POST 41. August 2, 2020. CORONAVIRUS. “Whenever a vaccine for the coronavirus becomes available, one thing is virtually certain: There won’t be enough to go around. That means there will be rationing.” (2)

to read POSTS 1-41 in chronological order, highlight and click on

“Someone will have to decide which of the world’s 7.8 billion people gets first crack at returning to a more normal life. Infectious disease experts and medical ethicists say this exceptionally complex decision must weigh not only who is most at risk from the virus and who is most likely to spread it, but also who is most important for maintaining the medical and financial health of a nation as well as its safety…

Arthur Caplan, a bioethicist at New York University, said the rush to bring vaccines to market likely will leave many questions unanswered at first about how well they work in different groups. He sees the first public doses as an extension of clinical trials. That will require careful tracking of recipients. “We keep acting as if the race to get FDA approval is the end of things,” he said. “I would say it’s just the start.”..

Traditionally, the U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommends who should get vaccines, and it has been discussing since April how to divvy up a new coronavirus shot. It is unclear whether officials from the Trump administration’s Operation Warp Speed on vaccine development will want in on the decision as well. “It’s a black box,” said Paul Offit, a vaccine expert at Children’s Hospital of Philadelphia. He thinks Warp Speed will probably focus on distribution. The National Academy of Medicine, at the behest of the National Institutes of Health, has also created an expert panel to study the issue.

At the panel’s first meeting on Friday, Victor Dzau, the academy’s president, said he expected final recommendations by late September to early October. CDC Director Robert Redfield stressed that it was important for Americans to see vaccine allocation as “equitable, fair, and transparent.”

National Institutes of Health Director Francis Collins, who has faced some criticism for potentially adding to decision-making confusion, said this issue is so thorny, we can benefit from extra “deep thinkers.”

“This is going to be controversial,” he said. “Not everybody is going to like the answer.”

Caplan favors an independent commission that includes both scientists and representatives of affected communities, such as people with disabilities and children. Whoever makes the decisions, he said, “it’s got to be trustworthy.”..

Who goes first?

Priorities need to consider the multiple public health roles vaccines can play, said William Schaffner, an infectious diseases specialist at Vanderbilt University Medical Center. Typically, younger people mount the strongest immune response, said Schaffner, who represents the National Foundation for Infectious Diseases as a liaison to ACIP. They are currently catching COVID-19 at higher rates and spreading it to other, more vulnerable populations. Vaccinating them could weaken the chain of transmission.

Older people and those with chronic health problems are clearly getting sickest, but vaccines tend to be less effective in these groups. A third group are “the people in society that are responsible for its most essential functions,” Schaffner said: medical workers, police and firefighters, those who make, sell and distribute food.

Schaffner said it’s important not to create such narrow categories that vaccine sits unused in refrigerators. “Vaccine does not prevent disease,” he said. “Immunization prevents disease.”” (A)

“Last month, National Institutes of Health Director Francis Collins called the National Academy of Medicine asking for help: Would the esteemed group be interested in developing guidelines for who should get the first doses of a coronavirus vaccine?

“It will allow the public to know it’s transparent, it’s not political,” said Dr. Victor Dzau, the academy’s president who told Collins that his organization was up to the task. “The American public will want to know how are you making that decision? Why am I not getting it first?”

After months of missteps and criticism across the political spectrum on everything from testing to personal protective equipment, the Trump administration is aiming to prove it can roll out a coronavirus vaccine quickly and fairly to millions of Americans as soon as one is ready. That means tackling thorny challenges like deciding who is first in line for vaccination, securing millions of glass vials and syringes and convincing Americans to get inoculated.

The administration is making moves that experts applaud like tapping top health officials and industry experts to lead vaccine plans rather than politicians, but they are still concerned that the overall effort — dubbed Operation Warp Speed — remains shrouded in secrecy. And the administration’s response to the rest of the pandemic has not inspired confidence.

“It’s sort of being handled like a secret weapon, which is never good,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. “Transparency is always good.”

Once a vaccine is approved, every American won’t be able to get it at once. That sets up the unenviable task of deciding, amid a deadly pandemic, who is most vulnerable to the disease and who is most essential to inoculate quickly.

“People are a little uneasy about the government calling the shots here,” NIH’s Dr. Collins told a Senate panel earlier this month.

Experts will have to consider vulnerable populations like those in assisted-living facilities or prisons, people working in close quarters like meat packing plants and how to assess Americans with preexisting conditions.

The National Academy of Medicine hopes to have its recommendations publicly available in August or September.

A second panel of vaccine advisers for the Centers for Disease Control and Prevention — the Advisory Committee on Immunization Practices (ACIP) — is also coming up with a set of guidelines. It’s still unclear whether the administration will select one set of recommendations over the other or take both into account when making its final decisions.

Last month, the ACIP convened electronically in a little-noticed meeting to discuss who counts as an essential worker, where teachers should fall in the priority list, vaccinations for pregnant women and whether race and ethnicity should factor into priority considerations.

“If we fail to address this issue of racial and ethnic groups as a high risk in prioritization, whatever comes out of our group will be looked at very suspiciously and with a lot of reservation,” Dr. José Romero, the panel’s chairman, said….

Once a vaccine is available, it could still take six months to a year to vaccinate enough of the population to slow the spread…

The CDC and Pentagon are working in tandem to deliver the vaccine across America, though they haven’t offered many details about how they plan to do so….

Convincing minority communities that have experienced higher rates of hospitalization and fatality to get vaccinated is a top concern. Experts said that will have to involve community outreach through organizations people already trust, such as faith-based organizations.

“There’s a lot of work that needs to be done in terms of making sure we that engage them earlier to gain their trust,” Dzau of the National Academy of Medicine said. “There are two ways that people can look at it. One is, are we the guinea pig? Or, two, we should get it first because we are more at risk.””  (B)

Why do we need more than one vaccine?

We’ll benefit from several vaccines, said Pulendran, because no single company could meet demand. In addition, the vaccines may differ, working better in some people than others.

“If we’ve got three acceptable vaccines, we’ll get the vaccine to more people,” said Ernst. “Maybe not everybody will get the best vaccine for somebody in their demographic. But assuming they’re equally safe and differ in efficacy only a modest amount, you’re better off being vaccinated than having no vaccine at all.”

Why first isn’t always best

Remember the Salk vs.Sabin polio vaccine debate? We started with Salk’s version, then shifted to Sabin’s. Now, with more information, we’re back to Salk’s.

Imagine that our first vaccine is only 50% effective. (The U.S. Food and Drug Administration, in an apparent effort to encourage vaccine companies, says that’s good enough for licensing, for now.) That will still leave some people, such as the elderly and those with high-risk medical conditions, perilously exposed.

If we’re lucky, vaccines will get better over time.

“It may not be the ultimate vaccine, but it’s the first iteration that can be improved upon,” said Pulendran.

“50% effective” sounds like more mask-wearing. Why can’t we do better?..

Who’s first in line?

If you’re an average healthy adult, you’ll likely be last in line. Health care workers and people at high medical risk would likely be first, Dr. Francis Collins, director of the National Institutes of Health, said Friday.

But there are other considerations. The military, students, underrepresented minorities, “essential workers” or people who volunteered for research may get priority too. If there’s an explosive local outbreak, vaccinating everyone nearby would limit the spread…

How will it be distributed?

Companies have said they’ll defer to the federal government. But experts, noting the disastrous distribution of PPE and tests, say we should look to the multi-channel distribution model of flu vaccines. They say it should be available from governments and doctors — but also directly from the companies, via CVS, Walgreens and other local pharmacies.

“It’s still inconceivable that we’ll be able to get vaccines to 330 million in three to six months,” Dr. Robert Wachter, chair of the Department of Medicine at UC San Francisco, tweeted this past week. During the 2009 swine flu epidemic, he noted, we vaccinated about one-quarter of all Americans — and that took six months.

Vaccinating 80 to 100 million of the nation’s most vulnerable people, including healthcare workers, “might be do-able by mid-’21,” he said.

Not everybody wants one.

Even people who believe in vaccines are showing reluctance to get the COVID-19 vaccine. They worry that politics are creating undue pressure, and corners will be cut in the rush to produce. Only about half of Americans say they would get a COVID-19 vaccine, according to a May poll from The Associated Press-NORC Center for Public Affairs Research. One-third weren’t sure and one-fifth would refuse, citing safety concerns.

If a vaccine is 50% effective, and 50% of the population gets vaccinated, then only 25% of the population is protected, said Ernst.

That’s far short of the 70% protection needed to stop this pandemic. The only solution is to make a better vaccine — and convince more people to take it.

“We’re not going to get this disease under control by just vaccinating health care workers and kindergarten teachers,” said Ernst.

“We need to be thinking about how are we going to convince people to comply with vaccinations,” he said, “so that we’ve got a sufficient amount of the population covered to actually get COVID-19 under control.” (C)

“Federal health officials are already trying to decide who will get the first doses of any effective coronavirus vaccines, which could be on the market this winter but could require many additional months to become widely available to Americans.

The Centers for Disease Control and Prevention and an advisory committee of outside health experts in April began working on a ranking system for what may be an extended rollout in the United States. According to a preliminary plan, any approved vaccines would be offered to vital medical and national security officials first, and then to other essential workers and those considered at high risk — the elderly instead of children, people with underlying conditions instead of the relatively healthy.

Agency officials and the advisers are also considering what has become a contentious option: putting Black and Latino people, who have disproportionately fallen victim to Covid-19, ahead of others in the population.

In private meetings and a recent public session, the issue has provoked calls for racial justice. But some medical experts are not convinced there is a scientific basis for such an option, foresee court challenges or worry that prioritizing minority groups would erode public trust in vaccines at a time when immunization is seen as crucial to ending the pandemic.

“Giving it to one race initially and not another race, I’m not sure how that would be perceived by the public, how that would affect how vaccines are viewed as a trusted public health measure,” said Claire Hannan, executive director of the Association of Immunization Managers, a group represented on the committee.

While there is a standard protocol for introducing vaccines — the C.D.C. typically makes recommendations and state and local public health departments decide whether to follow them — the White House has pressed the agency at times to revise or hold off on proposals it found objectionable. President Trump, who has been pushing to reopen schools, fill workplaces and hold large public events, has been acutely focused on the political consequences of public health guidance…

To speed distribution, the most promising vaccines will start being made even before they have cleared the final stages of clinical trials and been authorized for public use by the Food and Drug Administration.

But there will be a gap between the first doses coming off the manufacturing lines and a stockpile large enough to vaccinate the U.S. population. “I would say months,” Dr. José R. Romero, the chairman of the Advisory Committee on Immunization Practices, predicted.

The committee, which reports to the C.D.C. director, has long played a key role in determining how to implement new vaccines. The group includes 15 voting members selected by the health secretary who come from immunology, infectious disease and other medical specialties, 30 nonvoting representatives from across the health field, and eight federal officials focused on vaccines. Still, it operates largely out of sight.

Dr. Romero is among four committee members who have been deliberating on the plans since this spring alongside doctors at the C.D.C., representatives from the health field, ethicists and other outside consultants. In June, they briefed the full committee on their work, offering a glimpse of the questions being considered.

As they come up with a multitiered schedule for the first 1.2 million vaccine doses and then the next 110 million, they have focused on who should be considered essential workers, what underlying conditions should be taken into account and what kinds of living environments — nursing homes, homeless shelters — put people at high risk. Among the questions: What should be done about pregnant women? Should teachers go toward the front of the line? Should prisoners be in a top tier?

But for the broader committee, questions of whether to prioritize race and ethnicity sparked the most debate.

Black and Latino people have become infected with the virus at three times the rate of whites, and have died nearly twice as frequently. Many of them have jobs that keep them from working at home, rely on public transportation or live in cramped homes that increase their risk of exposure. They are more likely to suffer from underlying health problems, including diabetes and obesity, that raise the risk of hospitalization and death. Not only do the groups have less access to health services, they have a documented history of receiving unequal care.” (H)

“But let’s suppose that health care workers and people with underlying medical conditions use up the first doses of the available vaccine. Should some be held in reserve for Black and Latino people? What about bus drivers and train conductors? Perhaps teachers or schoolchildren should get it so they can return to classrooms with peace of mind.

If shortages happen, most of the nation will have no chance to get the initial lots of a vaccine under the C.D.C.’s plan. And as the United States combats a soaring number of coronavirus cases, rising demand for drugs and maybe ventilators is expected. They, too, will need a fair system of distribution.

One solution that is starting to attract the attention of public health experts is a so-called weighted lottery, which gives everyone a chance at access, although some get a better shot than others.

Doctors and ethicists rank patients, deciding which groups should be given preference and how much. First-responders, for example, may be weighted more heavily than, say, very sick patients who are unlikely to recover.

The goal is to prevent haphazard or inequitable distribution of a treatment or vaccine when there isn’t enough to go around. Such a system has already been used in allocations of remdesivir, the first drug shown to be effective against the coronavirus.

“This is all very new,” said Dr. Douglas White, an ethicist and vice chairman of the department of critical medicine at the University of Pittsburgh, which began using a weighted lottery last month to distribute remdesivir.

Patients have accepted the results, even when they lost in the lottery and ended up being denied the drug, he added.

“I speculate that is because we are very transparent about the reason and the ethical framework that applies to everyone who comes into hospital, whether that is the hospital president or someone who is homeless,” he said.

To allocate the drug, Pittsburgh doctors decided that the lottery would give preference to health care workers and emergency medical workers. The doctors also weighted the odds to favor people from economically disadvantaged areas, who tend to be mostly Black and Hispanic.

People with other illnesses and limited life spans, like end-stage cancer patients, had the odds weighted against them, giving them a smaller chance to win in the lottery. The system did not consider age, race, ethnicity, quality of life, ability to pay or whether a patient has a disability.

The lottery began in early June, Dr. White said: “We had 64 patients. We had to make the supply of remdesivir last at least two weeks. We only had enough to treat one in four patients.”

They had a brief respite from the lottery when cases began falling and supplies of remdesivir seemed adequate. But on Sunday, with cases rising again and enough remdesivir for only about half the patients who could be helped by taking it, the hospital system was forced to go back to a lottery….

Still, in principle, lottery data about a vaccine can be as useful as randomized clinical trial data, Dr. Pathak said.

“We would like to get people to think ahead about how vaccines are allocated,” he said. “There is no way we can vaccinate everybody, so we have to think about what’s fair and what’s just.”” (D)

“TA: Given that equitable distribution of vaccines is, at least in part, a question of ethics, how can computer models help us arrive at a solution?

Swann: It’s an interesting intersection, isn’t it? We can think of problems in terms of our objectives, which in this case might include efficiency (speed), effectiveness (avert deaths), and equity across the population. In public health, equity can be defined in different ways, including geographically (urban and rural) or by population (pro-rata). It can also be defined in terms of outcomes. For example, right now we know that communities of color, including African Americans, Hispanics, and Native Americans, are experiencing much higher rates of COVID-19 mortality than whites, and we know that people who are older or have high-risk medical conditions are also experiencing greater mortality than others.

Computer models can do many things to help with equitable distribution of vaccines. One really important role is to project the impact of different vaccination scenarios or strategies. For example, if there are limited vaccines, what is the impact of vaccinating essential workers, or ones who might interact with a vulnerable group (e.g., nursing home workers)? If there is a group at lower direct risk (e.g., children) who have significant contact with people at risk (parents or grandparents), what would be the impact of vaccinating them? If a vaccine requires two doses, or if immunity wanes after a time period, what strategies can avert the most hospitalizations and deaths? Which strategies would be most effective at reducing the disparities in COVID-19 outcomes associated with communities of color? These are just a few examples of many different decisions where humans could be aided by input from computer models.” (I)

“Nationwide distribution of any coronavirus vaccine will be a “joint venture” between the Centers for Disease Control and Prevention, which typically oversees vaccine allocation, and the Department of Defense, a senior administration official said today.

The Department of Defense “is handling all the logistics of getting the vaccines to the right place, at the right time, in the right condition,” the official said in a call with reporters, adding that CDC will remain in charge of tracking any side effects that emerge post-vaccination and “some of the communications through the state relationships [and] the state public health organizations.”

The plan breaks with the longstanding precedent that CDC distributes vaccines during major outbreaks — such as bad flu seasons — through a centralized ordering system for state and local health officials.

“We believe we’ve actually combined the best of both,” the official said. A second senior administration official stressed the agencies would be working as “one team” to distribute hundreds of millions of doses if any of the vaccines in development are approved in the coming months.

Private companies are also likely to join the effort. The first official said the government is bringing in people to integrate CDC IT capabilities with “some new applications that we’re going to need that the CDC never had.”

The background: The Pentagon will be guiding not just distribution logistics but also manufacturing and “kitting,” the process of safely packaging a vaccine with its necessary equipment such as syringes and needles.

“The DoD is handling all of those logistics — that is where their comparative advantage is,” said the first senior official. “And the CDC, some of their IT systems, relationships with the states following post-vaccination will belong to them.”…

State and local government groups have already raised concerns about Pentagon involvement and using new methods in coronavirus vaccine distribution. The CDC “already leads and maintains a highly effective system of vaccine ordering and distribution,” groups including the Association of State and Territorial Health Officials wrote in June. “With time of the essence we strongly recommend against designing new and untested systems of vaccine distribution.”

The state and local officials also questioned whether military involvement in vaccine administration would undermine already shaky public confidence in vaccines.”  (G)

“Executives from four companies in the race to produce a coronavirus vaccine — AstraZeneca, Johnson & Johnson, Moderna Therapeutics and Pfizer — told lawmakers on Tuesday that they are optimistic their products could be ready by the end of 2020 or the beginning of 2021. All four companies are testing vaccines in human clinical trials.

Three of the firms — AstraZeneca, Johnson & Johnson and Moderna — are getting federal funds for their vaccine development efforts. AstraZeneca and Johnson & Johnson pledged to the lawmakers that they would produce hundreds of millions of doses of their vaccines at no profit to themselves. Moderna, however, which has been granted $483 million from the government to develop its product, made no such promise.

“We will not sell it at cost,” said Dr. Stephen Hoge, the president of Moderna.

Many Democratic lawmakers have argued that federal funding for vaccine development should include provisions to guarantee affordability and guard against profiteering.

At the Congressional hearing on Tuesday, some House members raised concerns about Pfizer’s decision to reject federal funds, suggesting it could lead to price-gouging and a lack of transparency… (E)

“On June 26, a small South San Francisco company called Vaxart made a surprise announcement: A coronavirus vaccine it was working on had been selected by the U.S. government to be part of Operation Warp Speed, the flagship federal initiative to quickly develop drugs to combat Covid-19.

Vaxart’s shares soared. Company insiders, who weeks earlier had received stock options worth a few million dollars, saw the value of those awards increase sixfold. And a hedge fund that partly controlled the company walked away with more than $200 million in instant profits.” (F)

“The Serum Institute, which is exclusively controlled by a small and fabulously rich Indian family and started out years ago as a horse farm, is doing what a few other companies in the race for a vaccine are doing: mass-producing hundreds of millions of doses of a vaccine candidate that is still in trials and might not even work.

But if it does, Adar Poonawalla, Serum’s chief executive and the only child of the company’s founder, will become one of the most tugged-at men in the world. He will have on hand what everyone wants, possibly in greater quantities before anyone else.

His company, which has teamed up with the Oxford scientists developing the vaccine, was one of the first to boldly announce, in April, that it was going to mass-produce a vaccine before clinical trials even ended. Now, Mr. Poonawalla’s fastest vaccine assembly lines are being readied to crank out 500 doses each minute, and his phone rings endlessly.

National health ministers, prime ministers and other heads of state (he wouldn’t say who) and friends he hasn’t heard from in years have been calling him, he said, begging for the first batches.

“I’ve had to explain to them that, ‘Look I can’t just give it to you like this,’” he said.

With the coronavirus pandemic turning the world upside down and all hopes pinned on a vaccine, the Serum Institute finds itself in the middle of an extremely competitive and murky endeavor. To get the vaccine out as soon as possible, vaccine developers say they need Serum’s mammoth assembly lines — each year, it churns out 1.5 billion doses of other vaccines, mostly for poor countries, more than any other company…

But right now it’s not entirely clear how much of the coronavirus vaccine that Serum will mass-produce will be kept by India or who will fund its production, leaving the Poonawallas to navigate a torrent of cross-pressures, political, financial, external and domestic.

India has been walloped by the coronavirus, and with 1.3 billion people, it needs vaccine doses as much as anywhere. It’s also led by a highly nationalistic prime minister, Narendra Modi, whose government has already blocked exports of drugs that were believed to help treat Covid-19, the disease caused by the coronavirus.

Adar Poonawalla, 39, says that he will split the hundreds of millions of vaccine doses he produces 50-50 between India and the rest of the world, with a focus on poorer countries, and that Mr. Modi’s government has not objected to this.” (J)

“First we have to look at the global level. The private sector is really driving the vaccine development process, rather than government or academic labs. Major efforts are underway to figure out how private industrial developers can make vaccines available at an affordable price to all countries, particularly low and middle-income countries. It’s a bit like the ventilator supply situation we’ve all faced, but on steroids. Initially there will be scarce supply of the vaccine, governments will be scrambling to procure it, and, unless these efforts work, the winners will be fairly predictable: countries that have the resources.

On the next level, some wealthy countries will likely end up with substantial amounts of vaccine. Over time, if all goes well, these countries will have to decide how much product they’re going to keep and how much, if any, they’re willing to share with other countries where the vaccine may be in very short supply. These are complex questions of ethics, and they’re wrapped up in geopolitics, and also national politics.

There’s a term called vaccine nationalism—where countries understand their obligations to be primarily, if not exclusively, to their own residents. Although there is an expectation that countries with the resources and production capacity will meet their own health needs first, should they ignore the needs of people living in other countries with severe economic constraints? From an ethics perspective, a balance must be struck.” (K)

“As soon as the first COVID-19 vaccines get approved, a staggering global need will confront limited supplies. Many health experts say it’s clear who should get the first shots: health care workers around the world, then people at a higher risk of severe disease, then those in areas where the disease is spreading rapidly, and finally, the rest of us. Such a strategy “saves the most lives and slows transmission the fastest,” says Christopher Elias, who heads the Bill & Melinda Gates Foundation’s Global Development Division. “It would be ludicrous if low-risk people in rich countries get the vaccine when health care workers in South Africa don’t,” adds Ellen ‘t Hoen, a Dutch lawyer and public health activist.

Yet money and national interest may win out. The United States and Europe are placing advance orders for hundreds of millions of doses of successful vaccines, potentially leaving little for poorer parts of the world. “I’m very concerned,” says John Nkengasong, director of the Africa Centres for Disease Control and Prevention.

To avoid such a scenario, the World Health Organization and other international organizations have set up a system to accelerate and equitably distribute vaccines, the COVID-19 Vaccines Global Access (COVAX) Facility, which seeks to entice rich countries to sign on by reducing their own risk that they’re betting on the wrong vaccine candidates. But the idea has been put together on the fly, and it’s unclear how many rich countries will join.” (L)

“As scientists and pharmaceutical companies work at breakneck speed to develop a vaccine for the novel coronavirus, public health officials and senior U.S. lawmakers are sounding alarms about the Trump administration’s lack of planning for its nationwide distribution.

The federal government traditionally plays a principal role in funding and overseeing the manufacturing and distribution of new vaccines, which often draw on scarce ingredients and need to be made, stored and transported carefully.

There won’t be enough vaccine for all 330 million Americans right away, so the government also has a role in deciding who gets it first, and in educating a vaccine-wary here public about its potential life saving merits.

Right now, it is unclear who in Washington is in charge of oversight, much less any critical details, some state health officials and members of Congress told Reuters…

Health officials and lawmakers say they worry that without thorough planning and coordination with states, the vaccine distribution could be saddled with the same sort of disruptions that led to chronic shortages of coronavirus diagnostic tests and other medical supplies…

Some state public health officials, meanwhile, say their entreaties to the Trump administration have been unanswered.

“We have not heard anything from the federal government since April 23,” Danielle Koenig, health promotion supervisor for the Washington State Department of Health, said in an email.

That is when her agency received preliminary guidance on vaccine planning from the CDC.

Immunization experts along with state and local public health officials sent a letter here to Operation Warp Speed on June 23 pleading for fresh guidance.

States need to know promptly if the federal government will pay for the vaccines, as it did during the H1N1 outbreak in 2009, the letter says. Will alcohol swabs, syringes and personal protective equipment be included? What about record-keeping and refrigeration to store the vaccine and who will deliver it?

So far, there’s been no official response, said Claire Hannan, executive director of the Association of Immunization Managers, one of four organizations that signed the letter.

“We urgently await federal, state and local collaborative discussions to identify challenges and plan solutions. A vaccination campaign of this magnitude is unprecedented and it’s going to take more than an army,” Hannan said on Tuesday, referring to Trump’s repeated statements that the U.S. military stands ready to deliver vaccines.

Trump insists everything is in place.

“We’re all set to march when it comes to the vaccine,” Trump said at a White House briefing on Thursday. “… And the delivery system is all set. Logistically we have a general that’s all he does is deliver things whether it is soldiers or other items.

“We are way ahead on vaccines, way ahead on therapeutics and when we have it we are all set with our platforms to deliver them very, very quickly,” Trump said. (M)

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POST 41. August 2, 2020. CORONAVIRUS. “Whenever a vaccine for the coronavirus becomes available, one thing is virtually certain: There won’t be enough to go around. That means there will be rationing.”

to read POSTS 1-41 in chronological order, highlight and click on

“Someone will have to decide which of the world’s 7.8 billion people gets first crack at returning to a more normal life. Infectious disease experts and medical ethicists say this exceptionally complex decision must weigh not only who is most at risk from the virus and who is most likely to spread it, but also who is most important for maintaining the medical and financial health of a nation as well as its safety…

Arthur Caplan, a bioethicist at New York University, said the rush to bring vaccines to market likely will leave many questions unanswered at first about how well they work in different groups. He sees the first public doses as an extension of clinical trials. That will require careful tracking of recipients. “We keep acting as if the race to get FDA approval is the end of things,” he said. “I would say it’s just the start.”..

Traditionally, the U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommends who should get vaccines, and it has been discussing since April how to divvy up a new coronavirus shot. It is unclear whether officials from the Trump administration’s Operation Warp Speed on vaccine development will want in on the decision as well. “It’s a black box,” said Paul Offit, a vaccine expert at Children’s Hospital of Philadelphia. He thinks Warp Speed will probably focus on distribution. The National Academy of Medicine, at the behest of the National Institutes of Health, has also created an expert panel to study the issue.

At the panel’s first meeting on Friday, Victor Dzau, the academy’s president, said he expected final recommendations by late September to early October. CDC Director Robert Redfield stressed that it was important for Americans to see vaccine allocation as “equitable, fair, and transparent.”

National Institutes of Health Director Francis Collins, who has faced some criticism for potentially adding to decision-making confusion, said this issue is so thorny, we can benefit from extra “deep thinkers.”

“This is going to be controversial,” he said. “Not everybody is going to like the answer.”

Caplan favors an independent commission that includes both scientists and representatives of affected communities, such as people with disabilities and children. Whoever makes the decisions, he said, “it’s got to be trustworthy.”..

Who goes first?

Priorities need to consider the multiple public health roles vaccines can play, said William Schaffner, an infectious diseases specialist at Vanderbilt University Medical Center. Typically, younger people mount the strongest immune response, said Schaffner, who represents the National Foundation for Infectious Diseases as a liaison to ACIP. They are currently catching COVID-19 at higher rates and spreading it to other, more vulnerable populations. Vaccinating them could weaken the chain of transmission.

Older people and those with chronic health problems are clearly getting sickest, but vaccines tend to be less effective in these groups. A third group are “the people in society that are responsible for its most essential functions,” Schaffner said: medical workers, police and firefighters, those who make, sell and distribute food.

Schaffner said it’s important not to create such narrow categories that vaccine sits unused in refrigerators. “Vaccine does not prevent disease,” he said. “Immunization prevents disease.”” (A)

“Last month, National Institutes of Health Director Francis Collins called the National Academy of Medicine asking for help: Would the esteemed group be interested in developing guidelines for who should get the first doses of a coronavirus vaccine?

“It will allow the public to know it’s transparent, it’s not political,” said Dr. Victor Dzau, the academy’s president who told Collins that his organization was up to the task. “The American public will want to know how are you making that decision? Why am I not getting it first?”

After months of missteps and criticism across the political spectrum on everything from testing to personal protective equipment, the Trump administration is aiming to prove it can roll out a coronavirus vaccine quickly and fairly to millions of Americans as soon as one is ready. That means tackling thorny challenges like deciding who is first in line for vaccination, securing millions of glass vials and syringes and convincing Americans to get inoculated.

The administration is making moves that experts applaud like tapping top health officials and industry experts to lead vaccine plans rather than politicians, but they are still concerned that the overall effort — dubbed Operation Warp Speed — remains shrouded in secrecy. And the administration’s response to the rest of the pandemic has not inspired confidence.

“It’s sort of being handled like a secret weapon, which is never good,” said Dr. Paul Offit, director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. “Transparency is always good.”

Once a vaccine is approved, every American won’t be able to get it at once. That sets up the unenviable task of deciding, amid a deadly pandemic, who is most vulnerable to the disease and who is most essential to inoculate quickly.

“People are a little uneasy about the government calling the shots here,” NIH’s Dr. Collins told a Senate panel earlier this month.

Experts will have to consider vulnerable populations like those in assisted-living facilities or prisons, people working in close quarters like meat packing plants and how to assess Americans with preexisting conditions.

The National Academy of Medicine hopes to have its recommendations publicly available in August or September.

A second panel of vaccine advisers for the Centers for Disease Control and Prevention — the Advisory Committee on Immunization Practices (ACIP) — is also coming up with a set of guidelines. It’s still unclear whether the administration will select one set of recommendations over the other or take both into account when making its final decisions.

Last month, the ACIP convened electronically in a little-noticed meeting to discuss who counts as an essential worker, where teachers should fall in the priority list, vaccinations for pregnant women and whether race and ethnicity should factor into priority considerations.

“If we fail to address this issue of racial and ethnic groups as a high risk in prioritization, whatever comes out of our group will be looked at very suspiciously and with a lot of reservation,” Dr. José Romero, the panel’s chairman, said….

Once a vaccine is available, it could still take six months to a year to vaccinate enough of the population to slow the spread…

The CDC and Pentagon are working in tandem to deliver the vaccine across America, though they haven’t offered many details about how they plan to do so….

Convincing minority communities that have experienced higher rates of hospitalization and fatality to get vaccinated is a top concern. Experts said that will have to involve community outreach through organizations people already trust, such as faith-based organizations.

“There’s a lot of work that needs to be done in terms of making sure we that engage them earlier to gain their trust,” Dzau of the National Academy of Medicine said. “There are two ways that people can look at it. One is, are we the guinea pig? Or, two, we should get it first because we are more at risk.””  (B)

Why do we need more than one vaccine?

We’ll benefit from several vaccines, said Pulendran, because no single company could meet demand. In addition, the vaccines may differ, working better in some people than others.

“If we’ve got three acceptable vaccines, we’ll get the vaccine to more people,” said Ernst. “Maybe not everybody will get the best vaccine for somebody in their demographic. But assuming they’re equally safe and differ in efficacy only a modest amount, you’re better off being vaccinated than having no vaccine at all.”

Why first isn’t always best

Remember the Salk vs.Sabin polio vaccine debate? We started with Salk’s version, then shifted to Sabin’s. Now, with more information, we’re back to Salk’s.

Imagine that our first vaccine is only 50% effective. (The U.S. Food and Drug Administration, in an apparent effort to encourage vaccine companies, says that’s good enough for licensing, for now.) That will still leave some people, such as the elderly and those with high-risk medical conditions, perilously exposed.

If we’re lucky, vaccines will get better over time.

“It may not be the ultimate vaccine, but it’s the first iteration that can be improved upon,” said Pulendran.

“50% effective” sounds like more mask-wearing. Why can’t we do better?..

Who’s first in line?

If you’re an average healthy adult, you’ll likely be last in line. Health care workers and people at high medical risk would likely be first, Dr. Francis Collins, director of the National Institutes of Health, said Friday.

But there are other considerations. The military, students, underrepresented minorities, “essential workers” or people who volunteered for research may get priority too. If there’s an explosive local outbreak, vaccinating everyone nearby would limit the spread…

How will it be distributed?

Companies have said they’ll defer to the federal government. But experts, noting the disastrous distribution of PPE and tests, say we should look to the multi-channel distribution model of flu vaccines. They say it should be available from governments and doctors — but also directly from the companies, via CVS, Walgreens and other local pharmacies.

“It’s still inconceivable that we’ll be able to get vaccines to 330 million in three to six months,” Dr. Robert Wachter, chair of the Department of Medicine at UC San Francisco, tweeted this past week. During the 2009 swine flu epidemic, he noted, we vaccinated about one-quarter of all Americans — and that took six months.

Vaccinating 80 to 100 million of the nation’s most vulnerable people, including healthcare workers, “might be do-able by mid-’21,” he said.

Not everybody wants one.

Even people who believe in vaccines are showing reluctance to get the COVID-19 vaccine. They worry that politics are creating undue pressure, and corners will be cut in the rush to produce. Only about half of Americans say they would get a COVID-19 vaccine, according to a May poll from The Associated Press-NORC Center for Public Affairs Research. One-third weren’t sure and one-fifth would refuse, citing safety concerns.

If a vaccine is 50% effective, and 50% of the population gets vaccinated, then only 25% of the population is protected, said Ernst.

That’s far short of the 70% protection needed to stop this pandemic. The only solution is to make a better vaccine — and convince more people to take it.

“We’re not going to get this disease under control by just vaccinating health care workers and kindergarten teachers,” said Ernst.

“We need to be thinking about how are we going to convince people to comply with vaccinations,” he said, “so that we’ve got a sufficient amount of the population covered to actually get COVID-19 under control.” (C)

“Federal health officials are already trying to decide who will get the first doses of any effective coronavirus vaccines, which could be on the market this winter but could require many additional months to become widely available to Americans.

The Centers for Disease Control and Prevention and an advisory committee of outside health experts in April began working on a ranking system for what may be an extended rollout in the United States. According to a preliminary plan, any approved vaccines would be offered to vital medical and national security officials first, and then to other essential workers and those considered at high risk — the elderly instead of children, people with underlying conditions instead of the relatively healthy.

Agency officials and the advisers are also considering what has become a contentious option: putting Black and Latino people, who have disproportionately fallen victim to Covid-19, ahead of others in the population.

In private meetings and a recent public session, the issue has provoked calls for racial justice. But some medical experts are not convinced there is a scientific basis for such an option, foresee court challenges or worry that prioritizing minority groups would erode public trust in vaccines at a time when immunization is seen as crucial to ending the pandemic.

“Giving it to one race initially and not another race, I’m not sure how that would be perceived by the public, how that would affect how vaccines are viewed as a trusted public health measure,” said Claire Hannan, executive director of the Association of Immunization Managers, a group represented on the committee.

While there is a standard protocol for introducing vaccines — the C.D.C. typically makes recommendations and state and local public health departments decide whether to follow them — the White House has pressed the agency at times to revise or hold off on proposals it found objectionable. President Trump, who has been pushing to reopen schools, fill workplaces and hold large public events, has been acutely focused on the political consequences of public health guidance…

To speed distribution, the most promising vaccines will start being made even before they have cleared the final stages of clinical trials and been authorized for public use by the Food and Drug Administration.

But there will be a gap between the first doses coming off the manufacturing lines and a stockpile large enough to vaccinate the U.S. population. “I would say months,” Dr. José R. Romero, the chairman of the Advisory Committee on Immunization Practices, predicted.

The committee, which reports to the C.D.C. director, has long played a key role in determining how to implement new vaccines. The group includes 15 voting members selected by the health secretary who come from immunology, infectious disease and other medical specialties, 30 nonvoting representatives from across the health field, and eight federal officials focused on vaccines. Still, it operates largely out of sight.

Dr. Romero is among four committee members who have been deliberating on the plans since this spring alongside doctors at the C.D.C., representatives from the health field, ethicists and other outside consultants. In June, they briefed the full committee on their work, offering a glimpse of the questions being considered.

As they come up with a multitiered schedule for the first 1.2 million vaccine doses and then the next 110 million, they have focused on who should be considered essential workers, what underlying conditions should be taken into account and what kinds of living environments — nursing homes, homeless shelters — put people at high risk. Among the questions: What should be done about pregnant women? Should teachers go toward the front of the line? Should prisoners be in a top tier?

But for the broader committee, questions of whether to prioritize race and ethnicity sparked the most debate.

Black and Latino people have become infected with the virus at three times the rate of whites, and have died nearly twice as frequently. Many of them have jobs that keep them from working at home, rely on public transportation or live in cramped homes that increase their risk of exposure. They are more likely to suffer from underlying health problems, including diabetes and obesity, that raise the risk of hospitalization and death. Not only do the groups have less access to health services, they have a documented history of receiving unequal care.” (H)

“But let’s suppose that health care workers and people with underlying medical conditions use up the first doses of the available vaccine. Should some be held in reserve for Black and Latino people? What about bus drivers and train conductors? Perhaps teachers or schoolchildren should get it so they can return to classrooms with peace of mind.

If shortages happen, most of the nation will have no chance to get the initial lots of a vaccine under the C.D.C.’s plan. And as the United States combats a soaring number of coronavirus cases, rising demand for drugs and maybe ventilators is expected. They, too, will need a fair system of distribution.

One solution that is starting to attract the attention of public health experts is a so-called weighted lottery, which gives everyone a chance at access, although some get a better shot than others.

Doctors and ethicists rank patients, deciding which groups should be given preference and how much. First-responders, for example, may be weighted more heavily than, say, very sick patients who are unlikely to recover.

The goal is to prevent haphazard or inequitable distribution of a treatment or vaccine when there isn’t enough to go around. Such a system has already been used in allocations of remdesivir, the first drug shown to be effective against the coronavirus.

“This is all very new,” said Dr. Douglas White, an ethicist and vice chairman of the department of critical medicine at the University of Pittsburgh, which began using a weighted lottery last month to distribute remdesivir.

Patients have accepted the results, even when they lost in the lottery and ended up being denied the drug, he added.

“I speculate that is because we are very transparent about the reason and the ethical framework that applies to everyone who comes into hospital, whether that is the hospital president or someone who is homeless,” he said.

To allocate the drug, Pittsburgh doctors decided that the lottery would give preference to health care workers and emergency medical workers. The doctors also weighted the odds to favor people from economically disadvantaged areas, who tend to be mostly Black and Hispanic.

People with other illnesses and limited life spans, like end-stage cancer patients, had the odds weighted against them, giving them a smaller chance to win in the lottery. The system did not consider age, race, ethnicity, quality of life, ability to pay or whether a patient has a disability.

The lottery began in early June, Dr. White said: “We had 64 patients. We had to make the supply of remdesivir last at least two weeks. We only had enough to treat one in four patients.”

They had a brief respite from the lottery when cases began falling and supplies of remdesivir seemed adequate. But on Sunday, with cases rising again and enough remdesivir for only about half the patients who could be helped by taking it, the hospital system was forced to go back to a lottery….

Still, in principle, lottery data about a vaccine can be as useful as randomized clinical trial data, Dr. Pathak said.

“We would like to get people to think ahead about how vaccines are allocated,” he said. “There is no way we can vaccinate everybody, so we have to think about what’s fair and what’s just.”” (D)

“TA: Given that equitable distribution of vaccines is, at least in part, a question of ethics, how can computer models help us arrive at a solution?

Swann: It’s an interesting intersection, isn’t it? We can think of problems in terms of our objectives, which in this case might include efficiency (speed), effectiveness (avert deaths), and equity across the population. In public health, equity can be defined in different ways, including geographically (urban and rural) or by population (pro-rata). It can also be defined in terms of outcomes. For example, right now we know that communities of color, including African Americans, Hispanics, and Native Americans, are experiencing much higher rates of COVID-19 mortality than whites, and we know that people who are older or have high-risk medical conditions are also experiencing greater mortality than others.

Computer models can do many things to help with equitable distribution of vaccines. One really important role is to project the impact of different vaccination scenarios or strategies. For example, if there are limited vaccines, what is the impact of vaccinating essential workers, or ones who might interact with a vulnerable group (e.g., nursing home workers)? If there is a group at lower direct risk (e.g., children) who have significant contact with people at risk (parents or grandparents), what would be the impact of vaccinating them? If a vaccine requires two doses, or if immunity wanes after a time period, what strategies can avert the most hospitalizations and deaths? Which strategies would be most effective at reducing the disparities in COVID-19 outcomes associated with communities of color? These are just a few examples of many different decisions where humans could be aided by input from computer models.” (I)

“Nationwide distribution of any coronavirus vaccine will be a “joint venture” between the Centers for Disease Control and Prevention, which typically oversees vaccine allocation, and the Department of Defense, a senior administration official said today.

The Department of Defense “is handling all the logistics of getting the vaccines to the right place, at the right time, in the right condition,” the official said in a call with reporters, adding that CDC will remain in charge of tracking any side effects that emerge post-vaccination and “some of the communications through the state relationships [and] the state public health organizations.”

The plan breaks with the longstanding precedent that CDC distributes vaccines during major outbreaks — such as bad flu seasons — through a centralized ordering system for state and local health officials.

“We believe we’ve actually combined the best of both,” the official said. A second senior administration official stressed the agencies would be working as “one team” to distribute hundreds of millions of doses if any of the vaccines in development are approved in the coming months.

Private companies are also likely to join the effort. The first official said the government is bringing in people to integrate CDC IT capabilities with “some new applications that we’re going to need that the CDC never had.”

The background: The Pentagon will be guiding not just distribution logistics but also manufacturing and “kitting,” the process of safely packaging a vaccine with its necessary equipment such as syringes and needles.

“The DoD is handling all of those logistics — that is where their comparative advantage is,” said the first senior official. “And the CDC, some of their IT systems, relationships with the states following post-vaccination will belong to them.”…

State and local government groups have already raised concerns about Pentagon involvement and using new methods in coronavirus vaccine distribution. The CDC “already leads and maintains a highly effective system of vaccine ordering and distribution,” groups including the Association of State and Territorial Health Officials wrote in June. “With time of the essence we strongly recommend against designing new and untested systems of vaccine distribution.”

The state and local officials also questioned whether military involvement in vaccine administration would undermine already shaky public confidence in vaccines.”  (G)

“Executives from four companies in the race to produce a coronavirus vaccine — AstraZeneca, Johnson & Johnson, Moderna Therapeutics and Pfizer — told lawmakers on Tuesday that they are optimistic their products could be ready by the end of 2020 or the beginning of 2021. All four companies are testing vaccines in human clinical trials.

Three of the firms — AstraZeneca, Johnson & Johnson and Moderna — are getting federal funds for their vaccine development efforts. AstraZeneca and Johnson & Johnson pledged to the lawmakers that they would produce hundreds of millions of doses of their vaccines at no profit to themselves. Moderna, however, which has been granted $483 million from the government to develop its product, made no such promise.

“We will not sell it at cost,” said Dr. Stephen Hoge, the president of Moderna.

Many Democratic lawmakers have argued that federal funding for vaccine development should include provisions to guarantee affordability and guard against profiteering.

At the Congressional hearing on Tuesday, some House members raised concerns about Pfizer’s decision to reject federal funds, suggesting it could lead to price-gouging and a lack of transparency… (E)

“On June 26, a small South San Francisco company called Vaxart made a surprise announcement: A coronavirus vaccine it was working on had been selected by the U.S. government to be part of Operation Warp Speed, the flagship federal initiative to quickly develop drugs to combat Covid-19.

Vaxart’s shares soared. Company insiders, who weeks earlier had received stock options worth a few million dollars, saw the value of those awards increase sixfold. And a hedge fund that partly controlled the company walked away with more than $200 million in instant profits.” (F)

“The Serum Institute, which is exclusively controlled by a small and fabulously rich Indian family and started out years ago as a horse farm, is doing what a few other companies in the race for a vaccine are doing: mass-producing hundreds of millions of doses of a vaccine candidate that is still in trials and might not even work.

But if it does, Adar Poonawalla, Serum’s chief executive and the only child of the company’s founder, will become one of the most tugged-at men in the world. He will have on hand what everyone wants, possibly in greater quantities before anyone else.

His company, which has teamed up with the Oxford scientists developing the vaccine, was one of the first to boldly announce, in April, that it was going to mass-produce a vaccine before clinical trials even ended. Now, Mr. Poonawalla’s fastest vaccine assembly lines are being readied to crank out 500 doses each minute, and his phone rings endlessly.

National health ministers, prime ministers and other heads of state (he wouldn’t say who) and friends he hasn’t heard from in years have been calling him, he said, begging for the first batches.

“I’ve had to explain to them that, ‘Look I can’t just give it to you like this,’” he said.

With the coronavirus pandemic turning the world upside down and all hopes pinned on a vaccine, the Serum Institute finds itself in the middle of an extremely competitive and murky endeavor. To get the vaccine out as soon as possible, vaccine developers say they need Serum’s mammoth assembly lines — each year, it churns out 1.5 billion doses of other vaccines, mostly for poor countries, more than any other company…

But right now it’s not entirely clear how much of the coronavirus vaccine that Serum will mass-produce will be kept by India or who will fund its production, leaving the Poonawallas to navigate a torrent of cross-pressures, political, financial, external and domestic.

India has been walloped by the coronavirus, and with 1.3 billion people, it needs vaccine doses as much as anywhere. It’s also led by a highly nationalistic prime minister, Narendra Modi, whose government has already blocked exports of drugs that were believed to help treat Covid-19, the disease caused by the coronavirus.

Adar Poonawalla, 39, says that he will split the hundreds of millions of vaccine doses he produces 50-50 between India and the rest of the world, with a focus on poorer countries, and that Mr. Modi’s government has not objected to this.” (J)

“First we have to look at the global level. The private sector is really driving the vaccine development process, rather than government or academic labs. Major efforts are underway to figure out how private industrial developers can make vaccines available at an affordable price to all countries, particularly low and middle-income countries. It’s a bit like the ventilator supply situation we’ve all faced, but on steroids. Initially there will be scarce supply of the vaccine, governments will be scrambling to procure it, and, unless these efforts work, the winners will be fairly predictable: countries that have the resources.

On the next level, some wealthy countries will likely end up with substantial amounts of vaccine. Over time, if all goes well, these countries will have to decide how much product they’re going to keep and how much, if any, they’re willing to share with other countries where the vaccine may be in very short supply. These are complex questions of ethics, and they’re wrapped up in geopolitics, and also national politics.

There’s a term called vaccine nationalism—where countries understand their obligations to be primarily, if not exclusively, to their own residents. Although there is an expectation that countries with the resources and production capacity will meet their own health needs first, should they ignore the needs of people living in other countries with severe economic constraints? From an ethics perspective, a balance must be struck.” (K)

“As soon as the first COVID-19 vaccines get approved, a staggering global need will confront limited supplies. Many health experts say it’s clear who should get the first shots: health care workers around the world, then people at a higher risk of severe disease, then those in areas where the disease is spreading rapidly, and finally, the rest of us. Such a strategy “saves the most lives and slows transmission the fastest,” says Christopher Elias, who heads the Bill & Melinda Gates Foundation’s Global Development Division. “It would be ludicrous if low-risk people in rich countries get the vaccine when health care workers in South Africa don’t,” adds Ellen ‘t Hoen, a Dutch lawyer and public health activist.

Yet money and national interest may win out. The United States and Europe are placing advance orders for hundreds of millions of doses of successful vaccines, potentially leaving little for poorer parts of the world. “I’m very concerned,” says John Nkengasong, director of the Africa Centres for Disease Control and Prevention.

To avoid such a scenario, the World Health Organization and other international organizations have set up a system to accelerate and equitably distribute vaccines, the COVID-19 Vaccines Global Access (COVAX) Facility, which seeks to entice rich countries to sign on by reducing their own risk that they’re betting on the wrong vaccine candidates. But the idea has been put together on the fly, and it’s unclear how many rich countries will join.” (L)

“As scientists and pharmaceutical companies work at breakneck speed to develop a vaccine for the novel coronavirus, public health officials and senior U.S. lawmakers are sounding alarms about the Trump administration’s lack of planning for its nationwide distribution.

The federal government traditionally plays a principal role in funding and overseeing the manufacturing and distribution of new vaccines, which often draw on scarce ingredients and need to be made, stored and transported carefully.

There won’t be enough vaccine for all 330 million Americans right away, so the government also has a role in deciding who gets it first, and in educating a vaccine-wary here public about its potential life saving merits.

Right now, it is unclear who in Washington is in charge of oversight, much less any critical details, some state health officials and members of Congress told Reuters…

Health officials and lawmakers say they worry that without thorough planning and coordination with states, the vaccine distribution could be saddled with the same sort of disruptions that led to chronic shortages of coronavirus diagnostic tests and other medical supplies…

Some state public health officials, meanwhile, say their entreaties to the Trump administration have been unanswered.

“We have not heard anything from the federal government since April 23,” Danielle Koenig, health promotion supervisor for the Washington State Department of Health, said in an email.

That is when her agency received preliminary guidance on vaccine planning from the CDC.

Immunization experts along with state and local public health officials sent a letter here to Operation Warp Speed on June 23 pleading for fresh guidance.

States need to know promptly if the federal government will pay for the vaccines, as it did during the H1N1 outbreak in 2009, the letter says. Will alcohol swabs, syringes and personal protective equipment be included? What about record-keeping and refrigeration to store the vaccine and who will deliver it?

So far, there’s been no official response, said Claire Hannan, executive director of the Association of Immunization Managers, one of four organizations that signed the letter.

“We urgently await federal, state and local collaborative discussions to identify challenges and plan solutions. A vaccination campaign of this magnitude is unprecedented and it’s going to take more than an army,” Hannan said on Tuesday, referring to Trump’s repeated statements that the U.S. military stands ready to deliver vaccines.

Trump insists everything is in place.

“We’re all set to march when it comes to the vaccine,” Trump said at a White House briefing on Thursday. “… And the delivery system is all set. Logistically we have a general that’s all he does is deliver things whether it is soldiers or other items.

“We are way ahead on vaccines, way ahead on therapeutics and when we have it we are all set with our platforms to deliver them very, very quickly,” Trump said. (M)

M.Trump planning for U.S. rollout of coronavirus vaccine falling short, officials warn, by Richard Cowan, https://www.reuters.com/article/health-coronavirus-usa-vaccine/trump-planning-for-us-rollout-of-coronavirus-vaccine-falling-short-officials-warn-idUSL2N2EV0V4

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CORONOVIRUS TRACKING Links to Parts 1-41

CORONOVIRUS TRACKING

Links to Parts 1-41

Doctor, Did You Wash Your Hands?®

http://doctordidyouwashyourhands.com/

Curated Contemporaneous Case Study Methodology

Jonathan M. Metsch, Dr.P.H.

https://www.mountsinai.org/profiles/jonathan-m-metsch

PART 1. January 21, 2020. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”

PART 2. January 29, 2020. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”

PART3. February 3, 2020. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)

PART 4. February 9, 2020. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….

PART 5. February 12, 2020. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”

POST 6. February 18, 2020.  Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””

PART 7. February 20, 2020. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.

PART 8. February 24, 2020. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”

PART 9. February 27, 2020. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”

Part 10. March 1, 2020. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.

PART 11. March 5, 2020.  CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”

Part 12. March 10, 2020. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”

Part 13.. March 14, 2020. CORONAVIRUS. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”

PART 14. March 17, 2020. CORONAVIRUS. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”

PART 15. March 22, 2020. CORONAVIRUS. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.

PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT

PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.”  “New York’s private and public hospitals unite to manage patient load and share resources.

PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.

PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”

PART 20. April 20, 2020. CORONAVIRUS. “…nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence.”

PART 21. April 23, 2020. CORONAVIRUS. “We need to ask, are we using ventilators in a way that makes sense for other diseases but not this one?”

POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”

POST 23. May 3, 2020. CORONAVIRUS. … what Dr. Fauci really wants,…”is just to go to a baseball game. That will have to wait. The level of testing for the virus is not adequate enough to allow for such mass gatherings.’ (K)

POST 24. May 7, 2020. CORONAVIRUS. Former New Jersey governor Chris Christie said: “there are going to be deaths no matter what”… but that people needed to get back to work.

POST 25. May 10, 2020, CORONAVIRUS. “It is scary to go to work,” said Kevin Hassett, a top economic adviser to the president. “I think that I’d be a lot safer if I was sitting at home than I would be going to the West Wing.”

POST 26. May 14, 2020. CORONAVIRUS, “Deep cleaning is not a scientific concept”….”there is no universal protocol for a “deep clean” to eradicate the coronavirus”

POST 27. May 19, 2020. CORONAVIRUS. “Hospital…executives…are taking pay cuts…to help offset the financial fallout from COVID-19.” As “front line” layoffs and furloughs accelerate…

POST 28. May 23, 2020. CORONAVIRUS. ““You’ve got to be kidding me,”..”How could the CDC make that mistake? This is a mess.” CDC conflates viral and antibody tests numbers.

PART 29. May 22, 2020. CORONAVIRUS. “The economy did not close down. It closed down for people who, frankly, had the luxury of staying home,” (Governor Cuomo). But not so for frontline workers!

POST 30. June 3,202. CORONAVIRUS. “The wave of mass protests across the United States will almost certainly set off new chains of infection for the novel coronavirus, experts say….

POST 31. June 9, 2020. CORONAVIRUS. “I think we had an unintended consequence: I think we made people afraid to come back to the hospital,”

Post 32. June 16, 2020. CORONAVIRUS. Could the Trump administration be pursuing herd immunity by “inaction”?  “ If Fauci didn’t exist, we’d have to invent him.”

POST 33. June 21, 2002. CORONAVIRUS….. Smashing (lowering the daily number of cases) v. flattening the curve (maintaining a plateau)

POST 34. June 26, 2020. CORONAVIRUS. CDC Director Redfield… “the number of coronavirus infections…could be 10 times higher than the confirmed case count — a total of more than 20 million.” As Florida, Texas and Arizona become eipicenters!

POST 35. June 29, 2020. CORONAVIRUS. Pence: “We slowed the spread. We flattened the curve. We saved lives..”  While Dr. Fauci “warned that outbreaks in the South and West could engulf the country…”

POST 36. July 2, 2020. CORONAVIRUS. “There’s just a handful of interventions proven to curb the spread of the coronavirus. One of them is contact tracing, and “it’s not going well,” (Dr. Anthony Fauci)..

POST 37. June 8, 2020. CORONAVIRUS. When “crews arrive at a hospital with a patient suspected of having COVID-19, the hospital may have a physical bed open for them, but not enough nurses or doctors to staff it.”

POST 38. July 15, 2020. CORONAVIRUS. Some Lessons Learned, or not. AdventHealth CEO Terry Shaw: I wouldn’t hesitate to go to Disney as a healthcare CEO — based on the fact that they’re working extremely hard to keep people safe,” (M)

POST 39. July, 23,2020. CORONAVIRUS. A Tale of Two Cities. Seattle becomes New York (rolls back reopening) while New York becomes Seattle (moves to partial phase 4 reopening)

POST 40. July 27, 2020. CORONAVIRUS.” One canon of medical practice is that you order a test only if you can act on the result. And with a turnaround time of a week or two, you cannot. What we have now is often not testing — it’s testing theater.”

POST 41. August 2, 2020. CORONAVIRUS. “Whenever a vaccine for the coronavirus becomes available, one thing is virtually certain: There won’t be enough to go around. That means there will be rationing.”

August 2, 2020


 [JM1]

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POST 40. July 27, 2020. CORONAVIRUS.” One canon of medical practice is that you order a test only if you can act on the result. And with a turnaround time of a week or two, you cannot. What we have now is often not testing — it’s testing theater.”

“MLB and the NBA are getting coronavirus test results quickly and frequently. Some say that’s a problem in places where the results are sometimes so slow that they are worthless.”

to read POSTS 1-40 in chronological order, highlight and click on

“Any stimulus should be directed at the root cause of our recession: dealing with Covid. I know it isn’t popular to talk about in some Republican circles, but we still have a testing problem in this country. My son was tested recently; we had to wait 5 to 7 days for results. My daughter wanted to get tested before visiting her grandparents, but was told she didn’t qualify. That is simply inexcusable at this point in the pandemic.” Former White House Chief of Staff Mick Mulvaney. (P)

“President Trump has used increased coronavirus testing as an explanation for the surge in case counts across the U.S.

“If we didn’t test, you wouldn’t be able to show that chart,” Trump said in response to a question from Chris Wallace about rising U.S. Covid-19 cases in a Fox News interview that aired on July 19. “If we tested half as much, those numbers would be down.”

But a CNBC analysis of testing data found that even as the U.S. has increased its testing capacity, cases of the virus are being found at a higher rate, a pattern that contradicts what epidemiologists say should be happening as a country gets a pandemic under control.

“That claim is patently false,” said Dr. Yonatan Grad, a professor of immunology and infectious diseases at Harvard, in response to the idea that increased testing explains the recent outbreak. “It is at best misleading, and at worst intentionally subverting public health responses.”

In interviews with CNBC, epidemiologists pointed to the “percentage of positive tests” as a way to understand whether the growth in U.S. coronavirus cases is due solely to increased testing. When coronavirus tests are in short supply, only the sickest individuals are typically tested, causing the share of positive tests out of total tests to be high. But as more tests become available, those with mild or no symptoms — who are less likely to have Covid-19 — are able to get tests, which would lead to a lower positivity rate if the virus were not spreading.

The percentage of positive tests in the U.S. has increased from 5.4% on Memorial Day to 8.6% on July 23, according to a CNBC analysis of data from the Covid Tracking Project. Daily testing nationwide has nearly doubled over that period, from an average of 410,000 daily tests performed on May 25 to more than 775,000 daily tests as of July 23. To account for daily reporting fluctuations, CNBC’s analysis used a seven-day average of cases and tests to calculate percent positive rates…

“If the disease was not spreading and you were increasing testing, then the fraction positive should stay stable or go down,” Dr. Grad told CNBC. “But in fact we’re seeing that the fraction of tests that are positive is going up as testing is going up. That is a clear indication that there is increasing spread of the virus.” (R)

“Lines for coronavirus tests have stretched around city blocks and tests ran out altogether in at least one site on Monday, new evidence that the country is still struggling to create a sufficient testing system months into its battle with Covid-19.

At a testing site in New Orleans, a line formed at dawn. But city officials ran out of tests five minutes after the doors opened at 8 a.m., and many people had to be turned away.

In Phoenix, where temperatures have topped 100 degrees, residents have waited in cars for as long as eight hours to get tested.

And in San Antonio and other large cities with mounting caseloads of the virus, officials have reluctantly announced new limits to testing: The demand has grown too great, they say, so only people showing symptoms may now be tested — a return to restrictions that were in place in many parts of the country during earlier days of the virus.

“It’s terrifying, and clearly an evidence of a failure of the system,” said Dr. Morgan Katz, an infectious disease expert at Johns Hopkins Hospital.

In the early months of the nation’s outbreak, testing posed a significant problem, as supplies fell far short and officials raced to understand how to best handle the virus. Since then, the United States has vastly ramped up its testing capability, conducting nearly 15 million tests in June, about three times as many as it had in April. But in recent weeks, as cases have surged in many states, the demand for testing has soared, surpassing capacity and creating a new testing crisis.

In many cities, officials said a combination of factors was now fueling the problem: a shortage of certain supplies, backlogs at laboratories that process the tests, and skyrocketing growth of the virus as cases climb in almost 40 states and the nation approaches a grim new milestone of three million total cases.

Fast, widely available testing is crucial to controlling the virus over the long term in the United States, experts say, particularly as the country reopens. With a virus that can spread through asymptomatic people, screening large numbers of people is seen as essential to identifying those who are carrying the virus and helping stop them from spreading it to others….

Many places have been able to overcome some of the supply constraints that defined the earlier days of the outbreak, in part with their own resources. New York City, once faced with severe shortages as an epicenter of the virus, is now testing 30,000 people a day, officials say, an expansion that included the city building its own testing kits and partnering with private labs.

But even as Gov. Andrew M. Cuomo announced last week that anyone in New York State who wanted a test could get one, officials in other states have been left seeking a more robust testing system, and setting new limits on who can take one.

“We are too fragmented,” said Dr. Michael Mina, an assistant professor of epidemiology at Harvard’s T.H. Chan School of Public Health. “We don’t have a good way to load-balance the system.”” (A)

“The number of people infected with the coronavirus in different parts of the United States was anywhere from two to 13 times higher than the reported rates for those regions, according to data released Tuesday by the Centers for Disease Control and Prevention.

The findings suggest that large numbers of people who did not have symptoms or did not seek medical care may have kept the virus circulating in their communities.

The study indicates that even the hardest-hit area in the study — New York City, where nearly one in four people has been exposed to the virus — is nowhere near achieving herd immunity, the level of exposure at which the virus would stop spreading in a particular city or region. Experts believe 60 percent of people in an area would need to have been exposed to the coronavirus to reach herd immunity.

The analysis, based on antibody tests, is the largest of its kind to date; a study of a subset of cities and states was released last month.

“These data continue to show that the number of people who have been infected with the virus that causes Covid-19 far exceeds the number of reported cases,” said Dr. Fiona Havers, the C.D.C. researcher who led the study. “Many of these people likely had no symptoms or mild illness and may have had no idea that they were infected.”

About 40 percent of infected people do not develop symptoms, but they may still pass the virus on to others. The United States now tests roughly 700,000 people a day. The new results highlight the need for much more testing to detect infection levels and contain the viral spread in various parts of the country.” (B)

“The director of the National Institutes for Health said on Sunday that long delays Americans are seeing across the country in getting coronavirus test results is undercutting their usefulness.

“The average test delay is too long,” Dr. Francis Collins said Sunday on NBC’s “Meet the Press.” “And that really undercuts the value of the testing, because you do the testing to find out who’s carrying the virus and then quickly get them isolated so they don’t spread it around.”

As Covid-19 continues to surge in the US, some states, labs and public health departments are warning that turnaround times for diagnostic testing have slowed.

The challenges, which stem in part from persistent obstacles in the test supply chain, underscore that while overall US testing capacity has multiplied, the nation’s health system still struggles in some regions to rapidly detect the spread of the virus.

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Despite federal efforts to support testing in some cities and regions, major diagnostic companies said earlier this month that the growing demand for tests has in turn increased average wait times for delivering results. CNN previously reported results can now take an average of four to six days for the general population or in some states like Arizona up to three weeks.

Collins said Sunday that the government must invest in new technologies in order to keep up with the testing demand.”  (C)

“Health workers typically advise their patients to quarantine at home while they await their test results, out of an abundance of caution. To the extent that one can, “The best thing to do is to act as if you’ve been infected” in this interim period, said Olivia Prosper, an infectious disease modeler at the University of Tennessee, Knoxville. But the longer people are forced to wait, the more difficult that advice is to follow — and the larger toll their absence from work or family responsibilities can take.

Additionally, negative results can be of little use if they are delivered after too long of a delay. Diagnostic testing, which searches for bits of the coronavirus’s genetic material, can only assess a person’s health status from the time the sample was taken, and can’t account for any subsequent exposures to the virus.

Some have held out hope that new, confirmed coronavirus cases could soon peak in certain states, after which parts of the nation might experience a much-needed respite in infections — as, perhaps, some regions did for much of May. But the duration of that apex, which might actually manifest more like a plateau, can’t be definitively forecast. With many laboratories stretched to or past their limits, a leveling-off in confirmed cases could indicate a slowing in the coronavirus’s spread. Or it could simply reflect a regional ceiling in testing capacity.” (D)

“Testing that takes five days or longer is of little use, researchers from the University of Utrecht in the Netherlands reported Thursday in the journal Lancet Public Health.

“In our model, minimizing testing delays had the largest impact on reducing transmission of the virus and testing infrastructure is therefore the most critical factor for the success of a contact tracing system,” Marc Bonten, who helped lead the study, said in a statement.

Contact tracing is considered the gold standard for fighting an epidemic of infectious disease, but it requires testing all people who may be infected, isolating those who are, and then tracking down other people they may have infected and testing and isolating or quarantining them.

For these efforts to actually reduce the spread of the virus, three things need to happen, the researchers said. First, testing must happen on the day a person develops symptoms. Second, contacts must be traced starting the day test results come back. And third, there needs to be 100% tracing coverage.

With a testing delay of more than three days, not even perfect contact tracing could keep the spread of the virus from accelerating.

The researchers considered both conventional and app-based contact tracing methods. Because of their speed, app-based tracing methods were more effective than conventional methods, even with lower contact coverage.

In fact, app technology could keep the viral spread from accelerating even with a delay of up to two days, as long as there was 80% testing and tracing coverage.

Once the testing delay goes over to five or more days, app tracing “adds little effectiveness to conventional contact tracing or just isolation of symptomatic cases,” the researchers wrote.

“This study reinforces findings from other modelling studies, showing that contact tracing can be an effective intervention to prevent spread of the SARS-CoV-2 virus, but only if the proportion of contacts traced is high and the process is fast. “ (E)

“Quest Diagnostics, one of the companies performing a significant amount of the coronavirus testing in the U.S., said Monday that its average turnaround time for test results is at least seven days for most patients.

The announcement illustrates how the spike in coronavirus cases is overwhelming the country’s testing capacity.

The company said Monday that its average time to get coronavirus test results back is now “7 or more days” for everyone except the highest-priority patients, meaning people who are hospitalized or symptomatic health care workers.

Quest said the lagging turnaround times are due to “soaring demand” for coronavirus testing that is overwhelming the company’s capacity.

The rise in demand comes as coronavirus cases are surging in many regions across the country.

“We attribute this demand primarily to the rapid, continuing spread of COVID-19 infections across the nation but particularly in the South, Southwest and West regions of the country,” the company said.

Such long turnaround times greatly hinder the country’s response to the virus by reducing the ability to do contact tracing to identify and warn people who have been in contact with an infected person to cut off further transmission.

With waits this long, someone could unknowingly continue to spread the virus for days after getting tested but before getting their results.

The long turnaround times are not limited to Quest. The American Clinical Laboratory Association, which represents a wide range of commercial labs, warned at the end of June that the “significant increase in demand could extend turnaround times for test results.”” (F)

“The U.S. is testing over 700,000 people per day, up from less than 100,000 in March. Trump administration officials point out that roughly half of U.S. tests are performed on rapid systems that give results in about 15 minutes or in hospitals, which typically process tests in about 24 hours. But last month, that still left some 9 million tests going through laboratories, which have been plagued by limited chemicals, machines and kits to develop COVID-19 tests.

There is no scientific consensus on the rate of testing needed to control the virus in the U.S., which has the most cases and deaths of any nation. But experts have recommended for months that the U.S. test at least 1 million to 3 million people daily.

Health experts assembled by the Rockefeller Foundation said last week that the U.S. should scale up to testing 30 million Americans per week by the fall, when school reopenings and flu season are expected to further exacerbate the virus’ spread. The group acknowledged that their figure will not be possible with the current laboratory-based testing system.

The National Institutes of Health has set up a “shark tank” competition to quickly identify promising rapid tests and has received more than 600 applications. The goal is to have new testing options in mass production by the fall.

Until then, the the backbone of U.S. testing remains at several hundred labs with high-capacity machines capable of processing thousands of samples per day. Many say they could be processing far more tests if not for global shortages of testing chemicals, pipettes and other materials.

Dr. Bobbi Pritt of the Mayo Clinic in Rochester, Minnesota, says the hospital’s machines are running at just 20% of capacity. Lab technicians run seven different COVID-19 testing formats, switching back and forth depending on the availability of supplies.

At Emory University Hospital in Atlanta, lab workers lobby testing manufacturers on a weekly basis to provide more kits, chemicals and other materials.

“There’s no planning ahead, we just do as many as we can and cross our fingers that we’ll get more,” said Dr. Colleen Kraft, who heads the hospital’s testing lab.” (G)

“Atrium Health is processing coronavirus tests at just 20% to 25% of its capacity due to a national shortage of the chemicals needed to run the test, the Charlotte-based company’s president told a U.S. Senate panel Tuesday.

Gene Woods, president and CEO of the not-for-profit system, said Atrium can handle 4,000 coronavirus tests per day with its in-house lab equipment. But they are processing far less than that, he said, “due to the national supply shortage in reagents.”

Reagents are chemicals used in a reaction to detect a substance and are needed in COVID-19 testing to get a positive or negative result.

“We could probably do four times the amount of tests and have close to same-day turnaround, the challenge is reagents and, still in some respects, swabs,” Woods said. “We really need to continue to beef up the supplies of reagents so that we can expedite the testing. That would be our request.”

Nearly five months after the first lab-confirmed coronavirus case in North Carolina, the state is again dealing with long wait times for test results.

The average turnaround time is now closer to six or seven days, said Dr. Mandy Cohen, the state’s top health official. That turnaround time was two or three days in June.

Mecklenburg County Public Health Director Gibbie Harris said the turnaround time in the county is five to 10 days.” (H)

“Minnesota health officials are worried the state’s robust coronavirus testing capacity could be hampered by an increasingly stressed international medical supply chain.

Just a few weeks ago, Minnesotans were able to get the results of their coronavirus tests within about 24 hours. But now, the wait can be three days or more, delaying when contact tracers can begin investigating new infections.

“Health officials worry the ongoing national spike in cases could further impact Minnesota’s ability to screen for COVID-19 infections and return results quickly. Minnesota has screened on average about 12,000 samples per day since June 1 and is steadily approaching administering 1 million tests since the outbreak began.

The state currently has about 50,000 laboratory-confirmed cases and more than 1,560 COVID-19 deaths.

In some of the hardest hit parts of the U.S., test results can take a week or more — leaving Minnesota officials concerned about what may be on the horizon if supply chains don’t improve. Quick and precise testing is a key way to fight the virus by isolating positive patients so they cannot infect others.

“The faster the turnaround the better,” said Jan Malcolm, Minnesota’s health commissioner. “We are concerned this does have the potential to interfere with our testing capacity.”

Much of Minnesota’s ability to screen for the virus is based on a partnership between the state Department of Health, the Mayo Clinic, the University of Minnesota and other health care providers. Both the Mayo Clinic and M Health Fairview are reporting wait times for results of about three days.

“Unfortunately, Mayo Clinic is not immune to the shortages we have been seeing nationwide,” said Dr. Bobbi Pritt, a professor of clinical microbiology at the Mayo Clinic. “Some of these big manufacturers, with commonly used tests, are not able to deliver what they had agreed to deliver.”…

Dr. Pritt says there already are worrisome national shortages on materials needed to process COVID-19 tests. Large medical suppliers like Roche, Abbott and Hologic rely on the same supply chains to manufacture products and they are swamped with rising demand as cases surge in the U.S. and parts of the world.” (S)

“A recent article by my colleague Keith Collins found that California is one of 34 states that are currently not testing enough and that the state is 34 percent of the level that researchers at the Harvard Global Health Institute deemed necessary to mitigate the spread of the virus. By comparison, Vermont and Connecticut are way above, testing over 400 percent of the level above the target set by researchers. Arizona, Florida and Texas make up the bottom three.

And now, backlogs are causing delays in getting test results, so state officials have released new, stricter testing guidelines that will make it much tougher for many Californians who don’t have symptoms to get tested.

To understand how California’s testing performance matches up against other states, I asked Keith, a graphics editor, some questions about his findings and what it means for the Golden State.

According to your article, California is one of 34 states that you found to be below the testing target. What exactly does that mean, and what are the implications?

So California is pretty tricky because it’s so big. It’s in the top 10 in terms of daily tests per 100,000 people, which is pretty good, especially for a state its size. Unfortunately with testing, there’s not a lot of data that’s more granular than the state level so it’s hard to say where in the state testing is the worst.

In terms of the number of people it’s testing every day, it’s doing pretty well. But in terms of the target that Harvard has set as the minimum that a place needs to be doing to mitigate the virus, it’s way behind. It’s only doing 34 percent of that target right now.

How did researchers come up with the target goals in this model?

It’s based on the idea that anyone who has symptoms should be tested and then for anyone who tests positive, 10 of their contacts should also be tested. The idea is that you can’t really have a safe reopening if you’re not able to keep everyone who is sick isolated and that includes people who are asymptomatic. And right now a lot of places are just not testing people who are asymptomatic, at least not in a very concerted way.

These targets try to estimate how many tests you would need to do every day if you were going to identify nearly everyone who has the virus. And that’s going to include a lot of people who are not currently being tested right now.

It looks like there are currently 11 states, including New York, Hawaii and Massachusetts, that are currently meeting their target and six others that are close.

In the article’s charts you can see that a lot of those states only got to that level recently and some of those are trending downward again. Those charts are relative to the target so it can also mean that the target is rising and testing is steady. But New York and New Jersey really ramped up testing because they were hit so hard in the beginning. Still, only in early to mid-June have they started really catching up to that target.

It is a hard target to hit, but it is a conservative estimate. The Harvard researchers say that this target is really just to mitigate the spread of the virus. They have another estimate to suppress the virus. Their suppression target is way higher than this.”  (I)

“The U.S. Food and Drug Administration on Saturday gave emergency use authorization to a coronavirus testing method that could massively ramp up testing capabilities for the country.

The FDA is allowing Quest Diagnostics to test individual samples for coronavirus using a method known as batch testing, which mixes specimens from multiple people and tests the combined sample for coronavirus instead of testing samples one by one.” (J)

“Samples scraped from the back of patients’ noses and throats can now be bundled together and tested for the coronavirus in groups in one of the country’s biggest commercial labs. Quest Diagnostics, which handles tens of thousands of coronavirus tests each day, received authorization for the method, called pooled testing, from the Food and Drug Administration over the weekend.

The strategy helps conserve resources by running multiple tests using the materials usually required for one. It could also help Quest avoid backlogs and move testing along more quickly. Right now, demand for testing is so high that it takes an average of seven days for Quest labs to get results to patients.

However, the strategy can’t clear all testing roadblocks, and it may not work as well in the areas where it’s most needed: outbreak hotspots, where testing resources are stretched the thinnest. In those environments, where a high percentage of tests turn out to be positive, pools don’t end up saving materials — too many are positive, which means more retesting.

“When the positivity rate is high, pooling is not very effective, because you’re splitting apart way too many pools, and it’s just not worth your effort,” says Peter Iwen, director of the Nebraska Public Health Laboratory…

Pooling also doesn’t help once the rate of infections in a community starts ticking up. Iwen had to stop using pooled testing in the Nebraska lab a few weeks back because the percentage of tests that came back positive was too high — above 10 percent. In any random group of four or five tests, there was a high chance that one would be positive. If the positive rate is that high, pooling doesn’t tend to save a significant amount of chemicals or time.

The new instructions for the Quest pooled testing say that, if 13 percent of tests done at a lab are coming back positive, the lab should drop the pool size down to three. If 25 percent of a lab’s tests are coming back positive, they shouldn’t do pooled testing. Virginia and Massachusetts, home to the first Quest labs set to use pooled testing, positivity rate is about 6 and 2 percent, respectively. In Arizona, one of the hardest-hit states, it’s around 24 percent.”  (K)

“But what should the Food and Drug Administration do with a rapid test that is comparatively cheap but much less accurate than the tests currently on the market? A test like that is ready to go up for FDA approval, and some scientists argue it could be valuable despite its shortcomings.

At first blush, you wouldn’t want a medical test to be pushing out untrustworthy results. And that’s certainly the case for a medical diagnosis. But rapid test could be valuable if used to screen large numbers of people for infection repeatedly and frequently.

For example, some of the rapid tests under development don’t detect the virus in a person who is in the early or late stages of infection — they only catch an infection at its peak. Dr. Michael Mina at the Harvard T.H. Chan School of Public Health says that’s OK, under certain circumstances.

“As long as you’re using the test on a pretty frequent basis,” Mina says, “you will be more likely than not to catch the person on the day they might go out and transmit. And they’ll know to stay home.”

To be useful, such tests need to be widely available and affordable, he says. “I envision a time when everyone can order a pack of 50 tests for $50 and have those and use them every other day for a couple of months.”

When it comes to controlling the epidemic, that could be an appealing alternative to the current laboratory-based system, an overburdened process that has become a serious bottleneck. These days, some people are waiting a week or more for results, and by then they have potentially spread the virus to others.

Highly accurate at-home tests are probably many months away. But Mina argues they could be here sooner if the FDA would not demand that tests for the coronavirus meet really high accuracy standards of 80 percent or better.”  (L)

“The White House is trying to block billions of dollars for coronavirus testing and contact tracing in the upcoming stimulus relief bill, two Republican sources told NBC News, even as infections surge across the country and Americans face long wait times to receive test results amid high demand. 

Senate GOP lawmakers, in a break with the administration, are pushing back and trying to keep the money for testing and tracing in the bill, the sources told NBC News. Some White House officials reportedly believe new money shouldn’t be allocated for testing because previous funds remain unspent.

The White House declined CNBC’s request for comment. The Washington Post first reported the news.

The Trump administration also wants to block billions of dollars that would go toward bolstering the Centers for Disease Control and Prevention, the Pentagon and the State Department to combat the pandemic, The Post reported Saturday, citing people familiar with the deliberations. 

While moving to block testing assistance, the Trump administration is trying to use the legislation to fund priorities unrelated to the pandemic such as a new FBI building, according to the Post.

The White House effort to block funding for testing comes after the administration relied on overly optimistic models which suggested the U.S. moved past the peak of the outbreak in the spring, according to a report in The New York Times. As a result, the administration pushed to reopen the economy and shifted responsibility for responding to the pandemic from the federal government to the states with disastrous results, according to the Times.

President Trump has called coronavirus testing a “double-edged sword” and suggested at a campaign rally in Tulsa, Oklahoma that officials should slow testing down. White House officials later said Trump was joking.

The Times’ report portrayed a president who feels trapped politically because cases counts inevitably increase as more people are tested, jeopardizing the reopening of the economy and damaging his re-election chances.” (M)

“Nearly four months after the pandemic’s peak, New York City is facing such serious delays in returning coronavirus test results that public health experts are warning that the problems could hinder efforts to reopen the local economy and schools.

Despite repeated pledges from Gov. Andrew M. Cuomo and Mayor Bill de Blasio that testing would be both widely accessible and effective, thousands of New Yorkers have had to wait a week or more for results, and at some clinics the median wait time is nine days. One prominent local official has even proposed the drastic step of limiting testing.

The delays in New York City are caused in part by the outbreak’s spike in states like California, Florida and Texas, which has strained laboratories across the country and touched off a renewed national testing crisis.

But officials have also been unable to adequately expand the capacity of state and city government laboratories in New York to test rapidly at a time when they are asking more New Yorkers to get tested to guard against a second wave.

The delays limit the ability of public health officials to quickly identify — and isolate — people who are infected while also diminishing the usefulness of New York City’s contact-tracing program. They also can lead to growing blind spots that obscure the extent of the virus’s spread, which could spell trouble as the city tries to reopen.

As a result, some public officials and laboratory executives say New York’s strategy of allowing anyone and everyone who wants a test to get one is unsustainable.” (Q)

“Coronavirus testing in the United States has been bungled in every way imaginable. The latest fiasco is perhaps the most Kafka-esque: Tests are now widely available in many places, but results are often taking so long to come back that it is more or less pointless to get tested.

If it takes up to two weeks to get results, we can’t detect brewing outbreaks and respond with targeted shutdowns. We can’t do meaningful contact tracing. We can’t expect people to stay home from work or school for two weeks while they wait for the result of a screen. We have no way to render early treatment and attention to those who test positive, to try to prevent serious illness. It’s a disaster….

One canon of medical practice is that you order a test only if you can act on the result. And with a turnaround time of a week or two, you cannot. What we have now is often not testing — it’s testing theater.” (N)

“MLB and the NBA are getting coronavirus test results quickly and frequently. Some say that’s a problem in places where the results are sometimes so slow that they are worthless.

Connor Kelley feared he had been exposed to the coronavirus while playing miniature golf at a friend’s birthday party, so he visited a drive-through testing clinic near Orlando, Fla. He was told to expect results in a few days. It took 10 days.

A few miles and hundreds of millions of dollars away, professional athletes are being tested every day. Their results are coming back in less than 24 hours.” (O)

“Federal, state and local officials on Sunday appeared to agree on one thing: Test results are taking too long.

But they gave conflicting assessments of the U.S. response to recent spikes in coronavirus cases, which have severely strained testing nationwide and led to renewed shortages of supplies and weeklong backlogs at major labs.

Adm. Brett Giroir, the assistant health secretary overseeing the national coronavirus testing response, said the country was performing enough testing to “achieve the goals we need to achieve.”

Speaking on CNN’s “State of the Union,” Mr. Giroir acknowledged that turnaround times were too long. But he asserted that while testing was still not widely available to anyone who wanted it — despite past claims from Mr. Trump that it would be — it was available to those who needed it.

Testing is considered crucial to understanding and stopping the spread of the coronavirus. When turnaround times extend beyond several days, it can render the information useless since those tested may have spread the virus to other people by the time their results are back.

Mark Meadows, President Trump’s chief of staff, skirted questions about the administration’s early missteps by suggesting that medical advancements, not masks, would be the only way to end the pandemic. “Hopefully it is American ingenuity that will allow for therapies and vaccines to ultimately conquer this,” he said on the ABC program “This Week.”” (T)

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CORONOVIRUS TRACKING Links to Parts 1-40

CORONOVIRUS TRACKING

Links to Parts 1-40

Doctor, Did You Wash Your Hands?®

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Curated Contemporaneous Case Study Methodology

Jonathan M. Metsch, Dr.P.H.

https://www.mountsinai.org/profiles/jonathan-m-metsch

PART 1. January 21, 2020. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”

PART 2. January 29, 2020. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”

PART3. February 3, 2020. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)

PART 4. February 9, 2020. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….

PART 5. February 12, 2020. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”

POST 6. February 18, 2020.  Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””

PART 7. February 20, 2020. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.

PART 8. February 24, 2020. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”

PART 9. February 27, 2020. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”

Part 10. March 1, 2020. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.

PART 11. March 5, 2020.  CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”

Part 12. March 10, 2020. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”

Part 13.. March 14, 2020. CORONAVIRUS. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”

PART 14. March 17, 2020. CORONAVIRUS. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”

PART 15. March 22, 2020. CORONAVIRUS. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.

PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT

PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.”  “New York’s private and public hospitals unite to manage patient load and share resources.

PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.

PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”

PART 20. April 20, 2020. CORONAVIRUS. “…nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence.”

PART 21. April 23, 2020. CORONAVIRUS. “We need to ask, are we using ventilators in a way that makes sense for other diseases but not this one?”

POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”

POST 23. May 3, 2020. CORONAVIRUS. … what Dr. Fauci really wants,…”is just to go to a baseball game. That will have to wait. The level of testing for the virus is not adequate enough to allow for such mass gatherings.’ (K)

POST 24. May 7, 2020. CORONAVIRUS. Former New Jersey governor Chris Christie said: “there are going to be deaths no matter what”… but that people needed to get back to work.

POST 25. May 10, 2020, CORONAVIRUS. “It is scary to go to work,” said Kevin Hassett, a top economic adviser to the president. “I think that I’d be a lot safer if I was sitting at home than I would be going to the West Wing.”

POST 26. May 14, 2020. CORONAVIRUS, “Deep cleaning is not a scientific concept”….”there is no universal protocol for a “deep clean” to eradicate the coronavirus”

POST 27. May 19, 2020. CORONAVIRUS. “Hospital…executives…are taking pay cuts…to help offset the financial fallout from COVID-19.” As “front line” layoffs and furloughs accelerate…

POST 28. May 23, 2020. CORONAVIRUS. ““You’ve got to be kidding me,”..”How could the CDC make that mistake? This is a mess.” CDC conflates viral and antibody tests numbers.

PART 29. May 22, 2020. CORONAVIRUS. “The economy did not close down. It closed down for people who, frankly, had the luxury of staying home,” (Governor Cuomo). But not so for frontline workers!

POST 30. June 3,202. CORONAVIRUS. “The wave of mass protests across the United States will almost certainly set off new chains of infection for the novel coronavirus, experts say….

POST 31. June 9, 2020. CORONAVIRUS. “I think we had an unintended consequence: I think we made people afraid to come back to the hospital,”

Post 32. June 16, 2020. CORONAVIRUS. Could the Trump administration be pursuing herd immunity by “inaction”?  “ If Fauci didn’t exist, we’d have to invent him.”

POST 33. June 21, 2002. CORONAVIRUS….. Smashing (lowering the daily number of cases) v. flattening the curve (maintaining a plateau)

POST 34. June 26, 2020. CORONAVIRUS. CDC Director Redfield… “the number of coronavirus infections…could be 10 times higher than the confirmed case count — a total of more than 20 million.” As Florida, Texas and Arizona become eipicenters!

POST 35. June 29, 2020. CORONAVIRUS. Pence: “We slowed the spread. We flattened the curve. We saved lives..”  While Dr. Fauci “warned that outbreaks in the South and West could engulf the country…”

POST 36. July 2, 2020. CORONAVIRUS. “There’s just a handful of interventions proven to curb the spread of the coronavirus. One of them is contact tracing, and “it’s not going well,” (Dr. Anthony Fauci)..

POST 37. June 8, 2020. CORONAVIRUS. When “crews arrive at a hospital with a patient suspected of having COVID-19, the hospital may have a physical bed open for them, but not enough nurses or doctors to staff it.”

POST 38. July 15, 2020. CORONAVIRUS. Some Lessons Learned, or not. AdventHealth CEO Terry Shaw: I wouldn’t hesitate to go to Disney as a healthcare CEO — based on the fact that they’re working extremely hard to keep people safe,” (M)

POST 39. July, 23,2020. CORONAVIRUS. A Tale of Two Cities. Seattle becomes New York (rolls back reopening) while New York becomes Seattle (moves to partial phase 4 reopening)

POST 40. July 27, 2020. CORONAVIRUS.” One canon of medical practice is that you order a test only if you can act on the result. And with a turnaround time of a week or two, you cannot. What we have now is often not testing — it’s testing theater.”

July 27, 2020


 [JM1]

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POST 39. July 23,2020. CORONAVIRUS. A Tale of Two Cities. Seattle becomes New York (rolls back reopening) while New York becomes Seattle (moves to partial phase 4 reopening)

to read POSTS 1-39 in chronological order, highlight and click on

APRIL 26, 2020

“The first diagnosis of the coronavirus in the United States occurred in mid-January, in a Seattle suburb not far from the hospital where Dr. Francis Riedo, an infectious-disease specialist, works. When he heard the patient’s details—a thirty-five-year-old man had walked into an urgent-care clinic with a cough and a slight fever, and told doctors that he’d just returned from Wuhan, China—Riedo said to himself, “It’s begun.”…

Epidemiology is a science of possibilities and persuasion, not of certainties or hard proof. “Being approximately right most of the time is better than being precisely right occasionally,” the Scottish epidemiologist John Cowden wrote, in 2010. “You can only be sure when to act in retrospect.” Epidemiologists must persuade people to upend their lives—to forgo travel and socializing, to submit themselves to blood draws and immunization shots—even when there’s scant evidence that they’re directly at risk…

The lead spokesperson should be a scientist. Dr. Richard Besser, a former acting C.D.C. director and an E.I.S. alumnus, explained to me, “If you have a politician on the stage, there’s a very real risk that half the nation is going to do the opposite of what they say.” During the H1N1 outbreak of 2009—which caused some twelve thousand American deaths, infections in every state, and seven hundred school closings—Besser and his successor at the C.D.C., Dr. Tom Frieden, gave more than a hundred press briefings. President Barack Obama spoke publicly about the outbreak only a few times, and generally limited himself to telling people to heed scientific experts and promising not to let politics distort the government’s response. “The Bush Administration did a good job of creating the infrastructure so that we can respond,” Obama said at the start of the pandemic, and then echoed the sohco by urging families, “Wash your hands when you shake hands. Cover your mouth when you cough. I know it sounds trivial, but it makes a huge difference.” At no time did Obama recommend particular medical treatments, nor did he forecast specifics about when the pandemic would end…

Constantine told me that he understands why politicians “want to be front and center and take the credit.” And he noted that Seattle has many of “the same problems here you see in Congress, with the partisanship and toxicity.” But, he said, “everyone, Republicans and Democrats, came together behind one message and agreed to let the scientists take the lead.”…

Today, Washington State has less than two per cent of coronavirus cases in the U.S. At EvergreenHealth, hospital administrators have stopped daily crisis meetings, because the rate of incoming patients has slowed. They have empty beds and extra ventilators. The administrators remain worried, but are cautiously optimistic. “It feels like we might have stopped the tsunami before it hit,” Riedo told me. “I don’t want to tempt fate, but it seems like it’s working. Which is what makes it so much harder when I look at places like New York.”…

The initial coronavirus outbreaks in New York City emerged at roughly the same time as those in Seattle. But the cities’ experiences with the disease have markedly differed. By the second week of April, Washington State had roughly one recorded fatality per fourteen thousand residents. New York’s rate of death was nearly six times higher.

There are many explanations for this divergence. New York is denser than Seattle and relies more heavily on public transportation, which forces commuters into close contact. In Seattle, efforts at social distancing may have been aided by local attitudes—newcomers are warned of the Seattle Freeze, which one local columnist compared to the popular girl in high school who “always smiles and says hello” but “doesn’t know your name and doesn’t care to.” New Yorkers are in your face, whether you like it or not. (“Stand back at least six feet, playa,” a sign in the window of a Bronx bodega cautioned. “covid-19 is some real shit!”) New York also has more poverty and inequality than Seattle, and more international travellers. Moreover, as Mike Famulare, a senior research scientist at the Institute for Disease Modeling, put it to me, “There’s always some element of good luck and bad luck in a pandemic.”

It’s also true, however, that the cities’ leaders acted and communicated very differently in the early stages of the pandemic. Seattle’s leaders moved fast to persuade people to stay home and follow the scientists’ advice; New York’s leaders, despite having a highly esteemed public-health department, moved more slowly, offered more muddied messages, and let politicians’ voices dominate….

Today, New York City has the same social-distancing policies and business-closure rules as Seattle. But because New York’s recommendations came later than Seattle’s—and because communication was less consistent—it took longer to influence how people behaved. According to data collected by Google from cell phones, nearly a quarter of Seattleites were avoiding their workplaces by March 6th. In New York City, another week passed until an equivalent percentage did the same. Tom Frieden, the former C.D.C. director, has estimated that, if New York had started implementing stay-at-home orders ten days earlier than it did, it might have reduced covid-19 deaths by fifty to eighty per cent. Another former New York City health commissioner told me that “de Blasio was just horrible,” adding, “Maybe it was unintentional, maybe it was his arrogance. But, if you tell people to stay home and then you go to the gym, you can’t really be surprised when people keep going outside.”

More than fifteen thousand people in New York are believed to have died from covid-19. Last week in Washington State, the estimate was fewer than seven hundred people. New Yorkers now hear constant ambulance sirens, which remind them of the invisible viral threat; residents are currently staying home at even higher rates than in Seattle. And de Blasio and Cuomo—even as they continue to squabble over, say, who gets to reopen schools—have become more forceful in their warnings. Rasmussen said, “It seems silly, but all these rules and sohcos and telling people again and again to wash their hands—they make a huge difference. That’s why we study it and teach it.” She continued, “It’s really easy, with the best of intentions, to say the wrong thing or send the wrong message. And then more people die.” (A)

“You relish the little things here in Seattle: Toilet paper is back on some shelves, the hoarders sated for the moment. Instead of making vodka, distilleries are rolling out hand sanitizer. The dreaded daily number of new coronavirus cases shows that while the curve is not yet flat, the rate has gone both down and up on different days this week, carrying our hopes on the bumpy ride.

As for the tally of the dead: Instead of doubling every five days in Washington State, as it was just two weeks ago, now it doubles roughly every nine — a horrific number still, but that movement is in the right direction.

We are not necessarily your city’s future, but a likely version of your future if you do the right thing. Washington State had the first known case of Covid-19 in the United States, on Jan. 19; the first reported death, more than a month after that; and the first full-blown outbreak. We’re well ahead of the rest of the nation in our cycle of denial, panic, action.

Social distancing started early. Testing has been broad, though more help from the federal government is needed. A communal fight or flight instinct has moved into something more settled. Even as the president floats an idea that could sacrifice the elderly to keep Wall Street happy, we take care of our own. We will not throw Grandma from the train.

“There really is no middle ground,” said Bill Gates, whose foundation has put up $100 million to blunt the impact of the Covid-19 pandemic. “It’s very tough to say to people, ‘Hey, keep going to restaurants, go buy new houses, ignore that pile of bodies in the corner.’ ”

President Trump’s talk of opening the United States for business by Easter is greeted in this precinct of sanity as the heartless bluster of a career con man. The public radio station in Seattle, KUOW, has stopped airing Trump’s live briefings because the volume of misinformation he puts out cannot be corrected in real time.”  (B)

“…on Jan. 15, at the international airport south of Seattle, a 35-year-old man returned from a visit to his family in the Wuhan region. He grabbed his luggage and booked a ride-share to his home north of the city.

The next day, as he went back to his tech job east of Seattle, he felt the first signs of a cough — not a bad one, not enough to send him home. He attended a group lunch with colleagues that week at a seafood restaurant near his office. As his symptoms got worse, he went grocery shopping near his home.

Days later, after the man became the first person in the United States to test positive for the coronavirus, teams from federal, state and local agencies descended to contain the case. Sixty-eight people — the ride-share driver at the airport, the lunchmates at the seafood restaurant, the other patients at the clinic where the man was first seen — were monitored for weeks. To everyone’s relief, none ever tested positive for the virus.

But if the story ended there, the arc of the coronavirus’s sweep through the United States would look much different.

As it turned out, the genetic building block of the virus detected in the man who had been to Wuhan would become a crucial clue for scientists who were trying to understand how the pathogen gained its first, crucial foothold.

Working out of laboratories along Seattle’s Lake Union, researchers from the University of Washington and the Fred Hutchinson Cancer Research Center rushed to identify the RNA sequence of the cases from Washington State and around the country, comparing them with data coming in from around the world.

Using advanced technology that allows them to rapidly identify the tiny mutations that the virus makes in its virulent path through human hosts, the scientists working in Washington and several other states made two disconcerting discoveries.

The first was that the virus brought in by the man from Wuhan — or perhaps, as new data has suggested, by someone else who arrived carrying a nearly identical strain — had managed to settle into the population undetected.

Then they began to realize how far it had spread. A small outbreak that had established itself somewhere north of Seattle, they realized as they added new cases to their database, was now responsible for all known cases of community transmission they examined in Washington State in the month of February.

And it had jumped.

A genetically similar version of the virus — directly linked to that first case in Washington — was identified across 14 other states, as far away as Connecticut and Maryland. It settled in other parts of the world, in Australia, Mexico, Iceland, Canada, the United Kingdom and Uruguay. It landed in the Pacific, on the Grand Princess cruise ship.

The unique signature of the virus that reached America’s shores in Seattle now accounts for a quarter of all U.S. cases made public by genomic sequencers in the United States.

With no widespread testing available, the high-tech detective work of the researchers in Seattle and their partners elsewhere would open the first clear window into how and where the virus was spreading — and how difficult it would be to contain.

Even as the path of the Washington State version of the virus was coursing eastward, new sparks from other strains were landing in New York, in the Midwest and in the South. And then they all began to intermingle….

There was minimal coronavirus testing in the United States during February, leaving researchers largely blind to the specific locations and mutations of the spread that month. The man who had traveled from Wuhan was not at the dance, nor was anyone else known to have traveled into the country with the coronavirus. But researchers learned that the virus by then was already spreading well beyond its point of origin — and all the cases of community transmission that month were part of that same genetic branch.

There was another spreading event. On the Saturday after the dance, a group of friends packed the living room of a one-bedroom apartment in Seattle, sharing homemade food and tropical-themed drinks.

Over the following days, several people began coming down with coronavirus symptoms. “Among people who attended, four out of every 10 got sick,” said Hanna Oltean, an epidemiologist with the Washington State Department of Health.

Several people passed on the virus to others. By late March, the state health department had documented at least three generations of “transmission occurring before anyone was symptomatic,” Ms. Oltean said.

By then, it was becoming clear that there were probably hundreds of cases already linked to the first point of infection that had been spreading undetected. It left a lingering question: If the virus had this much of a head start, how far had it gone?

The large outbreak on the Grand Princess, a researcher said, could probably be traced to a single person linked to the Washington State cluster….

A group of cases throughout the Midwest, first surfacing in early March, appears to have roots in Europe. A group of cases in the South, which emerged around the same time, on March 3, appears like a more direct descendant from China.

But of all the branches that researchers have found, the strain from Washington State remains the earliest and one of the most potent.

It has surfaced in Arizona, California, Connecticut, the District of Columbia, Florida, Illinois, Michigan, Minnesota, New York, North Carolina, Oregon, Utah, Virginia, Wisconsin and Wyoming, and in six countries…

One of the enduring mysteries has been just how the virus managed to gain its first, fatal foothold in Washington.

Did the contact tracers who followed the steps of the man who had traveled from Wuhan miss something? Did he expose someone at the grocery store, or touch a door handle when he went to the restaurant near his office?

In recent days, the sequencing of new cases has revealed a surprising new possibility. A series of cases in British Columbia carried a genetic footprint very similar to the case of the Wuhan traveler. That opened up the possibility that someone could have carried that same branch of the virus from Wuhan to British Columbia or somewhere else in the region at nearly the same time. Perhaps it was that person whose illness had sparked the fateful outbreak.

But who? And how? That would probably never be known.” (C)

JULY 13, 2020

For the first time in months, there was a 24-hour period in which no one in New York City died of the coronavirus.

The New York City Department of Health and Mental Hygiene reported zero deaths on Saturday, but that number could change as death data can lag and new deaths could be confirmed retroactively at any point. The city’s first confirmed coronavirus death was March 11.

Mayor Bill de Blasio called the milestone a statement about “how this city fights back and people do not ever give in.”

“It’s something that should make us hopeful, but it’s very hard to take a victory lap because we know we have so much more ahead. This disease is far from beaten,” de Blasio said during a news conference Monday. “And we look around the country and we look at what so many other Americans are going through and so many other states and cities hurting so bad right now. So no one can celebrate, but we can at least take a moment to appreciate that every one of you did so much to get us to this point.”..

On Monday, the city reported a 2% positivity rating for coronavirus testing. Fifty-six patients were admitted to the hospital, and 279 patients were in intensive care units.” (D)

JULY 16, 2020

“In what seems like almost a lifetime ago, America’s coronavirus story started in January in Washington State, with the nation’s first confirmed case followed by an early outbreak that spread with alarming ferocity.

But swift lockdown measures were credited with holding down illnesses and deaths. By June, nail salons and bars had begun to reopen, even as the virus began to rage in Texas, Arizona and Florida. Washington still had relatively low case numbers, and some counties were even contemplating a return to movie theaters and museums.

Now, those plans are on hold.

The coronavirus is once again ravaging Washington, and the number of cases has hit grim new milestones. Since the middle of June, the state has reported an average of 700 new cases per day — the highest levels since the start of the pandemic. More than 45,000 people have been infected, and over 1,400 have died.

“If these trends were to continue, we would have to prepare to go back to where we were in March,” Gov. Jay Inslee said recently.

Six months after the coronavirus first reached the United States, the state that was on the initial front line — a state that locked down early and hard — is only now beginning to see how complicated and lengthy the fight may be.

A lot of things are going wrong at once. Young people, less likely to die of the virus and undoubtedly weary of social distancing measures, have been driving a spike in new infections in the Seattle area. And an outbreak here in Yakima County that began powering its way through agriculture workers in the spring has now spread widely through a community that has not embraced self-isolation and masking to the degree that many Seattleites have.

Yakima, the eighth-most populous county, now has the second-highest number of cases. While the county cannot be blamed for hot spots elsewhere, Yakima does show how the virus can simmer along at a seeming lull — until a new outbreak suddenly surges through an entire region, challenging officials to stitch together cohesive policies for a patchwork of different problems.

“It’s really important for people to understand that their individual behaviors, everyone’s individual behaviors, collectively have a big impact on transmission,” said Dr. Kathy Lofy, Washington’s health officer. “We can increase testing, we can do case and contact investigations, we can do outbreak response, but those activities only get us so far.”

When the virus first came to Washington, the eastern part of the state was not hit as badly as Seattle, a liberal city with legions of tech workers who dutifully stayed home. But lockdown measures were not as effective in Yakima, a much less affluent county where more than 60 percent of people work in meat- or fruit-packing plants or other essential jobs.

The county is home to a large Hispanic population, which officials have said is more at risk for the coronavirus because of crowded living conditions where the virus can easily spread or limited access to health care. Many people live paycheck to paycheck, and if they were able to get up and go to work, they did.

By mid-May, people who worked in Yakima’s fruit-packing facilities had started to get sick. Terrified of working on crowded assembly lines or in warehouses that were not regularly cleaned, many went on strike, even as the virus spread outside the buildings’ walls.

The Matson Fruit Company in Selah, Wash. More than 60 percent of people in Yakima work in meat- or fruit-packing plants or other essential jobs.Credit…Jovelle Tamayo for The New York Times

Cases hit a peak in early June, according to Dr. Teresa Everson, the health officer for the Yakima Health District, just as more workers were cramming into processing facilities for the beginning of Washington’s busy cherry-picking season.

Still, only a third of those in the county wore masks, according to one survey from health officials. In the past few weeks, infectious people have gone to at least 20 family gatherings, 15 birthday parties, two baby showers and two weddings, Dr. Everson said. Some businesses were even reluctant to work with her office, which was trying to track cases and do contact tracing.

“There are a few large employers that persistently do not return our phone calls and do not want to work with us,” Dr. Everson said…

Just a few weeks ago, the state was confident that it could reopen schools in the fall, allowing many parents to go back to work and fuel the state’s economic recovery. But amid mounting opposition from educators and health experts, those plans look increasingly unlikely. And on Tuesday, Mr. Inslee said that no counties would be allowed to loosen lockdown restrictions for at least two weeks.

In Seattle, still the heart of the state’s outbreak, many people are resigned to the precautions they envision for the foreseeable future. On July 4, families wearing masks grilled tortillas, played on swings and enjoyed the parks — many feet away from anyone else. Salons took customers’ temperatures before letting them in. At Target, people lined up six feet apart at the cashier.

“Mask usage is changing very rapidly in my state,” he said. “What we’re asking people to do, they are doing.”” (E)

“New York, once the center of the coronavirus pandemic, has so successfully stemmed the outbreak that its death and hospitalization rates have plummeted and it has among the lowest infection rates in the country.

But the state and its neighbors are facing a disquieting new threat: Can they keep the virus suppressed when it is raging across the South and West?

Officials and public health experts are especially concerned that infected travelers from any of the nearly 40 states where the outbreak is spiking could set off new clusters in New York. Gov. Andrew M. Cuomo on Monday imposed more restrictions on travelers from states with high infection rates, but it is not all clear that they will be followed — or are even enforceable.

Tens of thousands of people enter New York daily through its airports, highways and train stations, and compliance largely depends on the whims of visitors and of residents returning home.

Mr. Cuomo has warned it is almost inevitable that the virus will seep back into the state, much the way it came to New York through flights from Europe in February. He has also raised concerns that some New Yorkers might let their guard down and blamed local governments for not enforcing mask-wearing and social-distancing measures.

But his focus lately has been on trying to keep the virus from re-entering New York: Travelers from 22 states where cases have increased must now quarantine for two weeks upon arrival in New York. And beginning Tuesday, travelers arriving at New York airports will be required to fill out a form with their personal information and planned whereabouts, or face a $2,000 fine.

Epidemiologists said they were skeptical that the measures would work.

“I think it’s going to be incredibly hard to keep the virus out of New York State,” said Isaac Weisfuse, a former New York City deputy health commissioner. “I think that these types of travel restrictions may be somewhat helpful, but we should assume that they’re not going to be airtight.”

But Dr. Weisfuse, an adjunct professor at Cornell University’s master of public health program, and other epidemiologists said New York was better positioned to deal with a surge in cases this time around.

They said that government officials had a better understanding of the virus and that doctors in New York had learned invaluable lessons from treating the disease. People in New York, where more than 400,000 people were infected and more than 30,000 died, are keenly aware of the risks and, for the most part, of the importance of wearing masks. The state has also dramatically ramped up its testing capacity, processing about 60,000 tests per day.

“I don’t anticipate that in New York, we’re going to have a second wave that is going to look like what we have in Texas and Florida,” said Dr. W. Ian Lipkin, director of the Center for Infection and Immunity at the Mailman School of a Public Health at Columbia University. “We can’t become complacent, and I don’t think we will. I am cautiously optimistic.”

In July, New York averaged about 10 virus-related deaths a day, a huge drop from the 799 deaths over a 24-hour period at the peak of the outbreak in April. About 790 people are hospitalized, down from nearly 19,000 people a few months ago when hospitals were nearly overrun.

But New York officials are readying for a spike, however big or small, as states like Florida continue to report record number of cases — more than 12,000 on Monday — and others, like California, impose sweeping rollbacks of their reopening plans, forcing many businesses to close again.

Officials in New York — unlike in Connecticut and New Jersey, which also implemented a quarantine requirement — have sought to proactively enforce the quarantine order. The state instituted fines of up to $10,000 and made it legal to order people to self-isolate, if necessary.

But no fines or mandatory isolation orders have been issued in New York City since the order took effect on June 25, according to a city spokeswoman. Instead, both state and city officials have urged travelers to take the order seriously and are hoping visitors will comply voluntarily, as with similar executive orders mandating masks and social distancing.

Mr. Cuomo himself has acknowledged the difficulty of enforcing the mandate and the government’s limited reach, likening enforcement to “trying to catch water in a screen.”

“New York’s problem is we have the infection coming from other states back to New York,” Mr. Cuomo, a third-term Democrat, said on Monday, noting the state is not “a hermetically sealed bubble.”

Officials estimate about 12,000 people visit New York daily from the states on the quarantine list, which is updated regularly according to certain virus health metrics. The quarantine currently applies to travelers from a broad swath of mostly the West and South where cases have skyrocketed, including California, Florida and Texas. On Tuesday, Minnesota, New Mexico, Ohio and Wisconsin were added to the list and Delaware was removed.” (F)

“Monday brings a new stage of activity to the city, allowing some places to reopen outdoors, while many activities inside, like restaurant dining, will still be forbidden.

Mayor Bill de Blasio said the city would allow some outdoor entertainment venues like zoos and botanical gardens to reopen with limited capacities but that restrictions would remain on indoor activities.

We are moving forward with Phase 4 on Monday. Now, the state of New York is finishing some work today into this afternoon on the specifics, and they’ll have a formal announcement later on. But I can give you the broad outlines now of what we’ve talked about with the state. Let’s focus first on outdoors, again, outdoors has proven to be the area where we’re seeing a lot of things work successfully. So, we’re going to restart the low-risk outdoor arts and entertainment activities. This means things like botanical gardens and zoos, for example. They can reopen but at reduced capacity, 33 percent capacity. Production of movies, TV shows — that can proceed. The, obviously, something that matters to a lot of us, sports coming back. But again — without audiences. Indoors is where we have concerns. Some indoor activities can exist with the proper restrictions. But there’s going to be care when it comes to indoors. Each and every situation is going to be looked at very carefully, very individually. So some will not resume in Phase 4, certainly not right away. That continues to be, first of all, indoor dining. That could have started earlier. We’ve said that’s not happening. That continues to not happen. That is very high risk. And we’ve seen that around the country. Museums, not yet. Malls, not yet. Still closed for now. We’ve got to strike a balance, and we’ve got time to look at the evidence, watch what’s happened around the country, watch what’s happening here in the city, and make further decisions on some of these pieces. And we’ll do that very carefully with the state of New York.

Amid concerns about a coronavirus resurgence, New York City will enter a limited fourth phase of reopening on Monday, allowing some art and entertainment venues, like zoos and botanical gardens, to open for outdoor activities at a limited capacity, officials announced on Friday.

But stringent restrictions will remain on indoor activities: Gyms, malls, movie theaters and museums will remain shuttered, and indoor dining will still not be allowed.

“We’ve got to strike a balance, and we’ve got time to look at the evidence,” Mayor Bill de Blasio said at a news conference. “Watch what’s happening around the country, watch what’s happening here in the city and make further decisions on some of these pieces, and we will do that very carefully with the State of New York.”

Officials are increasingly concerned about the possibility that visitors from other states will spread the virus in New York, once the epicenter of the pandemic. Last month, Gov. Andrew M. Cuomo put in place an executive order that requires travelers from  states with high infection rates to quarantine for 14 days upon arrival.

But Mr. Cuomo said on Friday that the order might not be enough to fend off the virus, and reiterated that he was troubled by reports of New Yorkers, especially young people, letting their guard down and eschewing social-distancing and mask-wearing measures.

The governor announced new regulations on Thursday meant to crack down on outdoor drinking and mingling outside bars and restaurants. The new rules ban establishments from selling alcohol to customers who do not also buy food.

“It is inevitable that there will be a second wave,” Mr. Cuomo, a third-term Democrat, said in a conference call with reporters on Friday. “But the second wave is going to be the confluence of the lack of compliance and the local governments’ lack of enforcement, plus the viral spread coming back from the other states. It is going to happen.”

He added, “Just because it is not there today does not mean it’s not going to happen.”

New York City is the last part of the state to enter the final phase of reopening — a feat Mr. Cuomo described as “a hallmark.” Phase 4 permits groups of up to 50 people and indoor religious gatherings to operate at one-third of maximum capacity. Restrictions will also be eased to allow the resumption of outdoor film production and professional sports without audiences.

But concerned about the virus’s spreading more rapidly in dense and crowded New York City, Mr. Cuomo said that Phase 4 of reopening in the city would not restore any additional indoor activities — even though other regions of the state further along in reopening have done so, for example, by allowing indoor dining at up to half capacity.

Museums have also been permitted to open in upstate areas, and malls have been allowed to get back to business as long as they put in place specialized air filtration systems that can filter out virus particles.

The lack of uniformity in what is being allowed in different parts of the state has raised complaints from some buiness owners and patrons. Mr. Cuomo said the state would revisit the city’s relatively curtailed Phase 4 as the “facts change.”

The limits on indoor dining were a devastating blow for the city’s thousands of restaurants, many of which were expecting to supplement revenues from outdoor dining with the expected return of indoor dining at a reduced capacity.

Many restaurants are not making enough money with just takeout and outdoor dining, and are struggling to pay their current and back rent. Restaurants in neighborhoods like Midtown Manhattan that have been emptied of office workers are struggling more than those in residential neighborhoods.

“Extending the time frame for outdoor dining is critical, but long term, it won’t sustain the industry without financial support that needs to come from the federal government,” said Andrew Rigie, the executive director of the New York City Hospitality Alliance.

The cautious approach also upended the plans of several cultural institutions in New York City, including the Metropolitan Museum of Art and the Museum of the City of New York, both of which had announced intentions to reopen in a few weeks.

Still, four city zoos and the New York Botanical Garden have already announced they will open to the public at limited capacity by the end of the month.

Those openings are sure to give New York an added semblance of normalcy, even as small businesses and restaurants have struggled to operate on slim margins since the broad shutdown in mid-March.

Offices, hair salons, barbershops and construction sites have all opened, albeit with restrictions on capacity, strict cleaning requirements and mandatory social distancing.

More than 8,600 restaurants have set up outdoor dining operations, Mr. de Blasio said. The city will close off an additional 40 blocks to allow even more dining capacity, the mayor said, and extend the use of sidewalks and streets for outdoor dining through Oct. 31.

“A lot of people thought that ‘How could this place, this crowded, energetic place, possibly do shelter in place or social distancing or face coverings?’” said Mr. de Blasio, a Democrat. “Well, you proved to the world it could be done the right way, and that’s why we are now on the verge of Phase 4.” (G)

“State health officials confirmed 742 new coronavirus cases in Washington on Wednesday and 17 additional deaths linked to COVID-19.

According to the Department of Health, at least 372 patients are currently hospitalized with COVID-19 illnesses across Washington — an increase of 19 from the day before. Dr. Kathy Lofy, the state health officer, said the daily average for hospital admissions, while still well below the peak, is about double where it was in mid-May. The state continues to closely monitor hospital activity and occupancy, coordinate transfers and reprioritize distribution of protective gear to frontline workers as needed.

More than 4,884 new illnesses have been confirmed in Washington over the last seven days, representing a statewide case rate of 561.4 per 100,000 residents, according to the Centers for Disease Control and Prevention’s case tracker. The highest rate of cases by population continues to be seen in central Washington counties, particularly in Franklin, Adams and Yakima.

While a portion of the increase can be attributed to recent boosts in testing, other concerning trends continue to play a role.

“While we are doing more testing, we know that the number of cases is not simply due to more testing, but also a rate of increase in disease transmission as well,” said John Wiesman, the state secretary of health.

In King County, the effective reproductive number, a figure used to estimate how many people are infected by someone with the illness, is at 1.7 — above the target of one.

Wiesman said the state’s guidance on preventing the spread remains the same but must be followed by all to be effective: keep physical distance from others, interact with as few people as possible, maintain a “personal bubble” of a few people and wear face coverings in public spaces.

At least 43,046 people have now tested positive for COVID-19 in Washington. Nearly 734,000 Washingtonians have been tested for the virus, with 5.9 percent of tests coming back positive.

During a weekly telebriefing with reporters Wednesday, state health leaders pointed to early success in mask use in three counties where transmission rates have been alarmingly high.

Before the governor’s statewide mandate requiring masks inside businesses went into effect this month, it was required in just three counties with a large increase in cases: Benton, Franklin and Yakima. As the rules were put in place, the state asked each county to conduct surveys to track how well residents were complying with the directive.

A few weeks ago, Benton and Franklin counties had a 58 percent compliance rate. In the last week, that figure grew to 95 percent. In Yakima County, just 35 percent of those surveyed said they wore face coverings when the survey began. The latest results showed their rate of compliance also grew to 95 percent.

The state secretary of health said preliminary findings in Yakima County have coincided with a nearly 60 percent drop in transmission rates since early June.

A recent report from the Bellevue-based Institute for Disease Modeling shows significant progress must be made to curb the spread of the coronavirus if schools are to successfully reopen in the fall.

According to researchers, efforts to reduce spread in school buildings will not sufficiently suppress transmission on its own, if the rate of infection remains where it is now.

The report finds that community-wide mitigation efforts, including limited mobility, must improve before schools open in September, or risk triggering “exponential growth” in COVID-19 activity.

“Under a scenario in which mobility in the community increases to 80% of pre-COVID levels, none of the mitigating strategies in schools we explored would be able to reduce the effective reproductive number to one or below, meaning the epidemic will grow,” the authors wrote.” (H)

“Washington could be in for another round of coronavirus restrictions, Gov. Jay Inslee said Thursday, during a news conference where he announced a limit of 10 people at social gatherings in Washington counties that are further along in the reopening process.

Inslee’s announcement came as Washington set a new record for confirmed cases of the new coronavirus, with state health officials Thursday reporting 1,267 new cases and six additional deaths. The tally clocked in at nearly twice the average number of cases per day in the past two weeks.

Throughout Friday, on this page, we’ll be posting Seattle Times journalists’ updates on the outbreak and its effects on the Seattle area, the Pacific Northwest and the world. Updates from Thursday can be found here, and all our coronavirus coverage can be found here.

Washington Gov. Jay Inslee added a new state rule this week as COVID-19 cases surge in the state: There will now be a 10-person limit on social gatherings for counties that are in the third phase of Washington’s four-part coronavirus reopening plan.” (I)

“Under the “Safe Start” plan, individual counties are able to apply to the secretary of health to move between the phases or add new business activities. Counties are currently prohibited from applying to a new phase until at least July 28.

When applications are allowed, they must be submitted by a county executive. If a county does not have a county executive, it must be submitted with the approval of the County Council/Commission.

The Secretary of Health evaluates each application based on how their data compares to certain targets. Click here for a complete breakdown.

An individual county’s ability to respond to outbreaks, increased deaths, health system capacity and other factors are also considered.

The Secretary of Health can approve the plans as submitted, approve with modifications or can deny the application.

Here’s a breakdown of what is allowed in each phase:

Phase 1

High-risk populations: Continue to stay home, stay healthy.

Outdoor: Some outdoor recreation (hunting, fishing, golf, boating, hiking).

Gatherings: Religious organizations can now hold outdoor services with up to 100 people. Proper social distancing should be practiced and attendees should wear face coverings.

Travel: Only essential travel.

Business/Employers: Essential businesses open, including existing construction that meets agreed-upon criteria, landscaping, automobile sales, retail (curb-side pick-up orders only), car washes, pet walkers.

Phase 2

High-risk populations: Continue to stay home, stay healthy.

Outdoor: All outdoor recreation involving fewer than five people outside your household (camping, beaches, etc.)

Gatherings: Gather with no more than five people outside your household per week. Indoor religious gatherings can be held at 25% capacity or with less than 50 people, whichever is less.

Travel: Limited non-essential travel within proximity of your home.

Business/Employers: Remaining manufacturing, new construction, in-home/domestic services (nannies, housecleaning, etc.), retail (In-store purchases allowed with restrictions), real estate, professional services/office-based businesses (telework remains strongly encouraged), hair and nail salons/barbers, restaurants <50% capacity, with table sizes no larger than 5.

Phase 3

High-risk populations: Continue to stay home, stay healthy.

Outdoor: Outdoor group recreational sports activities (5-50 people), recreational facilities at <50% capacity (public pools, etc.). Beginning Monday, gatherings in phase three will be capped at no more than 10 people.

Gatherings: Allow gatherings with no more than 50 people.

Travel: Resume non-essential travel.

Business/Employers: restaurants <75% capacity/table size no larger than 10, bars at <25% capacity, movie theaters at <50% capacity, government (telework remains strongly encouraged), libraries, museums, all other business activities not yet listed except for nightclubs and events with greater than 50 people.

Phase 4

High-risk populations: Resume public interactions, with physical distancing

Outdoor: Resume all recreational activity.

Gatherings: Allow gatherings >50 people.

Travel: Continue non-essential travel.

Business/Employers: Nightclubs, concert venues, large sporting events, resume unrestricted staffing of worksites, but continue to practice physical distancing and good hygiene.

The state is using certain metrics to evaluate when and how to lift various restrictions. The five metrics being used are: COVID 19 disease activity; testing capacity and availability; case and contact investigations; risk to vulnerable populations, and health care system readiness.” (J)

“Leaving the nation’s coronavirus fight to individual states has created gaping holes in the public health response that have allowed the infection rate to soar and death rates to rise once again.

While countries like New Zealand and Germany have taken a unified national approach to fighting the virus — and are enjoying the fruits of a successful mitigation strategy — the Trump administration’s federalist philosophy has helped create chaos across the South and West.

Cash-strapped cities and states trying to create their own testing, tracing and public awareness campaigns from scratch are desperate for federal support as they grapple with questions about whether it’s safe for people to return to school and work, along with bars and beaches.

“Every governor is out there on his or her own working to build the same programs that are being built next door,” said Reed Schuler, a senior advisor to Democratic Washington Gov. Jay Inslee. “The federal government’s efforts range from a little bit of backup to not even being present.”

This dangerous new chapter of the coronavirus outbreak is intensifying calls from politicians and public health experts across the country for a set of national strategies to combat the virus.

The nursing home industry has been pushing for looser regulations for years. And they got what they wanted at the start of the pandemic. But now, advocates say lax standards are fueling the virus’ spread.

Arkansas’ entire congressional delegation — all Republicans — wrote Vice President Mike Pence this week asking the federal government to address shortages of chemical reagents needed to analyze coronavirus tests.

And New York Gov. Andrew Cuomo, a Democrat, expressed his frustration with the federal government’s pandemic response on Tuesday. “The White House doesn’t get it,” he tweeted. “Until we control this virus as a nation, the economy can’t fully recover. Where is the national plan?”

Rep. Greg Stanton (D-Ariz.), who represents hard-hit Maricopa County, expressed similar frustration. “How can you have national success without having a national plan?” he said. “How do you fight the worst pandemic in 100 years without a coordinated strategy?”

A White House official rejected such criticism. “We’re in a much better position now than we were at the beginning of the pandemic in terms of [personal protective equipment], ventilators, testing capacity, and vaccine and therapeutics development,” the official said.

The situation today is not as dire as it was in March and April in some ways. There are no shortages of ventilators, and doctors have more experience treating the virus. The country’s testing capacity has grown exponentially, and the death rate is lower thanks to concerted efforts to protect seniors and other vulnerable groups.

But with cases still rising, public health experts say much more federal support and leadership are needed to bring the outbreak under control — and keep it that way.

“We shut down the country for three months and we could have used that time for all kinds of planning and preparing, and we did not use it at all,” said David Eisenman, the director of the UCLA Center for Public Health and Disasters.

Once-isolated outbreaks have grown into a national calamity concentrated in the South and Sunbelt where governors took early victory laps. Now the virus is spreading northward into the heartland and industrial Midwest, erasing the progress made in March, April and May while the country was locked down.

With the death toll rising, several governors have reimposed restrictions on businesses and public life — a move they once described as a last resort. School districts in Arizona, California and North Carolina are delaying their return to in-person learning, despite the president’s threats to cut federal funding for districts that don’t fully reopen.

In many ways, the White House has positioned itself as a consultant to states as they battle the virus. Federal officials, including Vice President Mike Pence, have warned that the government’s Strategic National Stockpile is only a stopgap — and that states themselves are primarily responsible for securing masks, gowns, gloves and chemicals for testing on the open market.

Pence, White House coronavirus coordinator Deborah Birx and others have also gone on listening tours in states where cases are climbing the fastest. Federal officials have also worked to increase the country’s testing capacity from hundreds of thousands to millions of samples per week.

But the lack of stronger federal oversight has made it hard to maintain some of those gains.

Commercial labs like Quest Diagnostics, which are handling about half of all tests, have not been able to keep up with the spike in demand. It now takes a week for people to get their results in some places, and labs say they are having trouble getting basic supplies.

Oregon Gov. Kate Brown says her state’s testing capacity has been overwhelmed by the recent surge in infections. The state is now averaging more than 270 new coronavirus cases a day — a three-fold increase compared with a month ago.

“We could certainly use an assist from our federal partners,” Brown said. But her administration has been frustrated by the lukewarm responses it has received from the Trump administration.

Her next-door neighbor, Inslee, is one of several governors to call for a national testing strategy. In recent weeks, Washington state has struggled to buy enough swabs to collect patient samples and chemical reagents to test them.

And the federal government’s failure to fully use the Defense Production Act to increase available supplies and coordinate their distribution has put states like Washington in the “horrible position” of competing against one another, Schuler said.

“We have an obligation to the residents of Washington to ensure our labs are fully supplied, but we don’t want it to come at the expense of a less successful state,” he said.

In its letter this week to Pence, the Arkansas congressional delegation said that the ongoing shortages of testing reagents have prompted the state to consider abandoning its requirement for people to be tested for Covid-19 before undergoing elective surgery.

The testing problems are also hampering the country’s scattered and overwhelmed contact tracing efforts. Nationwide, there are fewer than a third of the 100,000 contact tracers that the Association of State and Territorial Health Officials estimates are necessary to contain the outbreak.

Nearly six months into the pandemic, some states are still struggling to get their programs off the ground. Others have abandoned location-tracking apps that were supposed to help scale contact tracing to unprecedented levels.

“You need federal leadership, and that’s been lacking,” said former CDC Director Tom Frieden, who, for months has been calling for the federal government to expand testing and provide support for people asked to quarantine at home.

Eisenman said the federal government should have used the spring lockdown to appoint expert commissions to address issues such as setting up contact tracing, distributing testing supplies and returning children to school safely.

Testing and contact tracing are the cornerstones of the test-trace-isolate strategy that governments have used to thwart infectious disease outbreaks since the 19th century. But many understaffed and underfunded local health departments have not been able to adequately expand the small workforces they usually use to track outbreaks of measles and sexually transmitted infections to combat the coronavirus pandemic.

Alabama only has about 200 contact tracers to investigate the more than 1,000 coronavirus cases diagnosed there each day. Most of those workers have been reassigned from other public health duties, such as restaurant inspections and immunizations. They are currently trading off in 10-day rotations between tracking coronavirus cases and their other work — meaning both are suffering. And with schools in the state set to reopen next month, the burden will only increase.

Ricardo Franco, an assistant professor of medicine at the University of Alabama at Birmingham, says the shortage of tracers is allowing the state’s outbreak to spiral out of control.

“If you asked me what we need, I would say we should have 5,000 contact tracers,” he said. “That would be the responsible thing to do.”

Washington state, which was among the first states hit by the virus, says that only 7 percent of the gowns, gloves and face shields it has handed out came from the federal government. The state has had to compete with other states and countries to purchase the rest itself.

“It’s jaw dropping that after what we’ve been through, we didn’t have hundreds of millions of face masks and other PPE stockpiled around the country,” said Irwin Redlener, founding director for the National Center for Disaster Preparedness at Columbia University.

Even as governors who once scoffed at fears they reopened their economies too quickly begin to reimpose restrictions, the White House is still struggling to put out a consistent message about the threat posed by the virus and how best to combat it.

Trump on Monday attacked his own administration’s public health officials, retweeting messages that suggested the CDC is lying about the virus and concern about the pandemic is overblown for political reasons, prompting top officials to defend themselves on national television.

John Henderson, president and CEO of The Texas Organization of Rural & Community Hospitals, said the lack of coordinated national coronavirus messaging has been compounded in states like Texas where governors, following Trump’s lead, took a laissez faire approach until cases skyrocketed.

“There’s just been a leadership void at the federal level,” he said. “We have pushed everything down to the states and then conservative states, like Texas, have just pushed all that decision-making down to the local level. … Every day that we go with a crisis and without a plan is another day lost.” (K)

“White House Press Secretary Kayleigh McEnany on Thursday emphasized that schools reopening this fall shouldn’t be contingent on science surrounding coronavirus, but then claimed the “science is on our side here” as the pandemic continues unabated.

In response to a question about what President Donald Trump would say to parents who have kids in school districts that may be online-only, McEnany said: “The president has said unmistakably that he wants schools to open. And when he says open, he means open in full, kids been able to attend each and every day at their school.

“The science should not stand in the way of this,” she added, saying it is “perfectly safe” to fully reopen all classrooms.

McEnany then claimed “science is on our side,” citing one study that said the risk of critical illness is less than the seasonal flu in children. She also quoted former Stanford Neuroradiology Chief Dr. Scott Atlas, who has appeared on Fox News to call the debate around reopening schools “hysteria.”

“We encourage localities and states to just simply follow the science, open our schools,” she continued.

The Trump administration has been pushing to reopen schools under the premise that children under the age of 18 “are at very low risk” if they catch the virus.

Some experts have expressed concerns about returning to classrooms because of the risk students could carry the virus home to older relatives. Education professionals have also expressed worry they may be in harms way.” (L)

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CORONOVIRUS TRACKING Links to Parts 1-39

CORONOVIRUS TRACKING

Links to Parts 1-39

Doctor, Did You Wash Your Hands?®

http://doctordidyouwashyourhands.com/

Curated Contemporaneous Case Study Methodology

Jonathan M. Metsch, Dr.P.H.

https://www.mountsinai.org/profiles/jonathan-m-metsch

PART 1. January 21, 2020. CORONAVIRUS. “The Centers for Disease Control and Prevention on Tuesday confirmed the first U.S. case of a deadly new coronavirus that has killed six people in China.”

PART 2. January 29, 2020. CORONAVIRUS. “If it’s not contained shortly, I think we are looking at a pandemic..”….. “With isolated cases of the dangerous new coronavirus cropping up in a number of states, public health officials say it is only a matter of time before the virus appears in New York City.”

PART3. February 3, 2020. “The Wuhan coronavirus spreading from China is now likely to become a pandemic that circles the globe…”..Trump appeared to downplay concerns about the flu-like virus …We’re gonna see what happens, but we did shut it down..” (D)

PART 4. February 9, 2020. Coronavirus. “A study published Friday in JAMA found that 41% of the first 138 patients diagnosed at one hospital in Wuhan, China, were presumed to be infected in that hospital.….

PART 5. February 12, 2020. CORONAVIRUS. “In short, shoe-leather public health and basic medical care—not miracle drugs—are generally what stop outbreaks of emerging infections..”

POST 6. February 18, 2020.  Coronovirus. “Amid assurances that the (ocean liner) Westerdam was disease free, hundreds of people disembarked in Cambodia…” “ One was later found to be infected”…. “Over 1,000… passengers were in…transit home”…. “This could be a turning point””

PART 7. February 20, 2020. CORONAVIRUS. With SARS preparedness underway in NJ LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.

PART 8. February 24, 2020. CORONAVIRUS. “…every country’s top priority should be to protect its health care workers. This is partly to ensure that hospitals themselves do not become sites where the coronavirus is spread more than it is contained.”

PART 9. February 27, 2020. CORONAVIRUS. Responding to a question about the likelihood of a U.S. outbreak, President Trump said, “I don’t think it’s inevitable…”It probably will. It possibly will,” he continued. “It could be at a very small level, or it could be at a larger level.”

Part 10. March 1, 2020. CORONAVIRUS. Stop Surprise Medical Bills for Coronavirus care. (&) Lessons Learned (or not) In California and Washington State from community acquired cases.

PART 11. March 5, 2020.  CORONAVIRUS. “Gov. Andrew Cuomo… would require employers to pay workers and protect their jobs if they are quarantined because of the coronavirus.”

Part 12. March 10, 2020. CORONAVIRUS. “Tom Bossert, Donald Trump’s former homeland security advisor…(said) that due to the coronavirus outbreak, “We are 10 days from the hospitals getting creamed.”

Part 13.. March 14, 2020. CORONAVIRUS. “If I’m buying real estate in New York, I’ll listen to the President….If I’m asking about infectious diseases, I’m going to listen to Tony Fauci,”

PART 14. March 17, 2020. CORONAVIRUS. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”

PART 15. March 22, 2020. CORONAVIRUS. “…Crimson Contagion” and imagining an influenza pandemic, was simulated by the Trump administration….in a series of exercises that ran from last January to August.

PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT

PART 17. April 2, 2020. CORONAVIRUS. Florida allows churches to continue holding services. Gun stores deemed “essential.”  “New York’s private and public hospitals unite to manage patient load and share resources.

PART 18. April 9, 2020. CORONAVIRUS. “The federal government’s emergency stockpile of personal protective equipment (PPE) is depleted, and states will not be receiving any more shipments, administration staff told a House panel.

PART 19. April 13, 2020 CORONOAVIRUS. “…overlooked in the United States’ halting mobilization against the novel coronavirus: the personal aides, hospice attendants, nurses and occupational or physical therapists who deliver medical or support services to patients in their homes.”

PART 20. April 20, 2020. CORONAVIRUS. “…nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence.”

PART 21. April 23, 2020. CORONAVIRUS. “We need to ask, are we using ventilators in a way that makes sense for other diseases but not this one?”

POST 22. April 29, 2020. CORONAVIRUS. ..the “ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries[JM1] ….”

POST 23. May 3, 2020. CORONAVIRUS. … what Dr. Fauci really wants,…”is just to go to a baseball game. That will have to wait. The level of testing for the virus is not adequate enough to allow for such mass gatherings.’ (K)

POST 24. May 7, 2020. CORONAVIRUS. Former New Jersey governor Chris Christie said: “there are going to be deaths no matter what”… but that people needed to get back to work.

POST 25. May 10, 2020, CORONAVIRUS. “It is scary to go to work,” said Kevin Hassett, a top economic adviser to the president. “I think that I’d be a lot safer if I was sitting at home than I would be going to the West Wing.”

POST 26. May 14, 2020. CORONAVIRUS, “Deep cleaning is not a scientific concept”….”there is no universal protocol for a “deep clean” to eradicate the coronavirus”

POST 27. May 19, 2020. CORONAVIRUS. “Hospital…executives…are taking pay cuts…to help offset the financial fallout from COVID-19.” As “front line” layoffs and furloughs accelerate…

POST 28. May 23, 2020. CORONAVIRUS. ““You’ve got to be kidding me,”..”How could the CDC make that mistake? This is a mess.” CDC conflates viral and antibody tests numbers.

PART 29. May 22, 2020. CORONAVIRUS. “The economy did not close down. It closed down for people who, frankly, had the luxury of staying home,” (Governor Cuomo). But not so for frontline workers!

POST 30. June 3,202. CORONAVIRUS. “The wave of mass protests across the United States will almost certainly set off new chains of infection for the novel coronavirus, experts say….

POST 31. June 9, 2020. CORONAVIRUS. “I think we had an unintended consequence: I think we made people afraid to come back to the hospital,”

Post 32. June 16, 2020. CORONAVIRUS. Could the Trump administration be pursuing herd immunity by “inaction”?  “ If Fauci didn’t exist, we’d have to invent him.”

POST 33. June 21, 2002. CORONAVIRUS….. Smashing (lowering the daily number of cases) v. flattening the curve (maintaining a plateau)

POST 34. June 26, 2020. CORONAVIRUS. CDC Director Redfield… “the number of coronavirus infections…could be 10 times higher than the confirmed case count — a total of more than 20 million.” As Florida, Texas and Arizona become eipicenters!

POST 35. June 29, 2020. CORONAVIRUS. Pence: “We slowed the spread. We flattened the curve. We saved lives..”  While Dr. Fauci “warned that outbreaks in the South and West could engulf the country…”

POST 36. July 2, 2020. CORONAVIRUS. “There’s just a handful of interventions proven to curb the spread of the coronavirus. One of them is contact tracing, and “it’s not going well,” (Dr. Anthony Fauci)..

POST 37. June 8, 2020. CORONAVIRUS. When “crews arrive at a hospital with a patient suspected of having COVID-19, the hospital may have a physical bed open for them, but not enough nurses or doctors to staff it.”

POST 38. July 15, 2020. CORONAVIRUS. Some Lessons Learned, or not. AdventHealth CEO Terry Shaw: I wouldn’t hesitate to go to Disney as a healthcare CEO — based on the fact that they’re working extremely hard to keep people safe,” (M)

POST 39. July, 23,2020. CORONAVIRUS. A Tale of Two Cities. Seattle becomes New York (rolls back reopening) while New York becomes Seattle (moves to partial phase 4 reopening)

July 21, 2020


 [JM1]

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