As a new spike in Covid cases in the Sun Belt states continued to worsen, governors across the country who had been eager to accelerate the pace for relaxing the lockdowns and forced business closures they had imposed during the first weeks of the outbreak have hit the brakes. In states with the highest numbers of new cases, elected officials have started to re-instate some of the earlier restrictions in the face of growing public resistance, especially among younger people, to the requirements to wear masks and practice social distancing.
For example, in Jacksonville, Florida, where President Donald Trump will receive the GOP nomination at the Republican national convention in late August, city officials announced Monday that the wearing of masks will be mandatory at the convention site in public and indoor locations, especially in “situations where individuals cannot socially distance.”
Republicans moved the site of their convention from Charlotte, North Carolina to Jacksonville after North Carolina officials balked at approving plans for tens of thousands of attendees at the convention due to coronavirus concerns. Republican National Committee officials running the convention had previously promised to conduct temperature checks and make masks available to all of the attendees.
Meanwhile, the World Health Organization (WHO) warned that the worldwide outbreak is far from over, as the virus also continued to spread rapidly in South America, and resurged in Israel and China, where it had seemed to be under control.
The pandemic passed a grim milestone Sunday, with the confirmed worldwide death count from the coronavirus surpassing 500,000, according to data compiled by Johns Hopkins University. Over the weekend, the number of coronavirus cases reported worldwide also soared past the 10 million mark.
In the U.S., the virus death toll is approaching 125,000, but because many of the new Covid cases are younger and healthier people, the death rate has not accelerated, despite the total number of reported cases topping 2.5 million, led by sharp spikes in Arizona, Florida and Texas.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, who is widely respected as the nation’s top expert in the field, said at a press conference last week that the US outbreak now being driven by rapid community asymptomatic (symptom-free) spread, with as many as 40% of new cases—especially those in young adults—involving people with few if any symptoms of infection.
NEW TESTING METHODS ARE NEEDED
Dr. Fauci said that because so many of the newly infected people are asymptomatic and therefore are unknowingly spreading the virus, the standard approach to controlling the spread of the diseases — testing sick people, isolating them and tracing their contacts — is not working well. He said that another problem is the fact that some people whom we know have been exposed to the virus are reluctant to self-quarantine or have no place to do so.
Fauci is now having “intense discussions” with other public health experts to come up with a new strategy, including a possible shift to “pool testing,” in which samples from many people are tested at once in an effort to quickly find and isolate the infected.
Fauci also said that he has never before seen a virus that results in such a wide array of outcomes in people who are infected, ranging from no symptoms at all to death. While the most common symptoms involve respiratory problems, the Covid virus affects many other vital organs, including the heart, kidneys and the pancreas, and its impact can linger for months after the virus is no longer present in the body.
At a congressional hearing last week, Dr. Fauci said that infection trends this summer will produce a “baseline” for determining how severe a second wave of the virus is likely to be in the fall and winter, and whether the country can rely on containment measures to control the spread, or will have to impose another round of widespread closures of businesses and schools.
WEARING A MASK IS MORE NECESSARY NOW
Fauci, is strongly urging the public to wear face masks especially now that more people are out in public and Covid cases are surging in many areas. “Plan A: Don’t go in a crowd. Plan B: If you do, make sure you wear a mask,” he said. But Fauci also claims to have no regrets for not insisting that all Americans wear masks earlier in the pandemic.
“At that time, there was a paucity of equipment that our health care providers needed — who put themselves daily in harm’s way of taking care of people who are ill. We did not want to divert masks and PPE (personal protective equipment) away from them, to be used by the people.” But now, Fauci said, “we have enough.”
STATES SETTING NEW COVID CASE RECORDS
Arizona saw another record high in Covid hospitalizations over the weekend, days after Trump attended a raucous indoor rally in Phoenix during which almost no one wore a face mask.
Florida reported more than 5,200 new cases on Monday and at least 28 deaths, bringing the total number of cases and deaths in the state during the pandemic to more than 146,000 and about 3,500, respectively.
For the past 3 weeks, the rolling average of new cases in Florida has set a record each day. South Carolina has set a record on its rolling seven-day average for 21 days, while Texas has for 19 days. In Louisiana, the seven-day average is 123% higher than it was a week ago.
California, which was the first state in the nation to impose a Covid shut down in early March and seemed to be successful in halting the spread of the virus at that time, is now suffering a new spike in cases, prompting its elected officials and infectious disease experts to ask themselves what went wrong. California reported more than 7,000 new cases on Monday, its highest single-day total of the pandemic. In response, Governor Gavin Newson shut down bars in a half-dozen counties, including Los Angeles and the Central Valley, and recommended that another eight counties voluntarily close their nightspots and public gathering places.
“OUR LUCK MAY HAVE RUN OUT”
“To some extent I think our luck may have run out,” said Dr. Bob Wachter, a professor and chair of the department of medicine at the University of California, San Francisco said, “I think our luck may have run out. This is faster and worse than I expected. You have to have a ton of respect for this thing [the virus]. It is nasty and it just lurks and waits to stomp on you if you let your guard down for a second.”
Mayor Eric Garcetti of Los Angeles blamed the resurgence of the virus on “irrational exuberance. A lot of people didn’t stick with the plan. The idea was, we would do a move, wait three weeks, check the impact, take the next move.”
Instead, Garcetti said, the reopening “was like a tidal wave — one move led to the next, led to the next, led to the next. And then we had the [George Floyd] protest on top of that, and other things. And we have yet to be able to identify where [the] spread is happening and what we can do to crank it down.”
Los Angeles County alone has reported a total of 100,772 Covid cases, with 3,326 deaths. Christina Ghaly, director for the Los Angeles County Department of Health Services, said the county could begin running out of hospital beds in the next few weeks.
Former Food and Drug Administration commissioner Scott Gottlieb said during a CNBC interview that the surging number of cases could result in nearly half the country being infected with the virus by the end of this year, and the overall deaths returning to more than 1,000 a day, where it was during much of the spring, before declining in recent weeks to an average of less than 600 a day.
YOUNGER PEOPLE ARE GETTING SICK SO FEWER ARE DYING
Gottlieb said the only saving grace is that younger people appear to be the most affected in those states where Covid cases are spiking. That means that death rates and hospitalization numbers might not be as severe as they were in the first wave of the virus if the current pattern of transmission doesn’t change.
Other experts agree that if local hospital ICU capacity in Covid hotspots does not get overwhelmed, the mortality rate is likely to remain much lower than it was during the peak in late March and early April because doctors now have a better understanding of how the virus should be treated and more effective drugs are becoming available.
Meanwhile, medical researchers are reviewing patient data and testing new drugs and experimental vaccines to gain new insights into how this uniquely persistent and deadly novel coronavirus works.
The WHO is sending a team to China to try to understand its origins, Director General Tedros Adhanom Ghebreyesus said at a news briefing Monday.
“We can fight the virus better when we know everything about the virus, including how it started,” Tedros said. “We hope that will lead into understanding. . . what we can do for the future to prepare.”
“We all want this to be over. We all want to get on with our lives,” Tedros said. “But the hard reality is this is not even close to being over.”
COVID STILL SPREADING AROUND THE WORLD
Governments in other parts of the world are also taking further steps to contain their outbreaks.
Great Britain Monday announced its first regionalized lockdown following a spike in cases in the city of Leicester, in central England. British Health Secretary Matt Hancock said some shops will shut and schools will close in the area to contain the outbreak in an area that accounted for 10% of all Covid cases in the U.K. last week. Pubs and restaurants, which were due to reopen nationwide this weekend, will remain closed in Leicester, he added.
In France, where the government began to lift its national lockdown on May 11, the virus seems to have remained largely dormant, and the emphasis is now on efforts to continue reviving the national economy following a sharp drop in April.
India’s government said schools would stay shut for another month, and lockdowns, non-essential business closures and other restrictions in virus hotspots will be extended until at least the end of July. A nighttime curfew will remain in effect across the country. Confirmed new cases in India are being reported at a rate of more than 18,000 a day, pushing the total number of infections to 566,840, while the nationwide Covid death toll has risen to 16,893.
In China, Beijing health authorities have reported a total of 325 cases since a new wave of infections emerged on June 11. The source of the new infections has once again been traced to a live animal market in the city.
Health authorities in South Korea have reported 43 new cases traced to virus transmissions at small gatherings which continue across the country. In addition to the widespread practice of wearing of masks, South Korean officials are proposing other measures to prevent transmissions such as staggering workers’ vacations to prevent crowding in popular areas during the summer. South Korean baseball fans will be able to return to stadiums in July, but everyone will be required to wear face masks, sit far apart, pass temperature checks and won’t be allowed to cheer or eat in the stadiums.
In Australia, stay-at-home orders for four weeks have been reimposed in 10 areas of Melbourne that are suffering new outbreaks. Recently re-opened businesses in those areas will face new restrictions, and restaurants will be limited to offering only takeout and delivery services. In addition, the government is considering diverting all commercial flights away from Melbourne to other cities for the next two weeks.
BAFFLING COVID AFTER-EFFECTS
Meanwhile, doctors in Israel are baffled by lingering symptoms suffered by recovered COVID patients. The recovered patients are complaining about freak pains, a variety of lung and breathing problems and a range of psychological issues.
“What we are seeing is very frightening,” said Dr. Gabriel Izbicki, the head of the Pulmonary Institute of Shaare Zedek Medical Center in in Yerushalayim. He told a reporter for Times of Israel, “more than half the [Covid] patients, weeks after testing negative, are still symptomatic.”
He said one of the biggest surprises is that there is no way to predict which of the recovered Covid patients will suffer from lingering symptoms. “There is no correlation between the seriousness of the disease during hospitalization and the extent of symptoms afterwards.”
In Bnei Brak, doctors at a recently opened Maccabi Healthcare community clinic have reported a spike in patients complaining of pains that suddenly come out of nowhere. “It can appear in the arms, legs, or other places where the virus doesn’t have a direct impact, and if you ask about the pain level on a 1 to 10 scale, it can be 10, with people saying they can’t get to sleep,” said Eran Schenker, the director of the month-old clinic.
For example, one woman in her 40s who was diagnosed with the virus in March and tested negative in May still suffers from severe fatigue and anxiety, and can only walk for a few minutes at a time.
She says that her husband, age 55, who also was diagnosed in March and tested negative for the virus in May, claims to feel worse now than he felt when he was hospitalized. She said he used to be active “from morning until night,” with plenty of energy, but now he is extremely lethargic, can hardly walk, and is suffering from new heart problems. This has come as a total surprise to his family because during his initial hospitalization, he did not require oxygen and X-rays showed no damage to his lungs. Only later did his pneumonia-like symptoms appear, along with various pains and breathing problems, while testing negative for the virus, and defying efforts by clinic doctors to find a diagnosis.
Dr. Schenker said that it was not unusual for seriously ill patients who have been put on ventilators to undergo a long, slow recuperation, but the pattern of persistent new symptoms developed months later by Covid patients who did not initially seem to be seriously ill and who seemed to have recovered has been totally unexpected.
UNEXPLAINED PAINS AND FATIGUE
The doctors have also been puzzled by the new pains which are appearing in recovered Covid patients, young and old alike.
Dr. Schenker said: “We check their lungs and hearts and they have no disease, and they have no neurological issues. We do scans and can’t see anything, but they have this pain — we’re told about it again and again. . .
“Painkillers block the pain but don’t relieve the source. We don’t know how to address the source and patients can’t be kept on painkillers for the rest of their life.”
Dr. Schenker added, “It’s amazing how many people went back to work — they can be educators, lawyers and in other professions — but when they sit for an hour they feel anxiety, feel insecure, and sometimes suffer from depression.”
Dr. Dan Oyero, Maccabi’s deputy director of medicine in central Israel, said that, “The most distressing thing is that people compare how they feel now compared to how they were a few weeks ago before they were infected, and they say they just can’t do the things they used to do. The main complaints are fatigue. Many people say that they don’t have the energy they had before. They are more tired. Some say they don’t have the drive to do things. But it is nothing we can give a name to.”
The sense of taste and smell, which is frequently the first symptom of the illness, sometimes does not return.
Elderly patients stricken by the coronavirus often emerge with their lungs working at only 50% of their normal capacity, long after testing negative, even if they had no previous respiratory issues, according to Dr. Schenker.
He believes that, “the damage was not done by the virus, but by an inflammation process which, we know from other diseases, will damage the capacity of the lungs to exchange oxygen.”
Doctors around the world are constantly coming up with surprising new findings about the effects of the virus. One recent study found that in some patients, the virus seems to have a long term effect on the pancreas, significantly increasing the risk that after recovery from Covid they will develop diabetes.
Another study found that pregnant women are unusually susceptible to infection by the virus, but the good news is that they typically suffer relatively mild symptoms.
A particularly important new finding about the spread of the virus is the discovery that only 10 percent of infected people are responsible for 80 percent of the new infections. These so-called “superspreaders,” under the right circumstances, can infect large numbers of people at the same time, while most people infected by the virus pass it on to few, if any.
For example, at a May 30 birthday party in Texas, one man infected 18 friends and family with the coronavirus.
But the pattern for how the virus spreads is inconsistent. In some cases, it immediately starts spreading though a community like a wildfire, setting off epidemics wherever it goes. But in other cases, the start of widespread transmission of the virus can be delayed.
In Italy, which suffered the first major Covid outbreak in Europe, scientists looked at stored samples of wastewater in an effort to identify when the virus first arrived there. They reported evidence that the virus was present in the Italian cities of Turin and Milan as early as December 18, 2019. But it would take another two months for northern Italy’s hospitals to begin filling up with seriously ill Covid victims. The reason for the delay is subject for speculation.
Ben Althouse, a research scientist at the Institute for Disease Modeling in Bellevue, Washington, suggests that the virus that was present in December just petered out, and that the Italian outbreak in February was started by a later exposure to the virus.
Althouse compares the process of starting a viral outbreak to throwing a lit match at kindling wood. “You throw one match, it may not light the kindling. You throw another match, it may not light the kindling. But then one match hits in the right spot, and all of a sudden the fire goes up.”
UNDERSTANDING THE R0 NUMBER
In their efforts to understand how a virus spreads from person to person, epidemiologists try to estimate the average number of people each sick person has infected, what is referred to as the virus’ reproductive number, more popularly known as R0.
Current estimates of the Covid virus R0 number range between 2.0 and 3.0. The exact figure will vary depending on how people who are infected behave. For example, do they have a tendency to come into close contact with others in enclosed spaces, do they tend to speak loudly, commute to work in crowded trains or buses, or cover their mouth when they cough or sneeze. By forcing its residents to go into lockdown, for example, the state of Massachusetts drove its coronavirus R0 number down from 2.2 at the beginning of March to 1.0 by the end of the month. Now that many people have gotten used to wearing masks, it’s down further to 0.74.
Viral diseases with a relatively low R0 number, such as influenza and smallpox, spread when a large fraction of infected people pass the virus on to just one or two more people at a time. These outbreaks tend to grow steadily but slowly. But the Covid virus has a higher R0 number, so it spreads much more rapidly, like measles and SARS, which have a tendency to flare up quickly in clusters and without warning.
Several teams of epidemiologists in different countries have independently tried to calculate the R0 for the Covid virus using different methods and all of them have come with a number between 2 and 3.
In Georgia, for example, a team of researchers found that 2 percent of infected people were responsible for 20 percent of viral transmissions.
Now researchers are trying to figure out which people are more likely to become super spreaders, and when and where is the process of transmission most likely to take place?
They suspect that the super spreaders are people who tend to speak loudly or breathe deeply, making their respiratory systems act like virus chimneys, blasting out pathogens with each breath with clouds of tiny droplets carrying the virus to anyone in the immediate vicinity.
A FUNCTION OF CLOSE CONTACT
Other people may have a weak immune system making them more likely to become infected with the virus and then make other people sick. Others may have jobs which frequently throw them into close contact with large numbers of people who may be susceptible to the virus, such as a bus driver or a nursing home worker.
Transmission of the Covid virus seems to happen most often in a window of time starting a couple days after being infected by the virus, even before any symptoms appear. In younger people with strong immune systems, the symptoms may never appear, but they typically do not have a high concentration of the virus in their bodies to transmit to others. They are considered to be much less of a threat to spread the disease than people who are more seriously ill and coughing out, forcefully, droplets with high concentrations of the virus into the air around them.
Certain places also seem to naturally lend themselves to supers preading. These include bars and restaurants full of people talking loudly, health care facilities, nursing homes, day care centers, gymnasiums, classrooms, school dormitories, indoor sports arenas and musical events, such as live concerts, as well as indoor political rallies.
The simplest way to prevent super spreading when an epidemic is raging is by simply banning such events and venues as part of a general lockdown. The real trick is finding effective ways to modify these environments so that the Covid virus’ effective R0 number is reduced to less than 1.0, enabling the country to re-open safely, without re-igniting the spread of the disease.
That, in a nutshell, is the big challenge that the elected leaders of this country, from New York to California to Texas and Florida, are currently struggling with.