Category Archives: Coronavirus

Federal Reserve – Semiannual Monetary Policy Report to the Congress

Posted on by • Posted in 2020 Election Issues, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economic Recovery, Economic Stimulus, Fiscal Policy, Gross Domestic Product (GDP), Job, Job Growth, Job Market, Mission, Monetary Policy, Paycheck Protection Program, Responsibility, The CARES Act, Transparency • Leave a comment

https://www.federalreserve.gov/newsevents/testimony/powell20200616a.htm

Federal Reserve Board - Structure of the Federal Reserve System

Chair Powell submitted identical remarks to the Committee on Financial Services, U.S. House of Representatives, Washington, D.C., on June 17, 2020.

Chairman Crapo, Ranking Member Brown, and other members of the Committee, thank you for the opportunity to present the Federal Reserve’s semiannual Monetary Policy Report.

Our country continues to face a difficult and challenging time, as the pandemic is causing tremendous hardship here in the United States and around the world. The coronavirus outbreak is, first and foremost, a public health crisis. The most important response has come from our health-care workers. On behalf of the Federal Reserve, I want to express our sincere gratitude to these dedicated individuals who put themselves at risk, day after day, in service to others and to our nation.

Current Economic Situation and Outlook
Beginning in mid-March, economic activity fell at an unprecedented speed in response to the outbreak of the virus and the measures taken to control its spread. Even after the unexpectedly positive May employment report, nearly 20 million jobs have been lost on net since February, and the reported unemployment rate has risen about 10 percentage points, to 13.3 percent. The decline in real gross domestic product (GDP) this quarter is likely to be the most severe on record. The burden of the downturn has not fallen equally on all Americans. Instead, those least able to withstand the downturn have been affected most. As discussed in the June Monetary Policy Report, low-income households have experienced, by far, the sharpest drop in employment, while job losses of African Americans, Hispanics, and women have been greater than that of other groups. If not contained and reversed, the downturn could further widen gaps in economic well-being that the long expansion had made some progress in closing.

Recently, some indicators have pointed to a stabilization, and in some areas a modest rebound, in economic activity. With an easing of restrictions on mobility and commerce and the extension of federal loans and grants, some businesses are opening up, while stimulus checks and unemployment benefits are supporting household incomes and spending. As a result, employment moved higher in May. That said, the levels of output and employment remain far below their pre-pandemic levels, and significant uncertainty remains about the timing and strength of the recovery. Much of that economic uncertainty comes from uncertainty about the path of the disease and the effects of measures to contain it. Until the public is confident that the disease is contained, a full recovery is unlikely.

Moreover, the longer the downturn lasts, the greater the potential for longer-term damage from permanent job loss and business closures. Long periods of unemployment can erode workers’ skills and hurt their future job prospects. Persistent unemployment can also negate the gains made by many disadvantaged Americans during the long expansion and described to us at our Fed Listens events. The pandemic is presenting acute risks to small businesses, as discussed in the Monetary Policy Report. If a small or medium-sized business becomes insolvent because the economy recovers too slowly, we lose more than just that business. These businesses are the heart of our economy and often embody the work of generations.

With weak demand and large price declines for some goods and services—such as apparel, gasoline, air travel, and hotels—consumer price inflation has dropped noticeably in recent months. But indicators of longer-term inflation expectations have been fairly steady. As output stabilizes and the recovery moves ahead, inflation should stabilize and then gradually move back up over time closer to our symmetric 2 percent objective. Inflation is nonetheless likely to remain below our objective for some time.

Monetary Policy and Federal Reserve Actions to Support the Flow of Credit
The Federal Reserve’s response to this extraordinary period is guided by our mandate to promote maximum employment and stable prices for the American people, along with our responsibilities to promote the stability of the financial system. We are committed to using our full range of tools to support the economy in this challenging time.

In March, we quickly lowered our policy interest rate to near zero, reflecting the effects of COVID-19 on economic activity, employment, and inflation, and the heightened risks to the outlook. We expect to maintain interest rates at this level until we are confident that the economy has weathered recent events and is on track to achieve our maximum-employment and price-stability goals.

We have also been taking broad and forceful actions to support the flow of credit in the economy. Since March, we have been purchasing sizable quantities of Treasury securities and agency mortgage-backed securities in order to support the smooth functioning of these markets, which are vital to the flow of credit in the economy. As described in the June Monetary Policy Report, these purchases have helped restore orderly market conditions and have fostered more accommodative financial conditions. As market functioning has improved since the strains experienced in March, we have gradually reduced the pace of these purchases. To sustain smooth market functioning and thereby foster the effective transmission of monetary policy to broader financial conditions, we will increase our holdings of Treasury securities and agency mortgage-backed securities over coming months at least at the current pace. We will closely monitor developments and are prepared to adjust our plans as appropriate to support our goals.

To provide stability to the financial system and support the flow of credit to households, businesses, and state and local governments, the Federal Reserve, with the approval of the Secretary of the Treasury, established 11 credit and liquidity facilities under section 13(3) of the Federal Reserve Act. The June Monetary Policy Report provides details on these facilities, which fall into two categories: stabilizing short-term funding markets and providing more-direct support for credit across the economy.

To help stabilize short-term funding markets, the Federal Reserve set up the Commercial Paper Funding Facility and the Money Market Liquidity Facility to stem rapid outflows from prime money market funds. The Fed also established the Primary Dealer Credit Facility, which provides loans against good collateral to primary dealers that are critical intermediaries in short-term funding markets.

To more directly support the flow of credit to households, businesses, and state and local governments, the Federal Reserve established a number of facilities. To support the small business sector, we established the Paycheck Protection Program Liquidity Facility to bolster the effectiveness of the Coronavirus Aid, Relief, and Economic Security Act’s (CARES Act) Paycheck Protection Program. Our Main Street Lending Program, which we are in the process of launching, supports lending to both small and midsized businesses. The Term Asset-Backed Securities Loan Facility supports lending to both businesses and consumers. To support the employment and spending of investment-grade businesses, we established two corporate credit facilities. And to help U.S. state and local governments manage cash flow pressures and serve their communities, we set up the Municipal Liquidity Facility.

The tools that the Federal Reserve is using under its 13(3) authority are appropriately reserved for times of emergency. When this crisis is behind us, we will put them away. The June Monetary Policy Report reviews the implications of these tools for the Federal Reserve’s balance sheet.

Many of these facilities have been supported by funding from the CARES Act. We will be disclosing, on a monthly basis, names and details of participants in each such facility; amounts borrowed and interest rate charged; and overall costs, revenues, and fees for each facility. We embrace our responsibility to the American people to be as transparent as possible, and we appreciate that the need for transparency is heightened when we are called upon to use our emergency powers.

We recognize that our actions are only part of a broader public-sector response. Congress’s passage of the CARES Act was critical in enabling the Federal Reserve and the Treasury Department to establish many of the lending programs. The CARES Act and other legislation provide direct help to people, businesses, and communities. This direct support can make a critical difference not just in helping families and businesses in a time of need, but also in limiting long-lasting damage to our economy.

I want to end by acknowledging the tragic events that have again put a spotlight on the pain of racial injustice in this country. The Federal Reserve serves the entire nation. We operate in, and are part of, many of the communities across the country where Americans are grappling with and expressing themselves on issues of racial equality. I speak for my colleagues throughout the Federal Reserve System when I say, there is no place at the Federal Reserve for racism and there should be no place for it in our society. Everyone deserves the opportunity to participate fully in our society and in our economy.

We understand that the work of the Federal Reserve touches communities, families, and businesses across the country. Everything we do is in service to our public mission. We are committed to using our full range of tools to support the economy and to help assure that the recovery from this difficult period will be as robust as possible.

Thank you. I am happy to take your questions.

 

 

 

 

Beijing cuts flights, shuts schools as new coronavirus cases raise alarm

Posted on by • Posted in Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, 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.washingtonpost.com/world/asia_pacific/beijing-cuts-flights-shuts-schools-as-new-coronavirus-cases-raise-alarm/2020/06/17/537dbe06-b069-11ea-98b5-279a6479a1e4_story.html?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most

Beijing cuts flights, shuts schools as new coronavirus cases raise ...

China is moving rapidly to seal off its capital of 22 million residents by canceling flights and trains amid growing fears that a potential second wave of covid-19 is gathering strength in Beijing and could spread to the rest of the country.

Authorities on Wednesday canceled 1,200 flights in and out of Beijing’s two airports and sharply reduced long-distance bus services. Beijingers were banned from making nonessential trips outside the city and required to take nucleic tests before they leave, municipal officials said at a briefing where they announced 31 new cases of the novel coronavirus.

While Beijing’s case numbers are low by global standards, they are vexing Chinese authorities who had touted their success in quickly stamping out the coronavirus and had taken pains to ensure it would not infect the seat of the ruling Communist Party. Government officials announced “wartime” measures on Saturday after dozens of cases were discovered at the Xinfadi wholesale market in southwest Beijing, which carried worrying echoes of the original outbreak in Wuhan late last year.

In the days since, Beijing has steadily reintroduced stricter measures, potentially foreshadowing the difficulty that many governments could face in warding off future waves of covid-19.

After classes resumed just a month ago, Beijing’s schools were again shut on Wednesday, as were some gyms, swimming pools and public attractions. The city raised its emergency response to the second-highest level, and entry and exit checkpoints and temperature checks returned to neighborhoods in the city center. The scenes were reminiscent of those during the outbreak’s peak in February and March, albeit with less-strict lockdown measures.

The risk of people in Beijing traveling in and out of the city and spreading infections countrywide is “severe,” acknowledged Chen Bei, Beijing’s deputy party chief. “We need to take decisive action . . . resolutely control this gathering epidemic and resolutely curb its spread inside and outside the city,” Chen said.

Officials said Beijing has tested 3.56 million people since June 13, underscoring the extent of their concern.

Adding to a sense of frustration with the virus’s reemergence, Chinese experts said it may have been lurking undetected for weeks.

“The Beijing outbreak very likely didn’t start in June, or May, but a month before that,” Gao Fu, head of the Chinese Center for Disease Control and Prevention, told reporters in Shanghai. “There can only be so many cases around us now if there were already many people with no symptoms or light symptoms back then. This is our current speculation, but we need to verify it.”

Chinese researchers say they are examining how the coronavirus made a sudden comeback. Fears that shipped livestock and produce could carry the virus — with potentially worrisome implications for international trade — began circulating this week after it was found at the Xinfadi market on cutting boards used for salmon, which is imported from Europe. The genetic material of viruses found at the market and in patients in Beijing also matched sequences typically found in patients in Europe.

Although the theory was fanned this week by nationalist media outlets including the party-run Global Times — which seized the opportunity to question whether the entire pandemic originated last year in Europe instead of China — Chinese and international experts, including the U.S. Food and Drug Administration, say there is relatively scant evidence that the virus is transmitted on food and packaging.

Wu Zunyou, the Chinese CDC’s top epidemiologist, said Tuesday that the virus was also found throughout the hall of the Xinfadi market, suggesting that the salmon was not necessarily the source. The strain of the virus found in Xinfadi is also prevalent in the United States, Wu added.

Michael Ryan, executive director of the World Health Organization’s Health Emergencies Program, also played down concerns about shipped food as a viral vector, saying the matter requires more study. “I’d be reticent to be in the position where all packaging and other things would need to be systematically tested,” Ryan said. “I don’t think it’s the primary hypothesis, but it needs to be explored.”

Meanwhile, supermarkets and restaurants in Beijing are not taking chances and have stopped selling salmon. The Beijing government said Wednesday it would carry out nucleic testing on all close contacts of people who visited the Xinfadi market, as well as workers in the city’s restaurants, which could number hundreds of thousands of people.

Cases in Beijing are expected to keep rising in the coming days because Xinfadi, which spans an area the size of 250 football fields, is such a large and central part of Beijing’s food distribution network, city officials warned.

As the capital fell again into quasi-lockdown this week, other Chinese cities, including Shanghai, began issuing quarantine requirements and restrictions for travelers from Beijing — a sudden reversal for residents who in normal times enjoy a privileged status.

Officials and state media have called for understanding and cooperation from Beijing residents while rallying citizens nationwide behind the city.

“Go Beijing! Go Zhajiang noodles!” said one popular meme on social media, referring to a classic Beijing dish.

 

 

 

 

Coronavirus drugmakers’ latest tactics: Science by press release

Posted on by • Posted in Clinical Research, Clinical Trials, Coronavirus, Coronavirus Treatment, False Hope, False Narrative, Food and Drug Administration (FDA), Hydroxychloroquine, Marketing, Mislead, Misleading, National Institute of Health (NIH), Partisanship, Pharmaceutical Industry, Political Pressure, Press Release, Remdesivir, Stock Manipulation, Vaccine, Whistleblower, Wishful Thinking • Leave a comment

https://www.politico.com/news/2020/06/05/drugmakers-media-coronavirus-303895

Coronavirus drugmakers' latest tactics: Science by press release ...

Pharmaceutical companies are using the media to tout treatments that are still under review.

Vaccine maker Moderna attracted glowing headlines and bullish investors when it revealed that eight participants in a preliminary clinical trial of its coronavirus vaccine had developed antibodies to the virus. The company’s share price jumped nearly 20 percent that day as it released a massive stock offering.

But the full results of the 45-person safety study haven’t been published, even though Moderna began a second, larger trial in late May aimed at determining whether the vaccine works. Several vaccine researchers say the scant public information on the earlier safety study is hard to evaluate because it addresses less than 20 percent of participants.

Call it science by press release — a tactic that pharmaceutical companies are increasingly relying upon to set their experimental coronavirus drugs and vaccines apart in a crowded field, shape public opinion and court regulators. Public health experts say the approach could increase political pressure on federal health officials to green-light drugs and vaccines before it is clear they are safe or effective, with potentially dangerous consequences.

“There’s a long history of pharmaceutical manufacturers putting out self-serving press releases related to clinical trial data that they’re developing that present an overly rosy picture of the data, usually with a boilerplate disclaimer at the end, which is fairly useless,” said Aaron Kesselheim, a professor of medicine at Harvard Medical School who studies drug regulation and pricing.

There are already signs of hype and political pressure influencing the U.S.’ coronavirus response. The Food and Drug Administration authorized emergency use of the malaria drug hydroxychloroquine in March without any proof that it was safe or effective for coronavirus patients — but with the backing of President Donald Trump, who had begun touting the treatment during daily White House briefings.

Subsequent studies have found that hydroxychloroquine doesn’t help those with Covid-19 and can cause potentially fatal side effects. And a top government scientist, Rick Bright, filed a whistleblower complaint in May alleging that he was ousted from his job leading the Biomedical Advanced Research Authority after he resisted political pressure to greenlight widespread use of the drug.

“The FDA has remained an unwavering, science-based voice helping to guide the all-of-government response,” agency Commissioner Stephen Hahn said in a statement. “I have never felt any pressure to make decisions, other than the urgency of the situation around COVID-19.”

But observers aren’t so sure. “From the outside looking in, there seems to be more political pressure than ever,” said Marc Scheineson, a former associate commissioner at the FDA and head of the FDA group at Alston & Bird. “The example in the White House is trickling down and there is a lot of pressure on the FDA … to color information on the optimistic side for political purposes and that is a hugely disturbing trend.”

A spokesperson for Moderna, which has received nearly a half billion dollars from the U.S. government and praise from Trump, said the company previewed its vaccine trial results by press release because it was concerned that the data might leak. The National Institutes of Health’s top infectious disease expert, Anthony Fauci, had hinted at the results in an interview with National Geographic, and data from a trial of the experimental drug remdesivir had leaked in April.

“You had this data moving widely around NIH and the remdesivir leak was also in our minds,” the Moderna spokesperson said.

But Peter Bach, director of Memorial Sloan-Kettering’s Center for Health Policy and Outcomes, said Moderna’s effort to preview its findings in the press “could be construed as an effort to make sure they are part of the conversation — and it worked on that front.”

Other groups have also previewed their hotly anticipated vaccine studies in the press. In late April, The New York Times revealed that six monkeys given a vaccine developed by researchers at the U.K.’s University of Oxford had stayed healthy for 28 days despite sustained exposure to the coronavirus. The article quoted Vincent Munster, a researcher at the NIH’s Rocky Mountain Laboratory, which conducted the monkey study at the British scientists’ behest.

The Oxford researchers, who signed a deal with AstraZeneca two days later to develop the experimental vaccine, did not publish a formal scientific analysis of the monkey data until mid-May. The study revealed that the noses of vaccinated monkeys and unvaccinated monkeys contained similar levels of coronavirus particles, suggesting that the vaccinated animals could still spread the disease — and the vaccine might not be as effective as the earlier data had hinted.

AstraZeneca has since inked a $1.2 billion deal with the U.S. government to provide 300 million vaccine doses, and a £65.5 million ($80 million) agreement with the U.K. government to supply 30 million doses.

Liz Derow, a spokesperson for Oxford’s Jenner Institute, where the vaccine researchers are based, said they did not give the monkey data to The New York Times. The NIH’s National Institute of Allergy and Infectious Disease, which operates the Rocky Mountain Laboratory, said it did not provide the data to the newspaper — but one of its researchers, Vincent Munster, spoke to a Times reporter about the monkey findings at the request of the Jenner Institute.

“I was really disturbed by not just Moderna, but the Oxford group as well, presenting a press release without data, without a scientific review, without knowing what the press release was based on,” said Barry Bloom, an immunologist at the Harvard School of Public Health. “And very positively enough to raise the stock price so two days later officials within the company sold their stock and made a whole lot of money, whether or not the vaccine works.”

Four of the pharmaceutical firm’s top executives together saw gains of $29 million from prescheduled sales of shares in the company in the two days following the vaccine announcement. The company has not yet responded to a request for comment on the stock sales.

Neither the Oxford nor Moderna vaccines are available to the public. But some drugs whose safety and efficacy are now being studied have already been repurposed or authorized for emergency use during the pandemic. The rush to release snippets of information on drug trials to the press ahead of full results has left some doctors wondering how to best treat their patients.

After leaked data from a trial of Gilead’s experimental antiviral remdesivir suggested the drug might be the first shown to help coronavirus patients, the company put out a press release in late April teasing results from a larger, government-run study. Hours later, Fauci revealed some findings of the study during an Oval Office press spray.

But the full analysis of the NIAID trial results was not published until three weeks later. Until that point, frontline physicians had no way to know that patients on ventilators did not benefit from remdesivir treatment — meaning that doctors may have inadvertently wasted some of the United States’ limited stock of the drug.

This lack of understanding on how to use remdesivir was evident in a recent survey more than 250 hospitals by the American Society of Health-System Pharmacists, which found that just 15 percent planned to use their remdesivir doses as described in the FDA’s emergency authorization for the drug.

Andre Kalil, an infectious disease doctor at the University of Nebraska Medical Center who led the NIAID trial, told POLITICO that physicians could have patterned their use of remdesivir on the dosages given during the trial.

Others say doctors using experimental treatments should have as much information as possible.

“If we want doctors to make rational medical decisions based on data, then before an authorized product reaches patients, the data should be available to review in some way, not just a press release,” said Walid Gellad, director of the University of Pittsburgh’s Center for Pharmaceutical Policy and Prescribing.

Kesselheim, too, said that clinical trial data should be made public alongside any emergency authorizations to give physicians “the maximum amount of help they need in figuring out how to prescribe the drug.”

Gilead did not respond to a request for comment. But NIAID said that the urgency of the coronavirus prompted Fauci to share initial results before a full analysis was ready for publication.

Ivan Oransky, a professor of medical journalism at New York University and co-founder of the blog Retraction Watch, which monitors errors and misconduct in scientific research, told POLITICO he fears that the temptation to conduct science by press release will get “worse before it gets better.”

The world is growing more desperate for drugs and vaccines that could bring the coronavirus to heel. And many members of the public and politicians are treating every scrap of scientific information about the pandemic equally, he said — whether data comes from a peer-reviewed study or a company press release.

“There have been mechanisms to review science critically that, given the speed of Covid, have gone out the window,” said Bloom.

And interpreting results of clinical trial data can be difficult under the best of circumstances — especially when that data concerns a virus that was unknown to science until December of last year. When to end a trial and which conclusions to highlight are in many cases a matter of discretion, said Scheineson.

“It’s an art, not a science, in that respect,” he said. “I, for one, will not be the first in line to the new Moderna vaccine.”

 

 

 

 

7 health systems report $1B+ losses in Q1

Posted on by • Posted in Coronavirus, Financially Distressed, Health System, Hospital, Hospital Industry, Net Income, Nonoperating Income, Operating Expenses, Operating Income, Operating Margin, Operating Performance, Operating Revenue • Leave a comment

https://www.beckershospitalreview.com/finance/7-health-systems-report-1b-losses-in-q1.html?utm_medium=email

The Dollar Total For 1996's Top Verdict Awards Continues On A ...

Health systems across the U.S. saw revenue decline, expenses rise and investment gains dwindle in the first quarter of this year due to the COVID-19 pandemic. 

For the three months ended March 31, some of the biggest nonprofit health systems in the U.S. reported losses. Below are seven health systems that reported net losses of $1 billion or more. 

Ascension (St. Louis)
Revenue: $6.1 billion
Operating loss: $429.4 million
Net loss: $2.7 billion

CommonSpirit Health (Chicago)
Revenue: $7.8 billion
Operating loss: $145 million
Net loss: $1.4 billion

Kaiser Permanente (Oakland, Calif.)
Revenue: $22.6 billion
Operating income: $1.3 billion
Net loss: $1.1 billion

Providence (Renton, Wash.)
Revenue: $6.3 billion
Operating loss: $276 million
Net loss: $1.1 billion

Sutter Health (Sacramento, Calif.)
Revenue: $3.2 billion
Operating loss: $236 million
Net loss: $1.1 billion

Advocate Aurora Health (Downers Grove, Ill., and Milwaukee)
Revenue: $3.1 billion
Operating loss: $85.6 million
Net loss: $1.3 billion

Intermountain Healthcare (Salt Lake City)
Revenue: $2.3 billion
Operating income: $115 million
Net loss: $1 billion

 

 

How America’s Hospitals Survived the First Wave of the Coronavirus

Posted on by • Posted in Centers for Disease Control & Prevention (CDC), Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Emergency Care, Health Policy, Health System, Hospital, Hospital Bed Shortage, Hospital Industry, Infection Control, Infection Control Plan, Infectious Virus, Mortality, Nurses, Pandemic, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Social Determinants of Health, Social Distancing, Supply Chain • Leave a comment

https://www.propublica.org/article/how-americas-hospitals-survived-the-first-wave-of-the-coronavirus?utm_campaign=KHN%3A%20Daily%20Health%20Policy%20Report&utm_medium=email&_hsmi=89534068&_hsenc=p2ANqtz-_ScZ5cfM_EdBiyP4jwWFycBvCn8JtmInnkxl0EQRlG5qsZADhpXleMqNI__2mSgqtsmLu3tSFHb1xe9BYu1uHhcdo3IA&utm_content=89534068&utm_source=hs_email

How America's Hospitals Survived the First Wave of the Coronavirus ...

ProPublica deputy managing editor Charles Ornstein wanted to know why experts were wrong when they said U.S. hospitals would be overwhelmed by COVID-19 patients. Here’s what he learned, including what hospitals can do before the next wave.

The prediction from New York Gov. Andrew Cuomo was grim.

In late March, as the number of COVID-19 cases was growing exponentially in the state, Cuomo said New York hospitals might need twice as many beds as they normally have. Otherwise there could be no space to treat patients seriously ill with the new coronavirus.

“We have 53,000 hospital beds available,” Cuomo, a Democrat, said at a briefing on March 22. “Right now, the curve suggests we could need 110,000 hospital beds, and that is an obvious problem and that’s what we’re dealing with.”

The governor required all hospitals to submit plans to increase their capacity by at least 50%, with a goal of doubling their bed count. Hospitals converted operating rooms into intensive care units, and at least one replaced the seats in a large auditorium with beds. The state worked with the federal government to open field hospitals around New York City, including a large one at the Jacob K. Javits Convention Center.

But when New York hit its peak in early April, fewer than 19,000 people were hospitalized with COVID-19. Some hospitals ran out of beds and were forced to transfer patients elsewhere. Other hospitals had to care for patients in rooms that had never been used for that purpose before. Supplies, medications and staff ran low. And, as The Wall Street Journal reported on Thursday, many New York hospitals were ill prepared and made a number of serious missteps.

All told, more than 30,000 New York state residents have died of COVID-19. It’s a toll worse than any scourge in recent memory and way worse than the flu, but, overall, the health care system didn’t run out of beds.

“All of those models were based on assumptions, then we were smacked in the face with reality,” said Robyn Gershon, a clinical professor of epidemiology at the NYU School of Global Public Health, who was not involved in the models New York used. “We were working without situational awareness, which is a tenet in disaster preparedness and response. We simply did not have that.”

Cuomo’s office did not return emails seeking comment, but at a press briefing on April 10, the governor defended the models and those who created them. “In fairness to the experts, nobody has been here before. Nobody. So everyone is trying to figure it out the best they can,” he said. “Second, the big variable was, what policies do you put in place? And the bigger variable was, does anybody listen to the policies you put in place?”

So, why were the projections so wrong? And how can political leaders and hospitals learn from the experience in the event there is a second wave of the coronavirus this year? Doctors, hospital officials and public health experts shared their perspectives.

The Models Overstated How Many People Would Need Hospital Care

The models used to calculate the number of people who would need hospitalization were based on assumptions that didn’t prove out.

Early data from the U.S. Centers for Disease Control and Prevention suggested that for every person who died of COVID-19, more than 11 would be hospitalized. But that ratio was far too high and decreased markedly over time, said Dr. Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington. IHME’s earliest models on hospitalizations were based on that CDC data and predicted that many states would quickly run out of hospital beds.

A subsequent model, released in early April, assumed about seven hospitalizations per death, reducing the predicted surge. Currently, Murray said, the ratio is about four hospital admissions per death.

“Initially what was happening and probably what we saw in the CDC data is doctors were admitting anybody they thought had COVID,” Murray said. “With time they started admitting only very sick people who needed oxygen or more aggressive care like mechanical ventilation.”

A patient with COVID-19 is taken into Mount Sinai Hospital in New York on May 3. (Alexi Rosenfeld/Getty Images)

A model created by the Harvard Global Health Institute made a different assumption that also turned out to be too high. Data from Wuhan, China, suggested that about 20% of those known to be infected with COVID-19 were hospitalized. Harvard’s model, which ProPublica used to build a data visualization, assumed a hospitalization rate in the United States of 19% for those under 65 who were infected and 28.5% for those older than 65.

But in the U.S., that percentage proved much too high. Official hospitalization rates vary dramatically among states, from as low as 6% to more than 20%, according to data gathered from states by The COVID Tracking Project. (States with higher rates may not have an accurate tally of those infected because testing was so limited in the early weeks of the pandemic.) As testing increases and doctors learn how to treat coronavirus patients out of the hospital, the average hospitalization rate continues to drop.

New York state’s testing showed that by mid-April, approximately 20% of the adult population in New York City had antibodies to COVID-19. Given the number hospitalized in the city and adjusting for the time needed for the body to produce antibodies, this means that the city’s hospitalization rate was closer to 2%, said Dr. Nathaniel Hupert, an associate professor at Weill Cornell Medicine and co-director of the Cornell Institute for Disease and Disaster Preparedness.

Dr. Ashish Jha, director of the Harvard Global Health Institute, and his team also assumed that between 20% and 60% of the population would be infected with COVID-19 over six to 18 months. That was before stay-at-home orders took effect nationwide, which slowed the virus’s spread. Outside of New York City, a far lower percentage of the population has been infected. Granted, we’re not even six months into the pandemic.

A number of factors go into disease models, including the attack rate (the percentage of the entire population that eventually becomes infected), the symptomatic rate (how many people are going to show symptoms), the hospitalization rate for different age groups, the fraction of those hospitalized that will need intensive care and how much care they will need, as well as how the disease travels through the population over time (what is known as “the shape of the epidemic curve”), Hupert said.

Before mid-March, Hupert’s best estimate of the impact of COVID-19 in New York state was that it would lead to a peak hospital occupancy of between 13,800 to 61,000 patients in both regular medical wards and intensive care. He shared his work with state officials.

David Muhlestein, chief strategy and chief research officer at Leavitt Partners, a health care consulting firm, said one takeaway from COVID-19 is that models can’t try to predict too far into the future. His firm has created its own projection tool for hospital capacity that looks ahead three weeks, which Muhlestein said is most realistic given the available data.

“If we were held to our very initial projection of what was going to happen, everybody would be very wrong in every direction,” he said.

Hospitals Proved Surprisingly Adept at Adding Beds

When calculating whether hospitals would run out of beds, experts used as their baseline the number of beds in use in each hospital, region and state. That makes sense in normal times because hospitals have to meet stringent rules before they are able to add regular beds or intensive care units.

Workers prepare dozens of extra beds that were delivered to Mount Sinai on March 31. (Spencer Platt/Getty Images)

But in the early weeks of the pandemic, state health departments waived many rules and hospitals responded by increasing their capacity, sometimes dramatically. “Just because you only have six ICU beds doesn’t mean they will only have six ICU beds next week,” Muhlestein said. “They can really ramp that up. That’s one of the things we’re learning.”

Take Northwell Health, a chain of 17 acute-care hospitals in New York. Typically, the system has 4,000 beds, not including maternity beds, neonatal intensive care unit beds and psychiatric beds. The system grew to 6,000 beds within two weeks. At its peak, on April 7, the hospitals had about 5,500 patients, of which 3,425 had COVID-19.

The system erected tents, placed patients in lobbies and conference rooms, and its largest hospital, North Shore University Hospital, removed the chairs from its 300-seat auditorium and replaced them with a unit capable of treating about 50 patients. “We were pulling out all the stops at that point,” Senior Vice President Terence Lynam said. “It was unclear if the trend was going to go the other way. We did not end up needing them all.”

Northwell went from treating 49 COVID-19 inpatients on March 16 to 3,425 on April 7. “I don’t think anybody had a clear handle on what the ceiling was going to be,” Lynam said. As of Wednesday, the system was still caring for 367 COVID-19 patients in its hospitals.

As hospitals found ways to expand, government leaders worked with the Army Corps of Engineers to build dozens of field hospitals across the country, such as the one at the Javits Center. According to an analysis of federal spending by NPR, those efforts cost at least $660 million. “But nearly four months into the pandemic, most of these facilities haven’t treated a single patient,” NPR reported. As they began to come online, stay-at-home orders started producing results, with fewer positive cases and fewer hospitalizations.

Demand for Non-COVID-19 Care Plummeted More Than Expected

Hospitals across the country canceled elective surgeries, from hip replacements to kidney transplants. That greatly reduced the number of non-COVID-19 patients they had to treat. “We generated a lot more capacity by getting rid of elective procedures than any of us thought was possible,” Harvard’s Jha said.

Northwell canceled elective surgeries on March 16, and over the span of the next week and a half, its hospitals discharged several thousand patients in anticipation of the coming surge. “In retrospect, it was a wise move,” Lynam said. “It just ballooned after that. If we had not discharged those patients in time, there would have been a severe bottleneck.”

What’s more, experts say, it’s clear that some patients with true emergencies also stayed home. A recent report from the CDC said that emergency room visits dropped by 42% in the early weeks of the pandemic. In 2019, some 2.1 million people visited ERs each week from late March to late April. This year, that dropped to 1.2 million per week. That was especially true for children, women and people who live in the Northeast.

In New York City, emergency room visits for asthma practically ceased entirely at the peak, Cornell’s Hupert said. “You wouldn’t imagine that asthma would just disappear,” he said. “Why did it go away? … Nobody has seen anything like that.”

Undoubtedly some people experienced heart attacks and strokes and didn’t go to the hospital because they were fearful of getting COVID-19. “I didn’t expect that,” Jha said. A draft research paper available on a preprint server, before it is reviewed and published in an academic journal, found that heart disease deaths in Massachusetts were unchanged in the early weeks of the pandemic compared to the same period in 2019. What that may mean is that those people died at home.

The Coronavirus Attacked Every Region at a Different Pace

Some initial models forecast that COVID-19 would hit different regions in similar ways. That has not been the case. New York was hit hard early; California was not, at least initially.

In recent weeks, hospitals in Montgomery, Alabama, saw a lot of patients. Arizona’s health director has told hospitals in the state to “fully activate” their emergency plans in light of a spike in cases there. The Washington Post reported on Tuesday that hospitalizations in at least nine states have been rising since Memorial Day.

St. Luke’s, a closed hospital in Phoenix, is prepared to receive overflow patients on April 23. Arizona initially wasn’t hit hard, but cases are now spiking. (Ross D. Franklin/AP Photo)

Dr. Mark Rupp, medical director of the Department of Infection Control and Epidemiology at the University of Nebraska Medical Center in Omaha, said his region hasn’t seen a tidal wave like New York. “What we’ve seen is a rising tide, a steady increase in the number of cases.” Initially that was associated with outbreaks at specific locations like meatpacking and food processing plants and to some degree long-term care facilities.

But since then, “it has just plateaued,” he said. “That has me concerned. This is a time when I feel like we should be working as hard as we can to push these numbers as low as possible.”

Rupp’s hospital has been caring for 50 to 60 COVID-19 patients on any given day. The hospital has started to perform surgeries and procedures that had been on hold because “elective cases stay elective for only so long.”

The hospital’s general medical/surgical beds are 70% to 80% filled, and its ICU beds are 80% to 90% full. “We don’t have a big cushion.”

Even in New York City, the virus hit boroughs differently. Queens and the Bronx were hard hit; Manhattan, Brooklyn and Staten Island less so. “Maybe we can’t even model a city as big as New York,” Hupert said. “Each neighborhood seemed to have a different type of outbreak.”

That needs further study but could be attributable to both social and demographic conditions and the type of jobs residents of the neighborhoods had, among other factors.

What We Can Learn From Coronavirus “Round One”

While hospitals were able to add beds more quickly than experts realized they could, some other resources were harder to come by. Masks, gowns and other personal protective equipment were tough to get. So were ventilators. Anesthesia agents and dialysis medications were in short supply. And every additional bed meant the need for more doctors, nurses and respiratory therapists.

In early February, before any cases were discovered in New York, Northwell purchased $5 million in PPE, ventilators and lab supplies just in case, Lynam said. “It turned out to be a wise move,” he said. “What’s clear is that you can never have enough.”

Northwell has spent $42 million on PPE alone. “We were going through 10,000 N95 masks a day, just a crazy amount,” he said. “One of the lessons learned is you have to stockpile the PPE. There’s got to be a better procurement process in place.”

If there’s one thing the system could have done differently, Lynam said, it’s bringing in more temporary nurses earlier. Northwell brought in 500 nurses from staffing agencies. “They came in a week later than they should have.”

Dr. Robert Wachter, chair of the department of medicine at the University of California, San Francisco, agreed. “I’ve helped run services in hospitals for 25 years,” he said. “I’ve probably given two minutes of thought to the notions of supply chains and PPE. You realize that is absolutely central to your preparedness. That’s a lesson.”

Experts and hospital leaders agree that everyone can do better if another wave hits. Here’s what that entails:

  • Having testing readily available, as it now is, to more quickly spot a resurgence of the virus.

  • Stocking up now on PPE and other supplies. “We definitely have to stockpile PPE by the fall,” Gershon of NYU said. “We have to. … [Hospitals and health departments] have to really get those contracts nailed down now. They should have been doing this, of course, all the time, but no one expected this kind of event.”

  • Being able to quickly move personnel and equipment from one hot spot to the next.

  • Planning for how to care for those with other medical ailments but who are scared of contracting COVID-19. “We have to have some sort of a mechanism by which we can offer people assurance that if they come in, they won’t get sick,” Jha said. “We can’t repeat in the fall what we just did in the spring. It’s terrible for hospitals. It’s terrible for patients.”

  • Providing mental health resources for front-line caregivers who have been deeply affected by their work. The intensity of the work, combined with watching patients suffer and die alone, was immensely taxing.

  • Coming up with ways to allow visitors in the hospital. Wachter said the visitor bans in place at many hospitals, though well intentioned, may have backfired. “When all hell was breaking loose and we were just doing the best we could in the face of a tsunami, it was reasonable to just keep everybody out,” he said. “We didn’t fully understand how important that was for patients, how much it might be contributing to some people not coming in for care when they really should have.”

Lynam of Northwell said he’s worried about what lies ahead. “You look back on the 1918 Spanish flu and the majority of victims from that died in the second wave. … We don’t know what’s coming on the second wave. There may be some folks who say you’re paranoid, but you’ve got to be prepared for the worst.”

 

 

 

Axios-Ipsos poll: Americans fear a second wave

Posted on by • Posted in 2020 Election Issues, Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economy Reopening, Expectations, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Mortality, Pandemic, Partisanship, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

https://www.axios.com/axios-ipsos-coronavirus-index-second-wave-87c327c2-42bb-43a5-80b2-5f2f513a24b2.html

Axios-Ipsos poll: Americans fear a second wave - Axios

Eight in 10 Americans are worried about a second wave of the coronavirus, with large majorities saying they’ll resume social distancing, dial back shopping and keep their kids out of school if it happens, in Week 13 of the Axios-Ipsos Coronavirus Index.

Why it matters: Businesses and schools around the country are trying to assess how quickly and fully they should reopen based in part on what Americans will demand and tolerate. These findings underscore the challenges in predicting how they should proceed.

  • But getting Americans to swallow a second round of 14-day self-quarantining could be tougher than getting them to go back to social distancing, with one in three saying they likely won’t do it.
  • The biggest factor is partisan identification, with 81% of Democrats but only 49% of Republicans saying they’ll self-quarantine if a second wave hits.

The big picture: The latest installment of our national weekly survey shows a renewed sense of risk following reports of new hospitalizations since states began lifting stay-at-home orders — but quarantine fatigue is still driving people to take their chances.

  • People’s assessment of large or moderate risk grew last week for each of these categories: returning to their normal workplace, dining out, retail shopping, going to the hair salon or participating in protests.
  • But the share of those going out to eat rose from 31% to 41%. Those visiting friends or relatives rose from 56% to 60%. Those getting their hair done rose from 26% to 31%. Those attending demonstrations rose from 11% to 14%.

What they’re saying: “People are starting to be concerned about it again,” said pollster Chris Jackson, senior vice president for Ipsos Public Affairs. “We’re not yet seeing changes in the patterns of their behavior yet, though.”

  • “Their behaviors are not really catching up to their concern level.”

By the numbers: 81% say they’re concerned about a second wave — including those who are extremely (30%), very (26%) or somewhat (24%) concerned.

  • 64% of those surveyed say returning to their normal pre-coronavirus life represents a large or moderate risk, up from 57% a week ago.
  • The share of people extremely or very concerned about getting sick rose from 32% to 40% last week. Those fearing U.S. economic collapse rose from 48% to 54%.
  • There also were upticks in people’s concerns about job security and the government’s response to the outbreak.
  • Americans’ ability to afford household goods also decreased.
  • One in 10 surveyed say they’ve been collecting unemployment benefits in recent weeks.
  • 35% of Americans now know someone who’s tested positive, a new high for the survey.

Between the lines: The survey suggests an evolving understanding of the racial disparities in the pandemic.

  • The share of those saying they are extremely or very concerned that the coronavirus is doing greater damage to people of color rose from 36% to 42%.
  • The share of those extremely or very concerned that official responses are biased against certain groups also rose from 36% to 42%.

 

 

 

 

Tower Health cutting 1,000 jobs as COVID-19 losses mount

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https://www.inquirer.com/business/health/tower-health-hospital-layoffs-covid-19-20200616.html

Tower Health cutting 1,000 jobs as COVID-19 losses mount

Tower Health on Tuesday announced that it is cutting 1,000 jobs, or about 8 percent of its workforce, citing the loss of $212 million in revenue through May because of the coronavirus restrictions on nonurgent care.

Fast-growing Tower had already furloughed at least 1,000 employees in April. It’s not clear how much overlap there is between the furloughed employees, some of whom have returned to work, and the people who are now losing their jobs permanently. Tower employs 12,355, including part-timers.

“The government-mandated closure of many outpatient facilities and the suspension of elective procedures caused a 40 percent drop in system revenue,” Tower’s president and chief executive, Clint Matthews, wrote in an email to staff. “At the same time, our spending increased for personal protective equipment, staff support, and COVID-related equipment needs.”

Despite the receipt of $66 million in grants through the federal CARES Act, Tower reported an operating loss of $91.6 million in the three months ended March 31, according to its disclosure to bondholders.

Tower, which is anchored by Reading Hospital in Berks County, expanded most recently with the December acquisition of St. Christopher’s Hospital for Children in a partnership with Drexel University. Tower paid $50 million for the hospital’s business, but also signed a long-term lease with a company that paid another $65 million for the real estate.

In 2017, Tower paid $418 million for five community hospitals in Southeastern Pennsylvania — Brandywine in Coatesville, Chestnut Hill in Philadelphia, Jennersville Regional in West Grove, Phoenixville in Phoenixville, and Pottstown Memorial Medical Center, now called Pottstown Hospital, in Pottstown.

Tower’s goal was to remain competitive as bigger systems — the University of Pennsylvania Health System and Jefferson Health from the Southeast, Lehigh Valley Health Network and St. Luke’s University Health Network from the east and northeast, and University of Pittsburgh Medical Center from the west — encroached on its Berk’s county base.

Tower had set itself a difficult task in the best of times, but COVID-19 has made it significantly harder for the nonprofit, which had an operating loss of $175 million on revenue of $1.75 billion in the year ended June 30, 2019.

Because health systems have high fixed costs for buildings and equipment needed no matter how many patients are coming through the door, it’s hard for them to limit the impact of the 30% to 50% collapse in demand caused by the coronavirus pandemic.

“Hospitals and all other health service providers were hit with this disruption with lightning speed, forcing the industry to learn in real time how to handle a situation for which there was no playbook,” Standard & Poor’s analysts David P. Peknay and Suzie R. Desai said in a research report last month.

Tower’s said positions will be eliminated in executive, management, clinical, and support areas.

The cuts include consolidations of clinical operations. Tower plans to close Pottstown Hospital’s maternity unit, which employs 32 nurses and where 359 babies were born in 2018, according to the most recent state data. Tower also has maternity units at Reading Hospital in West Reading and at Phoenixville Hospital.

Tower is aiming to trim expenses by $230 million over the next two years, Matthews told staff.

Like many other health systems, Tower has taken advantage of federal programs to ensure that it has ample cash in the bank to run its businesses. Tower has deferred payroll taxes, temporarily sparing $25 million. It received $166 million in advanced Medicare payments in April.

In the private sphere, Tower obtained a $40 million line of credit in April for St. Chris, which has lost $23.6 million on operations since Tower and Drexel bought it in December. Last month, Tower said it was in the final stages of negotiating a deal to sell and then lease back 24 medical office buildings. That was expected to generate $200 million in cash for Tower.

 

 

 

 

Major study finds common steroid reduces deaths among patients with severe Covid-19

Posted on by • Posted in Clinical Research, Coronavirus, Coronavirus Treatment, Dexamethasone, Hope, Hydroxychloroquine, National Institute of Health (NIH), Remdesivir • Leave a comment

Major study finds common steroid reduces deaths among patients with severe Covid-19

What is Dexamethasone? | What Is News,The Indian Express

A cheap, readily available steroid drug reduced deaths by a third in patients hospitalized with Covid-19 in a large study, the first time a therapy has been shown to possibly improve the odds of survival with the condition in the sickest patients.

Full data from the study have not been published or subjected to scientific scrutiny. But outside experts on Tuesday immediately embraced the top-line results. The drug, dexamethasone, is widely available and is used to treat conditions including rheumatoid arthritis, asthma, and some cancers.

In a statement, Patrick Vallance, the U.K. government’s chief scientific adviser, called the result “tremendous news” and “a ground-breaking development in our fight against the disease.” Scott Gottlieb, a former commissioner of the U.S. Food and Drug Administration, called it “a very positive finding” in an interview on CNBC. “I think it needs to be validated, but it certainly suggests that this could be beneficial in this setting.”

Atul Gawande, the surgeon, writer and public health researcher, urged caution, tweeting, “after all the retractions and walk backs, it is unacceptable to tout study results by press release without releasing the paper.”

The study randomly assigned 2,104 patients to receive six milligrams of dexamethasone once a day, by mouth or intravenous injection. These were compared to 4,321 patients assigned to receive usual care alone.

In patients who needed to be on a ventilator, dexamethasone reduced the death rate by 35%, meaning that doctors would prevent one death by treating eight ventilated patients. In those who needed oxygen but were not ventilated, the death rate was reduced 20%, meaning doctors would need to treat 25 patients to save one life. Both results were statistically significant.

There was no benefit in patients who didn’t require any oxygen. The researchers running the study, called RECOVERY, decided to stop enrolling patients on dexamethasone on June 8 because they believed they had enough data to get a clear result.

“Dexamethasone is the first drug to be shown to improve survival in COVID-19,” Peter Horby, one of the lead investigators of the study and a professor in the Nuffield Department of Medicine at the University of Oxford, said in a statement. He added that the drug should now become the standard treatment for patients with Covid-19 who need oxygen. “Dexamethasone is inexpensive, on the shelf, and can be used immediately to save lives worldwide.’”

A different arm of the same study showed on June 5 that hydroxychloroquine, widely touted as a potential Covid treatment, had no benefit in hospitalized patients. Yesterday, based in part on those results, the Food and Drug Administration revoked an Emergency Use Authorization for using hydroxychloroquine in those patients.

From the start of the pandemic in March, researchers have focused on two different stages of Covid-19, which will likely require very different interventions. Some drugs are designed to directly combat the novel coronavirus, SARS-CoV-2, that causes the disease. The first medicine shown to have a benefit, remdesivir from the biotech firm Gilead Sciences, falls into this category, even though, because it must be given intravenously, it has been tested in hospitalized patients. Remdesivir shortens the course of infection, but has not been shown to save lives.

After patients have become profoundly sick, the problem starts to become not only the virus but their own immune system, which attacks the lungs, a condition called acute respiratory distress syndrome, or ARDS. For these patients, doctors have believed, they would need to dampen patients’ immune response even as they fought the virus.

Initially, excitement in this area fell on new and expensive drugs, such as Actemra, a rheumatoid arthritis drug from Roche that is used to treat a similar condition caused by some cancer immunotherapies. But a study in patients who needed oxygen showed no benefit from a similar drug, although another arm in sicker patients is continuing. The National Institutes of Health is conducting a study of an Eli Lilly pill targeting rheumatoid arthritis, an extension of the study that showed remdesivir has a benefit.

Dexamethasone, which reached the market 59 years ago, seemed an unlikely candidate to help these patients; it was seen as too crude a way of tamping down the immune system. In guidelines for physicians treating the disease, the NIH doesn’t even mention the therapy.

Studies that are testing other medicines may now need to incorporate the use of the drug, which could complicate analyzing the results. A spokesperson for Regeneron, which is testing Covid-19 drugs focused on both attacking the virus and dampening the immune system, said the company’s studies are written so that when a new medicine becomes the standard of care, it becomes available to patients in the trial.

Some studies have shown a benefit for using dexamethasone in acute respiratory distress syndrome not related to Covid-19, although the benefit was smaller than in RECOVERY. 

The result, should it hold up to further scrutiny, shows the benefit of the strategy of Horby and Martin Landray, the Oxford researchers who designed the study, leveraging the U.K. health system to start a study of multiple inexpensive potential Covid-19 therapies — including hydroxychloroquine, dexamethasone, and also some older HIV medicines. Several months into the Covid-19 pandemic, two of the most important results come from this single study.

Neither of those results, however, have been scrutinized or published.

 

 

 

Coronavirus Cases Rise Sharply in Prisons Even as They Plateau Nationwide

Posted on by • 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

Protesters held a rally to bring awareness about the spread of the coronavirus inside the Marion Correctional Institution in Marion, Ohio, in May.

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.”