit the amount of virus in the air in the first place
- Intuitively, I think we all know how to think about cleaning surfaces: Wipe them down with a disinfectant, or scrub with good old soap and water. Cleaning the air is an entirely different challenge. You can’t just spray it with chemicals and call it a day.
- “Cleaning the air is at least as important as cleaning surfaces, but you do it very differently,” says Linsey Marr, a Virginia Tech engineer who studies the airborne spread of viruses. “We end up having to breathe whatever it is we spray. And if it’s harmful to the virus, it’s likely it’s also harmful to us. So we need to take a totally different approach.”
- There are other challenges to cleaning the air, too. One big one: Floating particles can move. If you clean one section of air in a space, new dirty air can move in and replace it. Also, air cleaning needs to be continuous in the spaces we inhabit. As long as there are living, breathing people in a space, we’re potentially contaminating it with virus.
- The first thing to do in thinking about cleaning the air, says Jeffrey Siegel, an air filtration expert at the University of Toronto, is to think about limiting the source of the contagion in the first place (i.e., living, breathing people). There’s an old saying in his line of work: “If you’ve got the odor of manure, don’t try and ventilate to get rid of it, get rid of the manure,” he says. “That’s the exact idea, right? Get rid of the source or manage that source.”
- The coronavirus gets into the air via human breath. So we should start by reducing the number of humans in a space, masking those who have to enter, and limiting activities like singing or shouting that can propel even more virus-laden particles into the air.
- From contact tracing studies, we know the virus spreads most readily through close contact, with the risks increasing with the amount of time spent in close proximity. However, there are some situations in poorly ventilated indoor spaces where the virus may be able to float in the air for an extended period (tens of minutes or more), or spread in a gaseous cloud over an area larger than 6 feet (some of that long-range floating virus may still be able to infect people, some of it may not). Ventilation may help decrease the chances of transmission in these indoor environments.
- “Ventilation may be able to help reduce indoors transmission, but it’s never going to be as effective as simply not having lots of people in a single indoor space,” Boston University epidemiologist Eleanor Murray says in an email. “If a workplace can function with employees working remotely, then it will be safer for them to do so than to have all employees come back to work even with better ventilation. But there may be a few employees who would be better served by being at the office, and for those, improving ventilation will help make the office as safe as possible.”
- Outside of source control, there are three basic ways to clean the air and reduce the concentration of airborne virus. The first is to simply ventilate, or increase the amount of outdoor air in indoor spaces, and to make sure the inside air is replaced by outside air several times per hour.
- “So the air in your home probably changes over once every hour or two hours,” Marr says. “We’re aiming for an air exchange rate of, like, six per hour.” That recommendation, she says, comes from studies of tuberculosis transmission. (Tuberculosis is not SARS-CoV-2. TB is much more contagious and is thought to be able to spread farther and stay longer in the air.)
- It’s important to remember, too, that scientists still don’t really have a specific figure on what amounts to a dangerous, infectious concentration of virus in the air. “There’s no perfectly ‘safe’ level of ventilation because we don’t actually know what ‘safe’ is, since we don’t know how much exposure leads to transmission,” Angela Rasmussen, a Columbia University virologist, says in an email.
- Six air changes an hour is a baseline. “If you want the risk down to zero, you’ve got to get to an infinite number of air changes per hour,” Marr adds. Which is impossible.
- Again, more ventilation may be “safer,” but it’s not “safe.”
- The easiest way to increase ventilation: open windows. This will increase the amount of outside air (which does not have virus in it) coming in to dilute indoor air (which may have virus in it). The less concentrated the virus is in the air, the less likely it is to infect people.
- It seems simple, but it’s not foolproof. There are some specific scenarios where opening windows can be counterproductive and yield unpredictable effects, as Siegel explains.
- Let’s say you have a bathroom. It would be a good idea to keep the bathroom air in the bathroom. After all, many types of viruses can spread in bathrooms, and in the case of C19, it’s possible for the virus to be sent into the air via toilet flushes (though it’s less clear if someone can be infected this way). So it’s ideally best to not let that bathroom air get out into other spaces.
- To keep the air in the bathroom in the bathroom, it needs what engineers call “negative pressure,” meaning that air can flow into the bathroom but not out.
- “And then you open a window in the room beside the bathroom,” Siegel says. “And once you open windows, you give up on any idea of controlling pressurization or depressurization.” When this happens, the potentially contaminated air in the bathroom will start flowing out.
- The point of this example isn’t to make people scared of opening windows. It’s just that indoor spaces are complicated, and airflow can be hard to predict.
- “No one I know — even some of the best building modelers in the world — can accurately model a building with open windows,” he says. “It’s just way too dynamic of a system. We know that, in general, ventilation rate increases. And I’m not going to tell anyone not to open the windows. But really we can’t tell you what it’s doing to airflow in the space.”
- This is one of the potential pitfalls with ventilation: “Ventilation pathway matters too,” Siegel explained on Twitter. If a fan meant to increase ventilation ends up blowing virus across people’s faces, it’s self-defeating. This is what’s believed to have happened in a restaurant in China, where people sitting in the path of an air conditioning fan got sick. Later, researchers also said that the restaurant A/C system pulled in no outdoor air, and the air in the restaurant wasn’t replaced even once in an hour, let alone six times, which likely contributed to the outbreak there.
How to monitor ventilation
- So how do you know if you’re doing ventilation right? Is there any way to monitor your airflow and know the air exchange rate? Here, things get tricky. One indirect way to do this is to purchase a carbon dioxide detector (which are around $100 online) to give you a rough sense of air quality. When we exhale, we exhale CO2. “How much CO2 is in an indoor space is basically a metric of how much air other people have expelled in that space,” Jose-Luis Jimenez, a chemistry professor at the University of Colorado Boulder, says. So high and rising CO2 levels in a space can be a sign it’s not properly ventilated.
- “The relationship between CO2 and outside air ventilation is really complicated and not something I’m advocating the public try to figure out,” Miller says. But, as a general benchmark, the average C02 concentration of outdoor air is around 400 ppm (parts per million). So indoor spaces should ideally have a CO2 concentration of under 500 or 600 ppm in a room where people are breathing. That will tell, roughly, whether outdoor air is being mixed with indoor air at a reasonable level.
- Building managers, though, shouldn’t depend entirely on a CO2 monitor. Again, it’s an indirect measure. If there are only a few people in a space, they may not generate enough CO2 to make the sensor rise that much even in a stagnant environment. And it only takes one person to start an outbreak.
- (There’s also some room for commonsense measurements, too: Use your nose. If you can smell odors wafting through a building coming from indoor sources, the space may not be adequately ventilated. “If you walk into a place and it feels stuffy and the windows aren’t open, then that’s an indicator that there’s not good ventilation there,” Marr says.)
- In commercial settings, some building operators might be able to adjust the amount of fresh air pumped into a building’s ventilation system. During the pandemic, they should do this. But, as Miller explains, “many [commercial HVAC] systems don’t run on 100% outside air.” It’s too energy-intensive. “You can’t provide air conditioning and heat with 100% outside air,” she says. So, in some cases, there is a limit to how much outside air an HVAC system can mix into a building.
- Other systems might be in disrepair and unable to ideally ventilate buildings, even if their systems are cranked up. Particularly in schools, ventilation systems can be old and in disrepair. In June, the Government Accountability Office published a survey of 65 school districts that receive aid from the federal government. It found 41% of the districts needed to update HVAC equipment in half of their schools. Separately, in New York City, a Daily News investigation found that “roughly 650 of the 1,500 buildings surveyed in 2019 by city inspectors had at least one deficiency in their exhaust fans.”
- A huge part of the challenge of increasing ventilation is that different buildings, built in different eras for different purposes, will need potentially different solutions. Older buildings might not have any central HVAC systems at all. And some with HVAC systems may operate well for some rooms but less well in others.
- “When I think about my daughter’s school,” Siegel says, “I don’t worry about the school as a whole as much as I worry about that classroom where they can’t open the windows because there’s a construction site right nearby.”
- It’s important to know here that ventilating schools has benefits that are broader than its pandemic applications. Kids need to breathe healthy air (the dangers of air quality for children’s’ health and cognitive well-being are as clear and critical as ever). And allowing them to do so will require huge investments.
- “We can’t even get the Congress to allocate, you know, $600 a week in unemployment, let alone a billion dollars to schools to upgrade their HVAC,” Miller says.
- “We have systematically neglected our HVAC systems for a very, very long time,” Siegel says. “Schools are one classic example of that. But also every building. And so now all of a sudden, we’ve got a pandemic, and we say, well, we want to increase ventilation … you don’t get there without some amount of investment.”
- (Hospitals, you might be curious to know, already have extensive requirements in place for ventilation. So which comes at a great cost and takes lots of energy to use.)
Air filters can work too — if used properly
- The goal in ventilation is to replace potentially virus-laden air indoors with virus-free air. One way to do this is to bring more outdoor air inside. But this isn’t always doable. You can’t easily open windows for ventilation when there’s a lot of hazardous pollution outside (like wildfire smoke). So, the other way is to filter the indoor air itself.
- This also is simple in theory, but the implementation can be tricky.
- It starts with getting a good air filter. For this, the American Society of Heating, Refrigerating, and Air-Conditioning Engineers suggests using filters with a MERV-13 designation or higher. Or use a portable HEPA filter (there are some DIY versions you can try on the cheap).
- MERVs are based on a filter’s performance in filtering out particles between 0.3 and 10 microns. The coronavirus could very well be found in respiratory droplets in this size range; the higher the MERV number, the higher the probability that the filter will remove these droplets.
- HEPA filters, more common in portable air filters, are slightly different. The “HEPA” designation means they filter out at least 99.97 percent of particles that are 0.3 microns. Which is to say, they filter out practically everything. (A quirk of the physics of filtration is the very smallest particles are actually easier to filter out than the 0.3 micron ones. The smallest particles get pushed toward filter fibers because of their collisions with gas molecules in the air, Siegel explains.)
- But installing higher-quality filters isn’t enough.
- “I can’t just tell you in good conscience, ‘This is the filter you should use to protect against C19 transmission,’ because it really depends how you use that filter,” Siegel says. “We much more often have an implementation problem than a lack of technology problem.”
- Often, he says, in buildings, a filter will be improperly sealed so that some unfiltered air sneaks past it and recirculates in the building; this downgrades its filtering ability. Also, not all systems can run these higher-efficiency filters, which can be quite dense. They often require more powerful fans to push air through.
- For instance, Siegel says that, typically, home window AC units don’t operate with very powerful fans. So if you put a good filter in the unit, “you would not move any air, your air conditioner would cease to perform as an air conditioner, the coil would ice up very rapidly, and you’d have a nice block of ice with no air blowing across it.”
- The other consideration: These higher-quality filters need to be replaced more frequently as they “fill up” with more stuff more quickly and it becomes harder to push air through the filter. Also (this list of caveats and considerations is getting long, right?) you need to buy a unit that’s sized correctly for the space you are in. The filtering unit should ideally, along with ventilation, lead to six or more air exchanges per hour.
- “You want something that’s good for the size of your room or bigger; bigger will give you better cleaning power,” Marr says. “But, you know, even if you get something that’s smaller, it’s not going to harm you.” She adds that you also need to be careful when changing the filters because they could be contaminated with virus.
- And finally: Air filters have to be constantly running to work.
- “Forced air systems [like centralized heating and cooling] in most residential contexts and in some commercial context only come on when there’s a need for conditioning,” Siegel says. That is, they only turn on when it gets too cold or too hot. For a filter to work at its best, air needs to be constantly running through it. Some systems may need to be tinkered with to get this to happen.
- Again, it’s hard to know, exactly, what impact air purifiers will have on transmission. “My main concern with these ventilation systems is that we do not know really whether they will decrease transmission risk substantially,” Muge Cevik, a physician and virology expert at the University of St. Andrews, says in an email. After all, there aren’t randomized controlled studies of using air cleaners during this pandemic to decrease transmission.
- In theory, air purifiers should help. “It’s not rocket science,” Jimenez, who strongly advocates for their use, says. “If you pass air through the filter, it will catch the particles.”
Watch out for snake oil air-cleaning products
- There’s yet another option for removing virus from the air: killing it with ultraviolet lamps. That said, Miller — who specializes in studying devices that do this sort of thing — doesn’t recommend these for the average consumer.
- “While they can be effective, there is not enough testing/certification for these devices,” she says. “These are pretty complex, and there are a lot of great applications and some really good companies that can help with design and install.” But, she says “there are also a lot of bad lamp manufacturers and people selling devices that don’t work. Best left to engineers and reputable companies to support these installations.”
- If you look at air cleaning products, you’ll find a lot of gimmicks: ionizers, plasma generators that claim to amp up the power of filters. “There’s very little science behind them,” Siegel says. “It’s not only that the devices are ineffective and maybe lull people into a false sense of security, but in some cases they’re actually harmful.”
- Watch out, in particular, for machines that can generate ozone. Ozone is a pollutant that can interact with a lot of different products in your home and create harmful chemicals to breathe in. “It reacts with carpets and skin oil and all kinds of things inside of buildings,” Siegel says, “forming all kinds of harmful byproducts, ultra-fine particles, formaldehyde, all kinds of other things that we would worry about indoors.”
- So stick with HEPA or MERV-13+ rated filters. Or just open windows.
- Remember: Hygiene theater is possible when it comes to air quality as well. If a school or any indoor space says it has improved ventilation, ask how. Marr suggests asking building operators what the air exchange rate is (if they don’t know it, maybe be wary about the space). Ask about what filters have been put in place. Ask if their HVAC systems have been routinely maintained.
- “Even if you can’t reach the target — six air changes per hour — if you can improve, that will still be helpful,” Marr says. “Do what you can, because that will reduce the risk of transmission. Don’t give up.”
We need to invest in cleaner air, period. Pandemic or not.
- There are no risk-free situations in a pandemic. Again, good ventilation needs to take place alongside other precautions. The hope is “if we can take this whole suite of stopgap measures from the ventilation standpoint and add it to masks, social distancing, reduced occupancy, limited time indoors, the whole package could reduce our risk substantially to help get the case rates down,” Miller says.
- This is particularly important heading into the fall and winter seasons, when more people will be spending more time indoors in potentially risky environments.
- Experts also worry that the US Centers for Disease Control and Prevention is not being helpful enough in its air quality recommendations. For instance, the CDC recommends that schools “ensure ventilation systems operate properly and increase circulation of outdoor air as much as possible, for example by opening windows and doors.” But they don’t even weigh in on the merits of putting a HEPA air purifier in each classroom.
- “It would carry more credibility,” Jimenez says, if the CDC would discuss their use rather than leave the conversation in the hands of independent scientists speaking for themselves. “When I was talking to a school district, they were all saying, ‘Well, the CDC doesn’t recommend air cleaners.’” In Jimenez’s mind, air cleaners are essential. But it’s hard to get the message across without a huge institution like the CDC echoing it.
- So much of the pain of the pandemic builds on preexisting problems. Too many schools and other buildings have overlooked their ventilation and indoor air quality to begin with. Addressing ventilation can’t just be a one-time Band-Aid during the pandemic. It’s an investment. And not just for future pandemics but for our overall health.
- “The best possible case is that you reduce risk of C19 and you make your indoor air quality better,” Siegel says. “The worst possible case is that you make indoor air quality better but don’t appreciably change C19 risk.”
2. Bring Fun Back Into Your Friendships—Despite the Covid Pandemic
- A new study published in the Journal of Personality and Social Psychology sheds light on why many of us are missing our friends so profoundly right now. It found that people report they’re happier hanging out with their friends than with their romantic partners or children. (Sadly of friends, kids and partners, people said they were least happy hanging out with the latter. But let’s save that for another column.)
- The lead researcher on the study, Nathan Hudson, an assistant professor of psychology at Southern Methodist University, in Dallas, says people often enjoy their friends’ company more because they spend more time doing fun things with them. (The study was conducted before the pandemic.) This isn’t to say that people don’t enjoy being with family members. But they spend a lot more time doing stuff that’s not fun with them: Chores. Caretaking. Home schooling.
- With this in mind, I think you need to put the fun back into your friendships. Start by taking the initiative: Reach out first rather than waiting for friends to call. If they are busy, ask when you should ring back—and be sure you do. Make the connections happen.
- If you live nearby, plan to get together—yes, in person—to do something enjoyable that you can do at a safe distance outdoors, such as taking a walk, riding bikes or having a picnic. What did you enjoy doing before? Replicate those activities as best you can.
- If you aren’t comfortable connecting in person—or if your friends live far away—come up with a fun project you can do together from afar. I recently asked my friends and family around the country to join me in the Leukemia & Lymphoma Society’s Resilience Challenge—we each pledged to move 50 miles in September under our own power (I planned to swim it) to raise money for the charity. To foster connection, I set up a Facebook page for our group, where we post photos and videos of our progress each day. I was surprised how much I’ve come to look forward to these posts, as I get a peek into my loved ones’ days, and I’m reminded of their sense of humor.
- Something else that’s worked for me lately: Connecting more often, in briefer spurts. It’s natural to want to know how your friends are holding up—everything feels so serious right now—and to support each other through tough times. But it’s emotionally exhausting when every single phone call turns into a therapy session. Look for ways to bond that allow you to share more than just the constant stress.
- Texts or video messages are perfect for day-to-day moments. Video is especially nice as it’s always great to see a face you love. Did your son say something hilarious? Did you try a recipe or finish a book you know your friend would like? Is there a beautiful sunset tonight? Share those moments. Often.
- Finally, think again about that study showing that people report doing more fun things with friends than family. It sounds as if it’s time to have more fun at home, right? As you are trying to add joy to your relationships, don’t forget family members.
L. Johns Hopkins C19 Update
September 30, 2020
1. Cases & Trends
- The WHO C19 Dashboard reports 33.44 million cases and 1.00 million deaths as of 6:00am EDT on September 30.
- The US CDC reported 7.13 million total cases and 204,598 deaths. The US is averaging 43,373 new cases and 733 deaths per day. In total, 22 states (no change) are reporting more than 100,000 cases, including California with more than 800,000 cases; Texas with more than 700,000; 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. Florida’s C19 website is reporting more than 700,000 cases, and we expect this to be reflected in the CDC data in the coming days.
- As daily C19 is once again on the rise in the US, the Midwest region continues to drive the current resurgence. As a whole, Midwestern states are currently reporting more than 12,500 new cases per day, more than a quarter of the national total. This daily incidence is more than 5 times the incidence at the minimum reported in mid-June and more than double the first peak in early May. The Midwest is approaching the peaks reported in the Mid-Atlantic (mid-April), Southwest (mid-June), and West (mid-to-late June). The Midwest and South are currently reporting the highest daily incidence. While the regional incidence is approximately equal, the South is decreasing while the Midwest is increasing. In addition to the Midwest, the Southwest and West regions have reported elevated incidence over the past 2 weeks as well.
- Multiple Midwest states are currently reporting daily incidence equal to or exceeding – in some cases by a considerable amount – their respective previous peaks. Wisconsin, North Dakota, and South Dakota are exhibiting the most concerning trends, with all three states reporting record high daily incidence.
- Wisconsin is currently reporting more than 2,200 new cases per day—and increasing rapidly—which is nearly 150% greater than its peak in late July. Additionally, Wisconsin’s test positivity has increased from 7.6% to 17% since August 23, setting a new record high for the state.
- North Dakota is currently reporting a record high for both active cases and hospitalizations, and its current daily incidence is nearly 6 times as high as its peak in late May.
- South Dakota’s first major peak was later than many states (late August); however, the daily incidence just a month later is already exceeding that peak by nearly 25%—and more than 80% greater than the low reported on September 12.
- Earlier this week, Iowa’s daily incidence was more than 50% greater than its July peak.
- Missouri’s daily incidence peaked in early August, and after a minor decline, the average is now exceeding the previous peak.
- Kansas’s and Minnesota’s respective epidemics have peaked several times, the highest and most recent of which occurred in early September for both states, and the daily incidence in both states is once again increasing. Kansas’ epidemic has nearly returned to the height of its previous peak, and Minnesota has already exceeded it (by nearly 20%).
- Nebraska’s daily incidence initially peaked in early May and declined through early July. Since that time, however, the daily incidence has increased steadily and now exceeds the initial peak.
- Indiana, Michigan, and Ohio are the only Midwest states currently reporting relatively steady or declining daily incidence, although Michigan’s daily incidence has been increasing slowly since it plateaued in late July.
- The Johns Hopkins CSSE dashboard reported 7.19 million US cases and 206,252 deaths as of 11:30pm EDT on September 30.
2. C19 AGE DISTRIBUTION
- Researchers from the CDC C19 Response Team published analysis of shifts in the age distribution of US C19 cases. The study, published in the CDC’s MMWR, evaluated age data from C19 cases reported in the US between May and August. The analysis included patients who visited the emergency department with COVID-like illness, patients with positive SARS-CoV-2 tests, and confirmed C19 patients as well as test positivity data among the defined age groups.
- From May to July, C19 incidence increased among all age groups, but the largest increases were observed in individuals under 30 years old, which drove a decrease in the median age of C19 cases—down from 46 years old in May to 38 years old in August. Similar trends were observed at the regional level, although with some variations between regions. The timing of these shifts coincided with many states’ efforts to relax social distancing in order to resume some social and economic activity.
- Notably, the researchers identified an increase in test positivity among individuals aged 20-39 years in several regions, particularly in the South, that preceded a similar increase among individuals 60 years and older by an average of 8.7 days—with a range of approximately 1-3 incubation periods. This study provides further evidence that transmission among younger portions of the population can drive subsequent increases among older individuals, who are at elevated risk of severe disease and death.
3. US CDC & WHITE HOUSE CORONAVIRUS TASK FORCE
- Reports continue to emerge from multiple media outlets regarding the role of political appointees on the White House Coronavirus Task Force in US C19 policy. This storyline has persisted for several weeks now, with various reports highlighting efforts by political appointees to dictate or direct C19 reporting and guidance developed by technical experts, including from the CDC. Based on accounts from US government officials, including former White House staff, The New York Times reports that White House officials pressured CDC officials to develop specific reports to support the White House’s position that the epidemic was waning and that the virus minimally affects children. Additionally, political appointees directed White House staff to “circumvent the C.D.C.” and develop their own C19 briefing materials in order to “better support the White House’s position.” The New York Times report focuses on White House efforts to provide support for reopening schools.
- According to the report, CDC officials have successfully prevented some guidance and reporting developed by the White House from being published; however, the influence of White House officials and the Coronavirus Task Force affected some aspects of multiple CDC documents. Notably, the “preamble” document to CDC guidance on reopening schools that supported in-person learning for K-12 students “contained information that C.D.C. officials had objected to” after being circulated to White House political appointees, including Chief of Staff Mark Meadows and senior policy advisers Jared Kushner and Stephen Miller.
4. VACCINE LOGISTICS
- As several vaccine candidates progress through their respective Phase 3 trials, vaccine manufacturers and the US government must cement plans for widespread distribution. Two of the leading candidate vaccines, from Pfizer/BioNTech and Moderna, have technical limitations that make distribution, storage, and administration more difficult than some traditional vaccines. These candidates use SARS-CoV-2 spike protein mRNA to elicit a protective immune response, and mRNA vaccines are generally hypothesized to be safer than inactivated or attenuated vaccines and are also quicker to manufacture. With that in mind, however, mRNA rapidly degrades in temperatures above freezing, which requires the cold chain to be maintained throughout vaccine distribution and storage in order to maintain efficacy. Some vaccines for other diseases can be stored in refrigerators or even at room temperature for several hours, but the Pfizer/BioNTech and Moderna candidates must be stored at -94°F and -4°F, respectively.
- In order to maintain these very cold temperatures, the manufacturers are simultaneously developing distribution systems and units to facilitate shipment and unpackaging for use. Pfizer’s “thermal shippers” are designed to keep vaccines frozen for up to 10 days, and they can be replenished with dry ice after opening. Additionally, both companies are expected to distribute their vaccines in multi-dose vials in order to mitigate the risk of a shortage of glass vials. Vaccine experts expect that multi-use vials could result in wastage as individual doses are extracted. This kind of wastage is already factored into manufacturing estimates, but it could potentially have a significant impact on the overall number of doses, particularly at the scale required for a national mass vaccination campaign—which could require hundreds of millions of doses.
- Notably, both of these vaccines require each person to receive 2 doses. Healthcare providers will face additional challenges in keeping track of multi-dose regimes. These vaccine candidates are not interchangeable—i.e., one dose of each vaccine is not the same as 2 doses of the same vaccine. Keeping track of dosing schedules amid patients’ busy schedules will likely create challenges for healthcare providers. While the CDC and state and local health departments coordinate to manage the distribution of existing vaccines, a SARS-CoV-2 vaccine could be a much different scenario. The CDC is implementing the Vaccine Administration Management System to support state and local efforts to implement mass vaccination; however, there are already barriers to linking the system to existing state vaccine databases.
5. ANTIGEN TESTING
- Since the onset of the pandemic, many countries around the world have struggled to establish and maintain sufficient testing capacity to support C19 response and prevention measures. Antigen-based tests could potentially provide rapid, on-site/point-of-care testing capacity on a large scale; however, barriers remain to effectively implementing antigen testing strategies. Antigen tests detect the presence of specific viral proteins, as opposed to antibodies or viral RNA, and they are faster and less expensive than traditional PCR-based diagnostic tests.
- In the US, antigen testing is gaining momentum, particularly as some companies and organizations are leaning heavily on antigen testing to resume normal operations. In particular, sports leagues have implemented antigen testing to provide routine surveillance capabilities for athletes, coaches, and other staff (e.g., on a daily basis), and multiple US airlines intend to utilize antigen testing for passengers. These programs may not necessarily be mandatory; however, they can provide increased screening capacity for travelers and crew. United Airlines will begin offering on-site antigen testing for flights from San Francisco to Hawai’i, but passengers will be charged an additional $250 to cover the cost of the test. Passengers will also have the option of conducting the test at home. Lufthansa will implement on-site testing for intercontinental flights in the near future.
- President Donald Trump announced a new program that will distribute 150 million antigen tests nationwide, with the aim of supporting screening efforts at schools and for higher-risk populations (e.g., long-term care facilities). The tests can provide results in approximately 15 minutes and can be performed by “medical personnel or trained operators in certain non-clinical environments.”
- The program could begin shipping 6.5 million tests this week, with additional tests to follow. Notably, the program will utilize antigen tests produced by Abbott Laboratories. The US FDA issued an Emergency Use Authorization for the Abbot tests; however, data published on the FDA website do not include any tests on individuals aged 21 or younger. Without testing pediatric specimens, it is unclear how accurate the test is in kids. Also, there are approximately 50 million children enrolled in public schools alone, so it is unlikely that 150 million tests would provide routine screening capacity nationwide. Elected and health officials in some states have commented that they are struggling to control where the tests will be distributed or to gather data on test results.
- In addition to antigen tests, the FDA issued its first Emergency Use Authorization for a point-of-care serological test. While traditional PCR-based diagnostic tests and antigen tests detect active infection, serological tests detect antibodies, which indicate prior infection. The test, produced by Assure Tech (China), uses a lateral flow approach and can provide test results in as little as 15 minutes using fingerstick blood specimens. The tests can be administered at common points of care, such as primary care physician offices and emergency departments, without the need to transport specimens to centralized laboratories with specialized equipment and personnel. The expanded availability of serological tests, particularly rapid tests capable of on-site testing, can further increase critical testing capacity and provide valuable data for both individuals and public health officials.
6. SCHOOL-AGED CHILDREN
- Researchers from the CDC C19 Response Team published findings from a study on C19 among school-aged children. The study, published in the CDC’s MMWR, focused principally on children aged 5-17 years in order to better characterize transmission and disease severity among pediatric cases, including associations with demographic characteristics and underlying health conditions. In total, more than 277,000 C19 cases were reported in US children in this age group from March through September. Among the pediatric cases, 3,240 were hospitalized (1.2%), including 404 that were admitted to an intensive care unit (ICU), and 51 died due to C19. Approximately 3% of the pediatric cases had at least 1 underlying health condition, and patients with underlying health conditions account for 16% of hospitalized patients, 27% of ICU patients, and 28% of the deaths.
- Notably, children aged 12-17 years had nearly twice the weekly rate of C19 incidence as 5-11-year-olds. Among patients with available demographic information, 42% of C19 cases were Hispanic/Latino, 32% were non-Hispanic White, and 17% were non-Hispanic Black, with slight variations between the 2 age groups. Using data from May-September, this study provides baseline data for pediatric C19 cases. As students return to school, including in-person classes, it will be critical to monitor C19 incidence trends and compare to the period of time prior to the start of the school year.
7. OPERATION WARP SPEED
- STAT News published a detailed report on Operation Warp Speed that depicts strong military involvement, especially in leadership roles. STAT News obtained an organizational chart for the program, which shows 61 of 90 leadership positions filled by Department of Defense (DOD) officials, many of whom have never worked in health care or vaccine development. While the DOD officials may not have direct experience in health care or pharmaceuticals research and development, they have extensive experience managing large contracts and logistical operations needed to support national and global distribution efforts.
- From this perspective, DOD is well positioned to support the goal of developing, producing, and distributing 300 million doses of coronavirus vaccine by January 2021. Some health experts have expressed concern that a lack of familiarity with the US health and public health systems, including associated programs and resources at the state and local levels, could potentially hinder distribution plans and operations. While the majority of leadership positions are military officials, most of the remaining positions are filled by health experts from the Department of Health and Human Services.
8. CONVALESCENT PLASMA
The NIH Treatment Guidelines Panel published an overview of the use of convalescent plasma as a treatment for C19. The article, published in the Annals of Internal Medicine, reviews the current scientific data on convalescent plasma use and associated recommendations. The article comes just a few days after the FDA announced updated evidence on the emergency use of convalescent plasma, including data from animal studies as well as results from the expanded access treatment protocol. The FDA noted that the use of convalescent plasma meets the “may be effective” standard for an Emergency Use Authorization, and strongly encouraged the continuation of randomized clinical trials to demonstrate efficacy. Additionally, the NIH announced a plan to expand placebo-controlled clinical trials, which will enroll hospitalized C19 patients across the country, including new trial sites. These trials are funded, in part, by Operation Warp Speed, which is providing US$48 million.
9. RACIAL & ETHNIC DISPARITIES
- In the US, it has been well established that racial and ethnic minorities have been disproportionately affected by C19, particularly in hospitalizations and ICU admissions. One study published in JAMA: Network Open evaluated C19 risk, including admission to the hospital and ICU, at a frontline hospital in Milwaukee, Wisconsin. Based on data from more than 2,500 patients in March (including 116 C19 patients), the researchers found that Black individuals were significantly more likely to test positive for C19 and be admitted to the hospital than people of other races/ethnicities. The odds of Black patients testing positive for SARS-CoV-2 were more than 5 times higher than other races, even after adjusting for socioeconomic status, comorbidities, zip code, and other factors. The odds of hospitalization or ICU admission for individuals enrolled in Medicaid—used as a proxy for evaluating the role of poverty—were more than 3.5 times those who were not, regardless of race.
- Some states have implemented measures that specifically aim to address the racial and ethnic disparities related to C19. For example, Black residents in Michigan represented 29.4% of the cases and 40.7% of the deaths at the beginning of the pandemic despite only representing 15% of the state’s population. Now, Black residents represent just 8.2% of cases and 9.9% of deaths. Michigan credits its Coronavirus Task Force on Racial Disparities for the decrease in racial disparities for C19. The Task Force implemented several targeted initiatives, including widespread public mask distribution and community testing in communities of color. Michigan’s success can serve as an example for other states and localities that implementing targeted measures can mitigate the elevated risk faced by racial and ethnic minorities.
10. SEASONAL INFLUENZA VACCINATION
- As influenza season approaches for the Northern Hemisphere, primary care providers and public health officials are concerned that parents may be hesitant to seek seasonal influenza vaccination for their children. A recent national poll conducted by the University of Michigan C.S. Mott Children’s Hospital found that fewer parents intend to get their children vaccinated against seasonal influenza compared to last year, particularly among parents of teenagers. The survey found that one-third of parents do not intend to get their children vaccinated against seasonal influenza. The most commonly cited concern was potential side effects of the vaccine (42%).
- Notably, 92% of parents who reported that their child’s regular healthcare provider strongly recommended seasonal influenza vaccination intend to get their child vaccinated, compared to only 62% of those whose provider simply recommended vaccination and 40% for those that could not recall their child’s healthcare provider making a recommendation. Among the parents who do not intend to get their children vaccinated, 14% are keeping their children away from healthcare facilities due to C19 exposure concerns. Public health experts are encouraging parents to vaccinate their children against seasonal influenza, particularly since C19 and influenza often present with similar symptoms. Increased vaccination will contribute to lower seasonal influenza incidence and, therefore, the fewer diagnostic tests that need to be conducted in order to distinguish between the two diseases. Healthcare providers will likely need to redouble their efforts to communicate the benefits of the seasonal influenza vaccination to parents as we progress further into flu season.