November 20, 2020
Pfizer to seek emergency vaccine approval today, doses could ship in 24 hours
“The speed of the vaccine did not compromise safety, nor did it compromise scientific integrity.”Dr. Fauci
“At no time has the CDC suggested schools should be closed…All schools should remain open. It is the safest place for children to be.”Bob Redfield, Director of the CDC
“There is such a disconnect between the hospital and the surrounding communities. I don’t drive home to bells, whistles and clanging pots and pans … I drive home stunned through a college town with lines out the doors for the local bars.”Twitter post by a doctor
“We put our lives on the line daily to keep you safe. So, do something for us. Wear. A. Mask.”Ad campaign by about 100 of the country’s largest hospital
“The antiviral drug remdesivir is not suggested for patients admitted to hospital with Covid-19, regardless of how severely ill they are, because there is currently no evidence that it improves survival or the need for ventilation.”Expert panel of the World Health Organization
1. Cases & Tests
3. Top 5 States in Cases, Deaths, Hospitalizations & Positivity
4. More than 1 million children in the U.S. have been infected with C19
1. A vaccine in 300 days – a remarkable achievement
4. FDA approves first fully at-home coronavirus diagnostic test kit (*)
N. Linked Stories
- Phase 2 trial of Oxford C19 vaccine in healthy older adults finds it is safe and provokes immune response
- Parents are agonizing over whether to enroll their kids in organized indoor sports
- The known unknowns of T cell immunity to C19
- The U.S. C19 Outbreak Is Worse Than It’s Ever Been. Why Aren’t We Acting Like It?
- Social isolation during C19 pandemic linked with high blood pressure
- Potential new target to combat inflammatory diseases
- Chemists Discover Structure of Key Coronavirus Protein
- UCLA model ID’s neighborhoods that should have priority for vaccine, other C19 help
- Web searches for insomnia surged at height of C19 stay-at-home orders
- Early details of brain damage in C19 patients
- UIC launches three C19 clinical trials for blood clot prevention
- X-ray study explores potential of hepatitis C drugs to treat C19
- Teeth grinding and facial pain increase due to coronavirus stress and anxiety
- Zoonosis Threat: Urgent Call for More Effective Wildlife Trade Legislation in Wake of C19
- You can access all of the updates on our website at https://dailycovid19post.com/. Please share the website address with anyone you believe might be interested in the updates.
- We are happy to add anyone to the distribution list – just send their email address to me and we’ll add them to the list. And, for those of you on social media, please forward or post any or all of our updates. Also, please forward to me any information or recommendations that you believe should be included in any update. Comments and suggestions are always welcome.
- We do not endorse, and may not agree with, any opinion or view included in this update. We include a wide spectrum of opinions and views as we believe that it gives perspective on what people are thinking and may give insights into our future.
A. Pandemic Headlines
(In no particular order)
- CDC warns against Thanksgiving travel amid COVID-19 surge
- 50,000,000 Americans expected to travel for Thanksgiving despite COVID-19 surge
- CDC report says COVID-19 symptom screening at airports is ‘ineffective’
- WHO Officially Counsels Against Prescribing Gilead’s Remdesivir To Treat COVID-19
- Pfizer ready to ship COVID-19 vaccine within ‘hours’ of approval
- Dr. Fauci says COVID will disappear if 75% get vaccinated
- Pfizer and BioNTech conclude Phase 3 study of Covid-19 vaccine candidate, meeting at primary efficacy endpoints
- Pfizer In Regular Contact With Biden Campaign, Expects To Seek Vaccine Emergency Approval Friday
- North Dakota Hits Highest COVID-19 Mortality Rate In The World
- US hospitalizations at new record
- US seeing 150,000+ new cases per day
- COVID-19 second wave slams New Rochelle, one of NY’s first hot spots
- Pennsylvania Tightens Mask Restrictions, Private Homes Included (!)
- New York City schools closing because of rising coronavirus rates — and so are all schools in Kentucky
- NYC Mayor Says Indoor Dining Will Be Shut In “Next Week Or Two”
- Hundreds of nurses outside Philadelphia strike as COVID-19 cases surge
- American health care workers issue a call to arms for wearing masks
- 900 Mayo Clinic staffers diagnosed with COVID-19 over last two weeks
- We know how to reduce the virus’s spread — even though we’re not doing it
- U.S. colleges have reported over 320,000 virus cases, one-fifth of them in the last month
- A Rush On Coronavirus Testing Strains Laboratories, Drives Supply Shortages
- Far Deadlier Strain Of Coronavirus Discovered In South Australia
- New York Sheriffs Refuse To Enforce Cuomo’s Thanksgiving COVID Order
- 67% Of Republicans, 21% Of Democrats Says Lives “Somewhat” Back To Pre-COVID Normal: Gallup
- El Paso using drones to air-drop COVID-19 tests amid virus spike
- Will the police enforce West Virginia’s mask order? The governor says yes, the attorney general says no.
- Tokyo raises alert level to highest
- Europe accounts for 28% of cases and 26% of deaths globally from coronavirus
- Illinois casinos ordered to close
- Ohio imposes 21-day curfew
- Maryland announces restaurant curfew
- New Jersey ICU occupancy quadruples
- Italy reports most new deaths in seven months
- U.S., Canada, Mexico to extend border restrictions until late December
- French bars, restaurants expected to remain closed until mid-January
- Scotland imposes lockdown in Glasgow and Stirling
- LA County reports new record jump
- Texas reports new record jump
- California announces curfew on 94% of the state
- New Hampshire imposes statewide mask mandate
- France sees drop in hospitalizations for 3rd day
- Rhode Island to impose 2 week pause next week
- Moderna CEO says vaccines can be made faster
- Minnesota governor latest to close indoor dining
- Finland faces rapid spike
- Tokyo imposes emergency measures
- Russian cases top 2 million
- Croatia plans 2nd lockdown
- WHO Europe director says lockdowns are a ‘last resort’
- Moderna strikes deal with the UK to sell 5 million doses
- India outbreak continues to slow
- African continent hits 2 million confirmed coronavirus cases
- Illinois, Michigan more than 10,000+ new cases
- Bill Gates Warns 50% Of Business Travel Will Never Come Back
- COVID Unleashes The Undead Army: 20% Of All US Corporations Are Now Zombies
- “Largest Distribution Ever” – Thousands Of Cars Lined Up At Texas Food Bank
- COVID Contact-Tracing Has Been A Monumental Failure
- UK MP Suggests People Shouldn’t Be Allowed To Work Without COVID Vaccine
- “People Are Afraid” – 300,000 New Yorkers Flee City Due To COVID-19
- Despite Vaccine Hope, Travel Spending Won’t Recover Until 2024
- Smithsonian to shut museums, National Zoo amid COVID-19 spike
- South Australian COVID-19 lockdown is so strict, people can’t walk their dogs
- Macy’s sales plunge 20% as COVID-19 threatens holiday season
- Royal Caribbean attracts 100,000 volunteers for cruise ship test runs
- Delta Air Lines extends middle seat blocks through March 30
- Serbia is a new, unlikely oasis for NYC residents fleeing the city
- Student in Siberian village forced to climb birch tree to access online classes
- COVID-19 stricken mom gives birth to premature twins while in coma
- New York won’t really live again until Broadway is back
- NY Attorney General warns of revenge porn increase online dating during the pandemic
- CityMD COVID-19 test line in Brooklyn is so long it has a Twitter account
- You will need to take a $50 COVID test to dine at City Winery
- Oklahoma megachurch to host Thanksgiving, asks congregants to ‘bring a neighbor’
- COVID-19 will keep Pennsylvania crowds away on Groundhog Day
- Airline offers speed-dating on dead-end ‘flight to nowhere’
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 = 57,223,140
- New Cases (7 day average) = 585,176
- 7 day average of new cases has been relatively flat for the last week
US Cases & Testing:
- Total Cases = 12,070,712
- New Cases (7 day average) = 169,813
- Percentage of New Global Cases = 29%
- Total Number of Tests = 174,984,245
- Percentage of positive tests (7 day average) = 12.2%
- Record high number of new cases (192,186)
- Record high 7 day average of new cases
- During the last 30 days, the 7 day average of new cases has increased from 58,203 to 169,813, an increase of 191.7%
- During the last 30 days, the 7 day average of the percentage of positive cases has increased from 6.6% to 12.2%, an increase of 84.8%
- Total Deaths = 1,364,868
- New Deaths (7 day average) = 9,450
- Record high new deaths on 11/18
- Record high 7 day average of new deaths
- 7 day average has been increasing rapidly since 10/15
- Total Deaths = 258,333
- New Deaths (7 day average) = 1,398
- Percentage of Global New Deaths = 14.8%
- New deaths exceed 2,000 for first time since May 7
- 7 day average of new deaths is increasing at a rapid rate
- 7 day average has increased 16.6% in 2 days
3. Top 5 States in Cases, Deaths, Hospitalizations, ICU Patients & Positivity (11/19)
- Nationally, the positivity rate increased to 12.2% from 10.9% as of 11/12.
- More than 64% of all tests are now positive in ND (down from 68% on 11/12), and 52% in SD. IA was previously 52.4% on 11/12 and has declined to 49%
- Four states (IA, MO, NE, MT) 7-day positivity rates greater than 40%.
- Six states (ID, WI, NV, KS, IN, MN) 7-day positivity rates greater than 30%.
- Five states (UT, RI, PA, CO, AL) had 7-day positivity rates greater than 20%.
- In total, 45 states have 7-day positivity rates greater than 5% (+4 states since 11/12)
- Hospitalizations in the US surge to 80,698, up 20.3% since 11/12.
- 39 states have had increases of hospitalized patients of more than 10% since 11/12.
- 26 states have more than 1,000 hospitalized patients (+3 since 11/12)
- Four states saw decreases in the number of hospitalized patients (HI, ND, MT, VT).
- ICU Patients in the US increase to 15,573 up from 12,796 (+ 21.7%) since 11/12
- 28 states have seen the number of ICU patients increase by more than 10% since 11/12
- 29 states have more than 100 patients in ICU, (+2 states since 11/12)
- Five states (SD, RI, ID, ND, VT) saw decreases in the number of ICU patients since 11/12
4. More than 1 million children in the U.S. have been infected with C19
- State-level reports are the best publicly available data on child C19 cases in the United States. The American Academy of Pediatrics and the Children’s Hospital Association are collaborating to collect and share all publicly available data from states on child C19 cases (definition of “child” case is based on varying age ranges reported across states; see report Appendix for details and links to all data sources).
- As of November 12th, over 1 million children have tested positive for C19 since the onset of the pandemic. The age distribution of reported C19 cases was provided on the health department websites of 49 states, New York City, the District of Columbia, Puerto Rico, and Guam. Children represented 11.5% of all cases in states reporting cases by age.
- A smaller subset of states reported on hospitalizations and mortality by age; the available data indicated that C19-associated hospitalization and death is uncommon in children.
- The number of new child C19 cases reported this week, nearly 112,000, is by far the highest weekly increase since the pandemic began. At this time, it appears that severe illness due to C19 is rare among children. However, there is an urgent need to collect more data on longer-term impacts on children, including ways the virus may harm the long-term physical health of infected children, as well as its emotional and mental health effects.
Summary of Findings (data available as of 11/12/20):
Cumulative Number of Child C19 Cases
- 1,039,464 total child C19 cases reported, and children represented 11.5% (1,039,464/9,037,991) of all cases
- Overall rate: 1,381 cases per 100,000 children in the population
Change in Child C19 Cases
- 111,946 new child C19 cases were reported the past week from 11/5-11/12 (927,518 to 1,039,464)
- Over two weeks, 10/29-11/12, there was a 22% increase in child COVID-19 cases (185,829 new cases (853,635 to 1,039,464))
Testing (10 states reported)
- Children made up between 5.0%-17.4% of total state tests, and between 3.9%-18.8% of children tested were tested positive
Hospitalizations (23 states and NYC reported)
- Children were 1.2%-3.3% of total reported hospitalizations, and between 0.5%-6.1% of all child C19 cases resulted in hospitalization
Mortality (42 states and NYC reported)
- Children were 0.00%-0.21% of all C19 deaths, and 16 states reported zero child deaths
- In states reporting, 0.00%-0.15% of all child C19 cases resulted in death
- As of the 11/12/20 report, 133 children have died
- Report: Children and COVID-19: State Data Report
C. New Scientific Findings & Research
1. Living with a dog and home delivery substantially increase risk of infection (and surprising factors that do not increase risk)
- A study carried out by researchers from the University of Granada (UGR) and the Andalusian School of Public Health has analyzed the main risk factors in the transmission of the coronavirus (SARS-CoV-2) during the national lockdown in Spain, between March and May 2020.
- The study, published in the journal Environmental Research, has revealed that living with a dog and buying basic products in the supermarket with home delivery were two of the socio-demographic variables (of those analyzed) that most increased the risk of contracting C19 during the period under study—by 78% in the case of living with a dog, and by 94% in that of supermarket home delivery.
- The authors warn dog-owners of the need to take extreme hygiene measures in relation to their pets, as it is not yet clear whether the owners were infected because the animal acted as a host for the virus (and transmitted it) or due to having taken it out for a walk in public.
- As explained by Cristina Sánchez González, a researcher at the UGR’s Biomedical Research Centre and the main author of this work, “in view of the rapid spread of the virus even during lockdown, we consider it important to study the socio-demographic characteristics, habits, and comorbidities of the SARS-CoV-2 infection in order to implement effective prevention strategies.”
- To this end, the researchers designed a survey to capture variables of interest during the lockdown period that might help explain the exponential spread of the virus, despite the highly restrictive mobility conditions implemented nationally in Spain.
Study based on 2,086 individuals
- This study, carried out throughout Spain, sought to shed light on other possible routes of transmission of the C19 disease, risk factors, and the effectiveness of the hygiene measures recommended by the Authorities, in order to detect critical points of exposure to the virus and thus minimize its spread—not only in this pandemic but also for any future events that could compromise public health.
- Based on a sample of 2,086 individuals, 41% of the population surveyed were aged between 40 and 54 years and had studied to degree (44%) or postgraduate (32%) level. This collective presented a prevalence of the disease of 4.7%.
- The results showed that the risk of suffering from C19 is 60 times higher among those who cohabit with a C19 patient.
- In addition, of all the socio-demographic variables analyzed, the one with the most powerful effect in terms of increasing the risk of contracting the disease (by up to 78%) was living with a dog and taking it for a walk. By contrast, having cats or other types of pets had no significant effect on the prevalence of the disease.
- “The results of our research warn of increased contagion among dog-owners, and the reason for this higher prevalence has yet to be elucidated. Taking into account the current scarcity of resources to carry out the diagnosis of SARS-CoV-2 in humans, the possibility of diagnosis in dogs is extremely unlikely,” notes Sánchez González.
- These results point to cohabiting with dogs as being a strong risk factor for C19 infection, although further studies are needed to determine whether the reason for this sharp increase in the risk of SARS-CoV-2 infection is due to transmission between humans and dogs, to the dog acting as a vehicle for the virus, or to the increased contact with other vehicles for the virus (that is, objects or surfaces where the virus is present). The latter could be caused by greater exposure to the virus due to the unhygienic behaviors and habits of dogs when out in the street and their subsequent return to the home.
- “At the international level, there are several studies that have obtained results similar to ours regarding coronavirus infection in dogs, but it is necessary to dig deeper on this issue and establish whether this prevalence of the virus among dog-owners is due to one reason or another,” explains the UGR researcher.
- Sánchez González warns that, “in the midst of a pandemic and in the absence of an effective treatment or vaccine, preventive hygiene measures are the only salvation, and these measures should also be applied to dogs, which, according to our study, appear to directly or indirectly increase the risk of contracting the virus.”
- The researcher also points out that “from a scientific point of view, there is no justification for children’s playgrounds being closed to prevent infections while parks, where dogs are walked, are allowed to remain open, when there are numerous objects there that can act as vehicles for SARS-CoV-2. At the same time, we should not rule out the possibility that the virus may be transmitted via fecal matter.”
Disinfecting supermarket products
- In this study, the effect of certain variables—gender, age, educational level, type of residence, size of household, cohabitation with children or adolescents, the presence of workers among the household members, the presence of domestic workers in the home during lockdown, or having any type of pet other than a dog—was found to have no statistical significance.
- The most effective hygiene measure in helping to reduce the prevalence of the disease was to disinfect products purchased from the market once back home (which reduced the risk by 94%). This was found to be more effective than other hygiene measures, such as the use of facemasks, gloves, disinfecting with ethanol or bleach, disinfecting shoes, and washing clothes when returning home.
- Among mobility variables that were studied, those with the greatest effect in terms of increasing the prevalence of the virus were working outside the home (which increased the risk by 76%) and the use of public transport (particularly the underground system or tram network).
- A higher prevalence of the disease was also detected among those surveyed who had purchased their basic products at a supermarket and then used the home delivery service, compared to those who brought their shopping home themselves (the risk increased by 94% among the former group).
- The authors emphasize that this was an epidemiological study, which neither addresses the mechanisms surrounding the virus nor establishes causal relationships. This was a descriptive study in which the selected variables were statistically associated with prevalence.
2. Immunity to the Coronavirus May Last Years
- How long might immunity to the coronavirus last? Years, maybe even decades, according to a new study — the most hopeful answer yet to a question that has shadowed plans for widespread vaccination.
- 8 months after infection, most people who have recovered still have enough immune cells to fend off the virus and prevent illness, the new data show. A slow rate of decline in the short term suggests, happily, that these cells may persist in the body for a very, very long time to come.
- The research, published online, has not been peer-reviewed nor published in a scientific journal. But it is the most comprehensive and long-ranging study of immune memory to the coronavirus to date.
- “That amount of memory would likely prevent the vast majority of people from getting hospitalized disease, severe disease, for many years,” said Shane Crotty, a virologist at the La Jolla Institute of Immunology who co-led the new study.
- The findings are likely to come as a relief to experts worried that immunity to the virus might be short-lived, and that vaccines might have to be administered repeatedly to keep the pandemic under control.
- And the research squares with another recent finding: that survivors of SARS, caused by another coronavirus, still carry certain important immune cells 17 years after recovering.
- The findings are consistent with encouraging evidence emerging from other labs. Researchers at the University of Washington, led by the immunologist Marion Pepper, had earlier shown that certain “memory” cells that were produced following infection with the coronavirus persist for at least three months in the body.
- A study published last week also found that people who have recovered from C19 have powerful and protective killer immune cells even when antibodies are not detectable.
- These studies “are all by and large painting the same picture, which is that once you get past those first few critical weeks, the rest of the response looks pretty conventional,” said Deepta Bhattacharya, an immunologist at the University of Arizona.
- Akiko Iwasaki, an immunologist at Yale University, said she was not surprised that the body mounts a long-lasting response because “that’s what is supposed to happen.” Still, she was heartened by the research: “This is exciting news.”
- A small number of infected people in the new study did not have long-lasting immunity after recovery, perhaps because of differences in the amounts of coronavirus they were exposed to. But vaccines can overcome that individual variability, said Jennifer Gommerman, an immunologist at the University of Toronto.
- “That will help in focusing the response, so you don’t get the same kind of heterogeneity that you would see in an infected population,” she said.
- In recent months, reports of waning antibody levels have created worry that immunity to the coronavirus may disappear in a few months, leaving people vulnerable to the virus again.
- But many immunologists have noted that it is natural for antibody levels to drop. Besides, antibodies are just one arm of the immune system.
- Although antibodies in the blood are needed to block the virus and forestall a second infection — a condition known as sterilizing immunity — immune cells that “remember” the virus more often are responsible for preventing serious illness.
- “Sterilizing immunity doesn’t happen very often — that is not the norm,” said Alessandro Sette, an immunologist at the La Jolla Institute of Immunology and co-leader of the study.
- More often, people become infected a second time with a particular pathogen, and the immune system recognizes the invader and quickly extinguishes the infection. The coronavirus in particular is slow to do harm, giving the immune system plenty of time to kick into gear.
- “It may be terminated fast enough that not only are you not experiencing any symptoms but you are not infectious,” Dr. Sette said.
- Dr. Sette and his colleagues recruited 185 men and women, aged 19 to 81, who had recovered from C19. The majority had mild symptoms not requiring hospitalization; most provided just one blood sample, but 38 provided multiple samples over many months.
- The team tracked four components of the immune system: antibodies, B cells that make more antibodies as needed; and two types of T cells that kill other infected cells. The idea was to build a picture of the immune response over time by looking at its constituents.
- “If you just look at only one, you can really be missing the full picture,” Dr. Crotty said.
- He and his colleagues found that antibodies were durable, with modest declines at 6 to 8 months after infection, although there was a 200-fold difference in the levels among the participants. T cells showed only a slight, slow decay in the body, while B cells grew in number — an unexpected finding the researchers can’t quite explain.
- The study is the first to chart the immune response to a virus in such granular detail, experts said. “For sure, we have no priors here,” Dr. Gommerman said. “We’re learning, I think for the first time, about some of the dynamics of these populations through time.”
- Worries over how long immunity to the coronavirus persists were sparked mainly by research into those viruses causing common colds. One frequently cited study, led by Jeffrey Shaman of Columbia University, suggested that immunity might fade quickly and that reinfections could occur within a year.
- “What we need to be very mindful of is whether or not reinfection is going to be a concern,” Dr. Shaman said. “And so seeing evidence that we have this kind of persistent, robust response, at least to these time scales, is very encouraging.” So far, at least, he noted, reinfections with the coronavirus seem to be rare.
- Exactly how long immunity lasts is hard to predict, because scientists don’t yet know what levels of various immune cells are needed to protect from the virus. But studies so far have suggested that even small numbers of antibodies or T and B cells may be enough to shield those who have recovered.
- The participants in the study have been making those cells in robust amounts — so far. “There’s no sign that memory cells are suddenly going to plummet, which would be kind of unusual,” Dr. Iwasaki said. “Usually, there’s a slow decay over years.”
- There is some emerging evidence that reinfections with common cold coronaviruses are a result of viral genetic variations, Dr. Bhattacharya noted, and so those concerns may not be relevant to the new coronavirus.
- “I don’t think it’s an unreasonable prediction to think that these immune memory components would last for years,” he said.
3. What the data say about asymptomatic COVID infections
- How many people don’t experience any symptoms after becoming infected with the coronavirus (SARS-CoV-2)? And what is their role in spreading C19? These have been key questions since the beginning of the pandemic.
- Now, evidence suggests that about 1 in 5 infected people will experience no symptoms, and they will transmit the virus to significantly fewer people than someone with symptoms. But researchers are divided about whether asymptomatic infections are acting as a ‘silent driver’ of the pandemic.
- Although there is a growing understanding of asymptomatic infections, researchers say that people should continue to use measures to reduce viral spread, including social distancing and wearing masks, regardless of whether they have symptoms.
- The issue with putting a reliable figure on the rate of asymptomatic C19 is distinguishing between people who are asymptomatic and pre-symptomatic, says Krutika Kuppalli, an infectious-disease researcher at Stanford University School of Medicine in California. “Asymptomatic is someone who never developed symptoms ever throughout the course of their disease, and pre-symptomatic is somebody who has mild symptoms before they do go on to develop symptoms,” Kuppalli says. There is also no standardized accepted definition of that, she says.
- Research early in the pandemic suggested that the rate of asymptomatic infections could be as high as 81%. But a meta-analysis published last month, which included 13 studies involving 21,708 people, calculated the rate of asymptomatic presentation to be 17%. The analysis defined asymptomatic people as those who showed none of the key C19 symptoms during the entire follow-up period, and the authors included only studies that followed participants for at least seven days. Evidence suggests that most people develop symptoms in 7–13 days, says lead author Oyungerel Byambasuren, a biomedical researcher at the Institute for Evidence-Based Healthcare at Bond University in Gold Coast, Australia.
- Byambasuren’s review also found that asymptomatic individuals were 42% less likely to transmit the virus than symptomatic people.
- One reason that scientists want to know how frequently people without symptoms transmit the virus is because these infections largely go undetected. Testing in most countries is targeted at those with symptoms.
- As part of a large population study in Geneva, Switzerland, researchers modelled viral spread among people living together. In a manuscript posted on medRxiv this month, they report that the risk of an asymptomatic person passing the virus to others in their home is about one-quarter of the risk of transmission from a symptomatic person.
- Although there is a lower risk of transmission from asymptomatic people, they might still present a significant public-health risk because they are more likely to be out in the community than isolated at home, says Andrew Azman, an infectious-disease epidemiologist at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, who is based in Switzerland and was a co-author on the study. “The actual public-health burden of this massive pool of interacting ‘asymptomatics’ in the community probably suggests that a sizeable portion of transmission events are from asymptomatic transmissions,” he says.
- But other researchers disagree about the extent to which asymptomatic infections are contributing to community transmission. If the studies are correct in finding that asymptomatic people are a low transmission risk, “these people are not the secret drivers of this pandemic”, says Byambasuren. They “are not coughing or sneezing as much, they’re probably not contaminating as much surfaces as other people”.
- Muge Cevik, an infectious-disease researcher at the University of St Andrews, UK, points out that because most people are symptomatic, concentrating on identifying them will probably eliminate most transmission events.
- To understand what is happening in people with no symptoms, Cevik and colleagues conducted a systematic review and meta-analysis of 79 studies on the viral dynamics and transmissibility of SARS-CoV-2, which is posted on social-sciences preprint server SSRN. Some studies showed that those without symptoms had similar initial viral loads — the number of viral particles present in the blood — when compared with people with symptoms. But asymptomatic people seem to clear the virus faster and are infectious for a shorter period.
- The immune systems of asymptomatic individuals might be able to neutralize the virus more rapidly, says Cevik. But that doesn’t mean these people have a stronger or more durable immune response — and there is evidence that people with severe C19 have a more substantial and long-lasting neutralizing antibody response, she says.
- Although there is a now a better understanding of asymptomatic infections and transmission of C19, Cevik says that asymptomatic people should continue to use measures that reduce viral spread, such as social distancing, hand hygiene and wearing a mask.
4. Danish Study Questions Effectiveness of Masks
- Researchers in Denmark reported on Wednesday that surgical masks did not protect the wearers against infection with the coronavirus in a large randomized clinical trial. But the findings conflict with those from a number of other studies, experts said, and are not likely to alter public health recommendations in the United States.
- The study, published in the Annals of Internal Medicine, did not contradict growing evidence that masks can prevent transmission of the virus from wearer to others. But the conclusion is at odds with the view that masks also protect the wearers — a position endorsed just last week by the Centers for Disease Control and Prevention.
- Critics were quick to note the study’s limitations, among them that the design depended heavily on participants reporting their own test results and behavior, at a time when both mask-wearing and infection were rare in Denmark.
- From early April to early June, researchers at the University of Copenhagen recruited 6,024 participants who had been tested beforehand to be sure they were not infected with the coronavirus.
- Half were given surgical masks and told to wear them when leaving their homes; the others were told not to wear masks in public.
- At that time, 2% of the Danish population was infected — a rate lower than that in many places in the United States and Europe today. Social distancing and frequent hand-washing were common, but masks were not.
- About 4,860 participants completed the study. The researchers had hoped that masks would cut the infection rate by half among wearers. Instead, 42 people in the mask group, or 1.8%, got infected, compared with 53 in the unmasked group, or 2.1%. The difference was not statistically significant.
- “Our study gives an indication of how much you gain from wearing a mask,” said Dr. Henning Bundgaard, lead author of the study and a cardiologist at the University of Copenhagen. “Not a lot.”
- Dr. Mette Kalager, a professor of medical decision making at the University of Oslo, found the research compelling. The study showed that “although there might be a symbolic effect,” she wrote in an email, “the effect of wearing a mask does not substantially reduce risk” for wearers.
- Other experts were unconvinced. The incidence of infections in Denmark was lower than it is today in many places, meaning the effectiveness of masks for wearers may have been harder to detect, they noted.
- Participants reported their own test results; mask use was not independently verified, and users may not have worn them correctly.
- “There is absolutely no doubt that masks work as source control,” preventing people from infecting others, said Dr. Thomas Frieden, chief executive of Resolve to Save Lives, an advocacy group, and former director of the C.D.C., who wrote an editorial outlining weaknesses of the research.
- “The question this study was designed to answer is: Do they work as personal protection?” The answer depends on what mask is used and what sort of exposure to the virus each person has, Dr. Frieden said, and the study was not designed to tease out those details.
- “An N95 mask is better than a surgical mask,” Dr. Frieden said. “A surgical mask is better than most cloth masks. A cloth mask is better than nothing.”
- The study’s conclusion flies in the face of other research suggesting that masks do protect the wearer. In its recent bulletin, the C.D.C. cited a dozen studies finding that even cloth masks may help protect the wearer. Most of them were laboratory examinations of the particles blocked by materials of various types.
- Susan Ellenberg, a biostatistician at the University of Pennsylvania Perelman School of Medicine, noted that protection conferred by masks on the wearer trended “in the direction of benefit” in the trial, even if the results were not statistically significant.
- “Nothing in this study suggests to me that it is useless to wear a mask,” she said.
- Dr. Elizabeth Halloran, a statistician at Fred Hutchinson Cancer Research Center in Seattle, said the usefulness of masks also depends on how much virus a person is exposed to.
- “If you show this article to a health care provider who works in a Covid ward in a hospital, I doubt she or he would say that this article convinces them not to wear a mask,” she said.
- But Dr. Christine Laine, editor in chief of the Annals of Internal Medicine, described the previous evidence that masks protect wearers as weak. “These studies cannot differentiate between source control and personal protection of the mask wearer,” she said.
- Dr. Laine said the new study underscored the need for adherence to other precautions, like social distancing. Masks “are not a magic bullet,” she said. “There are people who say, ‘I’m fine, I’m wearing a mask.’ They need to realize they are not invulnerable to infection.”
- You can read the study here: https://www.acpjournals.org/doi/10.7326/M20-6817
5. Domestic Cats Can Be Asymptomatic Carriers of the Coronavirus
- Two recently published studies from Kansas State University researchers and collaborators have led to two important findings related to the C19 pandemic: Domestic cats can be asymptomatic carriers of the coronavirus (SARS-CoV-2), but pigs are unlikely to be significant carriers of the virus. SARS-CoV-2 is the coronavirus responsible for C19.
- “Other research has shown that C19-infected human patients are transmitting SARS-CoV-2 to cats; this includes domestic cats and even large cats, such as lions and tigers,” said Jürgen A. Richt, the Regents distinguished professor at Kansas State University in the College of Veterinary Medicine. “Our findings are important because of the close association between humans and companion animals.”There are about 95 million house cats in the U.S. and about 60 million to 100 million feral cats, Richt said.
- Richt is the senior author on the two recent collaborative publications in the journal Emerging Microbes & Infections: “SARS-CoV-2 infection, disease and transmission in domestic cats” and “Susceptibility of swine cells and domestic pigs to SARS-CoV-2.”
- Through their in-depth study at the K-State Biosecurity Research Institute, or BRI, at Pat Roberts Hall, the researchers studied susceptibility to infection, disease and transmission in domestic cats. They found that domestic cats may not have obvious clinical signs of SARS-CoV-2, but they still shed the virus through their nasal, oral and rectal cavities and can spread it efficiently to other cats within two days. Further research is needed to study whether domestic cats can spread the virus to other animals and humans.
- “This efficient transmission between domestic cats indicates a significant animal and public health need to investigate a potential human-cat-human transmission chain,” said Richt, who is also the director of the university’s Center of Excellence for Emerging and Zoonotic Animal Diseases, known as CEEZAD, and the Center on Emerging and Zoonotic Infectious Diseases, known as CEZID.
- For the study involving pigs, the researchers found that SARS-CoV-2-infected pigs are not susceptible to SARS-CoV-2 infection and do not appear to transmit the virus to contact animals.
- “Pigs play an important role in U.S. agriculture, which made it important to determine the potential SARS-CoV-2 susceptibility in pigs,” Richt said. “Our results show that pigs are unlikely to be significant carriers of SARS-CoV-2.”
- The BRI has provided the high-security laboratories for Richt and collaborators to study SARS-CoV-2. It is a biosafety level-3 and biosafety level-3 agriculture facility that houses important multidisciplinary research, training and educational programs on pathogens that affect animals, plants and insects, as well as food safety and security.
- Richt and his collaborators plan further studies to understand SARS-CoV-2 transmission in cats and pigs. They also plan to study whether cats are immune to SARS-CoV-2 reinfection after they have recovered from a primary SARS-CoV-2 infection.
- “This research is important for risk assessment, implementing mitigation strategies, addressing animal welfare issues, and to develop preclinical animal models for evaluating drug and vaccine candidates for C19,” Richt said.
D. Vaccines & Testing
1. A vaccine in 300 days – a remarkable achievement
- In early January, about the only thing the world’s scientists knew for sure about the novel coronavirus was its genetic profile. Now, some 300 days later, vaccine developers are on the brink of a major victory against a pathogen that’s inflicted untold personal and economic damage.
- Pfizer said on Wednesday that a final analysis of clinical-trial data showed its vaccine was 95% effective, paving the way for the company to apply for the first U.S. regulatory authorization for a coronavirus shot within days. The news is fueling optimism for the quest to halt a disease that’s killed more than 1.3 million people and continues to run rampant.
- Bringing a conventional vaccine from inception to market takes more than a decade on average, and less than one in five that enters human trials gets to the finish line. Work on Covid-19 vaccines began Jan. 11, when researchers in China published the genome of the coronavirus later known as SARS-CoV-2. That same Saturday, researchers at the U.S. National Institutes of Health began the first steps of laying out a vaccine program that became Operation Warp Speed.
- Moderna, working with the NIH, and Pfizer along with collaborator BioNTech, used the genome sequence to design a molecule called messenger RNA. When injected into cells, the mRNA instructs them to make the coronavirus’ spike protein, which the virus normally uses to invade cells. That key protein induces an immune response from the body.
- Vaccines using mRNA have never been licensed for use in humans, but were pressed into service because of the speed with which they can be made. Researchers already had mRNA vaccine technology platforms, eliminating the need to create a new manufacturing process from scratch.
- There are still many questions to be answered, including how long protection from the vaccines will last and how they’ll hold up under the scrutiny of regulators. They must be manufactured and distributed to billions of people, in some cases under extreme storage conditions.
- In the meantime, the central question—can vaccines be designed and tested against a novel virus in a year—is on the cusp of being answered in the affirmative. Faith in science’s ability to answer that question was why Yasir Batalvi, a Massachusetts political strategist, volunteered for Moderna’s phase 3 trial, which has also released interim results.
- “The researchers just want the truth, and I trust the science,” he said.
Source: Bloomberg Coronavirus Daily
2. Experts doubt first coronavirus vaccines will lead to herd immunity
- Governments and officials are voicing hopes that C19 vaccines could bring “herd immunity”, with some calculating that immunizing just two-thirds of a population could halt the pandemic disease and help protect whole communities or nations.
- But the concept comes with caveats and big demands of what vaccines might be capable of preventing. Some experts say such expectations are misplaced.
- For a start, figuring out what’s needed to achieve herd immunity with C19 vaccines involves a range of factors, several of which are unknown.
- What is the rate of the spread of the C19-causing virus? Will the first vaccines deployed be able to stop transmission of the virus, or just stop people getting ill? How many people in a population will accept a vaccine? Will vaccines offer the same protection to everyone?
- “Herd immunity is sometimes wrongly understood as individual protection,” said Josep Jansa, an expert in health emergency preparedness and response at the Stockholm-based European Centre for Disease Prevention and Control (ECDC).
- “It’s inappropriate to think ‘I will not be affected myself because there is herd immunity’. Herd immunity refers to community protection, not to how an individual is protected.”
- The ECDC uses an estimated herd immunity threshold of 67% for its models, while Chancellor Angela Merkel said this month that C19 restrictions in Germany could be lifted if 60% to 70% of the population acquired immunity, either via a C19 vaccine or through infection.
- World Health Organization experts have also pointed to a 65%-70% vaccine coverage rate as a way to reach population immunity through vaccination.
- “The idea of herd community is to protect the vulnerable,” said Eleanor Riley, a professor of immunology and infectious disease at the University of Edinburgh. “And the idea behind it is that if, say, 98% of a population have all been vaccinated, there will be so little virus in the community that the 2% will be protected. That’s the point of it.”
Reproduction Rate is Crucial
- Central to the public health calculations on this concept for C19 is the reproduction rate, or R value, of the virus that causes it. This is a measure of how many other people an average infected person passes a pathogen on to in “normal”, or restriction-free, circumstances.
- Assuming complete vaccine efficacy, herd immunity percentage thresholds for infectious diseases are calculated by dividing 1 by the R value, deducting the result from 1, and multiplying by 100.
- For instance, herd immunity from highly contagious measles, with an estimated R value of 12 or higher, will kick in only if 92% or more within a group are immune. For a seasonal flu strain that could have an R value of 1.3, the threshold would be just 23%.
- “The problem is that for now we don’t know exactly how fast the virus spreads without any precautions and with the normal travel and social activities we had a year ago,” said Winfried Pickl, professor of immunology at the Medical University of Vienna.
- With so many countries still operating in far from normal circumstances, the assumption should be that the C19 R value would be “closer to 4 than to 2”, he said, since even with semi- or full lockdown measures the R value is around 1.5.
- Additionally, anything less than 100% vaccine efficacy – such as the 90% or so suggested in early data on the Pfizer-BioNTech and Moderna C19 shots – would require a matching rise in percentage of coverage to reach herd threshold.
- Amesh Adalja, a scholar at the Johns Hopkins Center for Health Security, said a good target for immunity in the United States would be for more than 70% of the population to be inoculated, but added that the figure could go up if vaccines are less effective.
- Experts say another important factor is whether the C19 vaccines a government chooses to deploy can stop transmission of the virus.
- Evidence so far suggests the first C19 vaccines to come to market will at least stop people developing the disease. But it cannot be ruled out that people will still catch the coronavirus (SARS-CoV-2) and pass it on to others unnoticed.
- “While protection against illness has a value for an individual, it will not prevent circulation of virus and risk of disease in unvaccinated (people),” said Penny Ward, a visiting professor in pharmaceutical medicine at King’s College London.
- Bodo Plachter, a professor and deputy director of the Institute of Virology at Germany’s Mainz University teaching hospital, said that respiratory infections in particular can be hard to block completely with vaccines – although the shots will go some way to reducing the amount of circulating virus.
- “It may well be that vaccinated people will shed fewer viruses,” he said. “But it would be a mistake to assume vaccination alone can suppress a pandemic.”
Focus on Protecting the Vulnerable?
- Edinburgh’s Riley said this suggests that for now, pursuing an idea of herd immunity through C19 vaccination is fruitless.
- A better approach, she said, could be to “turn herd immunity on its head”, and use the first limited supplies of vaccines to protect those most in need, without worrying about the more robust members of the “herd” who can live relatively happily with the virus.
- “Let’s forget about protecting the masses to protect the vulnerable,” she said. “Let’s directly protect the vulnerable.”
3. What Is Driving the Decline in People’s Willingness to Take the C19 Vaccine in the United States?
- Over the past few months, there has been an indisputable decline in the number of people in the US who say they plan to get the vaccine for coronavirus disease 2019 (C19) when one becomes available. A national survey by Pew Research Center in May found that 72% of people in the US said they would get the vaccine if it were available. By September, that number had dropped to 51%. Survey results from CNN showed a similar decline, from 66% who said they would get the vaccine in May to 51% in early October.
- What is disputable, however, is why this decline is occurring. The C19 pandemic has become highly politicized, with partisanship affecting attitudes toward wearing a mask and confidence in the accuracy and validity of C19 statistics. Similarly, much has been made about the politicization of the vaccine.
- And a number of voters believe that politics have influenced the development of the vaccine. A Kaiser Family Foundation survey from early October found that 62% of people in the US are worried that the US Food and Drug Administration (FDA) will rush to approve a C19 vaccine without making sure that it is safe and effective owing to political pressure from the Trump administration. Moreover, the survey found that 55% of people believe that President Trump is intervening with the FDA’s job of reviewing and approving a C19 vaccine.
- But while coverage has primarily pinpointed the driver of the decline to be political in nature, there are a number of other factors at hand. First, people in the US have a history of reluctance to accept new vaccines. Shortly after the polio vaccine was made available in 1954, Gallup found that 60% of people said they would get the newly created vaccine, while 31% said they would not get the vaccine and 9% were not sure. We know how history transpired, with near universal adoption of the polio vaccine in the US today; however, a sizable number of people were hesitant at the outset. Similarly, after the attacks of September 11 elevated concerns of biological attacks on people in the US, including the use of smallpox, Gallup found that 55% of people would get a smallpox vaccine, while 35% would not get the vaccine and 10% were unsure.
- Next, attitudes in the US on the importance of vaccines have endured some erosion over the past 20 years (though they are still high). A 2019 Gallup survey found that 84% of people believe it is extremely important that parents get their children vaccinated, down from 94% who said the same in 2001. Similarly, a 2018 Research America/Zogby Analytics national survey found that 70% of people in the US said they believe vaccines are very important to the health of our society, down from 80% who said the same in 2008.
- The decline in willingness to get the C19 vaccine might be a result of who people believe are driving decisions on the vaccine itself. A 2016 Pew Research Center survey in the US found that 73% of people believed that medical scientists should have a major role in making decisions about policy issues related to childhood vaccines. Comparatively, just 25% felt that elected officials should have a major role in those decisions. A study published in JAMA Network Open based on a convenience sample collected in July 2020 found that the probability of choosing a C19 vaccine was higher when recommended by the Centers for Disease Control and Prevention or the World Health Organization than by President Trump or former Vice President Biden.1
- Many people in the US are concerned about the expedited development and trial process. The Kaiser Family Foundation/The Undefeated Survey on Race and Health conducted in September found that 43% of people are not confident that the C19 vaccine will have been properly tested for safety and effectiveness when one becomes available. And despite our desire to return to normalcy, a survey from Pew Research Center in September found that 78% of people in the US are more concerned that the approval of a C19 vaccine will move too fast, compared with 20% who are more concerned that the approval will move too slow. The same survey found that 77% of people believe it is likely that a vaccine will be used before we fully understand whether it is safe and effective.
- Black individuals in the US, who have indicated from the early days of the pandemic that they are much less likely to be willing to get the vaccine than White individuals in the US, are highly skeptical about the development of the vaccine. The Kaiser Family Foundation/The Undefeated survey found that 33% of Black individuals are confident that the development of a C19 vaccine is taking the needs of Black people into account, compared with 65% who are not confident.
- The decline in willingness to take the vaccine has not been more significant for voters of one party or another. As the Pew Research Center data show, in May, 79% of Democrats and 65% of Republicans said they would get the vaccine. By September, those numbers had dropped to 58% of Democrats and 44% of Republicans, a 21-point drop among voters of both parties.
- People in the US are ready to move on from the C19 pandemic, but when it comes to a vaccine, many have a wait-and-see attitude. An October NBC News/Wall Street Journal survey found that just 20% of people in the US say they will get the vaccine as soon as they can, while another 50% plan to wait until the vaccine has been available for a while to see if there are major problems or adverse effects.
- The mumps vaccine was the fastest vaccine to be developed, taking 4 years. All signs point to the development of the C19 vaccine shattering that record. The breakneck pace of development is a testament to our innovative medical system and the research and development efforts by pharmaceutical companies and public health agencies. But as we move toward having an approved C19 vaccine, it is important to understand that for many, it will take time to feel comfortable and confident in getting the vaccine. While the politicization of the vaccine is to blame for some of that delay, the increased reluctance of people in the US to get a C19 vaccine runs much deeper than politics.
4. FDA approves first fully at-home coronavirus diagnostic test kit
- The US FDA granted Emergency Use Authorization to the first fully at-home coronavirus (SARS-CoV-2) diagnostic test kit. The Lucira C19 All-In-One Test Kit must be prescribed by a healthcare provider, but it can be performed by individuals at home. The manufacturer recommends that children under 14 years old should have the test performed by a healthcare provider in order to maximize the chances of obtaining a valid result.
- The kit comes with a nasal swab, a test tube with detection reagents, and a small test machine. Once the used nasal swab is swirled around the test tube for the requisite amount of time, the user inserts the tube into the machine, which will automatically process the sample and provide visual indication of the results. The test kit will light up as positive, negative, or inconclusive results in around 30 minutes.
Source: Johns Hopkins Coronavirus Update (11/18)
E. Improved & Potential Treatments
1. St. Jude scientists identify possible C19 treatment
- The C19 pandemic continues to cause significant illness and death while treatment options remain limited. St. Jude Children’s Research Hospital scientists have discovered a potential strategy to prevent life-threatening inflammation, lung damage and organ failure in patients with C19. The research appeared online in the journal Cell.
- The scientists identified the drugs after discovering that the hyperinflammatory immune response associated with C19 leads to tissue damage and multi-organ failure in mice by triggering inflammatory cell death pathways. The researchers detailed how the inflammatory cell death signaling pathway worked, which led to potential therapies to disrupt the process.
- “Understanding the pathways and mechanism driving this inflammation is critical to develop effective treatment strategies,” said corresponding author Thirumala-Devi Kanneganti, Ph.D., vice chair of the St. Jude Department of Immunology. “This research provides that understanding. We also identified the specific cytokines that activate inflammatory cell death pathways and have considerable potential for treatment of C19 and other highly fatal diseases, including sepsis.”
C19, cytokines, and inflammatory cell death
- C19 is marked by increased blood levels of multiple cytokines. These small proteins are secreted primarily by immune cells to ensure a rapid response to restrict the virus. Some cytokines also trigger inflammation.
- The phrase cytokine storm has been used to describe the dramatically elevated cytokine levels in the blood and other immune changes that have also been observed in C19, sepsis and inflammatory disorders such as hemophagocytic lymphohistiocytosis (HLH). But the specific pathways that initiate the cytokine storm and the subsequent inflammation, lung damage and organ failure in C19 and the other disorders was unclear. The cellular and molecular mechanisms that comprehensively define cytokine storm was also lacking.
- Kanneganti’s team focused on a select set of the most elevated cytokines in C19 patients. The scientists showed that no single cytokine induced cell death in innate immune cells.
- The St. Jude investigators then tried 28 cytokine combinations and found just one duo that, working together, induced a form of inflammatory cell death previously described by Kanneganti as PANoptosis. The cytokines are tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. PANoptosis is a unique type of cell death that features coordination of three different cell death pathways–pyroptosis, apoptosis and necroptosis. PANoptosis fuels inflammation through cell death, resulting in the release of more cytokines and inflammatory molecules.
- The investigators showed that blocking individual cell death pathways was ineffective in stopping cell death caused by TNF-alpha and IFN-gamma. A closer look at proteins that make up the pathways identified several, including caspase-8 and STAT1, that were essential for PANoptosis in response to these cytokines. Deleting those proteins blocked PANoptosis in innate immune cells called macrophages.
Potential for repurposing TNF-alpha and IFN-gamma blockers to treat C19
- Because TNF-alpha and IFN-gamma are produced during C19 and cause inflammatory cell death, the investigators questioned whether these cytokines were responsible for the clinical manifestations and deadly effects of the disease. They found that the TNF-alpha and IFN-gamma combination triggered tissue damage and inflammation that mirror the symptoms of C19 along with rapid death.
- Neutralizing antibodies against TNF-alpha and IFN-gamma are currently used to treat inflammatory diseases in the clinic. The investigators found that treatment with these antibodies protected mice from death associated with SARS-CoV-2 infection, sepsis, HLH and cytokine shock.
- “The findings link inflammatory cell death induced by TNF-alpha and IFN-gamma to C19,” Kanneganti said. “The results also suggest that therapies that target this cytokine combination are candidates for rapid clinical trials for treatment of not only C19, but several other often fatal disorders associated with cytokine storm.”
- Added co-first author Rajendra Karki, Ph.D., a scientist in the Kanneganti laboratory: “We were excited to connect these dots to understand how TNF-alpha and IFN-gamma trigger PANoptosis.” Co-first author Bhesh Raj Sharma, Ph.D., a scientist in the Kanneganti laboratory, added: “Indeed, understanding how PANoptosis contributes to disease and mortality is critical for identifying therapies.”
Redefining cytokine storm
- Based on this fundamental research, Kanneganti and her colleagues have proposed a definition of cytokine storm that puts the cytokine-mediated inflammatory cell death via PANoptosis at the center of the process. The researchers noted that PANoptosis results in the release of more cytokines and inflammatory molecules, which intensifies systemic inflammation.
- “We have solved a major piece of the cytokine storm mystery by characterizing critical factors responsible for initiating this process, and thereby identifying a unique combination therapy using existing drugs that can be applied in the clinic to save lives,” Kanneganti said.
2. Researchers identify 3 drugs as possible therapeutics for C19
- Researchers at the University of Tennessee Health Science Center working with colleagues at the University of New Mexico have identified three drugs, already approved for other uses in humans, as possible therapeutics for C19.
- Based on virtual and in vitro antiviral screening that began in the earlier months of the C19 pandemic, the researchers led at UTHSC by Colleen Jonsson, PhD, identified zuclopenthixol, nebivolol, and amodiaquine as promising therapeutics for the virus in its early stages.
- Dr. Jonsson is a professor and the Endowed Van Vleet Chair of Excellence in Virology in the College of Medicine at UTHSC. She also directs the UTHSC Regional Biocontainment Laboratory (RBL), where this research was conducted. The university’s RBL is one of roughly a dozen federally funded labs authorized to safely study contagious pathogens.
- In a paper published in ACS Pharmacology & Translational Science, the researchers propose the drugs as possible candidates for testing in future clinical trials to improve immune response to the virus. Amodiaquine is an older antimalarial, zuclopenthixol is an antipsychotic, and nebivolol is a blood pressure medication.
- “Particularly in the context of this pandemic, there is a stringent need for high-quality studies that can provide critical knowledge concerning the C19 disease and reliable treatment proposals,” the paper states. “With these caveats in mind, we conceived a computational workflow that included independent in vitro validation, followed by assessing emerging candidates in the context of available clinical pharmacology data with the aim of proposing suitable candidates for clinical studies for early stage (incubation and symptomatic phases) patients infected by the coronavirus (SARS-CoV-2).”
- “Given the need for improved efficacy and safety, we propose zuclopenthixol, nebivolol, and amodiaquine as potential candidates for clinical trials against the early phase of the SARS-CoV-2 infection,” the researchers wrote.
- Comparing the drugs to hydroxychloroquine, the anti-malarial drug most-frequently studied in clinical trials for use as a C19 therapeutic, the researchers examined 4,000 approved drugs and found these three to act similarly to the hydroxychloroquine, and in some cases, more safely. The research indicates they may also improve efficacy when combined in lower doses with remdesivir, an anti-viral given an emergency use authorization by the United States Food and Drug Administration as a therapeutic for C19.
- “Think of it as a whack-a-mole game,” said Tudor Oprea, MD, PhD, professor of Medicine and Pharmaceutical Sciences, chief of the UNM Division of Translational Informatics, and corresponding author on the paper. “Instead of having one hammer, you have two hammers, which is more effective. We’re trying to give the scientific community two hammers, instead of one.”
- Dr. Jonsson added, “This is a very exciting discovery and we are following up on the potential use of zuclopenthixol, nebivolol, and amodiaquine in additional research studies.”
3. Doctors Apply C19 Lessons Learned as U.S. Cases Surge
- When a man in his 40s with C19 and low oxygen saturation arrived at the Boston hospital where Brittany Bankhead-Kendall treated patients in April, he was quickly put on a ventilator, a standard first response at many American hospitals at the time.
- She relied on WhatsApp messages and video calls from doctors overseas, who were also using trial and error to treat a spreading virus few knew much about. Incoming patients at her hospital were randomly assigned to antiviral and other drug trials to see what might stem the disease. “We were really flying blind,” she said.
- In West Texas, where Dr. Bankhead-Kendall took a new job at Texas Tech University Health Sciences Center, the conditions of her C19 patients seven months later are similar to what she had seen back in Boston, yet she treats them differently. When a woman in her mid-40s showed low blood-oxygen levels, Dr. Bankhead-Kendall gave her high-flow oxygen therapy rather than putting her on a ventilator, avoiding the invasive risks of ventilation.
- The two patients spent a similar amount of time in intensive-care units, but the woman in Texas was able to avoid sedation and pain medication, with less pressure on her lungs from the treatment. “We’ve got better data now,” Dr. Bankhead-Kendall said. Memories of work earlier in the year, when she feared for her health during 12- to-14-hour shifts and rewrote her will, are fresh.
- Doctors who have been treating coronavirus patients from the pandemic’s earliest days in the U.S. said they are now better equipped to face a new rise in hospitalizations, with evidence on drugs that work to combat C19 symptoms, research on treatments, and their own patient experiences through the months. The virus’s resurgence across the country is testing whether what they have learned so far will lead to shorter hospital stays and fewer deaths.
- Several doctors said they now think of C19 as a two-phase disease. First they aim to combat the virus itself with antiviral drugs, and then address the cascade of problems caused by the usually outsize immune response. The doctors also said they were learning how to tailor treatments for each patient.
- “We’ve stopped throwing the kitchen sink at everybody,” said Roger Shapiro, an associate professor of immunology and infectious diseases at Harvard T.H. Chan School of Public Health who has treated coronavirus patients throughout the pandemic.
- He helped craft C19 response guidelines at Beth Israel Deaconess Medical Center in Boston in the early days of the pandemic, when evidence-based treatment strategies didn’t yet exist.
- Early treatment protocols at many hospitals included giving patients the antimalaria drug hydroxychloroquine, which was later found not to be beneficial, Dr. Shapiro said. Other steps included using anticoagulants to help patients avoid blood clots.
- Doctors are now informed by peer-reviewed papers from around the world, clinical trials and the Food and Drug Administration’s emergency clearance of some treatments. Promising treatments for hospitalized patients include the antiviral remdesivir and convalescent plasma. Steroids such as dexamethasone have been shown in testing to be effective at tamping down the immune-system overdrive.
- The number of people hospitalized with C19 in the U.S. and its territories reached a record high of 73,014 on Monday. With the virus spreading in swaths of the U.S., including less-populated areas with fewer and more remote hospitals, some doctors fear emergency rooms and intensive-care facilities will soon become overwhelmed again.
- This summer, as the number of C19 cases rose in Sunbelt states, Jeffrey Bander at Mount Sinai Health System in New York fielded calls from colleagues in Arizona. The cardiologist helped treat patients during New York’s first coronavirus surge in March and April, and he has since published research on plasma therapy for C19 and the virus’s impact on the heart. “If they come in a trickle it’s easier,” he said of the ability to treat patients. “If they come in waves it’s harder.”
- To get a better sense of whether and how emerging treatments are working, public-health officials, hospitals and doctors are monitoring how much patient hospital stays are shortening as treatment options expand.
- A crucial difference in hospital treatment has stemmed from a better understanding of how to approach respiratory problems caused by the virus. Instead of rushing to put patients with low oxygen saturation on ventilators, which brings its own risks, doctors now know that people with low oxygen levels can remain that way longer than previously thought, Dr. Bankhead-Kendall said. For the most critically ill who do require ventilation, hospitals are expanding the use of technology to monitor those patients.
- Doctors said that much remains unknown and that treatments continue to evolve. Researchers are still learning about the systemwide effects of C19, including blood clotting, fatigue, cognitive issues and kidney damage. The disease is still proving to take a harsh toll on some previously healthy people who become infected, and comorbidities common in many Americans including diabetes and asthma are complicating outcomes.
- Ben Daxon, a critical-care physician at Mayo Clinic in Rochester, Minn., arrived in New York to volunteer in April with almost no experience caring for C19 patients.
- During his first shift in New York, when protective gear was scarce, he donned a scuba mask with a viral filter held in place by a part made on a 3-D printer.
- Doctors in New York at the time debated when to try untested therapies, he said. Patients might benefit, but they might also be harmed. “I was in the middle,” Dr. Daxon said. He was surprised to find one patient on an uncommon mode of breathing support known as airway pressure release ventilation. Existing evidence suggests some benefit from it, but there isn’t a lot of evidence, said Dr. Daxon, who found that the doctors in New York were managing the patient’s breathing well.
- One evening, as the patient struggled to breathe, Dr. Daxon gave him paper to write on. He scrawled the word “scared.” The physician sat with him, telling him stories. “The air is good now,” wrote the patient.
- Dr. Daxon returned after a week to Minnesota, one of the Midwestern states now seeing hospitalizations rising. He said he would like to see the ventilation mode studied further, but he is now focused on well-researched therapies. Studies have shown, for example, the importance of carefully managing ventilator settings. “If we do those things well, then we’re going to do well by our patients,” he said.
4. Promising results from combination therapy against C19
- Researchers at Karolinska Institutet in Sweden report promising results from an in vitro combination therapy against C19. In a study published in EMBO Molecular Medicine, the researchers show that a combination of remdesivir, an approved drug against C19, and hrsACE2, a medicine currently in phase II trials for C19 treatment, reduced the viral load of SARS-CoV-2 and inhibited viral replication in cell cultures and organoids.
- Remdesivir, the only approved drug against C19 disease, works by inhibiting an enzyme that prevents the virus from multiplying. In high doses, however, it can cause damage to the liver and the lungs.
- Human recombinant soluble ACE2 (hrsACE2) is a genetically modified variant of the cell membrane protein angiotensin converting enzyme 2 (ACE2) that the coronavirus uses to enter our cells. Previous laboratory studies have shown that hrsACE2 lures the coronavirus to attach itself to the enzyme copy, hrsACE2, instead of to the actual cells, thereby reducing the viral load in cells.
- In this study, the researchers tested combining remdesivir and hrsACE2 in cell cultures from monkeys, liver spheroids and 3D kidney replicas, so-called organoids grown from human stem cells.
- By combining these two substances, the researchers were able to achieve a dual effect: reduced viral load and reduced viral proliferation to nearby cells. In addition, they achieved this effect with comparably low doses of each substance, which lowered their toxicity and made them safer to use.
- “By targeting different aspects of the viral cycle simultaneously, we may be able to increase the effectiveness of the treatment while reducing the risk for potential side-effects,” says Ali Mirazimi, corresponding author and adjunct professor in the Department of Laboratory Medicine, Karolinska Institutet. “Combination therapy is a model that has been used successfully in HIV therapeutics. So far, we have only tested our combination therapy in cell cultures and engineered tissues, but we hope that it can pave the way for clinical trials.”
- HrsACE2 is currently being evaluated in a double-blinded, placebo-controlled phase II trial involving 200 people with severe C19.
F. Concerns & Unknowns
1. ‘People are going to die’: Hospitals in half the states are facing a massive staffing shortage as C19 surges
- Hospitals in at least 25 states are critically short of nurses, doctors, and other staff as coronavirus cases surge across the United States, according to the industry’s trade association and a tally conducted by STAT. The situation has gotten so bad that in some places, severely ill patients have been transferred hundreds of miles for an available bed — from Texas to Arizona, and from central Missouri to Iowa.
- Many of these hospitals spent months building up stockpiles of medical equipment and protective gear in response to C19, but the supplies are of little use without adequate staffing.
- “Care is about more than a room with a hospital bed. It’s about medical professionals taking care of patients,” said John Henderson, chief executive of the Texas Organization of Rural & Community Hospitals (TORCH). “If you don’t have the staff to do that, people are going to die.”
- Staffing shortages are a serious concern in multiple regions. Intensive care unit nurses, who typically oversee no more than two patients at a time, are now being pushed to care for six to eight patients to make up for the shortfall in parts of Texas, said Robert Hancock, president of the Texas College of Emergency Physicians. In Ohio, some 20% of the 240 hospitals tied to the Ohio Hospital Association are reporting staffing shortages, according to spokesperson John Palmer.
- The American Hospital Association’s vice president of quality and patient safety, Nancy Foster, said she’s heard from two dozen hospital leaders over the past two weeks, warning her of staffing shortages in states including Texas, North and South Dakota, Minnesota, Wisconsin, and Illinois. Health care providers in Kansas, Oklahoma, Arkansas, Ohio, Missouri, Michigan, and Utah said they’re facing the same problem, as do local reports from New Mexico, Nebraska, Colorado, Wyoming, Tennessee, Georgia, Alabama, Indiana, Montana, California, Rhode Island, and South Carolina.
- The shortages are primarily caused by overwhelming numbers of patients as coronavirus spreads, combined with decreasing staff levels as nurses and doctors themselves fall sick or have to quarantine after being exposed to infected people. C19 is also prevalent in rural areas that have been struggling with a shortage of health professionals for years; hospitals in more remote regions don’t have equipment such as ventilators, and so must transfer severely ill patients to already-overwhelmed urban health care systems. The scale of the problem makes it harder to address: Systems designed to offset shortages by bringing in backup from other areas don’t work when so many states are affected simultaneously.
- States that sent doctors and nurses to New York at the beginning of the pandemic now have no one to turn to as hospitals across the country experience the same problem. “Early on, Texas was sending teams of caregivers to states like New York to help with their surge,” said Henderson. “You can’t do that when 48 states are going through a surge in the wrong direction and they all need help. Where do you pull from?”
- As the crisis proliferates, several health care systems are struggling to transfer urgent patients to hospitals with adequate support. Hospitals in Lubbock, Texas, had to send severe C19 patients to Arizona, said Henderson. A Missouri patient who urgently needed surgery to remove a mass in his brain was sent to a hospital in Iowa, said Alex Garza, head of the St. Louis regional pandemic task force and community health officer at SSM Health in St. Louis.
- “The mechanics of how you transport and accelerate care are broken at the moment,” said Henderson. Even major cities in Texas, such as Houston, Dallas, and Austin, are facing their own staff limitations, and so many rural hospitals in Texas are forced to try and treat patients that they would typically transfer out.
- C19 has so overwhelmed parts of Texas, including El Paso and Lubbock, that hospitals are running short of both beds and staff. “I treated a clinical patient in a recliner, because it was the only thing close to a bed we could find,” said Hancock, who works at hospitals in Oklahoma, Dallas-Fort Worth, and Amarillo, Texas, but declined to say where the incident happened. “We knew the patient was sick and had nowhere to put them. You look at what resources you’ve got and make it happen.”
- The lack of staff reflects the dramatic increase in patients. There has been an average of 157,318 new cases per day over the past week, according to the STAT C19 Tracker — 74% more than two weeks ago — and there simply aren’t enough ICU nurses, in particular, to meet the need. Hospitals currently have 2,000 ICU nurse jobs open on Trusted Health, a company that connects travel nurses, who hop from job to job around the country, with hospitals.
- The situation is exacerbated as staff get sick with coronavirus themselves, or else have to quarantine after exposure. The staffing need is so dire, hospital workers who have tested positive for C19 but are asymptomatic have been told to continue working in North Dakota.
- One rural hospital in Texas is struggling with 30% of staff nurses out of commission because of infection with or exposure to C19, said TORCH’s Henderson. At one point earlier this month, more than 1,000 staff from the Mayo Clinic were out of work because of C19, said Amy Williams, executive dean of Mayo Clinic Practice.
- “It could be caring for a family member who has Covid, it could be on quarantine because of being exposed in the community, or it could be because the staff member actually has Covid,” Williams said. More than 90% of possible exposures occurred in the community as transmission picked up, she said, not in the hospital.
- As health care systems compete for additional staff, salaries skyrocket. ICU nurses are a “hot commodity,” said Dan Weberg, a former emergency room nurse and head of clinical innovation at Trusted Health, and their fees are currently twice as much as pre-Covid rates, at around $5,000 to $6,000 per week.
- “This is how PPE was in the beginning of the pandemic. When you’re competing with everyone else in town, and state, and the country, that creates a market that’s not sustainable,” said SSM Health’s Garza.
- In response to the staffing shortage, several hospitals are postponing elective surgeries as many did in the spring at the start of the pandemic. This decision carries risks: “They call them elective but a lot are what I’d call urgent cases,” said Hancock, the Texas emergency physician. A surgeon recently had to cancel two intestinal surgeries for patients who were struggling to eat, said Kencee Graves, associate chief medical officer at University of Utah Health. Patients waiting for knee surgeries may well struggle to walk.
- But there are few alternatives for health care systems. “You can always add more beds. It’s much more difficult to add more workforce,” said Alan Morgan, chief executive of the National Rural Health Association. Some hospitals are turning to local dentists and Red Cross volunteers, and people with basic health experience to help with tasks that require less training, said the American Hospital Association’s Foster.
- The only other option is to ask existing staff to work more hours. University of Utah Health has been using additional ICU beds for months, which means nurses and providers are working extra shifts. “Our numbers keep increasing but they are tired. Our nurses feel like there’s no end in sight,” said Graves. “They get here, work 12 hour shifts in PPE, it’s just this churn of seeing critically ill patients. And then you go to your community and see peak numbers, and having people continue to go to bars and restaurants.”
- Trusted Health is trying to set a maximum of 60 hours per week in its nursing contracts. After working more than three 12-hour shifts in a row, error rates go up “exponentially,” said Weberg.
- What most worries hospital officials is that C19 has not yet reached its peak. “What I’m scared of, leading up to the holidays, is what’s going to happen immediately after Thanksgiving,” said Hancock. “Then everyone gets into a crisis situation and there’s nobody who can go help.”
- Their only hope is for demand to decrease by people reducing C19 transmission through quarantining and wearing masks, they said. “Many of us feel powerless because we feel people aren’t listening when we say don’t gather for Thanksgiving or Christmas,” said Graves. After months of dealing with the crisis, she worries that some nurses will be so burned out they’ll quit, making the staffing shortage even worse.
- Both hospitalizations and deaths are lagging indicators, meaning it takes a couple of weeks for newly diagnosed cases to translate into more ICU patients. “We’re in for a very rough Thanksgiving and Christmas,” said Henderson.
2. Diabetes, hypertension may increase risk of C19 brain complications
- Some patients with C19 are at higher risk of neurological complications like bleeding in the brain and stroke, according to a study being presented at the annual meeting of the Radiological Society of North America (RSNA). The researchers said these potentially life-threatening findings were more common in patients with hypertension and diabetes.
- The virus that causes C19 first attacks cells in the respiratory system, often leading to an inflammation of the lungs that puts people at risk of contracting pneumonia. But the virus’ impact has also been felt in other systems of the body.
- “C19’s effects extend far beyond the chest,” said study lead author Colbey W. Freeman, M.D., chief resident in the Department of Radiology at Penn Medicine in Philadelphia. “While complications in the brain are rare, they are an increasingly reported and potentially devastating consequence of C19 infection.”
- To learn more about the phenomenon, Dr. Freeman and colleagues in the Perelman School of Medicine at the University of Pennsylvania looked at C19 patients who underwent head CT and/or MRI in their health system from January to April 2020. Of the 1,357 patients with C19 admitted to the system in those four months, 81 had a brain scan performed. The most common reasons for the brain scans were altered mental state and focal neurologic deficits such as speech and vision problems.
- Out of 81 patients with brain scans, 18, or just over one in five, had findings that were considered emergency or critical, including strokes, brain bleeds and blocked blood vessels. At least half the patients had pre-existing histories of high blood pressure and/or type 2 diabetes. Three patients with emergent/critical findings died while admitted.
- “C19 is associated with neurologic manifestations, and hypertension and type 2 diabetes mellitus are common in individuals who develop these manifestations,” Dr. Freeman said. “These populations may be at higher risk for neurologic complications and should be monitored closely.”
- Two-thirds of the patients with critical results in the study were African American, suggesting that these patients also may require closer monitoring.
- The exact mechanisms for C19’s harmful neurological effects are not known and may involve multiple factors, although a popular theory holds that inflammation associated with the infection is the primary culprit. In the study, blood markers of inflammation were high in people with critical results.
- “When your body is in an inflammatory state, it produces all these molecules called cytokines to help recruit the immune system to perform its function,” Dr. Freeman said. “Unfortunately, if cytokines are overproduced, the immune response actually starts doing damage.”
- The study is ongoing, Dr. Freeman said, and the researchers will continue to publish findings as more data comes in. They are also investigating the incidence of neurologic complications in C19 patients on extracorporeal membrane oxygenation (ECMO), a pump system to circulate and replenish oxygen in the blood. Several patients in the study needed ECMO during their time at the hospital.
- “In addition, we have plans to initiate a larger prospective study evaluating delayed, long-term, and chronic neurologic manifestations that may not be known in this early period in the pandemic,” Dr. Freeman said.
3. 80% of Young US Adults Report Significant Symptoms of Depression
- A new national survey, looking at how the C19 pandemic has impacted young US adults’ loneliness, reveals “significant depressive symptoms” in 80% of participants.
- Over 1,000 Americans aged 18-35 took part in the online anonymous questionnaire, which also asked the subjects to report on their anxiety and substance use.
- The analyzed findings, published in the peer-reviewed Journal of Psychoactive Drugs, show that “alarming” levels of loneliness are associated with significant mental health issues, as approximately 61% of respondents reporting moderate (45%) to severe (17%) anxiety.
- Meanwhile, 30% of interviewees disclosed harmful levels of drinking. And, although only 22% of the respondents reported using drugs, 38% of these reported severe drug use.
- Therefore, a response with mental health care provision is “imperative”, lead author Professor Viviana Horigian, from the University of Miami, states.
- “The convergence of the C19 pandemic and the loneliness and addiction epidemics in the US is here to stay,” she said.
- “These young adults are the future of our nation’s social fabric. They need to be given access to psychological help, coupled with the development and dissemination of brief online contact-based interventions that encourage healthy lifestyles.
- “Addressing mental health and substance use problems in young adults, both during and after the C19 pandemic, is an imperative.”
- And co-author Renae Schmidt adds: “As we invest in developing the sense of cohesion and social connectedness in these generations, we can address social and physical resiliency in our communities at large.
- “Students need sustaining online delivery of [relevant] coursework, increasing counseling services, and deploying outreach through telehealth services. For young adults not engaged in school, aggressive patient outreach by primary care physicians should be used to ensure screening and intervention, also via telehealth. Access to psychological help coupled with the development and dissemination of brief online contact-based interventions that encourage healthy lifestyles.”
- The online, 126-item, survey was carried out between April 22 and May 11. 1,008 participants took part, with the average age 28 and 86% being over 23.
- Each symptom (loneliness, anxiety, depression, alcohol use, drug use) was measured against internationally recognized scoring systems.
- To examine the associations between loneliness and the mental health conditions highlighted, the researchers used a model that looked at the direct effects of both loneliness and social connectedness on depression, anxiety, alcohol use, and drug use. They also looked at the indirect effects of loneliness and social connectedness on alcohol and drug use working through anxiety and depression. In addition, they characterized relationships in pre-COVID and post-COVID behaviors and psychosocial symptomatology.
- The results show that most participants who reported an increase in feelings of loneliness also indicated an increase in drinking (58%), drug use (56%), anxiety (76%), and depression (78%), and a decrease in feelings of connectedness (58%).
- Looking at general increases of mental health issues or substance use due to the pandemic, most issues were recorded by participants as rising, with their feelings of loneliness going up by 65%, lack of connectedness 53%, alcohol use 48%, drug use 44%, anxiety 62%, and depression 64%.
- Overall, an “alarming” 49% of respondents reported a great degree of loneliness.
- Most respondents (80%) reported drinking alcohol, with 30% revealing harmful and dependent levels of drinking. 19% of respondents reported binge drinking at least weekly and 44% reported binging at least monthly.
- The team hopes that the results will now be used to guide intervention efforts.
- “Social prescribing, which draws from and promotes usage of community resources, also shows promise of improving social and psychological wellbeing,” Professor Horigian adds.
- “This could be positioned to then encourage service to others, bringing social comfort and reward as a result of connecting with others in need.
- “These efforts, and others, can help to alleviate the problems of loneliness and its manifestations; yet it may take an integrated, multi-faceted, and concerted approach, rooted, and supported by mental health prevention and wellbeing promotion boosted by workforce development and research on intervention development, to readdress these trajectories.”
4. Major Measles Outbreaks Likely in Wake of C19 Pandemic
- Major measles outbreaks will likely occur during 2021 as an unexpected consequence of the C19 pandemic, according to a new academic article.
- The article, published in The Lancet, calls for urgent international action to prevent potentially devastating measles epidemics in the coming years.
- Lead author Professor Kim Mulholland, from the Murdoch Children’s Research Institute and Chair of the World Health Organization’s SAGE Working Group on measles and rubella vaccines, said that many children have missed out on measles vaccination this year, making future measles outbreaks inevitable.
- Professor Mulholland said while 2020 had been a quiet year for measles, in part due to travel reductions and national C19 control measures, the economic impacts would lead to many cases of childhood malnutrition.
- Malnutrition worsens the severity of measles, leading to poorer outcomes and more deaths, especially in low- and middle-income countries.
- “Children who die from measles are often malnourished, but acute measles pushes many surviving children into malnutrition,” he said. “Malnutrition, along with measles-associated immune suppression, leads to delayed mortality, while co-existing vitamin A deficiency can also lead to measles-associated blindness.
- “The coming months are likely to see increasing numbers of unimmunized children who are susceptible to measles. Many live in poor, remote communities where health systems are less resilient, and malnutrition and vitamin A deficiency are already increasing.”
- Professor Mulholland said the C19 pandemic had also had a profound effect on the control of vaccine-preventable diseases, with vaccination campaigns paused in the early months of 2020 and routine immunization services greatly disrupted in many countries.
- The WHO estimates that by the end of October 2020, delayed vaccination campaigns in 26 countries have led to 94 million children missing scheduled measles vaccine doses.
- “All these factors create the environment for severe measles outbreaks in 2021, accompanied by increased death rates and the serious consequences of measles that were common decades ago,” Professor Mulholland said. “This is despite the fact that we have a highly cost-effective way to prevent this disease through measles vaccination.”
- In 2019, before the pandemic started, the world experienced a dramatic return of measles, more than at any time in the past 20 years. WHO data indicates that there were 9.8 million measles cases and 207,000 deaths in 2019, 50% more than in 2016.
- Most measles deaths in 2019 have been in Africa, many associated with major outbreaks in Madagascar and the Democratic Republic of the Congo. Measles also re-emerged in South America, especially among Indigenous communities.
- “The inadequate vaccination that led to the 2019 measles outbreaks has still not been adequately addressed, and the situation is now exacerbated by service disruptions during the C19 pandemic so that high-risk, unimmunized children are clustered together in unreached communities,” Professor Mulholland said.
- The article has identified three pillars for immediate action:
- Help countries reach unimmunized children through catch-up immunization and campaigns
- Better prepare countries for expected outbreaks. WHO and partners have developed a Strategic Response Plan to assist with measles outbreak prevention, preparedness and response
- Maintain measles and rubella elimination targets. WHO’s new Measles Rubella Strategic Framework 2021−2030, aligned with the Immunization Agenda 2030 provides a plan for strengthening routine immunization and surveillance.
- Professor Mulholland said the solutions would help end the cycle of inadequate immunization and outbreaks of the past decade.
- “Without concerted efforts now, it is likely that the coming years will see an increase in measles and its severe, frequently fatal, complications,” he said.
5. Smoking worsens COVID-19 infection in the airways
- UCLA researchers using a model of airway tissue created from human stem cells have pinpointed how smoking cigarettes causes more severe infection by the coronavirus (SARS-CoV-2).
- The study, led by scientists at the Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research at UCLA and published in Cell Stem Cell, will help researchers better understand C19 risks for smokers and could inform the development of new therapeutic strategies to help reduce smokers’ chances of developing severe disease.
- Cigarette smoking is one of the most common causes of lung diseases, including lung cancer and chronic obstructive pulmonary disease, and most demographic studies of C19 patients have indicated that current smokers are at increased risk of severe infection and death. But the reasons why have not been entirely clear.
- To help understand how smoking affects SARS-CoV-2 infection on a cellular and molecular level, Dr. Brigitte Gomperts partnered with co-senior authors Vaithilingaraja Arumugaswami, an associate professor of molecular and medical pharmacology, and Kathrin Plath, a professor of biological chemistry, to recreate what happens when the airways of a current smoker are infected with SARS-CoV-2.
- The team utilized a platform known as an air-liquid interface culture, which is grown from human airway stem cells and closely replicates how the airways behave and function in humans. The airways, which carry air breathed in from the nose and mouth to the lungs, are the body’s first line of defense against airborne pathogens like viruses, bacteria and smoke.
- “Our model replicates the upper part of the airways, which is the first place the virus hits,” said Gomperts, a professor pulmonary medicine and member of the UCLA Jonsson Comprehensive Cancer Center. “This is the part that produces mucus to trap viruses, bacteria and toxins and contains cells with finger-like projections that beat that mucus up and out of the body.”
- The air-liquid interface cultures used in the study were grown from airway stem cells taken from the lungs of five young, healthy, nonsmoking tissue donors. To replicate the effects of smoking, the researchers exposed these airway cultures to cigarette smoke for three minutes per day over four days.
- “This type of model has been used to study lung diseases for over a decade and has been shown to mimic the changes in the airway that you would see in a person who currently smokes,” said Gomperts, who is also vice chair of research in pediatric hematology-oncology at the UCLA Children’s Discovery and Innovation Institute.
- Next, the group infected the cultures exposed to cigarette smoke — along with identical cultures that had not been exposed — with live SARS-CoV-2 virus and the two groups were compared. In the models exposed to smoke, the researchers saw between two and three times more infected cells.
- Digging further, the researchers determined that smoking resulted in more severe SARS-CoV-2 infection, at least in part, by blocking the activity of immune system messenger proteins called interferons. Interferons play a critical role in the body’s early immune response by triggering infected cells to produce proteins to attack the virus, summoning additional support from the immune system, and alerting uninfected cells to prepare to fight the virus. Cigarette smoke is known to reduce the interferon response in the airways.
- “If you think of the airways like the high walls that protect a castle, smoking cigarettes is like creating holes in these walls,” Gomperts said. “Smoking reduces the natural defenses and that allows the virus to set in.”
6. Overweight and obese younger people at greater risk for severe C19
- Being younger doesn’t protect against the dangers of C19 if you are overweight, according to a new study from UT Southwestern. While all adults who are overweight or obese are at greater risk for serious complications from the disease, the link is strongest for those age 50 and under.
- More than 42% of American adults are now obese, according to the CDC, and another 30% or so are overweight. Being overweight is defined as having a BMI (Body Mass Index) of 25-29, while those with a BMI of 30 or above are said to be obese.
- “If you’re young and obese, you’re still at high risk despite your age,” says Justin Grodin, M.D., senior author of the study published today in Circulation. (In the study, young is defined as age 50 or younger.)
- “In general, obese individuals are more likely to be hospitalized with C19 than normal weight individuals,” adds Nicholas Hendren, M.D., a UTSW chief cardiology fellow and first author of the study, which will be presented this week at the American Heart Association Scientific Sessions 2020 conference. “In the hospital, obese individuals are at higher risk for death or the need for mechanical ventilation to help them breathe, even if they are young.”
- The study’s findings should alert people who are overweight or obese – including those age 50 and under who may feel safe because of their age – that they are at greater risk from C19, says Grodin, assistant professor of internal medicine at UT Southwestern. Those in the most severe category of obesity, called Class III and defined as having a BMI of 40 or higher, should be considered high risk and may warrant prioritization for a C19 vaccine when it becomes available, Grodin adds. About 7% of the adult population falls into this category, according to the study.
- While the numbers don’t explain why obesity worsens outcomes for C19 patients, the study suggests several possibilities.
- First, obesity is associated with diseases that have been linked to worse outcomes for C19, such as hypertension and diabetes, according to the study. Secondly, the coronavirus (SARS-CoV-2) uses an enzyme called ACE2 to enter and infect human cells, and that enzyme is abundant in fat tissue. In addition, simply having more weight on the chest may make it harder for C19 patients to breathe, Grodin says.
- Also, negative effects tied to obesity may be especially apparent in younger patients because older C19 patients have so many other risk factors, he adds.
- The Circulation study analyzed data from more than 7,600 patients at 88 U.S. hospitals who were enrolled in the American Heart Association’s C19 Cardiovascular Disease Registry. James de Lemos, M.D., a UTSW professor of internal medicine, helped create the registry along with volunteers and AHA staff. The Circulation study team adjusted its findings of risk to take into account patients’ age, sex, race, and prior health problems.
- Looking at patients age 50 and under hospitalized for C19, the researchers found that the vast majority – 85% – were either overweight or obese. That compares with 54% of patients over age 70, making weight more of a risk marker for the younger group. Among patients 50 and under, those with severe obesity had a 36% greater risk of dying, compared with normal weight individuals, the study found. Overall, adult patients with severe obesity had a 26% higher risk of dying.
- Looking at all adult patients, the risk of being sick enough to require a ventilator rose in lock-step as weight increased from overweight to Class III obesity, according to the study. The risk of death also rose for those who had Class III obesity.
- “There is a greater proportion of obese people among those hospitalized for C19,” says Grodin, “and obese patients are at higher risk for complications.”
- In addition to greater risk for death and the need for ventilation, higher BMI also was linked to the need for kidney dialysis and the development of blood clots in deep veins and the lungs, according to the study.
- Other studies are underway to examine how various patient characteristics affect C19 risk, using the AHA’s COVID Registry, Grodin says.
G. The Road Back?
1. The COVID Feedback Loop
- In the first of a three-part series published by Bank of America, the bank’s global economist Ethan Harris looks at the theoretical feedback loops and trends linking the economy and coronavirus, focusing on how changes in consumer behavior resulting from the pandemic are impacting the economy.
- Having analyzed “many countries and multiple episodes” of covid around the world, Harris has seen a “simple cycle in countries that have not contained the virus” which is as follows:
- When COVID cases come down, both individual behavior and official rules are eased.
- With a multi-week lag that boosts the economy.
- However, it also allows the virus to come back.
- Finally rising cases lead to rising hospitalizations with about a two week lag and that in turn leads to higher fatalities with another two week lag.
- While at the top-level it really is that simple, and is why any partial future lockdowns are doomed to failure while a comprehensive, long-term lockdown would destroy the economy, BofA notes that on top of this cycle there are both positive and negative secular trends.
- On a positive note:
- Learning by doing: people figure out how to function in a COVID world, without severe shutdowns. This happens over time as regions experience the virus surge first hand.
- Super spreaders stop spreading: some people spread the virus a lot more than others, but they likely get the virus early on and are no longer spreaders.
- Treatments improve: death rates are much lower than they were in the spring, although they stopped dropping in early August.
- Protect the vulnerable: the virus is much more dangerous for old people and people with comorbidities. Better testing, tracing and quarantining of these groups has helped lower the death rate as well.
- At the same time, there are also some negative trends:
- Pandemic fatigue: people have become tired of the weird world of social distancing and have started to take more chances. They are also tired of shutdowns and are increasingly willing to accept worsening public health for a more open economy.
- Super spreader events: a related trend is the increased incidence of “super spreader” events, including in-person voting, election-related protests/celebrations and the approaching holiday season.
- Cold weather: in the summer, surging cases in the US were contained in part by moving activities outdoors. That option is not available in the Northern Hemisphere as temperatures continue to drop.
- Fading fiscal backstop: in the spring and summer, local authorities in the US and elsewhere could lean on a generous fiscal backstop, knowing that workers and businesses would be compensated for the COVID shock. That is now no longer the case, forcing very tough choices.
As Harris concludes, “all of this is playing out as we speak” as rising cases are beginning to alter behavior and that is beginning to impact the economy.
- But, due to the circular nature of the covid-economy relationship, there are already hints of slowing case growth, especially in Europe where new cases have peaked.
- Whether that continues depends heavily on what happens in the months ahead. Meanwhile the lags will play out, with slowing economic growth, which may drag the Fed out of hibernation and force it to stimulate monetarily if Congress remains gridlocked and unable or unwilling to pass another massive stimulus.
2. In a pandemic, migration away from dense cities more effective than closing borders
- Pandemics are fueled, in part, by dense populations in large cities where networks of buildings, crowded sidewalks, and public transportation force people into tighter conditions. This contrasts with conditions in rural areas, where there is more space available per person.
- According to common sense, being in less crowded areas during a pandemic is safer. But small town mayors want to keep people safe, too, and migration of people from cities to rural towns brings concerns. During the C19 pandemic, closing national borders and borders between states and regions has been prevalent. But does it really help?
- In a paper published in Chaos, by AIP Publishing, two researchers decided to put this hypothesis to the test and discover if confinement and travels bans are really effective ways to limit the spread of a pandemic disease. Specifically, they focused on the movement of people from larger cities to smaller ones and tested the results of this one-way migration.
- “Instead of taking mobility, or the lack of mobility, for granted, we decided to explore how an altered mobility would affect the spreading,” author Massimiliano Zanin said. “The real answer lies in the sign of the result. People always assume that closing borders is good. We found that it is almost always bad.”
- The model used by the authors is simplified, without many of the details that affect migration patterns and disease spread. But their focus on changes in population density indicates travel bans might be less effective than migration of people to less dense areas. The result was reduced spread of disease.
- Zanin and collaborator David Papo placed a hypothetical group of people in two locations and assumed their travel was in random movement patterns. They used SIR dynamics, which is common in epidemiological studies of disease movement. SIR stands for susceptible, infected, and recovered — classifications used to label groups in a simulation and track disease spread according to their interactions.
- They ran 10,000 iterations of the simulation to determine the resulting disease spread among people in two locations when migration is one way: from dense cities to less dense towns. They also studied the effect of “forced migration,” which moves healthy people out of dense cities at the onset of a pandemic.
- The results showed that while movement from big cities to small towns might be slightly less safe for the people in small towns, overall, for a global pandemic situation, this reduction in the density of highly populated areas is better for the majority of all people.
H. Back to School!?
1. Schools are not the main driver of C19 among kids
- Data from 191 countries shows no consistent link between reopening schools and increased rates of coronavirus infection, UNICEF reported in an analysis Thursday.
- In releasing its first comprehensive assessment of the pandemic’s effects on children, the United Nations agency said “there is strong evidence that, with basic safety measures in place, the net benefits of keeping schools open outweigh the costs of closing them.”
- “Schools are not a main driver of community transmission, and children are more likely to get the virus outside of school settings,” UNICEF said.
- The numbers: As of November, 572 million students — about 33 percent of all students — are being affected by 30 nationwide school closures, the report found. At their peak, school closures affected almost 90 percent of students around the world.
- Kids accounted for one in nine reported C19 infections worldwide, the report found.
- “While children can get sick and can spread the disease, this is just the tip of the pandemic iceberg,” said Henrietta Fore, UNICEF executive director. “Disruptions to key services and soaring poverty rates pose the biggest threat to children. The longer the crisis persists, the deeper its impact on children’s education, health, nutrition and well-being. The future of an entire generation is at risk.”
- Dropoff in services: From surveys across 140 countries, UNICEF estimates that 70 percent of mental health services for children and adolescents have been disrupted during the pandemic, with 65 percent of countries reporting a decrease in home visits by social workers in September compared to last year.
- Nearly one-third of the countries saw a drop of at least 10 percent in coverage for health services. That includes routine vaccinations, outpatient care for childhood infectious diseases and maternal health services.
- Across 135 countries, there has been a 40 percent decline in the coverage of nutrition services for women and children. The number of children hurt by multidimensional poverty — characterized by poor health, education and living standards, in addition to the traditional monetary standards — is estimated to have increased by 15 percent globally by mid-2020.
- Transmission findings: Child-to-child transmission of the coronavirus in schools was “uncommon and not the primary cause” of infections among children who caught the virus while attending school, according to a July assessment of 31 countries conducted by the European Centre for Disease Prevention and Control.
- Children were more likely to get infected outside of school settings. But the report also concluded that colleges and universities ”have played a role in community transmission in many countries.”
- What’s next: The group emphasized that the long-term health effects of becoming infected with the coronavirus as a child are still unclear. UNICEF is calling on governments to collect “more reliable, age-disaggregated data on infection, deaths and testing” to “better understand how the crisis impacts the most vulnerable children.”
- The agency is also calling on governments and partners to commit to ensuring access to essential services, making vaccines affordable and available to all kids, and supporting mental health for children, among other priorities.
- “As we all re-imagine the future and look ahead toward a post-pandemic world, children must come first,” Fore said.
2. Infected Kids Test Negative for C19
- Children in a Melbourne family developed a C19 immune response after chronic exposure to the coronavirus (SARS-CoV-2) from their parents, a new case report has found.
- The research, led by the Murdoch Children’s Research Institute (MCRI) and published in Nature Communications, showed that despite close contact with symptomatic infected parents, including one child sharing the parents’ bed, the children repeatedly tested negative for C19 and displayed no or minor symptoms.
- MCRI’s Dr Shidan Tosif said compared to adults, children with C19 usually have very mild or asymptomatic infection, but the underlying differences between children’s and adults’ immune responses to the virus remained unclear.
- The study looked at the immune profile in a Melbourne family of two parents with symptomatic C19 and their three primary school aged children. Before C19 took hold in Australia, the parents attended an interstate wedding without their children. After returning, they developed a cough, congested nose, fever and headache, and all family members were immediately recruited for the research study.
- Samples including blood, saliva, nose and throat swabs, stools and urine were collected from the family every 2-3 days.
- The researchers found SARS-CoV-2 specific antibodies in saliva of all family members and in detailed serology testing compared to healthy controls.
- MCRI’s Dr Melanie Neeland, who led the laboratory-based aspect of the report, said the team performed a careful analysis of the various subsets of immune cells and antibody types, showing that the children mounted an immune response that potentially contained the virus.
- “The youngest child, who showed no symptoms at all, had the strongest antibody response,” she said. “Despite the active immune cell response in all children, levels of cytokines, molecular messengers in the blood that can trigger an inflammatory reaction, remained low. This was consistent with their mild or no symptoms.”
- Dr Tosif said that while all family members fully recovered without requiring medical care, the team unfortunately could still not be certain how long, if at all, they would be protected from reinfection.
- MCRI Associate Professor Nigel Crawford said the study raised the possibility that despite chronic exposure, children’s immune systems allowed them to effectively stop the virus from replicating inside their cells.
- “Investigating immune responses to SARS-CoV-2 across all age groups is key to understanding disease susceptibility, severity differences, and vaccine candidates,” he said.
I. Innovation & Technology
1. New Mayo Clinic Voice Test Could Detect C19
- As Director of Cardiovascular Research at Mayo Clinic, Dr. Amir Lerman believes we are just beginning to understand what he calls a new era in medicine, one that artificial intelligence is making sense of.
- “The body is sending us a lot of signals that we’re not paying attention to,” Dr. Lerman said.
- “When we talk about voice, it’s not exactly what you and I can hear. The voice is a spectrum of a lot of frequencies,” he added.
- Case studies at Mayo Clinic have honed in on those frequencies, identifying certain vocal biomarkers to screen and detect patient health.
- From pulmonary hypertension, to dementia, depression and now C19.
- “We’re trying to use the same element of voice recognition to find if you can actually enhance your sensitivity to detection to individualized with COVID,” Dr. Lerman said.
- Tal Wenderow is President and CEO of Vocalis Health, an Israeli medtech start-up using AI algorithms to screen, manage and predict health care.
- “Our early data indicates that we have a signal in both symptomatic and asymptomatic patients,” Wenderow said.
- “Now you’re asked to count from 50 to 70. You get five seconds to clear your throat and get ready,” the voice demo said.
- “We transfer the voice from the voice domain to the image domain,” Wenderow explained.
- “Then, every voice that comes we translate to an image and we compare and we look at that correlation,” he added.
- Vocalis is currently working with employers in Asia and India as they look for ways to bring employees back safely.
- While it may sound like something from the space age, Vocalis says it comes at a time contactless care is critical. He also reminds us to think back on how many times we’ve said this before.
- “You don’t sound so good today. That’s what we’re trying to quantify and standardize and use that as a tool in the healthcare toolbox,” Wenderow said.
- Once this COVID screening is published in a peer review journal, Mayo hopes to begin using it, too.
- Over the next two years, Mayo will work with 400 patients in its pulmonary hypertension study to screen patient’s voices to better understand their health and the progression of the disease.
J. Projections & Our (Possible) Future
1. As U.S. Reaches 250,000 Deaths From C19, A Long Winter Is Coming
- The United States has surpassed yet another devastating milestone in the ongoing C19 pandemic: 250,000 Americans have now died from the disease.
- Coronavirus case numbers are exploding across the country at the beginning of what is shaping up to be a difficult winter of illness in America.
- “Unfortunately, we are entering what I think will be the worst stretch that we have experienced so far,” says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. “We’re seeing hot spots all across the country and new highs for the number of cases and hospitalizations.”
- In the past week, 36 states and one territory set records for daily new confirmed cases, and 12 states saw a day with the highest number of new deaths.
- The virus is currently hitting the middle of the country especially hard, with the highest number of new cases per capita in North and South Dakota, Minnesota, Wyoming, Wisconsin, Iowa, Nebraska and Montana. More than 76,000 people are currently hospitalized with the virus, according to the COVID Tracking Project.
- With cases spiking, more deaths will follow — but advances in medicine in recent months have improved the odds of surviving C19.
- The infection fatality rate is declining by about 30%, says Ali Mokdad, professor and epidemiologist with the Institute for Health Metrics and Evaluation, and the chief strategy officer for Population Health at the University of Washington.
- That rate measures the fatality of those who are infected, not only those who are diagnosed, by using antibody testing data to understand the prevalence of the virus at a large scale.
- And the infection fatality rate is falling in all age groups, including among the elderly. Doctors and nurses now have more experience dealing with C19 and anticipating its complications, and there have been advances in treatment and triage, Mokdad says.
- Unfortunately, that decline in the infection fatality rate comes as winter arrives, and more hospitalizations and deaths are expected. “The virus loves the cold,” Mokdad says, and people are also moving more of their socializing indoors as temperatures drop.
- Now more infections are happening among family and friends in home settings. “These are the people you trust the most — you feel like they’re not going to hurt you. And we see a lot of people not wearing a mask, not paying attention to safe distance,” Mokdad says. “The virus is more likely to stay in the air, and more people are likely to get infected indoors.”
- So where are we in the trajectory of the coronavirus?
- According to the Institute for Health Metrics and Evaluation’s latest model, by March 1, the U.S. may see nearly 439,000 total deaths from C19. But Mokdad and his colleagues have calculated two alternative scenarios, depending on the path the country takes. If governmental mandates to limit the spread are eased, the model predicts more deaths: perhaps 587,000 by March 1.
- But if everyone in the U.S. would wear masks every time they are in public, the number of anticipated casualties by that date drops to about 371,000.
Better methods for treatment
- While the coronavirus continues to ravage communities across the country, much has been learned about the virus and how to treat it. Doctors have learned to put patients on their stomachs – known as “proning” – to ease breathing difficulties. A steroid called dexamethasone has proved effective in treating seriously ill patients.
- “Every day that we learn about it, I think we’re treating it more effectively,” says Ryan Taube, an emergency medicine physician in Fort Lauderdale, Fla.
- “When patients were first coming in with any kind of respiratory symptoms, the recommendation was to have them be intubated and put on ventilators right at the get-go — and that was why there was such a fear of critical shortage of ICU beds and ventilators throughout the United States,” Taube said. “But I think we’re finding now that if we can try to keep them off of the ventilator with other means of therapies, that the patients do better.”
- Taube remembers that at the beginning of the pandemic, people who were very ill were staying at home – out of fear of going to the hospital.
- “We had patients with delayed heart attacks who stayed at their home for three days with chest pain thinking, ‘Oh, I would normally go get this checked out, but I’m not going to because of I’m scared of COVID,’ ” he said. “People breaking legs and limbs and things like that … scared to come in. Now I still see some of that, but it’s much, much less now.”
Vaccines on the horizon
- There has been good news this month, with Pfizer and Moderna each announcing that their experimental vaccines are highly effective in preventing disease – 95% in the case of Pfizer’s, and nearly 95% for Moderna’s.
- Dr. Anthony Fauci, the country’s foremost infectious disease expert, told NPR this week that hopefully by the end of the year, the two companies will have enough doses available for 20 million people. Health care workers are expected to receive the vaccine first.
- Mokdad calls the vaccine progress welcome, life-changing news — but he warns that any vaccines won’t come in time to help us this winter. “All that we have between now and March 1 is to wear a mask, watch our distance and wash our hands,” he says.
- Rivers concurs: “We are still going to be facing the holidays. We’re still going to be facing the winter months using the nonpharmaceutical interventions: the hand-washing, the masks, the closures that we have all been using to slow transmission for the last number of months.”
- And she notes that the first emergency use authorization for the vaccines will likely not apply to children as more data need to be collected to ensure any vaccines are safe and effective for them as well.
- “That means that schools and other institutions that serve primarily children may continue to need to follow the nonpharmaceutical interventions longer than older adult communities, for example, just because they will not be eligible for the vaccine right away,” she says.
The problems we’re facing now
- In many places with spiking cases, a shortage of health care workers is plaguing hospitals as the beds fill with C19 patients.
- Unlike early in the pandemic, cases aren’t clustered in a few big hot spots. The virus is everywhere.
- “We are in a worse place than we were even in the spring, because in the spring it was primarily New York City and New Jersey and Connecticut that were experiencing a strain on their health care systems,” Rivers says. “Right now we are seeing intense community transmission really all across the country. And that doesn’t leave a lot of wiggle room to make sure that we are able to deploy extra resources to those places.”
- Adding to the problem is pandemic fatigue: As the pandemic stretches on, people get tired of being vigilant about masks and social distancing and not gathering with others indoors. Many people have suffered economic pain from the virus and the restrictions that have followed, and are eager for their lives to return to normal.
- But the times are not normal.
- “Unfortunately, because we are in such a bad spot right now, it’s more important now than ever that we are vigilant about taking these protective measures,” Rivers says.
“Thanksgiving could be a superspreader event”
- Earlier case upticks in some places followed holiday weekends such as Memorial Day, Mother’s Day and July Fourth — and those all took place in warmer months.
- “Now we are concerned that potentially Thanksgiving could be a superspreader event,” Mokdad says. Not only is Thanksgiving generally celebrated by bringing family and friends together, often over long distances, but the main event is a meal. It’s hard to wear a mask while you’re eating.
- Public health officials are pleading with Americans not to celebrate Thanksgiving the way they usually do but instead use this occasion to invent new traditions. One idea is to drop off food contactlessly to another household and then share the meal over video.
- Video meeting platform Zoom announced it will lift the 40-minute limit for its free accounts on Thanksgiving, to make it easier for loved ones to gather at a distance.
- We can always hold Thanksgiving dinners on a future date, Mokdad said, “but we can never get our loved ones back if they die because we didn’t pay attention. So delay it, cancel it, isolate yourself. Make sure you behave extremely well before you join your family.”
2. Time to rethink predicting pandemic infection rates?
- During the first months of the C19 pandemic, Joseph Lee McCauley, a physics professor at the University of Houston, was watching the daily data for six countries and wondered if infections were really growing exponentially. By extracting the doubling times from the data, he became convinced they were.
- Doubling times and exponential growth go hand in hand, so it became clear to him that modeling based on past infections is impossible, because the rate changes unforeseeably from day to day due to social distancing and lockdown efforts. And the rate changes differ for each country based on the extent of their social distancing.
- In AIP Advances, from AIP Publishing, McCauley explains how he combined math in the form of Tchebychev’s inequality with a statistical ensemble to understand how macroscopic exponential growth with different daily rates arise from person-to-person disease infection.
- “Discretized ordinary chemical kinetic equations applied to infected, uninfected, and recovered parts of the population allowed me to organize the data, so I could separate the effects of social distancing and recoveries within daily infection rates,” McCauley said.
- Plateauing without peaking occurs if the recovery rate is too low, and the U.S., U.K., and Sweden fall into that category. Equations cannot be iterated to look into the future, because tomorrow’s rate is unknown until it unfolds.
- “Modelers tend to misapply the chemical kinetic equations as SIR (Susceptible, Infectious, or Recovered) or SEIR (Susceptible, Exposed, Infectious, or Recovered) models, because they are trying to generate future rates from past rates,” McCauley said. “But the past doesn’t allow you to use equations to predict the future in a pandemic, because social distancing changes the rates daily.”
- McCauley discovered he could make a forecast within five seconds via hand calculator that is as good as any computer model by simply using infection rates for today and yesterday.
- “Lockdowns and social distancing work,” said McCauley. “Compare Austria, Germany, Taiwan, Denmark, Finland, and several other countries that peaked in early April, with the U.S., U.K., Sweden, and others with no lockdown or half-hearted lockdowns — they’ve never even plateaued, much less peaked.”
- He stresses that forecasting cannot foresee peaking or even plateauing. Plateauing does not imply peaking, and if peaking occurs, there is nothing in the data to show when it will happen. It happens when the recovery rate is greater than the rate of new infections.
- “Social distancing and lockdowns reduce the infection rate but can’t cause peaking,” McCauley said. “Social distancing and recoveries are two separate terms within the daily kinetic rate equations.”
- The implication of this work is that research money could be better spent than on expensive epidemic modeling.
- “Politicians should know enough arithmetic to be given instruction on the implications,” McCauley said. “The effect of lockdowns and social distancing show up in the observed doubling times, and there is also a predicted doubling time based on two days, which serves as a good forecast of the future.”
1. Nearly 50,000 doctors and scientists, 630,000 citizens have signed global anti-lockdown proclamation
- Six weeks after it was first published, the Great Barrington Declaration — an international pronouncement meant to shine light on what it calls the “damaging physical and mental health impacts of the prevailing C19 policies” — has garnered nearly 700,000 signatures from scientists, academics, doctors and citizens worldwide, with more signatories being added each day as a fresh spate of lockdowns continues across Europe and parts of the United States.
- Regional and nationwide lockdowns have been an international feature of the C19 pandemic since almost the start of the year. At the outset of the pandemic, China instituted a severe lockdown of the Hubei province where the disease first originated. Global health officials were initially skeptical of the Chinese lockdown, which went against many major established pandemic guidelines.
- As the virus spread west into Europe and the United States, however, many heads of state began instituting their own lockdowns, with major countries such as Italy, Spain and the United Kingdom instituting broad stay-at-home orders, business shutdowns, school closures and other unprecedented policies in order to prevent a modeled catastrophic death toll.
- In the United States, President Trump declined to impose a national lockdown, but throughout March and April governors and local leaders across the country issued their own shutdown orders, some of them lasting for months at a time. The ongoing fall spike of positive C19 tests, meanwhile, has been followed by governors reimposing some of those measures after they were loosened over the summer.
Lockdown policies ‘yield more damage than the disease itself’
- Many public health officials, scientists, epidemiologists and other experts have been broadly supportive of these measures, with many arguing that they are necessary to avoid huge death rates, overwhelmed medical systems and destabilized societies.
- Yet the Great Barrington Declaration has, in the relatively brief period since its Oct. 4 publication, managed to snag several dozen thousand signatures from experts in those fields and others who believe the lockdowns are causing, in the words of the declaration, “irreparable damage.”
- “Current lockdown policies are producing devastating effects on short and long-term public health,” the document states. “The results … include lower childhood vaccination rates, worsening cardiovascular disease outcomes, fewer cancer screenings and deteriorating mental health — leading to greater excess mortality in years to come, with the working class and younger members of society carrying the heaviest burden.”
- The ideal policy, according to the signatories, is “to allow those who are at minimal risk of death to live their lives normally to build up immunity to the virus through natural infection, while better protecting those who are at highest risk.”
- “Those who are not vulnerable should immediately be allowed to resume life as normal,” the document continues, arguing that “schools and universities should be open for in-person teaching” and “extracurricular activities, such as sports, should be resumed.” Work should be in-person as well, it adds, while restaurants, storefronts, art exhibits and other cultural activities should be permitted to resume normal operations.
- In many areas throughout the world, that advice has gone largely ignored over the past month and a half. Yet multiple signatories to the document this week still stood by their endorsement of its aims.
- Boris Kotchoubey, a medical psychology professor at the Universiy of Tubingen who has affixed his signature to the proclamation, told Just the News: “I signed the Declaration … because I share the views formulated in it.”
- “Anti-Corona measures in all countries that I know (mostly, West Europe) are non-directed, imprecise and, therefore, yield more damage than the disease itself,” he said.
- “Actually, we know more or less where the infection is spread,” he continued.
- Big events like high level sport events, rock concerts etc.;
- Loud parties;
- Activities in closed rooms, particularly with screams or songs (worship);
- Public transportation, particularly in big cities;
- Last but not least, Invasion of the infection in retirement homes.
- “Efficient measures should be directed to the prevention of infection in THESE situations,” he wrote. “Instead, for example, the German government forbids theaters and restaurants, although there is not the slightest evidence that anybody has been infected in such places, because all of them had highly developed sanitary concepts (e.g., since May all seats in theaters are at least 2 meters from each other;
etc.; the same in restaurants).”
- Rodney Sturdivant, another signatory and the director of Baylor University’s Statistical Consulting Center, echoed those criticisms of lockdown policies.
- Epidemiological research “does not reflect what has been reported and cited as justifying many policy decisions,” he told Just the News. He described the Declaration as “a call to return to public health practice supported by data and science.”
- “An important public health principle is to not ignore the totality of public health with fixation on a single aspect,” he said. “The consequences of doing so is catastrophic. We are already seeing the impacts: mental health issues, missed cancer treatments, missed immunizations, hunger, drug overdose, domestic abuse, incredible harm to children … the list is tragically long and preventable.”
- “Continuing with current approaches will lead to far more harm than Covid will produce,” he said.
- Apart from the Declaration itself, a variety of other health officials have warned of the effect that lockdowns are having on non-virus related aspects of public health. Parents in the U.S. over the course of the lockdowns here have reported “behavioral issues that previously their children had not exhibited,” WebMD Chief Medical Officer John Whyte told Fox News this week. Whyte attributed those issues to the “loneliness, anxiety and anger” he said many children are experiencing during school closures and stay-at-home orders.
- The New York Times last week, meanwhile, reported on the deleterious mental health effects that lockdowns can have on younger individuals. Recent research, for instance, suggests that adolescents in the Netherlands over the course of that country’s shutdown experienced “a significant increase in severe anxiety and sleeping problems,” the paper reported.
- Experts have also warned that delayed medical treatments could contribute to significant spikes in mortality following the eventual conclusion of the pandemic, at which point medical conditions normally detected by early screenings may have progressed too far to be adequately treated.
- Still, comparatively few health officials and scientists have spoken out publicly against lockdown measures. One motivation for staying silent might be fear of reprisal: Those who have been critical of the prevailing consensus of COVID shutdowns have often been publicly villified as being insufficiently concerned about the pandemic. American surgical oncologist David Gorski, for instance, last month called the signatories of the Great Barrington Declaration “C19 deniers,” comparing them to “creationists, HIV/AIDS denialists, and climate science deniers.”
- That sort of negative publicity can have adverse professional effects, as Sturdivant found out after he signed the Declaration. He shared with Just the News an email he received from some colleagues with whom he was participating in a “large multi-institution grant proposal.” The colleagues said that the stances of both the foundation funding the project and the project’s program officer could jeopardize the initiative’s success due to Sturdivant’s participation in the Declaration.
- “At this time, given the quick deadline for this project, we think it would be best to pause collaboration in light of what we know about this funder and program officer,” they wrote to Sturdivant. “We hope there will be opportunities to collaborate in the future.”
- Sturdivant said he eventually resumed working with those colleagues, but he said fear of opposing viewpoints is “too typical in academia.”
- “Fear/panic due to misreporting of data and science are resulting in actions that mislead people into a false notion about non-scientific ‘solutions’ that do not work,” Sturdivant said. The Great Barrington Declaration, he added, “comes at a critical time in trying to rectify these issues.”
L. Practical Tips & Other Useful Information
1. How to Protect Your Family From C19 During the Holidays
- The holidays will look remarkably different this year due to C19. Months into the global pandemic, we continue to see how family gatherings are often responsible for spreading the virus, sometimes with fatal consequences.
- That doesn’t mean we have to skip the holidays completely—but it does mean making major adjustments to our traditions to protect vulnerable relatives.
- “You’ll need to get creative and have honest (and possibly uncomfortable) conversations with every member of your family about their individual safety needs and risk tolerances,” said Assoc. Prof. Emily Landon of the University of Chicago Medicine. “Once you’ve done that, you’ll want to develop plans, more plans and back up plans so you’re prepared and ready to make any last-minute adjustments if someone wakes up on Christmas morning with a sore throat.”
- According to Landon, an infectious diseases physician who has become one of the state’s leading authorities on the pandemic, there are no easy answers or clear-cut decisions. But she does have recommendations and considerations that can help ensure your pandemic holidays are as safe as possible.
How can I safely celebrate holidays this year?
- If you really want to safely celebrate the holidays, you’ll need to figure out how to avoid travel and large gatherings entirely while still weaving in traditions you know and love. Opt for a small gathering with those in your quarantine bubble.
- Maybe organize a family recipe swap so everyone has a chance to try making your aunt’s famous mashed potatoes. Consider dropping off favorite foods to older relatives. Try an asynchronous gathering on Zoom or weave in things like a family movie night where everyone watches a favorite holiday movie while chatting online. Get creative.
Why aren’t family gatherings automatically considered safe?
- It’s really clear that family gatherings often become super-spreader events.
- That’s because people mistakenly assume they’re safe with trusted relatives and then don’t wear masks or practice social distancing. Holiday gatherings often involve travel, which adds risk. Plus, you’re spending time around extended family you may not see regularly. So on a practical level, whatever risk each person took in the past 10 or 14 days is the risk they’re now sharing with everyone else at your family’s dinner table.
- Your grandpa doesn’t need to go to a bar to get C19 from a bar. He could get it from your cousin who went to a bar last week and is now unknowingly spreading the virus. Having all family members minimize additional activities in the weeks leading up to any gathering will decrease the risk of unknowingly carrying and spreading the virus to vulnerable family members.
What steps do I need to take before the holidays if I want to celebrate with family?
- If you’re planning to host a holiday gathering, there are 3 main things you need to do ahead of time to ensure it’s safe.
- Require every person who attends to quarantine, preferably for 14 days. That means they shouldn’t go to work or in-person school. They shouldn’t leave the house at all except for medical care. If they do need to leave their home while they quarantine, they need wear masks, practice distancing and make sure anyone they’re interacting with is wearing masks, too.
- After quarantining, don’t travel long distances. Depending on what the situation is—where someone is, where they’re going and how they’re getting there—the risk of travel can be really significant for some people.
- Make sure everyone who’s attending is following the same set of protocols. Trust and honesty are absolutely crucial here.
What precautions do I need to take if I’m hosting an in-person holiday celebration?
- If you’re going to be together without masks or social distance—and everyone hasn’t quarantined and limited their travel beforehand—then you’re putting everyone at risk. I
- f you’re not sure your brother is really going to quarantine the way he says he’s going to, you can take some additional precautions:
- Have really good ventilation and air flow in the house and spend time in the largest room you can as opposed to smaller, confined spaces.
- Crank up the heat, open the windows and put the best filter you can in your HVAC system.
- An even better option is to socialize and eat a holiday meal outside.
- Whether you’re inside or out, keep people as far apart as possible and do that as much possible.
- Wear masks whenever you can.
- Make sure everyone washes their hands before they eat and have some hand sanitizer at the table if you’re using shared serving utensils or holding hands for prayer.
- Most of all, remember: If you really want to be protecting Grandma, the best choice may be not inviting her at all.
Is it safest to skip large family gatherings and holiday travel altogether?
- If you’ve ever been looking for an excuse to get out of a family holiday, this is your year to take a step back. Think long and hard about what’s right for you and your loved ones. For many people that may mean creating new, smaller (and safer) traditions.
What’s the best way to travel safely this holiday?
- While it’s always an individual decision, traveling long distances for holidays is not a good idea when older and more vulnerable family members are involved in your plan. People often have incidental or unanticipated close contacts during travel, so the last thing you want is to have unplanned, high-risk contacts and then stay at your grandma’s house.
- If you’re going to travel:
- Short flights are better than long.
- Consider staying in a hotel instead of with family.
- Wear a face mask while you’re traveling and wear eye protection (preferably a face shield) if you’re on a plane or in an area where others aren’t wearing a mask.
- Quarantine for 7 to 14 days after you arrive at your destination.
What do I need to discuss with my family/holiday guests before we celebrate?
- If spending time with your family is important, decide what level of risk you’re willing to take and talk honestly about it with everyone. The biggest mistake is assuming everyone has the same definition of “careful” or that everyone does things the way you do.
- That leads to misunderstandings and puts people in situations where they feel like they have to bow to peer pressure even when they’re uncomfortable. Have candid discussions about each person’s requirements and what everyone’s expectations are.
- Default to the standards of the most cautious person in your group. If you can’t go that far, be OK with allowing more risk-adverse people to stay home to join by Zoom.
I’m going to get a C19 test before I see my relatives. Is that enough to ensure that I’m being safe?
- Unfortunately, a one-time test isn’t going to give you definitive answers about whether it’s safe to attend a holiday event without a mask and social distancing.
- Rapid tests miss a lot of COVID diagnoses, and a negative test today doesn’t mean you won’t develop COVID tomorrow from an exposure several days ago.
- The best time to get a COVID test is on days five to eight after an exposure. And even then, a negative test doesn’t mean you’re out of the woods.
- So you should continue to quarantine until 14 days have passed from your exposure. If you develop symptoms after you get a negative test result, you may still have COVID, and you should consider getting another.
2. The Coronavirus Is Airborne, so why Are We Still Scrubbing Surfaces?
- At Hong Kong’s deserted airport, cleaning crews constantly spray baggage trolleys, elevator buttons and check-in counters with antimicrobial solutions. In New York City, workers continually disinfect surfaces on buses and subways. In London, many pubs spent lots of money on intensive surface cleaning to reopen after lockdown — before closing again in November.
- All over the world, workers are soaping, wiping and fumigating surfaces with an urgent sense of purpose: to fight the coronavirus. But scientists increasingly say that there is little to no evidence that contaminated surfaces can spread the virus. In crowded indoor spaces like airports, they say, the virus that is exhaled by infected people and that lingers in the air is a much greater threat.
- Hand washing with soap and water for 20 seconds — or sanitizer in the absence of soap — is still encouraged to stop the virus’s spread. But scrubbing surfaces does little to mitigate the virus threat indoors, experts say, and health officials are being urged to focus instead on improving ventilation and filtration of indoor air.
- “In my opinion, a lot of time, energy and money is being wasted on surface disinfection and, more importantly, diverting attention and resources away from preventing airborne transmission,” said Dr. Kevin P. Fennelly, a respiratory infection specialist with the United States National Institutes of Health.
A false sense of security
- Some experts suggest that Hong Kong, a crowded city of 7.5 million residents and a long history of infectious disease outbreaks, is a case study for the kind of operatic surface cleaning that gives ordinary people a false sense of security about the coronavirus.
- The Hong Kong Airport Authority has used a phone-booth-like “full-body disinfection channel” to spritz airport staff members in quarantine areas. The booth — which the airport says is the first in the world and is being used in trials only on its staff — is part of an all-out effort to make the facility a “safe environment for all users.”
- Such displays can be comforting to the public because they seem to show that local officials are taking the fight to C19. But Shelly Miller, an expert on aerosols at the University of Colorado Boulder, said that the booth made no practical sense from an infection-control standpoint.
- Viruses are emitted through activities that spray respiratory droplets — talking, breathing, yelling, coughing, singing and sneezing. And disinfecting sprays are often made from toxic chemicals that can significantly affect indoor air quality and human health, Dr. Miller said.
- “I can’t understand why anyone would think that disinfecting a whole person would reduce the risk of transmitting virus,” she said.
- A range of respiratory ailments, including the common cold and influenza, are caused by germs that can spread from contaminated surfaces. So when the coronavirus outbreak emerged last winter in the Chinese mainland, it seemed logical to assume that these so-called fomites were a primary means for the pathogen to spread.
- Studies soon found that the virus seemed to survive on some surfaces, including plastic and steel, for up to three days. (Studies later showed that much of this is likely to be dead fragments of the virus that are not infectious.) The World Health Organization also emphasized surface transmission as a risk, and said that airborne spread was a concern only when health care workers were engaged in certain medical procedures that produce aerosols.
- But scientific evidence was growing that the virus could stay aloft for hours in tiny droplets in stagnant air, infecting people as they inhaled — particularly in crowded indoor spaces with poor ventilation.
- In July, an essay in The Lancet medical journal argued that some scientists had exaggerated the risk of coronavirus infection from surfaces without considering evidence from studies of its closely related cousins, including SARS-CoV, the driver of the 2002-03 SARS epidemic.
- “This is extremely strong evidence that at least for the original SARS virus, fomite transmission was very minor at most,” the essay’s author, the microbiologist Emanuel Goldman of Rutgers University, said in an email. “There is no reason to expect that the close relative SARS-CoV-2 would behave significantly different in this kind of experiment,” he added, referring to the new coronavirus.
- A few days after Dr. Goldman’s Lancet essay appeared, more than 200 scientists called on the W.H.O. to acknowledge that the coronavirus could spread by air in any indoor setting. Bowing to enormous public pressure over the issue, the agency acknowledged that indoor aerosol transmission could lead to outbreaks in poorly ventilated indoor places like restaurants, nightclubs, offices and places of worship.
- By October, the Centers for Disease Control and Prevention, which had maintained since May that surfaces are “not the primary way the virus spreads,” was saying that transmission of infectious respiratory droplets was the “principal mode” through which it does.
- But by then, paranoia about touching anything from handrails to grocery bags had taken off. And the instinct to scrub surfaces as a Covid precaution — “hygiene theater,” as The Atlantic magazine called it — was already deeply ingrained.
- “My tennis partner and I have abandoned shaking hands at the end of a match — but, since I’ve touched the tennis balls that he has touched, what’s the point?” Geoff Dyer wrote in a March essay for The New Yorker magazine that captured the germaphobic zeitgeist.
Don’t touch this
- From Nairobi to Milan to Seoul, cleaners in hazmat suits have been fumigating public areas despite W.H.O. warnings that the chemicals could do more harm than good.
- In Hong Kong, where 299 people died during the original SARS epidemic, elevator buttons are often covered in plastic that is cleaned multiple times a day. Crews in some office buildings and subways wipe escalator handrails with disinfected rags as commuters ascend. Cleaners have blasted public places with antimicrobial coatings and added a fleet of robots to clean surfaces in subway cars.
- Several Hong Kong-based scientists insist the deep cleaning can’t hurt, and supported the government’s strict social-distancing rules and its months long insistence on near-universal mask wearing.
- Procter & Gamble said sales of its personal cleansing products grew more than 30% in the quarter that ended in September, with double-digit growth in every region of the world, including more than 20% in greater China.
What about the air?
- Hong Kong’s C19 burden — more than 5,400 confirmed cases and 108 deaths — is relatively low for any city. Yet some experts say it has been slow to address the risks of indoor aerosol transmission.
- Early on, officials required Hong Kong restaurants to install dividers between tables — the same sort of flimsy, and essentially useless, protection used at the U.S. vice-presidential debate in October.
- But as the Hong Kong authorities have gradually eased restrictions on indoor gatherings, including allowing wedding parties of up to 50 people, there is a fear of potentially new outbreaks indoors.
- Some experts say they are especially concerned that coronavirus droplets could spread through air vents in offices, which are crowded because the city has not yet developed a robust culture of remote work.
- “People are removing masks for lunch or when they get back to their cubicle because they assume their cubicle is their private space,” said Yeung King-lun, a professor of chemical and biological engineering at the Hong Kong University of Science and Technology.
- “But remember: The air you’re breathing in is basically communal.”
3. CDC Urges People to Avoid Singing at Holiday Gatherings
- Americans who are hosting gatherings over the holiday season should encourage guests not to sing while inside and should shield their pets from interacting with guests from outside their household, according to guidance from the Centers for Disease Control.
- The recommendations were included in a list of guidelines by the agency to help stop the spread of coronavirus as a second wave has spread like wildfire across the US as the holiday season approaches.
- “Encourage guests to avoid singing or shouting, especially indoors. Keep music levels down so people don’t have to shout or speak loudly to be heard,” the CDC wrote in their considerations for hosting or attending a holiday gathering.
- “Treat pets as you would other human family members – do not let pets interact with people outside the household,” they added.
- A small number of cases across the globe have been reported where pets came down with the virus that causes C19 after having close contact with infected people, the CDC said.
- While the risk of animals spreading the virus is low, people should still take precautions, including isolating themselves from pets if they become sick.
- The CDC had previously suggested Americans who are hosting Thanksgiving dinner do so outside if possible.
- In addition to an outdoor meal, the CDC said hosts should limit the number of guests they invite, talk to guests before they arrive about how they plan to celebrate and to limit the number of people in food preparation areas.
4. A regular dose of nature may improve mental health during the C19 pandemic
- A study published in Ecological Applications suggests that nature around one’s home may help mitigate some of the negative mental health effects of the C19 pandemic.
- An online questionnaire survey completed by 3,000 adults in in Tokyo, Japan, quantified the link between five mental-health outcomes (depression, life satisfaction, subjective happiness, self-esteem, and loneliness) and two measures of nature experiences (frequency of greenspace use and green view through windows from home).
- More frequent greenspace use and the existence of green window views from the home were associated with increased levels of self-esteem, life satisfaction, and subjective happiness, as well as decreased levels of depression and loneliness.
- “Our results suggest that nearby nature can serve as a buffer in decreasing the adverse impacts of a very stressful event on humans,” said lead author Masashi Soga, PhD, of The University of Tokyo. “Protecting natural environments in urban areas is important not only for the conservation of biodiversity, but also for the protection of human health.”
M. Johns Hopkins COVID-19 Update
November 18, 2020
1. Cases & Trends
- The WHO COVID-19 Dashboard reports 55.06 million cases and 1.33 million deaths as of 5am EST on November 18.
- The US CDC reported 11.14 million total cases and 246,232 deaths. From the first case reported in the US on January 22, it took 96 days to reach 1 million cases. From there:
- 1 to 2 million- 44 days
- 2 to 3 million- 27 days
- 3 to 4 million- 15 days
- 4 to 5 million- 17 days
- 5 to 6 million- 22 days
- 6 to 7 million- 25 days
- 7 to 8 million- 21 days
- 8 to 9 million- 14 days
- 9 to 10 million- 10 days
- 10 to 11 million- 7 days
- The United States’ average daily incidence surpassed 150,000 new cases per day, just 11 days after first reporting more than 100,000 new cases in a single day. The US has reported more than 100,000 cases for 9 consecutive days and 12 of the last 13. Additionally, the US is reporting 1,214 deaths per day, the highest average since May 22. The US daily mortality has increased nearly 75% over the past month, and the US could surpass 250,000 cumulative deaths in the next 3 days.
- Two-thirds of all US states have reported more than 150,000 cumulative cases, and 20 have reported more than 200,000 cases:
- In order to capture the rapidly increasing daily incidence across the US, the COVID Exit Strategy website added yet another category to classify per capita daily incidence. The new category (light purple) designates states reporting more than 1,000 new cases per million population, which corresponds to 1 new case for every 1,000 residents every day. This category currently applies to 8 states in the north central portion of the country, ranging from the western part of the Midwest region, across the Plains, and into the Mountain region:
- Iowa (1,082 daily cases per million population),
- Minnesota (1,197), Montana (1,102),
- Nebraska (1,185),
- North Dakota (1,804),
- South Dakota (1,607),
- Wisconsin (1,186), and
- Wyoming (1,286).
- To put these states in context, all 8 are reporting higher per capita daily incidence than any country or territory on Earth. Notably, North Dakota’s daily incidence is 87% higher than the global leader, Montenegro (964).
- In terms of C19 mortality—which is trending upward as well, lagging several weeks behind the surge in incidence—a number of US states are reporting extremely concerning numbers. In total, 15 states are reporting more than 6 daily deaths per million population. Both North and South Dakota—18 and 17 daily deaths per million population, respectively—are reporting daily per capita mortality on par with the global leaders. Bosnia and Herzegovina, #1 in the world, is reporting 18.0 daily deaths per million, and #2 Czech Republic is currently reporting 16.47. The remaining 13 states would fall somewhere in the top 25 globally. Additionally, North Dakota has reported 12% of its cumulative C19 deaths over just the past 7 days, and South Dakota has reported 17% of its deaths over the same period.
- The COVID Exit Strategy also created a new category to account for the elevated test positivity in some of these states. The new category (also light purple) represents states with test positivity greater than 50%, more than 10 times the WHO’s 5% benchmark. Iowa (51.0%), South Dakota (56.3%), and Wyoming (74.3%) all fall into this category. Additionally, Idaho (40.1%) and Kansas (40.9%) fall into the next highest category (purple; 30-50%). Again, to put these states in context, all 5 would fall in the top 3 globally, if they were countries. Wyoming is reporting test positivity greater than the global leader, Mexico (66.5%). Iowa and South Dakota would fall between #1 and #2, ahead of Poland (47.0%), and the remaining states are reporting test positivity greater than #3 Bulgaria (38.2%)*.
- The Johns Hopkins CSSE dashboard reported 11.38 million US cases and 248,995 deaths as of 11:30am EST on November 18.
2. PFIZER VACCINE
- Pfizer Pharmaceuticals issued a new press release regarding the “final efficacy analysis” in the Phase 3 clinical trials for its candidate SARS-CoV-2 vaccine, developed in partnership with BioNTech. Pfizer reported that the vaccine is even more efficacious than previously estimated, at 95% overall and 94% among individuals over the age of 65.
- Of the 170 total C19 cases detected among the participants, 162 were in the placebo group. The press release also indicates that Pfizer and BioNTech intend to submit an Emergency Use Authorization application to the US FDA in the coming days and that they intend to submit safety and efficacy data for peer review “once analysis of the data is completed.”
- The trials will continue to monitor participants over 2 years for adverse events and to analyze longer-term immunity. The press release notes that Pfizer aims to produce 50 million doses of the vaccine by the end of 2020 (enough for a 2-dose regimen for 25 million people) and as many as 1.3 billion total doses by the end of next year.
3. US THANKSGIVING
- Ahead of the US Thanksgiving holiday, schools and students are preparing for travel and instruction plans. Some universities, such as the University of South Carolina, Emory University, and Syracuse University are planning to end in-person instruction prior to the break so that students do not have to return to campus between Thanksgiving and the traditional end of the term, which typically falls later in December. In a different approach, Boston University is asking students to refrain from traveling and remain on campus during the Thanksgiving holiday break. The State University of New York (SUNY) announced a new policy as part of its testing program that requires all on-campus students to have a negative SARS-CoV-2 test within 10 days of leaving campus, which will require the 64 SUNY colleges and universities to test approximately 140,000 students.
- Canada celebrates Thanksgiving the second Monday in October. A surge in C19 incidence following Canadian Thanksgiving is a cautionary reminder for the coming US Thanksgiving and other winter holidays. Canadians were advised to limit celebrations to household contacts only or host remote/virtual events, but the extent to which Canadians adhered to that guidance is not fully known. A month after the holiday, C19 incidence continues to rise in Canada, but the largest increase was observed 2 weeks following the holiday, which is consistent with the epidemiology.
- US Thanksgiving and other winter holidays typically involve travel across the country as individuals and families gather with family and friends. Historically, the Wednesday before and Sunday after Thanksgiving are among the busiest travel days of the year in the US. With C19’s severe impact on travel, and associated travel restrictions in many US states, air travel in the US has been “subdued” throughout 2020; however, airlines and airports are expecting to see higher travel volumes over the upcoming Thanksgiving weekend.
- Notably, airlines have added hundreds of flights to account for the increased volume, and airports are adding surge staffing for airport security to mitigate lines. The US CDC published guidance regarding Thanksgiving and other holiday activities, including hosting and attending gatherings and holiday travel. The principal travel guidance includes mask use, maintaining appropriate physical distancing (ie, 6-foot separation), and enhanced hand hygiene.
4. US STATE RESPONSES
- In recent days, a number of states have implemented new restrictions in an effort to slow transmission as the US enters the holiday season. California Governor Gavin Newsom announced that the state is “pulling the emergency brake” on reopening plans and reinstating a number of restrictions in severely affected parts of the state.
- In the most recent update, 40 counties moved to higher risk levels, including 28 that moved to the state’s highest tier (more than 7 new cases per day per 100,000 population or test positivity greater than 8%), which reportedly covers 94% of the state’s population. The highest tier requires that many non-essential businesses close, including bars and nightclubs, concert venues and convention centers, and theaters and cinemas. Businesses and facilities that are permitted to remain open must implement specific C19 risk mitigation measures.
- In Michigan, Governor Gretchen Whitmer announced similar changes, such as suspending in-person dining at restaurants, limiting gatherings to 2 households only, shifting to remote learning for schools, and cancelling non-professional sporting events. Michigan is emphasizing “social pods” as a way to mitigate transmission risk over the holidays, and the new measures are scheduled to last for 3 weeks.
- Ohio Governor Mike DeWine instituted a 3-week statewide curfew from 10pm to 6am with the aim of reducing risky interactions. The curfew includes exemptions for individuals transiting to or from work, food delivery or pickup, and other essential services.
- New Mexico Governor Michelle Lujan Grisham took these efforts one step further and “reset” the state’s C19 measures, essentially reinstituting the same restrictions as earlier in the epidemic. The state will “clos[e] in-person services for all non-essential activities” through the end of November, and essential businesses will be limited to 25% capacity. Additionally, residents “are instructed to stay at home” except for essential services, such as grocery shopping and health care. New Mexico will evaluate the restrictions on a county-by-county basis starting in December.
- Even states that previously resisted large-scale C19 restrictions are implementing statewide policies. In Iowa, Governor Kim Reynolds announced a statewide mask mandate, Iowa’s first to date. Notably, the mandate applies only indoors when individuals are within 6 feet of each other for at least 15 minutes, and it includes a number of notable exceptions, such as school classrooms and workspaces where 6-foot distancing can be maintained, presentations and musical or theatrical performances, and religious gatherings. North Dakota Governor Doug Burgum announced his state’s first mask mandate as well as several other measures. North Dakota’s mask mandate also includes an exception for religious services, but it applies indoors as well as outdoor public spaces where physical distancing cannot be maintained.
- Texas is nearing its record high in terms of daily incidence, and daily C19 mortality has been increasing steadily since early October. In the city of El Paso, one of Texas’ major C19 hotspots, C19 deaths are overwhelming the county medical examiner’s office.
- Over the past week, several inmates incarcerated at a local detention facility have been supporting the medical examiner’s office, which has been forced to use refrigerated “mobile morgues” to hold the bodies of C19 victims because there is not enough room at existing facilities. El Paso County currently has at least 8 mobile units and has requested more to handle the volume of C19 deaths. Media reports have not specified how the inmates are assisting the medical examiner, but photos show them transporting bodies to and from the mobile morgue units. The inmates are reportedly working 8-hour shifts for $2 per hour and are being quarantined from the rest of the incarcerated population. Reportedly, El Paso has requested resources from the Texas National Guard to provide support as well.
- The North Texas Food Bank (NTFB) has experienced growing demand for food assistance since the onset of the US C19 epidemic, illustrating the downstream economic impact of the pandemic. Last weekend, NTFB distributed approximately 7,000 turkeys and 600,000 pounds of food in Fair Park, a suburb of Dallas, which is enough to feed approximately 25,000 people in need. This is the fifth distribution in the Fair Park neighborhood since the onset of the pandemic, and it was the largest event in NTFB’s history. Images from the event show lines of cars stretching for what appears to be miles. A NTFB spokesperson said that 40% of those who received food were doing so for the first time, further illustrating the economic impact of C19, including on individuals and families who are normally financially stable. The NTFB has also been a part of other C19 initiatives, including a mobile food pantry and a “Food 4 Kids” program, in partnership with the Red Cross, the Salvation Army, Volunteer Now, and the Texas National Guard.
6. CHEROKEE NATION
- A report by STAT News describes how Cherokee Nation, one of 3 federally recognized Cherokee tribes, took an aggressive posture early in the US epidemic by implementing control measures, including mandatory mask use, and expanded testing. In contrast, the state of Oklahoma, where Cherokee Nation land is located, still has not implemented a mask mandate, despite reporting record incidence and mortality in recent days. Tribal leadership also prioritized acquiring PPE, even to the point of being able to donate excess supply to other Cherokee tribes and local non-Native health departments and health systems. Cherokee Nation is using federal C19 funding (under the CARES Act) to develop its own PPE production capacity, including N95 respirators, to ensure that it is not reliant on external distributors during future emergencies.
- Even before the onset of C19, Cherokee Nation prioritized establishing and maintaining healthcare capacity, and tribal public health officials emphasized that tribal leadership, including Principal Chief Chuck Hoskin Jr., have followed evidence-backed recommendations from the beginning in order to implement effective prevention and response measures. As we have covered previously, tribal nations across the US are among the many racial and ethnic minorities facing disproportionate effects of the C19 epidemic, but the Cherokee Nation has undertaken many important steps to slow transmission.
7. HOME TEST KIT EUA
- The US FDA granted Emergency Use Authorization to the first fully at-home coronavirus (SARS-CoV-2) diagnostic test kit. The Lucira C19 All-In-One Test Kit must be prescribed by a healthcare provider, but it can be performed by individuals at home. The manufacturer recommends that children under 14 years old should have the test performed by a healthcare provider in order to maximize the chances of obtaining a valid result.
- The kit comes with a nasal swab, a test tube with detection reagents, and a small test machine. Once the used nasal swab is swirled around the test tube for the requisite amount of time, the user inserts the tube into the machine, which will automatically process the sample and provide visual indication of the results. The test kit will light up as positive, negative, or inconclusive results in around 30 minutes.
8. MILITARY OUTBREAKS
- Two studies recently published in The New England Journal of Medicine evaluated case studies of US Marine Corps recruits and active duty US Navy personnel, respectively. The first study describes the public health program implemented by the US Marine Corps to enhance C19 security among new recruits. Recruits first underwent a 14-day home quarantine, followed by a second 14-day quarantine on a nearby college campus after reporting for duty, where additional measures were strictly enforced. Among new recruits, 2% were diagnosed with C19 during the on-site quarantine. These positive cases led to small case clusters but were generally contained to individuals platoons rather than spread widely among recruits.
- The second study describes an outbreak on the aircraft carrier USS Theodore Roosevelt. The outbreak onboard the USS Roosevelt resulted in 1,271 infections out of a crew of 4,779 and forced the ship to remain in port in Guam for more than 2 months. Personnel working in confined spaces, such as the engine room, were at higher risk of contracting the virus than personnel who predominantly worked outdoors, such as the flight deck. Researchers also reported a number of comorbid conditions among hospitalized patients, including “asthma, lung disease…, hypertension, and liver disease-related conditions.”
- Following this outbreak, the US Navy implemented new C19 protocols to mitigate the risk of future outbreaks onboard ships. Prior to getting underway, Sailors will be placed in “restriction of movement” (i.e., quarantine) for 14 days and then undergo PCR-based diagnostic testing. Additionally, the Navy is limiting activities during port visits to reduce the risk of introducing SARS-CoV-2 to ships while on deployment.