More young people are getting — and spreading — the coronavirus

Posted on July 10, 2020 by henrykotula • Posted in 2020 Election Issues, Asymptomatic Transmission, Chronic Care Management, Chronic Conditions, Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economy Reopening, Essential Businesses, Essential Workers, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, False Hope, False Narrative, Front Lines, Infection Control, Infection Control Plan, Infectious Virus, Intensive Care (ICU), Mortality, National Strategy, Pandemic, Personal Protective Equipment (PPE), Preexisting Conditions, Public Health, Public Safety, Quarantine, Social Distancing, Vulnerable Populations, Worker Protection, Worker Rights • Leave a comment

https://www.axios.com/coronavirus-young-people-spread-5a0cd9e0-1b25-4c42-9ef9-da9d9ebce367.html

More young people are being infected with the coronavirus, and even though they’re less likely to die from it, experts warn the virus’ spread among young adults may further fuel outbreaks across the United States.

Why it matters: Some people in their 20s and 30s face serious health complications from COVID-19, and a surge in cases among young people gives the virus a bigger foothold, increasing the risk of infection for more vulnerable people.

“We may see a pattern of younger people being affected initially, but then, in a number of weeks from now, we’re going to see a more deadly pandemic spreading to elderly people,” says Alison Galvani, an epidemiologist at Yale University.

People can transmit the virus without knowing they have it, and younger people, in particular, could be unknowingly spreading the disease.

A study in Italy, yet to be peer reviewed, found the probability of having symptoms increased with age and that among 20–39-year-olds only about 22% had a fever or respiratory symptoms (compared to about 35% of 60–79-year-olds).
About half of the clusters in a study in Japan were traced back to people ages 20–39 at karaoke bars, offices and restaurants — and 41% of them did not have symptoms at the time.
“Younger people are at lower risk for serious COVID outcomes but are disproportionately responsible for asymptomatic transmission,” says Galvani, who published a study earlier this week that found the majority of COVID-19 transmission is from silent carriers who are pre-symptomatic or asymptomatic.

By the numbers: From Arizona to Allegheny County, Pa., young people increasingly account for COVID-19 cases.

In the county of Los Angeles, nearly 50% of cases are now in people under 40 (compared to about 30% in April), per the LA Times.
In Harris County, Texas, home to Houston, 43% of the 40,000 cases are in people ages 20–39, as of yesterday.
In Florida, the median age of confirmed cases is hovering in the mid- to late-30s, compared to age 65 in March.

And the proportion of young people hospitalized for COVID-19 has also grown.

40% of hospitalizations for COVID-19 at the end of June were for people 18–49-years-old, compared to 26% at the end of March, according to the COVID-NET database of hospitalizations in 14 states that represent about 10% of the U.S. population.

Between the lines: Yes, young people are going to bars and parties — but also to work.

42% of people ages 18–39 said they had socialized without social distancing compared to 26% of people over 40, in a survey last month from the Democracy Fund + UCLA Nationscape.
64% of frontline workers (grocery store clerks, health care workers, delivery drivers and other essential workers) are under 50.
There’s a need for better education so that young people choose to take steps to prevent infection, says Lauren Ancel Meyers, a mathematical epidemiologist at UT Austin.
“But it also might come down to policies or regulations that get employers to ensure they are providing a safe workplace or resources to protect 20, 30 and other age groups that are working for them.”

Where it stands: Young people are still much less likely to be hospitalized or die from the virus than people older than 60.

Yes, but: They can and do get very sick with the disease — from dangerous blood clots in their lungs to inflammation of the heart, lungs and even brain.
And the long-term consequences are unknown.
The risk is higher for young people of color: For example, the majority of coronavirus hospitalizations among Latino/Hispanic Americans are in people ages 18–49, my Axios colleague Caitlin Owens reported.

“The death rate among the young is not zero, and it is particularly not zero for people who have at least one co-morbid condition. This is not a completely benign disease of the young.”

— Joshua Schiffer, of the Fred Hutchinson Cancer Center

What to watch: “If hospitals are strained now dealing with younger cases, they are going to be all the more taxed when the age distribution of infections shifts to the elderly,” Galvani says.

Already hospitals in some states are hitting their capacity of ICU beds, indicating more vulnerable people are being infected with the disease, and the death rate is climbing in hot spots.

The emerging long-term complications of Covid-19, explained

Posted on July 7, 2020 by henrykotula • Posted in 2020 Election Issues, Asymptomatic Transmission, Centers for Disease Control & Prevention (CDC), Chronic Care Management, Chronic Conditions, Chronic Diseases, Chronic Fatigue, Clinical Testing, Contact Tracing, Coronavirus, Coronavirus Treatment, Crisis, Crisis Management, Diarrhea, Economic Crisis, Economy Reopening, Headaches, Heart Damage, Infection Control, Infection Control Plan, Infectious Virus, Infertility, Kawasaki Disease, Long-Term Cognitive Decline, Long-Term Consequences, Long-Term Damage, Long-Term Neurocognitive Problems, Low Oxygen Levels, Lung Scarring, Mortality, Nausea, Pandemic, Permanent Damage, Post-Traumatic Stress, Public Health, Public Safety, Quarantine, Short-Term Memory Loss, Social Distancing, Tremors • Leave a comment

https://www.vox.com/2020/5/8/21251899/coronavirus-long-term-effects-symptoms

“It is a true roller coaster of symptoms and severities, with each new day offering many unknowns.”

At first, Lauren Nichols tried to explain away her symptoms. In early March, the healthy 32-year-old felt an intense burning sensation, like acid reflux, when she breathed. Embarrassed, she didn’t initially seek medical care. When her shortness of breath kept getting worse, her doctor tested her for Covid-19.

Her results came back positive. But for Nichols, that was just the beginning. Over the next eight weeks, she developed wide and varied symptoms, including extreme and chronic fatigue, diarrhea, nausea, tremors, headaches, difficulty concentrating, and short-term memory loss.

“The guidelines that were provided by the CDC [Centers for Disease Control and Prevention] were not appropriately capturing the symptoms that I was experiencing, which in turn meant that the medical community was unable to ‘validate’ my symptoms,” she says. “This became a vicious cycle of doubt, confusion, and loneliness.”

An estimated 40 to 45 percent of people with Covid-19 may be asymptomatic, and others will have a mild illness with no lasting symptoms. But Nichols is one of many Covid-19 patients who are finding their recovery takes far longer than the two weeks the World Health Organization says people with mild cases can expect. (The WHO says those with severe or critical cases can expect three to six weeks of recovery.)

Because Covid-19 is a new disease, there are no studies about its long-term trajectory for those with more severe symptoms; even the earliest patients to recover in China were only infected a few months ago. But doctors say the novel coronavirus can attach to human cells in many parts of the body and penetrate many major organs, including the heart, kidneys, brain, and even blood vessels.

“The difficulty is sorting out long-term consequences,” says Joseph Brennan, a cardiologist at the Yale School of Medicine. While some patients may fully recover, he and other experts worry others will suffer long-term damage, including lung scarring, heart damage, and neurological and mental health effects.

The UK National Health Service assumes that of Covid-19 patients who have required hospitalization, 45 percent will need ongoing medical care, 4 percent will require inpatient rehabilitation, and 1 percent will permanently require acute care. Other preliminary evidence, as well as historical research on other coronaviruses like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), suggests that for some people, a full recovery might still be years off. For others, there may be no returning to normal.

There’s a lot we still don’t know, but here are a few of the most notable potential long-term impacts that are already showing up in some Covid-19 patients.

Lung scarring

Melanie Montano, 32, who tested positive for Covid-19 in March, says that more than seven weeks after she first got sick, she still experiences symptoms on and off, including burning in her lungs and a dry cough.

Brennan says symptoms like that occur because “this virus creates an incredibly aggressive immune response, so spaces [in the lungs] are filled with debris and pus, making your lungs less pliable.”

On CT scans, while normal lungs appear black, Covid-19 patients’ lungs frequently have lighter gray patches, called “ground-glass opacities” — which may not heal.

One study from China found that this ground-glass appearance showed up in scans of 77 percent of Covid-19 patients. In another study out of China, published in Radiology, 66 of 70 hospitalized patients had some amount of lung damage in CT scans, and more than half had the kind of lesions that are likely to develop into scars. (A third study from China suggests this is not just for critically ill patients; its authors found that of 58 asymptomatic patients, 95 percent also had evidence of these ground-glass opacities in their lungs. More than a quarter of these individuals went on to develop symptoms within a few days.)

“These kinds of tissue changes can cause permanent damage,” says Ali Gholamrezanezhad, a radiologist at the Keck School of Medicine at the University of Southern California.

Although it’s still too early to know if patients with ongoing lung symptoms like Montano will have permanent lung damage, doctors can learn more about what to expect from looking back to people who have recovered from SARS and MERS, other coronaviruses that resulted in similar lung tissue changes.

One small longitudinal study published in Nature followed 71 SARS patients from 2003 until 2018 and found that more than a third had reduced lung capacity. MERS is a little harder to extrapolate from, since fewer than 2,500 people were infected, and somewhere between 30 and 40 percent died. But one study found that about a third of 36 MERS survivors also had long-term lung damage.

Gholamrezanezhad has recently done a literature review of SARS and MERS and says that for this subset of people, “The pulmonary function never comes back; their ability to do normal activities never goes back to baseline.”

Additionally, Covid-19 scarring rates may end up being higher than SARS and MERS patients because those illnesses often attacked only one lung. But Covid-19 appears to often affect both lungs, which Gholamrezanezhad says escalates the risks of lung scarring.

He has already seen residual scarring in Covid-19 patients and is now designing a study to identify what factors might make some people at higher risk of permanent damage. He suspects having any type of underlying lung disease, like asthma, or other health conditions, like hypertension, might increase the risk of having longer-term lung issues. Additionally, “the older you are, probably the higher your chance of scarring,” he says.

For people with this kind of lung scarring, normal activities may become more challenging. “Routine things, like running up a flight of stairs, would leave these individuals gasping for air,” Brennan says.

Stroke, embolisms, and blood clotting

Many patients hospitalized for Covid-19 are experiencing unexpectedly high rates of blood clots, likely due to inflammatory responses to the infection. These can cause lung blockages, strokes, heart attacks, and other complications with serious, lasting effects.

Blood clots that form in or reach the brain can cause a stroke. Although strokes are more typically seen in older people, strokes are now being reported even in young Covid-19 patients. In Wuhan, China, about 5 percent of hospitalized Covid-19 patients had strokes, and a similar pattern was reported with SARS.

In younger people who have strokes, mortality rates are relatively low compared to those who are older, and many people recover. But studies show only between 42 and 53 percent are able to return to work.

Blood clots can also cut off circulation to part of the lungs, a condition known as a pulmonary embolism, which can be deadly. In France, two studies suggest that between 23 and 30 percent of people with severe Covid-19 are also having pulmonary embolisms.

One analysis found that after a pulmonary embolism, “symptoms and functional limitations are frequently reported by survivors.” These include fatigue, heart palpitations, shortness of breath, marked limitation of physical activity, and inability to do physical activity without discomfort.

Blood clots in other major organs can also cause serious problems. Renal failure has been a common challenge in many severe Covid-19 patients, and patients’ clotted blood has been clogging dialysis machines. Some of these acute kidney injuries may be permanent, requiring ongoing dialysis.

Clots outside organs can be serious, too. Deep vein thrombosis, for example, occurs when a blood clot forms in a vein, often the legs. Nick Cordero, a Tony-nominated Broadway and television actor, recently had to have his right leg amputated after Covid-related blood clots.

Abnormal blood clotting even seems to be happening in people after they’ve appeared to recover. One 32-year-old woman in Chicago, for example, had been discharged from the hospital for a week when she died suddenly with a severely swollen leg, a sign of deep vein thrombosis, according to local broadcaster WGN9. Or take Troy Randle, a 49-year-old cardiologist in New Jersey, who was declared safe to go back to work after recovering from Covid-19 when he developed a vicious headache. A CT scan confirmed he’d had a stroke.

Although there’s still a shortage of data, one study found that as many as 31 percent of ICU patients with Covid-19 infections had these kinds of clotting problems. In the meantime, the International Society on Thrombosis and Haemostasis has issued guidelines that recovered Covid-19 patients should continue taking anticoagulants even after being discharged from the hospital.

Heart damage

Being critically ill, especially with low oxygen levels, puts additional stress on the heart. But doctors now think that in Covid-19 patients, viral particles might also be specifically inflaming the heart muscle. (The heart has many ACE2 receptors, which scientists have identified as an entry point for the SARS-CoV-2 virus.)

“In China, doctors noted some people coming [in] with chest pain,” says Mitchell Elkind, president-elect of the American Heart Association and professor of neurology and epidemiology at Columbia University. “They had a heart attack, and then developed Covid symptoms or tested positive after.”

One study from Wuhan in January found 12 percent of Covid-19 patients had signs of cardiovascular damage. These patients had higher levels of troponin, a protein released in the blood by an injured heart muscle. Since then, other reports suggest the virus may directly cause acute myocarditis and heart failure. (Heart failure was also seen with MERS and is known to be correlated with even the seasonal flu.)

In March, another study looked at 416 hospitalized Covid-19 patients and found 19 percent showed signs of heart damage. University of Texas Health Science Center researchers warn that in survivors, Covid-19 may cause lingering cardiac damage, as well as making existing cardiovascular problems worse, further increasing the risk for heart attack and stroke.

A pulmonary critical care doctor at Mount Sinai Hospital in New York City, for example, recovered from Covid-19, only to learn she had developed cardiomyopathy, a condition in which your heart has trouble delivering blood around your body. Although previously healthy, when she returned to work, she told NBC, “I couldn’t run around like I always do.”

The specific consequences may vary depending on how the heart is affected. For example, Covid-19 has been linked to myocarditis, a condition where inflammation weakens the heart, creates scar tissue, and makes it work harder to circulate the body’s oxygen. The Myocarditis Foundation recommends these patients avoid cigarettes and alcohol, and stay away from rigorous exercise until approved by their doctor.

Neurocognitive and mental health impacts

Covid-19 also seems to affect the central nervous system, with potentially long-lasting consequences. In one study from China, more than a third of 214 people hospitalized with confirmed Covid-19 had neurological symptoms, including dizziness, headaches, impaired consciousness, vision, taste/smell impairment, and nerve pain while they were ill. These symptoms were more common in patients with severe cases, where the incidence increased to 46.5 percent. Another study in France found neurologic features in 58 of 64 critically ill Covid-19 patients.

As the pandemic goes on, Elkind says, “We need to be on the lookout for long-term neurocognitive problems.”

Looking back to SARS and MERS suggests that Covid-19 patients may have slightly delayed onset of neurological impacts. Andrew Josephson, a doctor at the University of California San Francisco, wrote in JAMA, “Although the SARS epidemic was limited to about 8,000 patients worldwide, there were some limited reports of neurologic complications of SARS that appeared in patients 2 to 3 weeks into the course of the illness.” These included muscular weakness, burning or prickling, and numbness, and the breakdown of muscle tissue into the blood. Neurological injuries, including impaired balance and coordination, confusion, and coma, were also found with MERS.

Long-term complications of Covid-19 — whether caused by the virus itself or the inflammation it triggers — could include decreased attention, concentration, and memory, as well as dysfunction in peripheral nerves, “the ones that go to your arms, legs, fingers, and toes,” Elkind says.

There are other cognitive implications for people who receive intensive treatment in hospitals. For example, delirium — an acutely disturbed state of mind that can result in confusion and seeing or hearing things that aren’t there — affects a third or more of ICU patients, and research suggests the presence of delirium during severe illness predicts future long-term cognitive decline.

Previous research on acute respiratory distress syndrome (ARDS) more generally may also provide clues to what neurological issues critically ill Covid-19 patients might see after leaving the hospital.

Research shows one in five ARDS survivors experiences long-term cognitive impairment, even five years after being discharged. Continuing impairments can include short-term memory problems and difficulty with learning and executive function. These can lead to challenges like difficulty working, impaired money management, or struggling to perform daily tasks.

ARDS survivors frequently have increased rates of depression and anxiety, and many experience post-traumatic stress. Although it’s still too early to have much data on Covid-19, during the SARS outbreak, former patients struggled with psychological distress and stress for at least a year after the outbreak.

“I felt imprisoned within my body, imprisoned within my home, and tremendously ignored and misunderstood by the general public, and even those closest to me,” Nichols says about her battle with Covid-19. “I feel incredibly alone.”

Jane, who prefers to use a pseudonym because she fears retribution at the hospital where she works, tested positive for Covid-19 more than a month ago. She’s still struggling with fevers, heart issues, and neurological issues, but the most difficult part, she says, is how tired she is of “being treated like I am a bomb that no one knows how to disarm.” Jane, a nurse who cared for AIDS patients during the ’90s, says, “This is exactly what those people went through. There is a terrible stigma.” In addition to the stigma, uncertainty has added to her mental health burden.

“People need to know this disease can linger and wreck your life and health,” she says. “And no one knows what to do for us.”

Childhood inflammation, male infertility, and other possible lasting effects

The novel coronavirus continues to frustrate scientists and patients alike with its mysteries. One of these is a small but growing number of children who recently began showing up at doctors’ offices in Britain, Italy, and Spain with strange symptoms, including a rash, a high fever, and heart inflammation.

On May 4, the New York City Health Department noted that at least 15 children with these symptoms had been hospitalized there, too. These cases present like a severe immune response called Kawasaki disease, where blood vessels can begin to leak, and fluid builds up in the lungs and other major organs. Although only some of these children have tested positive for Covid-19, Russell Viner, president of the Royal College of Pediatrics and Child Health, told the New York Times, “the working hypothesis is that it’s Covid-related.”

Children who survive Kawasaki-like conditions can suffer myocardial and vascular complications in adulthood. But it’s too early to know how Covid-related cases will develop. Many of the small number of reported cases appear to be responding well to treatment.

Other researchers are suggesting that Covid-19 may pose particular problems for men beyond their disproportionate mortality from the illness. The testicles contain a high number of ACE2 receptors, explained researcher Ali Raba, in a recent letter to the World Journal of Urology. “There is a theoretical possibility of testicular damage and subsequent infertility following COVID-19 infection,” he wrote.

Another study, looking at 38 patients in China who had been severely ill with Covid-19, found that during their illness, 15 had virus RNA in their semen samples, as did two of 23 recovering patients. (The presence of viral RNA doesn’t necessarily indicate infectious capacity.)

Another recent study also showed that in 81 men with Covid-19, male hormone ratios were off, which could signal trouble for fertility down the line. The authors called for more attention to be paid, particularly on “reproductive-aged men.” An April 20 paper published in Nature went so far as to suggest, “After recovery from COVID-19, young men who are interested in having children should receive a consultation regarding their fertility.”

And we are just at the beginning of figuring out what this complex infection means for other organ systems and their recovery. For example, a recent preprint from Chinese doctors looked at 34 Covid-19 survivors’ blood. While they saw a difference between severe and mild cases, the researchers found that regardless of the severity of the disease, after recovered patients were discharged from the hospital, many biological measures “failed to return to normal.” The most concerning measures suggested ongoing impaired liver function.

What all of this means for survivors and researchers

As all this preliminary research shows, we are still in the early days of understanding what this virus might mean for the growing number of Covid-19 survivors — what symptoms they might expect to have, how long it might take them to get back to feeling normal (if they ever will), and what other precautions they might need to be taking.

Many people aren’t even receiving adequate information about when it might be safe for them to stop self-isolating. Nichols and other survivors report feeling better one day and terrible the next.

But in the chaos Covid-19 has caused in the medical systems, survivors say it’s hard to get attention for their ongoing struggles. “The support and awareness is simply lacking,” Nichols says. “It is a true roller coaster of symptoms and severities, with each new day offering many unknowns: I may feel healthier one day but may feel utterly debilitated and in pain the next.”

Covid-19 cases are rising, but deaths are falling. What’s going on?

Posted on July 7, 2020 by henrykotula • Posted in 2020 Election Issues, Adverse Outcomes, Asymptomatic Transmission, Chronic Care Management, Chronic Conditions, Chronic Diseases, Clinical Testing, Communication, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economy Reopening, Health System, Hospital, Hospital Industry, Infection Control, Infection Control Plan, Infectious Virus, Intensive Care (ICU), Lagging Indicators, Leadership Decentralized, Mortality, National Strategy, Pandemic, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Scientists, Social Distancing, Vulnerable Populations, Wishful Thinking • Leave a comment

https://www.vox.com/2020/7/6/21314472/covid-19-coronavirus-us-cases-deaths-trends-wtf

By the time coronavirus deaths start rising again, it’s already too late.

There is something confounding about the US’s new coronavirus spikes: Cases are rising, but the country is seeing its lowest death counts since the pandemic first exploded.

The numbers are genuinely strange to the naked eye: On July 3, the US reported 56,567 new Covid-19 cases, a record high. On the same day, 589 new deaths were reported, continuing a long and gradual decline. We haven’t seen numbers that low since the end of March.

When laypeople observe those contradictory trends, they might naturally have a follow-up question: If deaths are not increasing along with cases, then why can’t we keep reopening? The lockdowns took an extraordinary toll of their own, after all, in money and mental health and some lives. If we could reopen the economy without the loss of life we saw in April and May, then why shouldn’t we?

I posed that very question to more than a dozen public health experts. All of them cautioned against complacency: This many cases mean many more deaths are probably in our future. And even if deaths don’t increase to the same levels seen in April and May, there are still some very serious possible health consequences if you contract Covid-19.

The novel coronavirus, SARS-Cov-2, is a maddeningly slow-moving pathogen — until it’s not. The sinking death rates reflect the state of the pandemic a month or more ago, experts say, when the original hot spots had been contained and other states had only just begun to open up restaurants and other businesses.

That means it could still be another few weeks before we really start to see the consequences, in lives lost, of the recent spikes in cases. And in the meantime, the virus is continuing to spread. By the time the death numbers show the crisis is here, it will already be too late. Difficult weeks will lie ahead.

Even if death rates stay low in the near term, that doesn’t mean the risk of Covid-19 has evaporated. Thousands of Americans being hospitalized in the past few weeks with a disease that makes it hard to breathe is not a time to declare victory. Young people, who account for a bigger share of the recent cases, aren’t at nearly as high a risk of dying from the virus, but some small number of them will still die and a larger number will end up in the hospital. Early research also suggests that people infected with the coronavirus experience lung damage and other long-term complications that could lead to health problems down the road, even if they don’t experience particularly bad symptoms during their illness.

And as long as the virus is spreading in the community, there is an increased risk that it will find its way to the more vulnerable populations.

“More infected people means faster spread throughout society,” Kumi Smith, who studies infectious diseases at the University of Minnesota, told me. “And the more this virus spreads the more likely it is to eventually reach and infect someone who may die or be severely harmed by it.”

This presents a communications challenge. Sadly, as Smith put it, “please abstain from things you like to benefit others in ways that you may not be able to see or feel” is not an easy message for people to accept after three-plus months in relative isolation.

But perhaps the bigger problem is the reluctance of our government to take the steps necessary to control the disease. Experts warned months ago that if states were too quick to relax their social distancing policies, without the necessary capacity for more testing or contact tracing, new outbreaks would flare up and be difficult to contain.

That’s exactly what happened — and now states are scrambling to reimpose some restrictions. Unless the US gets smarter about its coronavirus response, the country seems doomed to repeat this cycle over and over again.

Why Covid-19 deaths aren’t rising along with cases — yet

The contradiction between these two curves — case numbers sloping upward, death counts downward — is the primary reason some people are agitating to accelerate, not slow down, reopening in the face of these new coronavirus spikes.

The most important thing to understand is that this is actually to be expected. There is a long lag — as long as six weeks, experts told me — between when a person gets infected and when their death would be reported in the official tally.

“Why aren’t today’s deaths trending in the same way today’s cases are trending? That’s completely not the way to think about it,” Eleanor Murray, an epidemiologist at Boston University, told me. “Today’s cases represent infections that probably happened a week or two ago. Today’s deaths represent cases that were diagnosed possibly up to a month ago, so infections that were up to six weeks ago or more.”

“Some people do get infected and die quickly, but the majority of people who die, it takes a while,” Murray continued. “It’s not a matter of a one-week lag between cases and deaths. We expect something more on the order of a four-, five-, six-week lag.”

As Whet Moser wrote for the Covid Tracking Project last week, the recent spikes in case counts really took off around June 18 and 19. So we would not expect them to show up in the death data yet.

“Hospitalizations and deaths are both lagging indicators, because it takes time to progress through the course of illness,” Caitlin Rivers at the Johns Hopkins Center for Health Security told me late last week. “The recent surge started around two weeks ago, so it’s too soon to be confident that we won’t see an uptick in hospitalizations and deaths.”

The national numbers can also obscure local trends. According to the Covid Tracking Project, hospitalizations are spiking in the South and West, but, at the same time, they are dropping precipitously in the Northeast, the initial epicenter of the US outbreak.

And a similar regional shift in deaths may be underway, though it will take longer to reveal itself because the death numbers lag behind both cases and hospitalizations. But even now, Alabama, Arizona, Florida, Nevada, South Carolina, Tennessee, Texas, and Virginia have seen an uptick in their average daily deaths, according to Covid Exit Strategy, while Connecticut, Massachusetts, and New York have experienced a notable decline.

There are some reasons to be optimistic we will not see deaths accelerate to the same extent that cases are. For one, clinicians have identified treatments like remdesivir and dexamethasone that, respectively, appear to reduce people’s time in the hospital and their risk of dying if they are put on a ventilator.

The new infections are also, for now, skewing more toward younger people, who are at a much lower risk of dying of Covid-19 compared to older people. But that is not the case for complacency that it might superficially appear to be.

Younger people are less at risk from Covid-19 — but their risk isn’t zero

For starters, younger people can die of Covid-19. About 3,000 people under the age of 45 have died from the coronavirus, according to the CDC’s statistics (which notably have a lower overall death count than other independent sources that rely on state data). That is a small percentage of the 130,000 and counting overall Covid-19 deaths in the US. But it does happen.

Moreover, younger people can also develop serious enough symptoms that they end up having to be hospitalized with the disease. Again, their risk is meaningfully lower than that of older people, but that doesn’t mean it’s zero.

There can also be adverse outcomes that are not hospitalization or death. Illness is not a zero-sum game. A recent study published in Nature found that even asymptomatic Covid-19 patients showed abnormal lung scans. As Lois Parshley has documented for Vox, some people who recover from Covid-19 still report health problems for weeks after their initial sickness. Potential long-term issues include lung scarring, blood clotting and stroke, heart damage, and cognitive challenges.

In short, surviving Covid-19, even with relatively mild symptoms, does not mean a person simply reverts to normal. This is a new disease, and we are still learning the full extent of its effects on the human body.

But even if we recognize that young people face less of a threat directly from the coronavirus, there is still a big reason to worry if the virus is spreading in that population: It could very easily make the leap from less vulnerable people to those who are much more at risk of serious complications or death.

The coronavirus could easily jump from younger people to the more vulnerable

One response to the above set of facts might be: “Well, we should just isolate the old and the sick, while the rest of us go on with our lives.” That might sound good in theory (if you’re not older or immunocompromised yourself), but it is much more difficult in practice.

“The fact is that we live in communities that are all mixed up with each other. That’s the concern,” Natalie Dean, a biostatistics professor at the University of Florida, says. “It’s not like there’s some nice neat demarcation: you’re at high risk, you’re at low risk.”

The numbers in Florida are telling. At first, in late May and into early June, new infections accelerated among the under-45 cohort. But after a lag of a week or so, new cases also started to pick up among the over-45 (i.e., more at-risk) population.

“The rise in older adults is trailing behind, but it is starting to go up,” Dean said.

Anecdotally, nursing homes in Arizona and Texas — the two states with the most worrisome coronavirus trends right now — have seen outbreaks in recent weeks as community spread increases. The people who work in nursing homes, after all, are living out in the community where Covid-19 is spreading. And, because they are younger, they may not show symptoms while they are going to work and potentially exposing those patients.

As one expert pointed out to me, both Massachusetts and Norway have seen about 60 percent of their deaths come in long-term care facilities, even though the former has a much higher total fatality count than the latter. That would suggest we have yet to find a good strategy for keeping the coronavirus away from those specific populations.

“There is so far not much evidence that we know how to shield the most vulnerable when there is widespread community transmission,” Marc Lipsitch, a Harvard epidemiologist, told me.

That means the best recourse is trying to contain community spread, which keeps the overall case and death counts lower (as in Norway) and prevents the health care system from being overwhelmed.

Health systems haven’t been overwhelmed — but some hospitals in new hot spots are getting close

Arizona, Florida, and Texas still have 20 to 30 percent of their ICU and hospital beds available statewide, according to Covid Exit Strategy, even as case counts continue to rise. While some people use those numbers to argue that the health systems can handle an influx of Covid patients, the experts I spoke to warned that capacity can quickly evaporate.

“Let’s keep it that way, shall we?” William Hanage at Harvard said. “Hospitals are getting close to overwhelmed in some places, and that will be more places in future if action isn’t taken now. Also ‘not overwhelmed’ is a pretty low bar.”

Hospital capacity is another example of how the lags created by Covid-19 can lull us into a false sense of security until a crisis presents itself and suddenly it’s too late. Because it can take up to two weeks between infection and hospitalization, we are only now beginning to see the impact of these recent spikes.

And, to be clear, hospitalizations are on the rise across the new hot spots. The number of people currently hospitalized with Covid-19 in Texas is up from less than 1,800 on June 1 to nearly 8,000 on July 4. Hospitalizations in Arizona have nearly tripled since the beginning of June, up to more than 3,100 today.

And the state-level data doesn’t show local trends, which are what really matter when it comes to hospital capacity. Some of the hardest-hit cities in these states are feeling the strain, as Hanage pointed out. Hospitals in Houston have started transferring their Covid-19 patients to other cities, and they are implementing their surge capacity plans, anticipating a growing need because of the trendlines in the state.

Once a hospital’s capacity is reached, it’s already too late. They will have to endure several rough weeks after that breach, because the virus has continued to infect more people in the interim, some of whom will get very sick and require hospitalization when there isn’t any room available for them.

“We’re seeing some drastic measures being implemented right now in Texas and Arizona along those lines: using children’s hospitals for adults, going into crisis mode, etc.,” Tara Smith, who studies infectious diseases at Kent State University, told me. “So it shows how quickly all of that can turn around.”

And, on top of Covid-19, these health systems will continue to have the usual flow of emergencies from heart attacks, strokes, accidents, etc. That’s when experts start to worry people will die who wouldn’t otherwise have. That is what social distancing, by slowing the spread of the coronavirus, is supposed to prevent.

We don’t have to lock down forever — but we have to be smart and vigilant

Lockdowns are extraordinarily burdensome. Tens of millions of Americans have lost their jobs. Drug overdoses have spiked. There has been a worrying increase in heart-related deaths, which indicates people who otherwise would have sought medical treatment did not do so during the worst of the outbreak this spring.

But we cannot will the coronavirus out of existence. Experts warned months ago that if states reopened too early, cases would spike, which would strain health systems and put us at risk of losing more people to this virus. That appears to be what’s starting to happen. And it may get worse; if the summer heat has suppressed the virus to any degree, we could see another rebound in the fall and winter.

So we must strike a balance, between the needs of a human society and the reality that most of us are still susceptible to an entirely novel pathogen that is much deadlier and more contagious than the flu.

That means, for starters, being smarter about how we reopen than we have been so far. There is strong evidence that states were too cavalier about ending stay-at-home orders and reopening businesses, with just a handful meeting the metrics for reopening laid out by experts, as Vox’s German Lopez explained.

“What I’ve seen is that reopening is getting interpreted by many as reverting back to a Covid-free time where we could attend larger group gatherings, socialize regularly with many different people, or congregate without masks,” Kumi Smith in Minnesota said. “The virus hasn’t changed since March, so there’s no reasons why our precautions should either.”

To date, most states have opened up bars again and kept schools closed. Lopez made a persuasive case last week that we’ve got that backward. One of the most thorough studies so far on how lockdowns affected Covid-19’s spread found that closing restaurants and bars had a meaningful effect on the virus but closing schools did not.

That study also found that shelter-in-place orders had a sizable impact. While those measures may not be politically feasible anymore, individuals can still be cautious about going out — and when they do, they can stick to outdoor activities with a small number of people.

Masks are not a panacea either, but the evidence is convincingly piling up that they also help reduce the coronavirus’s spread. Whether a given state has a mandate to wear one or not, that is one small inconvenience to accept in order to get this outbreak back under control.

And, really, that is the point. While the current divergence between case and death counts can be confusing, the experts agree that Covid-19 still poses a significant risk to Americans — and it is a risk that goes beyond literal life and death. We know some of the steps that we, as individuals, can take to help slow the spread. And we need our governments, from Washington to the state capitals, to get smarter about reopening.

It will require collective action to stave off the coronavirus for good. Other countries have done it. But we have to act now, before we find out it’s already too late.

Coronavirus Cases may be 10x higher than official count says CDC

Posted on June 26, 2020 by henrykotula • Posted in 2020 Election Issues, Antibodies, Asymptomatic Transmission, Centers for Disease Control & Prevention (CDC), Chronic Care Management, Chronic Conditions, Chronic Diseases, Clinical Testing, Contact Tracing, Coronavirus, Economy Reopening, False Hope, False Narrative, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Leadership Decentralized, Mislead, Misleading, Mortality, National Strategy, Pandemic, Preexisting Conditions, Public Health, Public Safety, Quarantine, Social Distancing, Vulnerable Populations • Leave a comment

https://www.axios.com/newsletters/axios-vitals-59e9ac1a-ab86-4f8a-917a-8c9d52f5835f.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

The real number of U.S. coronavirus cases could be as high as 23 million — 10 times the 2.3 million currently confirmed cases — the Centers for Disease Control and Prevention told reporters yesterday, Axios’ Marisa Fernandez reports.

Between the lines: The new estimate is based on antibody testing, which indicates whether someone has previously been infected by the virus regardless of whether they had symptoms.

“This virus causes so much asymptomatic infection. The traditional approach of looking for symptomatic illness and diagnosing it obviously underestimates the total amount of infections,” CDC director Robert Redfield said.

The agency also expanded its warnings of which demographic groups are at risk, which now include younger people who are obese and who have underlying health problems.

The shift reflects what states and hospitals have been seeing since the pandemic began, which is that young people can get seriously ill from COVID-19.

The new guidance also categorizes medical conditions that can affect the severity of illness:

Conditions that increase risk: Chronic kidney disease; chronic obstructive pulmonary disease; obesity; weakened immune system from solid organ transplant; serious heart conditions, such as heart failure, coronary artery disease or cardiomyopathies; sickle cell disease; Type 2 diabetes.
Conditions that may increase risk: Chronic lung diseases, including moderate to severe asthma and cystic fibrosis; high blood pressure; a weakened immune system; neurologic conditions, such as dementia or history of stroke; liver disease; pregnancy.

Coronavirus Cases Rise Sharply in Prisons Even as They Plateau Nationwide

Posted on June 16, 2020 by henrykotula • Posted in Asymptomatic Transmission, Centers for Disease Control & Prevention (CDC), Clinical Testing, Contact Tracing, Coronavirus, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Mortality, Pandemic, Prison, Prison Safety, Public Debate, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

Prison officials have been reluctant to do widespread virus testing even as infection rates are escalating.

Cases of the coronavirus in prisons and jails across the United States have soared in recent weeks, even as the overall daily infection rate in the nation has remained relatively flat.

The number of prison inmates known to be infected has doubled during the past month to more than 68,000. Prison deaths tied to the coronavirus have also risen, by 73 percent since mid-May. By now, the five largest known clusters of the virus in the United States are not at nursing homes or meatpacking plants, but inside correction institutions, according to data The New York Times has been collecting about confirmed coronavirus cases since the pandemic reached American shores.

And the risk of more cases appears imminent: The swift growth in virus cases behind bars comes as demonstrators arrested as part of large police brutality protests across the nation have often been placed in crowded holding cells in local jails.

A muddled, uneven response by corrections officials to testing and care for inmates and workers is complicating the spread of the coronavirus. In interviews, prison and jail officials acknowledged that their approach has largely been based on trial and error, and that an effective, consistent response for U.S. correctional facilities remains elusive.

“If there was clearly a right strategy, we all would have done it,” said Dr. Owen Murray, a University of Texas Medical Branch physician who oversees correctional health care at dozens of Texas prisons. “There is no clear-cut right strategy here. There are a lot of different choices that one could make that are going to be in-the-moment decisions.”

The inconsistent response to the spread of the coronavirus in correctional facilities is in contrast with efforts to halt its spread in other known incubators of the virus: Much of the cruise ship industry has been closed down. Staff members and residents of nursing homes in several states now face compulsory testing. Many meat processing plants have been shuttered for extensive cleaning.

As the toll in prisons has increased, so has fear among inmates who say the authorities have done too little to protect them. There have been riots and hunger strikes in correctional facilities from Washington State to New York. And even the known case numbers are likely a significant undercount because testing has been extremely limited inside prisons and because some places that test do not release the results to the public.

“It’s like a sword hanging over my head,” said Fred Roehler, 77, an inmate at a California prison who has chronic inflammatory lung disease and other respiratory ailments. “Any officer can bring it in.”

Public officials have long warned that the nation’s correctional facilities would likely become vectors in the pandemic because they are often overcrowded, unsanitary places where social distancing is impractical, bathrooms and day rooms are shared by hundreds of inmates, and access to cleaning supplies is tightly controlled. Many inmates are 60 or older, and many suffer from respiratory illnesses or heart conditions.

In response, local jails have discharged thousands of inmates since February, many of whom had been awaiting trials to have charges heard or serving time for nonviolent crimes. State prison systems, where people convicted of more serious crimes are housed, have been more reluctant to release inmates.

Testing for the virus within the nation’s penal institutions varies widely, and has become a matter of significant debate.

Republican-led states like Texas, Tennessee and Arkansas — which generally spend less on prisoners than the national average — have found themselves at the forefront of testing inmates.

In Texas, the number of prisoners and staff members known to be infected has more than quadrupled to 7,900 during the past three weeks after the state began to test every inmate.

Yet states that typically spend far more on prisons have carried out significantly less testing.

California, which spends $12 billion annually on its prison system, has tested fewer than 7 percent of inmates in several of its largest, most crowded facilities, according to the state’s data. Other Democratic-led states that also spend heavily on prisons, including New York, Oregon and Colorado, have also conducted limited testing despite large outbreaks in their facilities.

New York has tested about 3 percent of its 40,000 prison inmates; more than 40 percent of those tested were infected.

Critics say that the dearth of testing in some facilities has meant that prison and public health officials have only vague notions about the spread of the virus, which has allowed some elected officials to suggest that it is not present at all.

“We have really no true idea of how bad the problem is because most places are not yet testing the way they should,” said Dr. Homer Venters, who served as chief medical officer for the New York City jail system and now works for a group called Community Oriented Correctional Health Services, which works to improve health care services in local jails. “I think a lot of times some of the operational challenges of either not having adequate quarantine policies or adequate medical isolation policies are so vexing that places simply decide that they can just throw up their hands.”

Most state prison systems have conducted few tests. Systems in Illinois, Mississippi and Alabama have tested fewer than 2.5 percent of inmates. And in Louisiana, officials had tested several dozen of its 31,000 inmates in March when the warden and medical director at one of the state’s largest prisons died of the coronavirus. The state has since announced plans to test every inmate.

Prison officials in states where only a limited number of inmates have been tested say they are following federal guidelines. The Centers for Disease Control and Prevention recommend that only prisoners with symptoms be tested.

Prisons that have conducted mass testing have found that about one in seven tests of inmates have come back positive, the Times database shows. The vast majority of inmates who have tested positive have been asymptomatic.

Public health officials say that indicates the virus has been present in prison populations for far longer than had previously been understood.

“If you don’t do testing, you’re flying blind,” said Carlos Franco-Paredes, an infectious-disease specialist at the University of Colorado School of Medicine.

But in California, there continues to be reluctance to test each of the state’s 114,000 inmates, despite growing criticism to take a more aggressive approach. One in six inmates in the state’s prisons have been tested, and the state has released some inmates who were later found to have the virus, raising fears that prison systems could seed new infections outside penal institutions.

“Nothing significant had been done to protect those most vulnerable to the virus,” said Marie Waldron, the Republican minority leader of the California State Assembly.

But J. Clark Kelso, who oversees prison health care in California, said that mass testing would provide only a snapshot of the virus’s spread.

“Testing’s not a complete solution,” Mr. Kelso said. “It gives you better information, but you don’t want to get a false sense of security.”

California’s health department has recommended that a facility’s prison inmates and staff members be given priority for testing once an infection has been identified there.

But the state prison system has conducted mass testing at only a handful of institutions where infections have been found, according to state data. In one of those facilities, the California Institution for Men in Chino, nearly 875 people have tested positive and 13 inmates have died.

Instead, California has employed surveillance testing, which involves testing a limited number of inmates at each state prison regardless of the known infection rate.

That method, Mr. Kelso said, had led officials to conclude that the vast majority of its prisons are free of the virus.

“We’re not 100 percent confident because we’re not testing everyone,” he said. “As we learn every single day from what we’re doing, we may suddenly decide, ‘No, we actually have to test all of them.’ We’re not at that point yet.”

In interviews, California prison inmates say prison staff have sometimes refused to test them, even after they complained about symptoms similar to the coronavirus. Several prisoners said they had been too weak to move for weeks at a time, but were never permitted to see a nurse and had never been tested.

“I had chest pains. I couldn’t breathe,” said Althea Housley, 43, an inmate at Folsom State Prison, where no inmates have tested positive, according to state data. “They told us it was the flu going around, but I ain’t never had a flu like that.”

Mr. Kelso did not dispute the prisoners’ accounts.

In Texas, mass testing has found that nearly 8,000 inmates and guards have been infected. Sixty-two people have died, including some who had not exhibited symptoms.

Dr. Murray, the physician who oversees much of Texas’ prison health care system, said the disparate approaches taken by prison authorities might actually be beneficial as officials compare notes.

“I’m glad we’ve got 50 states and everyone is trying to do something a little different — whether that’s by intent or not — because it’s really the only basis that we’re going to have for comparison later on,” he said.

But Baleegh Brown, 31, an inmate at a California prison, said he was displeased about being part of what he considered a science experiment. His prison has had more than 170 infections.

He said that he and his cellmate are confined to a 6-by-9-foot space for about 22 hours each day as the prison tries to prevent the virus from spreading further. Mr. Brown said he had a weakened immune system after a case of non-Hodgkin’s lymphoma, making him particularly vulnerable to illness.

“We need more testing here so everyone knows for sure,” he said. “And for me, my body has been compromised, so I don’t know how it is going to react. That makes all you don’t know even scarier.”

Beijing goes into ‘wartime mode’ as virus emerges at market

Posted on June 15, 2020 by henrykotula • Posted in 2020 Election Issues, Asymptomatic Transmission, Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economy Reopening, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Leadership Decentralized, Mortality, National Strategy, Pandemic, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

https://www.washingtonpost.com/world/beijing-goes-into-wartime-mode-as-virus-emerges-at-market-in-chinese-capital/2020/06/13/65c5aac8-ad40-11ea-868b-93d63cd833b2_story.html?stream=top&utm_campaign=newsletter_axiosvitals&utm_medium=email&utm_source=newsletter

A district in central Beijing has gone into “wartime mode” after discovering a cluster of coronavirus cases around the biggest meat and vegetable market in the city, raising the prospect of a second wave of infections in the sensitive capital, the seat of the Chinese Communist Party.

The discovery of dozens of infections, both symptomatic and asymptomatic, underscores the perniciousness of the virus and its propensity to spread despite tight social controls.

“We would like to warn everyone not to drop their guard even for a second in epidemic prevention control; we must be prepared for a prolonged fight with the virus,” Xu Hejian, a spokesman for the Beijing municipal government, said at a news conference Saturday.

“We have to stay alert to the risks of imported cases and to the fact that epidemic control in our city is complicated and serious and will be here for a long time,” he said.

Authorities are particularly alert to cases around markets because that is how the coronavirus spread: It emanated from the Huanan food market in the city of Wuhan, across China and soon across the entire globe.

The initial outbreak was linked to exotic wildlife being sold at the Huanan market, but there was no evidence of any such trade at the Xinfadi market in Fengtai district, in the southwest of Beijing.

A man who had visited the Xinfadi market June 3 to buy meat and seafood tested positive for the coronavirus, Beijing’s Center for Disease Control and Prevention reported Thursday.

Then on Friday, it announced that two quality control workers at the state-owned China Meat Food Research Center who had visited Xinfadi and five other markets in the city to check on standards had also tested positive.

That prompted a frenzy of testing. By the end of Friday, Beijing authorities had swabbed 1,940 workers in major supermarkets and other food markets in the capital, and collected 5,424 environmental samples.

The tests revealed another four symptomatic cases: three were people who worked at the Xinfadi market’s seafood section and another was a customer who had visited the market. None of them had traveled outside Beijing, signaling that the cases had all been transmitted within the city.

They also uncovered 45 asymptomatic cases in people associated with the market and one linked to another market in neighboring Haidian district. They also found coronavirus on 40 of the environmental samples, including on a chopping board used for imported salmon.

The findings prompted swift actions to control any spread in the capital, where life has been inching back to almost normal.

Xinfadi was shut down immediately and the other five markets visited by the meat inspectors were ordered to close, either completely or partially.

Because Xinfadi supplies about 70 percent of Beijing’s fresh vegetables and 80 percent of its fruit, capital authorities arranged for vegetables and fruit to be sent to two temporary markets to ensure stable supply and pricing.

All fresh salmon was removed from stores and markets across the city and disposed of, and authorities said they would start screening frozen and fresh meat in markets across the city.

Nine kindergartens and elementary schools around Xinfadi were ordered to close, and apartment complexes near the market were sealed off with movement severely restricted.

After a few days of a trial reopening, the National Center for the Performing Arts stopped allowing visitors Saturday, and all sports events in the city were prohibited. Beijing banned tourist groups from other provinces and regions.

But in a worrying development, the northeastern province of Liaoning on Saturday reported two asymptomatic cases in people who are close contacts of those infected in Beijing.

Experts said the findings underlined the difficulties in keeping domestically transmitted cases at or close to zero.

“We should have a realistic understanding of what it means for China to keep the status quo of almost zero domestic cases for a long time to come,” said Zhang Wenhong, a top infectious-disease expert in Shanghai who has a kind of celebrity status in China. “That doesn’t mean absolutely no new cases,” he wrote late Friday on Weibo, China’s answer to Twitter, after reports began emerging of new cases in Beijing.

“There is no need to go overboard over this so much as to halt the restoration of our economy and people’s livelihoods,” Zhang wrote. “As long as each and every one of us do our jobs well, and stay aware of personal hygiene and protection in our daily lives, we will be able to keep ourselves safe and keep our cities free from a second wave of infections and virus spread.”

When the virus began spreading in Wuhan in January, China introduced lockdown measures, considered draconian at the time but since widely replicated even in democratic parts of the world, to control the spread of the virus.

But the controls were particularly stringent in Beijing, home to the Communist Party leaders and also the site of the annual National People’s Congress, the most important event on China’s political calendar.

The Congress, which attracts thousands of delegates from around the country to gather in Beijing’s Great Hall of the People, was due to be held in early March but was delayed until late May because of the virus.

Even after Wuhan started to open, controls were kept in place in the capital to ensure the virus would not spread ahead of the political conclave. These include restrictions on people arriving into Beijing from elsewhere in China, while only Chinese citizens are allowed to enter the country from abroad, although a few exceptions have been granted to business people who are residents of China wanting to return.

All arrivals from overseas are tested for the virus and put into isolation in hotels. A handful of cases are found most days, usually Chinese people returning from hot spots like the United States or Britain.

Those controls have started to ease now that the meeting has passed, but the emergence of these new cases could prompt authorities to reconsider that.

A few superspreaders transmit the majority of coronavirus cases

Posted on June 14, 2020 by henrykotula • Posted in Asymptomatic Transmission, Coronavirus, Infection Control, Infection Control Plan, Infectious Virus, Mortality, Pandemic, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Social Distancing, Superspreader, Vaccination • Leave a comment

https://theconversation.com/a-few-superspreaders-transmit-the-majority-of-coronavirus-cases-139950?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20June%2012%202020%20-%201650015873&utm_content=Latest%20from%20The%20Conversation%20for%20June%2012%202020%20-%201650015873+Version+A+CID_db6d6c973ccfe2fa9f80ca414a282efe&utm_source=campaign_monitor_us&utm_term=A%20few%20superspreaders%20transmit%20the%20majority%20of%20coronavirus%20cases

The coronavirus has traveled the globe, infecting one person at a time. Some sick people might not spread the virus much further, but some people infected with the SARS-CoV-2 are what epidemiologists call “superspreaders.”

Elizabeth McGraw, the director of the Center for Infectious Disease Dynamics at Pennsylvania State University, explains the evidence and why superspreaders can be crucial to a disease’s transmission.

What is a superspreader?

Early in the outbreak, researchers estimated that a person carrying SARS-CoV-2 would, on average, infect another two to three people. More recent studies have argued, however, that this number may actually be higher.

As early as January, though, there were reports out of Wuhan, China, of a single patient who infected 14 health care workers. That qualifies him as a super spreader: someone who is responsible for infecting an especially large number of other people.

Since then, epidemiologists have tracked a number of other instances of SARS-CoV-2 superspreading. In South Korea, around 40 people who attended a single church service were infected at the same time. At a choir practice of 61 people in Washington state, 32 attendees contracted confirmed COVID-19 and 20 more came down with probable cases. In Chicago, before social distancing was in place, one person that attended a dinner, a funeral and then a birthday party was responsible for 15 new infections.

During any disease outbreak, epidemiologists want to quickly figure out whether superspreaders are part of the picture. Their existence can accelerate the rate of new infections or substantially expand the geographic distribution of the disease.

What are the characteristics of a superspreader?

Whether someone is a superspreader or not will depend on some combination of the pathogen, the patient’s biology and their environment or behavior.

Some infected individuals might shed more virus into the environment than others if their immune system has trouble subduing the invader. Additionally, asymptomatic individuals – up to 50% of all those who get COVID-19 – will continue their normal activities, inadvertently infecting more people. Even people who ultimately do show symptoms are capable of transmitting the virus during a pre-symptomatic phase.

A person’s behaviors, travel patterns and degree of contact with others can also contribute to superspreading. An infected shopkeeper might come in contact with a large number of people and goods each day. An international business traveler may crisscross the globe in a short period of time. A sick health care worker might come in contact with large numbers of people who are especially susceptible, given the presence of other underlying illnesses.

Public protests – where it’s challenging to keep social distance and people might be raising their voices or coughing from tear gas – are conducive to superspreading.

How big a part of COVID-19 are superspreaders?

Several recent preprint studies, which haven’t yet been peer-reviewed, have shed light on the role of superspreading in COVID-19’s dispersion around the globe.

Researchers in Hong Kong examined a number of disease clusters by using contact tracing to track down everyone with whom individual COVID-19 patients had interacted. In the process, they identified multiple situations where a single person was responsible for as many as six or eight new infections.

The researchers estimated that only 20% of all those infected with SARS-CoV-2 were responsible for 80% of all local transmission. Importantly, they also showed that these transmission events were associated with people who had more social contacts – beyond just family members – highlighting the need to rapidly isolate people as soon as they test positive or show symptoms.

Another study by researchers in Israel took a different approach. They compared the genetic sequences of coronavirus samples from patients inside the country to those from other places. Based on how different the genomes were, they could identify each time SARS-CoV-2 entered Israel and then follow how it spread domestically.

These scientists estimated that 80% of community transmission events – one person spreading the coronavirus to another – could be tracked back to just 1-10% of sick individuals.

And when another research group modeled the variation in how many other SARS-CoV-2 infections a single infected person tends to cause, they also found there were occasionally individuals who were very infectious. These people accounted for over 80% of transmissions in a population.

When have superspreaders played a key role in an outbreak?

There are a number of historical examples of superspreaders. The most famous is Typhoid Mary, who in the early 20th century purportedly infected 51 people with typhoid through the food she prepared as a cook.

During the last two decades, superspreaders have started a number of measles outbreaks in the United States. Sick, unvaccinated individuals visited densely crowded places like schools, hospitals, airplanes and theme parks where they infected many others.

Superspreaders have also played a key role in the outbreaks of other coronaviruses, including SARS in 2003 and MERS in 2015. For both SARS and MERS, superspreading mainly occurred in hospitals, with scores of people being infected at a time.

Can superspreading occur in all infectious diseases?

Yes. Researchers have identified superspreaders in outbreaks of diseases caused by bacteria, such as tuberculosis, as well as those caused by viruses, including measles and Ebola. Just as appears to be the case with the coronavirus, some scientists estimate that in an outbreak of any given pathogen, 20% of the population is usually responsible for causing over 80% of all cases of the disease.

The good news is that the right control practices specific to how pathogens are transmitted – hand-washing, masks, quarantine, vaccination, reducing social contacts and so on – can slow the transmission rate and halt a pandemic.

COVID-19 Can Last for Several Months

Posted on June 8, 2020 by henrykotula • Posted in Asymptomatic Transmission, Coronavirus, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Mortality, Pandemic, Public Health, Public Safety, Quarantine, Social Distancing, World Health Organization (WHO) • Leave a comment

https://www.theatlantic.com/health/archive/2020/06/covid-19-coronavirus-longterm-symptoms-months/612679/

The disease’s “long-haulers” have endured relentless waves of debilitating symptoms—and disbelief from doctors and friends.

For Vonny LeClerc, day one was March 16.

Hours after British Prime Minister Boris Johnson instated stringent social-distancing measures to halt the SARS-CoV-2 coronavirus, LeClerc, a Glasgow-based journalist, arrived home feeling shivery and flushed. Over the next few days, she developed a cough, chest pain, aching joints, and a prickling sensation on her skin. After a week of bed rest, she started improving. But on day 12, every old symptom returned, amplified and with reinforcements: She spiked an intermittent fever, lost her sense of taste and smell, and struggled to breathe.

When I spoke with LeClerc on day 66, she was still experiencing waves of symptoms. “Before this, I was a fit, healthy 32-year-old,” she said. “Now I’ve been reduced to not being able to stand up in the shower without feeling fatigued. I’ve tried going to the supermarket and I’m in bed for days afterwards. It’s like nothing I’ve ever experienced before.” Despite her best efforts, LeClerc has not been able to get a test, but “every doctor I’ve spoken to says there’s no shadow of a doubt that this has been COVID,” she said. Today is day 80.

COVID-19 has existed for less than six months, and it is easy to forget how little we know about it. The standard view is that a minority of infected people, who are typically elderly or have preexisting health problems, end up in critical care, requiring oxygen or a ventilator. About 80 percent of infections, according to the World Health Organization, “are mild or asymptomatic,” and patients recover after two weeks, on average. Yet support groups on Slack and Facebook host thousands of people like LeClerc, who say they have been wrestling with serious COVID-19 symptoms for at least a month, if not two or three. Some call themselves “long-termers” or “long-haulers.”

I interviewed nine of them for this story, all of whom share commonalities. Most have never been admitted to an ICU or gone on a ventilator, so their cases technically count as “mild.” But their lives have nonetheless been flattened by relentless and rolling waves of symptoms that make it hard to concentrate, exercise, or perform simple physical tasks. Most are young. Most were previously fit and healthy. “It is mild relative to dying in a hospital, but this virus has ruined my life,” LeClerc said. “Even reading a book is challenging and exhausting. What small joys other people are experiencing in lockdown—yoga, bread baking—are beyond the realms of possibility for me.”

Even though the world is consumed by concern over COVID-19, the long-haulers have been largely left out of the narrative and excluded from the figures that define the pandemic. I can pull up an online dashboard that reveals the numbers of confirmed cases, hospitalizations, deaths, and recoveries—but LeClerc falls into none of those categories. She and others are trapped in a statistical limbo, uncounted and thus overlooked.

Some have been diagnosed through tests, while others, like LeClerc, have been told by their doctors that they almost certainly have COVID-19. Still, many long-haulers have faced disbelief from friends and medical professionals because they don’t conform to the typical profile of the disease. People have questioned how they could possibly be so sick for so long, or whether they’re just stressed or anxious. “It feels like no one understands,” said Chloe Kaplan from Washington, D.C., who works in education and is on day 78. “I don’t think people are aware of the middle ground, where it knocks you off your feet for weeks, and you neither die nor have a mild case.”

The notion that most cases are mild and brief bolsters the belief that only the sick and elderly need isolate themselves, and that everyone else can get infected and be done with it. “It establishes a framework in which ‘not hiding’ from the disease looks a manageable and sensible undertaking,” writes Felicity Callard, a geographer at the University of Glasgow, who is on day 77. As the pandemic discourse turns to talk of a second wave, long-haulers who are still grappling with the consequences of the first wave are frustrated. “I’ve been very concerned by friends and family who just aren’t taking this seriously because they think you’re either asymptomatic or dead,” said Hannah Davis, an artist from New York City, who is on day 71. “This middle ground has been hellish.”

It “has been like nothing else on Earth,” said Paul Garner, who has previously endured dengue fever and malaria, and is currently on day 77 of COVID-19. Garner, an infectious-diseases professor at the Liverpool School of Tropical Medicine, leads a renowned organization that reviews scientific evidence on preventing and treating infections. He tested negative on day 63. He had waited to get a COVID-19 test partly to preserve them for health-care workers, and partly because, at one point, he thought he was going to die. “I knew I had the disease; it couldn’t have been anything else,” he told me. I asked him why he thought his symptoms had persisted. “I honestly don’t know,” he said. “I don’t understand what’s happening in my body.”

On March 17, a day after LeClerc came down with her first symptoms, SARS-CoV-2 sent Fiona Lowenstein to the hospital. Nine days later, after she was discharged, she started a Slack support group for people struggling with the disease. The group, which is affiliated with a wellness organization founded by Lowenstein called Body Politic, has been a haven for long-haulers. One channel for people whose symptoms have lasted longer than 30 days has more than 3,700 members.

“The group was a savior for me,” said Gina Assaf, a design consultant in Washington, D.C., who is now on day 77. She and other members with expertise in research and survey design have now sampled 640 people from the Body Politic group and beyond. Their report is neither representative nor peer-reviewed, but it provides a valuable snapshot of the long-hauler experience.

Of those surveyed, about three in five are between the ages of 30 and 49. About 56 percent have not been hospitalized, while another 38 percent have visited the ER but were not admitted. About a quarter have tested positive for COVID-19 and almost half have never been tested at all. Some became sick in mid-March, when their home countries were severely short on tests. (Most survey respondents live in the U.S. and the U.K.) Others were denied testing because their symptoms didn’t match the standard set. Angela Meriquez Vázquez, a children’s activist in Los Angeles, had gastrointestinal problems and lost her sense of smell, but because she didn’t have a cough and her fever hadn’t topped 100 degrees Fahrenheit, she didn’t meet L.A.’s testing criteria. By the time those criteria were loosened, Vázquez was on day 14. She got a test, and it came back negative. (She is now on day 69.)

A quarter of respondents in the Body Politic survey have tested negative, but that doesn’t mean they don’t have COVID-19. Diagnostic tests for SARS-CoV-2 miss infections up to 30 percent of the time, and these false negatives become more likely a week after a patient’s first symptoms appear. In the Body Politic survey, respondents with negative test results were tested a week after those with positive ones, on average, but the groups did not differ in their incidence of 60 different symptoms over time. Those matching patterns strongly suggest that those with negative tests are indeed dealing with the same disease. They also suggest that the true scope of the pandemic has been underestimated, not just because of the widespread lack of testing but because many people who are getting tested are receiving false negatives.

COVID-19 affects many different organs—that much is now clear. But in March, when many long-haulers were first falling sick with gut, heart, and brain problems, the disease was still regarded as a mainly respiratory one. To date, the only neurological symptom that the Centers for Disease Control and Prevention lists in its COVID-19 description is a loss of taste or smell. But other neurological symptoms are common among the long-haulers who answered the Body Politic survey.

As many people reported “brain fogs” and concentration challenges as coughs or fevers. Some have experienced hallucinations, delirium, short-term memory loss, or strange vibrating sensations when they touch surfaces. Others are likely having problems with their sympathetic nervous system, which controls unconscious processes like heartbeats and breathing: They’ll be out of breath even when their oxygen level is normal, or experience what feel like heart attacks even though EKG readings and chest X-rays are clear. These symptoms wax, wane, and warp over time. “It really is a grab bag,” said Davis, who is a co-author of the Body Politic survey. “Every day you wake up and you might have a different symptom.”

It’s not clear why this happens. Akiko Iwasaki, an immunologist at Yale, offers three possibilities. Long-haulers might still harbor infectious virus in some reservoir organ, which is missed by tests that use nasal swabs. Or persistent fragments of viral genes, though not infectious, may still be triggering a violent immune overreaction, as if “you’re reacting to a ghost of a virus,” Iwasaki says. More likely, the virus is gone but the immune system, having been provoked by it, is stuck in a lingering overactive state.

It’s hard to distinguish between these hypotheses, because SARS-CoV-2 is new and because the aftermath of viral infections is poorly understood. Many diseases cause long-lasting symptoms, but these might go unnoticed as trends unless epidemics are especially large. “Nearly every single person with Ebola has some long-term chronic complication, from subtle to obviously debilitating,” says Craig Spencer of the Columbia University Medical Center, who caught the virus himself in 2014. Some of those persistent problems had been noted during early Ebola outbreaks, but weren’t widely appreciated until 28,600 people were infected in West Africa from 2013 to 2016.

The sheer scale of the COVID-19 pandemic, which reached more than 6 million confirmed cases worldwide in a matter of months, means that long-haulers are now finding one another in sufficient numbers to shape their own narrative.

As the pandemic continues, long-haulers are navigating a landscape of uncertainty and fear with a map whose landmarks don’t reflect their surroundings. If your symptoms last for longer than two weeks, for how long should you expect to be sick? If they differ from the official list, how do you know which ones are important? “I’m acutely aware of my body at all times of the day,” LeClerc told me. “It shrinks your entire world to an almost reptilian response to your surroundings.”

If you’re still symptomatic, could you conceivably infect someone else if you leave your home? Garner, the infectious disease expert, is confident that this far out, he’s not shedding live virus anymore. But Meg Hamilton, who is a nursing student in Odenton, Maryland—and, full disclosure, my sister-in-law—said that her local health department considered her to be contagious as long as she had a fever; she is on day 56, and has only had a few normal temperature readings. Davis said that she and her partner, who live in different apartments, talked through the risks and decided to reunite on day 59. Until then, she had been dealing with two months of COVID-19 alone.

The isolation of the pandemic has been hard enough for many healthy people. But it has exacerbated the foggy minds, intense fatigue, and perpetual fear of erratic symptoms that long-haulers are also dealing with. “It plays with your head, man,” Garner said. Some feel guilt over being incapacitated even though their cases are “mild.” Some start doubting or blaming themselves. In her fourth week of fever, Hamilton began obsessively worrying that she had been using her thermometer incorrectly. “I also felt like I wasn’t being mentally strong enough, and by allowing myself to say that I don’t feel good, I was prolonging the fever,” she said.

Then there’s the matter of who to tell—and when. At first, Hamilton kept the news from her parents. She didn’t want them to worry, and she assumed she’d be better in two weeks. But as two weeks became three, then four, then five, the omission started feeling like an outright lie. Her concern that they would be worried morphed into concern that they would be mad. (She finally told them last week; they took it well.)

Other long-haulers have been frustrated by their friends’ and families’ inability to process a prolonged illness. “People know how to react to you having it or to you getting better,” LeClerc said. But when symptoms are rolling instead of abating, “people don’t have a response they can reach for.” They ask if she’s improving, in expectation that the answer is yes. When the answer is instead a list of ever-changing symptoms, they stop asking. Others pivot to disbelief. “I’ve had messages saying this is all in your head, or it’s anxiety,” LeClerc said.

Many such messages come from doctors and nurses. Davis described her memory loss and brain fog to a neurologist, who told her she had ADHD. “You feel really scared: These are people you’re trying to get serious help from, and they don’t even understand your reality,” she said. Vázquez said her physicians repeatedly told her she was just having panic attacks—but she knows herself well enough to discount that. “My anxiety is thought-based,” but with COVID-19, “the physical symptoms happen first,” she said.

Athena Akrami, a neuroscience professor at University College London, said two doctors suggested that she was stressed, while a fellow neuroscientist told her to calm down and take antidepressants. “I’m a very calm person, and something is wrong in my body,” said Akrami, who is now on day 79, and is also a co-author on the Body Politic survey. “As a scientist, I understand there are so many unknowns about the virus, but as a patient, I need acknowledgment.” Every day, Akrami said, “is like being in a tunnel.”

To be sure, many health-care workers are also exhausted, having spent several months fighting a new disease that they barely understand, without enough masks and other protective supplies. But well before the pandemic, the health-care profession had a long history of medical gaslighting—downplaying a patient’s physical suffering as being all in their head, or caused by stress or anxiety. Such dismissals particularly affect women, who are “less likely to be perceived as credible witnesses to our own experiences,” said LeClerc. And they’re especially common when women have subjective symptoms like pain or fatigue, as most long-haulers do. When Garner wrote about those same symptoms for the British Medical Journal’s blog, “I had an unbelievable feeling of relief,” Callard, the geographer, told me. “Since he’s a guy and a professor of infectious disease, he has the kind of epistemic authority that will be harder to discount.”

Garner’s descriptions of his illness are similar to those of many long-haulers who have been taken less seriously. “It wasn’t like he wrote those posts in some arcane language that’s steeped in authority,” said Sarah Ramey, a musician and author in Washington, D.C. “If you took his words, put my name on them, and put them up on Medium, people would say, ‘Ugh, who is this person and what is she talking about?’”

Ramey can empathize with long-haulers. In her memoir, The Lady’s Handbook for Her Mysterious Illness, she writes about her 17-year ordeal of excruciating pain, crushing fatigue, gastro-catastrophes, and medical gaslighting. “Being isolated and homebound, incredible economic insecurity, the government not doing enough, testing not being up to snuff—all of that is the lived experience of someone like me for decades,” she says. “The illness itself is horrible and ravaging, but being told you’ve made it up, over and over again, is by far the worst of it.”

Formally, Ramey has myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and complex regional pain syndrome. Informally, she’s part of a group she has dubbed WOMIs—women with mysterious illnesses. Such conditions include ME/CFS, fibromyalgia, and postural orthostatic tachycardia syndrome. They disproportionately affect women; have unclear causes, complex but debilitating symptoms, and no treatments; and are hard to diagnose and easy to dismiss. According to the Institute of Medicine, 836,000 to 2.5 million people in the U.S. alone have ME/CFS. Between 84 and 91 percent are undiagnosed.

That clusters of ME/CFS have followed many infectious outbreaks is noteworthy. In such events, some people get better quickly, others are sick for longer with postviral fatigue, and still others are suffering months or years later. In one Australian study, 11 percent of people infected with Ross River virus, Epstein-Barr virus, or the bacterium behind Q fever were diagnosed with ME/CFS after six months. In a study of 233 Hong Kong residents who survived the SARS epidemic of 2003, about 40 percent had chronic-fatigue problems after three years or so, and 27 percent met the CDC’s criteria for ME/CFS. Many different acute pathogens seem to trigger the same inflammatory responses that culminate in the same chronic endgame. Many individuals in this community are worried about COVID-19, according to Ramey: “You’ve got this highly infectious virus sweeping around the world, and it would be unusual if you didn’t see a big uptick in ME/CFS cases.”

ME/CFS is typically diagnosed when symptoms persist for six months or more, and the new coronavirus has barely been infecting humans for that long. Still, many of the long-haulers’ symptoms “sound exactly like those that patients in our community experience,” says Jennifer Brea, the executive director of the advocacy group #MEAction.

LeClerc, Akrami, and others have noted that their symptoms reappear when they try to regain a measure of agency by cleaning, working out, or even doing yoga. This is post-exertional malaise—the defining feature of ME/CFS. It’s a severe multi-organ crash that follows activity as light as a short walk. It’s also distinct from mere exhaustion: You can’t just push through it, and you’ll feel much worse if you try. The ME/CFS community has learned that resting as much as possible in the early months of postviral fatigue is crucial. Garner learned that lesson the hard way. After writing that “my disease has lifted,” he did a high-intensity workout, and was bedridden for three days. He is now reading literature about ME/CFS and listening to his sister, who has had the disease. “We have much to learn from that community,” he says.

The symptoms of ME/CFS have long been trivialized; its patients disbelieved; its researchers underfunded. The condition is especially underdiagnosed among black and brown communities, who are also disproportionately likely to be infected and killed by COVID-19. If the pandemic creates a large population of people who have symptoms that are similar to those of ME/CFS, it might trigger research into this and other overlooked diseases. Several teams of scientists are already planning studies of COVID-19 patients to see if any become ME/CFS patients—and why. Brea says she would welcome such a development. But she also feels “a lot of grief for people who may have to walk that path, [and] grief for the time we could have spent over the last four decades researching this so we’d have a better understanding of how to treat patients now.”

Some long-haulers will get better. The Body Politic Slack support group has a victories channel, where people post about promising moments on the road to recovery. Such stories were scarce last month, but more have appeared in the past weeks. The celebrations are always tentative, though. Good days are intermingled with terrible ones. “It’s a reverse-circling of the drain,” Vázquez said. “It has gotten better, but I track that trajectory in weeks, not days.” The COVID-19 dashboard from Johns Hopkins shows that about 2.7 million people around the world have “recovered” from the disease. But recovery is not a simple matter of flipping a switch. For some, it will take more time than the entire duration of the pandemic thus far.

Some survivors will have scar tissue from the coronavirus’s assault on their lungs. Some will still be weak after lengthy stays in ICUs or on ventilators. Some will eventually be diagnosed with ME/CFS. Whatever the case, as the pandemic progresses, the number of people with medium-to-long-term disabilities will increase. “Some science fiction—and more than a few tech bros—have led us to believe in a nondisabled future,” says Ashley Shew of Virginia Tech, who studies the intersection between technology and disability. “But whether through environmental catastrophe, or new viruses, we can expect more, exacerbated, and new disabilities.”

In the early 1950s, polio permanently disabled tens of thousands of people in the U.S. every year, most of whom were children or teenagers who “saw their futures as able and healthy,” Shew says. In the ’60s and ’70s, those survivors became pioneers of the disability-rights movement in the U.S.

Perhaps COVID-19 will similarly galvanize an even larger survivor cohort. Perhaps, collectively, they can push for a better understanding of neglected chronic diseases, and an acceptance of truths that the existing disability community have long known. That health and sickness are not binary. That medicine is as much about listening to patients’ subjective experiences as it is about analyzing their organs. That being a survivor is something you must also survive.

‘Between 25% and 50%’ of people who get the coronavirus may show no symptoms but still be contagious, Anthony Fauci said. Here’s the latest research on asymptomatic carriers.

Posted on April 7, 2020 by henrykotula • Posted in Asymptomatic Transmission, Centers for Disease Control & Prevention (CDC), Clinical Testing, Coronavirus, Crisis, Crisis Management, Health Policy, Infection Control, Infectious Virus, Pandemic, Presymptomatic Transmission, Public Health, Public Safety, World Health Organization (WHO) • Leave a comment

https://www.yahoo.com/news/1-4-people-coronavirus-may-234600518.html

Coronavirus carriers can transmit it without symptoms: What to ...

The coronavirus has infected more than 1.2 million people worldwide in just a few months. Scientists are racing to discover how it spreads so quickly.
According to Anthony Fauci, “between 25% and 50%” of people may be asymptomatic carriers — people who are contagious but not physically sick.
These carriers are thought to play a significant role in the virus’ spread and are the reason US residents have been asked to start covering their faces in public.

At least one-third of the world is under some type of lockdown because of the coronavirus pandemic, as governments urge social distancing to stymie the virus’ spread.

That’s because the COVID-19 virus is insidious.

“There’s significant transmission by people not showing symptoms,” Stephen Morse, an epidemiologist at Columbia University, told Business Insider.

According to Anthony Fauci, the director of the National Institute of Allergy and Infectious Disease, “somewhere between 25% and 50%” of people infected with the new coronavirus may never show symptoms or fall ill — but can still transmit the illness to others.

During a White House briefing on Sunday, Fauci cautioned that this was just an estimate, and said there is disagreement even among his colleagues as to how many people are asymptomatic. He added that antibody tests — which can confirm whether a person has already had COVID-19 — are needed to answer that question “in a scientifically sound way.”

Robert Redfield, director of the Centers for Disease Control and Prevention, gave NPR a similar estimate on Tuesday, saying that as many as 25% of people infected with the new coronavirus may never show symptoms.

These asymptomatic carriers, Redfield added, are most likely contributing to the rapid spread of the coronavirus worldwide — the number of confirmed cases passed 1 million last week — and making it challenging for experts to assess the true extent of the pandemic.

“We don’t know all the unidentified cases out there,” Morse said. “It’s mostly sicker people in hospitals who are being tabulated.”

The prevalence of asymptomatic transmission doesn’t bode well for global containment efforts, as Bill Gates recently wrote in an article published in the New England Journal of Medicine.

“That means COVID-19 will be much harder to contain than the Middle East respiratory syndrome or severe acute respiratory syndrome (SARS), which were spread much less efficiently and only by symptomatic people,” Gates said.

What we know about asymptomatic and presymptomatic transmission

The first confirmation that the novel coronavirus could be transmitted by asymptomatic people came in February, when a case study described a 20-year-old woman from Wuhan, China, who passed the coronavirus to five family members but never got physically sick herself.

A World Health Organization report about the coronavirus outbreak in China, also published in February, found few instances in which a person who tested positive never showed any symptoms. Instead, most people who were asymptomatic on the date of their diagnosis (a relatively small group) went on to develop symptoms later.

“The proportion of truly asymptomatic infections is unclear but appears to be relatively rare,” the report authors wrote.

In the WHO study, 75% of people in China who were first classified as asymptomatic later developed symptoms, ProPublica reported. That means, technically, “presymptomatic transmission” is what’s probably common.

Other research has reaffirmed these findings. A CDC study of coronavirus patients in a nursing home in King County, Washington, found that of 23 people who tested positive, only 10 showed symptoms on the day of their diagnosis. Ten people in the other group developed symptoms a week later.

“These findings have important implications for infection control,” the authors wrote, adding that many public-health approaches “rely on presence of signs and symptoms to identify and isolate residents or patients who might have COVID-19.”

The CDC also evaluated coronavirus patients on the Diamond Princess cruise ship, which was quarantined in Japan in February. Of the 3,711 people on board, 712 tested positive, but almost half of them had no symptoms at the time.

Other examples of asymptomatic and presymptomatic transmission abound

Redfield told NPR “it appears that we’re shedding significant virus” about 48 hours before symptoms appear.

“This helps explain how rapidly this virus continues to spread across the country, because we have asymptomatic transmitters and we have individuals who are transmitting 48 hours before they become symptomatic,” he added.

A handful of recent studies and reports suggest that presymptomatic and asymptomatic transmission is not unusual.

A small study among Japanese ex-pats evacuated from Wuhan in February found that 31% of people who tested positive showed no symptoms.
Research that examined coronavirus cases in Singapore found that of 157 cases acquired locally, 10 involved presymptomatic transmission. The scientists concluded that most presymptomatic transmission exposure occurred one to three days before a person developed symptoms.
Research from China in February found that 13% of the 468 confirmed cases studied involved presymptomatic transmission.
The Los Angeles Times recently reported that a three-quarters of a group of singers who attended a 60-person choir practice got the COVID-19 virus, even though none showed symptoms at the practice.
Last month, 14 NBA players, coaches, and staff tested positive for the coronavirus. Half of them didn’t have symptoms when they received their diagnosis, according to The Wall Street Journal.
A biotech company in Iceland that has tested more than 9,000 people found that about half of those who tested positive said they were asymptomatic, the researchers told CNN.

Presymptomatic people are shedding the highest amount of the virus

An especially troubling aspect of presymptomatic transmission is that people seem to shed more coronavirus in the earlier stages of their infection. But the average symptom onset takes five days.

Research that examined 23 coronavirus patients in two Hong Kong hospitals found that people’s viral load — how many viral particles they were carrying and shedding into their environment — peaked during the first week of symptom onset and then gradually declined. A SARS patient, by contrast, sheds the most virus seven days to 10 days after getting visibly sick.

A study from Guangzhou found similar results: Among 94 patients, people were most contagious right when symptoms started to show, or just before.

Children could be asymptomatic carriers

A notable group of asymptomatic carriers could be children. Thus far, children are among those least sickened by the novel coronavirus — but some could be getting very mild infections and then spreading the virus.

Research published March 25 in the journal The Lancet looked at 36 children who tested positive for the coronavirus from January 17 to March 1 in three Chinese hospitals. Half of those children had “mild disease with no presenting symptoms,” the authors wrote.

Another study, published today, looked at more than 2,500 coronavirus cases among children younger than 18 in the US between February 12 and April 2, 2020. The authors found that 73% of patients in this age group had a fever, cough, or shortness of breath, compared to 93% of adults between the ages of 18 and 64.

The researchers concluded that “children do not always have fever or cough as reported signs and symptoms” of COVID-19.

Yet another recent study, which has yet to be peer-reviewed, found that 56% of 700 children infected with COVID-19 in China had mild, if any, symptoms.

John Williams, an expert in pediatric infectious disease at the University of Pittsburgh Medical Center, told ABC that “asymptomatic infection is common in children, occurring in 10-30%” of cases.

Wearing masks could help reduce presymptomatic transmission

On Friday, the CDC recommended that people in the US wear cloth masks when they go out in public, even if they feel healthy.

The policy is different from the agency’s recommendations during the early days of the coronavirus outbreak, when CDC experts said they did not “recommend the use of face masks for the general public” and the US surgeon general urged Americans to stop buying masks.

The prevalence of presymptomatic transmission is a primary reason for the change.

“We have always recommended that symptomatic people wear a mask because if you’re coughing, if you have a fever, if you’re symptomatic, you could transmit disease to other people,” Surgeon General Jerome Adams said at the White House Friday. He added, “we now know from recent studies that a significant portion of individuals with coronavirus lack symptoms. This means that the virus can spread between people interacting in close proximity, for example, coughing, speaking, or sneezing, even if those people were not exhibiting symptoms.”

Face protection for the most part doesn’t benefit the wearer; instead, masks primarily protect others from the wearer’s germs.

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HENRY KOTULA

A Healthcare Leadership Blog

Category Archives: Asymptomatic Transmission

‘Between 25% and 50%’ of people who get the coronavirus may show no symptoms but still be contagious, Anthony Fauci said. Here’s the latest research on asymptomatic carriers.

What we know about asymptomatic and presymptomatic transmission

Other examples of asymptomatic and presymptomatic transmission abound

Presymptomatic people are shedding the highest amount of the virus

Children could be asymptomatic carriers

Wearing masks could help reduce presymptomatic transmission

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Lung scarring

Stroke, embolisms, and blood clotting

Heart damage

Neurocognitive and mental health impacts

Childhood inflammation, male infertility, and other possible lasting effects

What all of this means for survivors and researchers

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Why Covid-19 deaths aren’t rising along with cases — yet

Younger people are less at risk from Covid-19 — but their risk isn’t zero

The coronavirus could easily jump from younger people to the more vulnerable

Health systems haven’t been overwhelmed — but some hospitals in new hot spots are getting close

We don’t have to lock down forever — but we have to be smart and vigilant

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What is a superspreader?

What are the characteristics of a superspreader?

How big a part of COVID-19 are superspreaders?

When have superspreaders played a key role in an outbreak?

Can superspreading occur in all infectious diseases?

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What we know about asymptomatic and presymptomatic transmission

Other examples of asymptomatic and presymptomatic transmission abound

Presymptomatic people are shedding the highest amount of the virus

Children could be asymptomatic carriers

Wearing masks could help reduce presymptomatic transmission

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