November 13, 2020
Without reliable information, we rely on fear or luck.
“I expect the US to be reporting over 2,000 deaths per day in 3 weeks time.”Trevor Bedford, a computational biologist at the Fred Hutchinson Cancer Research Institute (see 2nd story under Projections)
“We have legitimate reason to be very, very concerned about our health system at a national level.”Lauren Sauer, assistant professor of emergency medicine at Johns Hopkins University who studies hospital surge capacity
“Everyone is going to die. There is no escaping from reality. We have to stop being a country of sissies.”Brazilian President Jair Bolsonaro
“Certainly it’s not going to be a pandemic for a lot longer because I believe the vaccines are going to turn that around.”Dr. Fauci
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity
6. Here’s where the virus has hit hardest
1. Schools in New York City may close
N. Linked Stories
- Airflow Videos Clearly Show Why Masks With Exhalation Valves Do Not Slow the Spread of C19 (*)
- CureVac says its COVID-19 vaccine can be stored in standard fridges, unlike Pfizer’s
- Life after COVID hospitalization: Study shows major lasting effects on health, work & more
- Researchers find evidence of pandemic fatigue
- The young resumed risky behaviors earlier than the elderly as C19 pandemic dragged on
- Employment insecurity linked to anxiety and depression among young adults during C19
- Mount Sinai develops machine learning models to predict critical illness and mortality in C19 patients
- NIH Trial Finds No Benefit From Hydroxychloroquine in Adults Hospitalized With C19
- Study identifies new “hidden” gene in C19 virus
- RNA structures of coronavirus reveal potential drug targets
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A. The Pandemic As Seen Through Headlines
(In no particular order)
- Dr. Fauci says Pfizer vaccine emergency use authorization one week away
- Feds strike deal to make COVID-19 vaccine free at major pharmacies
- Moderna closes in on release of COVID-19 vaccine data
- Cases rising in all 50 states for first time
- US coronavirus death toll hits level not seen in months
- Potential COVID-19 vaccine works against mutant mink strain in early trials
- North Dakota hospitals at full capacity amid COVID-19 surge
- Texas becomes 1st state to surpass 1 million COVID-19 cases
- California becomes second state to surpass 1 million COVID-19 cases
- Mississippi Governor says state would not follow any potential national lockdowns
- New Jersey sees COVID-19 surge as positivity rate hits 12%
- Fever, symptom screening still misses many coronavirus cases
- Fauci urges Americans to ‘double down’ on the basics as virus cases spike
- Biden ‘Science’ Advisor Calls For 4-6 Week Nationwide Lockdown To Avoid “COVID Hell”
- Biden COVID Advisor Supports Distributing Vaccine Globally Before It’s Available To All Americans
- Less Than Half Of Americans Likely To Comply With New COVID Lockdown: Gallup
- ‘We’re being left behind’: Rural hospitals can’t afford ultra-cold freezers to store the leading Covid-19 vaccine
- Thousands of Philadelphia area nurses plan to strike as virus cases surge and their working conditions worsen
- Children’s visits to the emergency room for mental health issues have risen sharply, the C.D.C. says
- “A Vaccine For The Rich” – Pfizer’s COVID-19 Vaccine Almost Impossible To Distribute In Poorer Countries
- Europe To Pay Lower Price For Pfizer COVID Vaccine Than US
- Fauci says he will take Pfizer COVID-19 vaccine if it’s approved by FDA
- Hungary prepares to carry out tests and a trial of Russia’s Covid-19 vaccine
- Chicago mayor issues stay-at-home advisory amid surge in COVID-19 cases
- French ICU occupancy up to 96.6%
- Detroit returns to remote learning
- CDC says masks can also benefit the wearer in strongest endorsement yet for face coverings
- Austria sees new daily record in cases
- UK outbreak may finally be starting to slow
- Global deaths top 12,000 for first time
- New cases finally starting to weaken in Europe
- COVID-19 hospitalizations soar in lockdown-free Sweden amid second wave
- Illinois sees new record hospitalizations
- New York tightens restrictions after reporting nearly 5,000 new cases
- Wisconsin creates new emergency category amid massive COVID-19 spike
- Italy reports most new deaths since April
- UK deaths top 50,000
- NYC on cusp of shutdown
- Illinois, Utah and Montana break COVID records
- Illinois fifth state to top 500,000 cases
- Maryland enters “red zone” COVID restrictions
- Spain daily cases jump 30%
- Brazil restarts Sinovac trial
- Russia says Sputnik 5 vaccine is 92% effective
- Tokyo reports another 300+ new cases, most since August
- California, Midwest States tighten restrictions
- Ohio gov reissues statewide mask order amid COVID-19 surge
- EU strikes deal for 300 million doses of Pfizer vaccine
- Iran reports new record jump in deaths
- Hungary makes masks mandatory in public spaces
- Germany reports most new deaths since mid-April
- Bulgaria reports daily record
- Turkey bans smoking on crowded streets
- Japan suffers biggest daily jump in cases yet
- Hungary strikes deal for Russian vaccine
- Across the country, school districts are shutting down or canceling plans to reopen
- NYC Mayor Prepares To Close Schools Despite ‘Strikingly Few’ COVID-19 Cases
- It Was A Mistake To Close Schools, UK Study Concedes
- Passenger Aboard First Caribbean Cruise Since Shutdown Tests Positive For C19
- Emirates Converts A380 Superjumbos Into “Mini Freighters” To Haul Medical Supplies Amid Second Wave
- Another 90,000 Airline Jobs Set To Disappear By Year-End As National Lockdown Looms
- South Africa will lift restrictions on all international travel
- There’s No Vaccine For A Terminally-Ill Economy
- Deutsche Bank Proposes A 5% “Work From Home” Privilege Tax
- Nearly 550 people banned from Delta flights for not wearing masks
- Black market for negative COVID-19 tests pops up across the globe
- Hospital overrun by COVID-19 starts giving oxygen to people in cars
- Newborns not likely to contract COVID-19 in the hospital, study says
- Hollywood gets back to work as film permits rise 24 percent
- NBA planning to have fans in some arenas this season
- Lockdown love: Virtual sex parties offer escape from isolation
- More Americans are tabling their Thanksgiving travel plans amid COVID-19
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 = 53,076,770
- New Cases = 643,043
- New Cases (7 day average) = 577,379
- Record high new cases
- Record high 7 day average of new cases
- The number of new cases is increasing at a rapid rate
- During the last 30 days, the 7 day average has increased from 332,113 to 577,379, an increase of 73.9%
- 1,000,000 new cases every 1.73 days (based on 7 day average)
US Cases & Testing:
- Total Cases = 10,873936
- New Cases = 161,541
- New Cases (7 day average) = 135,399
- Percentage of New Global Cases = 23.5%
- Total Number of Tests = 163,454,705
- Percentage of positive tests (7 day average) = 10.8%
- Record high number of new cases
- Record high 7 day average of new cases
- New cases are increasing at a very rapid rate
- During the last 30 days, the 7 day average of new cases has increased from 50,849 to 135,399, an increase of 166.3% (!)
- During the last 30 days, the 7 day average of the percentage of positive tests has increased by 96.4% (!)
- Total Deaths = 1,298,596
- New Deaths = 9,669
- New Deaths (7 day average) = 8,418
- Record high number of new deaths (10,156) occurred on 11/11
- Record high 7 day average of new deaths
- New deaths have been increasing at a rapid rate
- During the last 30 days, the 7 day average of new deaths has increased from 5,266 to 8,418, an increase of 59.9%
- With rapid increases in new cases continuing, further increases in new deaths can be expected
- Total Deaths = 248,585
- New Deaths = 1,190
- New Deaths (7 day average) = 1,086
- Percentage of Global New Deaths = 12.9%
- During the last 30 days, the 7 day average of new deaths has increased from 715 to 1,086, an increase of 51.9%
- With rapid increases in new cases and increases in the percentage of positive tests continuing, further increases in new deaths can be expected
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity (11/12)
- The positivity rate continues to rise across the country
- Nationally, the average 7-day positivity rate was 10.8% — up from 7.4% as of 10/29.
- More than 68% of all tests are now positive in ND (down from 70% on 11/10), 56% in SD, and 52% in IA
- Seven states (NE, ID, WY, WI, KS, IN, MT) 7-day positivity rates greater than 30%
- Six states (MN, NV, RI, UT, CO, MO) had 7-day positivity rates greater than 20%.
- In total, 41 states have 7-day positivity rates greater than 5% (+4 states since 10/29)
- Hospitalizations in the US surge to 67,096, up 46% since 10/29.
- 48 states have had increases of hospitalized patients of more than 10% since 10/29
- 23 states have more than 1,000 hospitalized patients.
- All states are seeing an increase in hospitalizations. Only NC and SC have seen increases less than 10% since 10/29.
4. New U.S. cases topped 144,000, a record, while C19 patients in ICUs hit their highest level since May 5
- New U.S. cases topped 144,000, a record, while C19 patients in ICUs hit their highest level since May 5.
- Chicago’s mayor issued a month long stay-at-home advisory. Illinois has recorded six days of more than 10,000 new infections.
- States are adding fresh restrictions as the coronavirus rages across America.
- Governors in New York, Maryland, Minnesota, Iowa, Utah and other states have imposed new social-distancing measures as daily confirmed U.S. coronavirus cases sustain highs not seen since the pandemic began and record hospitalizations begin to strain the health-care systems in some states and cities.
- Mayors in some major cities, including Chicago and San Francisco, have also announced their own local measures. Anthony Fauci said he is worried about winter in the U.S., and urged people not to let their guard down yet.
5. Record C19 Hospitalizations Strain System Again
- Hospitals across the nation face an even bigger capacity problem from the resurgent spread of C19 than they did during the virus’s earlier surges this year, pandemic preparedness experts said, as the number of U.S. hospitalizations hit a new high Wednesday.
- The number of hospitalized C19 patients reached 65,368, according to the Covid Tracking Project, passing the record set Tuesday for the highest number of hospitalizations since April. A spring surge in the Northeast pushed hospitalizations near 60,000. Hospitalizations hit a nearly identical peak again in late July, as the pandemic’s grip spread across the South and West.
- Epidemiologists said the record is likely to be swiftly replaced by another as C19 cases soar nationally. “We already know this is going to go far north,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
- Demand for health-care workers is of heightened concern in the latest surge, said hospital and disaster-response officials. Cases are more geographically widespread, reaching more remote regions than the spring and summer. Federal and private pools of health-care workers typically draw from one state to help another.
- New hospitalizations usually follow new cases by a few weeks. More widespread testing is finding more people with the virus, but that cannot fully account for surging cases, epidemiologists said.
- More young people are among those newly infected, and they are less likely to need hospital care than the elderly. But as infections rise among the young, so does transmission to high-risk older co-workers and family, said Jennifer Nuzzo, lead epidemiologist for the Johns Hopkins Covid-19 Testing Insights Initiative. “It doesn’t stay in one age group,” Dr. Nuzzo said.
- Pandemic fatigue is fueling transmission as people frustrated with months of restrictions have started to gather, public health officials said. “What we are finding is the disease is being spread in gatherings; family gatherings, weddings, holidays, and is being spread by people who know each other,” said Randall W. Williams, director of the Missouri Department of Health and Senior Services.
- “Lives are at stake,” said Eric Toner, an expert in health-care disaster preparedness at the Johns Hopkins Center for Health Security, who urged public-health precautions, such as masks. “When hospitals cannot accommodate all the patients, people die.”
- Despite improved treatments, hospitals have only so much capacity, doctors and health-care experts said. Overrun hospitals in New York in the spring scrambled to find ventilators and enough staff. Swamped hospitals in Arizona and California in the summer struggled to find nurses and frantically sought to transfer patients to hospitals with more capacity.
- “The medical system can only save so many people, and fortunately, things ebbed before things really got out of hand” during the spring and summer surges, said Charles Branas, chairman of epidemiology at the Columbia University Mailman School of Public Health. “There is a capacity limit here.”
- That limit is pronounced for patients who need the skilled staff and equipment of hospital intensive-care units. “That’s where there’s a resource bottleneck to be concerned about,” Dr. Branas said.
- The pandemic’s impact on patients and hospitals will vary widely because of regional differences in health-care services, said Molly Jeffery, scientific director of emergency medicine research at the Mayo Clinic.
- “This has not been a single pandemic,” Dr. Jeffery said. “This hospital system across the country looks totally different.”
- Hospitals outside metro areas have fewer intensive-care beds per 10,000 people, on average, an April analysis by the Kaiser Family Foundation found.
- The challenge of meeting the pandemic’s demand in rural parts of the U.S. is particularly acute. More rural residents, on average, are at risk of severe C19 because of age and health conditions than those living in metropolitan areas, researchers reported in June in the Journal of Rural Health. Local rural hospitals are often the nation’s smallest, with limited staff.
- North Dakota Gov. Doug Burgum, a Republican, said Monday that health-care workers with C19 but no symptoms would be able to continue working, but only with coronavirus patients, under an amended state order and Centers for Disease Control and Prevention guidelines for crisis staffing.
- In Harlowton, Mont., the 25-bed Wheatland Memorial Hospital has no intensive-care unit and it largely functions as the local nursing home.
- The hospital is located in Wheatland County, where the population of about 2,100 has seen an uptick in C19 cases since October, with 76 reported through Monday, Johns Hopkins University data show.
- Montana, where C19 cases and hospitalizations per 100,000 people in October were among the highest in the U.S., ranks among states with the fewest ICU beds per 100,000 people, according to data from the Covid Tracking Project and federal agencies.
- To prevent inadvertent spread of the virus to its vulnerable long-term patients, Wheatland Memorial locked the door to its emergency room, said Joan Marie McMahon, the hospital’s chief of staff. “We basically have a doorbell out there.” Hospital staff meet arrivals at the door to first screen them for infections and ensure anyone who enters wears a mask.
- Concerned about rising cases statewide, the hospital converted its ambulance bay to a temporary eight-bed unit for patients, she said.
- Wheatland Memorial carefully accepts referrals from Billings Clinic about 90 miles away to help the larger hospital make room for the most critical patients and minimize exposure to the virus.
- Rural hospitals aren’t equipped for the sickest patients and must send them to larger hospitals, which are now also grappling with the surge.
- In the Billings Clinic’s 290-bed flagship hospital, the ICU was at 167% occupancy Tuesday and its emergency room wasn’t accepting ambulances, a spokesman said.
- Bridget Brennan, chief of emergency medicine for the Benefis Medical Group in Great Falls, Mont., talks with doctors each morning at the state’s other larger hospitals for an update on where beds are available, she said. Benefis Hospital staff closely track beds within their hospital campuses, seeking openings. “We call it a tetris game,” Dr. Brennan said.
- The sustained surge will soon outmatch the state’s health-care system, she said: “The majority of people are not going to be sick enough to be in the hospital, but the number who are, all at once, is going to overwhelm what we have available here.”
6. Here’s where the virus has hit hardest
- The United States is reeling as infections and hospitalizations soar to all-time highs. Outbreaks are emerging from coast to coast. Which place is the worst off?
- Our reporters Mitch Smith and Amy Harmon dug into the data and found lots of places that would qualify — depending on the metrics.
The metro area with the most recent cases per capita: Minot, N.D.
- North Dakota has the most total cases per capita and the most recent cases per capita, and the Minot area, known for its Air Force base, is doing worse than anywhere else.
The county with the most known cases: Los Angeles County, Calif.
- More than 325,000 cases have been identified in Los Angeles County over the course of the pandemic, more than in 44 states — but this figure can be a bit misleading. On a per-capita basis, Los Angeles County has far fewer cases than many other counties in California and elsewhere.
The state with the highest hospitalization rate: South Dakota.
- About 54 of every 100,000 South Dakotans are hospitalized with Covid-19. The testing positivity rate remains sky-high, and there are few signs of progress. On Tuesday, Mayor Paul TenHaken of Sioux Falls cast the tiebreaking vote to strike down a citywide mask mandate, which he has called “simply unenforceable.”
The biggest cluster: Avenal State Prison, Calif.
- In the U.S., more than 30 correctional facilities have reported more than 1,000 cases each, but none have more than Avenal State Prison, in the San Joaquin Valley. It has logged more than 3,300 known cases among prisoners and correctional officers.
The state that has unraveled the fastest: Wisconsin.
- At the beginning of September, Wisconsin averaged about 700 cases a day. This week, it’s averaging more than 6,000. Hospitals are packed, positivity rates remain high, and testing supplies are strained. More than 300 deaths were reported in the state over the past week, a record.
The big city with the worst death toll: New York City.
- More than 24,000 New Yorkers, or one in every 351 city residents, have died from the virus. Still, some rural counties in other parts of the country may have higher death rates.
Source: New York Times Coronavirus Briefing
7. C19 Hospitalizations Hit Record Highs. Where Are Hospitals Reaching Capacity?
- Seriously ill C19 patients are starting to fill up hospital beds in record numbers, and health care workers are bracing for even more patients to come in the wake of skyrocketing coronavirus infections. But the burden on hospitals is not evenly spread. Some communities, particularly in the West and Midwest are particularly hard-hit.
- As of Wednesday, nearly 62,000 C19 patients were hospitalized around the country, surpassing the highs of the midsummer and spring surges. This is double the numbers hospitalized as of late September.
- “We have legitimate reason to be very, very concerned about our health system at a national level,” says Lauren Sauer, an assistant professor of emergency medicine at Johns Hopkins University who studies hospital surge capacity.
- The spring and summer waves of C19 hospitalizations were concentrated largely in a handful of cities in the Northeast and parts of the South.
- With the virus now surging across the country, experts warn that the impact of this next wave of hospitalizations will be even more devastating and protracted.
- “I fear that we’re going to have multiple epicenters,” says Dr. Mahshid Abir, an emergency physician at the University of Michigan and researcher at the Rand Corp. who has developed a model that helps hospitals manage surge capacity.
- If that happens, Abir warns that there won’t be flexibility to shuffle around resources to the places in need because everywhere will be overwhelmed.
- The impact varies state by state with certain areas showing much more rapid increases in hospitalizations. As of Monday, hospitalizations are rising in 47 states, according to data collected by The COVID Tracking Project, and 22 states are seeing their highest numbers of C19 hospitalizations since the pandemic began.
Where are hospitals at risk of maxing out?
- With the numbers growing nearly everywhere, the key question for hospital leaders and policymakers is, when is a community on the brink of having more patients than it can handle?
- In parts of the Midwest and the West, hospitals are already brushing up against their capacity to deliver care. Some are struggling to find room for patients, even in large urban hospitals that have more beds.
- But the surge in hospitalizations is not evenly spread — and hospitals’ capacity for weathering case surges varies greatly.
- One way to gauge the growing stress on a health care system is by tracking the share of hospital beds occupied by C19 patients.
- The federal department of Health and Human Services tracks and publishes this data at the state (but not the local) level. Several experts NPR spoke to say that, though imperfect, this is one of the best metrics communities have to work with.
- Though there’s not a fixed threshold that applies to all hospitals, generally speaking, once C19 hospitalizations exceed 10% of all available beds, that signals an increasing risk that the health care system could soon be overwhelmed, explains Sauer.
- “We start to pay attention above 5%,” says Sauer. “Above that, 10% is where we think, ‘Perhaps we have to start enacting surge strategies and crisis standards of care in some places.'”
- Crisis standards of care is a broad term for how to prioritize medical treatment when resources are scarce. In the most extreme cases, that can lead to rationing of care based on a patient’s chance of survival.
- The latest data from HHS shows that in 18 states — mostly in the Midwest — C19 hospitalizations have already climbed above 10%.
- Seven states are over 15%, including North Dakota and South Dakota, which are now over 20%.
Hospital capacity is flexible … until it’s not
- The percentage of hospital beds taken up by C19 patients does not tell a complete story about hospital capacity, says Sauer, but it’s a starting point.
- Hospital capacity is not so much a static number, but an ever-shifting balance of resources. “It’s space, staff and stuff, and you need all three, and if you don’t have one, it doesn’t matter if you have the other two,” says Abir.
- The level of C19 hospitalizations that would be a crisis in one place might not be in another. Still, a growing share of beds occupied by C19 patients can be a strong signal that the health care system is headed for trouble.
- C19 patients can be more labor intensive because health care workers have to follow intricate protocols around personal protective equipment and infection control. And some of the patients take up ICU space.
- “When the numbers go up like that, particularly for critical care, that strains the system pretty significantly,” says Abir. “This is a scarce resource. Critical care nurses are scarce. Ventilators are scarce. Respiratory therapists are scarce.”
- In Utah, where the share of hospitalized C19 patients is about 8%, state health officials have already warned that hospitals may soon be forced to ration care because of limited ICU space.
- There is no “magic number” to indicate when a health care system may be overwhelmed, says Eugene Litvak, who is CEO of the Institute for Healthcare Optimization and helps advise hospitals on how to manage their capacity. But hospitals must be alert to rapid increases in patient load.
- “Even a 10% increase can be quite dangerous,” says Litvak. “If you are a hospital that’s half empty, you can tolerate it.” But U.S. hospitals generally run close to capacity, Litvak says, with above 90% of beds already full — especially toward the end of the week.
- “Imagine that 10% of extremely sick patients on top of that,” he says. “What are your options? You can not admit ambulances and patients with non-COVID medical needs, or you have to cancel your elective surgeries.”
- In the spring, some states ordered that most elective surgeries come to a halt so that hospitals had room for C19 patients, but Litvak says this leads to all kinds of collateral damage because patients don’t get the care they need and hospitals lose money and lay off staff.
State data may miss local hot spots
- Statewide C19 hospitalization metrics mask huge variations within a state. Certain health care systems or metro areas may be in crisis.
- “It’s very valuable information, but a state average can be misleading,” says Ali Mokdad with the Institute for Health Metrics and Evaluation at the University of Washington, which projects that many states will face big problems with hospital capacity this winter. “It doesn’t tell you where in the states it’s happening.”
- Big urban centers may be much better equipped to absorb a rush of patients than smaller towns.
- In New York City, Mount Sinai Health System was able to more than double its bed capacity during the spring surge. Other communities don’t have the ability to ramp up capacity so quickly.
- “Especially the states that don’t have major cities with major hospitals, you see a lot of stress on them,” Mokdad says.
- But it’s hard for researchers and health leaders to get a clear picture of what’s happening regionally without good data, he adds. NPR has reported that the federal government does not share this local data, although it does collect it daily.
- Some states publish their own hospital data sets. Texas, which shares the data in detail, provides a striking example. Statewide, C19 hospitalizations have reached about 11%. Meanwhile, El Paso is above 40%, which has pushed the health care system to the brink.
- Ultimately, it’s difficult to know the true capacity for a region because many hospitals still don’t coordinate well, says Dr. Christina Cutter, an emergency physician at the University of Michigan who collaborated on the Rand model with Abir.
- “It’s really hard to make sure you’re leveraging all the resources and that one hospital is not overburdened compared to another hospital, and that may have unintended loss of life as a consequence,” Cutter says.
Dire consequences of overfilled hospitals
- During the height of Arizona’s summer surge, C19 patients filled nearly half of all beds in the state.
- “When 50% of our hospital is doing COVID, it means the hospital is overloaded. It means that other services in that hospital are being delayed,” says Mokdad. “The hospital becomes a nightmare.”
- Health care workers are pushed to their limits and are required to treat more patients at the same time. Hospitals can construct makeshift field hospitals to add to their capacity, but those can be logistically challenging and still require health care workers to staff the beds.
- In Wisconsin, C19 patients account for 17% of all hospitalizations, and many hospitals are warning that they are at or near capacity.
- The Marshfield Clinic Health System, which runs nine hospitals in primarily rural parts of the state, is expecting its share of C19 patients to double, if not more, by the end of the month.
- “That will push us well beyond our staffing levels,” says Dr. William Melms, chief medical officer at Marshfield. “We can always make more space, but creating the manpower to take care of our patients is the dilemma.”
- During earlier surges, many hospitals relied on bringing in hundreds or even thousands of out-of-state health care workers for backup, but Melms says that is not happening this time.
- “We are on an island out here,” he says.
- An increase in C19 hospitalizations statewide is also associated with higher mortality, according to a recent study that analyzed the relationship between C19 hospitalizations and deaths.
- “It’s an indicator that you’re going to have more deaths from COVID as you see the numbers inch up in the hospital,” says Pinar Karaca-Mandic, professor and academic director of the Medical Industry Leadership Institute at the University of Minnesota.
- Specifically, Karaca-Mandic’s research found that a 1% increase of C19 patients in a state’s ICU beds will lead to about 2.8 additional deaths in the next seven days.
- She says a statewide level of 20% C19 hospitalizations may not look all that alarming, but that number doesn’t capture the constraints on the health care system in adding more ICU beds.
- “That’s not very flexible,” she says. “It requires a lot of planning. It requires a lot of investments. So the more you fill up the ICU, the impact is going to be larger.”
1. Why do C19 death rates seem to be falling?
- Many regions of the world have experienced the pandemic in punishing waves, but Chennai in India endured a six-month flood, according to Bharath Kumar Tirupakuzhi Vijayaraghavan. The Apollo Main Hospital, where Vijayaraghavan works as an intensive-care specialist, was never overwhelmed, but it was relentlessly busy. And although the numbers of people with C19 finally began to fall in mid-October, Vijayaraghavan worries about the possible impact of the festival season, which began on 20 October, and the public’s waning compliance with health measures. “Everybody is exhausted,” he says. “It’s become a never-ending health-care problem.”
- One shining light that he can point to is his intensive-care unit’s dwindling fatality rate. In April, up to 35% of those in the unit with C19 perished, and about 70% of those on ventilators died. Now, the intensive-care mortality rate for people with the illness is down to 30%, and for those on ventilators it is around 45–50%. “This itself was a relief,” says Vijayaraghavan.
- Around the world, similar stories are emerging. Charlotte Summers, an intensive-care physician at the University of Cambridge, UK, says that data collected by the country’s National Health Service (NHS) show a decline in death rates1 (see ‘Mortality falls’). Critical-care physician Derek Angus at the University of Pittsburgh in Pennsylvania says that his hospital’s statistics team also saw reductions over time. “Without question, we’ve noticed a drop in mortality,” says Angus. “All things being equal, patients have a better chance of getting out alive.”
- The reasons are not entirely obvious. There have been no miracle drugs, no new technologies and no great advances in treatment strategies for the disease that has infected more than 50 million and killed more than 1.2 million around the world. Shifts in the demographics of those being treated might have contributed to perceived boosts in survival. And at many hospitals, it seems clear that physicians are getting incrementally better at treating C19 — particularly as health-care systems become less overwhelmed. Still, those gains could be erased by increasing case loads around the world.
- Vijayaraghavan credits the improvements in mortality at his institution to hard-earned experience, a better understanding of how to use steroids and a shift away from unproven drugs and procedures.
- Marcus Schultz, an intensive-care specialist at Amsterdam University Medical Center in the Netherlands, agrees, adding that it took time to realize that standard treatments were among the most effective. “In just half a year, I think we repeated 20 years of research in acute respiratory distress,” he says. “Everything was done again, and everything came with the same result.”
Crunching the numbers
- Researchers have struggled to work out whether the C19 death rates are truly dropping. The calculations can be complex. Case-fatality rates depend on testing: a country that tests only people with severe symptoms, for example, will have an outsized case-fatality rate compared with one in which asymptomatic testing is widespread. And fatality rates in intensive-care units can mislead if the demographics of the people admitted change over time. For example, many hospitals reported high numbers of younger patients as the pandemic wore on.
- The detailed data that are needed to parse these differences have been hard to come by in many countries, and that frustrates Andrew Levin, an economist at Dartmouth College in Hanover, New Hampshire. “We still don’t have the data that scientists and public-health officials should have,” he says.
- As a result, it has taken researchers some time to determine whether the number of deaths per infection is really falling, particularly for older people, says epidemiologist Ali Mokdad at the University of Washington in Seattle. Mokdad and his colleagues have been monitoring global data, with a focus on the United States and Europe. A provisional analysis, he says, which includes data from the American Hospital Association, now suggests that the number of fatalities per infection might have fallen by 20%.
- Intensive-care physicians point to early concerns about the increased production of proteins called cytokines that can rev up immune responses in some people with severe C19. This phenomenon, known as a ‘cytokine storm’, stimulated interest in using targeted therapies to dampen immune responses. Vijayaraghavan says that this prompted some physicians in India to treat C19 with tocilizumab, an antibody that blocks the activity of the cytokine interleukin-6 (IL-6). But, he says, the treatment might have made patients more susceptible to other infections, a particular risk in regions where drug-resistant bacteria are common.
- Since then, additional studies have shown that, although IL-6 levels are raised in some people with severe C19 compared with healthy individuals or those with mild infections, they are not elevated when compared with others with acute respiratory distress.
- Researchers have been looking — without success — at targeted ways to dampen immune responses in critically ill people for decades, says Angus. “And we have 20 to 30 years of failing to improve outcome with therapies that try to block the cytokine cascade.”
- Some studies have borne out Angus’s pessimism. A test of another IL-6-blocking antibody called sarilumab in the United States was halted because it showed no benefit, and a study of tocilizumab also found no effect on C19 death rates. A large, randomized, controlled clinical trial of tocilizumab taking place in the United Kingdom should have a result before the end of December, says Summers.
- In contrast to more-targeted drugs, blanket suppression of the immune system using steroids has been shown to cut death rates when used to treat severe C19. On 16 June, the UK RECOVERY trial found that a common steroid called dexamethasone could reduce C19 fatalities by as much as one-third when administered to patients who require supplemental oxygen or are on ventilators. (However, Summers cautions that dexamethasone treatment has not been shown to carry a benefit for people with mild C19 who do not need oxygen support, possibly because it weakens defenses against the virus itself.)
- Some intensive-care physicians were already giving low doses of dexamethasone to critically ill patients as part of their standard treatment for acute respiratory distress, but the safety of that approach was debated. The RECOVERY trial results encouraged more to use the drugs, and the doses were low enough that infections did not increase, says Vijayaraghavan.
- Thus far, steroids are the only medicine that has been shown to have a dramatic effect on C19 mortality. “Anyone who’s very sick should get steroids,” says Angus. “And everything else is a crapshoot.”
- The antiviral drug remdesivir, developed by the biopharmaceutical company Gilead Sciences in Foster City, California, has been shown by a US National Institutes of Health study to shorten hospital stays. A subsequent trial coordinated by the World Health Organization found that the drug had little, if any, effect on mortality, but the US Food and Drug Administration nevertheless approved it for treating C19 on 22 October.
- Hundreds of other therapies are being tested against C19, but many of the ongoing trials are too small to yield convincing results soon. Among the furthest along are studies of antibodies against the coronavirus (SARS-CoV-2) — either purified antibodies administered individually or in cocktails, or antibody-rich blood plasma taken from people recovering from the disease.
- Convalescent plasma studies have been hampered in the United States by the widespread availability of the treatment outside clinical trials, but the UK RECOVERY trial hopes to have data on this approach from a large, randomized, controlled trial this year. Meanwhile, a 464-person, open-label study in India found that convalescent plasma did not prevent moderate C19 from progressing to severe disease or reduce deaths.
- Tests of purified antibodies are also under way — such as those assessing the mixture of two antibodies produced by the biotechnology firm Regeneron Pharmaceuticals in Tarrytown, New York, that was administered to US President Donald Trump. These mainly target people who have mild C19 symptoms. Despite Trump’s claims that the treatment was a “cure”, large trials of the cocktail have not yet been completed, and there is no evidence that it has an impact on death rates from C19.
- Some studies in people with mild disease have shown that treatment with these antibodies can reduce hospitalizations. However, in October, the US National Institutes of Health halted a trial of an antibody produced by the pharmaceutical company Eli Lilly in Indianapolis, Indiana, in people hospitalized with C19 after finding no benefit from the treatment. Regeneron has also stopped enrolment in a trial of its antibody cocktail for people with severe symptoms.
- Researchers are also looking to find out whether drugs that prevent blood clots — an unexpected hallmark of C19 — could be given at higher doses or earlier during infection.
- Angus would like to see studies that test combinations of these treatments. He is an investigator for REMAP-CAP (Randomised, Embedded, Multi-factorial, Adaptive Platform Trial for Community-Acquired Pneumonia), a trial that spans more than 260 sites in 19 countries and is designed to allow treatments to be added or dropped. “For example, remdesivir might be better in the presence of steroids,” he says. “We need trials that simultaneously randomize several choices.”
Back to basics
- Some intensive-care researchers are sceptical of the chances that a highly effective medicine will be found, citing decades of failed attempts to find a ‘magic bullet’ for acute respiratory distress. “Apart from a vaccine, I think the differences in outcome will be driven by things like other ways to supply oxygen or help patients in their gas exchange,” says Schultz.
- In the early days of the pandemic, physicians were alarmed by the rapid deterioration of some people with C19, says Eddy Fan, an intensive-care physician at University Health Network in Toronto, Canada. “There were a lot of unknowns about the best way to manage this,” he says. “Because the patient could deteriorate very quickly, the thought was to put them on a ventilator and breathing tube quickly to prevent deterioration.”
- But, in retrospect, clinicians might have been overzealous at times. Schultz recalls asking patients to get off of their mobile phones so he could put them on a ventilator, but a candidate for a ventilator normally wouldn’t be well enough to hold a telephone conversation. As physicians became more comfortable treating people with C19, many realized that early ventilation was not necessary, says Fan.
- Unfortunately, the public began to become concerned that ventilators themselves were causing harm, says Summers. Now, she says, families are upset when physicians recommend that their loved ones be put on a ventilator — even when there are no other suitable ways of providing oxygen. “The narrative you’ve heard is that ventilators kill people,” she says. “That’s been particularly unhelpful.” The NHS health-care centres with the lowest mortality rates during the pandemic used ventilators, but not too early. They followed standard protocols for when to use the devices, says Summers.
- Ultimately, Summers and others attribute possible drops in death rates more to shoring up standard health-care practices than to medical advances. “It’s the little subtle things,” says Angus.
- This might mean that keeping death rates low could hinge on measures to reduce transmission. In Singapore, where C19 death rates are among the lowest in the world, intensive-care physician Jason Phua at Alexandra Hospital says the key to the country’s success has been suppressing transmission, so that hospitals were never overwhelmed. Early reports of mortality from Wuhan approached 97% for people with C19 who were on ventilators, he says. In Singapore, mortality rates in intensive-care units have been less than 15%. “I don’t think it’s because we are using the correct drugs,” he says. “I think what’s happening is that the others are overwhelmed.”
- In response to the pandemic, many hospitals rapidly expanded their numbers of intensive-care beds, but that meant bringing in extra staff from other departments. Over time, those staff members have become more familiar with intensive care, learning to recognize the patterns that can signal when a patient is about to deteriorate. And hospitals have learnt to triage those who have risk factors for more severe disease, placing them under more careful observation.
- Ultimately, reducing the C19 death rate by 10–20% would feel like a huge win in an intensive-care ward, says Levin. But that would still leave the number of deaths relatively high, particularly among older people, in whom the case-fatality rate approaches 30% for those more than 80 years old. Instead, he says, suppressing transmission is the best way to reduce C19 deaths: “In the grand scheme of things, from a public-policy angle, we need to say, ‘Let’s make sure that people in their 70s and 80s don’t get infected.’”
D. Vaccines & Testing
1. Everything You Don’t Want To Know About COVID Vaccines (Because You Can’t Be Bullish Anymore)
- Now that we’ve had the happy-talk about Pfizer’s messenger-RNA (mRNA) vaccine (and noted that Pfizer’s CEO sold the majority of his shares in the company immediately after the happy-talk), let’s dig into messenger-RNA (mRNA) vaccines which are fast approaching regulatory approval.
- Some people have concluded vaccines are not safe, regardless of their source or mechanisms. These people will never take any Covid vaccine.
- Others will also decline a vaccine because they’ve concluded Covid is overblown.
- Fair enough. But many other people conclude Covid is dangerous, partly because so little is known about its long-term effects (Long-Covid, Long-Haulers). Covid’s low mortality rate may be distracting us from its other more insidious consequences.
- Authorities desperate to restart the economy and reassure the populace are poised to approve novel vaccines using a new mechanism to generate an immune response: messenger RNA (mRNA) vaccines.
- I am not a scientist or clinician but I have followed scientific developments closely for the past 40 years and so I have a basic understanding of this new pathway.
- I’m posting links below to articles that describe the mRNA vaccines in greater detail. All these sources are respected journals or media outlets.
- Vaccines against viruses work by introducing an inactive virus or viral particle into the bloodstream where this new foreign particle activates our immune system to create antibodies against this specific virus. If the live virus infects us at some later date, our immune systems are already primed to identify and destroy the dangerous virus.
- Messenger RNA was only discovered in 1961. DNA is the set of instructions, the “blueprint”, and mRNA is a key part of the cellular machinery that copies a strand of the DNA “blueprint” and builds a protein based on the DNA instructions.
- Messenger RNA vaccines don’t introduce a viral particle to our immune systems–they deliver cellular instructions (i.e. a “blueprint”) for a viral particle which our cells reproduce once the mRNA enters our cells and delivers the “blueprint” for assembling the viral particle.
- Here’s a recent description of this mechanism from The Atlantic magazine:
- “Moderna works on RNA vaccines–injecting not proteins but the molecules of nucleic acid that encode the instructions for building the proteins. Your cells use RNA to instruct their builders to make proteins all the time; the RNA is like the blueprints or schematics that tell the workers on the factory floor what to build.”
- And here’s another description by a doctor writing in the independent.co.uk:
- “Moderna’s messenger RNA vaccine, on the other hand, is completely new and revolutionary to say the least. It uses a sequence of genetic RNA material produced in a lab that, when injected into your body, must invade your cells and hijack your cells’ protein-making machinery called ribosomes to produce the viral components that subsequently train your immune system to fight the virus. In this case, Moderna’s mRNA-1273 is programmed to make your cells produce the coronavirus’ infamous spike protein that gives the virus its crown-like appearance (‘corona’ is crown in Latin) for which it is named.”
- Many in the field see the potential for mRNA to deliver superior vaccines because they can generate T-Cell responses as well as the conventional immune responses to viral particles. They are also easier and cheaper to manufacture, and may be stable at room temperature for a week, unlike the Pfizer vaccine which must be
- But these are the first mRNA vaccines ever seeking approval for human use, and so there are no long-term studies of what might go wrong down the road.
- One concern is the possibility that mRNA vaccines could trigger a generalized immune response (interferon, etc.) rather than just a specific immune response to a specific virus (antibodies, etc.).
- Our immune system is extremely complex and I make no claim to have a complete understanding of it. That said, the immune system has several levels of response. A conventional vaccine triggers the production of a specific antibody that “recognizes” a specific invader. In other cases, the immune system can activate an “all hands on deck” generalized response.
- The danger is that the mRNA could trigger an “all hands on deck” response that could then cascade into autoimmune disorders in which the immune system goes haywire and starts attacking the body’s own cells rather than limiting its destructive capabilities to foreign viruses, bacteria, etc.
- One of my MD correspondents recently sent me an email which encapsulates these concerns.
- “I’ve been reading about the Pfizer vaccine.
- I’ve known for a while that it is an mRNA vaccine but it just hit me that it will be the first mRNA vaccine ever approved for human use.
- If COVID was a ‘Steven King’ (kills-everyone) virus, sure, go for it–prevent the deaths and take what comes.
- But mortality is low, acute treatments are improving, transmission is preventable, and the greatest risk now appears to be longer term morbidity.
- mRNA vaccines by the very nature of their components elicit an interferon response that triggers generalized autoimmunity. This may, in fact, be part of the mechanism of longer term morbidity associated with COVID infection.
- Mass introduction of mRNA strands into the populations may indeed reduce acute COVID morbidity and mortality, but how many autoimmune complications will result?
- No one knows.
- It’s never been done before–ever.
- It would take years of carefully controlled and limited trials across all ethnic groups to find out.
- Is the net good from a vaccine that fewer people die up front but a whole lot more folks suffer long term problems on the back end–especially (as seems likely) boosters will be required.
- Shouldn’t there be a discussion before ‘immunity passports’ are mandated?
- For that matter, shouldn’t we discover how long natural immunity lasts before trying to provoke induced immunity?
- I’m dumbstruck that, with the proposed approval timetable, this path is even being considered at a population level, let alone considered without an extensive discussion.
- First do no harm.”
- Indeed. And then there’s the self-interest of those seeking rapid approval of the vaccines. As noted in the independent.co.uk article referenced above:
- “But perhaps the most important question to ask about Moderna’s new messenger RNA vaccine is not scientific nor technical but one of ethics and morality. When it comes to the United States and its private healthcare system, pharmaceutical companies have a long and sordid history of putting profits over people and human lives.”
- Why would anyone trust that Big Pharma corporations will act in the public good rather than in pursuit of maximizing profits?
- The mad rush of profiteering Big Pharma corporations to own the first vaccine approved will create needless and potentially dangerous confusion about which vaccine actually works best over the longer term.
- “It has not yet dawned on hardly anybody the amount of complexity and chaos and confusion that will happen in a few short months,” said Dr. Gregory Poland, the director of the Vaccine Research Group at the Mayo Clinic.
- “I can see people reading a lot into even minor differences that could just be statistical chance,” said Natalie Dean, a biostatistician at the University of Florida.”
- The FDA has set the bar very low for Covid vaccines: the vaccine only has to be effective for 50% of those taking it to be approved. But as noted above, Big Pharma companies have mastered the art of statistical legerdemain that skew results so they look far more conclusive than they actually are.
- If you’ve actually pored over Phase III drug trial results (I have), you find uncertainties have been papered over with statistical analysis techniques. Many medications are approved that only work less than half of the time in the real world.
- Another healthcare professional correspondent recommended the book Tainted Truth: The Manipulation of Fact In America as a source for understanding how study data are manipulated to get the desired results.
- The danger here in my view is the poorly-informed, politically polarized general public will assume a Covid vaccine is essentially 100% effective like a measles vaccine, when the real-world efficacy might be considerably less certain. Maybe the vaccines will only work for 75% of the recipients. How will anyone be able to tell if they’re one of the 25% for whom the vaccine offers only false confidence?
- No one knows how long the immunity generated by these vaccines will last. These two uncertainties generate insurmountable doubts, very likely muddying the waters and making it more difficult to ascertain which vaccines actually work and for how long they offer immunity.
- America’s choice to optimize healthcare profiteering (a.k.a. “shareholder value”) over the public good is about to reap a whirlwind. Our educational deficiencies won’t help, as a populace which has a limited grasp of statistics and basic biology has few means to sort the wheat of real-world results from the chaff of self-interested PR.
- Maybe the mRNA vaccines will fulfill their promise the first time out of the gate, with near-perfect efficacy and long-lasting immunity. The problem is it will take a long time and careful, de-politicized, independently confirmed studies to reach any trustworthy conclusions.
- In such a highly polarized, politicized environment, is such a scrupulously objective study even possible? In a system that rewards self-serving statistical analysis and “first to market,” a system where Big Pharma insiders reap millions of dollars selling their stock on the PR of happy-talk, is it even possible to have truly objective studies of a vaccine’s efficacy and long-term effects?
- It seems doubtful. And that’s a problem that extends far beyond the unknowns of mRNA vaccines.
Also see: Here Are All The Things That Could Still Go Wrong With A C19 Vaccine at https://www.zerohedge.com/geopolitical/here-are-all-things-could-still-go-wrong-covid-19-vaccine
2. Russia’s claim of a successful C19 vaccine doesn’t pass the ‘smell test,’ critics say
- Another day, another promising C19 vaccine? A Russian institute announced today its vaccine candidate has had remarkable success in an efficacy trial, just 2 days after the widely celebrated news from Pfizer and BioNTech that their vaccine had greater than 90% efficacy. The Russian report, however, is being met with raised eyebrows—and some outright guffaws.
- In a press release, the Gamaleya National Center of Epidemiology and Microbiology in Moscow said an interim analysis of a large-scale trial underway in Russia had found 92% efficacy for its “Sputnik V” vaccine. The release quoted the Russian minister of health saying the results demonstrate that Sputnik V “is an efficient solution to stop the spread of coronavirus infection.” Yet it also noted the review covered just 20 total C19 cases in the vaccinated and placebo groups—far too few for the claim be convincing, experts inside and outside of Russia say.
- In contrast, they note, Pfizer and BioNTech analyzed 94 cases to make their efficacy claim, and other vaccinemakers plan to wait for at least 50 or more C19 cases to accumulate in a trial to assess a candidate’s worth. “It’s very difficult to explain [the Gamaleya] announcement,” says Svetlana Zavidova, a Moscow-based lawyer who heads Russia’s Association of Clinical Trials Organizations and closely follows C19 vaccine R&D in the country. “I’m afraid they looked at the results of Pfizer and added 2%.”
- The claims don’t pass “the smell test,” adds Wayne Koff, who heads the nonprofit Human Vaccines Project, which is attempting to improve the design of future vaccines. (The Gamaleya media contact on the press release did not reply to Science’s request for an interview.)
- The Gamaleya vaccine, made with support from the Russia Direct Investment Fund, uses two different shots in what’s known as a prime-boost scheme. Both shots rely on supposedly harmless adenoviruses as gene delivery “vectors”: Researchers have engineered them to hold the gene for the surface protein of the coronavirus (SARS-CoV-2). The first shot used adenovirus 26 (Ad26) as the vector for the coronavirus surface protein, called spike, while the second used adenovirus 5 (Ad5). The 20 cases described in the press release were detected among more than 16,000 people in the 40,000-person study. Participants were evaluated for C19 21 days after receiving the Ad26 shot, when they came to the trial site to received their Ad5 booster.
- The U.S. Food and Drug Administration “wouldn’t have accepted a report on 20 cases,” says John Moore, a vaccine researcher at Weill Cornell Medical College. He regards the announcement as “Putinology,” referring to the Russian president. “Why is Russia doing this?” Moore asks. “It’s the international vaccine race. They want to be seen to be keeping up with their competitors in other countries. It’s clearly a rushed out announcement. But it doesn’t mean it’s wrong.”
- The Gamaleya press release said the study had not found any serious side effects, but vaccine researcher Julie McElrath from the Fred Hutchinson Cancer Research Center says the Ad5 vector worries her. McElrath co-authored a commentary in The Lancet last month that raised concerns about using Ad5 as a vehicle for C19 vaccines, because it was linked to a catastrophe in an HIV vaccine study 13 years ago. In that trial, vaccine recipients had higher rates of HIV infection than those in the placebo group; the Ad5 vector has become the leading suspect for the problem. “Certainly, we need multiple vaccine strategies to end the pandemic, so I look forward to seeing additional data after a longer time interval,” McElrath says.
- One month before Sputnik V’s efficacy trial launched in September, the Gamaleya vaccine received a highly controversial approval from Russian regulatory authorities, which allowed it to be given to people outside of a clinical trial. The Gamaleya release says the vaccine has been used in “red zones” of Russian hospitals, which means health care workers and other high-risk groups. To date, the release says 10,000 people have received the vaccine under this authorization. “[T]he civil use of the vaccine out of clinical trials also confirmed the vaccine’s efficacy rate of over 90%,” the Gamaleya release says without offering any evidence to back this claim.
- Koff, who for many years headed the AIDS vaccine division of the U.S. National Institutes of Health (NIH), did allow that the efficacy claim is an “interesting observation,” though one that is hard to evaluate because Gamaleya, like Pfizer and BioNTech, offered scant data to back up their press release. He also notes that neither the center nor the Russian government has tried to harmonize their vaccine push with international standards for efficacy trials and vaccine approvals.
- Pfizer and BioNTech and many other companies have made their trial protocols public, but Gamaleya has not. Zavidova notes that she learned more about the details of Gamaleya’s study on a clinical trials website maintained by NIH than she did on a similar registry in Russia, which has “only the name of this protocol without any details.”
- In the press release, Alexander Gintsburg, the head of the Gamaleya, promises “mass vaccination in Russia against C19 in the coming weeks.” If the Gamaleya vaccine does become widely available, will Zavidova take it, given that the spread of C19 has rapidly accelerated in Russia? “No,” she says. “I will wait a little bit more.”
2. Accuracy of rapid COVID test may be lower than previously suggested
- The accuracy of a rapid finger-prick antibody test for the coronavirus (SARS-CoV-2) may be considerably lower than previously suggested, finds a study published by The BMJ.
- The results suggest that if 10% of people given the test had previously been infected, around 1 in 5 positive test results would be incorrect (false positive results).
- These conclusions contrast with an earlier (not yet peer reviewed) study suggesting that the test gives no false positive results.
- The findings suggest the test can deliver a sufficient degree of accuracy for surveillance studies of the population, but laboratory confirmation of positive results is likely to be needed if these tests are to be used to provide evidence of protection from the virus.
- The AbC-19TM Rapid Test uses a drop of blood from a finger-prick to see if it’s likely that someone has previously been infected with SARS-CoV-2. It gives results in 20 minutes, without the need to go to a laboratory, and is approved for use by health professionals in the UK and EU.
- The latest research was commissioned by the Department of Health and Social Care and conducted by scientists from Public Health England and the Universities of Bristol, Cambridge and Warwick.
- Scientists tested blood samples in a laboratory from 2,847 key workers (healthcare, fire, and police staff) in England in June 2020.
- Of these, 268 had a previous PCR (positive polymerase-chain reaction) positive result so were “known positives” while the remaining 2,579 had unknown previous infection status. A further 1,995 pre-pandemic blood samples were also tested as “known negatives.”
- Based on a series of analyses, the researchers estimated the specificity of the AbC-19 test (ability to correctly identify a true negative sample) to be 97.9%, meaning that 2.1% of people who did not have a previous SARS-Cov-2 infection incorrectly tested positive.
- They estimated the sensitivity of the AbC-19 test (ability to correctly identify a true positive sample) to be 92.5% based on PCR confirmed cases but considerably lower (84.7%) in people with unknown previous infection status prior to antibody testing.
- This difference is probably due to the test being more sensitive when antibody levels are higher, explain the researchers. As people with a positive PCR result tended to have more severe disease, it is likely that they would have produced more antibodies.
- They say the lower figure of 84.7% is probably a more realistic estimate of test sensitivity in the real world, if people were to choose to take the test to find out their own previous infection status. This means that 15.3% of people with a previous SARS-CoV-2 infection would be missed.
- Putting these findings into context, the researchers say that, if 1 million people were tested with AbC-19, of whom 10% had been previously infected with SARS-CoV-2, there would be 18,900 false positive results. Overall, about one in five positive results would be wrong.
- They also found that trained laboratory staff noted the test result band was often weak and disagreed on whether the result was positive or negative for almost 4% of AbC-19 tests. This implies that test accuracy could be lower still if the test was used at home by members of the public.
- This is a large study, using data from individuals with both known and unknown previous infection status, but the authors do highlight some limitations.
- For example, the test was evaluated in a laboratory, rather than having participants perform the test themselves, which may have overestimated performance, and the study included few people aged over 65 years, suggesting the need for further evaluation of the test in older ages when risk of severe covid-19 is substantially higher.
- It is possible that other lateral flow devices detecting antibodies to SARS-CoV-2 may also work less well at lower antibody concentrations; while this study did not investigate this, the authors note that their work “highlights the scope for overestimation of SARS-CoV-2 antibody test sensitivity in other studies in which sensitivity has been estimated only from PCR confirmed cases.”
- The UK Government has placed an order for one million AbC-19 tests for research purposes, to help build up a picture of how the virus has spread across the country.
- In a linked editorial, Dipender Gill at Imperial College London and Mark Ponsford at Cardiff University, say this study “identifies notable limitations of the UK government’s antibody test of choice and provides good evidence that its specificity in a “real life” setting is highly unlikely to be 100%.”
- They call for further work to clarify the relation between circulating antibody levels and immunity to SARS-Cov-2, and say “a clear message must be communicated to the public that positive results from these assays do not provide evidence of immunity.”
- “Apart from limited surveillance to estimate the proportion of a population that has been infected, widespread use of this assay in any other role could risk considerable harm,” they conclude.
E. Improved & Potential Treatments
1. Melatonin May Be a Viable Treatment for C19
- Results from a new Cleveland Clinic-led study suggest that melatonin, a hormone that regulates the sleep-wake cycle and is commonly used as an over-the-counter sleep aid, may be a viable treatment option for C19.
- As C19 continues to spread throughout the world, particularly with cases rising during what some have termed the “fall surge,” repurposing drugs already approved by the U.S. Food and Drug Administration for new therapeutic purposes continues to be the most efficient and cost-effective approach to treat or prevent the disease. According to the findings published today in PLOS Biology, a novel artificial intelligence platform developed by Lerner Research Institute researchers to identify possible drugs for C19 repurposing has revealed melatonin as a promising candidate.
- Analysis of patient data from Cleveland Clinic’s C19 registry also revealed that melatonin usage was associated with a nearly 30% reduced likelihood of testing positive for the coronavirus (SARS-CoV-2) after adjusting for age, race, smoking history, and various disease comorbidities. Notably, the reduced likelihood of testing positive for the virus increased from 30 to 52% for African Americans when adjusted for the same variables.
- “It is very important to note these findings do not suggest people should start to take melatonin without consulting their physician,” said Feixiong Cheng, Ph.D., assistant staff in Cleveland Clinic’s Genomic Medicine Institute and lead author on the study. “Large-scale observational studies and randomized controlled trials are critical to validate the clinical benefit of melatonin for patients with C19, but we are excited about the associations put forth in this study and the opportunity to further explore them.”
- Here, the researchers harnessed network medicine methodologies and large-scale electronic health records from Cleveland Clinic patients to identify clinical manifestations and pathologies common between C19 and other diseases. Specifically, they measured the proximity between host genes/proteins and those well-associated with 64 other diseases across several disease categories (malignant cancer and autoimmune, cardiovascular, metabolic, neurological and pulmonary diseases), where closer proximity indicates a higher likelihood of pathological associations between the diseases.
- They found, for example, that proteins associated with respiratory distress syndrome and sepsis, two main causes of death in patients with severe C19, were highly connected with multiple SARS-CoV-2 proteins. “This signals to us, then,” explained Dr. Cheng, “that a drug already approved to treat these respiratory conditions may have some utility in also treating C19 by acting on those shared biological targets.”
- Overall, they determined that autoimmune (e.g., inflammatory bowel disease), pulmonary (e.g., chronic obstructive pulmonary disease and pulmonary fibrosis) and neurological (e.g., depression and attention-deficit hyperactivity disorder) diseases showed significant network proximity to SARS-CoV-2 genes/proteins and identified 34 drugs as repurposing candidates, melatonin chief among them.
2. Nasal Spray May Prevent Coronavirus Infection
- A nasal antiviral created by researchers at Columbia University Vagelos College of Physicians and Surgeons blocked transmission of the coronavirus (SARS-CoV-2) in ferrets, suggesting the nasal spray also may prevent infection in people exposed to the new coronavirus.
- The compound in the spray—a lipopeptide developed by Anne Moscona, MD, and Matteo Porotto, PhD, professors in the Department of Pediatrics and directors of the Center for Host-Pathogen Interaction—is designed to prevent the new coronavirus from entering host cells.
- The antiviral lipopeptide is inexpensive to produce, has a long shelf life, and does not require refrigeration. These features make it stand out from other antiviral approaches under development, including monoclonal antibodies. The new nasal lipopeptide could be ideal for halting the spread of COVID in the United States and globally; the transportable and stable compound could be especially key in rural, low-income, and hard-to-reach populations.
- A preprint of the study appeared in bioRxiv on November 5, 2020; a paper describing a first generation of the compound and its effect in a 3D model of the human lung first appeared in the journal mBio on October 20, 2020. In this human lung model, the compound was able to extinguish an initial infection, prevent spread of the virus within the lung, and was not at all toxic to the airway cells.
Ferrets a model for respiratory diseases
- Ferrets are often used in studies of respiratory diseases because the lungs of these animals and humans are similar. Ferrets are highly susceptible to infection with SARS-CoV-2, and the virus spreads easily from ferret to ferret.
- In this study, 100% of the untreated ferrets were infected by their virus-shedding cagemates, approximating a setting like sharing a bed or close living conditions for people.
- Moscona and Porotto have previously created similar lipopeptides—small proteins joined to a cholesterol or tocopherol molecule—to prevent infection of cells by other viruses, including measles, parainfluenza, and Nipah viruses. These anti-viral compounds have been challenging to bring to human trials, in large part because the infections they prevent are most prevalent or serious in low-income contexts.
- When SARS-CoV-2 emerged earlier this year, the researchers adapted their designs to the new coronavirus. “One lesson we want to stress is the importance of applying basic science to develop treatments for viruses that affect human populations globally,” Moscona and Porotto say. “The fruits of our earlier research led to our rapid application of the methods to C19.”
Lipopeptides prevent viruses from infecting cells
- The lipopeptides work by preventing a virus from fusing with its host’s cell membrane, a necessary step that enveloped viruses, including SARS-CoV-2, use to infect cells. To fuse, the new coronavirus unfolds its spike protein before contracting into a compact bundle that drives the fusion.
- The compound designed by Moscona and Porotto recognizes the SARS-CoV-2 spike, wedges itself into the unfolded region, and prevents the spike protein from adopting the compact shape necessary for fusion.
- In the ferret experiments, the lipopeptide was delivered into the noses of six ferrets. Pairs of treated ferrets were then housed with two control ferrets that received a saline nasal spray and one ferret infected with SARS-CoV-2.
- After 24 hours of intense direct contact among the ferrets, tests revealed that none of the treated ferrets caught the virus from their infected cagemate and their viral load was precisely zero, while all of the control animals were highly infected.
Lipopeptides are easily administered
- Moscona and Porotto propose these peptides could be used in any situation where an uninfected person would be exposed, whether in a household, school, health care setting, or community.
- “Even in an ideal scenario with large segments of the population vaccinated—and with full trust in and compliance with vaccination procedures—these antivirals will form an important complement to protect individuals and control transmission,” Moscona and Porotto say. People who cannot be vaccinated or do not develop immunity will particularly benefit from the spray.
- The antiviral is easily administered and, based on the scientists’ experience with other respiratory viruses, protection would be immediate and last for at least 24 hours.
- The scientists hope to rapidly advance the preventative approach to human trials with the goal of containing transmission during this pandemic.
3. Fluvoxamine may prevent serious illness in C19 patients
- In a preliminary study of C19 patients with mild-to-moderate disease who were attempting to recover in their homes, researchers at Washington University School of Medicine in St. Louis have found that the drug fluvoxamine seems to prevent some of the most serious complications of the illness and make hospitalization and the need for supplemental oxygen less likely.
- The study, a collaboration between the university’s Department of Psychiatry and Division of Infectious Diseases, involved 152 patients infected with the coronavirus (SARS-CoV-2). Researchers compared the outcomes of those treated with fluvoxamine to the outcomes of those given an inactive placebo. After 15 days, none of the 80 patients who had received the drug experienced serious clinical deterioration. Meanwhile, six of the 72 patients given placebo (8.3%) became seriously ill, with four requiring hospitalization.
- The study is published online Nov. 12 in the Journal of the American Medical Association.
- “The patients who took fluvoxamine did not develop serious breathing difficulties or require hospitalization for problems with lung function,” said the paper’s first author, Eric J. Lenze, MD, the Wallace and Lucille Renard Professor of Psychiatry. “Most investigational treatments for C19 have been aimed at the very sickest patients, but it’s also important to find therapies that prevent patients from getting sick enough to require supplemental oxygen or to have to go to the hospital. Our study suggests fluvoxamine may help fill that niche.”
- Fluvoxamine is used commonly to treat obsessive-compulsive disorder (OCD), social anxiety disorder and depression. It is in a class of drugs known as selective serotonin-reuptake inhibitors (SSRIs), but unlike other SSRIs, fluvoxamine interacts strongly with a protein called the sigma-1 receptor. That receptor also helps regulate the body’s inflammatory response.
- “There are several ways this drug might work to help C19 patients, but we think it most likely may be interacting with the sigma-1 receptor to reduce the production of inflammatory molecules,” said senior author Angela M Reiersen, MD, an associate professor of psychiatry. “Past research has demonstrated that fluvoxamine can reduce inflammation in animal models of sepsis, and it may be doing something similar in our patients.”
- Reiersen said the drug’s effects on inflammation could prevent the immune system from mounting an overwhelming response, which is thought to occur in some C19 patients who seem to improve after a few days of illness and then worsen. Many of those patients end up hospitalized, and some die.
- In an innovative twist to research during the pandemic, the study was conducted remotely. When a symptomatic patient tested positive and enrolled in the study, research staff delivered the medication or inactive placebo to them, along with thermometers, automatic blood pressure monitors and fingertip oxygen sensors.
- “Our goal is to help patients who are initially well enough to be at home and to prevent them from getting sick enough to be hospitalized,” said Caline Mattar, MD, an assistant professor of medicine in the Division of Infectious Diseases. “What we’ve seen so far suggests that fluvoxamine may be an important tool in achieving that goal.”
- For two weeks, subjects took either the antidepressant drug or placebo sugar pills while having daily interactions with members of the research team — via phone or computer. That allowed patients to report on their symptoms, oxygen levels and other vital signs. If patients suffered shortness of breath or were hospitalized for pneumonia, or their oxygen saturation levels fell below 92%, their conditions were considered to have deteriorated.
- “The good news is that not a single person taking the active medication experienced deterioration,” Reiersen said. “We believe this drug may be the reason, but we need to study more patients to make sure.”
- The researchers will begin a larger study in the next few weeks. Lenze, the director of the Healthy Mind Lab at the School of Medicine, is an expert in using mobile and internet technology to conduct clinical trials. He said that although this initial study involved patients in the St. Louis region, the next phase of the research will involve patients from throughout the country.
- “We bring the study to the patients, giving them tools to monitor their health at home,” Lenze said. “Our hope is that we can keep these patients healthy enough to avoid hospitalization.”
4. Eli Lilly’s C19 Antibody Drug Gets FDA Green Light
- U.S. health officials on Monday authorized use of the first treatment for people with earlier-stage C19 who aren’t hospitalized, filling a gap in treatment.
- The U.S. Food and Drug Administration said Eli Lilly & Co.’s antibody drug should be used for patients ages 12 and up with mild to moderate C19, based on a study showing it helped improve symptoms and kept many patients out of the hospital.
- The FDA said the drug is authorized for patients at high risk of progressing to severe C19, including people 65 and older, or who have certain chronic medical conditions. The drug shouldn’t be given to hospitalized patients, the FDA said, because it showed no clinical benefit in a study among such patients.
- The drug’s authorization “provides health care professionals on the frontline of this pandemic with another potential tool in treating C19 patients,” said Patrizia Cavazzoni, acting director of the FDA’s Center for Drug Evaluation and Research.
- The drug is named bamlanivimab. Lilly said it will begin shipping the drug immediately to AmerisourceBergen Corp. , a national drug distributor, to distribute it as directed by a federal allocation program.
- The drug will be “a valuable tool for doctors fighting the now-increasing burden of this global pandemic,” said Lilly Chief Executive David Ricks.
- Regeneron Pharmaceuticals Inc. also has requested FDA authorization of its own antibody-based therapy for C19. “We continue productive discussions with the FDA regarding our EUA submission,” Regeneron said.
- The drugs are part of a class of medicines known as monoclonal antibodies that are designed in labs to mimic the naturally occurring antibodies that the immune system produces to fight off viruses and other foreign invaders.
- The C19 antibodies were derived from antibodies isolated in the blood of people who recovered from the disease and, in Regeneron’s case, from genetically modified mice.
- The class garnered lots of attention after President Trump was given Regeneron’s antibody drug and then attributed his return to health to the therapy, though doctors cautioned against singling out one factor.
- “They gave me Regeneron, and it was like, unbelievable. I felt good immediately,” Mr. Trump said in October.
- The drugs so far have shown the greatest effectiveness in treating patients early in the course of disease with mild or moderate symptoms. Most of those patients tend to clear the virus on their own regardless of whether they receive treatment, which could make it difficult for doctors to determine who should receive the relatively expensive and scarce doses of the drugs.
- Of 309 study subjects injected with Eli Lilly’s drug, five, or 1.6%, were later hospitalized or visited the emergency room, compared with nine of 143 people who received a placebo, or 6.3%. Lilly also said patients receiving the drug had more rapid improvement in symptoms compared with those who received a placebo.
- So far, only a few drugs have been shown to work against C19 and only in hospitalized patients, including Gilead Sciences Inc.’s remdesivir. The new antibodies from Lilly and Regeneron can be used before patients become severely ill.
- Lilly’s is the first authorized drug specifically designed this year to fight C19. Gilead’s remdesivir, for example, was originally designed to treat other viruses and was subsequently found to be effective for C19.
- The C19 antibody drugs also have the potential to prevent disease in people at risk of infection. Lilly is testing its drug in the staff and residents of nursing homes if a C19 case had been identified at a facility.
- The FDA’s clearance of the drug is technically known as an emergency-use authorization, which the agency uses in public-health emergencies to greenlight a drug more quickly than a standard approval.
- The federal government has agreed to buy hundreds of thousands of doses of Lilly’s and Regeneron’s drugs, and will be in charge of allocating supply to states, which will in turn determine which hospitals and health facilities should get them.
- The drugs are administered via intravenous infusion, requiring patients to go to a hospital outpatient clinic or standalone infusion clinic.
- The government-purchased doses will be allocated to states and U.S. territories based on their share of hospitalized and infected patients, a spokeswoman for the Department of Health and Human Services said.
- The drug will be provided for free, but doctors can charge insurers for the cost of administering the drug, the spokeswoman said.
- Lilly originally code-named its drug LY-CoV555 but is now calling it bamlanivimab. The company developed it in collaboration with AbCellera Biologics Inc., of Vancouver, British Columbia, which isolated antibodies from a blood sample taken from one of the first Americans to recover from C19. AbCellera also collaborated with the National Institute of Allergy and Infectious Diseases on discovering the antibody.
- In late October, Lilly signed an agreement to provide 300,000 doses of the antibody to the federal government for $375 million. Lilly said each vial, which is enough to treat one patient, will cost $1,250. Lilly said it expects to have 100,000 doses ready to ship within days of authorization, and expects to have up to one million doses by the end of the year.
F. Concerns & Unknowns
1. Coronavirus Could Evolve Resistance, Rendering C19 Vaccines Ineffective
Note: The series of illustrations on this page are a schematic illustrating three ways that standard samples from C19 clinical trials can be repurposed to assess the risk that vaccine resistance will evolve.
1. The complexity of B-cell and T-cell responses can be measured using blood samples. Different neutralizing antibodies are depicted above in different colors. More complex responses indicate more evolutionarily robust immunity.
- Similar to bacteria evolving resistance to antibiotics, viruses can evolve resistance to vaccines, and the evolution of the coronavirus (SARS-CoV-2) could undermine the effectiveness of vaccines that are currently under development, according to a paper published today (November 9, 2020) in the open-access journal PLOS Biology by David Kennedy and Andrew Read from Pennsylvania State University, USA. The authors also offer recommendations to vaccine developers for minimizing the likelihood of this outcome.
- “A C19 vaccine is urgently needed to save lives and help society return to its pre-pandemic normal,” said David Kennedy, assistant professor of biology. “As we have seen with other diseases, such as pneumonia, the evolution of resistance can quickly render vaccines ineffective. By learning from these previous challenges and by implementing this knowledge during vaccine design, we may be able to maximize the long-term impact of C19 vaccines.”
2. The effect of vaccination on transmission potential can be assessed by collecting viral titer data using routine nasal swabs. Plaque assays from multiple vaccinated and control individuals are compiled into a histogram. Undetectable viral titers suggest little or no transmission potential, due to either complete immune protection or the absence of exposure. High viral titers suggest high transmission potential due to the absence of a protective immune response. Intermediate viral titers, marked above with an asterisk, suggest moderate transmission potential due to partial vaccine protection. Intermediate titers indicate an increased risk for resistance evolution since pathogen diversity can be generated within hosts and selection can act during transmission between hosts.
- The researchers specifically suggest that the standard blood and nasal-swab samples taken during clinical trials to quantify individuals’ responses to vaccination may also be used to assess the likelihood that the vaccines being tested will drive resistance evolution. For example, the team proposes that blood samples can be used to assess the redundancy of immune protection generated by candidate vaccines by measuring the types and amounts of antibodies and T-cells that are present.
- “Much like how combination antibiotic therapy delays the evolution of antibiotic resistance, vaccines that are designed to induce a redundant immune response — or one in which the immune system is encouraged to target multiple sites, called epitopes — on the virus’s surface, can delay the evolution of vaccine resistance,” said Andrew Read, Evan Pugh Professor of Biology and Entomology and director of the Huck Institutes of the Life Sciences. “That’s because the virus would have to acquire several mutations, as opposed to just one, in order to survive the host immune system’s attack.”
3. Pre-existing variation for vaccine resistance can be assessed by recovering genome sequences from nasopharyngeal swabs of symptomatic C19 cases included in the study. In a placebo controlled, double blind study, any significant differences in the genome sequences of samples from vaccinated and control individuals would suggest at least partial vaccine resistance.
- The researchers also recommend that nasal swabs typically collected during clinical trials may be used to determine the viral titer, or amount of virus present, which can be considered a proxy for transmission potential. They noted that strongly suppressing virus transmission through vaccinated hosts is key to slowing the evolution of resistance, since it minimizes opportunities for mutations to arise and reduces opportunities for natural selection to act on those mutations that do arise.
- In addition, the team suggests that the genetic data acquired through nasal swabs can be used to examine whether vaccine-driven selection has occurred. For example, differences in alleles, or forms of genes that arise from mutations, between the viral genomes collected from vaccinated versus unvaccinated individuals would indicate that selection has taken place.
- “According to the World Health Organization, at least 198 C19 vaccines are in the development pipeline, with 44 currently undergoing clinical evaluation,” said Kennedy. “We suggest that the risk of resistance be used to prioritize investment among otherwise similarly promising vaccine candidates.”
2. Social distancing is increasing loneliness in older adults
- Social distancing introduced in response to C19 is increasing feelings of loneliness in Scotland’s older population and impacting their wellbeing, according to a new University of Stirling study.
- The research has identified a link between increases in loneliness in over 60s and the worsening of wellbeing and health. Increasing loneliness due to social distancing was associated with a smaller social network, lower perceived social support and a decrease in wellbeing, the study found.
- The findings emerge from research launched under the Scottish Government’s Chief Scientist Office Rapid Research in C19 programme in May. Professor Anna Whittaker, of the University’s Faculty of Health Sciences and Sport, led the work and hopes it will help to inform decision-making on the virus and support post-pandemic recovery strategies.
- Professor Whittaker said: “Previous studies have demonstrated the negative impacts of social isolation and loneliness. This is a key issue for older adults who may be more likely to have few social contacts. We know that social distancing guidelines introduced in response to C19 have restricted social activity engagement and impacted vulnerable groups, including older adults.
- “Our study, which involved a survey of more than 1,400 older people, examined the impact of social distancing during the pandemic on social activity, loneliness and wellbeing. The majority of survey participants reported that social distancing has made them experience more loneliness, social contact with fewer people, and less social contact overall.
- “We found that a larger social network and better perceived social support seems to be protective against loneliness and poorer health and wellbeing, due to social distancing. This underlines the importance of addressing loneliness and social contact in older adults, but particularly during pandemics or situations where the risk of isolation is high.”
- Of the 1,429 survey participants, 84% were aged 60 or over and had an average social network of five people. On average, the participants socialised five days per week, for more than 6.6 hours per week. 56% reported that social distancing regulations made them experience more loneliness – with scores that were significantly higher than reported norms; the same quality of perceived support; but social contact with fewer people and less social contact overall.
- Greater loneliness was significantly associated with a smaller social network, lower perceived social support, and a decrease in social support frequency, quality, and amount – and a worsening of wellbeing and health.
- Using the same survey data, the research also considered the impact of social distancing on physical activity. The majority of participants reported continuing to meet physical activity guidelines during lockdown – with 35% moderately active and 41% highly active. Walking was the greatest contributor to total physical activity, with just over a quarter (26.4%) walking more than before lockdown. Those living in rural areas reported greater volumes of physical activity.
- 40% of people said they were walking less, compared to before lockdown, and a similar proportion were engaging in less moderate physical activity. Those who reported in engaging in lower physical activity had poorer wellbeing.
- Individuals who reported no change in moderate physical activity were the most active pre-lockdown and those who reported no change in walking had significantly higher levels of total physical activity pre-lockdown.
- Professor Whittaker said: “Physical activity engagement during lockdown varied and this study indicates a positive link with wellbeing – supporting the notion that physical activity should be considered an important contributor in recovery strategies targeted at older adults as we emerge from the pandemic.
- “There appears to be a relationship between pre-lockdown physical activity and physical activity changes due to lockdown. This may be of significance in the context of trying to get older adults to maintain or increase physical activity, where appropriate, as we emerge from this pandemic, given our understanding of the benefits of physical activity in this age group.
- “Additionally, irrespective of pre-lockdown physical activity, older adults should continue to be encouraged to be active, and particularly to engage in some sort of strength and balance training – such as tai chi, yoga, or weights – which was very low in the sample but is vital for maintaining balance and physical function. Just 12 percent of the sample met the physical activity guidelines, which indicate strength training should be undertaken at least twice per week.”
3. C19 triggers OCD in children and young people
- Many children and young people with obsessive thoughts and compulsions experience that their OCD, anxiety and depressive symptoms worsen during a crisis such as C19. This is shown by a new research result from Aarhus University and the Centre for Child and Adolescent Psychiatry, Central Denmark Region. The findings have been published in BMC Psychiatry.
- Trauma and stress can trigger or worsen OCD. Researchers already know this. They have also shown us that C19 may be associated with adults developing psychiatric disorders. But we do not know much about what the corona crisis means for children and young people.
- A team of researchers from Aarhus University and the Centre for Child and Adolescent Psychiatry, Central Denmark Region, therefore decided to examine how children and young people with OCD experience the crisis. Professor, Department Chair Per Hove Thomsen led the research project.
- During the spring of 2020, the researchers sent a questionnaire to two groups of children and young people between the ages of seven and 21. One group had been diagnosed with OCD in a specialised OCD section at the Centre for Child and Adolescent Psychiatry – and all had been in contact with a therapist at the hospital. The other group was identified through the Danish OCD Association. The majority of these children and young people had been diagnosed years ago. A total of 102 children responded to the questionnaire.
- “Their experience was that their OCD, anxiety and depressive symptoms worsened during a crisis like C19. This worsening was most pronounced for the group identified through the OCD Association,” says Per Hove Thomsen.
- Almost half of the children and young people who belonged to the first group reported that their symptoms had become worse, while a third of them replied that their anxiety had worsened and a third that their depressive symptoms had worsened. And of these, almost a fifth experienced that both symptoms had got worse.
- In the other group, 73% reported that their condition had worsened, just over half that their anxiety had worsened, and 43% answered that the depressive symptoms had increased.
Disinfect and wash hands
- Judith Nissen, who is a consultant, was also one of the driving forces behind the study. She emphasises that it is no coincidence that the researchers have chosen to study OCD.
- “The disorder is particularly interesting to study in relation to the C19 pandemic, because OCD is a disorder with many different clinical expressions, including not least health anxiety, fear of bacteria and dirt, and excessive hand washing/use of disinfection. It’s therefore important to examine how such a significant crisis can affect the expression, frequency and progression of the disorder,” she explains.
- The children and young people who in the questionnaire had described thoughts and anxiety over how something serious could happen, e.g. that they themselves could become ill or lose family members, experienced the most significant worsening of their OCD symptoms. In particular, children who had begun suffering from OCD at an early age experienced the most pronounced worsening.
- “For children who are already anxious about loss, the daily descriptions in the media of illness and death and recommendations about isolation and focus on infection can exacerbate these anxious thoughts, perhaps also especially for the youngest children, who may have greater difficulty understanding the significance of the infection, but who are also very dependent on parents and grandparents and thus are most vulnerable to loss,” says Judith Nissen.
- On the other hand, there is no correlation with anxiety about infection and impulsive hand washing. The study thus indicates that children and young people with OCD may be vulnerable in relation to a crisis such as C19, where anxiety about something serious happening – including the loss of close relatives – characterises a particularly vulnerable group.
- “This may be related to both the direct threat of the infection and to the consequences of having to maintain social distancing, social isolation and the significant level of focus on hygiene.
- The crisis is not over yet, and it’s therefore very important that we continue to focus on vulnerable children and young people in the future,” says Judith Nissen.
4. New Research Finds Lasting Fatigue Common After C19 Infection
- More than half of people with acute C19 infection continue to have persistent fatigue 10 weeks after their initial illness, according to a new study published on November 9, 2020, in the open-access journal PLOS ONE by Liam Townsend of Trinity College Dublin, Ireland and colleagues.
- Fatigue is one of the most common initial presenting complaints of people infected with the coronavirus (SARS-CoV-2). The long-term consequences of C19 have not been well-studied and concern has been raised that the virus has the potential to trigger a post-viral fatigue syndrome.
- In the new study, researchers tracked fatigue, as well as patient characteristics including C19 severity, laboratory markers, levels of inflammatory markers and pre-existing conditions, in 128 study participants who had previously been infected with SARS-CoV-2. The participants, all recruited from a post-C19 outpatient clinic at St. James Hospital in Dublin, Ireland, were 54% female and averaged 49.5 years old (standard deviation ±15 years). 55.5% of the participants had been admitted to the hospital for their C19 treatment while the remainder were treated as outpatients. On average, they were assessed for the study 72 days after discharge from a hospital or, if managed as an outpatient, after a timepoint 14 days following diagnosis.
- Based on their score on the Chalder Fatigue Scale (CFQ-11), 52.3% (67/128) of study participants met the criteria for fatigue at the assessment point at least 6 weeks following C19 infection. Only 42.2% of the patients (54/128) reported feeling back to their full health. Importantly, there was no association between C19 severity, need for hospital admission, or routine laboratory markers of inflammation with the likelihood of experiencing persistent fatigue after infection. Though the study is limited in that the population cohort was predominantly white and Irish, and patients were only assessed at a single timepoint with no follow-up, the authors also found that female gender and a history of anxiety or depression was more common in the severe fatigue group (X2=9.95, p=0.002 for female; X2=5.18, p=0.02 for depression history).
- The authors add: “This study highlights the burden of post-COVID fatigue. It also demonstrates that post-COVID fatigue is unrelated to severity of initial infection, so predicting its development is not easy.”
5. Developmental disorders top the medical conditions that heighten the risk of dying from C19
- Some underlying medical conditions put C19 patients at higher risk of severe outcomes, including death. But much remains unknown about exactly which conditions are involved and how much they increase risk.
- To explore the connections between underlying conditions and C19, my organization, FAIR Health, collaborated with the West Health Institute and surgeon Marty Makary of the Johns Hopkins University School of Medicine. Our study, published on Wednesday, sheds some light on the subject.
- Using FAIR Health’s vast database of private health care claims, we studied 467,773 patients diagnosed with C19 from April 1 through Aug. 31, looking for the risk factors that increased their odds of dying from C19. Our goal was to inform public health policy, particularly protocols for distributing first-line vaccines or therapeutics.
- We did the analyses for people of all ages, and again for those under age 70.
- Across all age groups, C19 patients had greater odds of dying if they had any of the 15 underlying health conditions, also known as comorbidities, shown in the chart below.
- The comorbidities are ranked by odds ratio, a measure of the association between the comorbidity and mortality. (An odds ratio of 2 means double the risk compared with someone without the comorbidity.) The comorbidity with the highest odds ratio, 3.06, was developmental disorders, such as delays in development and disorders of speech and language, scholastic skills, and central auditory processing. All 15 odds ratios were statistically significant except for endometrial cancer. While patients with endometrial cancer had increased odds of dying, based on statistical analysis this could be due to chance. The uncertainty might result from the smaller sample size of this particular population.
- Next came lung cancer, followed by intellectual disabilities and related conditions such as Down syndrome and other chromosomal anomalies; mild, moderate, severe, and profound intellectual disabilities; and congenital malformations such as certain disorders that cause microcephaly. Other researchers have seen similar associations for developmental disorders and intellectual disabilities and for lung cancer. Our findings echo a warning by the directors of the Intellectual and Developmental Disabilities Research Centers network that C19 might have a disproportionate impact on individuals with intellectual and developmental disabilities.
- There are several possible reasons why individuals with developmental disorders and intellectual disabilities might be more likely to die from C19. They often have multiple chronic conditions, and another of our findings was that the odds of dying from C19 rise as the number of comorbidities increase. Individuals with intellectual and developmental disabilities are also at greater risk of becoming infected with the virus that causes C19, both because they are disproportionately represented as workers in essential service, and because many live in group residential settings.
Under age 70
- Our initial analysis revealed that C19-related death was highly associated with being age 70 and older. To see if the results differed if we excluded that patient age group, we evaluated the data for patients under age 70.
- Among C19 patients under age 70, the top 15 comorbidity risk factors were similar to those among all age groups, but with some differences. Spina bifida and other congenital anomalies of the nervous system, and spinal cord injury, were included only in the list for all age groups. Breast cancer and pressure and chronic ulcers were included only in the under-70 list.
- One striking difference between the two lists is that lung cancer, which ranked second in the all-age-groups list, ranked first in the under-70 list, with its odds ratio rising from 2.89 to 6.74. In fact, the risk of dying from C19 was generally higher for a comorbidity for patients under age 70 than it was for patients of all ages. This is likely due to patients over age 70 — who have a higher probability of dying regardless of whether they had the comorbidity in question — being included in the all-ages analysis.
Other risk factors
- Comorbidities aren’t the only risk factors for dying from C19. Men are more likely to die from it than women and, as said earlier, older people are more likely to die from it than younger people. In our analyses, males were somewhat less likely than females to be diagnosed with C19, with only 46% of all diagnoses in males. Yet 60% of deaths occurred among males.
- Similarly, individuals age 70 and older accounted for just 4.8% of C19 diagnoses, but accounted for 42.4% of all C19 deaths.
Lack of comorbidities isn’t 100% protective
- We also studied the just under half (48.3%) of C19 patients who had no comorbidities. That was found to be partially protective against dying from C19, but not completely. Among the C19 patients in our study who died, 16.7% did not have underlying health conditions.
Public health message
- Our goal in performing these analyses was to inform public health policy and, in particular, to provide actionable data to support policies on vaccine distribution and prioritization. We hope that our findings with respect to the high risk of C19 mortality associated with developmental disorders and intellectual disabilities will provide valuable building blocks into the formation of such policies.
- And aside from the potential impact of our findings on vaccine-related protocols, they may also prove valuable in heightening the care and treatment of individuals with comorbidities that render them particularly vulnerable to adverse C19 outcomes.
6. 20% of C19 patients are diagnosed with a mental illness within 3 months
- There have been increasing numbers of anecdotal reports of a link between surviving C19 and developing mental health problems in recent months. Now we have some numbers to back those reports up. A new study, published in Lancet Psychiatry, has found that almost one in five people who have had C19 go on to be diagnosed with a mental illness within three months of testing positive.
How the calculations were made:
- The researchers from Oxford University and NIHR Oxford Health Biomedical Research Centre gathered the electronic health records of 70 million patients in the US, including 62,354 who had been diagnosed with C19 from January 20 to April 1 2020 but did not need to be hospitalized. They found that 18% of patients were diagnosed with a mental health issue in the 14 to 90 days after a C19 diagnosis.
- To see how C19 patients compared to those suffering with other issues, the team compared data with six other conditions (including flu and fractures) over the same time period. They found that the likelihood of a C19 patient being diagnosed with a mental health issue for the first time was twice that of those with other conditions. Anxiety disorders, insomnia, and dementia were the most common diagnoses.
- Additionally, people with a pre-existing mental health condition—specifically attention deficit hyperactivity disorder, bipolar disorder, depression, or schizophrenia—were 65% more likely to be diagnosed with C19.
- We have been warned of an oncoming tsunami of mental health problems due to the pandemic for months now. “We know from previous pandemics that mental health difficulties usually follow in survivors, and this study shows the same pattern after C19, so it is not unexpected,” says Professor Til Wykes, Vice Dean for Psychology and Systems Sciences at King’s College London’s Institute of Psychiatry, Psychology and Neuroscience, who was not involved in this research.
- Either way, we ought to prepare for more mental health problems across society in the coming months and years. “This is clearly the tip of an iceberg. We need to develop as many different, accessible forms of mental health support as possible,” says Wykes.
G. The Road Back?
1. How to Shorten the Quarantine
- As people in the United States ponder how to safely reunite with family for Thanksgiving, a new study that includes data from offshore oil rig workers could help clarify the best strategy.
- The matter of reuniting with family for the holiday is fraught. The nation’s top infectious disease expert, Dr. Anthony Fauci, has urged Americans to skip Turkey Day altogether. Data from Canada, where Thanksgiving is celebrated in October, underscore the risks of gathering in big groups for the occasion. Canadian public health officials attributed an acceleration of C19 cases there to the festivities. It’s perhaps no surprise, then, that in the United States, a poll found that 21% of people have put their regular Thanksgiving travel plans on pause — yet 39% still intend to travel during the holiday.
- Many epidemiologists have recommended a two-week quarantine before gathering with loved ones to prevent spreading the coronavirus during Thanksgiving. Two weeks is also the amount of time that both the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization recommend to spend in quarantine if you have been exposed to someone who has tested positive for the SARS-CoV-2 virus that causes C19. (This is different from self-isolation for people who have tested positive, which lasts around 10 days and is shorter given that the incubation period has already passed.) Among people infected with the coronavirus, around 98% of people will develop symptoms by day 12 of quarantine, some research has shown, and the median incubation time is five days.
- “It makes no sense to use unduly restrictive quarantines while at the same time having indoor dining.”
- But given the financial and mental health downsides to long quarantines, some rules for travel-related quarantine are changing. The CDC moved away from a blanket 14-day quarantine for international travelers at the end of summer. On November 3, New York implemented new guidelines allowing travelers from out of state to test out of the mandatory 14-day quarantine if they obtain two negative tests — one before their journey to the state begins and another four days after. Meanwhile, Alberta, Canada, is piloting a program in which certain travelers can do a test at the airport. Participants can leave their quarantine if and when the results come back negative, which usually takes two days, and they must also obtain a second test four or five days after that.
- Now, however, researchers say they have combined data about various aspects of C19 that offers a more complete picture of how to shorten the standard 14-day quarantine.
- In a new study, Jeffrey Townsend, a biostatistician at the Yale School of Public Health, and his collaborators created a model using existing data on how infectious people with C19 are at different points of their illness, along with information about the accuracy of so-called PCR tests for the disease at those time points. Crucially, the model also takes into account data from other studies about the incubation period of SARS-CoV-2. This last bit is especially important given that infected individuals can spread the disease several days before they begin to feel ill (and some infected people never develop symptoms).
- The study, which was originally posted online on October 28 and has not yet been vetted by other scientists for publication in a scientific journal, suggests that an eight-day quarantine in which people are tested upon entry on day one and again on day seven before exiting on day eight (given that it typically takes a day for PCR test results) is just as effective as a 14-day quarantine without testing. It’s not possible to test twice in many places, however, and so the authors also modeled whether it would be better to test before or during quarantine. They concluded that testing upon exit of quarantine — ideally around day six or seven, when the amount of virus in the body has risen to detectable levels — is more effective than testing upon entry.
- The results are in line with a previous study from a British group posted online this summer that, based on modeling simulations, suggested an eight-day quarantine with PCR testing on day seven would provide similar protection to a 14-day quarantine period. However, the new study from Townsend and his colleagues went a step further and validated some of its findings by testing the recommendation with Australian company BHP, which does offshore oil drilling.
- BHP had already been requiring its workers to quarantine at a hotel on land before deploying to the drilling site offshore as a precaution, since conditions on the rig involve tight living and working quarters where C19 could easily spread. But the study findings prompted the company to implement exit testing as well. “They were incredibly receptive” to the change, Townsend says. After the new protocol was put in place, it identified 16 out of 1,026 individuals who tested negative on the entry test but then tested positive in the second test. Without the second test, they might not have been detected as having the virus and would have left for the offshore rigs. Townsend says he’s heard that the news about the importance of exit testing is making other firms rethink their approach: “Other oil companies heard about how well the BHP work was going in preventing outbreaks, and this [approach] migrated through the industrial sector.”
- “I think these findings are consequential, as they provide a path to making quarantine less burdensome for people.”
- The new study’s proposal to shorten the 14-day quarantine using carefully timed testing is a move in the right direction, says David Fisman, an epidemiologist at the University of Toronto’s Dalla Lana School of Public Health. “This makes total sense,” Fisman says. “We know Covid crosses borders. It makes no sense to use unduly restrictive quarantines while at the same time having indoor dining,” he adds, noting that more concern should be directed to the potential of superspreading events in the latter situation.
- “I think these findings are consequential, as they provide a path to making quarantine less burdensome for people,” says Angela Rasmussen, a virologist at Columbia University. “However, this depends heavily on testing capacity. Without sufficient testing, this won’t be feasible.” Laboratories across the United States have had a tough time keeping up with demands for C19 testing.
- Ronald Fricker, a professor of statistics at Virginia Polytechnic Institute and State University, says there are numerous advantages to the shortened quarantines supported by the new work. “In addition to the obvious economic benefits to people who can return to work more quickly, it could also improve public health practice since shorter quarantine times are probably associated with higher rates of compliance,” Fricker says. “Simply put, people are more likely to stay in quarantine for one week rather than two weeks. In addition, shorter times mean quarantine is less of a logistical and mental health burden on people.”
- Townsend, for his part, says his family has no travel plans and is staying isolated at home for Thanksgiving. “Being an epidemiologist doing this kind of work, you would feel like a hypocrite if you didn’t take the most extreme precautions,” he says. Townsend adds, though, that his wife and three kids will still mark the occasion, albeit in a scaled-down version: “We are going to have a Thanksgiving meal, and it’ll be fun and it’ll be great.”
2. COVID Misinformation a Roadblock to Curbing Pandemic
- The World Health Organization calls the spread of false information about the coronavirus (C19) an “infodemic,” and the results are broadly visible across society. The refusal of some people to wear a mask or socially distance, or self-quarantine when exposed to the virus, is often motivated by false information or conspiracy theories that are popular on social media.
- So what are public health officials to do?
- In a pair of newly published studies, University of Delaware researchers shed new light on the stigma, stereotypes and conspiracy theories that have spread alongside the novel coronavirus.
- Understanding the impact of misinformation “is important for identifying potential barriers to public health efforts” to combat the virus, said Valerie Earnshaw, associate professor in UD’s Department of Human Development and Family Sciences and lead author on both studies.
- “Evidence suggests that people are more likely to believe conspiracy theories when they feel anxious, powerless, and unable to control their outcomes, as well as in times of crisis and when faced with large-scale events with serious consequences,” she said. “Pandemics such as C19 are powerful contexts wherein individuals may turn to conspiracy theories in an attempt to restore feelings of safety and control.”
- Ultimately, the more prominent the misinformation, the more difficult it will be for communities to bring the pandemic under control.
- The first study, “Anticipated Stigma, Stereotypes, and C19 Testing,” which appeared in the journal Stigma and Health, suggests that stereotypes and anticipated stigma may be barriers to C19 testing efforts. The results, Earnshaw said, are very similar to previous studies about HIV and Ebola stigma.
- “We know from studies on mental illness and HIV that stigma will keep people from getting tested,” said Earnshaw. “And stereotypes are one way that people experience stigma. Stereotypes are how stigma gets into our heads and shapes our views. Stereotypes help people feel safe. Stereotypes help people believe that those who get COVID, or HIV, are unlike them or doing the wrong thing. Stereotypes can sometimes give people a false security blanket.”
- Participants who anticipated more stigma, and those who endorsed more harmful stereotypes, reported that they would be less likely to get tested for C19. By contrast, participants who demonstrated greater knowledge of C19 reported that they would be more likely to get tested.
- The second study, “C19 conspiracy beliefs, health behaviors, and policy support,” which appeared in the journal Translational Behavioral Medicine, found that one-third of participants believed in one or more conspiracies about C19, and the results suggest that belief in conspiracy theories makes a person less likely to support public health policies designed to slow the spread of the virus. Participants who believed in conspiracy theories said that they were less likely to get vaccinated and trusted public health experts less.
- The results of both studies were derived from an online survey of 845 U.S. adults that was conducted in April 2020. The survey was posted to Amazon Mechanical Turk, a crowdsourcing marketplace that researchers use to “collect rapid, high-quality data for psychological studies,” said Earnshaw.
- Despite the prevalence of misinformation, both studies suggest that people trust their personal doctor, regardless of their conspiracy beliefs. In the first study, most participants agreed that they would get tested if ordered by their doctor. In the second study, over 90% said they trusted information about C19 from their doctor.
- “Medical doctors are highly trusted sources of medical information,” said Earnshaw. “Doctors can play a leading role in combating misinformation because even people who believe conspiracy theories still believe information about COVID from their doctors.”
H. Back to School!?
1. Schools in N.Y.C. may close
- The nation’s largest school system is on the precipice of closing thousands of schools.
- New York City, once the global epicenter of the pandemic, now has far lower rates of community infection than most of the country, but the numbers are quickly climbing. On Thursday, the seven-day test positivity rate rose to 2.6%. If that number hits 3%, schools are supposed to close.
- For many of the approximately 300,000 families who have cobbled together ways to send their kids to classrooms for a few days a week in this fractured school year, the reversal is a gut punch.
- Particularly maddening is that restaurants, bars and gyms — indoor spaces which have been shown to be primary vectors of coronavirus infection — remain open, albeit with some restrictions.
- New York City’s schools have recorded a much smaller number of infections. A recent positive-test rate was just 0.17%, prompting one of the city’s top health officials to declare that public schools are among the safest public places around.
- Many countries in Western Europe have chosen to keep classrooms open and to place restrictions on bars and restaurants instead, a contrast that has not gone without notice.
- “That N.Y.C.’s public schools may have to shut down because the city and state felt they just had to let people dine indoors and work out at a gym says all we need to know about how much our society values public education, particularly when it comes to low-income Black & brown kids,” our colleague Nikole Hannah-Jones said on Twitter.
- Other major American cities with climbing cases have already delayed returns or walked back reopening plans for public schools.
- On Thursday, Detroit announced it would stop all in-person learning. This week, cities including Minneapolis and Philadelphia delayed planned returns. In late October, Boston pulled its few in-person students. And almost all public school students in Los Angeles; Chicago; Washington, D.C.; and San Francisco are also learning remotely.
Source: New York Times Coronavirus Briefing
I. Innovation & Technology
1. Cloth face masks that can be disinfected by the sun
- During the C19 pandemic, many people have become accustomed to wearing cotton face masks in public places. However, viruses and bacteria that stick to the mask could be transferred elsewhere when the wearer removes or touches it.
- Now, researchers reporting in ACS Applied Materials & Interfaces have developed a special type of cotton face mask that kills up to 99.9999% of bacteria and viruses within 60 minutes of daylight exposure.
- Face masks made of various cloth materials can filter nanoscale aerosol particles — such as those released by a cough or sneeze — potentially helping to reduce the spread of diseases, including C19. But live bacteria and viruses on the surface of the mask could still be contagious. Peixin Tang, Gang Sun, Nitin Nitin and colleagues wanted to develop a new cotton fabric that would release reactive oxygen species (ROS) when exposed to daylight, killing microbes attached to the fabric’s surfaces while being washable, reusable and safe for the wearer. Then, a person could disinfect their cloth mask during their lunch hour outside in the sun, or by spending a longer period of time under office or building lights, which are much less intense than sunlight.
- The researchers made their antimicrobial fabrics by attaching positively charged chains of 2-diethylaminoethyl chloride (DEAE-Cl) to ordinary cotton. Then, they dyed the modified cotton in a solution of a negatively charged photosensitizer (a compound that releases ROS upon exposure to light), which attached to the DEAE chains by strong electrostatic interactions.
- The team found that a fabric made with a dye called rose Bengal as the photosensitizer killed 99.9999% of bacteria added to the fabric within 60 minutes of daylight exposure and inactivated 99.9999% of T7 bacteriophage — a virus thought to be more resistant to ROS than some coronaviruses — within 30 minutes.
- Further testing showed that the material could be handwashed at least 10 times and constantly exposed to daylight for at least 7 days without losing its antimicrobial activity. The fabric shows promise for making reusable, antibacterial/antiviral cloth face masks and protective suits, the researchers say.
2. Plasma treatments quickly kill coronavirus on surfaces
- Researchers from UCLA believe using plasma could promise a significant breakthrough in the fight against the spread of C19.
- In Physics of Fluids, by AIP Publishing, modeling conducted in June showed strains of the novel coronavirus on surfaces like metal, leather, and plastic were killed in as little as 30 seconds of treatment with argon-fed, cold atmospheric plasma.
- The researchers used an atmospheric pressure plasma jet they built with a 3D printer to spray surfaces that were treated with SARS-CoV-2 cultures. The surfaces included plastic, metal, cardboard, and basketball, football, and baseball leather.
- The spray using plasma fed by argon killed all the coronavirus on the six surfaces in less than three minutes, and most of the virus was destroyed after 30 seconds. Additional testing showed the virus was destroyed in similar times on cotton from face masks.
- The novel coronavirus can remain infectious on surfaces for several hours. Author Richard E. Wirz said the findings show great potential for the use of plasma in halting the virus’s transmission cycle.
- “This is only the beginning,” Wirz said. “We are very confident and have very high expectations for plasma in future work. In the future, a lot of answers for the scientific community will come from plasma.”
- Plasma is one of the four basic states of matter and can be created by heating a neutral gas or subjecting it to a strong electromagnetic field. A relatively new technology, cold atmospheric plasma is an ionized, near-room-temperature gas that has proven effective in cancer treatments, wound healing, dentistry, and other medical applications.
- The authors ran a similar coronavirus test with helium-fed plasma, but the helium was not effective, even with treatments up to five minutes. The authors believe this was due to lower rates of reactive oxygen and reactive nitrogen when using helium-fed gas, compared to argon.
- Zhitong Chen said the authors are building a compact device that could be used widely to treat surfaces for the coronavirus with plasma. It is a safer, healthier option than chemicals or other treatments, he said.
- “Everything we use comes from the air,” he said. “Air and electricity: It’s a very healthy treatment with no side effects.”
- The researchers hope the benefits of plasma, like those shown in this study, can be made available to people around the world.
J. Projections & Our (Possible) Future
1. Stanford-led team creates a computer model that can predict how C19 spreads in cities
- A team of researchers has created a computer model that accurately predicted the spread of C19 in 10 major cities this spring by analyzing three factors that drive infection risk: where people go in the course of a day, how long they linger and how many other people are visiting the same place at the same time.
- “We built a computer model to analyze how people of different demographic backgrounds, and from different neighborhoods, visit different types of places that are more or less crowded. Based on all of this, we could predict the likelihood of new infections occurring at any given place or time,” said Jure Leskovec, the Stanford computer scientist who led the effort, which involved researchers from Northwestern University.
- The study, published today in the journal Nature, merges demographic data, epidemiological estimates and anonymous cellphone location information, and appears to confirm that most C19 transmissions occur at “superspreader” sites, like full-service restaurants, fitness centers and cafes, where people remain in close quarters for extended periods. The researchers say their model’s specificity could serve as a tool for officials to help minimize the spread of C19 as they reopen businesses by revealing the tradeoffs between new infections and lost sales if establishments open, say, at 20% or 50% of capacity.
- Study co-author David Grusky, a professor of sociology at Stanford’s School of Humanities and Sciences, said this predictive capability is particularly valuable because it provides useful new insights into the factors behind the disproportionate infection rates of minority and low-income people. “In the past, these disparities have been assumed to be driven by preexisting conditions and unequal access to health care, whereas our model suggests that mobility patterns also help drive these disproportionate risks,” he said.
- Grusky, who also directs the Stanford Center on Poverty and Inequality, said the model shows how reopening businesses with lower occupancy caps tend to benefit disadvantaged groups the most. “Because the places that employ minority and low-income people are often smaller and more crowded, occupancy caps on reopened stores can lower the risks they face,” Grusky said. “We have a responsibility to build reopening plans that eliminate – or at least reduce – the disparities that current practices are creating.”
- Leskovec said the model “offers the strongest evidence yet” that stay-at-home policies enacted this spring reduced the number of trips outside the home and slowed the rate of new infections.
- The study traced the movements of 98 million Americans in 10 of the nation’s largest metropolitan areas through half a million different establishments, from restaurants and fitness centers to pet stores and new car dealerships.
- The team included Stanford PhD students Serina Chang, Pang Wei Koh and Emma Pierson, who graduated this summer, and Northwestern University researchers Jaline Gerardin and Beth Redbird, who assembled study data for the 10 metropolitan areas. In population order, these cities include: New York, Los Angeles, Chicago, Dallas, Washington, D.C., Houston, Atlanta, Miami, Philadelphia and San Francisco.
- SafeGraph, a company that aggregates anonymized location data from mobile applications, provided the researchers data showing which of 553,000 public locations such as hardware stores and religious establishments people visited each day; for how long; and, crucially, what the square footage of each establishment was so that researchers could determine the hourly occupancy density.
- The researchers analyzed data from March 8 to May 9 in two distinct phases. In phase one, they fed their model mobility data and designed their system to calculate a crucial epidemiological variable: the transmission rate of the virus under a variety of different circumstances in the 10 metropolitan areas. In real life, it is impossible to know in advance when and where an infectious and susceptible person come in contact to create a potential new infection. But in their model, the researchers developed and refined a series of equations to compute the probability of infectious events at different places and times. The equations were able to solve for the unknown variables because the researchers fed the computer one, important known fact: how many C19 infections were reported to health officials in each city each day.
- The researchers refined the model until it was able to determine the transmission rate of the virus in each city. The rate varied from city to city depending on factors ranging from how often people ventured out of the house to which types of locations they visited.
- Once the researchers obtained transmission rates for the 10 metropolitan areas, they tested the model during phase two by asking it to multiply the rate for each city against their database of mobility patterns to predict new C19 infections. The predictions tracked closely with the actual reports from health officials, giving the researchers confidence in the model’s reliability.
- By combining their model with demographic data available from a database of 57,000 census block groups – 600 to 3,000-person neighborhoods – the researchers show how minority and low-income people leave home more often because their jobs require it, and shop at smaller, more crowded establishments than people with higher incomes, who can work-from-home, use home-delivery to avoid shopping and patronize roomier businesses when they do go out. For instance, the study revealed that it’s roughly twice as risky for non-white populations to buy groceries compared to whites. “By merging mobility, demographic and epidemiological datasets, we were able to use our model to analyze the effectiveness and equity of different reopening policies,” Chang said.
- The team has made its tools and data publicly available so other researchers can replicate and build on the findings.
- “In principle, anyone can use this model to understand the consequences of different stay-at-home and business closure policy decisions,” said Leskovec, whose team is now working to develop the model into a user-friendly tool for policymakers and public health officials.
2. With a meteoric rise in deaths, talk of waves is misguided, say C19 modelers
- The numbers have become both horrifying and numbing — and there is no end in sight.
- The consensus among major C19 modelers is that we could see 20,000 to 25,000 deaths in just the next two weeks, and 160,000 more by Feb. 1. That would be a frightening acceleration as winter approaches.
- The experts and their models also agree on the familiar tools at hand that can bend the curve: universal mask-wearing and social distancing. Even so, they say it’s too late for us to head off the surge ahead, as many Asian countries have been able to do.
- “We may have passed the point of no return in terms of getting it to a place like levels we’re seeing in China right now,” said Nicholas Reich, a University of Massachusetts, Amherst, biostatistician whose team compares different C19 models.
- The meteoric rise in U.S. C19 cases and death is not another wave.
- Experts modeling the coronavirus pandemic may differ on details, but they agree that calling this a second or third wave is incorrect because there was never a significant trough before cases began mounting again.
- The outbreak that slammed New York in the spring — as well as cities like Boston, New Orleans, and Detroit — was never brought under control, and instead it’s been allowed to keep building.
- “I don’t think the United States ever had multiple waves,” said Alessandro Vespignani, professor of physics, computer science, and health science at Northeastern University in Boston who models the pandemic’s impact. “We are leading the same wave that is moving across the country.”
- This is not 1918. Then, graphs show, there was a terrifying spike in influenza deaths followed by a flat line, when the epidemic almost went dormant in the summer before a monstrous second wave in the fall. Historical hindsight will have to tell what shape the C19 story will ultimately take, but maybe future modelers will call them humps, Reich offered. Broadly speaking, the U.S. is heading toward a third hump while Europe is near its second.
- There’s a worrying parallel there, Reich said. “It’s just that humans are tiring of having to be so vigilant and it’s really exhausting — emotionally exhausting and socially exhausting.”
- The world’s health is in a very bad place, heading into winter in the Northern Hemisphere with C19 cases, deaths, and hospitalizations all tallying new highs. That’s even before an expected spurt in all three metrics caused by colder weather and drier air, people spending much more time indoors, and overall weariness of lives disrupted by pandemic precautions — all of which make us more vulnerable to viruses.
- Trevor Bedford, a computational biologist at the Fred Hutchinson Cancer Research Institute in Seattle, reminded people taking comfort from an apparently lower death rate than earlier in the pandemic that deaths lag infections by about three weeks. “I expect the US to be reporting over 2000 deaths per day in 3 weeks time,” he tweeted Wednesday. That would be more than double the current numbers.
- The U.S. as a whole has seen regional curves go up, dip, climb even higher, dip a bit less, and then ascend still higher to set new records nearly every day and every week. The geography of the pandemic is uneven, with ripples and bursts in the Sun Belt over the summer and infections jumping in the Midwest and Mountain states in the fall. But states in the Northeast that nearly buckled beneath the spring surge have no safe harbor from the continuing crisis. Cases and deaths have been ticking upward for weeks, as regular in their climb as a metronome.
- Modelers make forecasts four weeks out, predicting cases and deaths. Separate models can be aggregated to yield an overall estimate of cases and deaths; some but not all include hospitalizations. The Centers for Disease Control and Prevention posts its ensemble forecasts, generated by Reich’s group at UMass from 36 independent models, for the country as a whole and for individual states. Models make assumptions about social distancing measures changing in the future or staying the same.
- Projections go farther than forecasts, but even they stretch only to Feb. 1, when warmer parts of the country might see crocus shoots poking through the soil in early signs of spring while winter is far from over in many states.
- The model from the Institute for Health Metrics and Evaluation projects 399,162 total deaths in the U.S. by Feb. 1, based on current conditions. If mask wearing became universal, defined as worn by 95% of the population, deaths would fall to 337,669, the model says. But if mandates for social distancing were eased, the death toll would rise to 513,657.
- February might be the earliest that the first vaccines become widely available, should they win approval. That means we are left with the tools and knowledge currently at hand to control spread this winter: pulling up our masks, tamping down numbers of people we gather with indoors (with optimal ventilation), getting our flu shots, and resisting the undertow of pandemic fatigue.
- “The projections for this winter, unfortunately, they’re going to hold unless we change our behavior. The vaccine is not going to help us,” said Ali Mokdad, professor of health metrics sciences at IHME. “All we have between now and the vaccine deployment is wearing a mask, keeping a safe distance. I would like to remind everybody in the U.S. we’re not out of the woods yet.”
- Mokdad calls for a national strategy that would set data standards and improve surveillance of cases and deaths so a coordinated response could be set into motion.
- Northeastern’s Vespignani also said the lack of a national strategy handicaps state efforts to fight the pandemic, especially when prompt reactions to rising cases can make a difference. Models that show climbing case counts, for example, should spur immediate measures before hospitals and their ICUs fill to overflowing two weeks later.
- Coherent messaging would help, particularly in a time of White House transition. Any approved, successful vaccine will be a game changer, Vespignani said, but not anytime soon, so telling people what works now will be essential. “We need to enforce the use of masks and we need to have people act responsibly. We need to have a lot of testing and tracing in place,” he said. “And then the most important thing is that we don’t want to catch up with the epidemic. We want to anticipate it.”
- Lockdowns are not on Vespignani’s list. “It would be very depressing. It would mean that we didn’t learn anything in the first nine months of the epidemic.”
- One lesson from the spring: Researchers who mined mobile phone data to identify the indoor public places most responsible for the spread of C19 say that sharply limiting the occupancy of these locales — chiefly restaurants, gyms, cafes, hotels, and houses of worship — could help control the pandemic without resorting to lockdowns.
- Modelers and policymakers alike struggle to find the sweet spot of doing just enough to keep the pandemic under control while keeping schools open, allowing people to work, and letting them go grocery shopping.
- “One of the reasons that C19 is so hard to predict is that the power to change the trajectory is within us,” Reich of UMass said. “If we all of a sudden decided to just be really careful about this for a sustained period of time, it would become under control — or at least become more under control.
- “It is the societal challenge of our times.”
3. Large, delayed outbreaks of endemic diseases possible following C19 controls
- Measures to reduce the spread of C19 through non-pharmaceutical interventions (NPIs) such as mask wearing and social distancing are a key tool in combatting the impact of the ongoing coronavirus pandemic. These actions also have greatly reduced incidence of many other diseases, including influenza and respiratory syncytial virus (RSV).
- Current reductions in these common respiratory infections, however, may merely postpone the incidence of future outbreaks, according to a study by Princeton University researchers published Nov. 9 in the Proceedings of the National Academy of Sciences.
- “Declines in case numbers of several respiratory pathogens have been observed recently in many global locations,” said first author Rachel Baker, an associate research scholar at the High Meadows Environmental Institute (HMEI) at Princeton University.
- “While this reduction in cases could be interpreted as a positive side effect of C19 prevention, the reality is much more complex,” Baker said. “Our results suggest that susceptibility to these other diseases, such as RSV and flu, could increase when NPIs are not in place, resulting in large outbreaks when they begin circulating again.”
- Baker and her co-authors found that NPIs could lead to a future uptick in RSV — an endemic viral infection in the United States and a leading cause of lower respiratory-tract infections in young infants — but that the same effect was not as pronounced for influenza.
- “Although the detailed trajectory of both RSV and influenza in the coming years will be complex, there are clear and overarching trends that emerge when one focuses on some essential effects of NPIs and seasonality on disease dynamics,” said co-author Gabriel Vecchi, Princeton professor of geosciences and the High Meadows Environmental Institute.
- The researchers used an epidemiological model based on historic RSV data and observations of the recent decline in RSV cases to examine the possible impact of C19 NPIs on future RSV outbreaks in the United States and Mexico.
- They found that even relatively short periods of NPI measures could lead to large future RSV outbreaks. These outbreaks were often delayed following the end of the NPI period, with peak cases projected to occur in many locations in winter 2021-22. “It is very important to prepare for this possible future outbreak risk and to pay attention to the full gamut of infections impacted by C19 NPIs,” Baker said.
- The authors also considered the implications of C19 NPIs for seasonal influenza outbreaks and found results qualitatively similar to RSV. The dynamics of influenza are much harder to project due to viral evolution, however, which drives uncertainty over future circulating strains and the efficacy of available vaccines.
- “For influenza, vaccines could make a big difference,” Baker said. “In addition, the impact of NPIs on influenza evolution is unclear but potentially very important.”
- “The decrease in cases of influenza and RSV — as well as the possible future increase we project — is arguably the broadest global impact of NPIs across a variety of human diseases that we’ve seen,” said co-author Bryan Grenfell, the Kathryn Briger and Sarah Fenton Professor of Ecology and Evolutionary Biology and Public Affairs, who is associated faculty in HMEI.
- “NPIs could have unintended longer-term impacts on the dynamics of other diseases that are similar to the impact on susceptibility we projected for RSV,” he said.
- A similar effect of pandemic-related NPIs on other pathogens was observed following the 1918 influenza pandemic. Historic measles data from London show a shift from annual cycles to biennial outbreaks following a period of control measures implemented at that time.
- Co-author C. Jessica Metcalf, associate professor of ecology and evolutionary biology and public affairs and an associated faculty member in HMEI, said that directly evaluating the associated risks of NPIs by developing and deploying tools such as serology that would better measure susceptibility is an important public health and policy direction. “The future repercussions of NPIs revealed by this paper hinge on how these measures change the landscape of immunity and susceptibility,” Metcalf said.
1. Feud Breaks Out On Wall Street Over Lockdowns: JPM Says “No Benefit’ While BofA Sees Urgent Need
- A quick recap on where we stand: the sharp rebound in US daily cases continues, with new infections topping 144,000 yesterday, up from 131,000 the previous day. The 7-day average is 125,000, up from a low of 34,000 two months ago. The week-on-week growth in US cases has re-accelerated to 40%, up from 20% last week. The Midwest continues to be the most affected region with Illinois (at 9,830) and Wisconsin (5,920) reporting the highest 7-day average in new cases among US states alongside Texas (7,960). However, the breadth of the virus spread is widening, with all states having seen new daily cases rise over the past week amid signs that the virus is resurging in US cities after mostly hitting rural areas over previous months. Daily death cases have reached its peak since August, at 1.1k yesterday.
- So far, the policy response has been limited and local. Yesterday, Ohio strengthened mask rules, threatening to close businesses that don’t follow the rules. Over the past week, numerous state governors warned that new mandatory measures might be required if cases continue rising. Some, including the governors of North Carolina, Iowa and Indiana, have imposed new measures in all or part of their states, often focused on indoor gatherings. In New York, private indoor and outdoor gatherings will now be limited to 10 people, while bars and restaurants must close at 10pm.
- In short, we are creeping slowly but surely toward what appears to be another nationwide lockdown, especially if Biden is in the White House. As confirmation of that, we remind you what Dr. Michael Osterholm, who serves as director of the Center of Infectious Disease Research and Policy at the University of Minnesota, and who is Biden’s “science advisor”, said yesterday. Speaking to Yahoo Finance, Osterholm said that “a nationwide lockdown would drive the number of new cases and hospitalizations down to manageable levels while the world awaits a vaccine.”
- “We could pay for a package right now to cover all of the wages, lost wages for individual workers for losses to small companies to medium-sized companies or city, state, county governments. We could do all of that,” he said. “If we did that, then we could lockdown for four-to-six weeks.”
- As a reminder, we note that this is the same ‘scientist’ who co-wrote an op-ed with Minneapolis Federal Reserve President Neel Kashkari in which the two argued for more restrictive and uniform lockdowns across the nation.
- “The problem with the March-to-May lockdown was that it was not uniformly stringent across the country. For example, Minnesota deemed 78% of its workers essential,” they wrote in the New York Times.
- “To be effective, the lockdown has to be as comprehensive and strict as possible.”
- There is just one problem with a Fed president setting health policy for the US: it is absolutely idiotic. Why? Because the real ‘science’ where falsifiable experiments are undergone, and where assumptions can be tested in the real world, results noted, and theses concluded – shows that lockdowns do not work.
- As we detailed yesterday in a surprising report out of JPMorgan, the bank found no meaningful curve development differences between countries with and without strong curve intervention. [Note: See following story.]
- This makes the bank question if existing public health intervention (i.e., lockdown/ stricter social distancing) should remain in place next year, and leads JPM to conclude that “public health policy should consider approaches biased towards economic/pubic mental health over the urge to close the curve in 2021.“
- To reach its “startling” conclusion, JPMorgan compared countries without lockdown, keeping the economy open under certain levels of social-distancing (Brazil, US, Sweden, Japan, Korea) to countries with strong curve intervention (UK, Germany, Italy, France, China, India) to see any meaningful differential in the curve development.
- This outcome suggest that C19 follows a similar diffusion and development process of other infectious diseases with certain life cycles. Therefore, JPMorgan would argue that public health policy should consider a bit more biased approach on economic/pubic mental health over the aim to close the infection curve in 2021 as lockdowns could be costly to the economy.
- JPMorgan’s conclusion: “Keeping public activities open and tracing susceptible people leveraging technology looks to have better risk reward to us.”
- And just in case you shrug off JPMorgan’s ‘scientific’ findings, a recent study in The Lancet (yes, that scientific journal) found no correlation whatsoever between severity of lockdown and number of covid deaths (a link to the stury in Lancet is at the bottom of this article). And they didn’t find any correlation between border closures and covid deaths either. And there was no correlation between mass testing and covid deaths either, for that matter. Basically, nothing that various world governments have done to combat covid seems to have had any effect whatsoever on the number of deaths.
- However, in a world where the Fed is now in charge of “fixing” global warming, where central bankers set health policy, it will hardly come as a surprise that in the latest politicization of finance, a feud has broken out on Wall Street between two banks: one which argues that lockdowns don’t work, the other claiming that mere curfews are insufficient to halt the spread of covid and another nationwide lockdown is urgently needed.
- We are talking about JPMorgan, on one hand, which as we reported yesterday found that there are no benefits from lockdowns, and instead the bank recommended that “keeping public activities open and tracing susceptible people leveraging technology looks to have better risk reward to us.”
- And while even a recent scientific study in the Lancet confirmed as much, finding no correlation whatsoever between severity of lockdown and number of covid deaths, today another bank has stepped into this political feud: in a note from Bank of America’s Ethan Harris (an economist, not a virologist), the Wall Street strategist writes that while curfews are necessary to halt the spread of covid, they are not sufficient, and wholesale, nationwide lockdowns should be implemented:
- As Harris writes (from the comfort of his home, where he is paid to sit before a computer and propose hypothetical scenarios whose practical outcomes could devastate millions of lives) “curfews have become a popular policy response to the pandemic. Many cities in Europe implemented curfews in recent weeks. Yesterday New York State followed suit: bars, restaurants and gyms must close by 10pm.” Harris argues that :
- Curfews are aimed at preventing the “most irresponsible” behavior while minimizing economic damage.
- But there is a risk of overcrowding, and hence greater spread of the virus, before the curfew time.
- Given the speed at which the virus is spreading, much stricter restrictions will probably be needed to bend the curve.
- Harris then rhetorically asks “why impose a curfew” and answers with three reasons:
- Shorter hours of service probably mean fewer clients at restaurants, bars and gyms. All else being equal, fewer people engaging in activities that are high-risk in terms of spreading the virus should mean fewer cases.
- Curfews are premised on the idea that people are less likely to follow social distancing rules later in the evening for a variety of reasons.
- Curfews cause less damage to the businesses affected than outright closure orders.
- “Unfortunately,” BofA sees three reasons why curfews might not be very effective at slowing the spread of the virus or limiting economic damage:
- Anecdotal evidence from Europe suggests that curfews could end up concentrating consumer traffic in the hours before the curfew. For example, suppose a restaurant usually serves 100 people from 7 pm to midnight (on average, 20 people per hour). If the restaurant loses 10% of its clients because of the curfew, it would now be serving 90 people through 10 pm (on average, 30 people per hour). This could be a lose-lose: less business for the restaurant and more crowding, leading to greater spread of the virus. Hopefully this concern is mitigated by capacity restrictions and social distancing rules.
- Another issue in Europe has been that people have crowded into public transportation around the curfew time.
- But wait a minute, we thought that all of Europe’s problems would be fixed because people wear masks, similar to what Joe Biden wants to mandate in the US. Apparently not.
- We expect a Biden Presidency and a Republican Senate to lead to a relatively modest fiscal stimulus package. Curfews, rather than business closures, might reduce the sense of urgency that policymakers feel about supporting small businesses. With consumers and state and local governments also in need of assistance, there is a risk that milder restrictions could push small businesses to the back of the stimulus line. This would offset some of the benefit from being allowed to stay open.
- Right, and to avoid some “risks” of staying open best to just shut them down altogether and eliminate all risks. Of course, millions of small businesses would go out of business almost instantly but for career economists that’s merely a statistic.
- So what is BofA’s suggestion? Why precisely the opposite of what JPMorgan recommended: full-blown shutdowns.
- Given the speed of the outbreak and the limited efficacy of curfews, we worry that stricter restrictions are inevitable. Curfews might simply be delaying measures such as gym and hair salon closures, and bans on indoor (and perhaps even outdoor) dining. We understand the hesitation to take these measures: many businesses did not survive the first round of shutdowns in the spring, and additional closures could be economically devastating. They also might not be politically popular, given growing social distancing fatigue. But delayed action might ultimately necessitate stricter and longer-lasting measures. The result is a worse economic and public health outcome.
- So… regardless of the “devastating” economic and personal cost, it’s time to boldly go where the US went before in March (and resulted in a record multi-trillion bailout of the economy by the Fed and Congress) because apparently once you shut down and reopen in a few months, there will never again be break outs like those the US experienced after it emerged from its post-March lockdown. Oh wait…
- In any case, while the political aspect of shutdowns in the fight to contain the pandemic may have determined the outcome of the presidential election where candidate Biden claimed to somehow have a comprehensive plan to “kill the virus” and which apparently revolves around just wearing a mask (and just waiting for the right moment to shutdown the economy again for another 4-6 weeks), we find it amusing that it is now also tearing Wall Street in two, with some analysts urging lockdowns as inevitable, while others slam this idea as too myopic when considering the far greater social and economic costs that would be unleashed if the US economy goes into lockdown for a second time.
- One thing that is clear is which of these two alternatives the top 0.1% of US society is rooting for: after all, in the past 6 months, the net worth of US billionaires exploded thanks to the surge in stocks resulting from the Fed’s “bailout of main street.” As such, if the US does indeed undergo yet another lockdown, it is absolutely certain that the already staggering wealth gap between the top 0.1% and the bottom 99% will grow even wider.
Also See: A country level analysis measuring the impact of government actions, country preparedness and socioeconomic factors on C19 mortality and related health outcomes at https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30208-X/fulltext#fig0002
2. JPMorgan Finds No Benefits From COVID Lockdowns
- While the latest vaccine progress news out of Pfizer was welcome by the market in a week where global infection resurgence continued with cases jumping 8% last week and EU/ UK re-imposed lockdowns, considering that approximately 60% of population will need to be covered by a vaccine, near term pressure on infection curve/hospital capacity, growing mortality tally, and stricter public health policies to pull back secondary infection rate (or R0) below 1 will likely persist for the foreseeable future.
- However, in a surprising report out of JPMorgan, the bank finds no meaningful curve development differences between countries with and without strong curve intervention. This makes the bank question if existing public health intervention (i.e., lockdown/stricter social distancing) should remain in place next year, and leads JPM to conclude that “public health policy should consider approaches biased towards economic/pubic mental health over the urge to close the curve in 2021.“
- To reach its “startling” conclusion, JPMorgan compared countries without lockdown, keeping the economy open under certain levels of social-distancing (Brazil, US, Sweden, Japan, Korea) to countries with strong curve intervention (UK, Germany, Italy, France, China, India) to see any meaningful differential in the curve development.
- Here is what the largest US bank found in its comparison between countries with and without strict social distancing measures and lockdowns:
- Confirmed cases scale: Infection scale is smaller for countries with strict control measures but no meaningful gap with countries without stricter controls (confirmed out of total population: 0.9% vs. 1.2%).
- Infection speed: Countries with strict control measures have a shorter period to arrive at first peak (78 days vs. 106 days), implying stricter social distancing measures or lockdowns could lead to faster peak infection.
- Tests performed: countries with stricter measures have performed a greater scale of tests, at 37% of the total population vs. 32% for those with certain levels of social distancing but no full lockdowns. Also in Brazil and India with relatively relaxed social distancing measures on C19, daily new infections have been trending down and this perhaps is due to the natural life cycle of infectious disease thus C19 could have a similar life span.
- Mortality comparison: In an unexpected twist, the mortality rate (= death/ confirmed cases) was higher for countries with stricter control measures, at 2.6% vs. 2.0% for those without.
- Death per million people: lower for countries with stricter control measures (240 deaths per 1 million people vs. 273 deaths per million) compared to those without strict control measures.
- Antibody level: the average antibody levels are similar for both groups of countries. Average 3.6% of participants were found to have antibodies in countries with strict control measures, vs. 3.0% in countries without. However the gap in between is not meaningfully large. Time to arrive at 80% recovery rate (= recovered/ confirmed cases): Days to arrive at 80% recovery rate is shorter for countries with stricter control measures than countries without (119 days vs. 129 days).
- Paradoxically, the data show that there exists some degree of i) shorter period to peak infection, ii) smaller scale of death per million and iii) slightly larger scale of antibody level found in countries with stricter social distancing measures and lockdowns. However JPMorgan does not see a large meaningful difference between two groups.
- This outcome suggest that C19 follows a similar diffusion and development process of other infectious diseases with certain life cycles. Therefore, JPMorgan would argue that public health policy should consider a bit more biased approach on economic/pubic mental health over the aim to close the infection curve in 2021 as lockdowns could be costly to the economy.
- JPMorgan’s conclusion: “Keeping public activities open and tracing susceptible people leveraging technology looks to have better risk reward to us.”
- Of course, if this had been known in early March when the establishment rushed to close the economy resulting in the biggest economic and financial crisis since the Great Depression, the consequences – for both the US economy and the outcome of the election where Trump’s handling of the covid crisis became the front and center issue – would have been profound.
L. Practical Tips & Other Useful Information
1. Supermarkets Limit Toilet Paper Purchases As COVID Cases Hit New Highs
- Some experts warn about the genuine possibility that US daily caseloads of coronavirus could breach 200,000 in the coming weeks or by the end of the year as daily new cases top more than 100,000 for the sixth consecutive day. Total cases exceeded ten million on Sunday since the pandemic began, far more than any other country.
- Weeks ago, on Oct. 28, we informed readers: “panic hoarding begins” – as anxieties of Americans soared in tandem with new cases as threats of a COVID winter along with new restrictions and possible lockdowns drove people to supermarkets.
- Coronavirus has turned tens of millions of Americans into preppers, as many fringe preppers were relentlessly mocked by mainstream media in February and March ahead lockdowns. Slightly more than half of Americans in a recent poll from Sports and Leisure Research Group say they already have or plan to stockpile food and other essentials. The chief reason is fears of a resurgent pandemic, which could cause disruptions such as new restrictions on businesses.
- It’s not just food people are prepping once again. New reports across the country suggest toilet paper is becoming a hot commodity. Stores are re-implementing limits on toilet paper as demand surges.
- Kroger, with more than 2,000 supermarkets nationwide, has just put limits on the essential items “to ensure all customers have access to what they need.”
- “We’ve proactively and temporarily set purchase limits to two per customer on certain products, including bath tissue, paper towels, disinfecting wipes and hand soap,” a Kroger spokesperson said in a statement which was quoted by Fox 11 LA.
- “Our buyers and suppliers are working hard to provide essential, high demand merchandise as well as everyday favorites,” the company wrote.
- Weeks ago, we noted how major food companies and suppliers of essential goods beefed up their supply chain this summer to increase production to ensure disruptions would not be seen during a panic buying episode. Companies such as General Mills, Campbell Soup, Conagra Brands, and Stonyfield Farm expanded internal and external product lines ahead of the fall.
- Texas grocery chain H-E-B is another grocery store that limits bath tissue, paper towels, and even brisket.
- “To help protect the supply chain in Texas, we’ve implemented temporary purchase limits on certain items. Limiting product purchases is a proven way to ensure the best service and product availability for all customers. Our stores are in strong supply and we continue to restock products daily,” the store said on its website.
- According to the York Daily, grocery chain Giant Co. once again re-instated purchase limits on 4-roll packs of toilet paper and paper towels for the southern Pennsylvania region. The limits were placed “as the supply chain for these products remains challenged,” the company said in a statement.
- Mike Brackett, founder & CEO of Centricity Insights, a company focused on cloud-based customer analytic platforms, told Good Morning America that “we’re absolutely starting to see shortages again” as another round of panic buying begins.
- “The spice category is absolutely gone through the roof,” Brackett said. “So we believe that during this pandemic, there’s been a totally different buying pattern and really generation that started to cook a lot more than they used to due to necessity.”
- With some supermarket chains placing limits on toilet papers, internet searches for “where can I buy toilet paper online” hits levels not seen since early May.
- Internet searches for “toilet paper shortage” are rising as well.
- People are also searching “preppers supplies.”
- Searches for “9mm ammo” could breakout.
- This round of prepping is much different than before, mainly because Americans also stockpiling weapons and combat gear like there’s no tomorrow – as threats of virus pandemic, civil war, and lockdowns continue to plague the country’s outlook into 2021.
2. Many Americans likely to attend large holiday gatherings despite C19
- A new national survey by The Ohio State University Wexner Medical Center finds that although a majority of Americans plan to take precautions at holiday gatherings, such as social distancing and asking those with COVID symptoms not to attend, many will also put themselves at risk. Nearly two in five report they will likely attend a gathering with more than 10 people and a third will not ask guests to wear masks.
- This holiday season comes with a lot of worry and stress as families try to find ways to balance their desire to celebrate together with the risk of spreading C19. While cases of the virus remain high, colder weather across the country is forcing gatherings indoors, where the virus can more easily spread.
- “We’re going to look back at what happened during this holiday season and ask ourselves, ‘Were we part of the solution or were we part of the problem?'” said Dr. Iahn Gonsenhauser, chief quality and patient safety officer at The Ohio State University Wexner Medical Center. “When you’re gathered together around the table, engaged in conversation, sitting less than six feet apart with your masks down, even in a small group, that’s when the spread of this virus can really happen.”
- Gonsenhauser says the safest solution is the one that people don’t want to hear: find ways to communicate virtually and cancel in-person plans. However, if you do decide to have guests, it’s important to have a plan in place and to communicate that plan to everyone attending. Consider wearing masks at all times, separating seating arrangements by household and assigning one or two people to serve the food. If you’re moving your holiday plans outdoors, make sure to follow the same precautions you would indoors. And if you plan to travel or welcome out-of-town guests, stay informed about the C19 rates and restrictions in both locations.
- “If you have someone in your household who’s high risk and you’re in a low incidence area, you’re going to want to think twice about having a celebration where people are coming from an area where there’s a lot of virus in the community,” Gonsenhauser said.
- While celebrations will certainly look different this year, Gonsenhauser says it can also be an opportunity to make treasured memories with loved ones and experiment with new traditions. Try a virtual dinner or gift exchange or drop off surprise treats on friends’ and family members’ door steps.
3. Thinking About a Holiday Gathering? Look at This Troubling Map First
- If you’re considering seeing family for the holidays, take a look at this map. It’s a color-coded guide to C19 risk level, sorted by geography (at the US county level) and crowd size. First, you choose the location where the gathering would happen. Then, at left, you can choose an event size with the slider, from 10 to 5,000 people, and watch the risk of at least one Covid-positive person being there skyrocket the bigger the gathering gets. In some locations where the virus is spreading out of control, like in parts of the Dakotas, that chance is darn near 100%, even if the gathering is just 10 people. Get any bigger than 10 people, and the map spits out odds calling it a virtual certainty in many places that you’ll be sharing space with a sick person.
- Public health experts would really rather we not gather for the holidays, but they say that if you do go through with it, the shindig should be held outdoors, with as few people as possible, and everyone keeping their distance and wearing masks. But if you look at that map now, it shows that across the US, there’s no such thing as a perfectly safe way to gather during the pandemic. Even with all those precautions, the risk right now is huge, particularly if you’re in the Midwest or hosting anyone coming from the Midwest. For example, in Cook County (which includes Chicago), the chance of a Covid-positive person attending a gathering of just 10 people is around 50 percent. In Jones County, Iowa, that chance is a staggering 99 percent. North Dakota, South Dakota, and Kansas also have counties sitting at 99 percent.
- The striking difference between the risks of a gathering of 10 people at left and 25 people at right. Darker reds are higher risk.
- “We highlight the fact that these sort of regional-level risks have shifted,” says Georgia Institute of Technology quantitative biologist Joshua Weitz, coauthor of a new paper in Nature Human Behaviour describing the map system. “In late summer it was in the South, Southeast. And late spring and early summer, the Northeast. So there’s definitely been regional shifts. And right now, the strongest and most worrisome rates of spread are in the Midwest plains and upper mountain region.”
- Weitz and his colleagues built the map by pulling in regularly updated C19 case reports from The New York Times for each county. But that doesn’t tell the whole story, because many more people are infected with the virus, but they don’t know it because they’re asymptomatic and never get tested. So if you look at the map again, at left you’ll see an option for “ascertainment bias.” Based on serological studies—that is, of people who’ve tested positive for the antibodies that indicate their immune systems mounted a defense against C19, even if they never felt sick—the researchers are assuming there are actually 10 times more cases in the US than are being reported. In areas where testing is more widely available, that rate may be lower, hence the option to choose an ascertainment bias of 5 on the map.
- No matter whether you toggle between an ascertainment bias of 5 or 10, the map spits out extremely troubling chances of you coming into contact with a Covid-positive person at a gathering, even a relatively small one of 10 people. Tick up the event size, and the risk grows bigger and bigger. Slide the gathering size over to 25, and you’ll see swaths of the Midwest where the map shows a nearly 100 percent chance of someone at the party having Covid. Even in California, which has found more success controlling the virus, some counties show a 50 percent chance for a gathering of 25 people. Florida, which became a C19 hot spot over the summer, is currently looking a bit worse.
- The troubling state of the Midwest. From left to right shows the risk of gatherings of 10, 25, and 50 people.
- The fact that so many parts of the US are now high-risk areas is particularly worrying because of the nature of holiday gatherings, which often bring together people who have traveled from different parts of the country, and mix together young and old family members. Young people are more likely to be asymptomatic if infected, and can pass the virus along to older relatives who would be more likely to suffer serious symptoms. “It’s almost certainly going to be cross-generation,” says Weitz of holiday events. “And that’s one of our biggest concerns right now. Whether it’s the return of students from universities and colleges, or simply social mixing and events, the idea is that an asymptomatic case within a certain group can then spread to an older individual, with a higher probability it will lead to a severe case of hospitalization. So those are both concerning trends.”
- The value of an interactive map is that it offers a striking visualization of abstract data that can be difficult for the human brain to parse. “People are intuitively bad at interpreting statistics, particularly when it comes to risk,” says Benjamin Singer, a critical care physician and pulmonologist at Northwestern Medicine, who wasn’t involved in the work. “And so I think any tool—and the one in the paper is pretty good—that visualizes the data in a more intuitive way, I think is a good thing.” (In addition to the Georgia Tech project, several other efforts have turned out color-coded risk charts for exactly this reason.)
- The American West is faring better than the Midwest, but the risk of gathering is still very high. From left to right, events of 10, 25, and 50 people.
4. Respirator 2.0: New N95-Alternative TEAL Introduces Sensors for a Better Fit
- Investigators from Brigham and Women’s Hospital and Massachusetts Institute of Technology have been working to design a better, reusable respirator that could serve as an alternative to an N95 respirator. In the latest iteration of their work, they have introduced sensors to inform the user if the respirator is on properly and whether the filters are becoming saturated. The team tested the respirator, known as the transparent, elastomeric, adaptable, long-lasting (TEAL) respirator, at the Brigham and at Massachusetts General Hospital (MGH), and reports a 100% success rate for fit testing among 40 participants, with feedback demonstrating exceptional fit, breathability and filter exchange. Results are published in ACS Pharmacology & Translational Science.
- “During the C19 pandemic, the need for respirators and masks has been urgent. Our team has worked to develop a respirator platform that not only fits comfortably and snugly but can also be sterilized and re-sterilized,” said corresponding author Giovanni Traverso, MB, BChir, PhD, a gastroenterologist and biomedical engineer in the Division of Gastroenterology at the Brigham and assistant professor in the Department of Mechanical Engineering at MIT. “In this study, we looked at up to 100 re-sterilization cycles and found that the TEAL respirator we’ve designed can withstand that.”
- The team evaluated 7 different methods for repeatedly sterilizing the TEAL respirator, including 100 cycles of autoclaving, 100 cycles of microwaving, prolonged exposure to UV treatment, high heat (200 °C), 100 percent isopropyl alcohol, and bleach. The researchers found minimal change to the respirator’s elasticity after repeated sterilization.
- The TEAL respirator is comprised of a transparent, stretchy shell that can be sterilized and filters that can be replaced by the user. The team found that all participants could successfully replace their filters and most participants (90%) reported an excellent or good fit for the respirator.
- “TEAL is the first elastomeric respirator designed for use in a surgical setting, preserving the sterile field and providing the user a comfortable, reusable personal protective equipment solution,” said co-author Adam Wentworth, MS, a senior research engineer in the Brigham’s Division of Gastroenterology and the Traverso lab.
- The respirator’s sensors can help detect respiratory rate, exhalation temperature, and exhalation and inhalation pressures. The team also added a thermochromic coating to the respirator — a coating that changes color from black to pink when the respirator is in direct contact with a person’s face and therefore has a snug fit.
- The researchers evaluated the respirator’s performance in a clinical setting, enrolling 47 subjects from the Brigham and MGH (40 of the subjects underwent fit testing). Participants were asked to score the respirator on its fit, breathability and ease of filter exchange, and were also asked if they preferred the TEAL respirator to other options. Of those queried, 60 percent preferred the TEAL respirator compared to 5 percent who preferred standard hospital-supplied respirators. The remaining 35 percent had no preference.
- “We were excited to receive the feedback from the trial participants that they would love to continue using and testing the respirator, given its comfort, transparency and ease of use,” said co-author James Byrne, MD, PhD, a resident in the Department of Radiation Oncology at the Brigham and a postdoctoral fellow in the Traverso lab.
- Byrne notes that in addition to its other features, the TEAL respirator’s transparency may offer some advantages over more traditional respirators.
- “One of the big benefits of the TEAL respirator is that it enables visualization of the lips,” he said. “This can be immensely helpful in communication and expression, especially during this time when communication through N95 respirators and surgical masks makes it challenging to understand one another.”
- The sample size of the study was small, and the investigators acknowledge the importance of additional evaluation in a larger cohort of individuals and over a longer timeframe to further test the respirator’s functionality. To use the respirator in a health care setting, additional testing according to National Institute for Occupational Safety and Health (NIOSH) criteria will be needed.
5. 5 mistakes people make when sharing C19 data visualizations on Twitter
- The frantic swirl of coronavirus-related information sharing that took place this year on social media is the subject of a new analysis led by researchers at the School of Informatics and Computing at IUPUI.
- Published in the open-access journal Informatics, the study focuses on the sharing of data visualizations on Twitter — by health experts and average citizens alike — during the initial struggle to grasp the scope of the C19 pandemic, and its effects on society. Many social media users continue to encounter similar charts and graphs every day, especially as a new wave of coronavirus cases has begun to surge across the globe.
- The work found that more than half of the analyzed visualizations from average users contained one of five common errors that reduced their clarity, accuracy or trustworthiness.
- “Experts have not yet begun to explore the world of casual visualizations on Twitter,” said Francesco Cafaro, an assistant professor in the School of Informatics and Computing, who led the study. “Studying the new ways people are sharing information online to understand the pandemic and its effect on their lives is an important step in navigating these uncharted waters.”
- Casual data visualizations refer to charts and graphs that rely upon tools available to average users in order to visually depict information in a personally meaningful way. These visualizations differ from traditional data visualization because they aren’t generated or distributed by the traditional “gatekeepers” of health information, such as the Centers for Disease Control and Prevention or the World Health Organization, or by the media.
- “The reality is that people depend upon these visualizations to make major decisions about their lives: whether or not it’s safe to send their kids back to school, whether or not it’s safe to take a vacation, and where to go,” Cafaro said. “Given their influence, we felt it was important to understand more about them, and to identify common issues that can cause people creating or viewing them to misinterpret data, often unintentionally.”
- For the study, IU researchers crawled Twitter to identify 5,409 data visualizations shared on the social network between April 14 and May 9, 2020. Of these, 540 were randomly selected for analysis — with full statistical analysis reserved for 435 visualizations based upon additional criteria. Of these, 112 were made by average citizens.
- Broadly, Cafaro said the study identified five pitfalls common to the data visualizations analyzed. In addition to identifying these problems, the study’s authors suggest steps to overcome or reduce their negative impact:
- Mistrust: Over 25 percent of the posts analyzed failed to clearly identify the source of their data, sowing distrust in the accuracy. This information was often obscured due to poor design — such as bad color choices, busy layout, or typos — not intentional obfuscation. To overcome these issues, the study’s authors suggest clearly labeling data sources as well as placing this information on the graphic itself rather than the accompanying text, as images are often unpaired from their original post during social sharing.
- Proportional reasoning: Eleven percent of posts exhibited issues related to proportional reasoning, which refers to the users’ ability to compare variables based on ratios or fractions. Understanding infection rates across different geographic locations is a challenge of proportional reasoning, for example, since similar numbers of infections can indicate different levels of severity in low- versus high-population settings. To overcome this challenge, the study’s authors suggest using labels such as number of infections per 1,000 people to compare regions with disparate populations, as this metric is easier to understand than absolute numbers or percentages.
- Temporal reasoning: The researchers identified 7 percent of the posts with issues related to temporal reasoning, which refers to users’ ability to understand change over time. These included visualizations that compared the numbers of deaths from flu in a full year to the number of deaths from C19 in a few months, or visualizations that failed to account for the delay between the date of infection and deaths. Recommendations to address these issues included breaking metrics that depend upon different time scales in separate charts, as opposed to conveying the data in a single chart.
- Cognitive bias: A small percentage of posts (0.5 percent) contained text that seemed to encourage users to misinterpret data based upon the creator’s “biases related to race, country and immigration.” The researchers state that information should be presented with clear, objective descriptions carefully separated from any accompanying political commentary.
- Misunderstanding about virus: Two percent of visualizations were based upon misunderstandings about the novel coronavirus, such as the use of data related to SARS or influenza.
- The study also found certain types of data visualizations performed strongest on social media. Data visualizations that showed change over time, such as line or bar graphs, were most commonly shared.
- They also found that users engaged more frequently with charts conveying numbers of deaths as opposed to numbers of infections or impact on the economy, suggesting that people were more interested in the virus’s lethality than its other negative health or societal effects.
M. Johns Hopkins C19 Update
November 11, 2020
1. Cases & Trends
- EPI UPDATE The WHO C19 Dashboard reports 51.25 million worldwide cases and 1.27 million deaths as of 12:00pm EST on November 11.
- The US CDC reported 10.04 million total cases and 237,731 deaths. A cumulative incidence of 10 million cases corresponds to approximately 3% of the entire US population. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
- 1 million to 2 million- 44 days
- 2 million to 3 million- 27 days
- 3 million to 4 million- 15 days
- 4 million to 5 million- 17 days
- 5 million to 6 million- 22 days
- 6 million to 7 million- 25 days
- 7 million to 8 million- 21 days
- 8 million to 9 million- 14 days
- 9 million to 10 million- 10 days
- The daily incidence in the US is nearly 110,000 new cases per day and still increasing exponentially. The US is also reporting 976 deaths per day, an increase of nearly 40 percent since October 18. We expect that the average daily mortality will once again exceed 1,000 deaths per day in the coming days. If the US continues on this trajectory, it could surpass 250,000 cumulative deaths in the next 2 weeks.
- More than half of all US states have reported more than 100,000 cumulative cases, and more than one-third have reported more than 200,000 cases:
> 800,000: Florida
> 500,000: New York
> 400,000: Illinois
> 300,000: Georgia
- The Illinois Department of Health is currently reporting more than 500,000 cases, so we expect that to be reflected in the CDC data in the coming days. We also expect North Carolina to surpass 300,000 cases and Virginia to surpass 200,000 cases in the near future.
- By essentially every metric, the US C19 epidemic is accelerating at a concerning rate. The average daily incidence more than doubled in less than a month—from approximately 50,000 new cases per day on October 12 to 110,000 daily cases on November 9—with no sign of slowing. Analysis published on the COVID Exit Strategy website classifies all but 3 states—Hawai’i, Maine, and Vermont—as having “Uncontrolled Spread.”
- Additionally, 19 states are reporting more than 500 daily cases per million population. Most of these states are in the central portion of the country, with the exception of Alaska and Rhode Island. Notably, only 2 states, Alabama and Georgia, are reporting flat or decreasing C19 incidence over the past 2 weeks. In fact, 11 states are reporting increases of more than 100% over that time, including Maine at 215%. More than half of all US states have reported their single day record incidence over the past 2 weeks.
- As we have covered previously, C19 incidence does not tell the full story. In addition to incidence, testing, hospitalizations, and mortality provide important insight into the current state of the US epidemic. The national testing capacity has largely increased on a linear trajectory since early in the US epidemic, but recent exponential increases in C19 incidence and hospitalizations illustrate that the current testing volume may not be sufficient to fully capture the scope of community transmission.
- In fact, the US test positivity has doubled, from 4.2% to 8.3%, since early-to-mid October, once again putting the US above the WHO’s recommended 5% threshold. C19 hospitalizations are increasing nationwide, with the Midwest exhibiting the most substantial surge over the past several weeks. Looking at mortality, it is clear that C19 deaths continue to follow trends in incidence, with a lag of approximately 3-4 weeks. The national surge in incidence began in mid-September, followed by a corresponding increase in mortality starting in mid-October. Since that time, daily C19 mortality has increased by more than one-third.
- To put the current US surge in the global context, the US is #29 globally in terms of per capita daily incidence. Additionally, the US (354 new cases per million population) has nearly caught up to the average across Europe (377), the current major global hotspot. Compared to the 8 European countries with populations greater than 20 million, the US is reporting per capita daily incidence greater than 4 of them, and the per capita daily incidence in the US is currently reporting 8 times the global average (71). The US is faring slightly better in terms per capita daily mortality, ranking #35 globally. At 3 daily deaths per million population, the US is currently reporting 60% of the European average (5 deaths per million), and the US ranks behind 6 of the 8 most populous countries in Europe. The US daily mortality is increasing, although not nearly to the same degree as some European countries.
- The Johns Hopkins CSSE dashboard reported 10.31 million US cases and 240,265 deaths as of 1:30pm EST on November 11.
2. NURSING HOMES
- Despite efforts to keep C19 out of nursing homes, incidence among residents and staff is increasing after a period of relative stability. From May through October, incidence among both residents and staff of these facilities nearly quadrupled, and mortality among residents doubled over that time. The federal government previously allocated US$5 billion to provide nursing homes with access to rapid testing capacity and personal protective equipment (PPE), but despite this investment, nursing home staff inevitably are exposed to community transmission, which can then introduce SARS-CoV-2 to high-risk residents in these facilities.
- This pattern is especially true for nursing homes in areas where community spread is the highest. Nursing home incidence has been elevated in more severely affected areas, regardless of heightened protective measures. A study conducted by researchers at the University of Chicago, on behalf of The Associated Press, found that nursing home quality was not a meaningful predictor of success against C19, after accounting for the level of community transmission.
- Furthermore, nursing homes have been struggling to manage increasing incidence, staffing shortages, and new health mandates. For example, the study found that for the week of October 25, 1 in 6 nursing homes had not tested staff in the previous week, despite a national mandate for such weekly testing. Additionally, nearly 25% of facilities reported some sort of staffing shortage, and 20% reported a shortage of PPE. Many experts argue that nursing home residents cannot be protected unless community transmission is effectively contained, regardless of the extra protective measures implemented.
3. US CDC MASK GUIDANCE
- Yesterday, the US CDC published updated analysis regarding the role of mask use in protecting the wearer. The official CDC guidance continues to emphasize the value of masks in terms of “source control”—ie, that masks limit the volume of droplets expelled into the environment—rather than as protection for the wearer; however, the updated analysis indicates that masks can provide protection for the wearer as well, including the ability to filter “fine droplets and particles less than 10 microns.”
- Recent studies found that the filtration effect varied between masks and mask types, with multi-layer masks constructed with more densely woven material performing better than single-layer masks made from lower thread count fabric. The guidance also references studies that evaluated various mask materials, including both synthetic (eg, polypropylene) and natural materials (eg, silk). The CDC does not appear to have issued a corresponding update to its guidance on mask use (ie, to highlight the benefit to the wearer), but we will monitor the CDC website for any forthcoming changes. Hopefully, this new information will encourage increased mask use among the public.
4. TESTING REFUSAL
- While mask reluctance and refusal has been a common phenomenon throughout the US C19 epidemic, there are also increasing reports of reluctance toward testing. Testing volume and capacity vary widely across the country, with some states having greatly increased their capacity and others still largely limited to symptomatic individuals; however, even in areas with sufficient testing capacity, some individuals may resist getting tested. Factors driving this reluctance could include the desire to keep schools or businesses open (eg, by not contributing to reported incidence or triggering contact investigations at local businesses), personal concerns about isolation or quarantine, and political viewpoints.
- Personal autonomy is a major driver of testing hesitancy, much like for anti-vaccine sentiment or vaccine hesitancy, with some individuals viewing their ability to decide whether or not to be tested as their personal right. Notably, the Equal Employment Opportunity Commission determined that employers can mandate diagnostic testing for employees who work on site, illustrating the competing interests between personal autonomy and public benefit, particularly under “exceptional circumstances” like a pandemic. The extent of testing reluctance remains unknown, but it is evident that more work is necessary in order to both educate the public on the importance of testing and better characterize the degree to which individuals and communities experience testing reluctance.
- Utah joins 34 other states in establishing a statewide mask mandate, as part of recent efforts to strengthen social distancing measures. Governor Gary Herbert declared a new state of emergency and unveiled new statewide public health measures to combat the state’s ongoing C19 surge. The state of emergency and public health order follow Utah’s most devastating week to date in terms of C19 incidence and mortality.
- In addition to the mask mandate, the new measures expand testing operations, including mandatory weekly testing for college and university students, and place restrictions on restaurants and bars, including a prohibition on on-site alcohol sales after 10pm. Utah will also limit social gatherings to single households only and suspend many athletic or other extracurricular activities (with exceptions for high school, collegiate, and professional sports). The new measures are scheduled to remain in effect through November 23, and additional recommendations for the Thanksgiving holiday weekend are expected to be announced in the coming days. Governor Herbert warned that those who violate the new measures could be subjected to fines of up to US$10,000 per violation.
6. HOPI TRIBE
- Two articles published last week in the US CDC’s MMWR detailed the Hopi Tribe’s C19 response efforts. The Hopi Tribe is a Native American tribe and sovereign nation with a population of approximately 7,500 spread across 12 rural villages in northeastern Arizona. The first article details the investigation of a C19 outbreak in May and June. The Hopi Health Care Center (HHCC) led the overall response efforts, in coordination with the tribal leadership and the Hopi Emergency Response Team. Following the identification of 2 related C19 patients (siblings), contact tracing efforts identified 58 primary and secondary contacts of the co-index patients. Among the contacts, 27 (47%) tested positive for SARS-CoV-2, and 22 of the 29 total infections (76%; including the co-index patients) were symptomatic. Health officials identified 2 gatherings of extended family members and workplace exposures as likely loci of transmission beyond household contacts.
- Additionally, both of the co-index patients were symptomatic for at least 1 week prior to their positive test, during which time they continued to socialize in the community. The investigation identified a “limited understanding of how and when to wear masks, adhere to physical distancing…and practice hand hygiene” among the community, highlighting the need for “enhanced community education,” particularly regarding mask use and the signs and symptoms of C19. Following the investigation, HHCC and tribal leadership “increased community messaging,” in both English and Hopi.
- The second article describes efforts by the HHCC and the Hopi Tribe Department of Health and Human Services (DHHS), in collaboration with the US CDC, to conduct community-wide screening, surveillance, and education in 2 Hopi villages. Early contact tracing efforts found inconsistent mask use and limited knowledge of SARS-CoV-2 testing, isolation, and quarantine procedures, and the Hopi DHHS and the CDC developed a community-focused program to enhance surveillance and health communication. A pilot test of the screening, surveillance, and education program was conducted in 2 villages, interviewing 141 individuals across 101 households in fewer than 10 hours.
- The effort achieved 95% participation and obtained information on more than 259 individuals. The health officials utilized a standardized form to screen for C19 symptoms and exposures and provide education on everyday prevention measures and testing using “culturally adapted materials.” The surveillance teams reported that residents of the 2 villages were receptive to and appreciative of the screening and education efforts, and they attributed the success, in part, to the involvement of trusted community health representatives. As a result of the successful pilot, the Hopi Tribe expanded the screening to cover all villages between July and October, and tribal leadership are seeking additional resources to expand the program, including increased frequency and additional services such as distributing masks.
7. MONOCLONAL ANTIBODY EUA
- The US FDA issued an Emergency Use Authorization (EUA) for the use of bamlanivimab, a monoclonal antibody, as a C19 treatment in some patients. The EUA pertains specifically to patients who meet several key criteria: (1) aged 12 years and older and weighing 40kg (88 pounds) or more; (2) test positive for SARS-CoV-2; (3) currently experiencing mild or moderate C19 disease, but not currently hospitalized; AND (4) at high risk for severe C19 disease. Notably, the EUA emphasizes that bamlanivimab should not be administered to individuals who are receiving supplemental oxygen therapy (ie, high-flow oxygen or mechanical ventilation), as this could increase the risk of “worse clinical outcomes.” This is the first EUA issued for a monoclonal antibody treatment for C19. Bamlanivimab will continue to be evaluated as a C19 treatment, but the data currently available indicate that the drug can “reduce C19-related hospitalization or emergency room visits in patients at high risk” for severe C19.
- Last week, the US government announced that it finalized the purchase of 300,000 doses of bamlanivimab in anticipation of the FDA’s decision. The Biomedical Advanced Research and Development Authority (BARDA) purchased the doses directly from the manufacturer, Eli Lilly, as part of Operation Warp Speed. The current contract is valued at US$375 million, with the option of 650,000 more doses through the end of 2021 at an additional cost of US$812.5 million.
8. VACCINE DISTRIBUTION
- Even before the announcement by Pfizer Pharmaceuticals this week regarding interim efficacy analysis of its candidate SARS-CoV-2 vaccine, hospitals, health systems, and public health departments have been working to purchase and set up “ultra-cold freezers” in anticipation that they may be needed to store SARS-CoV-2 vaccines. The Pfizer vaccine, developed in partnership with BioNTech, must be stored at -70°C (-94°F) in order to remain viable, which is below the temperatures typically capable in pharmaceutical freezers. Not all vaccines require this level of freezing, but if the Pfizer vaccine is the first available, maintaining the cold chain during the vaccine distribution and administration process could be a major barrier, particularly for rural areas.
- According to a report by STAT News, the US CDC has advised against the purchase of these freezers, but many organizations are moving forward anyway. While hospitals, health systems, and public health departments in large urban areas may be able to afford the cost of these freezers, those in rural parts of the country may not have funding available to cover the purchase, putting them at a disadvantage. According to the National Rural Health Association, “nearly half of U.S. rural hospitals were operating at a loss in April of this year,” and the situation has been exacerbated by the C19 epidemic.
- Pfizer is working with state and local health departments to coordinate national distribution plans. The plans include boxes that can provide temporary storage capacity using dry ice, but the system has major limitations, including that the boxes “can be opened only for a minute at a time no more than twice a day.” As the US and countries around the world look ahead to the availability of a SARS-CoV-2 vaccine, logistical challenges, including cold chain management, need to be addressed well in advance in order to mitigate their impact on mass vaccination operations.
9. COLLEGE FOOTBALL
- On Saturday, the University of Notre Dame football team (ranked #4 nationally) defeated Clemson University (ranked #1) in double-overtime, in what ESPN labeled an “epic win.” While that description is debatable—considering that Clemson’s starting quarterback, Heisman Trophy contender Trevor Lawrence, did not play following a positive SARS-CoV-2 test—Notre Dame’s students reacted predictably after the victory, charging the field en masse. Notre Dame is among the approximately 50% of schools that allow fans to attend football games, and while it does limit the number of spectators, approximately 11,000 students were present for the game against Clemson. Fortunately, images show that the vast majority of students were wearing masks; however, physical distancing was not maintained while the students were on the field. Some media commentary suggests that university leadership should have anticipated this kind of incident and questions whether it is appropriate for schools to permit spectators in the stadium, or even to continue the season, in light of the ongoing surge in transmission and mortality across the country.
- Following the incident, Notre Dame’s President, Reverend John Jenkins, issued a statement admonishing the students for their actions, both after the game and at other gatherings in recent days. Rev. Jenkins’ letter is reminiscent of those issued by a number of universities to their respective student bodies earlier this year as schools resumed in-person classes and students gathered in dormitories, houses, bars, and other locations on and near campus. In addition to chastising students for acting like students, Rev. Jenkins announced “zero tolerance” policies for student gatherings—under threat of “severe sanctions”—as well as mandatory testing for students, including exit testing before students are permitted to leave at the end of the semester. Those who do not get tested will not be able to register for future classes or obtain an official transcript from the university.
- With the letter, Rev. Jenkins’ letter also called attention to his own recent actions with respect to C19, including attending a White House ceremony during which he did not wear a mask. The event—US President Donald Trump’s announcement of now-Justice Amy Coney Barrett as his nomination for the US Supreme Court—was subsequently identified as the locus of transmission for a number of C19 cases among White House staff and other attendees, potentially including Rev. Jenkins himself. Notably, Notre Dame’s Faculty Senate met last week “to consider a vote of no confidence because of [Reverend] Jenkins’ appearance at the Rose Garden without a mask,” but the group ultimately decided to forgo the vote and, instead, passed a motion which “expresses its disappointment…(and) also accepts his apology.”
- In the week leading up to the game against Clemson, Notre Dame’s average daily C19 incidence climbed from 18.9 cases per day to 30.7, a 62% increase; however, increasing incidence on campus did not dissuade the university from allowing students to attend the game in person. This kind of incident should serve as a cautionary tale for other universities and sports teams, particularly as national incidence and mortality continues to increase and students prepare to return home for Thanksgiving, Christmas, and the end of the term.
10. RUSSIAN VACCINES
- Following Pfizer’s announcement regarding the preliminary efficacy analysis for its candidate SARS-CoV-2 vaccine, Russia made a similar announcement for its first vaccine*. On Monday, the Russian Ministry of Health announced that early observations from the public use of its vaccine indicated that it was more than 90% efficacious. According to multiple media reports, the initial announcement also indicated that Russia intends to publish interim results from its ongoing Phase 3 clinical trial for the vaccine in the near future.
- In a subsequent announcement today, Russia reported that interim clinical trial data shows the vaccine efficacy to be 92%, based on data from approximately 16,000 participants who have received both doses. The preliminary results were based on data obtained after 20 cases of C19 among study participants, compared to 94 cases in the Pfizer trial. Much like the announcement from Pfizer, there are no publicly available data to analyze, so many questions remain about the Russian vaccine, including the duration of immunity. Russia in continuing Phase 3 clinical trials on the vaccine, and it is already conducting a separate study on a second vaccine. Russia also anticipates that a third candidate vaccine will be available in the near future.