October 12, 2020
Without reliable information, we rely on fear or luck.
“Lockdowns will cause a doubling in the levels of world poverty and child malnutrition by 2021 and make poor people an awful lot poorer. So, I want to say it again: we in the World Health Organization do not advocate lockdowns as a primary means of controlling this virus.”Dr. David Nabarro, UK envoy to the WHO
“One of the ways people respond to their anxieties about a particular crisis is to monitor the media about that crisis. But that serves to amplify the distress, which leads to increased concerns, which leads to more media consumption.”Roxane Cohen Silver, a professor of psychological science, medicine and public health at the University of California at Irvine
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity
4. America’s newest wave of C19 cases
5. Negative Outlook for Refugee Camps
N. Linked Stories
- You can access all of the updates on our website at https://dailycovid19post.com/. Please share the website address with anyone you believe might be interested in the updates.
- We are happy to add anyone to the distribution list – just send their email address to me and we’ll add them to the list. And, for those of you on social media, please forward or post any or all of our updates. Also, please forward to me any information or recommendations that you believe should be included in any update. Comments and suggestions are always welcome.
- We do not endorse, and may not agree with, any opinion or view included in this update. We include a wide spectrum of opinions and views as we believe that it gives perspective on what people are thinking and may give insights into our future.
A. The Pandemic As Seen Through Headlines
(In no particular order)
- WHO warns against COVID-19 lockdowns due to economic damage
- UK study tests if BCG vaccine protects against COVID
- China will join a World Health Organization-backed vaccine consortium aimed at equitably distributing shots throughout the world
- Regeneron’s CEO says its promising Covid-19 treatment must be rationed
- A New Study Adds Support for Remdesivir
- Data shows the average age of death from coronavirus is 82.4 years
- Even moderately excess weight may raise the risk of severe COVID-19
- Many Covid-19 survivors are struggling with ‘brain fog’
- White House doctor says Trump no longer at risk of transmitting the coronavirus
- President Trump says he’s ‘immune’ to COVID-19, ready to hit campaign trail
- Trump tweet claiming coronavirus ‘immunity’ flagged by Twitter
- Trump says ‘miracle’ antibody treatment will get emergency use ‘very soon’
- Trump says he would ‘love’ to donate his plasma after COVID-19 battle
- The world recorded more than 1 million new cases in the last three days
- Across much of Europe, the virus is running wild again
- Public health officials in Europe say “pandemic fatigue” is creating resistance to new measures as nations work to avoid full lockdowns
- France reports another daily record
- Russia reports record cases
- Iran surpassed 500,000 cases and recorded a record 251 deaths
- India edged closer to overtaking the United States in total virus cases, passing the seven-million mark
- Brazil became the second country, after the United States, to record more than 150,000 deaths
- Health authorities in Sri Lanka, faced with a growing cluster of new cases, have ordered the closure of bars, restaurants, casinos, nightclubs and spas.
- Oman will reintroduce a nighttime curfew and enforce the overnight closure of shops and public places for two weeks to help contain the virus.
- Israeli military medics deploy to help virus patients
- A curfew in Berlin closed bars and restaurants at 11 p.m. on Saturday, curbing the German capital’s renowned nightlife
- Lebanon will close bars and nightclubs indefinitely to help contain the virus
- In Nepal, where hospital beds are few, thousands of Covid-19 patients just stay home — until they can’t
- With a second wave of COVID-19 building, Canadian public health officials are urging citizens to stay home as much as possible to re-flatten the curve
- Greece recorded a record 13 deaths on Sunday
- In South Korea, masks will be mandatory in public starting on Tuesday in an apparent effort to keep the coronavirus at bay as social distancing measures are eased
- Starting next week, Cuba will reopen to international tourists for the first time in six months, but Havana and other areas with higher case counts will remain closed
- Masks made compulsory outside in Poland as coronavirus cases surge
- Spain’s government today declared a state of emergency that allows it to reimpose lockdown measures on millions of people in and around Madrid, where coronavirus cases continue to spike
- NYC authorities handed out $150,000 in fines for COVID-19 violations this weekend
- Authorities break up ‘illegal rave’ in Queens park amid COVID-19 spike
- NYC public schools see significant spike in COVID-19 cases
- NYC delays approvals for homeschooling amid surge in requests
- Schools aren’t COVID-19 super-spreaders, new data suggests
- Miami-Dade Public Schools completed its return to five-day-a-week classroom instruction, becoming the largest U.S. school district to do so
- More parents in the US are seeking private schools for the in-person learning opportunities that aren’t available at many public schools
- NY to deploy rapid test kits to local governments, hospitals upon request
- Defying restrictions, Brooklyn’s Ultra-Orthodox sing and pray in crowds
- Ultra-Orthodox communities in NY and NJ are facing a surge in cases, driven in part by distrust of scientific messaging, dense living conditions and fatalism about the virus
- Catholic Priest Takes California to Court Over Coronavirus State of Emergency
- ‘Time to Choose Faith over Fear’: California Church Hosts ‘Freedom Sunday’ Calling for Churches to Reopen
- Judge declines to block NY Gov. Cuomo’s COVID restrictions on synagogues
- Off-campus trips and parties are fueling a spike at Syracuse University, officials say
- Pelosi warns on vaccines
- Chris Christie released from hospital after coronavirus scare
- Skipping the flu shot isn’t an option this year
- COVID-19 lockdowns seriously deepen the economic divide
- Goldman Offers Workers Free On-Site COVID-19 Testing After Latest Trading-Floor Outbreak
- Working remotely, chief executives have rediscovered the family dinner table
- U.S. Box Office Expected to Plunge by 81% in 2020
- New York movie theater marquees troll Gov. Andrew Cuomo
- Attendance at Disney World has been low since it reopened, but safety protocols have helped prevent the outbreaks that many feared
- Airbnb requires hosts to commit to enhanced cleaning
- The news is driving you mad, and that’s why you can’t stop devouring it
- Stevie Nicks: Coronavirus pandemic is ‘stealing my last youthful years’
- Space Helmet Launched Just-In-Time For ‘New Normal’ Travel
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 = 37,336,803
- New Cases = 278,013
- New Cases (7 day average) = 324,004 (+3,014) (+0.9%)
- Record high number of new cases on 10/10 (359,270 new cases)
- 7 day average of new cases is a record high
- 7 day average of new cases has increased 10.1% over the last week
- 1,000,000 new cases every 3.1 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 7,991,998
- New Cases = 41,935
- Percentage of New Global Cases = 12.9%
- New Cases (7 day average) = 46,960 (+1,303) (+2.9%)
- Total Number of Tests = 118,486,898
- Percentage of positive tests (7 day average) = 5.5%
- 7 day average of new cases has been rapidly increasing since 9/12
- Since 9/12, 7 day average has increased from 35,582 to 50,014, an increase of 40.6%
- Since 10/6, 7 day average has increased 12.5%
- Rapid increase in new cases may foreshadow an increase in new deaths
- Percentage of positive tests (7 day average) has been increasing since 9/29, which is another worrisome sign
- Total Deaths = 1,081,252
- New Deaths = 3,874
- New Deaths (7 day average) = 5,245 (+117) (+2.3%)
- 7 day average of new deaths has been gradually increasing since 10/3
- Since 10/3, the 7 day average has increased from 4,957 to 5,285, an increase of 6.6%
- Total Deaths = 219,695
- New Deaths = 325
- Percentage of Global New Deaths = 8.4%
- New Deaths (7 day average) = 725 (+5) (0.7%)
- 7 day average of new deaths has been gradually declining since 2nd peak on 8/4
- Since 2nd peak, 7 day average has declined 38.5%
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity (10/11)
- US total hospitalizations as of 10/11 increased 15.6% compared to 9/27 (two weeks ago)
- Average 7-day positivity in the US is unchanged (5.5%) from the prior two-week period (10/11 v 9/27)
- Average daily deaths (7-days) decreased 6.7% to 698 deaths compared to 748 average daily deaths as of 9/27.
4. America’s newest wave of C19 cases
- A new wave of Covid-19 cases is building across the United States, a harbinger of difficult winter months ahead.
- America is now averaging nearly 48,000 new confirmed cases every day, the highest numbers since mid-August, according to the Covid Tracking Project. More than 34,500 Americans are currently hospitalized with Covid-19 in the US, up from less than 30,000 a week ago. Nearly 700 new deaths are being reported on average every day, too — and while that is down from August, when there were often more than 1,000 deaths a day, deaths are going to eventually start increasing if cases and hospitalizations continue to rise. It’s a pattern we have seen before.
- Public health experts have been warning for months that fall and winter could lead to a spike in Covid-19 cases. Why? Because the best way to slow down the coronavirus’s spread is to keep your distance from other people and, if you are going to be around others, to be outside as much as possible — and both become harder when the weather gets cold.
- We may now be seeing those predictions start to come true. The US already has more than 7.7 million confirmed cases and 214,000 deaths. Both numbers will continue to climb.
- Eight months into the pandemic, America’s failures to contain Covid-19, and states’ eagerness to reopen even if they haven’t gotten their outbreaks under control, is once again leading to a surge in cases and hospitalizations.
C19 cases are rising everywhere across the country
- Earlier in the year, there was limited value to discussing “waves” because some states would have a decline in cases while other states were experiencing surges. What distinguishes this autumn wave is that it seems to be happening everywhere.
- Case numbers are up in the Northeast, the Midwest, and the West. The South appears to be, at best, plateauing at a level even higher than that which the Northeast endured during the worst of New York’s outbreak.
- What’s so worrisome is that no one state or region can be blamed for this new wave. Just 13 states have seen their number of new C19 cases drop over the last two weeks, according to Covid Exit Strategy. Cases are up in all the others.
- Raw case numbers can, of course, obscure important differences in population; 100 new cases means something different for California than it does for Wyoming. Experts will use another metric — new cases per million people — to gauge how saturated a given state is with C19.
- The goal would be to have fewer than 40 new cases per million people. But just three states — Maine, Vermont, and New Hampshire — meet that threshold. Meanwhile, North Dakota (627 cases per million), South Dakota (596), Montana (474), and Wisconsin (434) are some of the states seeing very high levels of new infections.
- As Vox’s German Lopez reported this week, just one state — Maine — meets all of the benchmarks established by experts for a state to consider its C19 outbreak contained. And yet, most states have reopened many of the businesses that were closed in the spring: 40 or so states have reopened restaurants, bars, gyms, movie theaters, and nonessential retail.
- “Part of the problem is America never really suppressed its C19 cases to begin with,” Lopez wrote, explaining why experts were anticipating a new surge in cases. “Think of a disease epidemic like a forest fire: It’s going to be really difficult to contain the virus when there are still flames raging in parts of the forest and small embers practically everywhere. The country always risks a full blaze with each step toward reopening and with each failure to take precautions seriously.”
Too many C19 tests are coming back positive right now
- Another closely watched indicator for renewed C19 spread is the percentage of coronavirus tests that come back positive. The number of tests being conducted doesn’t actually tell you all that much; if a high percentage of them are positive, that suggests that many others aren’t being caught at all and the virus could continue to spread unchecked.
- The country’s positive test rate is 5 percent, right at the threshold experts say would reflect adequate testing. Ideally, it would be even lower, 2 percent or less.
More Americans are being hospitalized with C19 too
- Both case numbers and the positive test rate can be a little deceptive, depending on how many tests are being performed. They suggest what’s happening on the ground — in this case, C19 is spreading — but they do have their limitations. There is some truth to the president’s claim that more tests will mean more cases, though that is not a reason to stop testing.
- Hospitalizations, on the other hand, are more concrete. If more people are developing symptoms severe enough to warrant being hospitalized, that is a strong indicator that the real number of people being infected with C19 is growing, regardless of whether they are getting tested.
- And after a dip in September, the number of Americans currently in the hospital with C19 is higher than it’s been in a month. That trend has been seen across the country.
- The worry becomes that if hospitals take in too many patients, they’ll have to turn other people away, or that overwhelmed staff and facilities could lead to some patients receiving substandard care. According to Covid Exit Strategy, 20 states currently have reduced ICU capacity that puts them in a danger zone; 21 states have an elevated occupancy rate in their regular hospital beds.
- Wisconsin, where the number of hospitalized C19 patients has risen over the last month from about 300 to 876 today, recently established a new field hospital on its state park fairgrounds over fears that the state’s hospitals wouldn’t have enough beds given the recent surge in cases.
- Fortunately, hospitals have gotten much better at treating C19. They have proven treatments, like remdesivir and dexamethasone, that reduce the length of hospital stays and reduce mortality in patients with severe symptoms. They have learned techniques like putting patients on their stomach to improve breathing. Hospitals that have endured multiple spikes of C19 cases report patients in the later waves are spending less time in the hospital and dying less frequently.
- Nevertheless, more people developing severe symptoms, as we are starting to see, will inevitably lead to more deaths. Over the summer, people wondered why deaths were falling while cases and hospitalizations rose — until deaths did start to increase. There is a long lag between cases rising and deaths rising, because it can take a month or more between when a person first contracts C19 and, if they die, when their death is reported.
- That’s why these new C19 trends in the US are so worrisome. Cases are rising, as are hospitalizations. It could be only a matter of time before deaths start to spike as well.
5. Negative Outlook for Refugee Camps
- Despite seeming at high risk for coronavirus outbreaks, refugee camps were mysteriously spared from the worst of the virus in the early months of the pandemic.
- Now, TIME’s Melissa Godin reports, that’s beginning to change. Over the past month, outbreaks have cropped up in refugee camps in Bangladesh, Greece, Lebanon, Syria and Palestine, raising concerns about how bad things could get in the coming weeks.
1. Backflip: W.H.O. Condemns Coronavirus Lockdowns, Just ‘Doubling’ Global Poverty
- The UK’s envoy to the World Health Organisation (W.H.O.) has condemned mass coronavirus lockdowns, slamming the “ghastly global catastrophe” caused by crashing the world economy.
- Dr. David Nabarro from the W.H.O. appealed to world leaders on Saturday, telling them to stop “using lockdowns as your primary control method” of the coronavirus.
- He claimed that the only thing lockdowns achieved was poverty – with no mention of the potential lives saved.
- This is in direct contrast to W.H.O. chief Tedros Adhanom Ghebreyesus who as far back as April gave his full support to lockdowns, and even warned against lifting them too soon, as Breitbart News reported.
- Then in August, Tedros praised several national governments including the UK, France, South Korea and Germany for “using all the tools at their disposal to tackle any new spikes” which included regional lockdowns.
- Speaking to Andrew Neil of the Spectator magazine, Dr. Nabarro bemoaned the collapse of the international tourism industry and claimed there would be a “doubling” in the levels of world poverty and child malnutrition by 2021 as he warned that lockdowns make “poor people an awful lot poorer.”
- “I want to say it again: We in the World Health Organisation do not advocate lockdowns as a primary means of controlling this virus,” Dr. Nabarro said.
- Instead, Dr. Nabarro is advocating for a new approach to containing the virus.
- “And so, we really do appeal to all world leaders: stop using lockdown as your primary control method. Develop better systems for doing it. Work together and learn from each other.”
- Dr. Nabarro’s interview came within hours of another W.H.O. recommendation for countries to avoid lockdowns because of their inherent damage to a range of national factors.
- The W.H.O.’s top emergencies expert said on Friday that authorities should try to avoid “punishing” lockdowns, echoing claims from the Chinese city of Wuhan, where the virus was first identified, that the cure was worse than the malady.
- Mike Ryan was speaking at a briefing in Geneva, the day after the W.H.O. reported a record one-day increase in global coronavirus cases, with the total rising by 338,779 in 24 hours led by a surge of infections in Europe, as Reuters reports.
- “What we want to try to avoid – and sometimes it’s unavoidable and we accept that – but what we want to try and avoid is these massive lockdowns that are so punishing to communities, to society and to everything else,” he said.
- The alternative is for everyone to get on with their lives while taking due personal precautions as those at much greater risk from coronavirus, such as the elderly and the long-term sick, are shielded.
2. Thresholds for effective herd immunity could be lower than predicted
- Basic models for C19 suggest herd immunity is achieved when 60% of people are immune. This is because in a population where everyone is susceptible to the coronavirus, an infected person is estimated to infect on average an additional 2.5 people. Yet if 60% of those theoretical 2.5 people are immune, then only one new infection can take place, and the outbreak cannot grow.
- This is based on a very simple model, though. It assumes that everyone in the population mixes to the same degree and at random. It’s unrealistic. In our research, we tried to reflect some of the diversity of behaviour found in human populations to show what effect it might have on reaching herd immunity.
- We looked at two factors that influence the degree to which people mix with each other. The first was sociability.
- Those who are more socially active are more likely to be infected in the early stages of an epidemic. This means that over time, naturally acquired immunity tends to be concentrated in those who make lots of social connections, while susceptibility to the disease – and the capability of spreading it – tends to be over-represented among people who make fewer connections.
- As we demonstrated, this can affect when the herd immunity threshold is reached. We created an illustrative model in which 25% of people socialize half as much as the average, 50% socialize an average amount, and the remaining 25% socialize twice as much as average. When you have these different groups mixing at these different rates, the model predicts that the herd immunity threshold will be considerably lower: 46.3% instead of 60%.
- If more differences between people are considered, the point at which herd immunity is reached through natural infection decreases even further. With this in mind, we considered the effect of age on social mixing.
- People in one age group don’t mix equally with people across other age groups; across a population, socialisation follows certain trends. To roughly model this, we split the population into six age groups, and then estimated the amount of contact between them using data from a previous study on social contacts.
- We found that accounting for age-specific mixing trends, together different sociability levels, lowered the herd immunity threshold a little further, to 43%.
What does this mean?
- The first important thing to say is that our estimates should be interpreted only as a demonstration of how differences in behavior can affect herd immunity. These figures aren’t exact values, or even best estimates. The activity levels and contact rates between age groups that we used in the model were simply illustrative.
- The second thing to note is that we’ve only accounted for two types of variation across the population. More realistic models would be more complex, including many other factors. For example, large household sizes, school and work environments, and metropolitan living all create higher rates of person-to-person contact. In such places a greater proportion of people will get infected, and infection and immunity will be more concentrated among highly active and connected individuals.
- Finally, for our model we’ve assumed that immunity doesn’t decrease over time and that it offers 100% protection. Neither of these things are necessarily true.
- But what our work does seem to suggest is that most forms of variation across a population will decrease the point at which herd immunity is reached through natural infection. This means that it could be reached at a lower human cost than previously expected. In countries or areas that have already been heavily hit by the virus, herd immunity might already be close. In such places, stopping the spread of the disease might therefore only require getting people to adhere to relatively mild restrictions on social behaviour.
- Some words of warning are needed though. Even if the threshold is lower, reaching herd immunity through natural infection will still require a lot of people to get infected. Though lower than initially thought, the human cost would still be very high. The city of Manaus in Brazil may be the first in the world to have reached herd immunity, but one in every 350 people infected with the virus there has died, amounting to around 2,500 deaths in total.
- Finally, while variation across the population generally decreases the overall level of immunity needed, among the most active people, the fraction that needs to be infected to reach herd immunity will be more than 60%.
D. New Scientific Findings & Research
1. Increased Risk From C19 for Older People Because of How the Immune System Ages
- People of all ages can get sick from the coronavirus (SARS-CoV-2). But the severity of the illness tends to worsen the older the patient is. Through the end of September, 79% of C19 deaths in the United States had been in patients over 65. These statistics are broadly similar in countries around the world.
- What is it that puts older people at increased risk from viruses like SARS-CoV-2? Scientists think it’s primarily due to changes in the human immune system as we age.
U.S. deaths from C19 by age
- The risk of dying if a person gets C19 rises with age. In the U.S., 79% of deaths linked to the coronavirus by late September had been in people ages 65 and older.
Your body’s tools to fight off virus infections
- As you go about your life, your body is constantly bombarded by pathogens – the bacteria, fungi and viruses that can make you sick. A human body is a great place for these organisms to grow and thrive, providing a nice warm environment with plenty of nutrients.
- That’s where your immune system comes in. It’s your body’s defense system against these kinds of invaders. Before you’re even born, your body starts producing specialized B-cells and T-cells – types of white blood cells that can recognize pathogens and help block their growth.
- During an infection, your B-cells can proliferate and produce antibodies that grab onto pathogens and block their ability to spread within your body. T-cells work by recognizing infected cells and killing them. Together they make up what scientists call your “adaptive” immune system.
- Maybe your physician has checked your white blood cell levels. That’s a measurement of whether you have more B-cells and T-cells in your blood than usual, presumably because they’re fighting infection.
- When you’re very young, you don’t have a lot of these B- or T-cells. It can be a challenge for your body to control infection because it’s simply not used to the job. As you mature, your adaptive immune system learns to recognize pathogens and handle these constant invasions, allowing you to fight off infection quickly and effectively.
- While white blood cells are powerful people-protectors, they’re not enough on their own. Luckily, your immune system has another layer, what’s called your “innate” immune response. Every cell has its own little immune system that allows it to directly respond to pathogens quicker than it takes to mobilize the adaptive response.
- The innate immune response is tuned to pounce on types of molecules that are commonly found on bacteria and viruses but not in human cells. When a cell detects these invader molecules, it triggers production of an antiviral interferon protein. Interferon triggers the infected cell to die, limiting infection.
- Another type of innate immune cell, called a monocyte, acts as a sort of cellular bouncer, getting rid of any infected cells it finds and signaling the adaptive immune response to shift into gear.
- The innate and adaptive immune systems can act together as a fine-tuned machine to detect and clear out pathogens.
C19 hospitalizations per 100,000 Americans by age
- Across the U.S., about 175 people out of every 100,000 had been treated in a hospital for C19 by mid-September, according to the CDC. Americans over 65 were twice as likely to be hospitalized as those 50-64 and four times more likely than those ages 18-49.
Cumulative U.S. hospitalizations as of September 19, 2020.
Older immune systems are weaker
- When a pathogen invades, the difference between illness and health is a race between how fast the pathogen can spread within you and how fast your immune response can react without causing too much collateral damage.
- As people age, their innate and adaptive immune responses change, shifting this balance.
- Monocytes from older individuals produce less interferon in response to viral infections. They have a harder time killing infected cells and signaling the adaptive immune response to get going.
- Low-grade chronic inflammation in individuals that commonly occurs during aging can also dull the ability of the innate and adaptive immune responses to react to pathogens. It’s similar to becoming used to an annoying sound over time.
- As you age, the reduced “attention span” of your innate and adaptive immune responses make it harder for the body to respond to viral infection, giving the virus the upper hand. Viruses can take advantage of your immune system’s slow start and quickly overwhelm you, resulting in serious disease and death.
Social distancing is vital
- Everyone, no matter their age, needs to protect themselves from infection, not just to keep themselves healthy but also to help protect the most vulnerable. Given the difficulty older individuals have in controlling viral infection, the best option is for these individuals to avoid becoming infected by viruses in the first place.
- This is where washing hands, avoiding touching your face, self-isolation and social distancing all become important, especially for C19.
The mist ejected by a sneeze can launch viruses airborne, so other people can inhale them.
- C19 is caused by a respiratory virus, which can spread via tiny virus-containing droplets. Larger droplets fall to the ground quickly; very small droplets dry up. Mid-range droplets are of most concern because they can float in the air for a few feet before drying. These droplets can be inhaled into the lungs.
- Keeping at least 6 feet away from other people helps significantly reduce your chance of being infected by these aerosol droplets. But there’s still the possibility for virus to contaminate surfaces that infected people have touched or coughed on. Therefore, the best way to protect vulnerable older and immunocompromised people is to stay away from them until there is no longer a risk. By stopping the spread of SARS-CoV-2 throughout the whole population, we help protect those who have a harder time fighting infection.
2. The CDC has finally acknowledged that the coronavirus can be airborne
- The US Centers for Disease Control and Prevention has updated its guidelines to acknowledge that the coronavirus can be spread by tiny particles that linger in the air.
- The agency said it made the decision because of the mounting evidence that people with C19 can infect people even if they are more than six feet away, or shortly after the infected person left the area. These cases all occurred in poorly ventilated and enclosed spaces, and often involved activities that cause heavier breathing, like singing or exercise.
- However, “the CDC continues to believe, based on current science, that people are more likely to become infected the longer and closer they are to a person with C19,” it said in a statement. The long-coming update could help to finally clarify the situation after the CDC published guidance acknowledging airborne transmission and then suddenly retracted it last month.
- Evidence that airborne transmission is occurring has been mounting for months; 239 experts wrote an open letter to the World Health Organization in July calling for them to acknowledge it. The WHO still has not recognized airborne transmission as a significant factor in the pandemic, and the CDC’s slowness to do so has caused frustration among aerosol researchers, some of whom say it is the main route for infections. The CDC maintains it occurs only in “limited, uncommon” circumstances. Airborne transmission has become a topic of fierce contention, partly because it makes it far riskier to reopen spaces like restaurants, gyms, bars, schools, and offices.
- What do we do now? The CDC advises that people stay at least six feet away from others, wear a mask that covers their nose and mouth, frequently wash their hands, clean high-touch surfaces often, and stay home when they are feeling sick. However, the implications of airborne transmission mean the CDC perhaps ought to shift its emphasis and go further, advising people to properly ventilate buildings, limit the number of people indoors at any given time while encouraging them to stay farther apart and masked, and try to socialize outdoors where possible.
- “The thing people need to understand is aerosol transmission is like everyone breathing out cigarette smoke, and you want to breathe in as little of others’ as possible. Everyone you are around, imagine they are breathing smoke, and try to avoid it,” Jose-Luis Jimenez, a chemistry professor at the University of Colorado, Boulder, who has studied aerosols for 20 years, told MIT Technology Review in an interview.
3. Previous Infection With Other Types of Coronaviruses – Including Common Cold Viruses – May Lessen Severity of C19
- Being previously infected with coronaviruses that cause the “common cold” may decrease the severity of severe acute respiratory syndrome coronavirus (SARS-CoV-2) infections, according to the results of a new study.
- Led by researchers at Boston Medical Center and Boston University School of Medicine, the study also demonstrates that the immunity built up from previous non-SARS-CoV-2 coronavirus infections does not prevent individuals from getting C19. Published in the Journal of Clinical Investigation, the findings provide important insight into the immune response against SARS-CoV-2, which could have significant implications on C19 vaccine development.
- There is a growing body of research looking into specific ways that the SARS-CoV-2 virus impacts different populations, including why some people are infected and are asymptomatic, as well as what increases one’s mortality as a result of infection. There are a number of vaccines under development in order to determine what type of vaccine (mRNA, viral vector) will be most effective at preventing SARS-CoV-2 infections.
- While SARS-CoV-2 is a relatively new pathogen, there are many other types of coronaviruses that are endemic in humans and can cause the “common cold” and pneumonia. These coronaviruses share some genetic sequences with SARS-CoV-2, and the immune responses from these coronaviruses can cross-react against SARS-CoV-2.
- In this study, the researchers looked at electronic medical record data from individuals who had a respiratory panel test (CRP-PCR) result between May 18, 2015, and March 11, 2020. The CRP-PCR detects diverse respiratory pathogens including the endemic “common cold” coronaviruses. They also examined data from individuals who were tested for SARS-CoV-2 between March 12, 2020 and June 12, 2020. After adjusting for age, gender, body mass index, and diabetes mellitus diagnosis, C19 hospitalized patients who had a previous positive CRP-PCR test result for a coronavirus had significantly lower odds of being admitted to the intensive care unit (ICU), and lower trending odds of requiring mechanical ventilation during COVID. The probability of survival was also significantly higher in C19 hospitalized patients with a previous positive test result for a “common cold” coronavirus. However, a previous positive test result for a coronavirus did not prevent someone from getting infected with SARS-CoV-2.
- “Our results show that people with evidence of a previous infection from a “common cold” coronavirus have less severe C19 symptoms,” said Manish Sagar, MD, an infectious diseases physician and researcher at Boston Medical Center, associate professor of medicine and microbiology at Boston University School of Medicine and the study’s co-corresponding author. Another interesting finding, the authors note, is that immunity may prevent disease (C19) in ways that are different from preventing infection by SARS-CoV-2. This is demonstrated by the fact that the patient groups had similar likelihoods of infection but differing likelihoods of ending up in the ICU or dying.
- “People are routinely infected with coronaviruses that are different from SARS-CoV-2, and these study results could help identify patients at lower and greater risk of developing complications after being infected with SARS-CoV-2,” said Joseph Mizgerd, ScD, professor of medicine, microbiology, and biochemistry at Boston University School of Medicine who is the study’s co-corresponding author. “We hope that this study can be the springboard for identifying the types of immune responses for not necessarily preventing SARS-CoV-2 infection but rather limiting the damage from C19.”
E. Vaccines & Testing
1. Inhaled Vaccines Aim to Fight Coronavirus at Its Point of Attack
- The C19 vaccines closest to the finish line are designed to be injected into the arm. Researchers are looking at whether they can get better protection from inoculations that fight the virus at its point of attack — the nose and mouth.
- Most vaccines in human testing require two shots for effectiveness, and developers still aren’t even sure if they’ll prevent infections. Scientists are hoping to generate superior immune responses with inhaled vaccines that directly target the airway cells the virus invades.
- An alternative to conventional jabs, sprayed and inhaled immunizations under development in the U.S., Britain and Hong Kong could play an important role in helping society escape restrictions that have upended economies and everyday life. Among their goals is to prevent the pathogen from growing in the nose, a point from which it can spread to the rest of the body, and to other people.
- “Local immunity matters,” said Frances Lund, a University of Alabama at Birmingham immunologist working with biotech Altimmune Inc. on an early-stage nasal inoculation. “The vaccines that can be delivered to generate that will have some advantages over vaccines that are delivered systemically.”
- Most early vaccine developers focused on a familiar route — injections — seen as the fastest to protecting the world from disease. Inhaled vaccine makers are counting on some of the unique features of the lungs, nose and throat, which are lined with mucosa. This tissue contains high levels of immune proteins, called IgA, that give better protection against respiratory viruses.
- Activating these immune weapons, they theorize, can protect areas deeper in the lungs where the SARS-CoV-2 does the most damage. They also may improve vaccines’ chances of blocking transmission.
- “The first generation of vaccines are probably going to protect a lot of people,” said Michael Diamond, an infectious disease specialist at Washington University in St. Louis. “But I think it’s the second- and third-generation vaccines — and maybe intranasal vaccines will be a key component of this — that ultimately are going to be necessary. Otherwise, we’ll continue to have community transmission.”
- In a study of mice in August, Diamond and his team found that delivering an experimental vaccine via the nose created a strong immune response throughout the body; the approach was especially effective in the nose and respiratory tract, preventing infection from taking hold. India’s Bharat Biotech and St. Louis-based Precision Virologics last month obtained rights to the single-dose technology.
- Vaccines that are sprayed into the nose or inhaled may hold other practical benefits. They don’t require needles, may not need to be stored and shipped at low temperatures and can reduce the need for health workers to administer them.
- Altimmune, based in Gaithersburg, Maryland, plans to enter human testing with a nasal vaccine in the fourth quarter after positive studies in mice. Scientists at the University of Oxford, where a promising shot under development at AstraZeneca Plc was designed, and Imperial College London are also planning studies of slightly different inhaled vaccines.
- The experimental immunizations in Britain would be delivered through a mouthpiece in an aerosol, similar to some asthma therapies. Imperial researchers point to evidence that delivering influenza vaccines via a nasal spray can protect people against illness and help reduce transmission; they’re keen to explore if that’s also the case for SARS-CoV-2. AstraZeneca makes the FluMist nasal spray vaccine.
- “This is a virus that’s transmitted through your respiratory tract, so if you want a vaccine that will really prevent infection and onward transmission you want to have an antibody response in your nose, in your lungs,” Shattock said. “The most efficient way to induce that is by inoculating through that route.”
- Questions about the durability of nasal vaccines have yet to be resolved, and they’re at an early stage. Despite the advantages, the delivery devices are also more complex, according to Nick Jackson, head of programs and technology at the Coalition for Epidemic Preparedness Innovations.
- “A needle and syringe work very well,” he said.
- Still, researchers said targeting the airways may pay off down the road. Oslo-based CEPI has provided funding to the Hong Kong project and is open to further investments in vaccines that are taking unconventional approaches as part of an effort to supply billions of doses to every corner of the world, Jackson said.
- “Whether it’s our vaccine or another one that goes through an intransasal route that actually is successful at disrupting transmission and disrupting the pandemic, I take my hat off,” Diamond said. “If we contribute by compelling or nudging these companies to think about an alternative route for what may be a successful platform, then we’ve done our job.”
2. Home-Made Covid Vaccine Appeared to Work, but Questions Remained
- Josiah Zayner’s plan was simple: replicate a C19 vaccine that had worked in monkeys, test it on himself and then livestream the experiment online over a period of months. Now, that improbable bid is over.
- Around the world, dozens of C19 vaccines are in human clinical trials involving tens of thousands of people. While vaccines typically take years to develop, U.S. scientists are racing to produce one in months through Operation Warp Speed. But Zayner, a one-time NASA researcher who left the scientific establishment in favor of engaging in do-it-yourself experiments, bet that by working outside regulatory structures, he could test a vaccine even more quickly and certainly more cheaply by giving it to himself.
- Instead, Zayner discovered, testing a vaccine is far more complicated than he had imagined.
- Even though his experiment yielded a promising result, Zayner found too many unanswered questions to say that it worked. For one, it wasn’t clear whether antibodies he found in his own body in extremely tiny measures before the experiment began made a difference. Zayner has long-believed that biohackers such as himself have the potential to make science move faster. In June, he told Bloomberg News that C19 presented “the perfect opportunity” to show just what biohackers can do.
- Now, his message is decidedly different: “Human beings — their biology is so complex,” he said in a recent interview. “The results are going to be messy. The experiments are going to be messy. So you test 30,000 people so that the messiness kind of averages out.”
- Zayner is infamous for attention-grabbing experiments in which he uses himself as a guinea pig. He self- injected the gene-editing tool Crispr while giving a talk at a San Francisco biotech conference, and performed his own fecal matter transplant. Such stunts have made him an informal figurehead for a growing movement of do-it-yourself scientists emboldened by advancements in technology that have made such feats as engineering biology increasingly simple. Zayner believes such cutting-edge science should be accessible to anyone, and that democratizing science could help curb exorbitant drug prices and speed science along.
- Initially, Zayner assumed that the experiment he named Project McAfee, after the antiviral software, would be relatively straightforward. The vaccine selected had triggered protective immunity against the virus in rhesus macaque monkeys in a paper published in May. Zayner was able to order the same spike protein sequence from the DNA-synthesis company the researchers had used. The plan: He and two fellow biohackers — Daria Dantseva in Ukraine and David Ishee in Mississippi — would themselves test the concoction they ordered online. They would then livestream the entire process online over several months, with the first showing to occur in June.
- But early on in the experiment, complications arose. Before starting, Zayner took a test at Lab Corp Inc. that told him he didn’t already have antibodies to the virus. But when he performed a similar test on himself shortly afterward, he found that he did have some antibodies, just not enough to produce a positive result on Lab Corp’s test. While those antibodies didn’t appear to be the neutralizing type, he wondered whether the result came because the vaccine was picking up signals from antibodies to a different virus — or how this faint antibody signal might affect things.
- “I’m very suspicious of my own data,” he said.
- He’s not alone. Hank Greely, a bioethicist at Stanford University, said Zayner’s experiment pointed out an underappreciated reality of vaccine development. “Actually making the vaccine isn’t that hard,” he said. “It’s testing it and knowing that it’s safe — and knowing that it’s effective.”
- Greely said that while Zayner’s DIY experiment probably presented more risks than potential benefits, there is value in demonstrating to people that vaccine development isn’t “magic.”
- For his part, Zayner said his turn at vaccine testing has tempered his appetite for DIY human experimentation. He still believes such experiments have a role to play, especially for those with fatal illnesses that lack approved treatments. But for now, he’s taking a break from experimenting on himself. His next project will focus on showing people how to grow chicken cells to make their own fake meat.
- With vaccines, Zayner concluded, “Large scale clinical trials are probably required, because it is so messy.”
F. Improved & Potential Treatments
1. Hydroxychloroquine does not counter the coronavirus in hamsters, high dose of favipiravir does
- Virologists at the KU Leuven Rega Institute have been working on two lines of the coronavirus (SARS-CoV-2) research: searching for a vaccine to prevent infection, and testing existing drugs to see which one can reduce the amount of virus in infected people.
- To test the efficacy of the vaccine and antivirals preclinically, the researchers use hamsters. The rodents are particularly suitable for SARS-CoV-2 research because the virus replicates itself strongly in hamsters after infection. Moreover, hamsters develop a lung pathology similar to mild C19 in humans. This is not the case with mice, for example.
- For this study, the team of Suzanne Kaptein (PhD), Joana Rocha-Pereira (PhD), Professor Leen Delang, and Professor Johan Neyts gave the hamsters either hydroxychloroquine or favipiravir – a broad-spectrum antiviral drug used in Japan to treat influenza – for four to five days. They tested several doses of favipiravir. The hamsters were infected with the SARS-CoV-2 virus in two ways: by inserting a high dose of virus directly into their noses or by putting a healthy hamster in a cage with an infected hamster. Drug treatment was started one hour before the direct infection or one day before the exposure to an infected hamster. Four days after infection or exposure, the researchers measured how much of the virus was present in the hamsters.
Hydroxychloroquine versus favipiravir
- Treatment with hydroxychloroquine had no impact: the virus levels did not decrease and the hamsters were still infectious. “Despite the lack of clear evidence in animal models or clinical studies, many C19 patients have already been treated with hydroxychloroquine,” explains Joana Rocha-Pereira. “Based on these results and the results of other teams, we advise against further exploring the use of hydroxychloroquine as a treatment against C19.”
- A high dose of favipiravir, however, had a potent effect. A few days after the infection, the virologists detected hardly any infectious virus particles in the hamsters that received this dose and that had been infected intranasally. Moreover, hamsters that were in a cage with an infected hamster and had been given the drug did not develop an obvious infection. Those that had not received the drug all became infected after having shared a cage with an infected hamster.
- A low dose of the drug favipiravir did not have this outcome. “Other studies that used a lower dose had similar results,” Professor Delang notes. “The high dose is what makes the difference. That’s important to know, because several clinical trials have already been set up to test favipiravir on humans.”
- The researchers are cautiously optimistic about favipiravir. “Because we administered the drug shortly before exposing the hamsters to the virus, we could establish that the medicine can also be used prophylactically, so in prevention,” Suzanne Kaptein notes.
- “If further research shows that the results are the same in humans, the drug could be used right after someone from a high-risk group has come into contact with an infected person. It may likely also be active during the early stages of the disease.”
- General preventive use is probably not an option, however, because it is not known whether long-term use, especially at a high dose, has side effects.
- Further research will have to determine whether humans can tolerate a high dose of favipiravir. “In the hamsters, we detected hardly any side effects,” says Delang. In the past, the drug has already been prescribed in high doses to Ebola patients, who appear to have tolerated it well.
- “Favipiravir is not a panacea,” the researchers warn. This flu drug, nor any other drug, has not been specifically developed against coronaviruses. As a result, the potency of favipiravir is to be considered moderate at best.
- The study also highlights the importance of using small animals to test therapies against SARS-CoV-2 in vivo. “Our hamster model is ideally suited to identify which new or existing drugs may be considered for clinical studies,” explains Professor Johan Neyts. “In the early days of the pandemic, such a model was not yet available. At that time, the only option was to explore in patients whether or not a drug such as hydroxychloroquine could help them. However, testing treatments on hamsters provides crucial information that can prevent the loss of valuable time and energy with clinical trials on drugs that don’t work.”
Not all research models are equal
- Kaptein, Rocha-Pereira, Delang and Neyts recently contributed to a commentary in Nature Communications in which they give additional context to the contradictory messages that have been circulating about (hydroxy)chloroquine. In the early days of the pandemic, several studies were set up to test these drugs in cell cultures. The results suggested that they could have an antiviral effect. As a result, clinical trials were organised to test the drugs on humans. However, cell cultures are not the best proxy for the human body, and no conclusive effect was found in humans.
- In their commentary, the authors describe several recent studies on human organ-on-chip and other complex in vitro models, mice, hamsters, and non-human primates. Each of these studies demonstrates that hydroxychloroquine and chloroquine do not have the efficacy suggested by the studies in cell cultures. Therefore, the authors conclude that these malaria drugs are very unlikely to be effective in humans as a C19 treatment.
2. New Hyperimmune Drug Created From Convalescent-Plasma
- The National Institute of Allergy and Infectious Diseases said a group of companies including Japanese drugmaker Takeda Pharmaceutical Co. began testing an experimental treatment for hospitalized C19 patients that is derived from the convalescent plasma of people who have recovered from the new coronavirus.
- The NIAID, a division of the National Institutes of Health, or NIH, is funding the study, which will enroll 500 hospitalized patients from across Africa, Asia, Europe, and North and South America, the NIAID said Thursday. The trial will compare the new drug in combination with the antiviral medication remdesivir made by Gilead Sciences Inc., versus a treatment of remdesivir and a placebo.
- The drug being tested combines anti-coronavirus antibodies derived from blood samples taken from multiple recovered patients. The aim is to make a more potent and effective form of so-called convalescent plasma therapy than is usually derived from a single patient. The new drug is called “hyperimmune intravenous immunoglobulin,” or hIVIG, and is sometimes referred to simply as “hyperimmune.”
- “We take the coronavirus convalescent plasma, and we pool it so there are literally thousands of donations that go into a manufacturing pool and we pull out the antibodies, purify it, and concentrate it down into the final medicine vial,” said Julie Kim, president of Takeda’s plasma-derived therapies unit.
- The hyperimmune drug is made from the liquid component of blood, or plasma, which contains antibodies. Convalescent plasma is a form of treatment in which plasma collected from recovered patients is transfused directly to C19 patients. Researchers hope the antibodies developed by the recovered patients can bolster the immune systems of new patients and help defeat coronavirus infections.
- The NIAID study will follow patients for 28 days and could be completed by the end of this year or in early 2021, said Bill Mezzanotte, CSL Behring’s global head of R&D and chief medical officer. If the drug shows a benefit in improving patient symptoms, it can be used by multiple companies to seek approval for their hyperimmune products, he said.
- The study is the latest of several efforts evaluating experimental drugs made from plasma donated by recovered patients. In July, Emergent BioSolutions announced plans to work with Mount Sinai Health System in New York City to test whether its own drug derived from the blood plasma of recovered C19 patients can prevent infections in doctors, nurses and military forces. In August, U.S. regulators granted an emergency-use authorization for convalescent plasma in treating seriously ill C19 patients.
- The NIAID study announced Thursday differs from these efforts in that the treatment contains several times more anticoronavirus antibodies than are typically contained in convalescent plasma, the institute said. Researchers pool the various plasma donations and purify and concentrate the antibodies, creating what is known as hyperimmune globulin.
- Whereas convalescent plasma must be used within 24 hours, hyperimmune globulins can be stored for as long as three years, according to Takeda. Such therapies have been shown to be effective in treating severe acute viral respiratory infections, the company said.
F. Concerns & Unknowns
1. Doctors Tell Me I Have COVID. Why Won’t the Tests?
- I first started feeling sick on Sunday night, August 16. I had spent the previous week dealing with excruciating neck pain whose origins I couldn’t quite explain. My mother, a doctor who takes great pride in her formidable diagnostic skills, was sure that this was the opening salvo of a COVID infection. I waved it off, insisting that I had probably just gone a little too hard on the ab workout. But by Sunday night, it was clear something was wrong. I barely made it through grocery shopping and had to lie down several times while making dinner. By morning, I had chills, a runny nose, and a scratchy throat. Something told me my mother was right. I called my primary-care physician’s office in Washington, D.C., and went downtown to their testing site. A quick swab of the nose yielded a negative result two days later. I was elated. I wasn’t feeling awful, just a little under the weather, and now the test confirmed what I wanted to hear: I didn’t have C19. But my mother and sister, a doctor who took care of COVID patients at the peak of the pandemic, were adamant: I was to stay home and quarantine for two weeks.
- Gradually, the symptoms came back—though they never went away, really. They came in waves. I’d spend most of the day feeling fine, only to have my temperature spike as I swaddled myself in layers of clothing and blankets to fight the chill. Within an hour or two, I’d feel completely fine again. My senses of taste and smell started fading in and out. I could no longer smell my cat’s litter box and ice cream just tasted cold. Then my sense of taste would come back, but some things, like sweets, tasted intolerably intense. A brain fog pulled in, and I found myself constantly searching for simple words. It was the first time I had felt this way while speaking English, rather than a foreign language.
- I was becoming increasingly convinced that I had COVID, so I tried to remember everyone I’d seen in the two weeks before I’d gotten sick in order to warn them that, by coming in contact with me, they might have been exposed. I told them by text that, even though I tested negative for COVID, I suspected I was infected and encouraged them to get tested. My friends’ responses surprised me: The vast majority said they felt fine and that they did not feel the need to get tested because my own result had been negative. In their minds, they could not have been exposed if I had tested negative—never mind the symptoms I was showing. There wasn’t much I could do to convince them, so I decided to get a repeat test. This time, I went to one of the walk-up testing sites the government of Washington, D.C., had set up all over the city. I filled out the questionnaire: “Have you experienced any of the following symptoms?” It listed the symptoms of COVID—cough, sore throat, body aches, chills, loss of taste, loss of smell, difficulty breathing. I checked nearly every box. A quick nose swab and I was home, where, 48 hours later, I received another negative result.
- In the meantime, the ebb and flow intensified. Every time I thought I was feeling better, a new wave of illness covered me. I’d have a good day, only to sleep 16 hours the next and feel utterly unable to move unless I also took a three-hour nap. Shit, I thought, convinced I was getting sicker, only to feel fine the day after that.
- About halfway through my third week of being sick, a tightness crept into my chest. It felt like someone had grabbed a hold of my trachea and was steadily strengthening their grip. I went from chills to sweats and back. My mother and sister were convinced it was COVID, but how could that be if I had twice tested negative? Friends checking in on me were growing increasingly certain: Two negative tests meant I did not have COVID. “Girl,” one friend texted, “stop telling people you have COVID when you just have a cold!”
- But it didn’t feel like a cold. In fact, it didn’t feel like anything I’d ever had before. No cold or even flu had ever been this wobbly. Not even mono or whooping cough had been this much of a roller coaster. All of them had been straightforward, linear illnesses, and none of them made me question my sense of reality. I felt like I was bobbing around in a kind of viral purgatory, with no end in sight. Still, two negative COVID tests felt pretty definitive.
- It made me wonder: Was it possible to have C19 and still test negative for SARS-CoV-2, the virus that causes it—twice? And if false negatives were possible, how frequent were they? I had read stories about false negatives in the spring, and I’d heard anecdotes from friends working in New York hospitals who didn’t fully trust the tests after having to place critically ill patients on ventilators, even though the patients had repeatedly tested negative for the novel coronavirus. A friend’s elderly grandmother had tested negative four times, but was still treated on the COVID floor of her Florida hospital. And I remembered my mother, who had been sick for a month and tested negative for COVID twice, despite sharing a home with my father, who had been sick and tested positive for the coronavirus. But my impression was that the tests had gotten much better since then.
- Moreover, compared to the early days of the pandemic, the tests had come to mean something different to many people. They’d become the key to getting life back to something approaching normal in the absence of a vaccine. A new kind of faith had been placed in them. All summer, people I knew were taking tests in order to join friends in beach houses or to visit family if the result came back negative. But now I wondered, if it were possible for someone with the virus to test negative for it—and given the politicization of the CDC’s testing guidelines—had we grown too confident in the tests and in our ability to find and isolate infected people?
- I started calling the directors of prominent labs, interviewing doctors who had cared for coronavirus patients and asking them: How likely was a false negative? And did I have COVID? In the meantime, I was feeling worse and worse. The fatigue and brain fog were overwhelming, the chest tightness wasn’t letting up, and a dry, barking cough was making it impossible to sleep. Against all medical advice, I went to get one more test—my third. I drove to a testing site in D.C. and, because I suspected the nasal swabs might have been missing something, asked the man administering the test if he could go back further than the nostril, to do the brain tickle I had read about. Oh, he told me, we don’t do those here. We only do nasal swabs. He showed me the short medical Q-tip before gently caressing the inside of each nostril.
- “You obviously have COVID,” my doctor said, brushing aside my now three negative tests. She told me to go to the hospital immediately.
- On the Saturday morning of Labor Day weekend, after three weeks of being sick, I got an email informing me that I had again tested negative. But by evening, it was becoming harder and harder to breathe. I had been measuring my blood oxygen levels with an oximeter, a gadget that clamps onto your index finger. Given how quickly some patients can deteriorate without even realizing that their oxygen levels are falling, doctors have said oximeters are helpful for COVID patients to have at home. For the three weeks I had been sick, my oxygen levels remained safe and steady. That weekend, as it became harder to breathe, the levels began dropping. By Sunday morning, my oxygen level was at 89—alarmingly low. I called my PCP. “You obviously have COVID,” she said, brushing aside my now three negative tests. She told me to go to the hospital immediately.
- How did this happen? How did I get so sick, and how did the tests miss it? And was it even possible that I had COVID after three negative tests?
- The answer, I realized, was extremely complicated.
- “Just because you’ve tested negative twice doesn’t mean that you don’t have it,” Geoffrey Baird, M.D., Ph.D., told me after my second negative test. Baird runs the lab at the University of Washington, which dealt with the first COVID hotspot in the U.S., and I had written about his team’s herculean efforts to develop their own test for the novel coronavirus. He was the first person I called in my quest to understand what was going on with me and if I was an outlier. “Your story is unusual,” Baird said, “but it is not unique.”
- During the peak of the pandemic in the spring, Baird told me it was not uncommon for doctors treating patients in the University of Washington hospital to call down to his lab, confused by the COVID test results they had just received. In front of them would be a patient with a fever and severe respiratory symptoms, but the lab results would say the patient was negative for the coronavirus. The two pieces of evidence—what the doctor saw and what the test said—seemed to contradict each other. Resolving this contradiction—and doing so quickly—was not only a matter of life and death, but of containing the pandemic. If a patient presenting in the emergency room with COVID-like symptoms tested negative for SARS-CoV-2 and was not, in fact, infected with the virus—what’s known as a true negative—then a doctor’s course of action would be very different than for someone who really did have C19. They might even send the patient home to recover without telling them to quarantine. But what if it was a false negative? That is, what if the patient actually did have SARS-CoV-2 in their system, but, for whatever reason, it was not showing up on the test? If the doctors relied only on the test and that patient were sent home or put in a regular wing of the hospital, they might end up infecting others with this new, highly contagious, and deadly virus.
- Part of the issue concerns the tests themselves. At the beginning of the pandemic, the United States government was using a testing kit—put out by the CDC—that turned out to be faulty. Infections in the U.S. were skyrocketing, and the FDA eventually allowed hospitals, university labs, and private manufacturers to create their own tests. The ad hoc approach helped fill America’s testing gap, but as a result, there was no gold standard for the coronavirus test. There still isn’t. Each of the test manufacturers who applied to the FDA for emergency permission to create a test—and there are 165 of them—had to submit their own data for how well those tests worked.
- Some tests were very accurate, but others weren’t. One review of available tests found that the likelihood of their yielding a false negative could be anywhere from 2% to 29%. Another found that up to 30% of tests could spit out a false negative. Other physicians gave me a range from 10 to 20%. One faster test, the Abbott ID NOW, which President Trump promoted in a Rose Garden press conference, was found to be only 51% sensitive. That is, this one test was just as likely to give you a false negative as it was to give you an accurate result: not much better than a coin toss. (Public debate has now shifted to the more rapid antigen tests, which use a different technique than the PCR tests that are in use now. But they, too, have a vast range of accuracy, and are far less sensitive than PCR tests. The chances of getting a false negative is, on average, around 30%, though on some of the tests, it can be as high as 50 or even 70%.)
- And though PCR tests have become far more sensitive—that is, less likely to yield a false negative—they are still not 100% accurate. They are also far more likely to produce a false negative than a false positive. “There’s no perfect test,” Baird told me. “The ones we have now are 80 to 90% sensitive. That’s really good, but that means there is still the one-in-five chance of a false negative.”
- In fact, when I went back to look at my test results, the disclaimers were there, in black and white. I had just missed them. Right under my first negative test result, for example, was the following warning: “When diagnostic testing is negative, the possibility of a false negative result should be considered in the context of a patient’s recent exposures and the presence of clinical signs and symptoms consistent with C19.” That is, if you tested negative for the coronavirus but still have symptoms of COVID, you might have gotten a false negative. You might still have COVID.
- And that’s just the probability for error built into the test itself. There is a whole other range of factors that all have the potential to chip away at the test’s accuracy.
- The standard COVID test is done through the nasopharyngeal swab, which samples the back of your nasal passage and throat. But this sampling technique, though highly sensitive, is not perfect either. “The virus enters through the nose, but it does a lot of its business in the lungs,” Baird explains. “The further away you get from your lungs, the less virus there is.” Baird, as well as clinicians I spoke to from New York, San Francisco, and Atlanta, told me that they had seen several instances of patients who had tested negative on the swab, but whose lung fluid was found to be teeming with the coronavirus. Of course, one would have to be pretty sick—hospitalized and intubated—to have their lung fluid tested. If you only have mild symptoms, as I did at the beginning, no one is going to go burrowing in your lungs.
- Conversely, the test might also miss a COVID infection, according to studies, if you’re swabbed too early after being exposed.
- One missed infection—and the false sense of confidence created by a false negative—can create a chain of transmission that snares dozens of people.
- Moreover, if there’s something specific in the way you are built—about the physical structure of your nose, for example—or if, for whatever reason, when the virus hit you, it went straight to your lungs, repeating a COVID test wouldn’t give you a more accurate result. Here, the laws of probability run into your specific physiology. “If there’s something about your nose or your disease that makes it harder for the test to catch,” explains Baird, “it’s more likely to repeat the false negative because whatever it is about your nose or your disease is also true the second time you get tested.”
- Then there is the question of how good of a sample the swab gets. Nasopharyngeal swabs—those long Q-tips that go so far back into your nose that they feel like they’re going to come out the back of your head—are more sensitive than simple nasal swabs that only make contact with the insides of your nostrils. But the city of Washington, D.C., for example, conducts COVID tests using nasal-only swabs. When I called the city’s public health department to ask why the city had opted for nasal swabs instead of the more sensitive brain ticklers, a spokesperson there told me that it was “mostly based on supply availability.” In the early days of the pandemic, when there were shortages of testing supplies, the city went with what was available and it stuck.
- Even when it’s done right, “there is no perfect test,” said David Hirschwerk, M.D., the vice chair of infectious diseases at Northwell, one of the largest private health care networks in the New York area. He and his team conducted a study in which they swabbed each patient with two different swabs. “We did see a discordance,” he told me. That is, the same patient yielded a negative and a positive result at the same time.
- The sheer scale of the pandemic—and the volume of testing—means that there are far more false negatives occurring than we think. “Even if a test were 98% sensitive and 99% specific,” warned a recent article in the New England Journal of Medicine, “it would still produce a false negative result in 2 of every 100 people infected. If we test 5 million Americans daily and only 1% of them have C19, a total of 1000 positive cases will be missed, which increases the risk of spread.” And as we know, one missed infection—and the false sense of confidence created by a false negative—can create a chain of transmission that snares dozens of people.
- So what is a physician to do? Do you trust the test or the patient? And what was I to do?
- “I would probably tell you you still have COVID and you should quarantine and act as if you have COVID,” Neda Frayha, M.D., an internal medicine doctor who teaches medicine at the University of Maryland, told me. “If someone has symptoms that look and feel and sound like COVID but the result is negative, we need to treat it as if it’s COVID.”
- One young doctor, who treated the crush of COVID patients when her hospital in New York City was overwhelmed in the spring, told me that back then, “we relied heavily on clinical diagnoses.” At the time, she said, “if the picture fit COVID, then it’s COVID unless you can convince us otherwise. At the end of the day, the COVID test was very helpful to have when it was positive, but there were patients that clearly had COVID, based on things like their X-rays, their labs, and their symptoms.” (This doctor asked for anonymity because she was not authorized to speak to the press.)
- Though a false negative is far less likely when the virus isn’t raging in your community, “if you have symptoms that are concordant with COVID, and it’s the time of year when there isn’t much flu going around,” Hirschwerk said, referring to August, when I got sick, “there’s probably a very good chance that, irrespective of the test, you have COVID.”
- “If you come in with COVID symptoms, you’re severely ill and have the classic presentation, you’re still pretty likely to have it,” said Baird. “Using just the test is a rookie mistake,” he explained, likening such a move to using merely glucose levels to diagnose something as complex as diabetes. “It’s why we have doctors and not robots.”
- Why do these doctors feel they can override my negative COVID tests? The answer lies in something called Bayes’ Theorem and its idea of pretest probability. Since the beginning of the pandemic, medical journals have been publishing articles reminding doctors to use Bayes’ Theorem, which encourages a physician to integrate all the pieces of evidence in front of them, both the test and what their clinical acumen is telling them. According to Bayes’ Theorem, if a patient’s pretest probability is high—they have all the COVID symptoms, say, or they had close contact with a confirmed COVID patient—getting a positive test result slides their probability to 100% probability of having the coronavirus, but getting a negative test does not take them to zero. “There’s a moving dot on a continuum between zero and 100,” Baird explained. “With a negative test, we’ve lowered the probability, but it would still not be zero.”
- James Crawford, M.D., who runs the diagnostic labs at Northwell, put it even more bluntly. “When the pretest probability is really high, you’re going to ignore the test,” he said. “Yes, there are some crystal-clear diagnoses in medicine, but you spend a lot of time as a doctor doing probabilistic medicine and trying to do right by your patient.”
- In my case, I had all the cardinal symptoms of COVID (including the loss of taste and smell), I live in an area of Washington with some of the highest COVID rates in the city, and I got sick during the height of summer, making the flu far less likely. My pretest probability, according to Frayha, was very high. “It’s the fact that you have symptoms and that they feel and sound a whole lot like COVID,” she said. If she is right, according to Bayes’ Theorem and a research study recently published in the BMJ (originally the British Medical Journal), the likelihood of my having COVID is not negligible—in fact, it’s quite high. “For a pretest probability of 90%, someone with a negative test has a 74% chance of having C19,” the authors of the paper wrote. “With two negative tests this risk is still around 47%.”
- When Frayha and I spoke, I asked her if it was significant that whatever I had was so in and out, and felt so different from anything I’d had before. By that point, I had been sick for nearly three weeks and had had two negative tests, and though I was tired of non-doctor friends questioning whether it was really COVID, there was a growing part of me that was afraid they were right, even as I was spending more and more energy trying to prove to them—and to myself—that I wasn’t crazy.
- “I must sound totally insane to you,” I told Frayha. “I must sound like I’m making it up.”
- “Actually, it makes me think more of COVID than anything else,” she replied. “Other upper respiratory viruses are very linear. This virus is very unpredictable, and there’s a lot of mystery to it still. But people know when what they’re going through is something different than what they’ve been through before. When my patients tell me, ‘This is nothing like anything I’ve ever experienced,’ I pay attention to that. Those personal memory points are very important in interpreting what’s going on. People know when something different is going on, and that’s very important to pay attention to. That should be empowering, even more than what a laboratory says. Listen to your body.”
- On Monday, September 14, I got another COVID test. This time it was a brain tickler, and this time it was in the emergency room. After my Labor Day scare, I was prescribed steroids, which recent studies have shown to be effective in dealing with the fact that the coronavirus sends the immune system into overdrive, sometimes to lethal effect. The steroids worked like magic. No more coughing, no more fatigue, and I could breathe without having to think about it or struggle for air. But then the course of treatment was over, the steroids left my system, and by Monday afternoon, I was sitting on my couch, pale and sweating and panting for air. My oxygen levels started going wonky again.
- In the ER, I told the staff that I had tested negative for COVID three times, but the nurse taking care of me repeated what I had heard from all the doctors I had interviewed when I was still well enough to work. “We’re going to treat you like it’s COVID unless you can convince us otherwise,” he said.
- “The CDC has guidelines on this,” the ER doctor told me ruefully, “but I don’t trust the CDC anymore.”
- A few hours later, the doctor treating me came in to discuss the results of the tests they’d run. I didn’t have blood clots, nor did I have pneumonia, but the X-ray did show that I had bibasilar atelectasis—partially deflated lungs. A few days later, at the pulmonologist’s office, I would learn that I also had what is called reactive airway disease, a vicious cycle of post-viral inflammation that results in coughing fits and difficulty breathing. (“Sure sounds like COVID,” the pulmonologist said.) I also found out that my last COVID test—my fourth—had come back negative. The ER doctor had warned me this might happen. Most people this far along in their illness—five weeks in my case—were usually no longer positive for the coronavirus. Plus, he added, “the tests aren’t perfect. They’re only about 80% accurate.”
- This made me wonder. “Do you think I’m still contagious?” I asked the ER doctor.
- “I don’t know,” he said, explaining that the science had not reached a verdict on this yet. But that was his educated guess. “The CDC has guidelines on this,” he told me ruefully, “but I don’t trust the CDC anymore.”
- “You’re not crazy, you’re not alone,” one doctor I spoke to assured me, as did the other physicians treating me. Still, my case is an outlier. The PCR tests are mostly very good, said Caitlin Rivers, Ph.D., an epidemiologist at Johns Hopkins. “It’s very possible to receive a false positive or a false negative, but I suspect that number is very small,” she told me. Even if people like me occasionally fall through the cracks, she added, “on a public health level, the tests are accurate enough to, on average, serve our needs to contain the epidemic. On a population level, the tests work.”
- Testing, Doctor Baird reminded me, “is not curative and it is not protective.” He went on: “The clear answer is, if you don’t follow all the rules, it will keep spreading.”
- Baird and Crawford, who run big diagnostic labs that were once at the center of COVID hotspots, are also pretty confident in the tests. Crawford estimates that the test he’s using at Northwell is 98% sensitive. It’s not 100%, but it’s close. They also stress that this is why it is important to get a handle on the spread of the virus: The less virus circulating in your community, the lower your pretest probability and the more you can trust a negative COVID test to mean you are really free from the virus.
- The other message is a more somber one: Tests are important, but they’re not the solution. Behavior is. Getting tested before you join friends at a beach house won’t protect you; social distancing and mask-wearing will. Getting tested before going on a trip doesn’t keep you from catching the virus en route; not going on the trip will. Testing, Baird reminded me, “is not curative and it is not protective, it’s an adjunctive to all the other things we’re doing.” He went on: “The clear answer is, if you don’t follow all the rules, it will keep spreading. There’s a reason the COVID pandemic maps onto the electoral map. It’s not testing or a lack of therapy, it’s choice and behavior. It’s a hugely bummer message to send out there, but COVID is real and it’s totally unforgiving. The virus will punish us right away for doing what we shouldn’t be doing.”
2. Immune cell activation in severe C19 resembles lupus
- In severe cases of C19, Emory researchers have been observing an exuberant activation of immune cells, resembling acute flares of systemic lupus erythematosus (SLE), an autoimmune disease.
- Their findings point towards tests that could separate some C19 patients who need immune-calming therapies from others who may not. They also may begin to explain why some people infected with the coronavirus (SARS-CoV-2) produce abundant antibodies against the virus, yet experience poor outcomes.
- The results were published online on Oct. 7 in Nature Immunology.
- The Emory team’s results converge with recent findings by other investigators, who found that high inflammation in C19 may disrupt the formation of germinal centers, structures in lymph nodes where antibody-producing cells are trained. The Emory group observed that B cell activation is moving ahead along an “extrafollicular” pathway outside germinal centers – looking similar to they had observed in SLE.
- B cells represent a library of blueprints for antibodies, which the immune system can tap to fight infection. In severe C19, the immune system is, in effect, pulling library books off the shelves and throwing them into a disorganized heap.
- Before the C19 pandemic, co-senior author Ignacio (Iñaki) Sanz, MD and his lab were focused on studying SLE and how the disease perturbs the development of B cells.
- Sanz is head of the division of rheumatology in the Department of Medicine, director of the Lowance Center for Human Immunology, and a Georgia Research Alliance Eminent Scholar. Co-senior author Frances Eun-Hyung Lee, MD is associate professor of medicine and director of Emory’s Asthma/Allergy Immunology program.
- “We came in pretty unbiased,” Sanz says. “It wasn’t until the third or fourth ICU patient whose cells we analyzed, that we realized that we were seeing patterns highly reminiscent of acute flares in SLE.”
- In people with SLE, B cells are abnormally activated and avoid the checks and balances that usually constrain them. That often leads to production of “autoantibodies” that react against cells in the body, causing symptoms such as fatigue, joint pain, skin rashes and kidney problems. Flares are times when the symptoms are worse.
- Whether severe C19 leads to autoantibody production with clinical consequences is currently under investigation by the Emory team. Sanz notes that other investigators have observed autoantibodies in the acute phase of the disease, and it will be important to understand whether long-term autoimmune responses may be related to the fatigue, joint pain and other symptoms experienced by some survivors.
- “It’s an important question that we need to address through careful long-term follow-up,” he says. “Not all severe infections do this. Sepsis doesn’t look like this.”
- In lupus, extrafollicular B cell responses are characteristic of African-American patients with severe disease, he adds. In the new study, the majority of patients with severe infection were African-American. It will be important to understand how underlying conditions and health-related disparities drive the intensity and quality of B cell responses in both autoimmune diseases and C19, Sanz says.
- The study compared 10 critically ill C19 patients (4 of whom died) admitted to intensive care units at Emory hospitals to 7 people with C19 who were treated as outpatients and 37 healthy controls.
- People in the critically ill group tended to have higher levels of antibody-secreting cells early on their infection. In addition, the B cells and the antibodies they made displayed characteristics suggesting that the cells were being activated in an extrafollicular pathway. In particular, the cells underwent fewer mutations in their antibody genes than seen in a focused immune response, which is typically honed within germinal centers.
- The Nature Immunology paper was the result of a collaboration across Emory. The co-first authors are Matthew Woodruff, PhD, an instructor in Sanz’s lab, and Richard Ramonell, MD, a fellow in pulmonary and critical care medicine at Emory University Hospital.
- Ramonell notes that the patients studied were treated early during the C19 pandemic. It was before the widespread introduction of the anti-inflammatory corticosteroid dexamethasone, which has been shown to reduce mortality.
- The team’s findings could inform the debate about which C19 patients should be given immunomodulatory treatments, such as dexamethasone or anti-IL-6 drugs. Patients with a greater expansion of B cells undergoing extrafollicular activation also had higher levels of inflammatory cytokines, such as IL-6.
- Some C19 patients have been given drugs that push back against IL-6, but results have been mixed in clinical trials. Patients with markers of unregulated immune responses may be appropriate candidates for treatment with anti-inflammatory drugs that target the corresponding pathways, Sanz suggests.
3. Over 80% of hospitalized coronavirus patients experience neurological symptoms
- While respiratory issues are a well-documented symptom of coronavirus, researchers have found that over 80% of hospitalized C19 patients experience some type of neurological manifestation as well. In examining 509 patients admitted to a Chicago hospital network, researchers found that 419 of them presented a neurological issue at some point during the course of their C19 infection.
- “The most frequent neurologic manifestations were myalgias, headaches, encephalopathy, dizziness, dysgeusia [impaired sense of taste] and anosmia [loss of smell],” the authors wrote in their study, which was published Monday in the Annals of Clinical and Translational Neurology. “Strokes, movement disorders, motor, and sensory deficits, ataxia and seizures were uncommon.”
- The patients involved in the study were admitted to the Northwestern Medicine Healthcare system between March 5 and April 6, and all had been diagnosed with C19. The team noted neurologic symptoms based on a review of clinical notes, diagnostic studies, and physician-documented diagnoses taken during the patients’ hospitalizations. The patients ranged in age from 16.9 years old to 58.5 years old, and 134 required mechanical ventilation during their stay.
- The researchers noted that patients with neurologic symptoms experienced longer hospital stays than those without, but discharge functional outcomes and mortality were not significantly different between those with and without. They also found that those experiencing neurologic issues were found to be younger than those who were not.
- “The fact that any neurologic manifestations as a whole were more likely to occur in younger people is surprising, and could potentially be explained by greater clinical emphasis on the risk of respiratory failure than other symptoms in older patients,” the study authors noted. “Alternatively, early neurologic manifestations such as myalgia, headache, or dizziness may have prompted earlier medical care. In contrast, encephalopathy was more frequent in older patients.”
- The authors also acknowledged that the study has several limitations, including that fewer than 6% of patients were evaluated by a neurologist, were cared for under strict infection control, and that the data is retrospective. However, they say the data did provide a more generalized view of neurologic symptoms that should be further explored.
- “Only 9 months into the pandemic, the long-term effects of C19 on the nervous system remain uncertain,” the authors wrote. “Our results suggest that, of all the neurologic manifestations, encephalopathy is associated with a worse functional outcome in hospitalized patients with C19, and may have lasting effects.”
- They called for long-term follow-up in patients with these symptoms and said that cognitive and neurologic-focused rehabilitation could potentially have a “significant” role in recovery.
4. Flurry of coronavirus reinfections leaves scientists puzzled
- On 15 August, a 33-year-old man landed in Hong Kong after flying home from Spain. On arrival, he was screened for coronavirus. Despite feeling well he tested positive. It was the second time he had picked up C19 in less than five months.
- The case immediately caught scientists’ attention. The man was the first in the world to have a confirmed coronavirus reinfection and there were positives to take from the report. First and foremost, he was asymptomatic. Although reinfected with the coronavirusn(Sars-Cov-2), his immune system swung into action fast and contained the virus without him knowing.
- Many researchers took heart from the case, but since the patient came to light a flurry of reinfections around the world have raised fresh concerns. Within days of the Hong Kong case being made public, doctors in the US reported that a 25-year-old man from Reno, Nevada, had been hospitalised with a C19 reinfection after shrugging off an earlier brush with the disease. More cases soon followed. While most infections were no worse the second time around, a good number cropped up – in the US, the Netherlands, Ecuador and India – where the reinfection was more severe.
- “It’s really hard to find a pattern right now,” said Akiko Iwasaki, a professor of immunobiology at Yale University who has been following cases of reinfection closely. “Essentially every case is different.”
- So far, only two dozen or so reinfections have been confirmed worldwide in a pandemic that has infected more than 30 million people. For now at least, reinfection seems uncommon. But scientists point out that confirming reinfection is no easy task and many cases are missed.
- To confirm a reinfection, scientists must examine the genetic code of the virus from each round of illness and prove they are distinct. That means having access to both sets of swabs and the wherewithal to do whole genome sequencing. Even in hospitals where the capacity exists, such tests are rarely done. Reinfected patients simply go unnoticed or unreported. “There is probably a lot more than we are seeing,” said Iwasaki.
- The immune system’s battle against coronavirus is unleashed in several waves. The first line of defense, the innate immune system, is imprecise but fast. Invading pathogens prompt cells to churn out signaling proteins called cytokines which call in an army of white blood cells that engulf and disrupt the virus.
- Next to gear up is the adaptive immune system, a more specialized attacking force. This unleashes T-cells, which destroy infected cells, and prompts B-cells to make antibodies that stick to viruses and stop them spreading further. If and when the infection is beaten, the T- and B-cells stand down, but some should be stored in the body for years, an immune memory that can be recommissioned should the virus try again.
- Given the complexity of the immune response, it is no surprise that scientists are struggling to unravel why reinfections occur. Blood tests on patients reveal that virus-disabling antibodies can wane after a few months, particularly in those with mild or no symptoms. But even with healthy levels of antibodies, reinfection can not only happen, but cause more serious disease.
- In a report on reinfected healthcare workers in India, Prof Jayanthi Shastri and her team at Kasturba hospital for infectious disease in Mumbai describe a 25-year-old nurse who suffered more with a reinfection two months after her first battle with coronavirus. “Her immunity wasn’t enough to protect her from the second, more severe infection despite the presence of neutralizing antibodies,” Shastri said.
- The finding, and similar cases, has refocused attention on a handful of questions that scientists are struggling to answer. What does protective immunity look like? How long does it last? Do some patients fail to mount the right response? Does the virus damage the immune system? And are reinfected people infectious to others?
- Danny Altmann, professor of immunology at Imperial college in London, guesses that those who recover from C19 will have perhaps 90% protection for a “fair while”. But how long is that? “I would bet my house on you being safe for possibly a year but not much longer,” he said. “The problem is that whenever an immunologist says anything about Covid immunity to a journalist, it’s right for about two weeks and then it’s completely wrong.”
- Reinfections may be worse for a whole host of reasons. The person might have been exposed to more virus the second time around, or may simply have been under the weather already when the virus struck again.
- Another possibility is so-called antibody-dependent enhancement – a glitch in the immune system where antibodies help an invading virus rather than hinder it. This is seen in dengue fever where second infections can be far more dangerous than the first.
- Yet another possibility is that the virus harms T-cells, in some patients at least. “We need to study the T-cells,” said Swapneil Parikh, who worked with Shastri on reinfected hospital workers. “Is the virus doing something to the immune system that is setting you up for more severe infections?”
- The virus can certainly disrupt the immune system. In August, Shiv Pillai, an immunologist at the Ragon Institute of Massachusetts general hospital, examined tissue taken from dead C19 patients. He looked for structures called “germinal centres” in the spleen and lymph nodes. These are where B-cells go to develop antibodies before they are stored in the immune system’s memory. Pillai failed to find any, suggesting the patients were unable to generate highly effective, long-lasting antibodies that would fight the virus for years.
- He believes the same problem may arise in people with milder C19 too. “If we want antibodies that will persist for a few years and protect us, it’s not clear that’s going to happen,” he said. The good news is that a vaccine should not cause the same problem as the virus. “I don’t see why the vaccines won’t work. They may not be fantastic, but I believe that’s what’s going to protect us,” he said.
- If the virus spreads further through the autumn and winter, Iwasaki expects to see more reinfections, with some patients infectious enough to pass the virus on.
- According to Stephen Reicher, professor of social psychology at the University of St Andrews, and a member of the behavioural science subgroup of Sage, that poses another problem. People who have recovered from C19, and many who falsely believe they had it, may believe they are protected in the second wave. “I think it is important, all ways round, to dispel the myth of invulnerability,” he said.
5. Even Mild C19 Infections Can Make People Sick for Months
- C19 patients who experience even the mildest illness risk suffering symptoms for months, researchers in France found.
- Two-thirds of patients who had a mild-to-moderate case of C19 reported symptoms 60 days after falling ill, when more than a third still felt sick or in a worse condition than when their coronavirus infection began. Prolonged symptoms were more likely among patients aged 40 to 60 years and those who required hospitalization, according to staff at Tours University Hospital, who followed 150 non-critical patients from March to June.
- Their study, published Monday in the journal Clinical Microbiology and Infection, adds to evidence that a proportion of the 35 million people known to have been infected with the SARS-CoV-2 virus worldwide will suffer lingering effects weeks to months later. Post–Covid clinics are opening in the pandemic’s wake to cater for an expanding population of so-called long-haulers — survivors left with scarred lungs, chronic heart damage, post-viral fatigue and other persistent, debilitating conditions.
- “We were able to assess the evolution of the disease and demonstrate that even the mildest presentation was associated with medium-term symptoms requiring follow up,” Claudia Carvalho-Schneider and colleagues wrote. “Thus, the C19 pandemic will involve a care burden long after its end.”
- Two months after developing C19 symptoms, 66% of adult patients reported suffering from at least one of 62 complaints, mainly a loss of smell and taste, shortness of breath, and fatigue, the researchers found. The study sought to identify the risk of longer symptom duration in patients with non-critical C19, since much of the existing international research was based on survivors admitted to intensive care units, they said.
- Longer-ranging studies and clinical trials will be critical to elucidate the durability and depth of health consequences attributable to C19 and how these may compare with other serious illnesses, Carlos del Rio, executive associate dean at Emory University School of Medicine, and colleagues wrote in an editorial Monday in the Journal of the American Medical Association that reviewed the coronavirus’s persistent effects.
6. Does C19 Cause Diabetes?
- From the outset of the pandemic, data coming out of early coronavirus hot spots like China, Italy, and New York City foretold that certain groups of people would be more vulnerable to C19. The disease hit older people and people with underlying medical conditions the hardest. As early as February, diabetes had emerged as one of the conditions associated with the highest risk. In one large study out of China, people with diabetes were more than three times as likely to die of C19 than the overall population.
- But that’s not what brought four diabetes experts from Australia and the United Kingdom onto a Zoom call back in April. They were supposed to just be catching up—a virtual tea among friends. But talk soon turned to something strange that they’d been seeing in their own hospitals and hearing about through the grapevine. The weird thing was that people were showing up in C19 wards, after having tested positive for the virus, with lots of sugar in their blood. These were people with no known history of diabetes. But you wouldn’t know it from their lab results.
- After that call, the experts reached out to colleagues in other countries to see if they’d seen or heard of similar cases. They had.
- Acute viral infections of all sorts can stress the body, causing blood sugar levels to rise. So that in itself wasn’t unusual, says Francesco Rubino, a bariatric surgeon and diabetes researcher at King’s College in London, who was on that first Zoom call. “What we were seeing and hearing was a little bit different.”
- Doctors around the world had described to him strange situations in which C19 patients were showing symptoms of diabetes that didn’t fit the typical two-flavor manifestation of the disease. In most people with type 1 diabetes, their immune cells suddenly turn traitorous, destroying the cells in the pancreas that produce insulin—the hormone that allows glucose to exit the bloodstream and enter cells. People with type 2 diabetes have a different problem; their body slowly becomes resistant to the insulin it does produce. Rubino and his colleagues were seeing blended features of both types showing up spontaneously in people who’d recently been diagnosed with C19. “That was the first clinical puzzle,” he says.
- For clues to an explanation, Rubino and his colleagues looked to ACE2, the protein receptor that SARS-CoV-2 uses to invade human cells. It appears in the airways, yes, but also in other organs involved in controlling blood sugar, including the gut. Doctors in China discovered copies of the coronavirus in the poop of their C19 patients. And a meta-analysis found that gastrointestinal symptoms plague one out of 10 C19 sufferers.
- In the last few decades, scientists have discovered that the gut is not the passive digestive organ once thought. It actually is a major endocrine player—responsible for producing hormone signals that talk to the pancreas, telling it to make more insulin, and to the brain, ordering it to make its owner stop eating. If the coronavirus is messing with these signals, that could provide a biological basis for why C19 would be associated with different forms of diabetes, including hybrid and previously unknown manifestations of the disease. Rubino is one of a growing number of researchers who think that the relationship between the coronavirus and diabetes is actually a two-way street. Having diabetes doesn’t just tip the odds toward contracting a worse case of C19. In some people, the virus might actually trigger the onset of diabetes, and the potential for a lifetime of having to manage it.
- Take for example, three men who showed up at a hospital in the northern part of India weak, feverish, and without any history of diabetes. They all tested positive for SARS-CoV-2. And when their bloodwork came back, they all had dangerously high buildups of glucose and ketones, which the body produces when it doesn’t have enough insulin to break down sugar. The official term for the potentially deadly complication is diabeteic ketoacidosis, and it is usually seen in children with type 1 diabetes.
- Mohammad Shafi Kuchay, an endocrinologist who consulted on the cases, told WIRED via email that he and the other doctors assigned to the cases assumed the virus had somehow knocked out these patients’ insulin-making cells, giving them type 1 diabetes. And so the doctors put the men on a regimen of insulin injections. But as the months went by, they needed the injections less and less. They were shifted to oral antidiabetic drugs, and have been managing like this for more than two months now. “That means the patients have type 2 diabetes,” Shafi Kuchay wrote. Whatever damage the virus caused to these patients’ insulin-secreting cells appears to be transient. More monitoring will be necessary to determine if their type 2 diabetes diagnosis is short-lived, as well.
- Will other patients also find that their blood sugar problems go away when their infection resolves? Or will C19 cause diabetes for life? “None of those questions could be addressed with just the anecdotal case reports that were coming out,” says Rubino. That’s why he and an international group of scientists decided to act on their hunch and establish a global repository for tracking information about the coronavirus-related diabetes.
- The CoviDiab Registry allows doctors around the world to upload anonymized data about C19 patients with abnormal blood sugar levels who have no prior history of diabetes. That includes the basics, like age, sex, past medical history, and details of the person’s disease progression: Do they wind up in the ICU or on a ventilator? But the registry also asks doctors to catalogue which medications they’re administering, on the off chance that it’s not the coronavirus infection that’s triggering the diabetes but an unknown side effect of something used to treat it.
- The goal of this information-gathering effort is to grok the scale and scope of the problem, as well as potential solutions. How often is C19 associated with new-onset diabetes? And what flavor—type 1, type 2, or a new form of the disease? What exactly causes the metabolic malfunction? How long do such cases of diabetes last, and what are the best ways to treat them? It might be a while before there’s enough data to answer questions about prevalence and mechanism. But Rubino thinks they could have information about what kinds of diabetes most frequently develop in C19 patients—and what might predispose people to this particular coronavirus complication—by the end of the year.
- This is not the first registry to track the overlap between people with C19 and other conditions. Similar data pooling efforts spun up early this year for people with inflammatory bowel disease, chronic liver disease, and rheumatoid disorders, among others. Eric Topol, a leading cardiologist at the Scripps Research Translational Institute, has advocated for a similar approach to tracking heart complications of C19. The diabetes database launched in June, and since then, more than 275 physicians have requested access to share data about at least one patient who meets the criteria. Vetting each physician contributor takes time, and after that, registry organizers have to set up data-sharing agreements that comply with Europe’s strict data protection laws. But so far, dozens of cases have been uploaded. And what’s clear, says Rubino, is that this is not just an anecdotal problem. “From what we’ve seen so far, C19-related diabetes will not be a prevalent issue that affects the majority of people,” he says. “But now we know it’s a possibility, even if not a common one.”
- That’s important for people to know, because diabetes can be easily managed, as long as it’s recognized. Be aware, not alarmed, says Rubino. If you’ve recently been diagnosed with C19 and notice that you’re having to pee more often than usual, or are continuing to feel fatigued after you’ve recovered from other symptoms like fever, coughing, and loss of smell, that could be a good reason to ask your doctor about getting a blood test.
- Provided they find funding to keep it going, Rubino and his colleagues hope to keep the registry running for years. That would allow them to investigate whether Covid-associated diabetes is a fleeting condition that passes when the infection clears or a long-term diagnosis. It could also capture situations in which the infection doesn’t cause diabetes immediately, but causes enough damage to tissues involved in metabolism that it heightens a person’s risk of developing the disease later. “We’re looking at a possible legacy effect of C19,” says Rubino. “With the registry we hope to be able to look into the future, not just the present.”
H. The Road Back?
1. Operation Moonshot: UK Says Weekly COVID Tests Could Offer “Passport To Freedom”
Moon Shot Plan
- Boris Johnson recently announced a “Moonshot Plan” for the coronavirus that includes COVID passports.
- COVID Passports would give those who test negative the ability to return to “normalcy”. They would be able to attend sports events, concerts, got to work and school, without wearing masks. The proposed 20-minute tests that would allow this to happen have been suggested by Prime Minister Boris Johnson.
- Many people say these rapid, cheap tests are still in the development process and have not been approved. The likely hood of false positives and negatives would do nothing but create confusion and chaos. The entire process of developing these tests would require testing technology that does not yet exist.
- In articles written by Tom Shearsmith for The Industry and Turkey’s Anadolu Agency:
- Prime Minister Boris Johnson has suggested in today’s live broadcast Coronavirus press conference that the UK may “regain a sense of normality” by possibly introducing 20 minute testing to offer the equivalent of a C19 passport.
- During the conference, Johnson confirmed that from Monday a “rule of six” will be introduced in England, meaning people should not meet up in groups of more than six.
- He says this measure replaces current guidance – “people only need to remember the rule of six”. He says that two households cannot meet socially if they make a group bigger than six.
- Plans to pilot larger audiences in stadiums and to allow conferences to go ahead from October will be put on hold for review.
- Regarding a potential C19 passport, Johnson said: “In the near future we want to start using testing to identify people who are negative, who don’t have coronavirus, who are not infectious, so we can allow them to behave in a more normal way in the knowledge they can’t infect anyone else with the virus.”
- This could allow office workers who test negative in the morning being able to work how they did before the pandemic, or allow people to attend venues for entertainment, for example.
- “Up to now, we have used testing primarily to identify people who are positive – so we can isolate them from the community and protect high-risk groups. And that will continue to be our priority. We are working hard to increase our testing capacity to 500,000 tests a day by the end of October,” Johnson said.
- “But in future, in the near future, we want to start using testing to identify people who are negative – who don’t have coronavirus and who are not infectious – so we can allow them to behave in a more normal way, in the knowledge they cannot infect anyone else with the virus.
- “And we think, we hope, we believe that new types of tests which are simple, quick and scalable will become available. They use swabs or saliva and can turn round results in 90 or even 20 minutes. Crucially, it should be possible to deploy these tests on a far bigger scale than any country has yet achieved – literally millions of tests processed every single day,” added Johnson.
- Already Big Tech is working with the UK government to create these passports. Under discussion is the use of facial biometrics in order to prove which workers have had COVID.
- One such tech firm is Onfido, a firm that specializes in facial biometrics has already delivered detailed plans to the government about what it is able to help accomplish on a nationwide basis. It claims that its proposals could actually be realized within a couple of months. The proposals state that the firm could use antigen or antibody tests.
- It is telling that the World Health Organization is warning against “spreading false hope” with the immunity passport scheme. They argue we simply don’t know enough about how immunity develops after having had COVID. Yet the WHO and most countries are still going ahead with vaccine development.
Where is this going?
- We are actually witnessing a vaccine passport scheme, not an immunity scheme. “We don’t know enough about immunity” means having had COVID will not be enough to allow someone their “passport to freedom” as The Guardian has described it. However, the holy grail of vaccines will never be in question and we can offer a passport based upon proof of your vaccination. Predictably, this vaccine passport will extend to every other vaccine currently mandated by the governments of the “free world” upon its subjects.
- Onfido claims that its new “COVID passport” could be the “linchpin of the new normality.”
- The Guardian describes the scheme as follows:
- Their solution would embed Onfido technology within another organization’s app to establish someone’s identity. The person would be asked to take a selfie and an image of their government-issued identification, such as a passport or driver’s license. The technology can determine whether the person’s face matches their ID, and also if the ID is genuine. This creates a digital identity.
- They are then tested for coronavirus under a system endorsed by the government and the result is stored by another provider – in the UK this would most likely be the NHS.
- When the person goes to their workplace, they open the app, take a photo of their face and that unlocks a QR code. That QR code would be scanned by reception using simple camera technology and on their system they would see the test result and a photo of the employee’s face for a short time, allowing them to visually determine the identity of the person in front of them.
- The only technology a business would need to make this work would be a camera to take an image of the QR code as they arrive. No information about someone’s name, date of birth, address would be visible to the person on reception, only that they are fit to go into work.
- A government source said a form of certification system is “still on the table and being considered” and that conversations around this concept fall under the government’s “track and trace” plans.
- The list of ONFIDO investors includes Microsoft.
- Right now, “Digital Identity experts” say they are only in the discovery phase of a plan that would be tailored to the needs of the UK government.
I. Back to School!?
1. “Schools Aren’t Superspreaders” – The Atlantic Explains Why Students Should Be Back In School, Now
- After months of waging war, mainstream media outlets recently started to seriously address the reality of herd immunity, or at least the type of “focused” approach described in documents like the Great Barrington declaration, as a credible alternative to the lockdown-first strategy embraced by Dr. Fauci and the public health establishment around the world, to varying degrees of success.
- So far, we’ve seen WSJ (these are just a couple of examples), the FT and now the Atlantic, with its “Schools Aren’t Super Spreaders” article about why schools – at least for minor students – haven’t emerged as the C19 breeding grounds that many feared.
- The article was written by Emily Oster, an economist at Brown University. In it, she makes some surprising points. Before readers can write her off as an “economist” and not a “subject matter expert”, Oster explains that she has been working with national teacher and principal associations to collect data on school reopenings as part of a sprawling research project, which was also recently profiled in the NYT.
- While Brown acknowledges that she has seen a deluge of stories and datas about small (but decidedly not deadly) outbreaks on colleges campuses, she notes that there has been vanishingly little evidence of outbreaks in K-12 schools, whether private or public.
- Data on almost 200,000 kids in 47 states from the last two weeks of September shows an infection rate of 0.13% among students and 0.24% among staff. That translates to 1.3 infections over two weeks in a school of 1,000 kids, or 2.2 infections over two weeks in a group of 1,000 staff. Even in the most high-risk areas where schools were open, the risk to students was always well under 0.5%, Oster explains.
- What’s more, researchers in Texas and other states have arrived at similar conclusions.
- School-based data from other sources show similarly low rates. Texas reported 1,490 cases among students for the week ending on September 27, with 1,080,317 students estimated at school—a rate of about 0.14 percent. The staff rate was lower, about 0.10 percent.
- Of course, as Oster readily acknowledges, while these infection numbers are low, and deaths (among the children, at least) have been rare, they’re not zero.
- But for everybody who insists on 100% safety, Oster warns, it comes at a serious cost to the long-term well-being of children. And this burden is felt most intensely by low-income families and students, as parents simply don’t have the time and resources to supervise their child’s education from home.
- While infection numbers across the US have picked back up since Labor Day, Oster claims there’s no evidence connecting this to schools reopening. Indeed, even with schools still virtual in the nation’s largest districts, cases have still rebounded.
- The risk to children, at this point, has been well documented.
- One might argue, again, that any risk is too great, and that schools must be completely safe before local governments move to reopen them. But this approach ignores the enormous costs to children from closed schools. The spring interruption of schooling already resulted in learning losses; Alec MacGillis’s haunting piece in The New Yorker and ProPublica highlights the plight of one child unable to attend school in one location, but it’s a marker for more. The children affected by school closures are disproportionately low-income students of color. Schools are already unequal; the unequal closures make them more so. Virtual school is available, but attendance levels are not up to par. Pediatricians have linked remote schooling to toxic stress.
- Parents are struggling as well, not just children. Cities have recognized the need for child care for parents who cannot afford to quit their jobs to supervise their kids, but this has led to a haphazard network of options. Houston, for example, has opened some schools as learning centers. L.A. has learning centers set up for low-income students in alternative locations. These spur the questions: If school isn’t safe for everyone, why is it safe for low-income students? And if school is safe for low-income students, why isn’t it safe for everyone?
- From all the data she’s collected and distilled, Oster concludes simply this: “We do not want to be cavalier or put people at risk. But by not opening, we are putting people at risk, too.”
- It’s just another example of how research is challenging credentialed experts’ initial assumptions about C19.
J. Assessing Risk
1. Group Most Likely to Get C19 Is Least Likely to Die From It
- It isn’t clear whether President Trump, who is 74 years old, was infected with the coronavirus by a 31-year-old political adviser—but if he was, the transmission route from young to old would follow an international trend.
- Young people account for the majority of known C19 infections, but the elderly account for most of the deaths.
- “It’s a social moral dilemma,” said Mun Sim Lai, a population-affairs officer with the United Nations who has examined the trend. “Young people get the virus and don’t die, but they are the ones spreading it to old people. This is true over the world.”
- Dr. Lai analyzed data from 55 countries, including the U.S., and found that through Sept. 1, people who were 65 and older represented just 12% of confirmed coronavirus cases but 66% of deaths.
- Those who were 44 and younger accounted for 60% of known cases but only 7% of deaths.
- In the countries Dr. Lai examined, 11.7 million people younger than age 65 had been infected with Covid-19 and around 169,400 died. In comparison, 1.6 million older people had been infected and around 331,000 died.
- That doesn’t mean younger people have gotten a free pass.
- While the raw number of deaths caused by Covid-19 is low for ages 25 to 44, mortality has increased by around 25% this year compared with the previous five years, according to data provided by the U.S. Centers for Disease Control and Prevention.
- “Even though it’s a relatively small number of deaths, it’s a big impact,” said Robert Anderson, chief of the mortality-statistics branch at the National Center for Health Statistics, a division of the CDC. “It’s an additional fourth of what’s normal.”
- Another way to think about the impact is to consider how many people were expected to die this year based on historical data versus how many people have actually died.
- In the U.S., there were 10 deaths for every 10,000 people ages 25 to 44 on average in the first 32 weeks of the year from 2015 through 2019, Dr. Lai said, a period selected to match the number of weeks this year affected by C19 at the time of her analysis.
- Under normal circumstances, she would anticipate about the same mortality rate this year.
- “But what has happened,” she said, “is there were about 12 deaths for every 10,000 people ages 25 to 44 years old. The absolute risk for dying for that group is about two deaths per 10,000 people more than we would expect.”
- In the U.S., the leading cause of death for ages 25 to 44 is unintentional injury, including drug overdoses, with around 47,000 fatalities in 2018, the most recent year the information is available from the CDC.
- The fifth-leading cause of death for this group is homicide (behind suicide, cancer and heart disease) with 5,843 deaths in 2018. So far this year, around the same number have died from C19, according to the CDC’s provisional counts.
- The provisional numbers, which are based on death-certificate data, lag behind case surveillance by two weeks on average, according to the CDC, and are lower in comparison.
- Experts caution that the coronavirus might not have caused all of this year’s additional deaths.
- “It’s a good hypothesis that it’s from Covid, but you have to take into account if there is an increase of other things young people die of, like overdoses and accidents,” said Amira Roess, a professor of global health and epidemiology at George Mason University.
- For people 65 and older, Dr. Lai found 281 deaths per 10,000 people during the first 32 weeks of 2020 in the U.S., or about 40 more deaths per 10,000 people than expected.
- The leading cause of death for this age group is heart disease, with more than half a million losing their lives to that condition in 2018, followed by cancer, with more than 431,000 deaths. So far this year, at least 143,790 older people have died from C19, according to the CDC’s provisional counts, which would make it the third-leading cause of death.
- In some ways, the difference in mortality between the young and old isn’t surprising. The coronavirus kills the elderly more frequently than it does younger people—but so does pretty much everything else.
- According to data from the CDC, Americans who are 85 or older account for 30% of all deaths and 31% of C19 losses. Those who are 75 to 84 years old make up 24% of all deaths and 26% of C19 fatalities. And those who are 65 to 74 years old represent 20% of all deaths and 21% of coronavirus losses.
- “The percentages are remarkably close to how mortality affects the total population of each group,” Dr. Anderson said.
- But most leading causes of death aren’t contagious, and what concerns experts is the role resilient younger people have played in transmitting a deadly coronavirus to a vulnerable elderly population.
- “The fact is these younger folks don’t live in a bubble,” Dr. Anderson said. “They’re interacting with older folks. Even if they’re not at risk of dying, they’re at risk of infecting someone else who is at risk of dying.”
- And that might be hard to live with.
K. Projections & Our (Possible) Future
1. As C19 fills French ICUs again, doctors ask what went wrong
- During a single overnight shift this week, three new C19 patients were rushed into Dr. Karim Debbat’s small intensive care ward in the southern French city of Arles. It now has more virus patients than during the pandemic’s first wave and is scrambling to create new ICU beds elsewhere in the hospital to accommodate the sick.
- Similar scenes are playing out across France.
- C19 patients now occupy 40% of ICU beds in the Paris region, and more than a quarter of ICUs nationwide as weeks of growing infections among young people spread to vulnerable populations.
- Despite being one of the world’s richest nations — and one of those hardest hit when the pandemic first washed over the world — France hasn’t added significant ICU capacity or the staff needed to manage extra beds, according to national health agency figures and doctors at multiple hospitals.
- Like in many countries facing resurgent infections, critics say France’s leaders haven’t learned their lessons from the first wave.
- “It’s very tense, we don’t have any more places,” Debbat told The Associated Press. The Joseph Imbert Hospital in Arles is converting recovery rooms into ICUs, delaying non-urgent surgeries and directing more and more of his staff to high-maintenance C19 patients.
- Asked about extra medics to help with the new cases, he said simply, “We don’t have them. That’s the problem.”
- When protesting Paris public hospital workers confronted French President Emmanuel Macron this week to demand more government investment, he said: “It’s no longer a question of resources, it’s a question of organization.”
- He defended his government’s handling of the crisis, and noted 8.5 billion euros ($9.3 million) in investment promised in July for the hospital system. The protesting medics said the funds are too little and too slow in coming, after years of cuts that left France with half the number of ICU beds in 2020 that it had in 2010.
- ICU occupancy rates are considered an important indicator of how saturated the hospital system is and how effective health authorities have been at protecting at-risk populations. And France’s numbers aren’t looking good.
- It reported more than 18,000 new daily virus cases Thursday, and COVID patients now occupy 1,427 ICU beds nationwide — a figure that has doubled in less than a month. France’s overall ICU capacity is 6,000, roughly the same as in March, according to national health agency figures provided to the AP.
- In comparison, Germany entered the pandemic with about five times as many intensive care beds as France. To date, Germany’s confirmed virus-related death toll is 9,584 compared to 32,521 people in France.
- Getting ICU capacity right is a challenge. Spain was caught short in the spring, and has expanded its permanent ICU capacity by about 1,000 beds. Britain expanded ICU capacity by building emergency field hospitals. They were mothballed because they were barely used, but the government says they can be utilized again if required.
- France added extra makeshift beds in the spring and transported patients by plane and high-speed train from hotspots to less saturated areas. The health agency said French hospitals could eventually double their ICU capacity if needed this fall.
- Compared to March and April, doctors say French intensive care wards are better armed this time around, both with protective equipment and more knowledge about how this coronavirus works. Medics put fewer patients on breathing machines now and hospitals are practiced in how to rearrange their operations to focus on C19.
- The number of virus patients in the ICU quickly doubled last month in the New Civilian Hospital in Strasbourg, but the atmosphere is surprisingly calm. An AP reporter watched teams of medics coordinating closely to manage the trajectory and treatment of each patient according to strict protocols they’re now accustomed to.
- But that extra practice doesn’t mean managing resurgent virus cases in ICUs is easy. In addition to extra breathing machines and other equipment, adding temporary ICU beds also takes time and labor – as does treating the C19 patients in them.
- “The work is harder, and takes longer” than for most other patients, said Pierre-Yves, head of the intensive care ward at the Laveran Military Training Hospital in Marseille. He was not authorized to be identified by his last name because of military policy.
- Seven or more of his 47 staffers are needed each time they slowly and carefully rotate a patient from back to stomach or vice versa. Entering and leaving the ward now involves a lengthy, careful dance of changing full-body gear and disinfecting everything they’ve touched.
- Dr. Debbat in Arles said training ICU staff takes several months, so he’s relying on the same personnel levels as in the spring, and he worries they could burn out.
- “I’m like a coach and I have just one team, with no reserve players,” he said.
- He also worries about non-virus patients, who were already put on the back burner earlier this year. And he worries about the upcoming flu season, which sends about 2,000 patients to ICUs in France every year.
- The head of emergency medical service SOS Medecins, Serge Smadja, doesn’t think France will again face the situation it saw in the spring, when more than 7,000 virus patients were in intensive care at the peak of the crisis, and some 10,000 infected people died in nursing homes without ever making it to hospitals. But he said the French public and its leaders were wrong to think “the virus was behind us.”
- “There aren’t enough beds … and there is especially a lack of personnel,” he said. And with his service seeing a steady uptick in cases and the pandemic wearing on, he warned, “what’s missing is an end date.”
L. Practical Tips & Other Useful Information
1. Experts say extra pounds gained in quarantine may land you in hospital
- Those pounds you packed on during quarantine? Drop ’em before another wave of C19 hits.
- That’s the strong message coming from medical experts.
- Being obese has always been linked with the infection, but new studies show just how big a role weight plays. Now, doctors are warning that those considered only overweight, not obese, are at also at much higher risk of ending up in the hospital, the intensive care unit or dead.
- “It’s a very real thing that we’re seeing and talking about,” the University of Vermont’s Dr. Anne Dixon said of weight as an independent risk factor.
- An analysis of roughly 400,000 patients worldwide found that obese people were 113% more likely to be hospitalized, 74% more likely to be admitted to the ICU, and 48% more likely to die.
- Two more studies separated out the overweight. Researchers with Genentech, a biotech company, discovered that 29% of 17,000 patients hospitalized were overweight. Another 48% were obese. And a review of 334,000 people in England determined the rate of hospitalization began to rise for those with a Body Mass Index of 25 to 30 — the overweight, not obese, category.
- One reason the United States has had so many more confirmed cases than other countries, Dixon surmises, is because 40% of adult Americans are obese and another 32% are overweight.
- Dixon explains why carrying extra weight is so bad: the immune system is compromised, making it harder to fight the infection; the lungs are compressed, making it much harder for doctors to ventilate someone who’s sick; and the doses of medication for someone heavy are different than for someone lean and something that doctors don’t understand all that well.
- Personal trainers like Mauro Maietta, who oversees fitness for Crunch gyms on the East Coast, are spreading the word.
- “One of the things I’ve heard a lot is the quarantine 15 — almost like the freshman 15,” he said, “Some have gained 10 to 15 pounds. Others, 20 to 25 pounds.”
2. Why This Year’s Flu Vaccine Will Be Vital in the Fight Against C19
- While the world awaits a proven C19 vaccine, medical experts are turning their attention to a shot that’s long been a key component in the public health toolbox: the flu vaccine.
- Experts hope this year’s flu shot can help prevent an influenza epidemic paired with another wave of coronavirus, which could overwhelm hospitals and lead to general confusion, given that it can be difficult to tell a C19 infection from a case of the flu. This flu season is also something of a dress rehearsal for the eventual rollout of a C19 vaccine amid the ongoing pandemic, allowing doctors, nurses and pharmacists a chance to get more people comfortable with the idea of a vaccine while also finding safe ways to inoculate people without spreading the coronavirus.
- “While historically it’s fine to line [people] up and put them in close quarters—often in the winter, that’s inside—that’s not what we want to do here,” says Daniel Salmon, director of the Institute for Vaccine Safety at the Johns Hopkins Bloomberg School of Public Health. “So I think finding approaches and environments that are safe from a social distancing standpoint to vaccinate large numbers of people quickly—it’s absolutely an opportunity to get that right.”
- Moreover, there are already data showing that people have mentally linked the flu shot with the coronavirus vaccine—suggesting that if public health officials can get more people to receive the former, those same people might be more likely to get the latter when it’s available. Abram Wagner, a research assistant professor at the University of Michigan’s department of epidemiology, recently conducted a yet-to-be-published survey of people from around the world, including 881 Americans, on their inoculation plans this August. He found that Americans who got a flu shot in the previous year were 363% more likely to want the flu shot again this year. More importantly, he found that those who received a flu shot during the last influenza season were 63% more likely to be planning to get the C19 vaccine than those who did not.
- Wagner says it would be understandable if some people wanted the flu shot but remained skeptical of the C19 vaccine. After all, the flu vaccine, unlike those currently being developed for C19, has been battle-tested over many decades (although it’s typically changed every year to counter the specific flu viruses expected to circulate in a given season). But people seem to be putting all vaccines in the same emotional bucket. “If you have experience with getting the jab, and you have the shot, it’s no big deal, then I think you will be just more likely to get another shot in the future, even if it’s not the same shot you got in the past,” Wagner says.
- Influenza season in the northern hemisphere has only just begun, but there are some signs that the C19 pandemic may be nudging more people than usual to get the flu shot. In an August survey of 1,000 people by the National Foundation for Infectious Diseases, 28% percent of U.S. respondents said the pandemic made them more likely to get the flu vaccine. Overall, 59% of people are planning to get the flu shot this season, the survey found, compared to 52% last season. (The U.S. Centers for Disease Control and Prevention estimates about 48.4% of American adults got the flu vaccine during the 2019-20 season, far short of the agency’s 70% target).
- In terms of C19, that 70% figure is also key—scientists think it’s generally about the amount of people in a given community that need to be immune to C19 to reach herd immunity, depending on the vaccine’s effectiveness and the the strength of natural immunity through exposure. We may never reach that point. According to a Pew Research Center survey conducted in September, nearly half of U.S. adults said they probably or definitely would not get a C19 vaccine—a sharp increase since May, when only 27% of Americans said they probably or definitely wouldn’t get the shot. That suggests faith in the eventual vaccine is quickly eroding, especially amid fears that it’s being rushed for political purposes.
- Still, this year’s influenza vaccine rollout could help make Americans feel more comfortable about a possible coronavirus vaccine. For instance, medical practitioners could use a patient’s flu shot appointment to answer their questions about vaccines more broadly and make them more comfortable with the process, says Ann Philbrick, an associate professor at the College of Pharmacy and the Department of Family Medicine and Community Health at the University of Minnesota. Healthcare workers can provide “reassurance” about vaccines, she says, and “put the seed in your patient’s mind that we’re working on a COVID vaccine, and once we have one, it’s important to get one.”
3. Face masks: what the data say
- When her Danish colleagues first suggested distributing protective cloth face masks to people in Guinea-Bissau to stem the spread of the coronavirus, Christine Benn wasn’t so sure.
- “I said, ‘Yeah, that might be good, but there’s limited data on whether face masks are actually effective,’” says Benn, a global-health researcher at the University of Southern Denmark in Copenhagen, who for decades has co-led public-health campaigns in the West African country, one of the world’s poorest.
- That was in March. But by July, Benn and her team had worked out how to possibly provide some needed data on masks, and hopefully help people in Guinea-Bissau. They distributed thousands of locally produced cloth face coverings to people as part of a randomized controlled trial that might be the world’s largest test of masks’ effectiveness against the spread of C19.
- Face masks are the ubiquitous symbol of a pandemic that has sickened 35 million people and killed more than 1 million. In hospitals and other health-care facilities, the use of medical-grade masks clearly cuts down transmission of the SARS-CoV-2 virus. But for the variety of masks in use by the public, the data are messy, disparate and often hastily assembled. Add to that a divisive political discourse that included a US president disparaging their use, just days before being diagnosed with C19 himself. “People looking at the evidence are understanding it differently,” says Baruch Fischhoff, a psychologist at Carnegie Mellon University in Pittsburgh, Pennsylvania, who specializes in public policy. “It’s legitimately confusing.”
- To be clear, the science supports using masks, with recent studies suggesting that they could save lives in different ways: research shows that they cut down the chances of both transmitting and catching the coronavirus, and some studies hint that masks might reduce the severity of infection if people do contract the disease.
- But being more definitive about how well they work or when to use them gets complicated. There are many types of mask, worn in a variety of environments. There are questions about people’s willingness to wear them, or wear them properly. Even the question of what kinds of study would provide definitive proof that they work is hard to answer.
- “How good does the evidence need to be?” asks Fischhoff. “It’s a vital question.”
Beyond gold standards
- At the beginning of the pandemic, medical experts lacked good evidence on how SARS-CoV-2 spreads, and they didn’t know enough to make strong public-health recommendations about masks.
- The standard mask for use in health-care settings is the N95 respirator, which is designed to protect the wearer by filtering out 95% of airborne particles that measure 0.3 micrometres (µm) and larger. As the pandemic ramped up, these respirators quickly fell into short supply. That raised the now contentious question: should members of the public bother wearing basic surgical masks or cloth masks? If so, under what conditions? “Those are the things we normally [sort out] in clinical trials,” says Kate Grabowski, an infectious-disease epidemiologist at Johns Hopkins School of Medicine in Baltimore, Maryland. “But we just didn’t have time for that.”
- So, scientists have relied on observational and laboratory studies. There is also indirect evidence from other infectious diseases. “If you look at any one paper — it’s not a slam dunk. But, taken all together, I’m convinced that they are working,” says Grabowski.
- Confidence in masks grew in June with news about two hair stylists in Missouri who tested positive for C191. Both wore a double-layered cotton face covering or surgical mask while working. And although they passed on the infection to members of their households, their clients seem to have been spared (more than half reportedly declined free tests). Other hints of effectiveness emerged from mass gatherings. At Black Lives Matter protests in US cities, most attendees wore masks. The events did not seem to trigger spikes in infections2, yet the virus ran rampant in late June at a Georgia summer camp, where children who attended were not required to wear face coverings3. Caveats abound: the protests were outdoors, which poses a lower risk of C19 spread, whereas the campers shared cabins at night, for example. And because many non-protesters stayed in their homes during the gatherings, that might have reduced virus transmission in the community. Nevertheless, the anecdotal evidence “builds up the picture”, says Theo Vos, a health-policy researcher at the University of Washington in Seattle.
- More-rigorous analyses added direct evidence. A preprint study4 posted in early August (and not yet peer reviewed), found that weekly increases in per-capita mortality were four times lower in places where masks were the norm or recommended by the government, compared with other regions. Researchers looked at 200 countries, including Mongolia, which adopted mask use in January and, as of May, had recorded no deaths related to C19. Another study5 looked at the effects of US state-government mandates for mask use in April and May. Researchers estimated that those reduced the growth of C19 cases by up to 2 percentage points per day. They cautiously suggest that mandates might have averted as many as 450,000 cases, after controlling for other mitigation measures, such as physical distancing.
- “You don’t have to do much math to say this is obviously a good idea,” says Jeremy Howard, a research scientist at the University of San Francisco in California, who is part of a team that reviewed the evidence for wearing face masks in a preprint article that has been widely circulated6.
- But such studies do rely on assumptions that mask mandates are being enforced and that people are wearing them correctly. Furthermore, mask use often coincides with other changes, such as limits on gatherings. As restrictions lift, further observational studies might begin to separate the impact of masks from those of other interventions, suggests Grabowski. “It will become easier to see what is doing what,” she says.
- Although scientists can’t control many confounding variables in human populations, they can in animal studies. Researchers led by microbiologist Kwok-Yung Yuen at the University of Hong Kong housed infected and healthy hamsters in adjoining cages, with surgical-mask partitions separating some of the animals. Without a barrier, about two-thirds of the uninfected animals caught SARS-CoV-2, according to the paper7 published in May. But only about 25% of the animals protected by mask material got infected, and those that did were less sick than their mask-free neighbours (as measured by clinical scores and tissue changes).
- The findings provide justification for the emerging consensus that mask use protects the wearer as well as other people. The work also points to another potentially game-changing idea: “Masking may not only protect you from infection but also from severe illness,” says Monica Gandhi, an infectious-disease physician at the University of California, San Francisco.
- Gandhi co-authored a paper8 published in late July suggesting that masking reduces the dose of virus a wearer might receive, resulting in infections that are milder or even asymptomatic. A larger viral dose results in a more aggressive inflammatory response, she suggests.
- She and her colleagues are currently analysing hospitalization rates for C19 before and after mask mandates in 1,000 US counties, to determine whether the severity of disease decreased after public masking guidelines were brought in.
- The idea that exposure to more virus results in a worse infection makes “absolute sense”, says Paul Digard, a virologist at the University of Edinburgh, UK, who was not involved in the research. “It’s another argument for masks.”
- Gandhi suggests another possible benefit: if more people get mild cases, that might help to enhance immunity at the population level without increasing the burden of severe illness and death. “As we’re awaiting a vaccine, could driving up rates of asymptomatic infection do good for population-level immunity?” she asks.
Back to ballistics
- The masks debate is closely linked to another divisive question: how does the virus travel through the air and spread infection?
- The moment a person breathes or talks, sneezes or coughs, a fine spray of liquid particles takes flight. Some are large — visible, even — and referred to as droplets; others are microscopic, and categorized as aerosols. Viruses including SARS-CoV-2 hitch rides on these particles; their size dictates their behaviour.
- Droplets can shoot through the air and land on a nearby person’s eyes, nose or mouth to cause infection. But gravity quickly pulls them down. Aerosols, by contrast, can float in the air for minutes to hours, spreading through an unventilated room like cigarette smoke.
- Time-lapse images show how cough droplets spread from a person wearing an N95 mask that has a valve to expel exhaled air.
- What does this imply for the ability of masks to impede C19 transmission? The virus itself is only about 0.1 µm in diameter. But because viruses don’t leave the body on their own, a mask doesn’t need to block particles that small to be effective. More relevant are the pathogen-transporting droplets and aerosols, which range from about 0.2 µm to hundreds of micrometres across. (An average human hair has a diameter of about 80 µm.) The majority are 1–10 µm in diameter and can linger in the air a long time, says Jose-Luis Jimenez, an environmental chemist at the University of Colorado Boulder. “That is where the action is.”
- Scientists are still unsure which size of particle is most important in C19 transmission. Some can’t even agree on the cut-off that should define aerosols. For the same reasons, scientists still don’t know the major form of transmission for influenza, which has been studied for much longer.
- Many believe that asymptomatic transmission is driving much of the C19 pandemic, which would suggest that viruses aren’t typically riding out on coughs or sneezes. By this reasoning, aerosols could prove to be the most important transmission vehicle. So, it is worth looking at which masks can stop aerosols.
All in the fabric
- Even well-fitting N95 respirators fall slightly short of their 95% rating in real-world use, actually filtering out around 90% of incoming aerosols down to 0.3 µm. And, according to unpublished research, N95 masks that don’t have exhalation valves — which expel unfiltered exhaled air — block a similar proportion of outgoing aerosols. Much less is known about surgical and cloth masks, says Kevin Fennelly, a pulmonologist at the US National Heart, Lung, and Blood Institute in Bethesda, Maryland.
- In a review9 of observational studies, an international research team estimates that surgical and comparable cloth masks are 67% effective in protecting the wearer.
- In unpublished work, Linsey Marr, an environmental engineer at Virginia Tech in Blacksburg, and her colleagues found that even a cotton T-shirt can block half of inhaled aerosols and almost 80% of exhaled aerosols measuring 2 µm across. Once you get to aerosols of 4–5 µm, almost any fabric can block more than 80% in both directions, she says.
- Multiple layers of fabric, she adds, are more effective, and the tighter the weave, the better. Another study10 found that masks with layers of different materials — such as cotton and silk — could catch aerosols more efficiently than those made from a single material.
- Benn worked with Danish engineers at her university to test their two-layered cloth mask design using the same criteria as for medical-grade ventilators. They found that their mask blocked only 11–19% of aerosols down to the 0.3 µm mark, according to Benn. But because most transmission is probably occurring through particles of at least 1 µm, according to Marr and Jimenez, the actual difference in effectiveness between N95 and other masks might not be huge.
- Eric Westman, a clinical researcher at Duke University School of Medicine in Durham, North Carolina, co-authored an August study11 that demonstrated a method for testing mask effectiveness. His team used lasers and smartphone cameras to compare how well 14 different cloth and surgical face coverings stopped droplets while a person spoke. “I was reassured that a lot of the masks we use did work,” he says, referring to the performance of cloth and surgical masks. But thin polyester-and-spandex neck gaiters — stretchable scarves that can be pulled up over the mouth and nose — seemed to actually reduce the size of droplets being released. “That could be worse than wearing nothing at all,” Westman says.
- Some scientists advise not making too much of the finding, which was based on just one person talking. Marr and her team were among the scientists who responded with experiments of their own, finding that neck gaiters blocked most large droplets. Marr says she is writing up her results for publication.
- “There’s a lot of information out there, but it’s confusing to put all the lines of evidence together,” says Angela Rasmussen, a virologist at Columbia University’s Mailman School of Public Health in New York City. “When it comes down to it, we still don’t know a lot.”
Minding human minds
- Questions about masks go beyond biology, epidemiology and physics. Human behaviour is core to how well masks work in the real world. “I don’t want someone who is infected in a crowded area being confident while wearing one of these cloth coverings,” says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota in Minneapolis.
- US baseball players wore masks while playing during the 1918 influenza epidemic.
- Perhaps fortunately, some evidence12 suggests that donning a face mask might drive the wearer and those around them to adhere better to other measures, such as social distancing. The masks remind them of shared responsibility, perhaps. But that requires that people wear them.
- Across the United States, mask use has held steady around 50% since late July. This is a substantial increase from the 20% usage seen in March and April, according to data from the Institute for Health Metrics and Evaluation at the University of Washington in Seattle (see go.nature.com/30n6kxv). The institute’s models also predicted that, as of 23 September, increasing US mask use to 95% — a level observed in Singapore and some other countries — could save nearly 100,000 lives in the period up to 1 January 2021.
- “There’s a lot more we would like to know,” says Vos, who contributed to the analysis. “But given that it is such a simple, low-cost intervention with potentially such a large impact, who would not want to use it?”
- Further confusing the public are controversial studies and mixed messages. One study13 in April found masks to be ineffective, but was retracted in July. Another, published in June14, supported the use of masks before dozens of scientists wrote a letter attacking its methods (see go.nature.com/3jpvxpt). The authors are pushing back against calls for a retraction. Meanwhile, the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) initially refrained from recommending widespread mask usage, in part because of some hesitancy about depleting supplies for health-care workers. In April, the CDC recommended that masks be worn when physical distancing isn’t an option; the WHO followed suit in June.
- Nevertheless, most scientists are confident that they can say something prescriptive about wearing masks. It’s not the only solution, says Gandhi, “but I think it is a profoundly important pillar of pandemic control”. As Digard puts it: “Masks work, but they are not infallible. And, therefore, keep your distance.”
Source: Face masks: what the data say
4. Neck gaiters work as well as masks at blocking C19
- Neck gaiters work just as well as masks at stopping the spread of C19 — despite a past study that suggests otherwise, according to new research.
- Researchers at Virginia Tech found that the roll-up face gear blocked 100% of large particles from another person’s sneeze or cough, according to KYR News.
- The protective wear also trapped up to 90% of large particles from escaping, along with 50% of superfine particles — roughly on par with cloth face masks, the scientists said.
- During the unpublished research project, which is not peer-reviewed, scientists used anatomical models and spray bottles to test the effectiveness of both forms of face wear.
- “Neck gaiters provide similar performance to other cloth masks we have tested on manikins,” the researchers said.
- The findings fly in the face of a study by Duke University, published last month in the journal Science Advance, noting neck gaiters may make infectious droplets spread more easily.
- In that case, researchers found that they may actually cause more infectious particles to enter the wearer’s nose and mouth and nose, rendering them “counterproductive”
- The study measured the effectiveness of 14 types of facial wear using laser beam technology.
5. The Art of the Pandemic Meltdown
- Welcome to the Pandemic Meltdown. Have you had yours yet?
- It’s what happens after you’ve held it together for all these turbulent months—through a pandemic and quarantine, working from home and home schooling, civil unrest and the most divisive public discourse in several lifetimes. And then something seemingly small happens and suddenly you’re screaming alone in your car or sobbing to your dog about, well, everything.
- People lost control of their emotions before 2020, of course. But we’re doing it a whole lot more now because of our sustained levels of stress, anger and fear. We’re overwhelmed by constant bad news. We’re exhausted by the need to be ever-vigilant. It’s no wonder our fuses are short.
- Think you’ve never had a meltdown? Think again. Although we typically expect meltdowns to look like the adult version of a toddler’s tantrum—wailing, whining, whimpering—psychologists say they can manifest in different ways: Crying. Rage. Silence or an emotional shut down. “Often, people don’t identify with the word ‘meltdown’ because of the stigma of having a mental-health crisis,” says Amanda Luterman, a licensed psychotherapist in Montreal. “They will just say they are having a really horrible day.”
- What most meltdowns have in common is a loss of emotional control—often manifested physically—and a sense of helplessness. They occur when we no longer have the emotional resources to deal with our stress. And they’re typically triggered by something small and unanticipated—a stubbed toe, a spill on our shirt, or (for me recently) a broken backspace key on the laptop.
- Yet meltdowns have an upside. They allow us to release tension. And once we do that, we can think more clearly, because we’re no longer spending all our energy trying to hold it together. “A meltdown is the body’s natural mechanism to let go, to cleanse itself of painful emotions,” says Tal Ben-Shahar, a psychologist who specializes in the science of happiness. “It lets us reset.”
- Not all meltdowns are created equal. Bad ones happen too often, interfere with our life, hurt people around us or leave us feeling worse than before. Good ones are rare, ideally happen when we’re alone, and leave us feeling better than we did before, with a sense of relief.
- To have a productive meltdown, experts say we should accept it.
- We need to identify what will make us feel better—and explain this to others. We should be careful to minimize the negative effects, and explore the meaning afterward.
How to Have an Effective Meltdown
- Accept it. Don’t judge yourself. Meltdowns are as natural as gravity, says Tal Ben-Shahar, a psychologist who specializes in the science of happiness. A meltdown lets you release tension and frees up energy that was spent suppressing emotions.
- Plan ahead (if possible). Better to cry in private than to start sobbing in the middle of a Zoom board meeting. When you start to feel overwhelmed, talk to your partner, a friend or a therapist. Find a private place, such as the shower or a parked car, where you can be alone—you may feel freer to let your emotions out. Or try writing about your feelings.
- Know what you need—and tell others. Some people prefer to be left alone when they lose control. Others want a hug or a pep talk. You should figure out what helps you before a meltdown and be clear with your loved ones about your needs, says Amanda Luterman, a licensed psychotherapist in Montreal. And be careful never to take your meltdown out on other people.
- Model a good meltdown. No kicking the dog or punching the wall or screaming at your family while visiting your dad in the ICU. (Yes, it’s happened.) And be very careful never to have a full-blown meltdown in front of children—it can frighten them. But showing others, especially kids, that you can express painful emotions in a productive way that doesn’t negatively affect others can be an important lesson. “Having an occasional meltdown and recovering from it helps people see that we can be OK through these expressions,” says Carrie Krawiec, a licensed marriage and family therapist in Troy, Mich.
- Try an “alternate rebellion.” When we lose control of ourselves, we often want to rebel: quit our job, fire off a snotty email to our boss, tell off our father-in-law. Instead, plan a healthy rebellion that satisfies the need to assert control in your life, recommends Jenny Taitz, a psychologist and assistant clinical professor at the University of California, Los Angeles. One idea: Explain to others that you are turning off your phone for a while and can’t be reached. Then do something you enjoy—and crank some loud music on the way.
- Calm yourself. Dr. Taitz suggests a technique from a form of therapy called Dialectical Behavior Therapy, referred to by the acronym TIPP. The first “T” refers to temperature—put your face in extremely cold water. This immediately lowers your body temperature, which activates your body’s diving response, reducing your body’s emotional and physiological reflexes. The “I” is for intense exercise—go get some energy out. The first “P” is for paced breathing—six counts in and eight counts out—which calms your nervous system. And the final “P” is for progressive muscle relaxation.
- Explore the meaning of your meltdown. First, give yourself time to recover. Then reflect on what happened. This helps you turn your meltdown into a growth experience, says Maru Torres-Gregory, a faculty member and staff therapist at the Family Institute at Northwestern University in Evanston, Ill.
- Move on. Apologize if you’ve upset others—and don’t expect someone else to clean up your mess. Forgive yourself: Having a meltdown makes you human. And make a fresh start. Research shows that picking a date on the calendar to begin anew can help people achieve a goal. So pick midnight tonight and decide that tomorrow will be better.
6. 1 in 4 Americans aren’t washing their hands regularly
- More Americans are washing their hands amid the C19 pandemic, but 1 in 4 don’t lather up when they need to, such as after blowing their nose, according to a new report.
- The report, from the Centers for Disease Control and Prevention (CDC), examined Americans’ hand washing behaviors before and during the C19 pandemic. The authors analyzed the results of two nationally-representative surveys, with the first administered in October 2019, and the second in June 2020.
- The surveys asked participants about situations where they usually remember to wash their hands, such as after using the bathroom at home; after using the bathroom in public; after coughing, sneezing, or blowing your nose; before eating at home; before eating at a restaurant and before preparing food at home.
- The report found that, thankfully, the vast majority of people remember to wash their hands after using the bathroom. In both 2019 and 2020, more than 85% of participants said they remembered to wash their hands after using the bathroom at home, and 95% said they remembered to wash their hands after using a public restroom. Similarly, in both years, about 86% of participants said they remembered to wash their hands before preparing food.
- In 2019, about 63% said they washed hands before eating at home, 55% said they washed their hands before eating at a restaurant and 53% said they washed their hands after coughing, sneezing or blowing their nose. During the pandemic, more people reported washing their hands in these situations, but the numbers were still not ideal — 74% said they remembered to wash their hands before eating at home, 70% said they remembered to wash their hands before eating at a restaurant and 71% said they remembered to wash their hands after coughing, sneezing or blowing their nose.
- And in general, some demographic groups were less likely to remember to wash their hands, including men, young adults and white people.
- For example, in 2020, 65% of men reported washing their hands after coughing, sneezing or blowing their nose; compared with 76% of women. And 69% of white adults said they washed their hands after coughing, sneezing or blowing their nose, compared with 83% of Black adults and 72% of Hispanic adults.
- “These findings underscore the importance of promoting frequent hand-washing during the ongoing C19 pandemic, especially after coughing, sneezing and blowing one’s nose,” the authors wrote. “Men, young adults, and white adults continue to be less likely to remember to wash their hands, despite improvements made from 2019 to 2020.”
- The authors conclude that more work is needed to identify ways to get people to wash their hands, not only to prevent C19, but also to reduce transmission of other diseases that spread via coughs, sneezes or poop.
M. Johns Hopkins COVID-19 Update
October 9, 2020
1. Cases & Trends
- The WHO COVID=19 Dashboard reports 36.36 million cases and 1.06 million deaths as of 9:30am EDT on October 9. Yesterday, the WHO reported 336,500 new cases, setting a new record for global daily incidence.
- The C19 resurgence in Europe continues to exhibit concerning trends, leading a number of countries to re-institute social distancing and other restrictions to contain their respective epidemics. Europe recently surpassed North America in terms of per capita daily incidence, and it is on pace to surpass South America in the coming days. In terms of total daily incidence, Europe is on pace to surpass Asia in the very near future. Europe’s epidemic is now more than more than twice as large as during its first peak in early April.
- Most countries in Europe* are exhibiting exponential growth, and have for several weeks or months. While the top countries in terms of per capita daily incidence are dominated by smaller countries (eg, Andorra, Montenegro), several countries with sizeable populations (eg, France, Spain, the Netherlands, the UK) are high on the list as well, illustrating the scale of transmission in Europe. The epidemics in most European countries continue to accelerate. The biweekly change in both incidence and mortality is positive for nearly every country in Europe, including a number of countries that are currently reporting increases of more than 100%, in one or both categories, over the past 2 weeks. A number of European countries have reported concerning increasing trends in test positivity as well—greater than 10% and still increasing in several countries—indicating that testing capacity may not be sufficient to accurately capture the full scale of increased transmission.
- The US CDC reported 7.53 million total cases and 211,132 deaths. The US daily C19 incidence continues to climb, now up to 44,984 new cases per day, the highest since August 20. Yesterday, the CDC reported 53,051 new cases, the highest daily total since August 15. The US C19 mortality continues to decline slowly, now down to 675 deaths per day, the lowest daily average since July 10. We have observed previously, however, that mortality trends tend to lag 2-3 weeks behind incidence, so it will be important to monitor mortality over the coming weeks.
- Half of all US states are reporting more than 100,000 cases, including California with more than 800,000 cases; Texas and Florida with more than 700,000; New York with more than 400,000; Georgia and Illinois with more than 300,000; and Arizona, New Jersey, North Carolina, and Tennessee with more than 200,000.
- The Johns Hopkins Coronavirus Resource Center reported 7.62 million US cases and 213,016 deaths as of 12:30pm EDT on October 9.
2. NEW ZEALAND
- Following a C19 outbreak in Auckland, New Zealand once again stepped down social distancing measures to Alert Level 1 nationwide. During the outbreak, the majority of the country remained at a lower Alert Level while more restrictive measures were implemented in Auckland. In June, New Zealand interrupted all domestic SARS-CoV-2 transmission and moved the entire country to Alert Level 1. New Zealand reported the Auckland outbreak on August 11, shortly after passing 100 days with no new domestic cases. New Zealand moved the affected area to Alert Level 3 and the rest of the country to Alert Level 2. New Zealand methodically stepped down restrictions in Auckland and the rest of the country as it steadily brought the outbreak under control. As of October 7, Auckland rejoined the rest of the country at Alert Level 1.
- New Zealand has reported 2 cases over the past 24 hours, both of which were among individuals currently in the Managed Isolation and Quarantine program (eg, travelers arriving from other countries). No new cases associated with known clusters have been reported in the past 24 hours, but the Auckland outbreak will remain “Open” until 28 days—2 incubation periods—after the last case completes isolation. The Auckland cluster has been linked to 179 cases, the country’s largest outbreak to date.
3. LATIN AMERICA
- Countries throughout Latin America are still struggling to control outbreaks of C19. Peru has faced challenges maintaining national testing capacity, so it is reportedly shifting its focus to serological tests to supplement traditional diagnostic testing capacity. The laboratory equipment and supplies required to conduct traditional PCR diagnostic testing for SARS-CoV-2 are often expensive, and the country does not have sufficient access to facilities that can conduct these types of tests. Serological tests detect antibodies produced in response to SARS-CoV-2 infection rather than the presence of the virus itself, and they are not traditionally used for diagnostic purposes. In an effort to overcome this limitation, the Peruvian government purchased approximately 1.6 million antibody tests from a number of foreign sources. Notably, the accuracy of many of these tests has been called into question, including multiple tests that have failed to receive any kind of authorization from the US FDA. Accuracy issues and inherent limitations of serological tests have resulted in many false negative results, which can delay diagnosis and treatment and increase the risk of severe disease and death. The use of antibody tests in place of more sensitive tests, like PCR-based diagnostics, has hindered the effectiveness of Peru’s C19 response; however, expanded serological testing appears to have resulted in increased detection of cases. Peru has reported more than 190,000 cases and 33,000 deaths nationwide.
- In Guatemala, the government reportedly denied entry to nearly 3,500 refugees who attempted to cross the border from neighboring Honduras due to concerns about C19. It is unclear whether any of the individuals attempting to enter Guatemala were infected, but Guatemalan President Alejandro Giammattei argued that they were stopped because these types of caravans are capable of spreading the virus. The refugees were reportedly attempting to pass through Guatemala en route to Mexico and ultimately the US. Guatemala has reported more than 96,000 cases and 3,000 deaths.
- Countries across Europe have been experiencing a growing surge of C19 cases and hospitalizations, prompting states of emergency and shortages of medical supplies for some countries.
- Earlier this week, the Czech Republic instituted a new state of emergency in response to the country’s growing C19 epidemic. The order will last at least 30 days, and it will include highly restrictive social distancing measures, including closing secondary schools, prohibiting spectators at events, suspending indoor sporting events, restricting restaurant in-person service and operating hours, and limiting the size of events like weddings and funerals to 30 people. The Czech Republic reported new records for daily incidence for 3 consecutive days, and the epidemic is more than 10 times larger than during its first peak.
- France is now averaging nearly 13,500 new cases per day, nearly 3 times the average at its first peak in early April. Additionally, approximately 40% of ICU beds among hospitals in Paris are currently occupied, illustrating the burden on the country’s health system. The rise in incidence has led Parisian authorities to shut down bars and cafes for 2 weeks, although restaurants can remain open. Additionally, residents have been strongly urged to work from home as much as possible. Paris hospitals have also been directed to implement emergency provisions in an effort to ensure surge capacity is available, including adding beds, postponing non-essential procedures, and suspending vacations for staff.
- Last month, the European Parliament announced that a monthly parliamentary meeting that usually occurs in Strasbourg, France, would now be held in Brussels, Belgium, the home of the European Parliament. The decision was made due to concerns about hundreds of Members of Parliament and staff converging on France at a time when France and other European countries are battling a resurgence of C19. French leaders opposed the decision, as the monthly meeting had been held in France since the European Union was first established. The monthly Strasbourg meetings were reportedly a point of contention even before the pandemic due to cost and logistical constraints, but the pandemic has exacerbated these tensions.
- The surge in cases across Europe has led to supply constraints for remdesivir. The UK has reportedly begun rationing remdesivir and prioritizing its administration only to those patients who need it the most. Reportedly, the UK Ministry of Health intends to maintain the rationing plan for several weeks, as supply is expected to increase later this month. That being said, availability will depend on future trends in SARS-CoV-2 transmission. Notably, hospitals in the northern part of the UK are facing major patient surges, and the director of public health in Liverpool indicated that some of the city’s hospitals could reach their maximum capacity in the next week. European countries have arranged to purchase 500,000 courses of remdesivir directly from the manufacturer, Gilead Sciences, to distribute as appropriate to countries in need. Currently, most of the global supply has been secured by the US, prompting concerns and criticism as other countries experience surges in infections.
5. C19 SYMPTOMS & INFECTION
- Researchers at the University College London published findings from their analysis of whether C19 symptoms are markers of SARS-CoV-2 infection. The study, published in Clinical Epidemiology, used data from the Office for National Statistics C19 Infection Survey, which is a survey of households in England, the researchers estimated the sensitivity, specificity, and proportion of asymptomatic cases in order to determine the ability to use C19 symptoms to predict SARS-CoV-2 infection. The study assessed data from more than 36,000 individuals tested between April and June. Among those tested, 625 (1.7%) reported symptoms at time of testing and 115 people tested positive (0.32%). Of the 115 people who tested positive, 76.5% were asymptomatic on the day they were tested. The researchers then assessed a subset of the study population that exhibited at least one of the following symptoms: cough, fever, or loss of taste/smell. Of the 115 individuals who tested positive, 99 (86%) did not exhibit those particular symptoms at the time of testing. The researchers concluded that the presence or absence of C19 symptoms was a poor predictor of SARS-CoV-2 infection. This study provides further evidence of the high prevalence of asymptomatic infection or mild disease (ie, that may not necessarily be recognized as being symptomatic) during the C19 pandemic.
6. DEBT RELIEF
- The President of the World Bank, David Malpass, called this week for debt forgiveness for low-income countries, which have been severely affected by the C19 pandemic. The economic impact in many countries, coupled with the resources required to combat the pandemic, may make it impossible for some countries to repay their debts. He previously noted that the economic consequences on individuals could drive as many as 100 million people into extreme poverty, exacerbating the need for economic forgiveness in the coming months and years. In his recent comment, he called on private banks to play a more active and direct role in the debt recovery process, warning of the potential for an economic depression following extended restrictions to routine economic activity.
7. POOLED TESTING STRATEGY
- A mathematician at Cardiff University (UK) published an algorithm that aims to improve the efficiency of pooled testing. Pooled testing is a technique that performs a single test on specimens from multiple individuals in order to reduce both the overall number of tests needed and the time required to obtain results. A positive test indicates that at least 1 person in the “pool” is positive (and additional testing may be required to determine who), but a negative test can rule out the entire pool. The new algorithm, published in Health Systems, utilizes multiple tests per pool, and each specimen is assigned to a unique subset of those tests. In an example provided in the overview published by SciTechDaily, 200 specimens may utilize 10 tests, and each specimen would be included in 5 different tests. If a single specimen is positive, the 5 tests that return positive results will correspond to only 1 specimen, eliminating the need for subsequent testing. If there are more than 5 positive test results, it indicates that multiple specimens are positive. If that is the case, mathematical analysis performed based on the quantity of virus present in each specimen can determine which specimens are positive without the need for further testing.
- This is at least the second effort to develop algorithms to increase the efficiency of pooled testing. As we covered previously, a mathematical epidemiologist in Rwanda developed a similar process, utilizing a hypercube model (preprint) to create overlapping pools that can provide highly accurate results with 2 rounds of testing. Pooled testing can significantly increase the available testing capacity without the need for additional tests or equipment, which can enable large-scale, rapid screening and/or substantially expand testing capacity in resource-limited settings. Efforts to increase the efficiency of these programs can further expand available capacity.
8. MONOCLONAL ANTIBODY EUA
- Regeneron Pharmaceuticals applied for an Emergency Use Authorization (EUA) from the US FDA for its monoclonal antibody cocktail. Regeneron announced preliminary results from a Phase 1 clinical trial, which indicated that the drug showed promise in reducing viral loads and mitigating symptoms in non-hospitalized C19 patients. The Phase 1 trial included 275 participants, and the Phase 2/3 portion of the trial aims to include 1,300 participants. If the EUA is issued, the drug will be made available to the public free of charge, and Regeneron stated that it has enough currently available to treat 50,000 patients. The company also expects to have enough for 300,000 patients “within the next few months.”
- The antibody cocktail is one of the investigational drugs used to treat US President Donald Trump, but it has not yet been demonstrated to be safe and effective in clinical trials. President Trump reportedly received access to multiple drugs outside of a clinical trial and EUA via a process known as “compassionate use.” STAT News provided an excellent overview of various implications and factors in the decision to make investigational products like the Regeneron monoclonal antibody cocktail available to President Trump.
9. NEWS FROM THE CENTER: NEW PhD & SCHOLARSHIP OPPORTUNITY
- The Johns Hopkins Center for Health Security announced a new Health Security PhD track in the Johns Hopkins Bloomberg School of Public Health Department of Environmental Health and Engineering. The track will begin accepting students for the 2021-22 school year, and applicants can indicate interest in their SOPHAS doctoral program application, which is due December 1, 2020. Full funding, supported by the Open Philanthropy Project, is available for up to 2 students. Dr. Tara Kirk Sell and Dr. Gigi Gronvall, both Senior Scholars at the Center for Health Security, will direct the track. A webinar will be held on October 21, 2020, at 2pm EDT to provide additional details about the program. Advance registration is required.
- The Center for Health Security also announced a new Health Security Scholarship for Johns Hopkins Bloomberg School of Public Health students pursuing a master of public health (MPH) degree. This scholarship is supported by the Open Philanthropy Project and is intended for MPH students with an interest in the field of health security, particularly those with interest in pandemics and global catastrophic biological risks. The scholarships will cover full tuition for the Johns Hopkins Bloomberg School of Public Health MPH degree, and up to 2 scholarships will be awarded per academic year. The inaugural scholarships will be awarded for the 2021–22 program year.
10. US PRESIDENTIAL DEBATE
- The US vice presidential debate was held earlier this week, and the Commission on Presidential Debates implemented additional precautions to mitigate transmission risk, including plexiglass barriers between the candidates and mandatory mask use. After the VP debate, the Commission announced that the upcoming presidential debate scheduled for October 15 would be held virtually, following positive SARS-CoV-2 tests among White House staff, including President Trump. President Trump opposed the decision and announced that he will not participate in the debate if it is not held in person. President Trump’s campaign has issued several statements about the second debate, including a proposal for delaying the event in order to allow it to be held in person and a call for it to be held in person as originally scheduled. President Biden announced that he intends to participate in a town hall event if the second debate does not take place as scheduled. At this time, it remains unclear if or how the second debate would take place or if any changes could subsequently affect the third and final debate scheduled for October 22.