Research

19 Truths We Must Face About Covid-19

Commentary: If we want schools and the economy to restart, we’ve got to accept some facts and deal with them

In reporting on the coronavirus since January, I’ve interviewed dozens of infectious-disease researchers, epidemiologists and other scientists and health experts, and this much is crystal clear: The terrible situation we’re in now was widely, loudly and frequently predicted since very early on. Many U.S. political leaders didn’t listen then. If they don’t listen now, it will just get worse. At least, that’s what the experts say. Here’s a review of lessons not learned, the foibles that got us here, and the sad fact about who must take responsibility to change the course of the growing pandemic.

1: We knew in early February that this already was or would soon be a global pandemic. And we knew then that the handful of U.S. cases were just a prelude…

“It’s very, very transmissible, and it almost certainly is going to be a pandemic.”
—Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, February 2, 2020

“We are preparing as if this were the next pandemic.”
— Dr. Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC), said February 3, 2020

“It appears we are currently in the early stages of a mild pandemic.”
— Dr. Amesh Adalja, an infectious disease expert at the Center for Health Security at Johns Hopkins University, February 5, 2020

But from the beginning, the experts were ignored and the reality distorted…

“It’s an unforeseen problem.”
— President Donald Trump, March 6, 2020

“It’s something that nobody expected.”
— President Donald Trump, March 14, 2020

“Nobody could have predicted something like this.”
— President Donald Trump, March 30, 2020

2: We knew in early April, when New York City was in the midst of its crisis, that the disease would spread across the country. “Every state will experience their own curve and their own peak,” Mark Cameron, PhD, an immunologist and medical researcher in the School of Medicine at Case Western Reserve University in Ohio, said on April 4, joining a chorus of experts predicting same.

3: Three months later, after economically and socially brutal shutdowns, every measure of the Covid-19 pandemic is now going in the wrong direction nationwide: New cases are soaring, hospitalizations are rising, and deaths, which lag behind both of those metrics, are starting a long-predicted uptick.

4: Like few other threats to the health of American people and the economy, the response to the Covid-19 pandemic nationally and in several states is marked not by missteps but by outright refusal to listen to health experts and accept established science. From Feb. 10 through July 1, President Trump has predicted at least 19 times that the coronavirus would just go away, including claiming that “like a miracle, it will disappear.” The White House has silenced the CDC repeatedly and announced the U.S. will withdraw from the World Health Organization. Mind you, these are the two top health organizations in the world when it comes to pandemic response. This is, plain and simple, antiscience.

5: The lack of a national plan, of leadership from the top, and the White House’s outright dismissal of advice from health experts, are the main reasons that the United States leads the world in Covid-19 deaths, with 24% of the global total despite having just 4.2% of the world’s population. You don’t become №1 in deaths by doing more testing.

6: We can’t get the U.S. economy going or safely restart schools without healthy people — workers, teachers, parents and kids. We won’t have healthy people if we don’t stamp out the pandemic. “States that opened without controlling Covid had to close,” Dr. Tom Frieden, former head of the CDC, tweeted today. “It’s 100% predictable: schools that open with either extensive spread or without careful planning will have to close. It’s SO important that our kids get back to school. That’s why it’s so important we do so thoughtfully.” (Here’s what educators and scientists say is needed, and here’s why federal funding for school reopenings would make sense.)

7:Without serious effort, the pandemic could get much worse this fall. And it will be around for years to come, barring a vaccine, which so far is still at least months away and may never happen (successful vaccines are really hard to do). And no, natural herd immunity is not the answer, unless you just get a kick out of a million or more Americans dying.

8:The virus spreads incredibly easily, mostly through the air when people are within 6 feet of each other for some length of time, and especially indoors, and double especially if they’re not wearing masks. If that sounds like a rally, it is. We know this. We’ve known this for months. Any confusion over the value of masks has been cleared up for weeks.

9:The virus does not respect borders. It goes where people go. One state’s vigilance can be nullified by another state’s ambivalence, by one traveler, one ember.

10: The lockdowns were totally squandered, by opening back up too quickly and too widely and not requiring masks in public, and failing to limit large indoor gatherings.

11: The reopening of bars and indoor dining and large indoor gatherings should have been on a delay, allowed only after evidence showed that other reopenings were not causing outbreaks.

12: The party atmosphere that was fostered with total lifts of lockdowns helped wipe out all the gains, the flattening of the curve, and in fact caused a surge in infections among younger adults, which is partly behind the soaring number of cases now.

13: The more the virus spreads, the harder it will be to bring under control. Contact tracing, which can work early on in smaller outbreaks to get isolate people who might have been exposed, is near impossible to conduct when you have 60,000 new cases daily. Every new case, meanwhile, represents greater odds of additional infections.

14:There is no question that a serious, national strategy should have been, and still should be, put in place to fight this pandemic, just as nearly every other nation on the planet has done. There is no indication that will happen. But we should not throw up our hands.

15: Nothing should be more important for the White House and the nation’s governors right this moment than getting this pandemic under control. “This should be our number one national priority right now,” Caitlin Rivers, PhD, an epidemiologist at the Johns Hopkins Center for Health Security and assistant professor at the Johns Hopkins Bloomberg School of Public Health, said June 26. “We are headed in the wrong direction at top speed.”

16: The science and on-the-record evidence on all the above is solid. We are where the scientists predicted we would be, where all of them hoped we would not be. Anyone who says “Who knew this would happen?” was simply ignoring the evidence that was everywhere, in the media and in verbal and written briefings to top officials (and even a White House pandemic playbook created by the previous administration).

17: Yes, science is not perfect, and we can quibble about some details, the fumbles of communication, the uncertainties and evolving understanding of a novel virus, the late-coming advice on masks. But epidemiologists and other health experts have been remarkably prescient about the risk and the need for a national plan, and if we don’t listen to their advice now, they’ll tell you to expect 1 million or more American deaths before this is over.

18: People who don’t wear masks when around other people in public are either ignorant of the facts or self-centered and uncaring of their fellow humans. Some say shaming doesn’t work, but that’s not shaming, it’s just facts. We cover our genitals in public. We don’t smoke in restaurants anymore. We make our kids wear seatbelts. We stay at home when we have the flu. We get vaccines. We do things for the good of public health. Mask refusal is not about liberty. It’s about death.

19: Even without state or national leadership, there are three selfless and highly effective things we can all do toward the goal of making the nation, and the economy, healthier, and hopefully getting kids back to schools so parents can go back to work: Avoid large indoor crowds, keep distance, wear masks. The pandemic response should not have to be planned by the people, but it seems to have been left to us.

Researchers report nearly 300 cases of inflammatory syndrome tied to Covid-19 in kids

Two U.S. research groups have reported finding nearly 300 cases of an alarming apparent side effect of Covid-19 in children, a condition called multisystem inflammation syndrome, or MIS-C. While researchers have previously reported on the condition, the papers mark the first attempt to measure how frequently the side effect occurs and how it affects children who develop it.

The studies, published in the New England Journal of Medicine, describe children who develop severe inflammation affecting multiple organ systems after having had Covid-19, sometimes between two and four weeks after the infection. The majority of the children were previously healthy.

In one of the studies, led by researchers at Boston Children’s Hospital, 80% of the children who developed the condition required intensive care, 20% required mechanical ventilation, and four children, or 2%, died. In the second study, from researchers from New York state, a similar percentage of 99 children who developed the syndrome required ICU care and two children died. In both studies, many of the children developed cardiovascular and clotting problems and many had gastrointestinal symptoms. A high proportion also had skin rashes.

“Ours were really sick kids,” said Adrienne Randolph, an ICU physician at Boston Children’s Hospital and senior author on one of the papers, which was based on reports from 26 states.

How likely are kids to get Covid-19? Scientists see a ‘huge puzzle’ without easy answers

Manish Patel, from the Centers for Disease Control and Prevention’s Covid-19 response team, said the message to parents is they should be on the lookout for fever and rash in children who have recently had Covid-19.

“I think being a little vigilant is important,” said Patel, who is an author on Randolph’s paper. “Fever, rash and I think especially in the setting of areas where you have a lot of coronavirus infections, SARS-CoV-2 infections — have a lower threshold for seeking care, I would say.”

On the whole, children appear to contract SARS-CoV-2 less often than adults and have a milder course of disease when they do.

But in late April, doctors in London alerted the world to the possibility that some children who had Covid-19 appeared to go on to develop something that looked like Kawasaki’s disease, an inflammatory condition that can attack the heart. KD, as it is called, is generally seen in children under the age of 5. Shortly thereafter, doctors in New York began to report cases as well.

In mid-May, the CDC asked doctors across the country to be on the lookout for cases of multisystem inflammatory syndrome in children.

The nearly 300 cases identified in these two studies share some similarities with KD, but there are also differences. Few of the children are under the age of 5. The average age of children in the larger study was 8; 42% of the children in the New York cohort were aged 6 to 12.

Another difference: While KD disproportionately affects children of Asian descent, MIS-C cases in the New York cohort were of all racial and ethnic backgrounds, the researchers reported.

“Among our patients, predominantly from the New York Metropolitan Region, 40% were Black and 36% were Hispanic. This may be a reflection of the well-documented elevated incidence of SARS CoV-2 infection among black and Hispanic communities,” they wrote.

The New York group estimated that the majority of MIS-C cases occurred about one month after the peak of Covid-19 cases in the state. They estimated that between March 1 and May 10, two of every 100,000 people under the 21 years of age who had laboratory-confirmed SARS-CoV-2 virus developed MIS-C in the state. The infection rate in people under the age of 21 years was 322 in 100,000 over that period.Trending Now: 

An editorial written by Michael Levin, from the department of infectious diseases at Imperial College London, said there have been roughly 1,000 pediatric cases of the condition reported worldwide to date. He suggested more are likely going unrecorded, because case definitions require evidence of prior Covid-19 infection.

“There is concern that children meeting current diagnostic criteria for MIS-C are the ‘tip of the iceberg,’ and a bigger problem may be lurking below the waterline,” Levin wrote.

Unless it’s done carefully, the rise of telehealth could widen health disparities

The Covid-19 pandemic has pushed telehealth — the remote provision of health care resources, tools, and consultation, usually via digital technologies — from the backwaters of medicine to its leading edge.

Though novel to some health care providers, and considered impractical by others, telehealth will likely endure — and become even more appealing — after the Covid-19 pandemic has faded away. We are concerned that this crisis-driven acceleration in the adoption of virtual visits and use of algorithmic tools will have uncertain implications for the equitable distribution of health resources and will widen racial and class-based disparities in health.

The changes that have made possible the wider use of telehealth appear to be temporary. For instance, health insurers, who once declined to fully reimburse virtual visits to physicians, nurse practitioners, and other health providers, are now making exceptions expressly tied to the nature of the pandemic. Yet research and theory from the social sciences on institutional change would predict that there may not be a clear-cut return to “normal” once this crisis is over.

The adaptation to Covid-19 has realigned the power and positions of physicians, nurses, insurance companies, hospitals, and telehealth startups in providing health services to different communities. Providers are establishing new policies and automated systems around triage, virtual visits, and infection control that may become taken-for-granted work routines going forward. Such practices may be laying the foundation for opportunism in the expansion of telehealth markets above and beyond their value in treating disease and saving lives by allowing compensation for unnecessary visits.

Related: 

Telehealth is a ‘silver lining’ of the pandemic, but implementing it permanently won’t be easy

For some time, technology companies have sought to disrupt the health sector with algorithms and other patient-centered digital innovations. These companies are now rushing to consolidate their positions before the opportunities presented by the pandemic abate.

Some providers and hospitals, attracted by potential reductions in cost and in potential improvements in patients’ health outcomes, were early adopters of virtual visits and other telehealth technologies. With the emergence of Covid-19, providers who had once been prudently looking for an evidence-based way to add value to their practices have been pushed into rapidly developing telehealth strategies to keep their practices afloat. Academic medical centers that had previously piloted telehealth as a strategy to expand their referrals or to decrease readmissions are now leveraging this infrastructure to more intentionally maintain contact with patients who have been seen in their outpatient offices.

There’s no question that the expansion of telehealth could be a force for good. These changes may save lives during this crisis by keeping patients out of health care settings where exposure to Covid-19 may be high. In the post-pandemic era, they could provide greater access and convenience for some patients. But they could also worsen health disparities down the road if not implemented carefully.

In its earliest days, one of telehealth’s missions was to ensure greater access to health care services by populations that otherwise would go without proper or timely care and consultation, such as those who are incarcerated or who live in rural areas. Now it is being used as a tool to supplant in-person visits and expand patient markets, partly in response to consumer demand for convenience and efficiency. This emphasis on expanding patient markets and responding to well-resourced consumers’ demand may put marginalized groups with poor health, no health insurance, or few digital resources at risk.

A market-driven, consumer-centered vision of telehealth could have negative implications for marginalized groups that already face discrimination during in-person medical encounters. Marginalized racial and ethnic minorities are more likely to report discrimination within health care settings, influencing their willingness to trust providers and seek medical attention early.

Discrimination and mistrust could be magnified in virtual doctor-patient encounters, in which patients may not feel they can fully communicate and providers may be less mindful of guarding against implicit bias based on attributes such as race, ethnicity, or educational status.

The potential for racism and class bias to be encoded into telehealth algorithms is also worrisome. Predictive tools are imperfect — although they may be able to predict average patterns across groups, they can neither fully account for the complexity of individuals nor incorporate subtle variables that may assist in the identification and treatment of disease. While doctors misuse of these algorithms is mitigated by clinical judgement and training, a patients’ uninformed use of such algorithms in lieu of seeking professional medical advice could be harmful. This is particularly true of patients who belong to social groups underrepresented in algorithmic data.

Hospitals, insurers, policymakers, and health care professionals must carefully consider how the telehealth policies and routines they implement might have durable — and potentially harmful — reverberations. Research into the costs and benefits of specific telehealth applications at the individual and population levels is essential.

Institutional policies created during this pandemic will have long-lasting consequences on health disparities. We must work to ensure they are net positive.

Matthew Clair is a sociologist and assistant professor of sociology at Stanford University. Brian W. Clair is an orthopedic surgeon at Lahey Hospital and Medical Center in Burlington, Mass. Walter K. Clair is a cardiologist, professor of medicine at Vanderbilt University Medical School, and executive medical director of the Vanderbilt Heart and Vascular Institute.

Op Ed: Off to a Tough Start: Managing Birth During the Covid-19 Pandemic

As I begin writing this story I sit at my desk in the hospital ready for the next page on my phone asking me to attend a C-section delivery, evaluate a newborn with low blood sugar, admit a youth with a seizure, or a myriad of other issues that might arise during my shift tonight. As a hospitalist physician trained in internal medicine and pediatrics, I cover many areas of the hospital while caring for adults and children of all ages. Tonight I am on-call for pediatrics which includes the pediatric floor, the newborn nursery, and the labor and delivery unit.

What happens if an infant is born this evening to a mother with the novel coronavirus? Perhaps you are pregnant or have a friend or loved one expecting soon and are asking yourself a similar question. Let’s take a look at how things have played out so far during the pandemic and talk about the most up-to-date recommendations on handling this complex situation.

A concerning event

A story was recently published about a woman in Montreal who was separated from her newborn for 55 days. The infant required care in the neonatal ICU because of prematurity. His mother had tested positive for Covid-19 but recovered quickly. Regional policy dictated that this mother would require two consecutive negative tests before being allowed in the hospital to visit her child. Surprisingly, she continued to test positive weeks after her symptoms had resolved. This was not an isolated occurrence as other similar events have been noted elsewhere. The regrettable outcome, in this case, and others like it, was an unnecessary separation of mother and baby during a crucial phase of the infant’s emotional and physical development.

Based on recent evidence, many experts have advised against such policies. The reason being that the PCR (polymerase chain reaction) test performed in this setting assesses for the presence of viral RNA. The test is very sensitive to pick up small fragments of the virus, SARS-CoV-2, but unfortunately, it cannot distinguish between active or dead viral particles. This can lead to persistently positive results even in a patient who has already recovered from Covid-19 and is no longer able to spread the virus to others.

“Someone that is PCR-positive, especially after they’ve recovered, especially if they’re weeks and weeks into their recovery, it’s not likely that they are still infectious,” — Maria Van Kerkhove, epidemiologist, and technical lead of the Covid-19 response for the World Health Organization.

Best practice

During this health crisis, how should women in labor be cared for if they choose to deliver at a hospital? Multiple organizations including the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG) have provided guidelines for managing birth in the midst of the pandemic and these guidelines generally agree with one another. What follows is a compilation and summary of their recommendations.

Are pregnant women considered high risk? Studies thus far have suggested that pregnant women with Covid-19 are not at increased risk for complications when compared to the general population. However, some data indicate that pregnant women may indeed be at a higher risk when compared to nonpregnant women of the same age group. Because more research is needed, the CDC currently includes pregnant women on their list of people who need to take extra precautions to avoid exposure to SARS-CoV-2.

On arrival at the hospital, those with symptoms of Covid-19 should undergo testing. Many hospitals also test women in labor even if they do not have symptoms of Covid-19, but this practice is not considered mandatory by the guidelines. For expectant mothers who either test positive for SARS-CoV-2 or have a pending test, the number of visitors should be limited — generally to just one family member or support person. Because there is no evidence that the virus can be transmitted across the placenta, delayed cord clamping may still be performed.

What is known about risk in newborns? In general, babies infected with Covid-19 recover without issue, but there have been reports of rare complications and even death in infants. This can be worrisome and troubling to expectant mothers which is why it is important to discuss ways to reduce the risk of exposure as much as possible.

Infants born to mothers who have confirmed or suspected Covid-19 should be tested within the first 24 hours of birth, and if negative, have an additional test within the first 48 hours of birth if the infant is still in the hospital. For infants who test negative, it is recommended that a discussion regarding the risks and benefits of separation be held between the mother and medical providers. Separation can occur by multiple methods and to varying degrees including keeping the infant in a separate room, placing the baby in an isolette, keeping the child greater than 6 feet from the mother, and having the mother wear a mask. As you might guess, if the infant and mother both test positive for SARS-CoV-2, separation is not indicated.

Guidelines also recommend a discussion about the risks and benefits of breastfeeding. While early data suggests that the virus cannot be transmitted through breastmilk, clearly, it remains challenging to avoid exposure through the air or by contact while feeding at the breast. Choosing to breastfeed remains reasonable as long as precautions are taken to reduce the likelihood of viral transmission such as hand hygiene and a cloth mask for the mother. Placing a mask on the infant is not recommended.

“Given the benefits of breast milk, when feasible, breast milk should be fed to infants regardless of maternal COVID-19 status.” Sonja A. Rasmussen, MD, and Denise J. Jamieson, MD, Caring for Women Who Are Planning a Pregnancy, Pregnant, or Postpartum During the COVID-19 Pandemic, Journal of the American Medical Association, June 5th, 2020

When can a mother with COVID-19 discontinue separation precautions from her infant? This is not the easiest to explain but here is my best attempt to break it down: The mother needs to either go 72 hours without a fever (without fever-reducing medication) and at least 10 days since her first symptom (or the first positive test in the case of an asymptomatic patient) or have two consecutive negative tests for SARS-CoV-2 at least 24 hours apart.

For mothers with planned pregnancies, except for those whose infants have arrived prematurely, none were aware at the time of conception that they would be giving birth during a global pandemic. Moreover, this crisis can heighten the already strong emotions often experienced by those whose pregnancy was unplanned. While missteps in caring for mothers and their newborns cannot be entirely avoided, healthcare providers and systems continue to adapt and improve. This shifts the focus away from the harsh reality of the pandemic and back to where it belongs — the welcoming of a beautiful new life.

  • By: Bo Stapler

Masking Is Not Just a Matter of If, but What Kind and When

We are making headway (maskway?) here in the United States, with more consensus that masks are key. Collectively, we can drive transmission down big time by wearing them. But if we accept that the average person—talking about myself here—can’t wear a mask 24/7, then we need to make sure we have the best masks possible, and that we wear them when it is most critical.

Masks are important because they both block transmission to others and protect the wearer. They don’t do either perfectly—the better the mask, the better it works—but perfect is the enemy of good enough to keep the R0 below one. So, masks are better than no masks. That’s the most important point.

We would greatly benefit from better masks. Folded up T-shirts work, but the better the mask, the less the viral transmission. This is especially true for essential workers and those at high risk of severe disease. Higher filtration masks are key.

How do we get better masks? This will have to happen either through the federal government — which seems unlikely, unless officials invoked the Defense Production Act — or through the private sector. Investors and companies should be racing toward making these, with a huge market opportunity in addition to the massive public health benefit.

Masks are not just needed to stop Covid-19 cases, hospitalizations, and deaths. They are also our ticket to actually reopening safely, getting back to work, and doing the things that we love to do. Without a vaccine, masks are our next, most pragmatic and achievable step to burning out the epidemic.

Masking is not an all or nothing behavior, either. I keep seeing people running outside alone with masks on, yet not masking indoors while socializing with friends and family. When you mask is almost as important as if you mask. If people can only realistically mask for X number of hours, then they must do so when transmission risk is highest.

This means masking indoors. This may very well mean masking around family or relatives as well, especially if they are in vulnerable risk groups and you live in a high-transmission area. In addition, this means masking while riding public transportation and at work.

Masking while alone in your car or when you are on a walk by yourself or for the second you pass by someone on the street is less useful. Your mask here likely won’t do too much as your risk of transmission is already very low.

So in short: Masks work, better masks work better, and masking during high-risk transmission situations matters more than during those which are low risk. Lastly, don’t shame those not wearing a mask. It won’t work. A genuine conversation may go further—but keep your own mask on.