Category Archives: Covid-19

Volunteer Ekebar Emet, a 21-year-old student, publicizes epidemic prevention measures in Urumqi in northwest China's Xinjiang region on Aug. 3. His messaging reaches an estimated 78 households each day. Zhao Ge/Xinhua News Agency via Getty Images hide caption

Volunteer Ekebar Emet, a 21-year-old student, publicizes epidemic prevention measures in Urumqi in northwest China's Xinjiang region on Aug. 3. His messaging reaches an estimated 78 households each day.

Across China, life has largely returned to normal. Domestic travel is picking back up as a coronavirus pandemic brought under control recedes from memory. Businesses and factories have reopened.

Except in Xinjiang. A sweeping, western region nearly four times the size of California, Xinjiang remains largely cut off from the rest of the country and its some 22 million residents under heavy lockdown, an effort officials say is needed to contain a cluster of more than 800 officially diagnosed cases.

In mid-July, officials declared a "wartime mode" for the region. Community officials continue to go door to door, sealing doors with paper strips, tape and in some cases metal bars, to prevent residents from leaving their homes.

The region has effectively been penned off from the rest of the country, meaning scant information about the lockdown has emerged. In July, Xinjiang's train stations were closed, intercity bus routes canceled, and centralized quarantine imposed on residents returning to the region.

"It has been more than a week since we last had a case, but that does not mean we should relax," said Tang Shan, a Communist Party official who oversees Xinjiang's Ganquanbao district, an industrial zone just outside the region's capital of Urumqi. "We still ask our residents and the society at large, including our government organs, to work together in order to maintain the success we have achieved so far."

The monthlong lockdown has angered residents, thousands of whom took to social media this week to complain about what they said are heavy-handed quarantine and testing policies out of sync with the severity of the outbreak. The region's last new COVID-19 case was diagnosed on Aug. 17.

"The government has used an ax where a scalpel was needed," said a 21-year-old resident of Urumqi, where the vast majority of cases have occurred. He asked to remain anonymous because of potential legal retribution for talking to foreign media. "I just want government officials to refrain from lazy policymaking and combat the outbreak with scientific, reasonable measures."

Xinjiang is home to about 11 million Uighurs, a Turkic ethnic minority. Since 2017, local authorities with backing from the country's leader, Xi Jinping, have extralegally detained or imprisoned hundreds of thousands of Uighurs and other historically Muslim ethnic minorities. Those not detained live under heavy government surveillance and a web of restrictions that forbid most religious activities and travel.

Xinjiang's police state has mobilized over the last month to contain the latest coronavirus outbreak. Urumqi residents told NPR that they had been given mandatory tests for the coronavirus as many as three times in the last month and their temperature taken by local officials three times a day.

This past weekend, frustration from Xinjiang residents spilled over to social media, as the hashtag "Xinjiang refugees" briefly began trending on China's Twitter-like platform, Weibo. Most of the posts were soon deleted, and several accounts suspended. Videos shared on the platform by frustrated residents show Xinjiang residents cuffed to window bars and balcony railings outside their homes, a punishment for violating home quarantine rules.

"I want to strongly emphasize to everyone to now open your front door. Those who are discovered [outside their homes] by neighborhood officials will be reported to the nearest police station," read a warning sent to a chat group of residents in Urumqi's Tianshan district, according to screenshots sent to NPR by one of the group's participants.

The policy is similar to strict lockdown policies adopted for weeks at a time in other Chinese cities such as Wuhan and in coastal Zhejiang province during the height of the epidemic. To feed trapped residents, community officials and volunteers rallied to deliver daily essentials to each household several times a week.

With comparatively less-developed community services, residents in Xinjiang said they have been left hungry in their own homes. One woman in Kashgar, a former Silk Road oasis town, said she had been sealed into her house with a random assortment of groceries sent by community officials once a week usually basic vegetables such as potatoes, carrots and cabbage.

Four Uighur residents NPR spoke to said they had also been forced to drink a brown, herbal Chinese traditional medicine packaged by a company called Beijing Donghuayuan Medical. China's state news agency has said asymptomatic cases in Xinjiang were given an "herbal concoction" to prevent symptoms from appearing and that participation in traditional Chinese medicine treatment had "reached one hundred percent" in Xinjiang, though there is no medical evidence proving its efficacy against the virus.

On Monday, the regional government softened its lockdown policy slightly, allowing residents living in compounds with no cases to leave their homes so long as they are wearing a mask.

To further quell public outrage this week, state media also published the mobile phone numbers for about a dozen senior officials and party members at the provincial and city level, encouraging irate residents to reach out directly with recommendations.

"There has been an endless queue of complaints coming in," said Ye Hailong, a county-level Urumqi official.

On Monday, the Xinjiang regional government softened its stance and said it would allow residents without diagnosed cases in their compounds to leave their homes.

But when asked when Xinjiang's "wartime mode" would be entirely lifted, officials declined to offer a specific date. "Our lockdown policies have to follow the timeline of the epidemic and when the epidemic ends," said Chen Xinjian, an Urumqi district official.

Amy Cheng contributed research from Beijing.

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China's Coronavirus Lockdown In Xinjiang Is Severe And Controversial : Goats and Soda - NPR

TheWest Virginia Department of Health and Human Resources (DHHR) reports as of 10:00 a.m., on August 24,2020, there have been 398,479 total confirmatorylaboratory results received for COVID-19, with 9,312 totalcases and 179 deaths.

DHHR has confirmed the death of a 59-yearold male from Lincoln County. We mourn the tragic loss of this West Virginianand send our deepest sympathies to the family, said Bill J. Crouch, DHHRCabinet Secretary.

CASESPER COUNTY: Barbour (33), Berkeley (767), Boone(128), Braxton (9), Brooke (85), Cabell (490), Calhoun (8), Clay (19),Doddridge (6), Fayette (187), Gilmer (18), Grant (133), Greenbrier (98),Hampshire (92), Hancock (118), Hardy (63), Harrison (256), Jackson (190),Jefferson (324), Kanawha (1,225), Lewis (32), Lincoln (115), Logan (439),Marion (208), Marshall (135), Mason (84), McDowell (66), Mercer (276), Mineral(131), Mingo (213), Monongalia (1,060), Monroe (65), Morgan (37), Nicholas(43), Ohio (288), Pendleton (48), Pleasants (14), Pocahontas (42), Preston(135), Putnam (247), Raleigh (325), Randolph (219), Ritchie (3), Roane (25),Summers (18), Taylor (101), Tucker (11), Tyler (15), Upshur (40), Wayne (227),Webster (7), Wetzel (45), Wirt (7), Wood (291), Wyoming (51).

Pleasenote that delays may be experienced with the reporting of information from thelocal health department to DHHR. As case surveillance continues at the localhealth department level, it may reveal that those tested in a certain countymay not be a resident of that county, or even the state as an individual inquestion may have crossed the state border to be tested.Such is the case of Greenbrierand Randolph counties in this report.

Pleasevisit the dashboard located at http://www.coronavirus.wv.gov for more information.

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COVID-19 Daily Update 8-24-2020 - West Virginia Department of Health and Human Resources

Following individual human stories in a sprawling event like a global pandemic is a challenging task. Making thoughtful connections between the two is even harder. But this long read from The California Sunday Magazine on Americas first COVID-19 epicenter, a nursing home in Washington state, does the job with compelling and tragic precision.

It focuses on two inhabitants of a single room in the nursing facility, the Life Care Center of Kirkland, part of the largest privately held chain of long-term care centers in the US. It tracks how the coronavirus spread through the facility like a spectral haunting, and how underpaid and overworked staff battled against the odds to bring it under control.

Around the world, nursing homes have been hit hard by the pandemic, which is no surprise considering that their residents are some of the most vulnerable in society. In the US alone, as of mid-August, 177,129 nursing home residents have tested positive for COVID-19 and 45,958 have died from the disease. This means that nursing-home residents account for more than a quarter of total pandemic deaths, writes journalist Katie Engelhart.

In America, though, these individual tragedies connect to larger trends. As Engelhart lays out in rigorous detail, the financial and regulatory landscape of the US has seriously diminished the quality of care in nursing homes. The freakish architecture of health insurances is one issue, incentivizing management to treat patients with profit in mind:

At one Life Care facility in Florida, the entire rehab staff had signed a letter declaring that they had been encouraged to maximize reimbursement even when clinically inappropriate.

And the financialization of the industry is another. Nursing homes are lucrative businesses thanks to a regular supply of customers. This has attracted buyouts from private equity firms and owners concerned only with making money. Nursing homes are folded into complicated company structures that make it harder for patients to sue, while middle managers are brought in on bloated salaries, draining funds from frontline staff.

The results are grimly predictable, explains Engelhart:

Earlier this year, a Wharton SchoolNew York UniversityUniversity of Chicago research team found robust evidence that private-equity buyouts lead to declines in patient health and compliance with care standards. When nursing homes are bought by private-equity groups, the team concluded, frontline nursing staff are cut, and residents are more likely to be hospitalized.

Lax government regulations have also played a part. One study found that three-quarters of US nursing homes were understaffed before the pandemic, while 82 percent had been cited by the Government Accountability Office for failing to control the spread of infections between 2013 and 2017. These conditions were ripe for the pandemic to move in.

Engelharts piece is extremely affecting when detailing the plight of nursing home residents themselves. These are mothers and fathers, daughters and sons, whose tragedy is simply aging in a country that does not provide for them. As Engelhart puts it, many people see the tens of thousands of deaths in US nursing homes as evidence of a cultural abdication on the part of society. Weve failed to look after our elders and the human cost is staggering. Perhaps this pandemic can at least wake people up to the change that is needed.

Go read Engelharts full story right here.

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Go read this damning story about the spread of COVID-19 in Americas first pandemic hotspot - The Verge

At a Sunday press conference, U.S. President Donald Trump (right) announced that Food and Drug AdministrationCommissioner Stephen Hahn (left) had approved an emergency use authorization for using plasma from recovered COVID-19 patients to treat new patients with the disease.

By Kai Kupferschmidt, Jon CohenAug. 24, 2020 , 9:00 PM

Sciences COVID-19 reporting is supported by the Pulitzer Center and the Heising-Simons Foundation.

At a highly unusual Sunday night press conference, U.S. President Donald Trump revealed what he described as a very historic breakthrough in the fight against COVID-19that would save countless lives: The U.S. Food and Drug Administration (FDA) had issued an emergency use authorization (EUA) for convalescent plasma to treat people with severe COVID-19.

The authorization could allow more hospitalized patients to receive the antibody-rich plasma, which is donated by people who have recovered from the disease. But in the wake of Trumps announcement, which came a day before the start of the Republican National Convention, researchers struggled to sort the politics from the medical and scientific import of the EUA.

Trump, flanked by FDA Commissioner Stephen Hahn, claimed that convalescent plasma was safe and very effective, and had proven to reduce mortality by 35%what he called a tremendous number. But that number has received a tremendous amount of scrutiny. It surprised even the researchers who conducted the study on which Trump apparently based declaration. I dont know where the 35% number comes from, says Arturo Casadevall of Johns Hopkins Universitys Bloomberg School of Public Health, the last author of the study, which has been posted as a preprint but has yet to be peer reviewed.

Randomized, controlled trials (RCTs), the gold standard for assessing therapies, havent yet shown any benefit of convalescent plasma on COVID-19 patients. One such study, which includes thousands of patients, is underway as part of the Recovery trial in the United Kingdom. An FDA review of the request for the EUAmade by a branch of FDAs parent agency, the Department of Health and Human Services (HHS)notes an RCT with small numbers of participants in China and another in the Netherlands. Both were stopped early and failed to show the benefits of convalescent plasma.

But the EUA rests heavily on data from the COVID-19 Plasma Consortium, funded by HHS to provide access to the treatment and assess its safety. The group has treated more than 90,000 patients at nearly 3000 sites in the United States and its territories. That study has no untreated control group, however, so it cannot ultimately address whether convalescent plasma has any risks that outweigh benefits.

The treatment was allowed under FDAs Expanded Access program, which gives patients access to experimental treatments. Casadevall says this program requires burdensome, time-consuming paperwork that the EUA will do away with. That will be particularly helpful for understaffed hospitals that treat underserved populations, he says. I think the FDA made the right call. The political noise is unfortunate.

Others say the political noise is drowning out the science.

Hahn claimed at the press conference that Trumps 35% figure translates to 35 lives saved per 100 sick people. Casadevall and others suspect both numbers are based on a small subset ofpatients, and the closest data that fit seem to be from a group that was analyzed together because of the specific test that assessed the COVID-19 antibody levels in the plasma they received. In this group of about 3000 people, 8.9% of those who received plasma containing high antibody levels died within 7 days, versus 13.7% of those who received plasma with low levels. Although that is a 35% relative difference between the groups, the absolute difference, 4.8%, amounts to 4.8 lives saved per 100 sick peoplenot 35. And after 30 days, the relative difference between the groups had dropped to 25%. At that point, the mortality rates were 22.3% and 29.6% respectively among recipients of plasma with high and low levels of antibodieshardly a historic breakthrough. (On Monday evening, after this story was posted, Hahn acknowledged he had made a mistake, tweeting that the criticism of his remark was entirely justified. What I should have said better is that the data show a relative risk reduction not an absolute risk reduction.)

Luciana Borio, a former chief scientist at FDA, calls the data presented yesterday statistical acrobatics. If the treatment effect was real and meaningful, we would probably have detected it by now, says Borio, who formerly worked on the Trump White Houses National Security Council and now is a vice president at In-Q-Tel, a not-for-profit that invests in high-tech companies.

Nicole Bouvier, a virologist and infectious disease clinician at the Icahn School of Medicine at Mount Sinaiand a participant in the Mayo Clinicled consortiumsays the data gathered so far do suggest convalescent plasma may help some COVID-19 patients. There is probably a benefit to it, but its probably not a major breakthrough as it was described, Bouvier says. She wishes the U.S. government had organized large-scale RCTs for the intervention, although they would have been costly and difficult to run. Were trying to build a wall of evidence and were putting in pebbles, she says. It would have been nice to have a great big boulder of an RCT. But it just has not evolved in that way, and I dont see it evolving that way anytime soon.

Borio and others worry the EUA may make it harder to gather that kind of evidence for other treatments. Convalescent plasma contains a mixture of different antibodies, only some of which hinder the virus that causes COVID-19, and Borio and many others have high hopes for a more targeted and standardized intervention: monoclonal preparations that contain high levels of the most potent antibodies only. But now that the EUA has put convalescent plasma within reach of more patients, it may become harder to enroll people in RCTs for monoclonal antibodies, Borio says.

Myron Cohen of the University of North Carolina, Chapel Hill, who oversees large-scale RCTs of monoclonals now taking place under the aegis of the U.S. National Institutes of Health, agrees. If potential study participants for a COVID-19 treatment intervention in a randomized controlled trial believe there is a beneficial and safe agent they can receive without randomization to a placebo, they may logically and often chose that path, Cohen says.

Given that the tens of thousands of Americans have already received convalescent plasma through FDAs Expanded Access program, its unclear how many more people the EUA will actually benefit. Bouvier says her hospital may not even be able to use the EUA, because it requires that convalescent plasma be first characterized with a specific antibody test that it does not have. How do you even do what the FDA is mandating in the EUA right now? Bouvier asks.

Over the past week, several U.S. government health officials had urgedFDA not to issue an EUA on plasma for COVID-19, which led Trump to post a tweet accusing them of being part of the deep statea supposed inside movement against himand trying to delay approvals until after the 3 November presidential election. He repeated those accusations last night. I think that there are people in the FDA and actually in your larger department that can see things being held up and wouldnt mind so much, Trump said, addressing Hahn. Thats my opiniona very strong opinion. And thats for political reasons.

Eric Topol, a cardiologist who directs the Scripps Research Translational Institute, says the EUA again represents the FDA caving directly to Trump pressure, as he believes it did when it issued an EUA (later rescinded) for hydroxychloroquine treatment for COVID-19. It sadly and unacceptably exemplifies loss of independent FDA assessment of evidence and data overridden by political pressure, Topol says. Many scientists worry the same could happen in future decisions about EUAs for COVID-19 vaccineswith far greater potential consequences because vaccines presumably will be given to hundreds of millions of healthy people.

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In FDA's green light for treating COVID-19 with plasma, critics see thin evidenceand politics - Science Magazine

The coffins are a better place to scream than at Japanese theme parks, which have encouraged visitors to keep their mouths shut on roller coasters to prevent virus transmission through droplets. (Please scream inside your heart, the Fuji-Q Highland amusement park suggested in June in a video demonstration by two of its executives, who inspired social media users to try the serious face challenge on their own roller coaster rides.)

Kenta Iwana, founder of Kowagarasetai, said he wanted to give people a way to express themselves without holding back.

There are no places to scream, Mr. Iwana, 25, told Agence France-Presse this summer as he introduced another one of his socially distanced productions, a drive-in haunted house. In addition to providing people with an emotional outlet, he said, his company creates job opportunities for performers who normally work at theme parks.

Japan, which has been fighting a resurgence of the virus in recent weeks, reported 740 new cases nationwide on Sunday, including 212 in Tokyo.

Reporting was contributed by Sarah Almukhtar, Gillian R. Brassil, Alexander Burns, Stephen Castle, Choe Sang-Hun, Abdi Latif Dahir, Richard Faussett, Sheri Fink, Michael Gold, Jenny Gross, Javier C. Hernndez, Shawn Hubler, Mike Ives, Annie Karni, Isabella Kwai, David Leonhardt, Apoorva Mandavilli, Jonathan Martin, Tiffany May, Patricia Mazzei, Claire Cain Miller, Heather Murphy, Eshe Nelson, Amelia Nierenberg, Adam Pasick, Elian Peltier, Monika Pronczuk, Dana Rubinstein, Eliza Shapiro, Mitch Smith, Eileen Sullivan, Katie Thomas, Tracey Tully, Katherine J. Wu and Elaine Yu, Carl Zimmer.

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C.D.C. Changes Testing Guidance to Exclude People Without Covid-19 Symptoms, Worrying Experts - The New York Times

As hundreds of thousands of students return to classrooms across Wisconsin, the state has no plans to publicize details about COVID-19 outbreaks when they occur at schools.

Freedom of information advocates say that information should be available to the broader public, and some researchers say data could help schools learn from one another. But others worry about protecting students, parents and communities from stigma if information about outbreaks is shared widely.

Without a state-level source of information, what you know about outbreaks in your schools may depend on the openness of local school districts and health departments.

The Wisconsin Department of Health Services confirmed last week it will publish only the number of schools in the state with COVID-19 investigations, which launch when as few as two cases are identified in a given space.The departmentdoesn't plan to name the schoolsor describe the severity of the outbreaks.

This is similar to how the state treats other facility-wide investigations, which it tracks by category, like outbreaks in group housing, health care settings and other workplaces. One exception is nursing homes, which are regulated by the state and federal governments andare named on the DHS site when an investigation occurs.

Bill Lueders, president of the Wisconsin Freedom of Information Council, said the location and size of school outbreaks should be made public, just as he believes the state health agency should post thenames of businesses and other establishments connected to at least two cases of COVID-19, as it had initially planned.

"I think it's tragic that the Department of Health Services is being so secretive of COVID cases, and I think it's contrary to public interest and public health," he said. "They consistently have shown they don't particularly trust the people of Wisconsin to make reasonable and rational use of public information. Instead they just assume people are going to flip out if a school or business has some experience with COVID."

School teachers and staff across the state also are wonderingwhat information will be available to them, since most school decisions are made at the district level, said Ron Duff Martin, president of the Wisconsin Education Association Council, which represents about 50,000 members across the state.

While schools are bound by privacy laws, he said, teachers and staff have concerns about keeping themselves, their families and their students safe.

"Isn't this just a prime example of how this is the Wild West in Wisconsin, that we don't have one consistent policy for all of our schools?" Martin said.

"There's a difference between local control and being able to give the direction and guidance from state level," he said. "There are certain things that should be consistent from school district to school district and county to county."

Jenni Hofschulte of the Wisconsin Public Education Network saidthe education advocacy organization supports local control in school districtsbutwould prefer districts follow a common set of rules and practices so families can better understand how theyll be applied in their communities.

Were disappointed as a network in some of the guidance thats come out and that so many of these decisions big decisions with big consequences have been put onto local schools in a way thats not something like choosing a textbook for a class, she said. Its about how to handle a global pandemic.

Schools are often the heart of their communities, Hofschulte said, meaning everyone should have access to information about outbreaks.

How many people have contact with a school building in a day? Its far more than students, parents, teachers or school staff. It's volunteers, grandparents and so much more, she said. People deserve the right to know.

Across the country, schools have cited medical and educational privacy laws in keeping outbreak numbers confidential. But legal experts recently told USA TODAY that these laws don't bar schools from sharing this information, as long as it can't be used to identify specific people.

Standing guidance from the U.S. Department of Health and Human Services says that the Health Insurance Portability and Accountability Act, or HIPAAwhich prohibits medical providers from releasing identifying information about a patient doesn't apply to elementary or secondary schools.

Educational records are kept private by the Family Educational Rights and Privacy Act, or FERPA, but the U.S. Department of Education said in March that the law doesn't prevent schools from sharing non-identifying details about COVID-19 cases.

Wisconsin statute requires schools to notify local health officials if they know or suspect a communicable disease is present in a building, either among students, teachers or other staff.

New DHSguidance issued to schools last week says administrators should track cases, other illnesses and student absences. In the event of a confirmedor probable case of COVID-19, DHS said administrators shouldnotify families and all teachers and staff.

But no recommendations are given as to how or whenWisconsin schools should inform the public about the size and location of outbreaks.

Other states have similarly shielded details about specific school outbreaks fromthe public,including Michigan and Tennessee. In Oklahoma, school districts aren't even required to report COVID-19 cases to local public health officials,according to aNew York Times report.

In the absence of a federal system to track school outbreaks, Emily Oster, an economist at Brown University, has teamed up with national school superintendents and principals' associations to collect data on school COVID-19 casesfrom as many schools across the countryas possible.

Their dashboard, which is expected to go live about a week after data collection starts in early September, will provide the public with basic information like enrollment numbers, the school'sreopening plans and precautions taken, as well as suspected and confirmed COVID-19 cases, and absences.

Schools can choose to participate, Oster said, but she's hopeful thatsupport from the superintendents and principalswill persuade many districts to opt in.

"The best thing we can do is just be honest about what we see as the value here," Oster said. "There's a lot of enthusiasm about having these data, and I think we're going to have to rely on making clear to people:'If you want this data to exist, then we do need participation.'"

The value of the data, she said, would be as a tool for more informed decision-making. With this data in hand, schools can look to one another to determine what mix of precautions and COVID-19 prevalencecreates the safest situation to open schools, and they also can track differences in outbreaks across age groups.

It also rids parents, teachers and families of uncertainty, she said.

"When we report on outbreaks without doing a comprehensive data collection, it can be hard for people to understand: Was that just one outbreak, or is every school like that?" Oster said. "This effort can answer those questions and allay some fears or, maybe, tell us it's not safe."

For many school officials and families, the benefits of having information about an outbreak are clear. But somedisagree on whether the general public needs to see it, too.

Dr. Maggie Nolan, a preventative medicine physician in Madison whose oldest child is starting first grade this year at Madison Country Day School in Waunakee, said she's asked the school to provide parents with the number of students absent from school on a given day.

Because COVID-19 has a wide range of symptoms and may not present the same way in all children, she said, she might opt for virtual learning if several of her daughter's classmates are out sick whether or not they've been confirmed COVID-positive.

She served on a medical advisory board to help guide the school's reopening, and said she feels like she's gotten "a strong commitment" from school leaders that they'll tell parents what they want to know about outbreaks.

Still, Nolan said she doesn't believe that information necessarily needs to be shared with the broader public. Especially within smaller schools, she said, even de-identified information about cases could be enough to make someone's identity known.

"There will be talk of it in the community enough to make people aware," Nolan said. "But adding stigma to certain schools or communities (with outbreaks) is really a slippery slope."

What no one wants, she said, is a situation where parents are discouraged from getting their kids tested if they feel a positive COVID test will stigmatize them in some way.

But Patrick Remington, an epidemiologist at the University of Wisconsin-Madison, said people like day care providers andcoaches also need to beinformed about an outbreak involving students.

He recommends schools to go beyond sending a letter home to families and operate some sort of dashboard to track outbreaks.

"In my mind, I can't imagine any information that parents need to know that a community wouldn't also be interested in knowing," he said.

It's critical, Remington said, that schools take control of the message and share information on outbreaks transparently rather than letting rumors proliferate on social media.

"You've seen schools where (they'll say), 'Ms. Johnson isn't going to be here tomorrow. She'll be gone for two weeks,'" he said. "You think a parent doesn't know what's going on?"

Without outbreak details from DHS, the responsibility falls to local health departments and the school districts themselves to decide what information to share, and how.

Martin said the state teacher'sunion has been holding town halls with its members and state and local officials trying to address their concerns.

"What really has our educators anxious." he said, "is if there's an outbreak, what can we know? What can't we know? ... They're very anxious about what's happening in their districts and beyond.

"And the onus of tracking down information, on top of getting ready for an uncertain school year, just places another layer of stress on them."

It's not clear how much more transparency there will be atthe local level.

Twohealth departments in Milwaukee County in Milwaukee and Greenfield said they have no plans to publicly list numbers of COVID-19 cases by school or school district.

The Milwaukee Health Department said in an email to USA TODAY NETWORK-Wisconsinthatschools will be required to notify all parents in a school about positive cases, but the health department will not reportnumbers publicly by school or district. It said it doesnot provide information about positive cases for companies or organizations in any other sector and that it would not treat schools differently.

"Sharing specific, small-scale, demographic information with the public does not aid in the publichealthmitigation strategies," the department said in an email.

But Milwaukee Health Commissioner JeanetteKowalik, in her regularly scheduled Tuesday briefing, appeared to suggest that listing cases by school might happen eventually. She called it "a sensitive topic" and said any decision would have to be made in collaboration with districts, teachers unions and the Department of Public Instruction.

"Most schools are virtual in the city of Milwaukee, so it gives us a little time to figure this out," she said.

In the city of Greenfield, in southwestern Milwaukee County, Health Officer Darren Rausch said his office has not yet thought through whether and how it will release information about schools to the general public. But he said his officedoesn't typically release public health data in small numbers because that can identify individuals. And schools would likely be treated the same way, he said.

"Disease is all around us," Rausch said. "I'm not any more concerned because there's a case in my school, because I know there are other settings that my child is in or could be in where I could get COVID."

In Waukesha County, west of Milwaukee, health officials added a map to their COVID-19 dashboard showing the number of active cases involving children under 18 by school district geographic area. But it does not cite numbers by school or district, and it includes all children, regardless of where they go to school, including those in private and charter schools and those who are home-schooled.

Nicole Armendariz, spokeswoman for Waukesha County Executive Paul Farrow, said it will be up to schools and districts to determine whether to notify anyone, including parents and staff, "who are not close contacts of a positive COVID-19 case."

RELATED:Here's how Wisconsin health officials say schools should respond to a COVID-19 outbreak

RELATED:'What do we do now?': With federal support running out, Wisconsin child care providers struggle to survive the pandemic

Contact Madeline Heim at 920-996-7266 or mheim@gannett.com. Follow her on Twitter at @madeline_heim.Contact Annysa Johnson atanjohnson@jrn.comor 414-224-2061. Follow her on Twitter at@JSEdbeat.Contact Samantha West at 920-996-7207 or swest@gannett.com. Follow her on Twitter at @BySamanthaWest.

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Wisconsin officials won't name schools that have COVID-19 outbreaks, or say how big they are - Appleton Post Crescent

A new national study of four Maine summer camps details how the overnight camps prevented outbreaks of COVID-19, while similar camps in other states suffered through major outbreaks.

Dr. Laura Blaisdell, a pediatrician from South Portland and also a medical director at one of the camps, said the four camps coordinated to devise similar prevention strategies. The strategies included testing, masking, quarantine, physical distancing and making sure students stayed in small groups of 10-20 to prevent outbreaks.

We needed to throw the entire kitchen sink of public health intervention to prevent the spread of a disease like COVID-19, said Blaisdell, the lead author of the study.

The study was published by the U.S. Centers for Disease Control on Wednesday, with Blaisdell and four other scientists as authors.

The Maine prevention strategy stands in contrast to summer camp outbreaks reported across the country, including in Texas, Missouri and Georgia. In the Georgia outbreak, more than 260 campers out of 344 tested were positive for COVID-19.

In Maine, through a combination of pre-screening, testing prior to starting camp and testing 1,022 campers and staff while they were at the overnight camps, a total of seven campers and staff tested positive. One of the tests of a camper ended up being a false positive.

Campers were told to quarantine with their families prior to arrival, and 15 attendees of one camp were instructed to quarantine while waiting for pre-screening test results to come back. When the tests came back negative a few days into camp, they were released from quarantine.

The four camps that were part of the study are not being identified to protect patient privacy, Blaisdell said.

Blaisdell said all of the staff and campers who tested positive for COVID-19 were asymptomatic.

She said thats different from other infectious diseases, such as the flu. When people are most contagious from influenza, they feel sick and tend to stay home. She said what makes COVID-19 so difficult to contain is that people who feel healthy can have the disease and be contagious.

You cant pick or choose one strategy. You have to layer several strategies all day every day, every layer to have the best success. We know we cant provide a COVID-free environment, Blaisdell said.

She said by keeping students in groups of 10-20, that means just that group would go into quarantine when one person tested positive, rather than the entire camp.

Dr. Jeff Vergales, a Virginia pediatrician who was the medical director at two Maine summer camps and one of the authors of the study, said once the campers and staff arrived and tested negative, each camp turned into a bubble.

From an epidemiological standpoint, we could control who was coming in and out, Vergales said. We had an advantage of knowing about what these kids were doing day in and day out.

This story will be updated.

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Study shows how 4 Maine summer camps avoided COVID-19 infections - The Bethel Citizen

The Illinois Department of Public Health announced 2,157 new confirmed cases of COVID-19 and 37 deaths on Wednesday.

The spike comes as new restrictions on public gatherings go into effect in Will and Kankakee counties, due to the rising number of people testing positive for the coronavirus.

There will be no indoor service for bars or restaurants, outside bar and food service must close at 11 p.m., and gatherings are capped at 25 people or 25% of the overall room capacity. Casinos also must close at 11 p.m. and are limited to 25% capacity.

The stricter rules come after counties posted an 8% positivity rate for three consecutive days, becoming the second of the states 11 regions to be sent backward from the phase four rules that are widely in place throughout the state.

Counties in the Metro East area near St. Louis have also been placed under the restrictions, and could face tighter limits if their positivity rate stays high.

On Tuesday, Gov. J.B. Pritzker announced a new statewide restaurant and bar policy requiring all patrons to wear a mask while interacting with wait staff and other employees, when food and beverages are brought to the table and when picking up carry-out orders.

Heres whats happening Wednesday with COVID-19 in the Chicago area and Illinois:

2:24 p.m.: Indiana governor extends statewide mask order for 30 days; Lake County, Ind., nears 8,800 cases

Indianas governor extended the statewide face mask order Wednesday that he first issued a month ago aimed at slowing the coronavirus spread.

Republican Gov. Eric Holcomb announced he was keeping the mask mandate in place for another 30 days.

Holcomb said he was also extending the states limits crowd sizes for restaurants, bars and public events. Those orders were all set to expire late Wednesday unless the governor acted.

Holcomb said he was pleased the states rates of new coronavirus cases have been holding steady and he does not want to see it trending up again.

1:45 p.m.: The stress of dealing with COVID-19 is causing decision fatigue. Heres how to cope.

Even before the pandemic, making constant decisions daily could create stress.

COVID-19 has added weight to small and big decisions alike. Should I pick up takeout? Do I send my child to school? Do we allow a babysitter to come over? Should we attend a birthday party? Is one item from the grocery store worth the trip?

The concept of exhaustion and stress after making choices is known as decision fatigue. After months of assessing the risk and benefit of daily choices during the coronavirus crisis, people are tired. Especially as school begins, many families have been agonizing over whether to send their children to school or how to manage remote learning.

12:12 p.m.: 2,157 new known COVID-19 cases, 37 additional deaths

The Department of Public Health on Wednesday announced 2,157 new confirmed cases of COVID-19 and 37 deaths. Overall, Illinois has reported 225,627 cases, including 7,954 deaths.

11:42 a.m.: Jobless workers could get an extra $300 a week in benefits. Pritzker says Illinois is applying for Trumps benefits program.

Illinois is applying for the $300 weekly unemployment benefits supplement President Trump ordered earlier this month to provide financial assistance to jobless workers during the coronavirus pandemic.

On Aug. 8, President Trump authorized the federal supplement, which is being doled out to states by the Federal Emergency Management Agency, as a temporary fix to replace the extra $600-a-week in federal benefits that expired last month. Congress remains at a standstill on negotiations for an additional coronavirus relief package, which could restore some, if not all, of those benefits.

At a news conference Tuesday, Gov. J.B. Pritzker was asked to respond to President Trumps comment that Illinois is one of the states that has not applied for the benefits.

Pritzker said We have begun that process, indeed. It takes a lot of setup on an internal basis for us to move forward with that and so thats what weve been doing.

More than 30 states have received approval for the benefits program as of Tuesday, according to FEMA. The agency, which typically handles disaster relief, will provide up to $44 billion from the Disaster Relief Fund for lost wage payments, and states will administer those funds.

10:11 a.m.: Theres been an awful lot of partying: Northwestern University asks Evanston residents to report students who ignore COVID-19 precautions in off-campus gatherings

Northwestern Universitys campus in Evanston is going to feel less crowded this fall, with residence hall capacity reduced to about 70% and more than half of all employees still working from home, school officials said Tuesday.

But those estimates didnt fully assuage concerns from residents that students will instead move into neighborhood apartments and throw raucous parties, potentially accelerating the spread of COVID-19 in a suburb that has so far avoided an uncontrollable outbreak.

Residents raised the issue Tuesday evening during a 90-minute Zoom meeting, billed as a community town hall, to discuss NUs plan for repopulating its suburban campus when classes begin next month.

9:55 a.m.: CDC advice to retail workers: Dont argue with anti-mask shoppers

The Centers for Disease Control and Prevention has issued a warning about a new coronavirus health risk you probably didn't expect: getting slapped, choked or kicked in the workplace by angry customers. And the best way to avoid it is not to engage.

The health agency issued guidance this week for retail and service workers suggesting ways consumer-facing companies can limit violence toward workers that may occur when businesses implement policies to stop the spread of the virus. Or in other words, how to protect workers tasked with the unenviable job of asking shoppers to wear masks, keep 6 feet apart or wait their turn before entering a capacity-limited store.

The new CDC page gives a series of actions companies can take to protect workers, from installing panic buttons to having staff enforcing mask-wearing operate in teams of two. Above all, workers shouldnt put themselves in the direct line of danger, according to the federal agency that usually focuses on disease prevention.

7 a.m.: CDC now says people exposed to coronavirus may not need to be tested

The Centers for Disease Control and Prevention has changed its COVID-19 guidelines, no longer recommending testing for most people without symptoms, even if theyve been in close contact with someone known to have the virus.

The CDC had said that viral testing was appropriate for people with recent or suspected exposure, even if they were asymptomatic. Its previous guideline had said, Because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts of individuals with (COVID-19) infection be quickly identified and tested.

The guideline now reads, "If you have been in close contact (within 6 feet) of a person with a COVID-19 infection for at least 15 minutes but do not have symptoms, you do not necessarily need a test unless you are a vulnerable individual or your health care provider or State or local public health officials recommend you take one."

The CDC guidelines still say people should get tested if they have symptoms and that someones health care provider may advise a COVID-19 test.

6:45 a.m.: COVID-19 tracking apps, supported by Apple and Google, begin showing up in app stores

They work by sharing anonymous Bluetooth beacons with nearby devices running the same software, tagging those that suggest extended and close contact associated with coronavirus spread, and saving the last 14 days of these records.

A positive test for COVID-19 in one of those states should include a code you enter into the app to upload its close-contact records to a health-authority server that then makes this anonymized data available to all these apps at their daily check-ins. If the app sees one of these reports match its saved list of close contacts, it warns of possible exposure and advises testing and quarantine.

Stay up to date with the latest information on coronavirus with our breaking news alerts.

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COVID-19 in Illinois updates: Heres whats happening Wednesday - Chicago Tribune

In a special virtual town hall, House Speaker Nancy Pelosi joined UC San Francisco Chancellor Sam Hawgood, MBBS, to discuss the role of science and science advocacy in shaping federal policy during a global pandemic, her leadership during these turbulent times, and lessons learned during her long tenure as the first and only female Speaker of the House of Representatives.

The Democratic Congresswoman, whose district covers a large portion of San Francisco, began the event on Tuesday by thanking UCSF for being a longtime partner and leader in science and health, both in San Francisco and worldwide. She recalled how decades earlier, UCSFs work in community-based research, prevention and care during the HIV/AIDS epidemic helped lead to the Ryan White CARE act.

Asked about the national response to the COVID-19 pandemic, Pelosi said denial and distortion of the reality of the pandemic had prevented a more coordinated national response. There are two things here at work that are not so good: One is an anti-science attitude, and the other is an anti-government attitude, she said. So lets just hope that rather than looking back, that we can look forward and hope that the public awareness of all of this will take us to a place where we have unity around science.

Hawgood said the pandemic had raised the question of how research universities like UCSF could contribute to preparing for and responding to future pandemics. History tells us that COVID-19 will definitely not be the last pandemic that we experience in our lifetimes, he said. And Ive been thinking and speaking to my peers across the country about how we could perhaps create a more unified research university academic response in working with the federal government to prepare the country for what we know will come.

Pelosi said that support from universities would be critical for legislative funding, such as when leading institutions came together in the 1990s to help double the National Institutes of Health budget.

The conversation then turned to how the pandemic has affected early career scientists and how the federal government could help. Hawgood described the risk of losing a generation of early career scientists, particularly women, due to lack of support for caregivers, as an existential challenge.

Pelosi said that a massive investment in childcare, more debt forgiveness for students, and expanding access to healthcare was needed on a national level.

She said that evidence-based research, including UCSFs work in COVID-19 testing in the Mission District which showed that the Latinx community was disproportionately affected by the disease was critical to getting Congress to recognize and redress health disparities.

Its immoral for us to proceed with this without recognizing the disparity in the communities of color you know that better than anyone, she said to Hawgood. But we have to kind of convey that to some people who, shall we say, are not as close to the public experience as some of the rest of us are.

We just have to recognize that if were going to crush this virus, which we must do, it is going to take resources scientifically spent, she said.

Finally, asked how her approach to leadership has changed over time and lessons learned for aspiring leaders, Pelosi said the best advice was to be authentic and to know your own motivations. But to women, especially, I say, be ready. Because I didnt think for a minute I would be going to Congress and never thought I would run for leadership, but I was ready.

Join our students, faculty, staff, alumni and supporters who stand up for values and policies fundamental to UCSFs mission of advancing health worldwide.

Become a UCSF advocate

Pelosi closed out her portion of the town hall with a question-and-answer segment, facilitated by Francesca Vega, Vice Chancellor of Community and Government Relations. Asked how the UCSF community could help the democratic process during the pandemic, Pelosi encouraged people to vote early. Right now the most important thing is for people to vote and to do so early enough so that their vote is counted as cast, she said.

The town hall continued with brief presentations by Keith Yamamoto, PhD, Special Advisor to the Chancellor for Science Policy and Strategy, and Natalie Alpert, Executive Director of Federal Government Relations, discussing the continued need for advocacy at the federal level.

Vega ended the event by bringing attention to various voter engagement efforts across UCSF, including the UCSF Votes initiative to update addresses for mailed ballots. Now is the ask of all of you, she said. And thats ensuring that our voice is indeed heard and that we are aware of all the opportunities that we have within the UCSF community to get engaged.

See more here:

House Speaker Nancy Pelosi Joins UCSF Town Hall to Discuss COVID-19, The Role of Science in Turbulent Times - UCSF News Services

Infectious respiratory disease caused by severe acute respiratory syndrome coronavirus 2

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[9] It was first identified in December 2019 in Wuhan, Hubei, China, and has resulted in an ongoing pandemic.[10][11] The first confirmed case has been traced back to 17 November 2019 in Hubei.[12] As of 27 July 2020, more than 16.2million cases have been reported across 188 countries and territories, resulting in more than 648,000 deaths. More than 9.4million people have recovered.[8]

Common symptoms include fever, cough, fatigue, shortness of breath, and loss of smell and taste.[13][5][6][14] While the majority of cases result in mild symptoms, some progress to acute respiratory distress syndrome (ARDS) possibly precipitated by cytokine storm,[15] multi-organ failure, septic shock, and blood clots.[16][17][18] The time from exposure to onset of symptoms is typically around five days, but may range from two to fourteen days.[5][19]

The virus is primarily spread between people during close contact,[a] most often via small droplets produced by coughing,[b] sneezing, and talking.[6][20][22] The droplets usually fall to the ground or onto surfaces rather than travelling through air over long distances.[6][23] Transmission may also occur through smaller droplets that are able to stay suspended in the air for longer periods of time.[24] Less commonly, people may become infected by touching a contaminated surface and then touching their face.[6][20] It is most contagious during the first three days after the onset of symptoms, although spread is possible before symptoms appear, and from people who do not show symptoms.[6][20] The standard method of diagnosis is by real-time reverse transcription polymerase chain reaction (rRT-PCR) from a nasopharyngeal swab.[25] Chest CT imaging may also be helpful for diagnosis in individuals where there is a high suspicion of infection based on symptoms and risk factors; however, guidelines do not recommend using CT imaging for routine screening.[26][27]

Recommended measures to prevent infection include frequent hand washing, maintaining physical distance from others (especially from those with symptoms), quarantine (especially for those with symptoms), covering coughs, and keeping unwashed hands away from the face.[7][28][29] The use of cloth face coverings such as a scarf or a bandana has been recommended by health officials in public settings to minimise the risk of transmissions, with some authorities requiring their use.[30][31] Health officials also stated that medical-grade face masks, such as N95 masks, should be used only by healthcare workers, first responders, and those who directly care for infected individuals.[32][33]

There are no vaccines nor specific antiviral treatments for COVID-19.[6] Management involves the treatment of symptoms, supportive care, isolation, and experimental measures.[34] The World Health Organization (WHO) declared the COVID19 outbreak a public health emergency of international concern (PHEIC)[35][36] on 30 January 2020 and a pandemic on 11 March 2020.[11] Local transmission of the disease has occurred in most countries across all six WHO regions.[37]

Fever is the most common symptom of COVID-19,[13] but is highly variable in severity and presentation, with some older, immunocompromised, or critically ill people not having fever at all.[39][40] In one study, only 44% of people had fever when they presented to the hospital, while 89% went on to develop fever at some point during their hospitalization.[41]

Other common symptoms include cough, loss of appetite, fatigue, shortness of breath, sputum production, and muscle and joint pains.[13][1][5][42] Symptoms such as nausea, vomiting, and diarrhoea have been observed in varying percentages.[43][44][45] Less common symptoms include sneezing, runny nose, sore throat, and skin lesions.[46] Some cases in China initially presented with only chest tightness and palpitations.[47] A decreased sense of smell or disturbances in taste may occur.[48][49] Loss of smell was a presenting symptom in 30% of confirmed cases in South Korea.[14][50]

As is common with infections, there is a delay between the moment a person is first infected and the time he or she develops symptoms. This is called the incubation period. The typical incubation period for COVID19 is five or six days, but it can range from one to fourteen days[6][51] with approximately ten percent of cases taking longer.[52][53][54]

An early key to the diagnosis is the tempo of the illness. Early symptoms may include a wide variety of symptoms but infrequently involves shortness of breath. Shortness of breath usually develops several days after initial symptoms. Shortness of breath that begins immediately along with fever and cough is more likely to be anxiety than COVID-19. The most critical days of illness tend to be those following the development of shortness of breath.[55]A minority of cases do not develop noticeable symptoms at any point in time.[56] These asymptomatic carriers tend not to get tested, and their role in transmission is not fully known.[57][58] Preliminary evidence suggested they may contribute to the spread of the disease.[59] In June 2020, a spokeswoman of WHO said that asymptomatic transmission appears to be "rare", but the evidence for the claim was not released.[60] The next day, WHO clarified that they had intended a narrow definition of "asymptomatic" that did not include pre-symptomatic or paucisymptomatic (weak symptoms) transmission and that up to 41% of transmission may be asymptomatic. Transmission without symptoms does occur.[56]

COVID19 is a new disease, and many of the details of its spread are still under investigation.[6][20][22] It spreads easily between peopleeasier than influenza but not as easily as measles.[20] People are most infectious when they show symptoms (even mild or non-specific symptoms), but may be infectious for up to two days before symptoms appear (pre-symptomatic transmission).[22] They remain infectious an estimated seven to twelve days in moderate cases and an average of two weeks in severe cases.[22] People can also transmit the virus without showing any symptom (asymptomatic transmission), but it is unclear how often this happens.[6][20][22] A June 2020 review found that 4045% of infected people are asymptomatic.[61]

COVID-19 spreads primarily when people are in close contact and one person inhales small droplets produced by an infected person (symptomatic or not) coughing, sneezing, talking, or singing.[22][62] The WHO recommends 1 metre (3ft) of social distance;[6] the US Centers for Disease Control and Prevention (CDC) recommends 2 metres (6ft).[20]

Transmission may also occur through aerosols, smaller droplets that are able to stay suspended in the air for longer periods of time.[24] Experimental results show the virus can survive in aerosol up to three hours.[63] Some outbreaks have also been reported in crowded and inadequately ventilated indoor locations where infected persons spend long periods of time (such as restaurants and nightclubs).[64] Aerosol transmission in such locations has not been ruled out.[24] Some medical procedures performed on COVID-19 patients in health facilities can generate those smaller droplets,[65] and result in the virus being transmitted more easily than normal.[6][22]

When the contaminated droplets fall to floors or surfaces they can, though less commonly, remain infectious if people touch contaminated surfaces and then their eyes, nose or mouth with unwashed hands.[6] On surfaces the amount of viable active virus decreases over time until it can no longer cause infection,[22] and surfaces are thought not to be the main way the virus spreads.[20] It is unknown what amount of virus on surfaces is required to cause infection via this method, but it can be detected for up to four hours on copper, up to one day on cardboard, and up to three days on plastic (polypropylene) and stainless steel (AISI 304).[22][66][67] Surfaces are easily decontaminated with household disinfectants which destroy the virus outside the human body or on the hands.[6] Disinfectants or bleach are not a treatment for COVID19, and cause health problems when not used properly, such as when used inside the human body.[68]

Sputum and saliva carry large amounts of virus.[6][20][22][69] Although COVID19 is not a sexually transmitted infection, direct contact such as kissing, intimate contact, and fecaloral routes are suspected to transmit the virus.[70][71] The virus may occur in breast milk, but it's unknown whether it's infectious and transmittable to the baby.[72][73]

Estimates of the number of people infected by one person with COVID-19, the R0, have varied. The WHO's initial estimates of R0 were 1.42.5 (average 1.95), however an early April 2020 review found the basic R0 (without control measures) to be higher at 3.28 and the median R0 to be 2.79.[74]

Severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) is a novel severe acute respiratory syndrome coronavirus, first isolated from three people with pneumonia connected to the cluster of acute respiratory illness cases in Wuhan.[75] All features of the novel SARS-CoV-2 virus occur in related coronaviruses in nature.[76]Outside the human body, the virus is destroyed by household soap, which bursts its protective bubble.[26]

SARS-CoV-2 is closely related to the original SARS-CoV.[77] It is thought to have an animal (zoonotic) origin. Genetic analysis has revealed that the coronavirus genetically clusters with the genus Betacoronavirus, in subgenus Sarbecovirus (lineage B) together with two bat-derived strains. It is 96% identical at the whole genome level to other bat coronavirus samples (BatCov RaTG13).[46] In February 2020, Chinese researchers found that there is only one amino acid difference in the binding domain of the S protein between the coronaviruses from pangolins and those from humans; however, whole-genome comparison to date[when?] found that at most 92% of genetic material was shared between pangolin coronavirus and SARS-CoV-2, which is insufficient to prove pangolins to be the intermediate host.[78]

The lungs are the organs most affected by COVID19 because the virus accesses host cells via the enzyme angiotensin-converting enzyme 2 (ACE2), which is most abundant in type II alveolar cells of the lungs.[79] The virus uses a special surface glycoprotein called a "spike" (peplomer) to connect to ACE2 and enter the host cell.[80] The density of ACE2 in each tissue correlates with the severity of the disease in that tissue and some have suggested decreasing ACE2 activity might be protective,[81][82][unreliable medical source?] though another view is that increasing ACE2 using angiotensin II receptor blocker medications could be protective.[83] As the alveolar disease progresses, respiratory failure might develop and death may follow.[82][unreliable medical source?]

SARS-CoV-2 may also cause respiratory failure through affecting the brainstem as other coronaviruses have been found to invade the central nervous system (CNS). While virus has been detected in cerebrospinal fluid of autopsies, the exact mechanism by which it invades the CNS remains unclear and may first involve invasion of peripheral nerves given the low levels of ACE2 in the brain.[84][85][unreliable medical source?]

The virus also affects gastrointestinal organs as ACE2 is abundantly expressed in the glandular cells of gastric, duodenal and rectal epithelium[86] as well as endothelial cells and enterocytes of the small intestine.[87][unreliable medical source?]

The virus can cause acute myocardial injury and chronic damage to the cardiovascular system.[88] An acute cardiac injury was found in 12% of infected people admitted to the hospital in Wuhan, China,[44] and is more frequent in severe disease.[89][unreliable medical source?] Rates of cardiovascular symptoms are high, owing to the systemic inflammatory response and immune system disorders during disease progression, but acute myocardial injuries may also be related to ACE2 receptors in the heart.[88] ACE2 receptors are highly expressed in the heart and are involved in heart function.[88][90] A high incidence of thrombosis (31%) and venous thromboembolism (25%) have been found in ICU patients with COVID19 infections, and may be related to poor prognosis.[91][unreliable medical source?][92][unreliable medical source?] Blood vessel dysfunction and clot formation (as suggested by high D-dimer levels) are thought to play a significant role in mortality, incidences of clots leading to pulmonary embolisms, and ischaemic events within the brain have been noted as complications leading to death in patients infected with SARS-CoV-2. Infection appears to set off a chain of vasoconstrictive responses within the body, constriction of blood vessels within the pulmonary circulation has also been posited as a mechanism in which oxygenation decreases alongside the presentation of viral pneumonia.[93][bettersourceneeded]

Another common cause of death is complications related to the kidneys.[93][bettersourceneeded] Early reports show that up to 30% of hospitalized patients both in China and in New York have experienced some injury to their kidneys, including some persons with no previous kidney problems.[94]

Autopsies of people who died of COVID19 have found diffuse alveolar damage (DAD), and lymphocyte-containing inflammatory infiltrates within the lung.[95][unreliable medical source?]

Although SARS-CoV-2 has a tropism for ACE2-expressing epithelial cells of the respiratory tract, patients with severe COVID19 have symptoms of systemic hyperinflammation. Clinical laboratory findings of elevated IL-2, IL-7, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), interferon- inducible protein 10 (IP-10), monocyte chemoattractant protein1 (MCP-1), macrophage inflammatory protein 1- (MIP-1), and tumour necrosis factor- (TNF-) indicative of cytokine release syndrome (CRS) suggest an underlying immunopathology.[44]

Additionally, people with COVID19 and acute respiratory distress syndrome (ARDS) have classical serum biomarkers of CRS, including elevated C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer, and ferritin.[96]

Systemic inflammation results in vasodilation, allowing inflammatory lymphocytic and monocytic infiltration of the lung and the heart. In particular, pathogenic GM-CSF-secreting T-cells were shown to correlate with the recruitment of inflammatory IL-6-secreting monocytes and severe lung pathology in COVID19 patients.[citation needed] Lymphocytic infiltrates have also been reported at autopsy.[95][unreliable medical source?]

The WHO has published several testing protocols for the disease.[98] The standard method of testing is real-time reverse transcription polymerase chain reaction (rRT-PCR).[99] The test is typically done on respiratory samples obtained by a nasopharyngeal swab; however, a nasal swab or sputum sample may also be used.[25][100] Results are generally available within a few hours to two days.[101][102] Blood tests can be used, but these require two blood samples taken two weeks apart, and the results have little immediate value.[103] Chinese scientists were able to isolate a strain of the coronavirus and publish the genetic sequence so laboratories across the world could independently develop polymerase chain reaction (PCR) tests to detect infection by the virus.[10][104][105] As of 4April2020[update], antibody tests (which may detect active infections and whether a person had been infected in the past) were in development, but not yet widely used.[106][107][108] Antibody tests may be most accurate 23 weeks after a person's symptoms start.[109] The Chinese experience with testing has shown the accuracy is only sixty to seventy percent.[110] The US Food and Drug Administration (FDA) approved the first point-of-care test on 21 March 2020 for use at the end of that month.[111] The absence or presence of COVID-19 signs and symptoms alone is not reliable enough for an accurate diagnosis.[112]

Diagnostic guidelines released by Zhongnan Hospital of Wuhan University suggested methods for detecting infections based upon clinical features and epidemiological risk. These involved identifying people who had at least two of the following symptoms in addition to a history of travel to Wuhan or contact with other infected people: fever, imaging features of pneumonia, normal or reduced white blood cell count, or reduced lymphocyte count.[113]

A study asked hospitalised COVID19 patients to cough into a sterile container, thus producing a saliva sample, and detected the virus in eleven of twelve patients using RT-PCR. This technique has the potential of being quicker than a swab and involving less risk to health care workers (collection at home or in the car).[69]

Along with laboratory testing, chest CT scans may be helpful to diagnose COVID19 in individuals with a high clinical suspicion of infection but are not recommended for routine screening.[26][27] Bilateral multilobar ground-glass opacities with a peripheral, asymmetric, and posterior distribution are common in early infection.[26] Subpleural dominance, crazy paving (lobular septal thickening with variable alveolar filling), and consolidation may appear as the disease progresses.[26][114]

In late 2019, the WHO assigned emergency ICD-10 disease codes U07.1 for deaths from lab-confirmed SARS-CoV-2 infection and U07.2 for deaths from clinically or epidemiologically diagnosed COVID19 without lab-confirmed SARS-CoV-2 infection.[115]

Few data are available about microscopic lesions and the pathophysiology of COVID19.[116][117] The main pathological findings at autopsy are:[citation needed]

A COVID-19 vaccine is not expected until 2021 at the earliest.[127] The US National Institutes of Health guidelines do not recommend any medication for prevention of COVID19, before or after exposure to the SARS-CoV-2 virus, outside the setting of a clinical trial.[128][129] Without a vaccine, other prophylactic measures, or effective treatments, a key part of managing COVID19 is trying to decrease and delay the epidemic peak, known as "flattening the curve".[123] This is done by slowing the infection rate to decrease the risk of health services being overwhelmed, allowing for better treatment of current cases, and delaying additional cases until effective treatments or a vaccine become available.[123][126]

Preventive measures to reduce the chances of infection include staying at home, wearing a mask in public, avoiding crowded places, keeping distance from others, washing hands with soap and water often and for at least 20 seconds, practising good respiratory hygiene, and avoiding touching the eyes, nose, or mouth with unwashed hands.[130][131][132][133]

The US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend individuals wear non-medical face coverings in public settings where there is an increased risk of transmission and where social distancing measures are difficult to maintain.[134][30][135] This recommendation is meant to reduce the spread of the disease by asymptomatic and pre-symtomatic individuals and is complementary to established preventive measures such as social distancing.[30][136] Face coverings limit the volume and travel distance of expiratory droplets dispersed when talking, breathing, and coughing.[30][136] Many countries and local jurisdictions encourage or mandate the use of face masks or cloth face coverings by members of the public to limit the spread of the virus.[137][138][139][140]

Masks are also strongly recommended for those who may have been infected and those taking care of someone who may have the disease.[141] When not wearing a mask, the CDC recommends covering the mouth and nose with a tissue when coughing or sneezing and recommends using the inside of the elbow if no tissue is available.[131] Proper hand hygiene after any cough or sneeze is encouraged.[131]

Social distancing strategies aim to reduce contact of infected persons with large groups by closing schools and workplaces, restricting travel, and cancelling large public gatherings.[142] Distancing guidelines also include that people stay at least 6 feet (1.8m) apart.[143] After the implementation of social distancing and stay-at-home orders, many regions have been able to sustain an effective transmission rate ("Rt") of less than one, meaning the disease is in remission in those areas.[144]

The CDC also recommends that individuals wash hands often with soap and water for at least 20 seconds, especially after going to the toilet or when hands are visibly dirty, before eating and after blowing one's nose, coughing or sneezing. The CDC further recommends using an alcohol-based hand sanitiser with at least 60% alcohol, but only when soap and water are not readily available.[131] For areas where commercial hand sanitisers are not readily available, the WHO provides two formulations for local production. In these formulations, the antimicrobial activity arises from ethanol or isopropanol. Hydrogen peroxide is used to help eliminate bacterial spores in the alcohol; it is "not an active substance for hand antisepsis". Glycerol is added as a humectant.[145]

Those diagnosed with COVID19 or who believe they may be infected are advised by the CDC to stay home except to get medical care, call ahead before visiting a healthcare provider, wear a face mask before entering the healthcare provider's office and when in any room or vehicle with another person, cover coughs and sneezes with a tissue, regularly wash hands with soap and water and avoid sharing personal household items.[32][146]

Sanitizing of frequently touched surfaces is also recommended or required by regulation for businesses and public facilities; the United States Environmental Protection Agency maintains a list of products expected to be effective.[147]

On 7 July 2020, the WHO said in a press conference that it will issue new guidelines about airborne transmission in settings with close contact and poor ventilation.[148]

For health care professionals who may come into contact with COVID-19 positive bodily fluids, using personal protective coverings on exposed body parts improves protection from the virus.[149] Breathable personal protective equipment improves user-satisfaction and may offer a similar level of protection from the virus.[149] In addition, adding tabs and other modifications to the protective equipment may reduce the risk of contamination during donning and doffing (putting on and taking off the equipment).[149] Implementing an evidence-based donning and doffing protocol such as a one-step glove and gown removal technique, giving oral instructions while donning and doffing, double gloving, and the use of glove disinfection may also improve protection for health care professionals.[149]

People are managed with supportive care, which may include fluid therapy, oxygen support, and supporting other affected vital organs.[150][151][152] The CDC recommends those who suspect they carry the virus wear a simple face mask.[32] Extracorporeal membrane oxygenation (ECMO) has been used to address the issue of respiratory failure, but its benefits are still under consideration.[citation needed][153] Personal hygiene and a healthy lifestyle and diet have been recommended to improve immunity.[154] Supportive treatments may be useful in those with mild symptoms at the early stage of infection.[155]

The WHO, the Chinese National Health Commission, and the United States' National Institutes of Health have published recommendations for taking care of people who are hospitalised with COVID19.[128][156][157] Intensivists and pulmonologists in the US have compiled treatment recommendations from various agencies into a free resource, the IBCC.[158][159]

The severity of COVID19 varies. The disease may take a mild course with few or no symptoms, resembling other common upper respiratory diseases such as the common cold. Mild cases typically recover within two weeks, while those with severe or critical diseases may take three to six weeks to recover. Among those who have died, the time from symptom onset to death has ranged from two to eight weeks.[46]

Children make up a small proportion of reported cases, with about 1% of cases being under 10 years and 4% aged 1019 years.[22] They are likely to have milder symptoms and a lower chance of severe disease than adults. In those younger than 50 years the risk of death is less than 0.5%, while in those older than 70 it is more than 8%.[166][167][168] Pregnant women may be at higher risk of severe COVID19 infection based on data from other similar viruses, like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), but data for COVID19 is lacking.[169][170] According to scientific reviews smokers are more likely to require intensive care or die compared to non-smokers,[171][172] air pollution is similarly associated with risk factors,[172] and obesity contributes to an increased health risk of COVID-19.[172][173][174]

A European multinational study of hospitalized children published in The Lancet on June 25, 2020 found that about 8% of children admitted to a hospital needed intensive care. Four of those 582 children (0.7%) died, but the actual mortality rate could be "substantially lower" since milder cases that did not seek medical help were not included in the study.[175]

Most of those who die of COVID19 have pre-existing (underlying) conditions, including hypertension, diabetes mellitus, and cardiovascular disease.[220] The Istituto Superiore di Sanit reported that out of 8.8% of deaths where medical charts were available, 97% of people had at least one comorbidity with the average person having 2.7 diseases.[221] According to the same report, the median time between the onset of symptoms and death was ten days, with five being spent hospitalised. However, people transferred to an ICU had a median time of seven days between hospitalisation and death.[221] In a study of early cases, the median time from exhibiting initial symptoms to death was 14 days, with a full range of six to 41 days.[222] In a study by the National Health Commission (NHC) of China, men had a death rate of 2.8% while women had a death rate of 1.7%.[223] In 11.8% of the deaths reported by the National Health Commission of China, heart damage was noted by elevated levels of troponin or cardiac arrest.[47] According to March data from the United States, 89% of those hospitalised had preexisting conditions.[224]

Most critical respiratory comorbidities according to the CDC, are: moderate or severe Asthma, pre-existing COPD, pulmonary fibrosis, cystic fibrosis.[225] Current evidence stemming from meta-analysis of several smaller research papers, also suggest that smoking can be associated with worse patient outcomes.[226][227] When someone with existing respiratory problems is infected with COVID-19, they might be at greater risk for severe symptoms.[228] COVID-19 also poses a greater risk to people who misuse opioids and methamphetamines, insofar as their drug use may have caused lung damage.[229]

Complications may include pneumonia, acute respiratory distress syndrome (ARDS), multi-organ failure, septic shock, and death.[10][16][230][231] Cardiovascular complications may include heart failure, arrhythmias, heart inflammation, and blood clots.[232]

Approximately 2030% of people who present with COVID19 have elevated liver enzymes reflecting liver injury.[233][129]

Neurologic manifestations include seizure, stroke, encephalitis, and GuillainBarr syndrome (which includes loss of motor functions).[234] Following the infection, children may develop paediatric multisystem inflammatory syndrome, which has symptoms similar to Kawasaki disease, which can be fatal.[235][236]

Concerns have been raised about long-term sequelae of the disease. The Hong Kong Hospital Authority found a drop of 20% to 30% in lung capacity in some people who recovered from the disease, and lung scans suggested organ damage.[237] This may also lead to post-intensive care syndrome following recovery.[238]

It is unknown (as of April 2020) if past infection provides effective and long-term immunity in people who recover from the disease.[needs update][239][240] Some of the infected have been reported to develop protective antibodies, so acquired immunity is presumed likely, based on the behaviour of other coronaviruses.[241] Cases in which recovery from COVID19 was followed by positive tests for coronavirus at a later date have been reported.[242][243][244][245] However, these cases are believed to be lingering infection rather than reinfection,[245] or false positives due to remaining RNA fragments.[246] An investigation by the Korean CDC of 285 individuals who tested positive for SARS-CoV-2 in PCR tests administered days or weeks after recovery from COVID-19 found no evidence that these individuals were contagious at this later time.[247] Some other coronaviruses circulating in people are capable of reinfection after roughly a year.[248][249]

The virus is thought to be natural and has an animal origin,[76] through spillover infection.[250] The first known human infections were in China. A study of the first 41 cases of confirmed COVID19, published in January 2020 in The Lancet, reported the earliest date of onset of symptoms as 1December 2019.[251][252][253] Official publications from the WHO reported the earliest onset of symptoms as 8December 2019.[254] Human-to-human transmission was confirmed by the WHO and Chinese authorities by 20 January 2020.[255][256] According to official Chinese sources, these were mostly linked to the Huanan Seafood Wholesale Market, which also sold live animals.[257] In May 2020, George Gao, the director of the Chinese Center for Disease Control and Prevention, said animal samples collected from the seafood market had tested negative for the virus, indicating that the market was the site of an early superspreading event, but it was not the site of the initial outbreak.[258] Traces of the virus have been found in wastewater that was collected from Milan and Turin, Italy, on 18 December 2019.[259]

There are several theories about where the very first case (the so-called patient zero) originated.[260] According to an unpublicised report from the Chinese government, the first case can be traced back to 17 November 2019; the person was a 55-year old citizen in the Hubei province. There were four men and five women reported to be infected in November, but none of them were "patient zero".[12] By December 2019, the spread of infection was almost entirely driven by human-to-human transmission.[161][261] The number of coronavirus cases in Hubei gradually increased, reaching 60 by 20 December[262] and at least 266 by 31 December.[263] On 24 December, Wuhan Central Hospital sent a bronchoalveolar lavage fluid (BAL) sample from an unresolved clinical case to sequencing company Vision Medicals. On 27 and 28 December, Vision Medicals informed the Wuhan Central Hospital and the Chinese CDC of the results of the test, showing a new coronavirus.[264] A pneumonia cluster of unknown cause was observed on 26 December and treated by the doctor Zhang Jixian in Hubei Provincial Hospital, who informed the Wuhan Jianghan CDC on 27 December.[265] On 30 December, a test report addressed to Wuhan Central Hospital, from company CapitalBio Medlab, stated an erroneous positive result for SARS, causing a group of doctors at Wuhan Central Hospital to alert their colleagues and relevant hospital authorities of the result. That evening, the Wuhan Municipal Health Commission issued a notice to various medical institutions on "the treatment of pneumonia of unknown cause".[266] Eight of these doctors, including Li Wenliang (punished on 3January),[267] were later admonished by the police for spreading false rumours, and another, Ai Fen, was reprimanded by her superiors for raising the alarm.[268]

The Wuhan Municipal Health Commission made the first public announcement of a pneumonia outbreak of unknown cause on 31 December, confirming 27 cases[269][270][271]enough to trigger an investigation.[272]

During the early stages of the outbreak, the number of cases doubled approximately every seven and a half days.[273] In early and mid-January 2020, the virus spread to other Chinese provinces, helped by the Chinese New Year migration and Wuhan being a transport hub and major rail interchange.[274] On 20 January, China reported nearly 140 new cases in one day, including two people in Beijing and one in Shenzhen.[275] Later official data shows 6,174 people had already developed symptoms by then,[276] and more may have been infected.[277] A report in The Lancet on 24 January indicated human transmission, strongly recommended personal protective equipment for health workers, and said testing for the virus was essential due to its "pandemic potential".[278][279] On 30 January, the WHO declared the coronavirus a public health emergency of international concern.[277] By this time, the outbreak spread by a factor of 100 to 200 times.[280]

On 31 January 2020, Italy had its first confirmed cases, two tourists from China.[281] As of 13 March 2020, the WHO considered Europe the active centre of the pandemic.[282] On 19 March 2020, Italy overtook China as the country with the most deaths.[283] By 26 March, the United States had overtaken China and Italy with the highest number of confirmed cases in the world.[284] Research on coronavirus genomes indicates the majority of COVID-19 cases in New York came from European travellers, rather than directly from China or any other Asian country.[285] Retesting of prior samples found a person in France who had the virus on 27 December 2019[286][287] and a person in the United States who died from the disease on 6February 2020.[288]

On 11 June 2020, after 55 days without a locally transmitted case,[289] Beijing reported the first COVID-19 case, followed by two more cases on 12 June.[290] By 15 June, 79 cases were officially confirmed.[291] Most of these patients went to Xinfadi Wholesale Market.[289][292]

Several measures are commonly used to quantify mortality.[293] These numbers vary by region and over time and are influenced by the volume of testing, healthcare system quality, treatment options, time since the initial outbreak, and population characteristics such as age, sex, and overall health.[294]

The death-to-case ratio reflects the number of deaths divided by the number of diagnosed cases within a given time interval. Based on Johns Hopkins University statistics, the global death-to-case ratio is 4.0% (648,913/16,262,481) as of 27 July 2020.[8] The number varies by region.[295]

Other measures include the case fatality rate (CFR), which reflects the percent of diagnosed individuals who die from a disease, and the infection fatality rate (IFR), which reflects the percent of infected individuals (diagnosed and undiagnosed) who die from a disease. These statistics are not time-bound and follow a specific population from infection through case resolution. Many academics have attempted to calculate these numbers for specific populations.[296]

Outbreaks have occurred in prisons due to crowding and an inability to enforce adequate social distancing.[297][298] In the United States, the prisoner population is aging and many of them are at high risk for poor outcomes from COVID19 due to high rates of coexisting heart and lung disease, and poor access to high-quality healthcare.[297]

Total confirmed cases over time

Infection fatality rate (or infection fatality ratio) is distinguished from case fatality rate. The case fatality rate ("CFR") for a disease is the proportion of deaths from the disease compared to the total number of people diagnosed with the disease (within a certain period of time). The infection fatality ratio ("IFR"), in contrast, is the proportion of deaths among all the infected individuals. IFR, unlike CFR, attempts to account for all asymptomatic and undiagnosed infections.

Our World in Data states that, as of 25 March 2020, the infection fatality rate (IFR) for coronavirus cannot be accurately calculated.[301] In February, the World Health Organization reported estimates of IFR between 0.33% and 1%.[302][303] On 2July, The WHO's Chief Scientist reported that the average IFR estimate presented at a two-day WHO expert forum was about 0.6%.[304][305]

The CDC estimates for planning purposes that the infection fatality rate is 0.65% and that 40% of infected individuals are asymptomatic, suggesting a fatality rate among those who are symptomatic of 1.08% (.65/60) (as of 10 July).[306][307] According to the University of Oxford Centre for Evidence-Based Medicine (CEBM), random antibody testing in Germany suggested a national IFR of 0.37% (0.12% to 0.87%).[308][309][310] To get a better view on the number of people infected, as of April2020[update], initial antibody testing had been carried out, but peer-reviewed scientific analyses had not yet been published.[311][312] On 1May antibody testing in New York City suggested an IFR of 0.86%.[313]

Firm lower limits of infection fatality rates have been established in a number of locations such as New York City and Bergamo in Italy since the IFR cannot be less than the population fatality rate. As of 10July, in New York City, with a population of 8.4million, 23,377 individuals (18,758 confirmed and 4,619 probable) have died with COVID-19 (0.28% of the population).[314] In Bergamo province, 0.57% of the population has died.[315]

Early reviews of epidemiologic data showed greater impact of the pandemic and a higher mortality rate in men in China and Italy.[316][1][317] The Chinese Center for Disease Control and Prevention reported the death rate was 2.8 percent for men and 1.7 percent for women.[318] Later reviews in June 2020 indicated that there is no significant difference in susceptibility or in CFR between genders.[319][320] One review acknowledges the different mortality rates in Chinese men, suggesting that it may be attributable to lifestyle choices such as smoking and drinking alcohol rather than genetic factors.[321] Sex-based immunological differences, lesser prevalence of smoking in women and men developing co-morbid conditions such as hypertension at a younger age than women could have contributed to the higher mortality in men.[322] In Europe, 57% of the infected people were men and 72% of those died with COVID-19 were men.[323] As of April 2020, the US government is not tracking sex-related data of COVID-19 infections.[324] Research has shown that viral illnesses like Ebola, HIV, influenza and SARS affect men and women differently.[324]

In the US, a greater proportion of deaths due to COVID-19 have occurred among African Americans.[326] Structural factors that prevent African Americans from practicing social distancing include their concentration in crowded substandard housing and in "essential" occupations such as public transit and health care. Greater prevalence of lacking health insurance and care and of underlying conditions such as diabetes, hypertension and heart disease also increase their risk of death.[327] Similar issues affect Native American and Latino communities.[326] According to a US health policy non-profit, 34% of American Indian and Alaska Native People (AIAN) non-elderly adults are at risk of serious illness compared to 21% of white non-elderly adults.[328] The source attributes it to disproportionately high rates of many health conditions that may put them at higher risk as well as living conditions like lack of access to clean water.[329] Leaders have called for efforts to research and address the disparities.[330]

In the U.K., a greater proportion of deaths due to COVID-19 have occurred in those of a Black, Asian, and other ethnic minority background.[331][332][333] Several factors such as poverty, poor nutrition and living in overcrowded properties, may have caused this.[citation needed]

During the initial outbreak in Wuhan, China, the virus and disease were commonly referred to as "coronavirus" and "Wuhan coronavirus",[334][335][336] with the disease sometimes called "Wuhan pneumonia".[337][338] In the past, many diseases have been named after geographical locations, such as the Spanish flu,[339] Middle East Respiratory Syndrome, and Zika virus.[340]

In January 2020, the World Health Organisation recommended 2019-nCov[341] and 2019-nCoV acute respiratory disease[342] as interim names for the virus and disease per 2015 guidance and international guidelines against using geographical locations (e.g. Wuhan, China), animal species or groups of people in disease and virus names to prevent social stigma.[343][344][345]

The official names COVID19 and SARS-CoV-2 were issued by the WHO on 11 February 2020.[346] WHO chief Tedros Adhanom Ghebreyesus explained: CO for corona, VI for virus, Dfor disease and 19 for when the outbreak was first identified (31 December 2019).[347] The WHO additionally uses "the COVID19 virus" and "the virus responsible for COVID19" in public communications.[346]

After the initial outbreak of COVID19, misinformation and disinformation regarding the origin, scale, prevention, treatment, and other aspects of the disease rapidly spread online.[348][349][350]

The pandemic has had many impacts on global health beyond those caused by the COVID-19 disease itself. It has led to a reduction in hospital visits for other reasons. There have been 38% fewer hospital visits for heart attack symptoms in the United States and 40% fewer in Spain.[351] The head of cardiology at the University of Arizona said, "My worry is some of these people are dying at home because they're too scared to go to the hospital."[352] There is also concern that people with strokes and appendicitis are not seeking timely treatment.[352] Shortages of medical supplies have impacted people with various conditions.[353] In several countries there has been a marked reduction of spread of sexually transmitted infections, including HIV, attributable to COVID-19 quarantines and social distancing measures.[354][355] Similarly, in some places, rates of transmission of influenza and other respiratory viruses significantly decreased during the pandemic.[356][357][358] The pandemic has also negatively impacted mental health globally, including increased loneliness resulting from social distancing.[359]

Humans appear to be capable of spreading the virus to some other animals. A domestic cat in Lige, Belgium, tested positive after it started showing symptoms (diarrhoea, vomiting, shortness of breath) a week later than its owner, who was also positive.[360] Tigers and lions at the Bronx Zoo in New York, United States, tested positive for the virus and showed symptoms of COVID19, including a dry cough and loss of appetite.[361] Minks at two farms in the Netherlands also tested positive for COVID-19.[362]

A study on domesticated animals inoculated with the virus found that cats and ferrets appear to be "highly susceptible" to the disease, while dogs appear to be less susceptible, with lower levels of viral replication. The study failed to find evidence of viral replication in pigs, ducks, and chickens.[363]

In March 2020, researchers from the University of Hong Kong have shown that Syrian hamsters could be a model organism for COVID-19 research.[364]

No medication or vaccine is approved with the specific indication to treat the disease.[365] International research on vaccines and medicines in COVID19 is underway by government organisations, academic groups, and industry researchers.[366][367] In March, the World Health Organisation initiated the "Solidarity Trial" to assess the treatment effects of four existing antiviral compounds with the most promise of efficacy.[368] The World Health Organization suspended hydroxychloroquine from its global drug trials for COVID-19 treatments on 26 May 2020 due to safety concerns. It had previously enrolled 3,500 patients from 17 countries in the Solidarity Trial.[369] France, Italy and Belgium also banned the use of hydroxychloroquine as a COVID-19 treatment.[370]

There has been a great deal of COVID-19 research, involving accelerated research processes and publishing shortcuts to meet the global demand. To minimise the harm from misinformation, medical professionals and the public are advised to expect rapid changes to available information, and to be attentive to retractions and other updates.[371]

There is no available vaccine, but various agencies are actively developing vaccine candidates. Previous work on SARS-CoV is being used because both SARS-CoV and SARS-CoV-2 use the ACE2 receptor to enter human cells.[372] Six vaccination strategies are being investigated. Four of these, as of early July 2020, are being tested in clinical trials.[373] First, researchers aim to build a whole virus vaccine. The use of such inactive virus aims to elicit a prompt immune response of the human body to a new infection with COVID19. A second strategy, subunit vaccines, aims to create a vaccine that sensitises the immune system to certain subunits of the virus. In the case of SARS-CoV-2, such research focuses on the S-spike protein that helps the virus intrude the ACE2 enzyme receptor. A third strategy is that of the nucleic acid vaccines (DNA or RNA vaccines, a novel technique for creating a vaccination). Fourthly, scientists are attempting to use viral vectors to deliver the SARS-CoV-2 antigen gene into the cell.[374] These can be replicating or non-replicating. As of early July 2020, only non-replicating viral vectors are in clinical trials. Viral vectors in clinical trials include Chimpanzee Adenovirus 63,[374] Adenovirus type-5,[373] and Adenovirus type-26.[375] Scientists are also working to develop an attenuated COVID-19 vaccine and a COVID-19 vaccine using virus-like particles, but these are still in preclinical research.[373] Experimental vaccines from any of these strategies would have to be tested for safety and efficacy.[376]

Antibody-dependent enhancement has been suggested as a potential challenge for vaccine development for SARS-COV-2, but this is controversial.[377]

At least 29 Phase IIIV efficacy trials in COVID19 were concluded in March 2020, or scheduled to provide results in April from hospitals in China.[378][379] There are more than 300 active clinical trials underway as of April 2020.[129] Seven trials were evaluating already approved treatments, including four studies on hydroxychloroquine or chloroquine.[379] Repurposed antiviral drugs make up most of the research, with nine PhaseIII trials on remdesivir across several countries due to report by the end of April.[378][379] Other candidates in trials include vasodilators, corticosteroids, immune therapies, lipoic acid, bevacizumab, and recombinant angiotensin-converting enzyme 2.[379]

The COVID19 Clinical Research Coalition has goals to 1) facilitate rapid reviews of clinical trial proposals by ethics committees and national regulatory agencies, 2) fast-track approvals for the candidate therapeutic compounds, 3) ensure standardised and rapid analysis of emerging efficacy and safety data and 4) facilitate sharing of clinical trial outcomes before publication.[380][381]

Several existing medications are being evaluated for the treatment of COVID19,[365] including remdesivir, chloroquine, hydroxychloroquine, lopinavir/ritonavir, and lopinavir/ritonavir combined with interferon beta.[368][382] There is tentative evidence for efficacy by remdesivir, and on 1May 2020, the United States Food and Drug Administration (FDA) gave the drug an emergency use authorization for people hospitalized with severe COVID19.[383] Phase III clinical trials for several drugs are underway in several countries, including the US, China, and Italy.[365][378][384]

There are mixed results as of 3 April 2020 as to the effectiveness of hydroxychloroquine as a treatment for COVID19, with some studies showing little or no improvement.[385][386] One study has shown an association between hydroxychloroquine or chloroquine use with higher death rates along with other side effects.[387][388] A retraction of this study by its authors was published by The Lancet on 4June 2020.[389] The studies of chloroquine and hydroxychloroquine with or without azithromycin have major limitations that have prevented the medical community from embracing these therapies without further study.[129] On 15 June 2020, the FDA updated the fact sheets for the emergency use authorization of remdesivir to warn that using chloroquine or hydroxychloroquine with remdesivir may reduce the antiviral activity of remdesivir.[390]

In June, initial results from a randomised trial in the United Kingdom showed that dexamethasone reduced mortality by one third for patients who are critically ill on ventilators and one fifth for those receiving supplemental oxygen.[391] Because this is a well tested and widely available treatment this was welcomed by the WHO that is in the process of updating treatment guidelines to include dexamethasone or other steroids.[392][393] Based on those preliminary results, dexamethasone treatment has been recommended by the National Institutes of Health for patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen but not in patients with COVID-19 who do not require supplemental oxygen.[394]

A cytokine storm can be a complication in the later stages of severe COVID19. There is preliminary evidence that hydroxychloroquine may be useful in controlling cytokine storms in late-phase severe forms of the disease.[395]

Tocilizumab has been included in treatment guidelines by China's National Health Commission after a small study was completed.[396][397] It is undergoing a PhaseII non-randomised trial at the national level in Italy after showing positive results in people with severe disease.[398][399] Combined with a serum ferritin blood test to identify a cytokine storm (also called cytokine storm syndrome, not to be confused with cytokine release syndrome), it is meant to counter such developments, which are thought to be the cause of death in some affected people.[400][401][402] The interleukin-6 receptor antagonist was approved by the Food and Drug Administration (FDA) to undergo a PhaseIII clinical trial assessing its effectiveness on COVID19 based on retrospective case studies for the treatment of steroid-refractory cytokine release syndrome induced by a different cause, CAR T cell therapy, in 2017.[403] To date,[when?] there is no randomised, controlled evidence that tocilizumab is an efficacious treatment for CRS. Prophylactic tocilizumab has been shown to increase serum IL-6 levels by saturating the IL-6R, driving IL-6 across the blood-brain barrier, and exacerbating neurotoxicity while having no effect on the incidence of CRS.[404]

Lenzilumab, an anti-GM-CSF monoclonal antibody, is protective in murine models for CAR T cell-induced CRS and neurotoxicity and is a viable therapeutic option due to the observed increase of pathogenic GM-CSF secreting T-cells in hospitalised patients with COVID19.[405]

The Feinstein Institute of Northwell Health announced in March a study on "a human antibody that may prevent the activity" of IL-6.[406]

Transferring purified and concentrated antibodies produced by the immune systems of those who have recovered from COVID19 to people who need them is being investigated as a non-vaccine method of passive immunisation.[407][408] The safety and effectiveness of convalescent plasma as a treatment option requires further research.[408] This strategy was tried for SARS with inconclusive results.[407] Viral neutralisation is the anticipated mechanism of action by which passive antibody therapy can mediate defence against SARS-CoV-2. The spike protein of SARS-CoV-2 is the primary target for neutralizing antibodies.[409] It has been proposed that selection of broad-neutralizing antibodies against SARS-CoV-2 and SARS-CoV might be useful for treating not only COVID-19 but also future SARS-related CoV infections.[409] Other mechanisms, however, such as antibody-dependent cellular cytotoxicity and/or phagocytosis, may be possible.[407] Other forms of passive antibody therapy, for example, using manufactured monoclonal antibodies, are in development.[407] Production of convalescent serum, which consists of the liquid portion of the blood from recovered patients and contains antibodies specific to this virus, could be increased for quicker deployment.[410]

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