POST 257. June 18, 2022. CORONAVIRUS. “We’re now in a very weird pandemic phase. On Twitter, doctors such as Eric Topol sound five-alarm warnings about the latest subvariants of omicron. Offline, even in blue states, people are back to parties, bars and restaurants — and will soon be flying around the world with no testing requirements to return to the US. Things feel as if they’ve lost any coherence. There’s no discernible strategy or guidance on what Covid precautions we should still be taking.”

It’s one of those weeks with no big COVID-19 headlines perhaps except for Dr. Fauci testing positive. But under-the-radar a number of unrelated reports suggest that policy makers know we can’t get ahead of the virus and are no longer following the data, and instead are capitulating and normalizing non-compliant activity. Because of the current low increase in hospitalizations and continued flat death rates are they accepting a slow road to herd immunity? Are they letting our guard down and our readiness for a surge of a highly transmissible and deadly COVID variant? (or a different emerging virus?)

for links to POSTS 1-257 in chronological order highlight and click on

https://doctordidyouwashyourhands.com/2022/06/coronavirus-tracking-links-to-posts-1-257/

“The cost of the COVID-19 pandemic is staggering, in terms of both human life and and economic activity. But Bill Gates believes humanity is fortunate that the virus was not even more devastating…

While the official global death toll from COVID-19 is about 6.3 million, experts estimate that the real number of deaths is much higher. In May, the World Health Organization estimated that there were about 14.9 million excess deaths associated with the pandemic in 2020 and 2021.

Gates warned that we should not count on similar lucky during the next global pandemic. Considering how destabilizing the COVID-19 pandemic has been, if another virus emerges with similar virulence but a much higher fatality rate—say, 5%— it could be “society ending,” Gates said.

And Gates believes there may very well be a next time for many people alive today. “The chance of another pandemic in the next 20 years, either natural or intentional, I’d say, is over 50%,” he said…

As Gates explained…. the COVID-19 pandemic has created a unique opportunity to prevent another pandemic from ever happening again—but only if the world is willing to make key investments.

Specifically that means improving technology, including vaccines, therapeutics, and diagnostics; building up health systems; and improving global monitoring of diseases. In his interview with TIME, Gates emphasized that these changes are necessary in both wealthy and poor countries, to ensure that scientists everywhere have the resources they need to raise red flags about bourgeoning outbreaks, and to get them under control within just 100 days, a key window during the COVID-19 pandemic, Gates said, before the virus began to spread exponentially.” (A)

“COVID-19 cases have risen in the U.S. to around 100,000 per day, and the real number could be as much as five times that, given many go unreported. 

But the situation is far different from the early months of the pandemic. There are now vaccines and booster shots, and new treatments that dramatically cut the risk of the virus. So how much do cases alone still matter?

That question has prompted debate among experts, even as much of America goes on with their lives, despite the recent surge in cases. 

How much concern high case numbers alone should prompt is “the trillion-dollar question,” said Bob Wachter, chair of the department of medicine at the University of California-San Francisco. 

In the early days of the pandemic, dying of COVID-19 was a concern for him, but now, in an era of vaccines and treatments, “it doesn’t even cross my mind anymore,” he said. 

But he noted there are other risks, including long COVID-19: symptoms like fatigue or difficulty concentrating that can linger for months. 

“I think long COVID is pretty scary,” he said. 

While cases have risen to around 100,000 reported per day, deaths have stayed flat, a testament to the power of vaccines and booster shots in preventing severe illness, as well as the Pfizer treatment pills Paxlovid, which cut the risk of hospitalization or death by around 90 percent. 

Hospitalizations have risen, but only modestly, to around 27,000, one of the lowest points of the pandemic, according to a New York Times tracker. 

Cases have now been “partially decoupled” from causing hospitalizations and deaths, said Preeti Malani, an infectious disease expert at the University of Michigan, such that hospitals are no longer overwhelmed.

“[Cases are] not without any consequence, but in terms of pressure on the health system, so far we’re not seeing that, which is really what drove all of this,” she said. 

The behavior of much of America reflects a lessened concern about the risk of being infected. Restaurants and bars are packed. Many people do not wear masks even on airplanes or on the subway. 

An Axios-Ipsos poll in May found just 36 percent of Americans said there was significant risk in returning to their “normal pre-coronavirus life.”

In the Biden administration, health officials are still advising people to wear masks in areas the Centers for Disease Control and Prevention classifies as at “high” risk. But President Biden himself is talking about the virus far less than he did at the start of his administration, and is not making sustained calls for people to wear masks. 

White House COVID-19 response coordinator Ashish Jha touted progress in defanging cases on Thursday. 

“We see cases rising, nearly 100,000 cases a day, and yet we’re still seeing death numbers that are substantially, about 90 percent lower, than where they were when the president first took office,” he told reporters. 

Some experts are pushing back on the deemphasis of case numbers, saying they still matter. 

“The bunk that cases are not important is preposterous,” Eric Topol, professor of molecular medicine at Scripps Research, wrote last month. “They are infections that beget more cases, they beget Long Covid, they beget sickness, hospitalizations and deaths. They are also the underpinning of new variants.”

Even if one does not get severely ill oneself, more cases mean more chances for the virus to spread on to someone who is more vulnerable, like the elderly or immunocompromised. 

While deaths are way down from their peak earlier in the pandemic, there are still around 300 people dying from the virus every day, a number that would have proved shocking in a pre-COVID-19 world.”  “(C)

“At one point last month, children were admitted to Yale New Haven Children’s Hospital with a startling range of seven respiratory viruses. They had adenovirus and rhinovirus, respiratory syncytial virus and human metapneumovirus, influenza and parainfluenza, as well as the coronavirus — which many specialists say is to blame for the unusual surges.

“That’s not typical for any time of year and certainly not typical in May and June,” said Thomas Murray, an infection-control expert and associate professor of pediatrics at Yale. Some children admitted to the hospital were coinfected with two viruses and a few with three, he said.

More than two years into the coronavirus pandemic, familiar viruses are acting in unfamiliar ways. Respiratory syncytial virus, known as RSV, typically limits its suffocating assaults to the winter months.

Rhinovirus, cause of the common cold, rarely sends people to the hospital.

And the flu, which seemed to be making a comeback in December after being a no-show the year before, disappeared again in January once the omicron variant of the coronavirus took hold. Now flu is back, but without one common lineage known as Yamagata, which hasn’t been spotted since early 2020. It could have gone extinct or may be lying in wait to attack our unsuspecting immune systems, researchers said.

The upheaval is being felt in hospitals and labs. Doctors are rethinking routines, including keeping preventive shots on hand into the spring and even summer. Researchers have a rare opportunity to figure out whether behavioral changes like stay-at-home orders, masking and social distancing are responsible for the viral shifts, and what evolutionary advantage SARS CoV-2 may be exercising over its microscopic rivals.

“It’s a massive natural experiment,” said Michael Mina, an epidemiologist and chief science officer at the digital health platform eMed. Mina said the shift in seasonality is explained largely by our lack of recent exposure to common viruses, making us vulnerable to their return…

She and other infectious-disease specialists are also revisiting their response to RSV, a common virus that hospitalizes about 60,000 children younger than 5 each year, according to the Centers for Disease Control and Prevention. It can create deadly lung infections in preemies and other high-risk infants. The typical treatment for them is monthly shots of a monoclonal antibody, palivizumab, from around November through February. But last summer, RSV suddenly surged and this year it is causing trouble in May and June. Infectious-disease experts are carefully tracking cases so that they are prepared to reactivate the pricey protocol.

“We monitor the number of cases so that if it exceeds a number, we are ready,” Murray said. The Yale hospital, which typically holds meetings to prepare for upswings in fall through spring, is preparing pandemic-fatigued staffers for out-of-season surges…

The moment you stop seeing a virus on this regular cadence, as happened during the pandemic, that natural balance is upset, Mina said. The extraordinary measures we took to limit exposure to the coronavirus — necessary steps to contain a deadly new foe — also limited our exposure to other viruses. If you do get exposed to a virus again once too much time has passed, you may not be able to protect yourself as well, leading to out-of-season surges across the population and surprisingly virulent infections for individuals.

That, Mina and others say, is what happened once people doffed their masks and started gathering indoors. Viruses began circulating out of season because population immunity was low even if other conditions for them were not optimal.

“All of these decisions have consequences,” Murray said. “You do the best you can with the information you have.”” (D)

“Efforts to update COVID vaccines can’t seem to keep up with changes in the virus itself.

State of play: New variants appear to be even more immune-resistant than the original Omicron strain, raising the possibility that even retooled vaccines could be outdated by the time they become available this fall.

Driving the news: Preliminary data suggests that the most recent Omicron subvariants are significantly different from the original version that began spreading late last year.

One preprint released last week found that BA.4 and BA.5, which originated in South Africa, are substantially more resistant to antibodies — compared to an earlier strain, and also to the one that’s dominant in the U.S. right now — and thus more likely to lead to breakthrough infections.

Other preliminary research has found that the latest subvariants are more pathogenic and can potentially evade even the immune protection that comes from a previous Omicron infection.

The big picture: Clinical trials are underway to study tweaked versions of the Pfizer and Moderna vaccines, and the FDA has said it will decide this summer whether to recommend these updated versions for use later this year.

A leading option is to target multiple variants, including Omicron, with the same vaccine. But the Omicron version that’s around in a few months may be significantly different than the strain the vaccine was designed to target.

Between the lines: Although the vaccine manufacturers have said they can quickly adapt to produce new vaccine versions, collecting data on those vaccines’ effectiveness through real-world clinical trials takes time.

“It takes six months for the omicron BA.1 vaccines to be properly tested and then longer to produce them. That’s inevitable,” Cornell virologist John Moore said.

What they’re saying: “It’s unclear what the mix will be in the vaccine that’s used in the fall, but there’s a very good chance that it’ll be against the original Omicron,” said Celine Gounder, an infectious disease specialist and KHN editor-at-large.

“But it’s really unclear that it’s going to be much of an improvement versus the original vaccine when BA.4 and BA.5 are so significantly different than the original Omicron.”

“It’s pretty challenging. We’re very much behind the virus given the speed at which it’s moving,” Gounder added…

.

The bottom line: Keeping up with a virus that is evolving this quickly is inherently in tension with collecting the data traditionally required to make big regulatory decisions.” (E)

“We’re now in a very weird pandemic phase. On Twitter, doctors such as Eric Topol sound five-alarm warnings about the latest subvariants of omicron. Offline, even in blue states, people are back to parties, bars and restaurants — and will soon be flying around the world with no testing requirements to return to the US. Things feel as if they’ve lost any coherence. There’s no discernible strategy or guidance on what Covid precautions we should still be taking.

Danish social scientist Michael Bang Petersen, of Aarhus University, told me that familiarity with Covid is changing people’s attitudes. Many stopped fearing the virus once they contracted it and recovered. In Denmark, he said, studies show 80% of the population has been infected. Here in the US, a similar study showed about 60% had had Covid as of last February — before the latest wave started.

And people are taking cues from those around them. Social signals are really important, he said, so it’s very difficult to keep your guard up when others are going back to normal. Behavior can change in a cascading way. People wonder why they should bother if nobody else is. “That’s straight out of basic psychology of collective action,” said Bang Petersen.

Of course, some people are still being cautious and still have not caught Covid, such as epidemiologist Michael Osterholm of the Center for Infectious Disease Research and Policy…

And that means it’s hard to adapt our behavior to the situation — the way public health officials urged us to do during previous waves. Osterholm added that compared with previous surges, there are relatively few deaths this time, so the death rate is getting closer to something people are used to seeing with flu. “We don’t really know for certain how to act,” Osterholm said. We’ve never been expected to change our everyday lives because of influenza. But that might all change again if the next variant is more dangerous.” (F)

“Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and President Biden’s chief medical adviser, has tested positive for Covid-19, the institute said Wednesday.

Fauci, 81, has mild symptoms and has been boosted twice, the institute said in a statement. The institute told CNN that he is being treated with the antiviral medication Paxlovid.” (G)

“As COVID-19 cases began to accelerate again this spring, federal data suggests the rate of breakthrough COVID infections in April was worse in boosted Americans compared to unboosted Americans — though rates of deaths and hospitalizations remained the lowest among the boosted.

The new data do not mean booster shots are somehow increasing the risk. Ongoing studies continue to provide strong evidence of additional protection offered by booster shots against infection, severe disease, and death.

Instead, the shift underscores the growing complexity of measuring vaccine effectiveness at this stage of the pandemic. It comes as officials are weighing key decisions on booster shots and pandemic surveillance, including whether to continue using the “crude case rates” at all.

It also serves to illustrate a tricky reality facing health authorities amid the latest COVID-19 wave: even many boosted Americans are vulnerable to catching and spreading the virus, at a time when officials are wary of reimposing pandemic measures like mask requirements.

“During this Omicron wave, we’re seeing an increased number of mild infections — at-home type of infections, the inconvenient, having a cold, being off work, not great but not the end of the world. And that’s because these Omicron variants are able to break through antibody protection and cause these mild infections,” John Moore, a professor of microbiology and immunology at Weill Cornell Medical College, told CBS News.

“So, one of the dynamics here is that people feel, after vaccination and boosting, that they’re more protected than they actually are, so they increase their risks,” he said. “That, I think, is the major driver of these statistics.”…

Further down the road, a panel of the Food and Drug Administration’s outside vaccine advisers is scheduled to meet later this month to weigh data from new booster candidates produced by Pfizer and BioNTech as well as Moderna.

BioNTech executives told investors last month that regulators had asked to see data for both shots specifically adapted for the Omicron variant in addition to “bivalent vaccines,” which target a blend of mutations.

Those new vaccines would take about three months to manufacture, the White House’s top COVID-19 official Dr. Ashish Jha told reporters.

“It’s a little bit of a challenge here because we don’t know how much further the virus will evolve over the next few months, but we have no choice because if we want to produce the hundreds of millions of doses that need to be available for a booster campaign, we have to start at risk in the early July timeframe or even somewhat sooner,” Dr. Peter Marks, the FDA’s top vaccines official, said at a recent webinar hosted by the American Medical Association.

Marks said that bivalent shots seemed likely to be favored, given the “wiggle room” it could offer for unforeseen variants beyond Omicron.

Vaccines that might offer even better “mucosal immunity” – actually fighting off the virus where it first infects the respiratory system – are still a ways off, Marks cautioned.

“I think that we are in a transition time and I, again, will speak openly to the fact that 2022 to 2023 is a year where we have to plan for trying to minimize the effect of COVID-19 with the tools that we have in hand,” Marks said at a recent event with the National Foundation for Infectious Diseases.

“I do believe that, potentially by the 2023-2024 season, we’ll start to see second generation SARS-CoV-2 vaccines,” he added later.” (H)

“Pharmacies, states, U.S. territories and federal agencies discarded 82.1 million Covid vaccine doses from December 2020 through mid-May — just over 11 percent of the doses the federal government distributed, according to data the Centers for Disease Control and Prevention shared with NBC News. That’s an increase from the 65 million doses the CDC told the Associated Press had been wasted as of late February.

Two retail pharmacy chains, CVS and Walmart, were responsible for over a quarter of the doses thrown away in the United States in that time period, in part due to the sheer volume of vaccine they handled.

Five other pharmacies or dialysis centers — Health Mart, DaVita, Rite Aid, Publix and Costco — wasted fewer overall doses, but a higher share: more than a quarter of the vaccine doses they received, well above the national average. Two states also discarded more than a quarter of their doses: Oklahoma, which tossed 28 percent of the nearly 4 million doses it received, and Alaska, which threw away almost 27 percent of its 1 million doses, according to the CDC data.

The overall amount of waste is in line with World Health Organization estimates for large vaccination campaigns. But public health experts said the waste is still alarming at a time when less than half of fully vaccinated Americans have a booster shot — which is critical to fight newer, more contagious virus strains — and when many poorer countries continue to struggle with vaccine supply.

“It’s a tremendous loss to pandemic control — especially in the context of millions of people around the world who haven’t even been able to get a first dose,” said Dr. Sheela Shenoi, an infectious disease expert at the Yale School of Medicine.

The millions of wasted vaccine doses include some that expired on pharmacy shelves before they could be used, others that were spoiled by the thousands when power went out or freezers broke, and still others that were tossed at the end of the day when no one wanted the last few doses in an opened vial.

Unlike most other immunizations in the U.S., the coronavirus vaccines come in multidose vials, which means all the doses must be used within hours once the vials are opened — or discarded.

State health officials and pharmacies said that’s been a major contributor to vaccine waste. Some also said the vaccines come in such large minimum orders that they are left with more than they need…

“The latest CDC guidance advises that providing COVID-19 vaccinations should be prioritized, even if it leads to vaccine waste,” the company said.

The challenge of getting shots into arms and avoiding waste has become especially difficult as demand wanes for the vaccines, experts and officials say.

“The demand has plateaued or is coming down, and that leads to open-vial wastage — especially with multidose vials,” said Ravi Anupindi, a professor of operations research and management at the University of Michigan who has studied vaccination campaigns.

“It’s a demand problem,” he added.” (I)

“Inspectors for the Centers for Medicare & Medicaid Services will no longer check for provider compliance with the staff COVID-19 vaccine mandate during all surveys.

The agency, in a memo to state survey agencies on Wednesday, announced that oversight of the regulation will now be performed primarily in response to complaints alleging non-compliance with the requirement, rather than during all surveys. Compliance will also continue to be checked during initial and recertification surveys.

CMS said the reduction in survey frequency is “supported by the high rates of compliance in initial surveys” and keeping with the normal survey process for oversight of any Medicare requirement…

The healthcare worker vaccine mandate has been effective in all states since late February, and about 12,000 providers and suppliers have been surveyed for compliance with the rule. So far, 95% of those surveyed have been found in “substantial compliance” with the rule, according to CMS.

Federal data also shows that 87.1% of nursing home staffers have been vaccinated for COVID-19.

“While we are seeing a significant increase in COVID-19 cases in parts of the country — driven by the highly transmissible omicron subvariants — hospitalizations and deaths currently remain relatively low nationwide,” CMS wrote Wednesday.

“This is a testament to the tools and protections in place today, particularly the work that federal, state, local, and private partners have done to get over 220 million people vaccinated and over 100 million boosted.” (M)

“One passenger on a recent Carnival cruise bound for Seattle claimed there were about 200 people sick with COVID-19 on board, and that the crew were overwhelmed. Carnival downplayed the situation with Seattle press, but wouldn’t disclose the case count.

That ship, the Carnival Spirit, is now cruising between Seattle and Southeast Alaska for the summer. If its crew are following protocol, the Centers for Disease Control and Prevention, the U.S. Coast Guard and the Alaska Department of Health and Social Services should all have good data about the COVID situation on board on any given day. But very little of that information is available to the public for the Spirit, or any of the ships operating in Alaska this summer.

This year, the cruise lines operating all of the big ships in Alaska committed to regularly report illness data by opting into the CDC’s COVID-19 Program for Cruise Ships. They’ve agreed to fill out and send a form every day for every ship so the CDC can track COVID-19 cases on board.

Individuals’ health information is protected. That hasn’t stopped state health authorities from publishing individual communities’ overall case counts, hospitalization figures, hospital capacity, deaths or other stats helpful for gauging COVID-19 risk. But the CDC isn’t doing that for cruise ships.

The CDC does publish and update daily a color-coded cruise ship status on its website for each ship. Green means they have no cases of COVID-19 or COVID-like illnesses.

The Carnival Spirit has been in the orange category. That could mean as few as seven passengers are sick — or it could be hundreds. The majority of the ships sailing right now are in that category…

The CDC’s most severe category for cruise ships is red, which indicates the medical capacity onboard is overwhelmed. Some of the Spirit’s recent passengers described a poorly managed COVID-19 outbreak that did overwhelm the crew. However, Carnival told Seattle press that there were no serious health issues and that it maintained its health and safety protocols.

The CDC has not made anyone available for an interview about its cruise ship program.

Like last year, the cruise lines have made a lot of commitments to Alaska port communities to reduce the spread of COVID-19 and to manage cases themselves. Cruise passengers and crew aren’t supposed to burden local health care systems. Barr said the agreements this year say that medical facilities in the bigger ports like Juneau, Ketchikan and Whittier could help out if the need arises.

“But occasionally, occasionally we can assist,” Barr said. “In the event that we can’t, then each line is required in the agreement to transport impacted passengers and/or crew to Seattle.”

The CDC’s description of its cruise ship program also says the Coast Guard is supposed to get the most timely information about illness before ships arrive in a port. The Coast Guard has not made anyone available for an interview about this.

That leaves the Alaska Department of Health and Social Services. It’s been regularly publishing COVID-19 data statewide on online dashboards of its own since the pandemic began. The data can be narrowed to specific Alaska regions and communities. But it’s not helpful for teasing out cruise ships.

Department spokesperson Clinton Bennett said lots of factors affect how cases identified aboard a cruise ship operating in Alaska get published. And there is potential for cruise ship cases to cause spikes in different communities’ COVID-19 data that don’t reflect higher risk.

For example, a cruise ship passenger could spend a day in one community, get back on board, test positive at sea, then end up in the case counts for the next port of call — even though they would stay quarantined aboard the ship.

Bennett said cases caught in Alaska waters could also be geographically tagged as “at sea,” which isn’t searchable.

“Our overall takeaway,” Bennett wrote in an email, “is that the dashboard case counts announced in relation to the cruise industry shouldn’t be relied upon alone in understanding impact to local communities or the total size of an outbreak on a vessel.”..

“This lack of transparency — you know, I’m sorry, but for CDC to expect the cruise ships to honestly report? … These are the same ships in many cases that have polluted our waters and falsified their pollution records,” she said.

Carnival and its subsidiaries, which include Holland America and Princess, recently completed a five-year probation period for the environmental crimes Schrader mentioned.

“And we’re supposed to now believe them that they’re going to report how many potential crew and passengers have COVID?” she said.

For the state’s top health officials, the answer appears to be yes. Health Commissioner Adam Crum and Chief Medical Officer Dr. Anne Zink recently described the cruise lines as good stewards in protecting public health on board and in the communities they visit. They say the industry has demonstrated its desire to be transparent, good partners.” (J)

“The Jewel of the Seas sailed from Amsterdam on May 20th with 1,752 guests onboard the Royal Caribbean cruise ship. There were twelve (12) crew members and three (3) guests who initially tested positive for COVID-13. After two days of the cruise, the number of guests who tested positive for the virus increased to seven (7)…

The ship has recently focused on the fact that, according to Royal Caribbean, there has been an increase in the number of infected crew members, leading to a senior officer reminding the crew to wear KN95 masks on the ship.

The ship’s Staff Captain, Frank Jensen, recently sent this email to the crew:

“Good morning fellow Ship Mates,

We have unfortunately lately seen a spike in the COVID19 cases among our crew!

Please ensure following is strictly adhered to in order for us to break this inclining curve of C+ cases:

KN95 Masks are to be worn at all the times, except when in your cabin or when eating, drinking or smoking.

We will keep you posted.

Regards”

As far as passengers are concerned, the wearing of masks on the ship is strictly optional. As a practical matter, no guests seem to wear masks voluntarily. Royal Caribbean does not instruct guests to wear mask though it knows that COVID-19 cases are “spiking” among the crew.

As we previously reported, the Jewel of Seas had as many as one hundred (100) to two hundred (200) infected crew members at any given time late last year and earlier this year during a surge in cases as the Omicron variant emerged. The Jewel was one of three Royal Caribbean cruise ships (including the Serenade of the Seas and the Vision of the Seas) used by the cruise line as a floating quarantine hotel / walk-in clinic at sea for infected crew members. The ship previously would rendevous with other Royal Caribbean ships to pick up hundreds of other infected/ill crew members. It is our understanding that Royal Caribbean is no longer housing infected crew members on quarantine-ships after the Omicron variant surge largely abated.

Nonetheless, it remains risky to board a cruise ship maskless, as Royal Caribbean seems to privately realize.”  (K)

“As an infectious diseases doctor at Rutgers Robert Wood Johnson Medical School, I’ve been watching the spread of Candida auris with great concern.

This fungus can cause serious infection, pain, suffering, and even death — and people with weak immune systems are at particularly high risk. It has caused outbreaks in health care facilities across the country. We saw 61 cases in New Jersey last year — more than in more populous states like Pennsylvania, Ohio and Texas. More than 1,000 cases were reported nationwide.

Considering the COVID-19 pandemic, that may not sound like much, but Candida auris is on the rise. There were no cases before 2009 and, in recent years, it has been noted to be highly resistant to antifungal drugs. In many instances, there are few therapies left that can successfully treat it, and some strains are resistant to all available treatments.

The emergence and spread of C. auris is part of a wider crisis known as antimicrobial resistance, or AMR. Like other organisms, disease-causing bacteria and fungi evolve to become increasingly resistant to available therapies. When exposed to an effective medication, most of the pathogens die, but some resist. These survivors can grow into drug-resistant “superbugs” and can pass their resistance on to their next-generation offspring.

Antimicrobial drugs are the foundations of modern medicine — but deep cracks are causing that foundation to crumble. Superbugs took at least 1.27 million lives worldwide in 2019, shattering previous estimates.

In some cases, we’re unable to provide critically needed organ transplants because we lack effective antibiotics. Since transplant patients must have their immune systems suppressed so they don’t reject the transplanted organs, their compromised immune systems often cannot fend off superbugs without effective antimicrobials.

If we don’t strengthen the development of new treatments, it will be increasingly difficult to safely provide many types of surgeries because the risk of untreatable antimicrobial-resistant infection will be too high. The pipeline for new antimicrobials is already inadequate to address current threats, let alone future superbugs that are bound to emerge.

Moreover, antimicrobial resistance and the pandemic have exacerbated one another. Amid the first surges of COVID-19, as intensive care units filled with critically ill patients on ventilators, I found myself treating multidrug-resistant infections more frequently than ever. Secondary bacterial infections led to serious illness and death in a significant share of COVID-19 patients.” (B)

“The intensive care unit is full. A patient coded early in the morning, and my pager alerts me that an older man is intubated in the emergency department and a woman with cystic fibrosis is coughing up blood. There is so much sickness that I am almost too busy to notice what once would have been a remarkable fact: I am not taking care of a single patient with the coronavirus.

In many ways, my hospital is back to normal. Families can enter once again, though still with limited visiting hours. There is no more talk of canceling elective procedures. The cafeteria salad bar has returned. We still wear masks, but I do not obsessively check the seal of my N95. Though this virus is not gone, I am no longer scared.

But I find myself wondering whether we should expect more. At the height of the pandemic, as we watched the vulnerable die, we made promises that when this ended, so much would be different. And yet here in the hospital, we seem to have settled into a new kind of normal, one characterized by limited staffing and medication shortages and an erosion of the family presence that we once embraced. So yes, I am not taking care of a single patient with the coronavirus. But is that as good as it gets?” (L)

“Confirmation of one case of monkeypox, in a country, is considered an outbreak. The unexpected appearance of monkeypox in several regions in the initial absence of epidemiological links to areas that have historically reported monkeypox, suggests that there may have been undetected transmission for some time.

WHO assesses the risk at the global level as moderate considering this is the first time that many monkeypox cases and clusters are reported concurrently in many countries in widely disparate WHO geographical areas, balanced against the fact that mortality has remained low in the current outbreak…

Interim guidance is being or has been developed to support Member States with raising awareness; surveillance, case investigation and contact tracing; laboratory diagnostics and testing; clinical management and infection prevention and control (IPC); vaccines and immunization; and risk communication and community engagement (please refer to the WHO Guidance and Public Health Recommendations section below).

Currently, the public health risk at the global level is assessed as moderate considering this is the first time that monkeypox cases and clusters are reported concurrently in many countries in widely disparate WHO geographical areas, balanced against the fact that mortality has remained low in the current outbreak.

In apparently newly affected countries, cases have mainly, but not exclusively, been confirmed amongst men who self-identify as men who have sex with men, participating in extended sexual networks. Person to person transmission is ongoing, still primarily occurring in one demographic and social group. It is likely that the actual number of cases remains an underestimate. This may in part be due to the lack of early clinical recognition of an infectious disease previously thought to occur mostly in West and Central Africa, a non-severe clinical presentation for most cases, limited surveillance, and a lack of widely available diagnostics. While efforts are underway to address these gaps, it is important to remain vigilant for monkeypox in all population groups to prevent onward transmission…

All countries should be on the alert for signals related to patients presenting with a rash that progresses in sequential stages – macules, papules, vesicles, pustules, scabs, at the same stage of development over all affected areas of the body – that may be associated with fever, enlarged lymph nodes, back pain, and muscle aches. During this current outbreak, many individuals are presenting with atypical symptoms, which includes a localized rash that may present as little as one lesion.  The appearance of lesions may be asynchronous and persons may have primarily or exclusively peri-genital and/or peri-anal distribution associated with local, painful swollen lymph nodes. Some patients may also present with sexually transmitted infections and should be tested and treated appropriately. These individuals may present to various community and health care settings including but not limited to primary and secondary care, fever clinics, sexual health services, infectious disease units, obstetrics and gynaecology, emergency departments and dermatology clinics.

Increasing awareness among potentially affected communities, as well as health care providers and laboratory workers, is essential for identifying and preventing further cases and effective management of the current outbreak.

Any individual meeting the definition for a suspected case should be offered testing. The decision to test should be based on both clinical and epidemiological factors, linked to an assessment of the likelihood of infection. Due to the range of conditions that cause skin rashes and because clinical presentation may more often be atypical in this outbreak, it can be challenging to differentiate monkeypox solely based on the clinical presentation.

Caring for patients with suspected or confirmed monkeypox requires early recognition through screening adapted to local settings, prompt isolation and rapid implementation of appropriate IPC measures (standard and transmission-based precautions, including the addition of respirator use for health workers caring for patients with suspected/confirmed monkeypox, and an emphasis on safe handling of linen and management of the environment), physical examination of patient, testing to confirm diagnosis, symptomatic management of patients with mild or uncomplicated monkeypox and monitoring for and treatment of complications and life-threatening conditions such as progression of skin lesions, secondary bacterial infection of skin lesions, ocular lesions, and rarely, severe dehydration, severe pneumonia or sepsis. Patients with less severe monkeypox who isolate at home require careful assessment of the ability to safely isolate and maintain required IPC precautions in their home to prevent transmission to other household and community members.

Precautions (isolation) should remain in place until lesions have crusted, scabs have fallen off and a fresh layer of skin has formed underneath.” (N)

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