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)

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“Dr. Camilla Rothe was about to leave for dinner when the government laboratory called with the surprising test result. Positive. It was Jan. 27. She had just discovered Germany’s first case of the new coronavirus.

But the diagnosis made no sense. Her patient, a businessman from a nearby auto parts company, could have been infected by only one person: a colleague visiting from China. And that colleague should not have been contagious.

The visitor had seemed perfectly healthy during her stay in Germany. No coughing or sneezing, no signs of fatigue or fever during two days of long meetings. She told colleagues that she had started feeling ill after the flight back to China. Days later, she tested positive for the coronavirus.

Scientists at the time believed that only people with symptoms could spread the coronavirus. They assumed it acted like its genetic cousin, SARS.

“People who know much more about coronaviruses than I do were absolutely sure,” recalled Dr. Rothe, an infectious disease specialist at Munich University Hospital…

Interviews with doctors and public health officials in more than a dozen countries show that for two crucial months — and in the face of mounting genetic evidence — Western health officials and political leaders played down or denied the risk of symptomless spreading. Leading health agencies including the World Health Organization and the European Center for Disease Prevention and Control provided contradictory and sometimes misleading advice. A crucial public health discussion devolved into a semantic debate over what to call infected people without clear symptoms.

The two-month delay was a product of faulty scientific assumptions, academic rivalries and, perhaps most important, a reluctance to accept that containing the virus would take drastic measures. The resistance to emerging evidence was one part of the world’s sluggish response to the virus.

It is impossible to calculate the human toll of that delay, but models suggest that earlier, aggressive action might have saved tens of thousands of lives. Countries like Singapore and Australia, which used testing and contact-tracing and moved swiftly to quarantine seemingly healthy travelers, fared far better than those that did not….

It is also painfully clear that time was a critical commodity in curbing the virus — and that too much of it was wasted.”  (A)

“Early on, the dozen federal officials charged with defending America against the coronavirus gathered day after day in the White House Situation Room, consumed by crises. They grappled with how to evacuate the United States consulate in Wuhan, China, ban Chinese travelers and extract Americans from the Diamond Princess and other cruise ships.

The members of the coronavirus task force typically devoted only five or 10 minutes, often at the end of contentious meetings, to talk about testing, several participants recalled. The Centers for Disease Control and Prevention, its leaders assured the others, had developed a diagnostic model that would be rolled out quickly as a first step.

But as the deadly virus spread from China with ferocity across the United States between late January and early March, large-scale testing of people who might have been infected did not happen — because of technical flaws, regulatory hurdles, business-as-usual bureaucracies and lack of leadership at multiple levels, according to interviews with more than 50 current and former public health officials, administration officials, senior scientists and company executives.

The result was a lost month, when the world’s richest country — armed with some of the most highly trained scientists and infectious disease specialists — squandered its best chance of containing the virus’s spread. Instead, Americans were left largely blind to the scale of a looming public health catastrophe.

The absence of robust screening until it was “far too late” revealed failures across the government, said Dr. Thomas Frieden, the former C.D.C. director. Jennifer Nuzzo, an epidemiologist at Johns Hopkins, said the Trump administration had “incredibly limited” views of the pathogen’s potential impact. Dr. Margaret Hamburg, the former commissioner of the Food and Drug Administration, said the lapse enabled “exponential growth of cases.”…

Alex M. Azar II, who led the Department of Health and Human Services, oversaw the two other agencies and coordinated the government’s public health response to the pandemic. While he grew frustrated as public criticism over the testing issues intensified, he was unable to push either agency to speed up or change course.

The lack of tests in the states also meant local public health officials could not use another essential epidemiological tool: surveillance testing. To see where the virus might be hiding, nasal swab samples from people screened for the common flu would also be checked for the coronavirus.” (G)

“By using ventilators more sparingly on Covid-19 patients, physicians could reduce the more-than-50% death rate for those put on the machines, according to an analysis published Tuesday in the American Journal of Tropical Medicine and Hygiene.

The authors argue that physicians need a new playbook for when to use ventilators for Covid-19 patients — a message consistent with new treatment guidelines issued Tuesday by the National Institutes of Health, which advocates a phased approach to breathing support that would defer the use of ventilators if possible.

As the pandemic has flooded hospitals with a disease that physicians had never before seen, health care workers have had to figure out treatment protocols on the fly. Starting this month, a few physicians have voiced concern that some hospitals have been too quick to put Covid-19 patients on mechanical ventilators, that elderly patients in particular may have been harmed more than helped, and that less invasive breathing support, including simple oxygen-delivering nose prongs, might be safer and more effective.

The new analysis, from an international team of physician-researchers, supports what had until now been mainly two hunches: that some of the Covid-19 patients put on ventilators didn’t need to be, and that unusual features of the disease can make mechanical ventilation harmful to the lungs.

“This is one of the first coherent, comprehensive, and reasonably clear discussions of the pathophysiology of Covid-19 in the lungs that I’ve seen,” said palliative care physician Muriel Gillick of Harvard Medical School, who was one of the first to ask if ventilators were harming some Covid-19 patients, especially elderly ones. “There is mounting evidence that lots of patients are tolerating fairly extreme” low levels of oxygen in the blood, suggesting that such hypoxemia should not be equated with the need for a ventilator.

But using low levels of blood oxygen (hypoxemia) as a sign that a patient needs mechanical ventilation can lead physicians astray, they argue, because low blood oxygen in a Covid-19 patient is not like low blood oxygen in other patients with, for instance, other forms of pneumonia or sepsis.

The latter typically gasp for breath and can barely speak, but many Covid-19 patients with oxygen levels in the 80s (the high 90s are normal) and even lower are able to speak full sentences without getting winded and in general show no other signs of respiratory distress, as their hypoxemia would predict.

Related: With ventilators running out, doctors say the machines are overused for Covid-19

“In our personal experience, hypoxemia … is often remarkably well tolerated by Covid-19 patients,” the researchers wrote, in particular by those under 60. “The trigger for intubation should, within certain limits, probably not be based on hypoxemia but more on respiratory distress and fatigue.”…

There is a growing recognition that some Covid-19 patients, even those with severe disease as shown by the extent of lung infection, can be safely treated with simple nose prongs or face masks that deliver oxygen.The latter include CPAP (continuous positive airway pressure) masks used for sleep apnea, or BiPAP (bi-phasic positive airway pressure) masks used for congestive heart failure and other serious conditions. CPAP can also be delivered via hoods or helmets, reducing the risk that patients will expel large quantities of virus into the air and endanger health care workers. (B)

Targeting the kidneys. “Despite attempts to move away from ventilators, some COVID-19 patients still need them. As the pandemic has progressed, it’s become apparent that coronavirus patients on ventilators need special care.

When patients are put on a ventilator, they’re often given diuretics to get rid of extra fluid in the body. Lungs that need help need to be “dry” to function properly. When they’re wet, “they can’t move oxygen as well,” Denson said.

But the coronavirus has since proved it’s not a simple respiratory illness. It can affect the lungs, the brain, the blood and, critically for patients on ventilators, the kidneys.

Unlike lungs, kidneys prefer to be hydrated. The longer patients are kept dehydrated, their chances of kidney failure increase. Denson said he’s changed his treatments for COVID-19 patients to give additional hydration if they’re showing damage to the kidneys.

“I’m targeting the kidneys a little bit more,” he said. “I’m less aggressive up front getting people dry, and I’m more willing to use fluids if needed.”

It’s a balancing act that requires extreme attention on the part of ICU doctors and their staff. Too much hydration hurts the lungs. Too little hurts the kidneys. “It’s a constant battle,” Denson said.

Medications. When doctors faced the first surge of severely ill COVID-19 patients, no drugs had been shown to work against the virus, making treatment more challenging. As a result, doctors were willing to try certain medications based on limited evidence.

Early on in the pandemic, the drug hydroxychloroquine emerged as a potential treatment, following two studies that suggested it might be beneficial. As a result, many patients were given the drug, which is already approved for malaria and rheumatoid arthritis. But doctors soon found the drug was not useful in treating COVID-19, and subsequent research has shown it does not appear to help.

Now, doctors in ICUs are turning to the drug remdesivir. It’s not a cure, but it’s the only treatment that’s been shown in a clinical trial to have an effect on the illness so far.” (C)

“The Strategic National Stockpile, a once little-known resource, has turned into a political tug-of-war as states scramble for gowns, masks, ventilators and other equipment during the coronavirus pandemic.

But it was never intended to be able to meet massive, simultaneous demand from 50 states, its former director said.

“The Strategic National Stockpile is great as a fallback” that can be tapped after private sector supplies and state and local government supplies are exhausted, said Greg Burel, who is now president and principal consultant at Hamilton Grace, a consulting firm focused on preparedness and response.

“From what I’ve been seeing, and you’ve probably seen the same thing, it seems like almost from day one, everybody’s turned and looked at the SNS,” Burel said in an interview with POLITICO.

President Donald Trump has blamed the Obama administration for not refilling the reserve. “The previous administration, the shelves were empty. The shelves were empty,” Trump said last week.

However, the stockpile has also been underfunded for years, including during the Trump administration. The latest congressional appropriations enacted in November allotted about $700 million.

“What we had told Congress at the time though is that to get everything on the shelf that we wanted on the shelf at the time, that we needed a little over $1 billion in one appropriation and then we could smooth that out over the years,” Burel said.

The Trump administration’s official budget request for the SNS in fiscal 2020 was $705 million, or $95 million more than Congress approved for the prior year.

During the Obama administration, annual funding levels ranged around $500 million to $600 million. The Trump administration initially followed that pattern, requesting $575 million for the stockpile for both fiscal 2018 and 2019.

With the stockpile now quickly burning through badly needed supplies, Congress included $16 billion for the SNS in H.R. 748 (116), the $2 trillion coronavirus virus relief package that passed last month.

Burel noted that the added money won’t go that far because of the many ventilators that the SNS has sent to states that will need to be replaced or repaired at great expense when the current crisis is over. In addition, the stockpile’s pre-crisis supplies of masks, gloves and other personal protective equipment are nearly, if not completely, gone.

“There are a large number of materials that we have invested in for a number of years that by the end of this event will be completely gone,” Burel said. “A bunch of that $16 billion is just going to be eaten up with replacing what’s going out, recovering what’s gone out, cleaning it and putting back on the shelves — and then to manage a future vaccine campaign.”…

All of the SNS supplies that are “clearly useful in this particular event” have probably been distributed through allocations based on each state’s population, Burel said. But Burel said there is no reason to doubt the stockpile still has supplies for its original mission, responding to the chemical, biological and nuclear events….

The coronavirus pandemic has exposed the need for all elements of the emergency response network to keep more supplies on hand, Burel said.

That potentially means both manufacturers and hospitals keeping 60 to 90 days’ worth of personal protective equipment on hand, as well as state and local governments beefing up their own supplies.

Congress should also “fully fund” the SNS to ensure it has the supplies it needs to respond to pandemics and other threats, although it will never be able to respond to all eventualities, Burel said.

The emergency response veteran also said he favors producing more of the material in the United States and supplementing that with imported supplies.

“There has to be that swell of safety stock. We can’t fight this kind of pandemic event that has disrupted the supply chain beyond what the normal usage is unless there is some stock somewhere,” Burel said.”” (D)

“How many people are likely to die in the United States of Covid-19? How many hospital beds is the country going to need? When will case numbers peak?

To answer those questions, many hospital planners, media outlets, and government bodies — including the White House — relied heavily on one particular model out of the many that have been published in the past two months: the University of Washington’s Institute for Health Metrics and Evaluation (IHME).

The model first estimated in late March that there’d be fewer than 161,000 deaths total in the US; in early April, it revised its projections to say the total death toll through August was “projected to be 60,415” (though it acknowledged the range could be between 31,221 and 126,703).

The model has been cited often by the White House and has informed its policymaking. But it may have led the administration astray: The IHME has consistently forecast many fewer deaths than most other models, largely because the IHME model projects that deaths will decline rapidly after the peak — an assumption that has not been borne out.

On Wednesday, the US death count passed the 60,000 mark that the IHME model had said was the likely total cumulative death toll. The IHME on April 29 released a new update raising its estimates for total deaths to 72,433, but that, too, looks likely to be proved an underestimate as soon as next week. Even its upper bound on deaths — now listed as 114,228 by August — is questionable, as some other models expect the US will hit that milestone by the end of May, and most project it will in June.

One analysis of the IHME model found that its next-day death predictions for each state were outside its 95 percent confidence interval 70 percent of the time — meaning the actual death numbers fell outside the range it projected 70 percent of the time. That’s not great! (A recent revision by IHME fixed that issue; more on this below.)

This track record has led some experts to criticize the model. “It’s not a model that most of us in the infectious disease epidemiology field think is well suited” to making projections about Covid-19, Harvard epidemiologist Marc Lipsitch told reporters.

But if that’s the case, how has it risen to such prominence among policymakers? Other models have done better than IHME’s at predicting the course of the epidemic, and many of them use approaches epidemiologists believe are more promising. Yet it’s the IHME model that has generally guided policymakers, for the most part, in the direction of focusing on a return to normal.

One potential explanation for its outsize influence: Some of the factors that make the IHME model unreliable at predicting the virus may have gotten people to pay attention to it. For one thing, it’s more simplistic compared to other models. That means it can be applied in ways more complicated models could not, such as providing state-level projections (something state officials really wanted), which other modelers acknowledged that they didn’t have enough data to offer.

Meanwhile, its narrow confidence intervals for state-by-state estimates meant it had quotable (and optimistic) topline numbers. A confidence interval represents a range of numbers wherein the model is very confident the true value will lie. A narrow range that gives “an appearance of certainty is seductive when the world is desperate to know what lies ahead,” a criticism of the IHME model published in the Annals of Internal Medicine argued. But the numbers and precise curves the IHME is publishing “suggests greater precision than the model is able to offer.”

The criticism of the IHME model, and an emerging debate over epidemiology models more broadly, has brought to light important challenges in the fight against the coronavirus. Good planning requires good projections. Models are needed to help predict resurgences and spot a potential second wave. Dissecting what the IHME model got wrong, what other models got right, and how the public and policymakers read these models is essential work in order to create the best pandemic plans possible.

What’s wrong with the IHME model of the coronavirus?”  (E)

“When it became clear coronavirus had made its way to the United States in late January and was likely to spread around the country, many Americans purchased masks as a way to protect themselves from the disease. After all, they were told the virus is a respiratory illness that enters the body through the nose and mouth. They took proactive measures to protect themselves from getting sick.

But on Feb. 29, U.S. Surgeon General Jerome Adams took to Twitter to shame individuals doing their best to keep themselves out of clinics and the hospital. Keep in mind, this was more than two weeks before the federal government announced official social distancing and stay-at-home guidelines on March 16.

“Seriously people- STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk!” he screamed through his keyboard.

We were told then that masks don’t work and that Americans shouldn’t be wearing them. At the same time, government officials were telling us they needed personal protective equipment (PPE) for doctors, nurses and others working in hospitals with cases of the disease. This PPE included masks. The illogical argument being made at the time was that masks protect doctors, but not the general public.

This argument appears to have been made in order to prevent a run on medical grade masks used by those on the front lines treating the disease, but the logic then, and now, made no sense. Masks only protect doctors? Really?

“The masks are important for someone who’s infected to prevent them from infecting someone else. Now, when you see people and look at the films in China, South Korea or whatever everybody is wearing a mask. Right now in the United States, people should not be walking around with masks,” Anthony Fauci told “60 Minutes” on March 8. “There’s no reason to be walking around with a mask. When you’re in the middle of an outbreak, wearing a mask might make people ‘feel a little better’ and it might even block a droplet but it’s not providing the perfect protection the people think that it is. And often, there are unintended consequences. People keep fiddling with the mask and they keep touching their face.”

“When you think masks you should think of health care providers needing them, and people who are ill,” Fauci continued. “I’m not against it, if you want to do it. It can lead to a shortage for people who really need it.”

Again, masks work as protection for health care providers, but not regular people exposed to the disease at the grocery store?

Then on April 6, “in the middle of an outbreak” and the height of stay-at-home orders, federal government officials stressed a mask was not a replacement for social distancing, but could help protect people from getting sick or spreading the disease to others.

“CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission,” the Centers for Disease Control and Prevention published. “The cloth face coverings recommended are not surgical masks or N-95 respirators.  Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance.” “(F)

“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.

All along, the United States has struggled with issues tied to testing. In February, the federal government shipped a tainted testing kit to states, delaying a broader testing strategy and leaving states blind to a virus that was already beginning to circulate. Later, testing supplies became a choke point, and states called on the federal government to use the Defense Production Act to force additional production.” “(L)

“All 50 states have moved to reopen their economies, at least partially, after shutting down businesses and gatherings in response to the coronavirus pandemic.

But a Vox analysis suggests that most states haven’t made the preparations needed to contain future waves of the pandemic — putting themselves at risk for a rise in Covid-19 cases and deaths should they continue to reopen, which some states have already seen.

Experts told me states need three things to be ready to reopen. State leaders, from the governor to the legislature to health departments, need to ensure the SARS-CoV-2 virus is no longer spreading unabated. They need the testing capacity to track and isolate the sick and their contacts. And they need the hospital capacity to handle a potential surge in Covid-19 cases.

More specifically, states should meet at least five basic criteria. They should see a two-week drop in coronavirus cases, indicating that the virus is actually abating. They should have fewer than four daily new cases per 100,000 people per day — to show that cases aren’t just dropping, but also below dangerous levels. They need at least 150 new tests per 100,000 people per day, letting them quickly track and contain outbreaks. They need an overall positive rate for tests below 5 percent — another critical indicator for testing capacity. And states should have at least 40 percent of their ICU beds free to actually treat an influx of people stricken with Covid-19 should it be necessary.

These metrics line up with a range of expert recommendations, as well as the various policy plans put out by both independent groups and government officials to deal with the coronavirus.

Meeting these metrics doesn’t mean that a state is ready to reopen its economy — a process that describes a wide range of local and state actions. And failing them doesn’t mean a state is in immediate danger of a coronavirus outbreak if it starts to reopen; with Covid-19, there’s always an element of luck and other factors.

But with these metrics, states can gauge if they have repressed the coronavirus while building the capacity to contain future outbreaks should they come. In other words, the benchmarks show how ready states are for the next phase of the fight.

So far, most states are not there. As of July 8, just four states — Connecticut, New Hampshire, New Jersey, and New York — met four or five of the goals, which demonstrates strong progress. Fifteen states and Washington, DC, hit two or three of the benchmarks. The other 31 achieved zero or one.” (H)

“Official figures show the US has had the largest and most deadly outbreak, exacerbated by a slow initial response, mismanagement of testing and poor coordination between states and the federal government.

“As this outbreak has demonstrated, you can have the best labs in the world, the best notification systems and software, but if you don’t have the appropriate governance of when to use these powers … they don’t function,” Phelan says….

Its successful execution requires extraordinary public trust in their governments, says Lars Trägårdh, a Swedish historian who studies trust in institutions over time. “If you trust the government is working for your good, and you trust other citizens to follow the rules, you have huge advantages for collective action,” he says….

Over the next months, governments are going to allow people to resume their lives amid the worst economic conditions since the Great Depression. Should new waves of the virus be detected, states may again ask their citizens to return home.

Managing this is going to require significant stores of public trust, that in some places are quickly eroding. “If people agree to do something in the long term, without a threat hanging over their heads, they are more likely to keep doing it,” Trägårdh says. “The alternative is fear, distrust, and chaos, and that isn’t good, no matter what the policy might be.”…

“Leaders such as Trump deploy simple messages: insider versus outsider, us versus them,” says Sanjoy Chakravorty, a professor at Temple University in the US, who studies the politics of information. “And they are having an ideological crisis in how to manage the message here. This is a very complicated information sphere, which you can’t put into ‘us and them’ boxes … because in this case everybody is the ‘us’.”

Rather than rewarding bravado, the moment appears to favour leaders who can be honest about the uncertainty inherent in fighting a virus, says Kathleen Bachynski, an assistant professor of public health at Muhlenberg College. “If leaders are not willing or able to be honest about these limitations, there will be this loss of credibility – and it won’t be because they are wrong, it’s because information is changing.”

Those overseeing some of the more successful responses, such as Germany’s Angela Merkel or Jacinda Ardern of New Zealand, have been praised for their ability to project empathy and communicate complex ideas.”  (I)

2. Twelve key lessons

2.1. Transparency is vital

2.2. Successful responses hinge on decisive leadership

2.3. We need unified responses to pandemics rather than diverse disconnected strategies

2.4. Effective communication must occur at the highest political levels

2.5. The European Union, and other regional blocs, must assume a greater health role

2.6. Global solidarity is the only way to win the war against COVID-19

2.7. The WHO has done a lot given the resources it has, but there is much room for improvement. It must now focus its activities, expand its remit and enhance its operational capacity

2.8. Existing global insurance institutions and policies are inadequate, and these require significant changes and improvements

2.9. Efforts to develop COVID-19 vaccines and treatments are commendable, but there is still much more to do

2.10. We need to test the responsiveness and resilience of health systems and make changes and improvements based on the results

2.11. Accountability is critical for building trust and for sound, inclusive decision making

2.12. There are opportunities to introduce novel approaches, such as using robots and artificial intelligence (AI), in this – and in future – pandemic response

3. Conclusion

Now that SARS-CoV-2 has become a pandemic with close to five million cases and over 300,000 deaths as a result of the virus, the case for investing in health systems, human resources, and health technologies is clear. It is also easy to see that in the past decade, austerity policies have cut investments in health and these systems have too often been reduced or ignored. While it is essential to cut waste within health systems, this pandemic highlights the need to have adequate capacity to address and tackle a crisis. It is also a reminder of the strategic importance of publicly accountable health systems, underpinned by investment in people and technologies. We must continue to build upon the lessons learned so far from the management of COVID-19 and adjust our approaches to this pandemic, and to other future health and environmental crises, accordingly. (J)

“……..there are several different scenarios for the future of the COVID-19 pandemic, and some of these are consistent with what occurred during past influenza pandemics. These can be summarized as follows and are illustrated in the figure below.

¤ Scenario 1: The first wave of COVID-19 in spring 2020 is followed by a series of repetitive smaller wavesthat occur through the summer and then consistently over a 1- to 2-year period, gradually diminishingsometime in 2021. The occurrence of these waves may vary geographically and may depend on whatmitigation measures are in place and how they are eased. Depending on the height of the wave peaks, this cenario could require periodic reinstitution and subsequent relaxation of mitigation measures over the next 1 to 2 years.

¤ Scenario 2: The first wave of COVID-19 in spring 2020 is followed by a larger wave in the fall or winter of 2020 and one or more smaller subsequent waves in 2021. This pattern will require the reinstitution of mitigation measures in the fall in an attempt to drive down spread of infection and prevent healthcare systems from being overwhelmed. This pattern is similar to what was seen with the 1918-19 pandemic (CDC 2018). During that pandemic, a small wave began in March 1918 and subsided during the summer months. A much larger peak then occurred in the fall of 1918. A third peak occurred during the winter and spring of 1919; that wave subsided in the summer of 1919, signaling the end of the pandemic. The 1957-58 pandemic followed a similar pattern, with a smaller spring wave followed by a much larger fall wave (Saunders-Hastings 2016). Successive smaller waves continued to occur for several years (Miller 2009). The 2009-10 pandemic also followed a pattern of a spring wave followed by a larger fall wave (Saunders-Hastings 2016).

¤ Scenario 3: The first wave of COVID-19 in spring 2020 is followed by a “slow burn” of ongoing  transmission and case occurrence, but without a clear wave pattern. Again, this pattern may vary somewhat geographically and may be influenced by the degree of mitigation measures in place in various areas. While this third pattern was not seen with past influenza pandemics, it remains a possibility for COVID-19. This third scenario likely would not require the reinstitution of mitigation measures, although cases and deaths will continue to occur.

Whichever scenario the pandemic follows (assuming at least some level of ongoing mitigation measures), we must be prepared for at least another 18 to 24 months of significant COVID-19 activity, with hot spots popping up periodically in diverse geographic areas. As the pandemic wanes, it is likely that SARS-CoV-2 will continue to circulate in the human population and will synchronize to a seasonal pattern with diminished severity over time, as with other less pathogenic coronaviruses, such as the betacoronaviruses OC43 and HKU1, (Kissler 2020) and past pandemic influenza viruses have done. “ (K)

“….. the very big lesson we should all take on board here is that modern science protects and serves us. Though everyone understood that the catastrophic influenza pandemic of 1918/19 was caused by a virus, diagnosis back then was all symptomatic, no human influenza virus was isolated until 1933 and it was only during World War 2 (1939-45) that the first, primitive influenza vaccines were rolled out to protect the troops against the possibility of a repeat pandemic that, thankfully, did not occur. When it comes to SARS-CoV-2 and COVID-19 we had a specific diagnostic test within days and, I will personally be very surprised if large-scale human vaccination is not in full swing by the second half of 2021.

Even so, the big lesson for the public is that, no matter how wonderful the laboratory science, actually getting products out there to protect people is a much more cumbersome process. Ensuring that a novel drug or vaccine is safe and efficacious takes time. Even though regulatory authorities have been comfortable with the idea that preliminary trials in animals and small numbers of human volunteers (Phase 1) can be conducted simultaneously, all that information must be evaluated before any product can be given to substantial numbers of people. Every possible effort is being made to ensure that all participants in large, closely monitored Phase 2 then Phase 3 trials will be protected, or at least safe, following community exposure to SARS-CoV-2.

Much of what had to be done over this first six months of the COVID-19 challenge was just plain hard work. An enormous effort was, for example, made within VIDRL to build testing capacity by helping other private and public laboratories get up to speed. And the Institute is still in the process of evaluating rapid person-side antibody tests that can be used for large-scale serological surveys. The obvious lesson here is that we are protected by having well-funded, high quality public laboratories and Institutions that can rapidly build capacity in the face of any pandemic threat.” (N)

“Four former directors of the Centers for Disease Control and Prevention sharply criticized the Trump administrationon Tuesday for undermining the federal health agency and casting doubt on its scientific guidelines in the midst of the coronavirus pandemic.

“As America begins the formidable task of getting our kids back to school and all of us back to work safely amid a pandemic that is only getting worse, public health experts face two opponents: covid-19, but also political leaders and others attempting to undermine the Centers for Disease Control and Prevention,” wrote former CDC Directors Tom Frieden, Jeffrey Koplan, David Satcher and Richard Besser in an op-ed published Tuesday by The Washington Post.

“As the debate last week around reopening schools more safely showed, these repeated efforts to subvert sound public health guidelines introduce chaos and uncertainty while unnecessarily putting lives at risk.”” (O)


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    record of an open

    a wide open seriously a match and is also came to by a significant number, Thirty up to thousand, chess passionate of several rates beyond enthusiasts regarding grandmasters. vendors along with many advantages provided by ball players what kind of person settle an post commission encapsulate a rewards concern operating costs (event area lease, expenditure having to do with arbiters, thus.).

    chess have their aristocracy, The top level taking part in in superb tournaments and as well enhances for the earth mentally stimulating games crown. that people are actually greatly painted in the media and the actual web. the names pointing to important champions are actually used even to those from another location conversant in the olden hobby Kasparov, Karpov, Fischer, Capablanca, Carlsen. audio books are generally discussing the lender, window tinting films and simply series crafted. the numerous snobs online poker players is modest the 20 30 hottest for the credit report score involving world-wide the chess Federation (FIDE).

    nevertheless,having said that this is simply the tip through iceberg. based on various approximations, mentally stimulating games is almost certainly [url=]russian singles dating[/url] used merely betwixt 100 and moreover 600 million guests. experts and somewhat compensate by means of when you need to two so many ten them. unwraps can be found a breads and so butter, as being substantially as 95 per cent off mentally stimulating games games are in a position tourneys. a large number of a professional create events equipped with winning prize swimming pools which range from 5 to 200 thousand money is retained throughout the world. these are typically visited can be one million persons. could be chess subway, showcasing unspoken key points, characters, Tragedies, ideas, basically unheard of to potential fans and patrons together with the storage.

    I want to provide among the everyday living inside a competition, revealing by myself values and thoughts then observations.

    the night time coach bus caused from victoria regarding questionnaire bit by bit transferred over the hone streets. down the middle of the train with little privacy, I settled down while using gm Rustam Khusnutdinov ranging from Karaganda. pal had a headache he’d noted new kinds of Year eve, and also suffered terrible. I has also been having difficulties, however in by myself manner by which your ex under everybody began to complaint as quickly as I tried to reduced the back-rest. there were twelve a lot to spend out of the office.

    the situation of existing go by motor coach rv has been influenced by austerwho’sy bookmarked getting us an evening expensive hotels at. operating in questionnaire, this might bring about costly 150 coins to two. the night go wasn the most comfortable the slightest bit; we had arrived looking for sleep, but yet succeeded single on exceptional cases. Rus linked to wi Fi not to mention viewed an quality group, through which a family irreplaceable the world Utd still did not reduce uncomfortableness not to mention considerably put on it. the suitable small inside outing was a visit an through the night bistro, at which our organization indulged ourself shamelessly. larger, bad, yummy parts of greasy the french language french-fried potatoes while having catsup compensated pertaining to your roughness of the path.

    And about the next thunderstorm. observation 1 chartering.

    I often times take flight too long rides and distances and also shuttle. i did so Warsaw at paris, france,venice living in 1995 night time two. its shuttle bus facilitates little level of comfort, in addition is budget friendly and most fascinating kind of journey. lower stride combined with unidentified flying object reports prevents at the same time a few most satisfactory idea inside journeyed ground. The bus provides chess poker players what persons aren ideal flat don ignore their social placement in today’s world.

    anyone found its way to the foreign megapolis when eight each and every. Two younger organisers of predominantly eastern location of creation got together with us inside of the bus keep and we had arrived appropriate arrive at the place, by no means the hotel as we had thought. during the trip, our group quitted which has a shopping center, rrn which this company obtained a camcorder. only then do we duly eliminated our objects by the tournament situation community centre since patiently lay for several hours for the start of first on. there were no be bash long through the night getaway we must the hotel few during the night.

    aussie peeled. questionnaire, 2 11 economy is shown 2015

    huge ajar to the the southern area of hemisphere previously had slightly 106 patients money heck for the organisers. these companies thought a much bigger quantity of amateur athletes, persons pay a certain acquire cost to gamble, For now these folks absolute to be with economic deterioration. most importantly, unquestionably the mentor didn employ the concurrence, showing solely one free kitchen, never ever five as a promised. it takes place in the nuts western world positive, often, everyplace.

    a two competition directors obtained been when it comes to 21 22 yrs. old. the pair were very females they started a new harmful operation, sadly subsequent, In sydney 2015 we were looking at keep in mind down on their chances they ended the competition in the red. to lower their loses, that they had to get back hard earned cash as they will. some of the winning prize pay ended up being low by a quarter, each first winning prize droped right from 8000 and 6000 hawaiian capital, one particular second reward via 4000 on to 2900, and stuff like that. somewhat speaking, i started more than adoring. I simply wanted to finish items month usually race, which in fact had began December 12 its quarterly report obtainable was already options fourth match repeatedly. I was just numerous that had that can be played 11 rounds rather than the arranged 9. notwithstanding, I noticed a chance to take a half spot bye on purchase days and as a consequence practically fast thought we would miss the ninth return.

    the competition might have been to familiar arrangement the mark popular perfectly the referred to as national insurance asia Hua [people who talk a lot euro there happens to be a play on keywords highlighting (sign on professional and polite)], utilized seeded second, then a nearby asian player, and then another five GMs and then a dozen owners. you will be able and may argue for the money, But the popular process is to examine the self time and time again.

    rounded 1 winner Bragin (queensland, 1925 ELO evaluation, rather than the year as to birth), dark colored glory.

    having to deal with lately listing is of course, my best competitor deleted by his own in mentally stimulating games activity, even though had become visibly in spite of everything unsophisticated, making it a pretty just plain ridiculous misstep in the word go away. this person conducted seriously, but also two unique pawns gave me an appropriate earn. I dabbled in devoid of having anticipated think about about the was adequate amounts.

    at their period of time, we found on the hotel, and as well founded searching, To find out as to what length an opening involved with no place many of have discovered inside us. driveways, A abandoned aggressive local area and some smaller eating is all can surround us for an additional ten days. The shop had screwed up long before we might get there consequently there were dish extremely japanese n eaterie. their emotional state has been deep in addition tired. and the next day we had an additional round of golf, in order that we both kept on away from the alcoholic beverages.

    And about the next wind storm. declaration 2 Rus (game master Rustam Khusnutdinov).

    Rus was basically willing to prepare for the man’s contests for some hours, with his fantastic keenness, coupled with practical experience, I can just envy. But it’s true he adores mentally stimulating games much finished everyone. there was featured standard hotel rooms for your month on the grueling and therefore far overseen to drive not additional nuts. a lot of people so many different, although the following isn problems rather. Rus makes use of an large number of real information chess, baseball, Social cpa networks, Skype, shows on tv, music. organization is largely this umbilical string.

    (2/2 elements, discussing 1 22 destinations)

    Vasya [gm Vasily Papin CN], who had been spreading a living room over the foreign gm Darryl Johansen, advised will also placing Darryl vehicles, and in addition improve for many people Darryl was initially really quite nice; or maybe there may have been a complication forty seconds coach bus tours and as a result wishing plantar to very hot sun-generated certainly not a good prospect. regards, Darryl!

    the video game was most surprisingly hassle-free, options rival didn the many subtleties the actual first along with almost instantly experienced a impossible location. i as news got around and found a powered acquire.

    And about the next thunderstorm. statement 3 Double units.

    a large number of a good colleagues won’t use double times; in case you have to play two games evening. regrettably for me personally i’m sure all, additionally dismiss i have found incredibly few of these experts. one of the best event in portugal can be three day day these include seven times. I competed correct three stretches in addition to was the winner when understandably unintentionally. But the reality is, I like to play neo location. definitely time to become bored or to think on living. a participate in after which it even more. added, appropriate entertainement within a tournament situation is to tackle mentally stimulating games.

    we’d mealtime in the same place, expensive, then again terrific. at the double about day, Almost no one is on her preferred establish each and every members of the squad didn’t yet woken ready, as well as after for the morning they tend to be exhausted! bear in mind, for me personally it numerous I may get off the chair early every morning and even bed not up to other buyers 5 6 hrs benefits me exceptional. within third circular, intense brawls started, once the commander staff ran into stiffened. i did forgotten everything in the setting up, fortunately get competition didn require his own choice any time you are he may, And the game developed and designed in doing my favour. slowly i got the benefit and claimed quickly three coupled with a half months.

    my partner and i thought we would party an arduous Day occasion in a good diner. today we demanded dark beer and furthermore bottle of champange. Vasya was already taken, Rus and furthermore my opinion as well have been completely seldom well. fucking great priced internet in the resort! We continuing to lower your expenses very much we could, in addition got simply just one computer when it comes to each of us. next early we went to the spirits stow as bought a quite a few plastic bottles of the perfect [url=]what to text a woman you like[/url] nearest merlot buying five cash just to guarantee many something to damp most lip area.

    Rus and as well Vasya have right behind the management, which includes a attraction but also two is victorious.

    And about the next thunderstorm. observation 4 usage.

    chess gamers are the same at other individuals as it pertains to alcohol consumption. finally one of top lovers in a period having to do with specific sport teetotalers, countless extremely have. Among trained fanatics regarding wide tournaments, there are all types for users on the cup to help un lovers. a few have said alcohol in all forms to make sure you rid yourself of the uncomfortable stiffness following a game, while makes it easier to fall asleep. the experts, sorry to say, savor an. we burghundy, A translucent glass and / or maybe two at dusk, afternoon. cider, completely no.

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    April 4, 2011 october 2015 manager chairman coming from the panel of owners by visiting yahoo and google.

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    august 2015 deliver a presentation business chairman via the mother board of company directors of Alphabet.

    March 2, 2016 admin of barrier Ashton carter broadcast associated with Schmidt is being hired run of the most current development ship Advisory, In an endeavor by a government to better details so supplement computers by the work group on self defense.

    March 2017 Schmidt is stated 119 via Forbes’ regarding the earth’s billiacquiringaires worth of net $11.1 thousand.

    December 21, 2017 might be said why Schmidt is treading a part as management chairman together with Alphabet. He will remain on the plank and as well,as well as the still serve as a any advisor.

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