Public service messages are projected on bus stop screens in Chicago, Ill. A modified stay-at-home order remains in effect statewide through May 30. Charles Rex Arbogast/AP hide caption
Public service messages are projected on bus stop screens in Chicago, Ill. A modified stay-at-home order remains in effect statewide through May 30.
Updated May 1 at 10:35 p.m. ET
Part of a series on coronavirus-related restrictions across the United States.
Jump to a state: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin, other states
The first version of this page was originally published on March 12. This is a developing story. We will continue to update as new information becomes available.
NPR's Brakkton Booker, Merrit Kennedy, Vanessa Romo, Colin Dwyer, Laurel Wamsley, Aubri Juhasz and Bobby Allyn contributed to this report.
This is part of a series about coronavirus-related restrictions across the United States.
Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont
Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin
South: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, West Virginia
West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming
As more people around the world are infected with Covid-19, were learning that the novel coronavirus can not only cause severe respiratory illness, but also can attack just about every major organ system in the body. And lately doctors have been sounding the alarm about a disturbing new outcome: blood clots and strokes, which are striking even healthy young people with no known risk factors and sometimes no other symptom of the virus.
An April 28 report from the New England Journal of Medicine details the cases of five people, ages 33 to 49, in New York City who had strokes and subsequently tested positive for Covid-19. All of them had large-vessel strokes outside of the hospital before experiencing other severe symptoms of the virus; one of them has since died.
It was very surprising to see the increase in this large-vessel stroke in young people, Thomas Oxley, a neurosurgeon at Mount Sinai in New York and a coauthor of the new report, tells Vox. As he explains, The bigger the vessel, the bigger the stroke.
Its the biggest story emerging about Covid-19, he adds. The rate of large-vessel stroke victims under 50 they saw was seven times higher than before the pandemic.
Blood clots are also causing other unexpected problems for Covid-19 patients. For example, Broadway actor Nick Cordero, who has been hospitalized since March with severe Covid-19, had his right leg amputated earlier this month after doctors were unable to control clotting there.
And many patients are developing small-clots in their lungs, reducing the amount of oxygen they can move into their bodies. For others, their blood is clogging dialysis machines (which has been a problem due to the amount of kidney failure this illness is also causing).
Im a hematologist, and this is unprecedented, says Jeffrey Laurence of Weill Cornell Medical College, who has been in the field for three decades. This is not like a disease weve seen before.
Nearly every patient he has seen for blood disorders in the past month and a half has had Covid-19. Ive never had so many consults in my life. These people are clotting, and we cant shut it off.
Doctors and researchers are racing to figure out why this is happening, and how they might be able to best use existing therapies, such as blood thinners, to mitigate it in patients. The clots and strokes also add to the list of potential symptoms some people with Covid-19 might experience early on and gives another possible reason that the number of coronavirus-related deaths around the country is looking far larger than those officially being counted in hospitals.
When we get injured, we depend on our bloods ability to clot to stop the flow of blood. Clotting is a complex process that involves small cell fragments called platelets congregating and changing shape, proteins that help even more cells bind together, and the secretion of substances called blood clotting factors. If any of these processes go off course, people can experience excessive bleeding, which can be life-threatening.
On the other end of the spectrum, sometimes clots form inside blood vessels (or, more rarely, arteries) without an injury. These can cause serious harm and sometimes death. There are many risk factors for developing internal blood clots, including smoking, obesity, heart disease, and others. And, now, it looks like Covid-19 is a risk factor as well.
Some clots remain in the place where they form and are known as thrombosis. This can cause severe pain and swelling. These clots can also travel to or form in a major organ, where they can do even more serious damage.
For example, a clot in the leg can travel up to the lungs, cutting off blood flow and causing a pulmonary embolism (which can lead to death or permanent lung damage). A clot can also flow to the heart, triggering a heart attack. And one in or near the head can block blood flow in part of the brain, bringing on a stroke.
Small early studies and case reports about the link between the novel coronavirus and blood clots are now pouring in. For example, one team in the Netherlands followed 184 severe Covid-19 patients who were receiving treatment in three different intensive care units. They found that 31 percent of these people had some sort of blood clotting issue, a percentage they call remarkably high.
Other data is emerging with similar implications. In patients with severe disease, various forms of blood clots are estimated to occur in 15-35 percent of patients, Behnood Bikdeli, a cardiology fellow at Columbia University Medical Center, tells Vox. And these clots, especially the small ones, could impact the illness severity and involvement of many of the organs, he says. (He and an international team of dozens of researchers published an April review of clotting issues in the Journal of the American College of Cardiology.)
Laurence has been studying small blood clots in HIV/AIDS patients for decades. In March, a dermatologist sent him a photo of surprising skin lesions on a young man who was severely ill with Covid-19. Laurence was stunned. Its a picture of microvascular clotting, where you can see exactly where the vessels have clotted, he says. He started wondering if something similar might be happening in the lungs.
Just hours later, another doctor called, giving him access to an autopsy of a different Covid-19 patient. Not only did this individual have small clots in the skin but also in his lungs. (Laurence and his colleagues published descriptions of these and three other cases of severe clotting in an April Translational Research paper.)
The presence of small clots in the lungs is disturbing, but it also might help to explain a puzzling trend medical staff have noticed in some Covid-19 patients. When people develop more advanced illness, their lungs can become stiff, making breathing on their own very difficult. This leads to a drop in oxygen in the blood if they are not on mechanical ventilation.
But health care workers have seen many patients with low oxygen levels but who still have fairly flexible lungs, Laurence explains. This points to the presence of microvessel clots [in the lungs] shutting off the ability of people to bring oxygen into their blood, he says. (He also noted that sustained time on a ventilator can, itself, increase lung stiffness, which could have been throwing off clinicians who were seeing that as an outcome of the illness, and perhaps along the way missing signs that something else was going on.)
Laurence also describes the multitude of people sick with Covid-19 whose blood clots are plugging up the dialysis machines in their wards. Beyond that, he says, even as the nurses are drawing their blood, its clotting in the tubes, and theyre on full doses of Heparin and other blood thinning medications. Everyone is seeing a similar kind of thing, he says.
These observations also bear out in autopsies.
A team of Chinese researchers that looked at 183 people hospitalized with Covid-19 pneumonia in Wuhan, China, found evidence of clotting in 71 percent of those who died but less than 1 percent of those who didnt. (Notably, this paper was published early in the pandemic, in February.)
The prevalence of blood clots also raises the question of whether some stroke or heart attack home deaths in recent months were actually linked to Covid-19. Its yet another possible way Covid-19 fatalities might be being undercounted. Many people who have already died are not currently tested for Covid-19 (often in the interest of preserving tests for those who are still alive). But more widespread posthumous testing could help clarify the full impact of this disease.
Scientists still dont understand exactly what is triggering this excessive blood clotting. (Some viruses, such as the Ebola virus, cause extreme bleeding, but others, such as HIV, can trigger small clots.) And its not yet clear if these changes in the blood are from the virus itself or the bodys immune response to the infection.
One of the hypotheses has to do with how the virus gains entry to our cells. Researchers have found that this coronavirus manages to sneak into our cells via a specific type of receptor known as ACE2. These are prominently found in the lungs, which might explain why so much of the viruss damage has been centered there. But ACE2 receptors are also very common along the walls of blood vessels throughout the body, Oxley explains. So its possible that its presence there is spurring additional inflammation of the vessels, prompting the formation of blood clots.
Laurence also points to this inflammatory problem. It is this insidious feedback loop of inflammation, he says. And once its going, he says, you cant intervene in that system effectively.
To be sure, sustained immobility, such as in a hospital bed, can increase the risk for blood clots, but the rates currently being reported in Covid-19 patients is way above what would normally be expected, Laurence notes.
With the new evidence about this viruss potential effect on the blood, doctors at many major medical facilities have begun administering low doses of preventative blood thinners to Covid-19 patients.
Its a tricky move, though, because too much blood thinner can cause a patient to bleed internally and possibly die. To gauge the best doses, many physicians are going off of a patients D dimer levels, which is a biomarker for the presence of blood clots. New clinical trials have quickly spun up (including a multi-state one in the US to test one type of powerful blood thinners, known as tPA (tissue plasminogen activator) in Covid-19 patients, as STAT News reports). And Bikdeli and others have formed an international collective to provide interim consensus-based guidance, he says. What is needed most is high-quality data.
But these preventative treatments wont help those whove had strokes or other major blood-clot complications before receiving medical care. And that number, though still small, is real, as the five young stroke victims from New York City show.
The New England Journal of Medicine report included all stroke patients under 50 at the Mount Sinai health system in New York City during a two-week period in late March and early April. That this rate was nearly seven times the number of stroke patients in that age group during any average two-week period over the previous year indicates a very strong correlation between Covid-19 even mild and asymptomatic cases and the potential for major blood-clotting.
These patients were at home with mild or no symptoms who suddenly developed signs of stroke, Oxley says.
Some of these young patients had also been reluctant to seek medical attention even after fairly severe stroke symptoms. And it wasnt unreasonable for them not to be on the lookout for such a major neurological issue. These are people among the least likely statistically to have a stroke, J Mocco, a Mount Sinai neurosurgeon and coauthor of the report, told the Washington Post.
For example, the youngest, a 33-year-old woman, developed slurred speech and felt weak and numb on her left side for 28 hours before seeking help. She (as well as one other stroke patient in the study) was concerned about going to a hospital during the pandemic, the authors noted even though she had had a cough, headache and chills for a week.
She is one of the lucky ones. She is the only one who has been able to start speaking again. After 10 days in the hospital to treat her blood clotting, she was discharged to a rehabilitation center.
There is also a question of how long the danger of Covid-19-related clotting lasts. Laurence notes that a lot of our cases, they went through their cough and fever, then all of a sudden, theres a stroke or a blood clot in their legs. For other patients, after having recovered from their primary Covid-19 symptoms, their difficulty of breathing came back, signaling that they have a pulmonary embolism in their lungs, he says. So people have to be vigilant to look for possible signs even after they feel like they have passed the worst of their illness.
Additionally, people at high risk for thrombotic events need to be vigilant, keep good hydration, and keep being active, especially during the period of social distancing and lockdown, Bikdeli says. This group includes people with a family history of blood clots or strokes, obesity, some cancer treatments and surgeries, pregnancy, some birth control methods, and others.
But major strokes can be treatable, Oxley notes. Its just a question of timing. For best results treatment must begin within six hours of stroke. As he told the Washington Post, the message we are trying to get out is if you have symptoms of stroke, you need to call the ambulance.
The Coronavirus Genome
The coronavirus is an oily membrane packed with genetic instructions to make millions of copies of itself. The instructions are encoded in 30,000 letters of RNA a, c, g and u which the infected cell reads and translates into many kinds of virus proteins.
RNA instructions to make the ORF1a protein
Start of coronavirus genome
Start of coronavirus genome
Start of the
coronavirus
genome
Start of the
coronavirus
genome
In December, a cluster of mysterious pneumonia cases appeared around a seafood market in Wuhan, China. In early January, researchers sequenced the first genome of a new coronavirus, which they isolated from a man who worked at the market. That first genome became the baseline for scientists to track the SARS-CoV-2 virus as it spreads around the world.
Genome Wuhan-Hu-1, collected on Dec. 26 from an early patient in Wuhan
Genome Wuhan-Hu-1, collected on Dec. 26 from an early patient in Wuhan
Genome Wuhan-Hu-1, collected on Dec. 26 from an early patient in Wuhan
Genome Wuhan-Hu-1, collected on Dec. 26 from an early patient in Wuhan
A cell infected by a coronavirus releases millions of new viruses, all carrying copies of the original genome. As the cell copies that genome, it sometimes makes mistakes, usually just a single wrong letter. These typos are called mutations. As coronaviruses spread from person to person, they randomly accumulate more mutations.
The genome below came from another early patient in Wuhan and was identical to the first case, except for one mutation. The 186th letter of RNA was u instead of c.
Genome WH-09, collected on Jan. 8 from another patient in Wuhan
186th RNA letter changed
Genome WH-09, collected on Jan. 8 from another patient in Wuhan
186th RNA letter changed
Genome WH-09, collected on Jan. 8 from another patient in Wuhan
186th
RNA letter
changed:
Genome WH-09, collected on Jan. 8 from another patient in Wuhan
186th RNA letter
changed:
When researchers compared several genomes from the Wuhan cluster of cases they found only a few new mutations, suggesting that the different genomes descended from a recent common ancestor. Viruses accumulate new mutations at a roughly regular rate, so the scientists were able to estimate that the origin of the outbreak was in China sometime around November 2019.
Outside of Wuhan, that same mutation in the 186th letter of RNA has been found in only one other sample, which was collected seven weeks later and 600 miles south in Guangzhou, China. The Guangzhou sample might be a direct descendent of the first Wuhan sample. Or they might be viral cousins, sharing a common ancestor.
During those seven weeks, the Guangzhou lineage jumped from person to person and went through several generations of new viruses. And along the way, it developed two new mutations: Two more letters of RNA changed to u.
Genome GZMU0030, collected on Feb. 27 in Guangzhou
Another RNA letter mutated
This mutation also changed an amino acid
Genome GZMU0030, collected on Feb. 27 in Guangzhou
Another RNA letter mutated
This mutation also changed an amino acid
Genome GZMU0030, collected on Feb. 27 in Guangzhou
Another RNA letter mutated. This mutation also changed an amino acid.
Genome GZMU0030, collected on Feb. 27 in Guangzhou
Another RNA letter mutated. This mutation also changed an amino acid.
Mutations will often change a gene without changing the protein it encodes.
Proteins are long chains of amino acids folded into different shapes. Each amino acid is encoded by three genetic letters, but in many cases a mutation to the third letter of a trio will still encode the same amino acid. These so-called silent mutations dont change the resulting protein.
Non-silent mutations do change a proteins sequence, and the Guangzhou sample of the coronavirus acquired two non-silent mutations.
Amino acid change in the ORF1a protein
Amino acid change in the E protein
Amino acid change in ORF1a
Amino acid change in E
Amino acid change in the E protein
Amino acid change in the ORF1a protein
Amino acid change in the E protein
Amino acid change in the ORF1a protein
But proteins can be made of hundreds or thousands of amino acids. Changing a single amino acid often has no noticeable effect on their shape or how they work.
As the months have passed, parts of the coronavirus genome have gained many mutations. Others have gained few, or none at all. This striking variation may hold important clues to coronavirus biology.
The parts of the genome that have accumulated many mutations are more flexible. They can tolerate changes to their genetic sequence without causing harm to the virus. The parts with few mutations are more brittle. Mutations in those parts may destroy the coronavirus by causing catastrophic changes to its proteins. Those essential regions may be especially good targets for attacking the virus with antiviral drugs.
Total number of amino acid substitutions found in 4,400 coronavirus genomes from Dec. to April
Longer lines may show places where the genome is more tolerant of mutations.
Gaps may show critical spots in the genome that cannot tolerate mutations.
Total number of amino acid changes in 4,400 coronavirus genomes from Dec. to April
Longer lines may show places where the genome is more tolerant of mutations.
Gaps may show critical spots in the genome that cannot tolerate mutations.
Total number of amino acid changes in 4,400 coronavirus genomes from Dec. to April
Longer lines may show places where the genome is more tolerant of mutations.
Gaps may show critical spots in the genome that cannot tolerate mutations.
Total number of amino acid changes in 4,400 coronavirus genomes from Dec. to April
Longer lines may show places where the genome is more tolerant of mutations.
Gaps may show critical spots in the genome that cannot tolerate mutations.
As mutations accumulate in coronavirus genomes, they allow scientists to track the spread of Covid-19 around the world.
On January 15, a man flew home to the Seattle area after visiting family in Wuhan. After a few days of mild symptoms he tested positive for Covid-19. He became the first confirmed case of Covid-19 in the United States.
An X-ray of the patients lungs showed evidence of pneumonia.NEJM
The genome of his virus contained three single-letter mutations also found in viruses in China. They allowed scientists to trace the mans infection to its source.
Genome WA1, collected on Jan. 19 from a man in the Seattle area who visited Wuhan
Genome WA1, collected on Jan. 19 from a man in the Seattle area who visited Wuhan
Genome WA1, collected on Jan. 19 from a man in the Seattle area who visited Wuhan
Genome WA1, collected on Jan. 19 from a man in the Seattle area who visited Wuhan
Identical genomes collected on Jan. 21 in Fujian and Guangdong provinces
Identical genomes collected on Jan. 21 in Fujian and Guangdong provinces
Identical genomes collected on Jan. 21 in Fujian and Guangdong provinces
Identical genomes collected on Jan. 21 in Fujian and Guangdong provinces
Five weeks later, a high school student in Snohomish County, Wash., developed flu-like symptoms. A nose swab revealed he had Covid-19. Scientists sequenced the genome of his coronavirus sample and found it shared the same distinctive mutations found in the first case in Washington, but also bore three additional mutations.
Genome WA2, collected on Feb. 24 from a high-school student in the Seattle area
Genome WA2, collected on Feb. 24 from a high-school student in the Seattle area
Genome WA2, collected on Feb. 24 from a high-school student in the Seattle area
Genome WA2, collected on Feb. 24 from a high-school student in the Seattle area
That combination of old and new mutations suggested that the student did not acquire the coronavirus from someone who had recently arrived from another country. Instead, the coronavirus was probably circulating undetected in the Seattle area for about five weeks, since mid-January.
Since then, viruses with a genetic link to the Washington cluster have now appeared in at least 14 states and several countries around the world, as well as nine cases on the Grand Princess cruise ship.
Genome collected on March 5 from two passengers on the Grand Princess cruise ship
Genome collected on March 5 from two passengers on the Grand Princess cruise ship
Genome collected on March 5 from two passengers on the Grand Princess cruise ship
Genome collected on March 5 from two passengers on the Grand Princess cruise ship
A different version of the coronavirus was also secretly circulating in California. On Feb. 26, the C.D.C. announced that a patient in Solano County with no known ties to any previous case or overseas travel had tested positive.
A sample taken the next day revealed that the virus did not have the distinctive mutations found in Washington State. Instead, it only had a single mutation distinguishing it from the original Wuhan genome. That indicates that it got to California through a separate introduction from China.
Genome UC4, collected on Feb. 27 from a patient in Solano County, Calif.
The tension between private liberty and public health in the United States is hardly new. Americans have demanded the latter in times of plague and prioritized the former in times of well-being since at least the Colonial Era. Politicians and business leaders have alternately manipulated and deferred to that tension for about as long.
In 1701, members of the Massachusetts Bay Colony fought a yearlong political battle to enact the nations first quarantine laws against opponents who said such measures were too severe. In 1918, during the flu pandemic, the mayor of Pittsburgh brought a ban on public gatherings to a swift and premature conclusion over concerns about a coming election.
In 2020, the same tension is back with a vengeance. The nation is under siege from the worst pandemic in a century, and the United States is on track to suffer more deaths than any other industrialized country from SARS-CoV-2, the medical name for the novel coronavirus.
Attorney General William Barr last Monday ordered Justice Department lawyers to be on the lookout for state and local directives that could be violating the constitutional rights and civil liberties of individual citizens. He was talking about state and local orders closing businesses and requiring people to shelter in place to help combat the spread of the virus. The Constitution is not suspended in times of crisis, Mr. Barr said in an April 27 memo.
Yet the same Mr. Barr, early in the outbreak, was seemingly so concerned about its impact that he proposed letting the government pause court proceedings and detain people indefinitely without trial during emergencies effectively suspending the core constitutional right of habeas corpus.
Temporary limitations on some liberties dont seem to concern most Americans at this moment. Polls show that 70 percent to 90 percent of the public support measures to slow the spread of the virus, even if those measures require temporarily yielding certain freedoms and allowing the economy to suffer in the short run.
Indeed, it is wealthy and powerful conservatives and their allies, including President Trump and Fox News, who are driving the relatively small protests demanding a liberation of the states from oppressive lockdowns as opposed to any overwhelming public sentiment to that effect.
Whats more, every country that has managed to get its Covid-19 outbreak under control has done so with measures far more aggressive than anything tried in the United States so far.
In China, South Korea and Singapore, the authorities quickly established comprehensive testing, along with rigorous contact tracing, isolation and quarantine. In the United States, such efforts are still under construction and are proceeding at a snails pace; three-plus months into the crisis, just a tiny fraction of the needed tests, contact tracers and quarantine facilities are operational anywhere.
Civil liberties may feel to some like a second-order problem when thousands of Americans are dying of a disease with no known treatment or vaccine. Yet while unprecedented emergencies may demand unprecedented responses, those responses can easily tip into misuse and abuse, or can become part of our daily lives even after the immediate threat has passed. For examples, Americans need look no further than the excesses of the post-Sept. 11 Patriot Act.
As the nation starts looking ahead to the next phase of its battle against the coronavirus, we need to have a more honest conversation about the extent to which governments may impose restrictions on their citizens that would not and should not be tolerated under normal conditions.
FREEDOM OF SPEECH AND RELIGION
Consider the rights to free speech, association and religious exercise under the First Amendment: These freedoms are central to our self-definition, and yet they have all been infringed on to varying degrees across the country, as states ban gatherings where the virus can spread quickly and easily. In Maryland and Iowa, for example, all types of large events and gatherings, including church services, have been prohibited. (Many other states have exempted religious services from their bans, which raises the separate question of whether the government is impermissibly favoring religion.)
Bans like these are legal, as long as they are neutral and applicable to everyone. A state may not shut down only certain types of events, or prohibit speakers expressing only certain viewpoints. Under Supreme Court precedent, any infringement on speech or religion must be incidental to the central goal of the restriction, which in this case is clear: stopping the spread of the coronavirus.
But even if all these bans are legal on their face, what happens as the 2020 election approaches? Speech and association rights are at their peak in the political context, and Americans will be especially wary of any incursions on those rights in the months or weeks before Election Day. What if a state lifts some restrictions on large gatherings, then reimposes them in the days before an election? That may be necessary if there is another wave of the virus, and yet in a highly polarized political environment, citizens might well distrust official motivations behind a crackdown, and that could generate public unrest.
This is why its so important for the authorities to build that trust now, and to rely openly on scientific consensus when imposing and lifting bans on gatherings and other events.
SURVEILLANCE AND CELLPHONES
Another area of concern is the governments ability to know where we are and whom were with. In normal times, the authorities generally have to obtain a warrant to search your personal property, like a cellphone, or to retrieve its data to find your location.
But giving the government access to all that data carries huge risks. There were already far too many examples of law-enforcement officials abusing their access to cellphone data in the pre-Covid era, taking advantage of revolutions in technology to track people in ways that no one would imaginably consent to. Even if people give their consent to be tracked during the pandemic, governments have a very poor track record of relinquishing new powers once they have them.
The question then becomes: Can cellphone data be used in a way that helps stem the spread of the coronavirus while also being kept out of the hands of the government to avoid abuse, now or down the road?
Apple and Google are in the process of producing an app that would use secret codes to track people through their phones, while leaving the location data on those phones. People who test positive would be given the choice of putting their phone on a list. Other peoples phones could automatically check that list, and if any were within range of the infected person, those people would be notified that they could be at risk.
Fine, in theory. But for a system like this to work, the public needs to buy into it. Enough people have to use these apps to make them effective at least 60 percent of cellphone users, by some estimates and no city or country is anywhere close to that level of adoption. In Norway, only 30 percent of people have downloaded this type of location app.
Another hurdle is that the big technology companies have a poor record of protecting their users private information.
In the end, contact tracing a central feature of any comprehensive public-health response will need to be a cooperative endeavor, involving not only downloadable apps but perhaps hundreds of thousands of human beings, all doing the hard work of direct outreach to find those people at the highest risk of infection.
LIBERATING AMERICA
It would be one thing if the calls to reopen America from President Trump and his allies were part of a coordinated pandemic response strategy by a federal government that had taken strong and science-based measures from the start. But the White House failed to do that at virtually every turn, which makes the current protests ring hollow.
Its possible that at least some of the current lockdowns could have been avoided had the Trump administration led the way back in January when we still had time to take advantage of the information coming out of China and prepare the United States for what lay ahead. In that sense, these devastating shutdowns represent a catastrophic failure of timely government action. Even today, top officials are refusing to take the most basic safety measures. On Tuesday, Vice President Mike Pence toured the Mayo Clinic but refused to follow the clinics requirement to wear a mask. What message does he think that sends to the American people? (On Thursday Mr. Pence visited a plant producing ventilators in his home state, Indiana, and wore a mask.)
In a large self-governing society, civil liberties exist as part of a delicate balance. That balance is being sorely tested right now, and there is often no good solution that does not infringe on at least some liberty. At the same time, the coronavirus provides Americans with an opportunity to reimagine the scope and nature of our civil liberties and our social contract. Yes, Americans are entitled to freedom from government intrusion. But they also have an obligation not to unnecessarily expose their fellow citizens to a deadly pathogen. Protecting Americans from the pandemic while also preserving our economy and our civil liberties is not easy. But its essential.
Six weeks after first feeling unwell, Jenny* is still recovering from what she believes was Covid-19.
On 17 March she, like many others, began preparing for an expected lockdown in the UK, stocking up on supermarket essentials. She was feeling a little flushed something she put down to a reemergence of cold-like symptoms from a few weeks before.
Then the other symptoms began, including a runny nose, sneezing and phlegm. At that time, everybody was saying that runny noses and sneezing were not symptoms of coronavirus so I still didnt think I had it, the 33-year-old said. Then I started coughing.
As the days marched on, other symptoms developed, including chest pains, shortness of breath and marks like dappled bruising on the feet something Spanish doctors have suggested could be a sign of the disease.
It really was like one thing after another, Jenny said, adding that on attempting to get back to work, typing in bed, she developed muscle pains in her wrists.
Her flatmate also became ill with symptoms including a fever and loss of taste and smell. Without testing, it is impossible to be sure, but it seemed highly probable that the cause of the illness in both flatmates was Covid-19.
Jenny still feels exhausted, with days of feeling better followed by setbacks. I still dont feel better because a few days ago I started shivering, like I got a chill somehow, she said.
She is not alone: Fiona Lowenstein, a writer in the US, co-founded a group on the social media platform Slack for people who have experienced Covid-19 after it took her weeks to recover from being admitted to hospital with the disease.
Dr Andy Whittamore, a GP in Portsmouth and Asthma UKs clinical lead, says that viruses are a trigger for asthma and asthma symptoms, and therefore it is fair to assume that coronavirus will act in the same way.
Health bodies around the world are listing asthma as a condition that might be considered high risk, but so far there is no evidence to suggest that having asthma increases the infection rate from the coronavirus. There is, though, some evidence that people who have asthma and catch the coronavirus are more likely to go on to have a more severe case of Covid-19. There is yet to be any data which shows how asthma impacts on the mortality rate from the coronavirus, but doctors are advising that people with the condition try to manage their asthma symptoms as best they can in case they catch the coronavirus.
Asthma is a condition of the airwaves, causing inflammation of the airwaves. It can lead to wheezing, coughing and a tight chest, and be triggered both by internal factors in the body, like levels of hormones, and external factors, like viruses, pollution and allergens. Colds and flu are considered a major trigger.
Many report waves of symptoms over a period of weeks from heart palpitations to headaches, shortness of breath and fatigue.
In a survey of group members, 89% of the 465 respondents said they had symptoms that fluctuated in intensity and frequency; 23% had tested positive for coronavirus, taking on average just over nine days to be tested from the onset to symptoms; 28% tested negative and were, on average, tested after about 15 days; and just 3.5% were admitted to hospital, although 38% visited an emergency department.
With symptoms long-lasting, some members have concerns over whether they are still infectious.
A report published in February by the World Health Organization, based on preliminary data, suggested in mild cases, the median recovery time from Covid-19 is about two weeks from the onset of symptoms, and about three to six weeks for severe or critical cases.
But while severe Covid-19 may mean a long road to recovery, it seems even mild cases can, for some, involve many weeks of recuperation.
Alice* is still experiencing symptoms more than 50 days after first becoming ill. Based in the UK, the 51-year-old said she joined the Slack group after reading an article by Lowenstein in the New York Times, and that finding the group was a big relief.
From 11 March, Alice experienced consistent severe fatigue, chest pain and tightness, and a cough but no fever. Other symptoms came and went in waves, including chills, insomnia and heart palpitations. Day eight, nine, 10 was just really horrible, you are just concentrating on breathing and hanging in there, she said.
It is like a storm. One day you have zero symptoms then it will just go crazy and as quickly as it hits you it can go.
By week four she felt on the mend, and began some work and to exercise but then relapsed. Eventually she went to A&E. But despite being put in one of the hospitals coronavirus pods, and having various investigations, she was not tested for the virus, she said.
The symptoms continued to come and go, Alice said. It is like a storm. One day you can have zero symptoms then it will just go crazy and as quickly as it hits you it can go.
Lauren Nichols, 32, from Boston, Massachusetts, is another member of the Slack group. She has tested positive for Covid-19 twice and still has symptoms more than 50 days after first feeling unwell. She said the experience was a rollercoaster of symptoms and severities.
My biggest concern is that there is little visibility into the reality of what recovery truly looks like, as recovery from a medical perspective simply means that the patient did not die and simply does not capture the lingering and painful symptoms that the Covid-19 recovery road truly entails for some or many, Nichols said, adding that some of her most alarming symptoms occurred in her third and fifth weeks of being unwell.
I am concerned that employers and governments are rushing the recoveries of thousands who are still in pain and still symptomatic, without understanding that this causes both mental and physical complications for people already in a very vulnerable and unwell state of being, she said, adding that she was also concerned about the lack of support for those recovering.
Dr Michael Head, a senior research fellow in global health at the University of Southampton, said it was perhaps not surprising that some people had long recoveries. Many people often take weeks to completely recover from pneumonia, he said. In these cases, the viral illness has typically long since subsided and thus it is unlikely the patient will be infectious.
But it is unclear why some take longer than others to recover. We know that recovery time after pneumonia is often influenced by the presence of co-morbidities and by age of the patient, said Head. Alongside that, many people will have undiagnosed co-morbidities, such as diabetes, also influencing how ill a patient becomes, and their recovery time.
The Slack group survey found two-thirds of respondents had a pre-existing medical condition, mainly seasonal allergies or asthma.
Why there should be such variation in recovery time remains unknown, but a genetic element may play a part, said Dr James Gill, an honorary clinical lecturer at the University of Warwick and a locum GP. Preliminary work from Kings College London has suggested that genetic factors could account for about half of the variation in a number of key symptoms of Covid-19.
Gill said he was only seeing about two to three patients a week with long-lasting symptoms, suggesting the experience is not common, although he noted that without community-level testing to know who had had the virus, it would remain unclear how common a recovery path was.
But Gill said data from the Sars outbreak revealed that almost a third of those who had had that particular coronavirus still had a reduced tolerance to exercise many months later, despite having normal lung function. While Gill stressed that Covid-19 was a different disease, he said it could be that a similar proportion of about a fifth or a third of those with Covid-19 had lengthy recovery time .
Although symptoms may linger, it is thought an individual is unlikely to be infectious once three days have passed with no raised temperature, but coughing should be treated with caution, Gill said.
What recovery looks like is an evolving picture, he continued. We are learning on a daily, weekly basis, things about how people are recovering from this, and we cant know about the long-term impacts until we are in the long term.
The only way to completely understand is by observation over the long term and this includes recovery time.
Prof David Heymann, of the London School of Hygiene and Tropical Medicine, agreed with Gill. Whenever a new virus that has come from the animal kingdom is identified in humans there is great concern about what is not known because humans do not have previous experience with this virus and the immune response it will cause, Heymann said. The only way to completely understand is by observation over the long term and this includes recovery time from infection.
With suggestions that some cases of chronic fatigue syndrome (CFS) may arise after illnesses including viral infections, Gill said concern was starting to mount.
There are a lot of people wondering whether or not we are going to see an uptick in cases of chronic fatigue going forwards as a result [of Covid-19], he said. We dont know that, but it is something that we are thinking may be possible.
Carmine Pariante, a professor of biological psychiatry at Kings College London, agreed there could be a rise in people experiencing a CFS-like syndrome. We dont know if this is going to happen with Covid-19 because we dont have the follow-up data, he said. But the picture unfortunately, both in terms of the biochemical picture [of the immune response] and the acute fatigue, which is very prevalent, make us think it will be possible.
Gill said it was important that those who had had a coronavirus infection or suspected Covid-19, had access to physiotherapists and nutritional advice.
Also helpful would be leaflets with advice on recovery, such as reminding patients to drink plenty of fluids and to do breathing exercises, said Gill, adding that some advice could be drawn from existing knowledge of other conditions.
Ultimately, it is important to take time to recover, he said. If you have had coronavirus and you have been flattened by it, you have no get-up-and-go, and you are fatigued. You need to rest, and you need to go back to work or doing whatever you do in a step-wise progression.
*Some names have been changed
Sweden has persisted with the strategy of coronavirus mitigation that the UK government eventually abandoned in March. The policy is widely supported by the public, even though the Swedish Covid-19 mortality rate is among the 10 highest in the world, at 240 per million population and steadily rising, and many of the nursing homes in Stockholm are now affected.
The typical explanation for this continued public support is that Swedes are trusting and unflappable. The countrys chief epidemiologist, Anders Tegnell, the public face of the Swedish response to the pandemic, is after all a dry scientist-turned-bureaucrat, not some populist politician trying to whip up nationalist go-it-alone emotion.
But beneath the surface, Sweden is anything but calm. The public debate is inflamed with a sense of wounded national pride. As a believer in the kind of liberal nationalism that encourages self-critical national attachment, this pains me. But as a scholar of nationalism, I recognise the pattern. This is what Isaiah Berlin called the nationalism of the bent twig, which lashes out against anyone who steps on it.
It began with a self-conceit that seemed more comical than harmful. Why, one columnist asked, could we not just let Sweden be Sweden? Others suggested we brand ourselves smart Sweden or kind Sweden, the country immune to the hysteria of southern Europe.
The next step was the ridicule and delegitimisation of opponents. A group of 22 scientists wrote a joint opinion column arguing for a drastic change of strategy. But within a few hours no one was paying attention to the substance of their arguments. Instead the debate came to revolve entirely around the fact that they used Covid-19 death numbers that made Sweden look worse than the more cautious estimates of the public health agency. This was certainly clumsy, but did not undermine their main conclusion. Nor does the fact that Sweden does indeed now have close to six times more deaths per capita than neighbouring Norway or Finland.
Then came contempt for emotions, mixed with misogyny. Lena Einhorn, one of the 22 critics, was interviewed via videolink from her home. She broached research reports and numbers, but influential columnists focused on making fun of her hair or curtains. Her hysterical voice when describing the suffering of Covid-19 patients was also widely mocked. The detached response to her by chief epidemiologist Tegnell was hailed as evidence of his credibility. It is true that he speaks clinically about death in terms of statistical curves. But it is equally true that he did not offer much rebuttal of the research reports she quoted.
From this trope of Sweden being alone in doing it right, we seem now to have shifted to denying that Sweden is doing anything exceptional at all. An opinion piece by a political scientist suggested that the Guardian had blacklisted Sweden, and that its reporting had described Sweden as free from restrictions. Who would have thought Trumps fake news would one day turn out to be somewhat real? he concluded.
But these claims are themselves untrue. The Guardian among others rightly reported the comparatively mild restrictions in Sweden. Nor was it fake news when Italian newspaper La Repubblica reported that Swedish doctors could soon be denying respirators to patients over the age of 80, and even those as young as 60 with underlying health conditions. In fact, this is now taking place.
The public veneration for Tegnell has gone far beyond trust. He has become an icon, his face appearing on tattoos and baby garments. Writers otherwise known to cringe at any sign of nationalism describe him as the incarnation of Swedens soul. He should be named Swede of the year, says the former minister of public health. Serious newspapers run hagiographic stories on Tegnell and the general director of the public health agency, Johan Carlson. Pictures of their head offices flooded with flowers sent by private citizens are included.
Some failures of the Swedish model have been acknowledged. But they are often linked to the lack of compliance of immigrants. Former chief epidemiologist Johan Giesecke explains the failure to protect the elderly in nursing homes with reference to asylum seekers and refugees on the staff, who may not always be understanding the information. This has met with silence, if not approval. It may already have been picked up by the Sweden Democrats, Swedens anti-immigration party, who now claim the health of elderly people has been put at risk for the sake of integrating uneducated immigrants.
Defenders of the governments strategy keep repeating that it is too early to evaluate it. But carrying that argument through to its logical conclusion suggests that veneration should also be postponed until the pandemic has passed. Any successful strategy should be transparent and welcome public scrutiny. My fear is that in our vehement defence of the Swedish approach, we have released forces we cannot control. As is clear for anyone who has followed Brexit, a nationalism unable to handle criticism can easily tear a society apart.
Gina Gustavsson is an associate professor at the Department of Government, Uppsala University, and an associate member of Nuffield College, University of Oxford. With David Miller she is the co-editor of Liberal Nationalism and Its Critics: Normative and Empirical Questions
In 2018, I wrote an Op-Ed for this paper under the headline Were All in the Ghetto Now. I criticized Donald Trumps flagrant disregard of constituents and constituencies he didnt like or consider allies.
Back then, I used the ghetto to describe the impact of Mr. Trumps tendency to demonize his perceived enemies and then cast them into a permanent irrelevance that justified his ignoring of their concerns, to put them over there. I was exploring the connections between a white authoritarian politicians dangerous worldview and the most demonized of American spaces, the black ghetto.
When I wrote in 2018, the ghetto was a metaphor. It feels more real all the time.
Thanks to the coronavirus pandemic, a majority of us are living in a ghetto of Mr. Trumps creation, physically and politically. The ghetto is a large majority of America, confined at home and in neighborhoods that went from being sanctuaries to stagnant, stressful places whose prospects have vanished overnight.
Like generations of black people whove lived in segregation everywhere in country, people of all colors from California to Maine are frustrated, anxious and significantly jobless. They are being ignored and dismissed by top leadership that is indifferent about whether they live or die.
This is life in the ghetto that Mr. Trumps inept and heartless handling of the coronavirus pandemic has created.
The president has said the enemy is the virus, but thats too abstract for him; the real enemy is anyone who acknowledges the seriousness of the coronavirus crisis, which continues to upstage and overshadow him.
This means that people obeying lockdown orders, sheltering at home, demanding tests, getting sick or dying all disturb Mr. Trumps embattled sense of superiority and control. They have all been relegated to the enemy list the ghetto and in his mind deserve not just irrelevance but also contempt.
Of course this was preceded by his ghettoizing of the governors of states who have ordered lockdowns and other measures, like Jay Inslee of Washington, Andrew Cuomo of New York and Gavin Newsom of California. (The fact that these are blue states made Mr. Trumps dismissal of the well-being of their residents that much easier. You might say that blue is the new black.)
This would all be absurd it were not so tragically real. The more the death toll rises and the clearer it becomes that Mr. Trump is totally unsuited for the moment, the more he rails and divides, taking the conservative phenomenon of blaming the victim to shameless new heights. This time the victims are not just protesters or poor, black urban dwellers; they are all of us living everywhere, because the virus lives everywhere.
At least now we have confirmation of what many of us have known for a long time Trumpism is not a new political philosophy or coherent agenda, but simply him versus us. And in his mind he always wins, even if hes actually losing, as he certainly is now. Yet this bears repeating Mr. Trumps outrageous stance tracks with the American view of ghettos, projecting them as failures deserving indifference at best, even though the failure is all ours. As a country, we have a long and sordid history of not taking responsibility for the most vulnerable among us.
Mr. Trumps relentless ghettoizing confirms something else that has been obvious for a long time, long before he became president: The United States is not united, especially when the chips are down. The most resources-rich country in the world could not find the wherewithal to warn its people about what was coming, and it continues to bumble basic things like administering tests and acquiring enough ventilators. This is because Republicans have been vilifying the federal government, embedded with the ideal of a common good for a common American people, for the past 40 years. The fact that the most conscientious response to this historic crisis is coming from individual governors, not the White House, may be appalling, but its not surprising.
It was inevitable that the group suffering the highest fatality rate from the virus would be black. Instead of putting that statistic over there, per usual, other Americans have to see themselves within it, because they are at risk, too.
Can we save ourselves? I would like to think so, but the fact that traditional ghettos have not been able to do so it has been structurally impossible does not bode well for our future. I have occasionally been heartened to see all the messages and images of people heroically coming together in very tough times. Americans are good, almost instinctual, at campaigns like this.
But the campaigns are not enough. They are a reaction to the forces of separation, alienation and devaluation that Mr. Trump did not create but that he expands at will, with little pushback. He puts us in ghettos whenever and however he feels like it. The question is when, and how, we will break out of them.
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Mannequins dressed in wedding gowns and wearing protective face masks in Gaza City in March. With wedding halls closed and public gatherings forbidden to prevent the spread of the virus, many couples have celebrated their marriage in alleyways and apartments so grooms can save the fortune they're normally expected to spend on big parties. Mohammed Abed/AFP via Getty Images hide caption
Mannequins dressed in wedding gowns and wearing protective face masks in Gaza City in March. With wedding halls closed and public gatherings forbidden to prevent the spread of the virus, many couples have celebrated their marriage in alleyways and apartments so grooms can save the fortune they're normally expected to spend on big parties.
For Gaza's broke grooms, the coronavirus crisis has been the perfect time to get married.
With wedding halls closed and public gatherings forbidden to prevent the spread of the virus, many couples have celebrated their marriage in alleyways and apartments so grooms can save the fortune they're normally expected to spend on big parties.
Palestinian tradition dictates that the groom pay for the wedding, not the bride or her family.
"I have saved at least $5,000 on renting a wedding hall, having a banquet, two wedding parties, renting cars and other details," said Aziz Masoud, 26 and jobless, who was carried on his friends' shoulders in an alleyway of Gaza's Jabaliya refugee camp earlier this month.
Officials do not collect statistics on wedding parties, but one hair and makeup salon for brides reported a 60% jump in business since Gaza imposed restrictions in March, and the chief justice of Gaza's Islamic court in charge of registering marriages said he'd noticed the unseasonable wedding boom.
Marriage is one of many financial burdens in beleaguered Gaza. The strip is sandwiched between Israel and Egypt, which imposed a blockade on the territory after the Islamist group Hamas took it over in 2007.
Most of the territory's 2 million residents live in poverty and 43% were unemployed at the end of 2019.
Many young men in Gaza delay marriage because they can't afford the two traditional parties they're meant to sponsor: a bachelor party with a traditional marching band for the groom and his male friends, and a big celebration in a wedding hall for the families and friends of the bride and groom, featuring a banquet during the day and dancing at night.
The newlywed Masoud signed a marriage contract a year and a half ago, but in Gaza's socially conservative society, he couldn't live together with his wife until he threw the requisite parties. He asked his father for cash, but he too is out of work.
In March, Palestinian Authority President Mahmoud Abbas ordered wedding halls, schools, mosques and some markets shut in the West Bank, and Hamas in Gaza imposed the same restrictions, despite its deep rivalry with the West Bank leadership.
"Use the coronavirus crisis to save money"
"I whispered in my son's ear to use the coronavirus crisis to save money, especially because I don't have work anymore," Sami Masoud, the groom's father, said.
His son's several dozen friends sang, danced and set off celebratory fireworks in the alleyway until neighbors complained, mistaking the booms for Israeli airstrikes. Outdoor parties aren't allowed anyway, due to coronavirus restrictions, so they moved the festivities indoors.
No one wore masks or was concerned about gathering. Officials warn of disaster should the virus spread in the small seaside territory with health services frayed from years of war and blockade. But the young men shared the confidence of many locals that the virus is contained in Gaza.
There have been only 17 confirmed virus cases, all were quarantined, and all but five have recovered, according to Gaza's Health Ministry. About 1,900 Palestinians who crossed into Gaza from Egypt have been held in quarantine centers to ensure they are not infected. Testing has not been widespread, but Gaza's suffocating blockade prevented an influx of travelers able to bring in the virus early on.
Dream wedding deferred
Couples rushed to hold wedding parties before the April 23 start of Ramadan, a month of prayer and fasting when weddings are not typically held. By the time Ramadan ends, many Gazans expect coronavirus restrictions to be lifted, wedding halls to be reopened and social pressure back again to throw lavish wedding parties.
One big hidden cost of a low-cost Gaza coronavirus wedding: Couples do not get the wedding of their dreams, perhaps in one of Gaza's fancy wedding halls with beach views of the Mediterranean Sea.
Mohammed Aqel, 24, called off the two parties he'd planned, canceled his wedding hall reservation and held a small gathering inside his house in March with plastic chairs and balloons.
"It's awesome that I saved at least $4,500," Aqel said. "But honestly, I have pain in my heart." His wife, Islam Abu Matar, was not happy.
"I lost the most important night in my life. It will not be repeated," said Abu Matar, 20. She compared herself to her married friends. "They did their night with lots of guests and a big wedding hall. But I had very limited number of guests with no hall."
Another bride, 23-year-old architecture student Diana Aqel, of no relation to Mohammed, faced pressure from her fianc and his family to ditch the traditional wedding party and have a more modest event this month. She refused.
"If I did it, I would feel remorse for the rest of my life," said Aqel. "Happiness is more important than money."
Sami Abu Salem reported from Gaza.
A new test for the coronavirus is so simple and straightforward, almost anyone could do it: Spit a glob of saliva into a cup, close the lid and hand it over.
While not as fast to process as the speediest swab tests, saliva tests could transform the diagnosis of Covid-19. If manufactured in enough numbers and processed by enough labs across the country, they could alleviate the diagnostic shortages that have hampered containment of the pandemic and offer a less onerous way for companies to see if workers are infected.
The first saliva-based test, already being offered in parts of New Jersey, detects genetic material from the virus, just as the existing tests do, but it avoids a long swab that reaches disturbingly far up a persons nose. For the saliva-based, health care workers do not need to wear and discard precious gowns and masks. And early evidence suggests it is just as sensitive, if not more so, than the swabs.
Because the saliva test relies on equipment that is widely available, it also offers the hope of a nationwide rollout without encountering the supply problems that have plagued the swabs.
Starting about two weeks ago, New Jersey has offered the saliva test at a walk-up site in New Brunswick; drive-through sites in Somerset and Edison; the states Department of Corrections; 30 long-term care facilities; and even the American Dream mall.
Experts not involved with the test praised it as a welcome solution to diagnostic shortages across the country.
If people are going back to work, and theyre going to be tested presumably on a regular basis, we really do need to have less invasive sampling methods than the swabs, said Angela Rasmussen, a virologist at Columbia University. To have to do nasopharyngeal swabs twice a week? No, thanks.
The next step would be an at-home saliva test kit that skirts even the need to go to a walk-in center, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security.
Dr. Adalja noted that LabCorp, one of the nations largest commercial laboratories, now offers an at-home test that people can use to swab their own nose. If we can do nasal swabs unsupervised, theres no reason why we cant do these tests unsupervised as well, he said.
On April 13, the Food and Drug Administration granted an emergency-use authorization, waiving some usual requirements, to a saliva test made by a Rutgers University lab, RUCDR Infinite Biologics.
The Rutgers lab has already processed close to 90,000 tests, according to its chief executive, Andrew Brooks, and expects to ramp up eventually to 30,000 tests per day. Results are available within 72 hours, although they could be sped up to just a few hours with enough infrastructure in place. By contrast, some rapid tests that rely on swabs deliver results in minutes.
Other states are expressing interest. Working with Rutgers, Oklahoma has begun validating a version of the test, and the Rutgers researchers have fielded questions from the White Houses coronavirus task force, from Indiana, Illinois, California and from several large companies. In New Jersey, the test is available for between $65 and $100.
After a disastrously slow start, the United States is starting to see an increase in testing types and capacity. The National Institutes of Health on Wednesday announced a new $1.5 billion shark tank style program aimed at encouraging swift innovation in coronavirus testing, with a goal of new tests by the end of summer. Also Wednesday, the testing manufacturer Hologic said that it had a new test that could allow labs to begin running up to 1 million additional tests per week.
The nasopharyngeal swabs that have mostly been used to test for the coronavirus are invasive and uncomfortable, and may be difficult for severely ill people to tolerate. They also put health care workers at high risk of infection and require them to wear gloves, gowns and masks.
The saliva test, by contrast, doesnt require any interaction with a health care worker. And its easy enough that New Jersey has also started using it at developmental centers with residents who have intellectual and developmental disabilities.
The saliva is immersed in a liquid that preserves it until it can be analyzed. This will be particularly important for developing tests that people can use at home and mail or drop off at a lab, or when dealing with large numbers of samples.
When youre testing 10,000 at a drive-through a day, when youre at a correctional facility collecting it from 1,500 people per day, the use of a preservation agent is really critical, Dr. Brooks said.
He said that the preservative in the Rutgers test is a secret sauce made by a Utah-based partner, Spectrum Solutions, but that the ingredients are easily available and unlikely to pose supply problems.
However, some of the PCR machines, which amplify viral genetic material, require labs to use the manufacturers own reagents. That could potentially be a supply issue, Dr. Rasmussen said.
The Rutgers test was validated in people who were severely ill, but the saliva test often yielded a stronger signal than the swab, suggesting that it is more sensitive yielding fewer false negatives than the swab. It also generated no false positives in all of the samples tested.
False negatives in particular have been a problem with the nasopharyngeal swabs. (A different type of test for antibodies, which can say whether a person was exposed to the virus and has recovered, is riddled with false positives.)
In separate research, a Yale University team reported that saliva may be able to detect the virus in people who are only mildly ill, while a nasopharyngeal swab cannot.
In their study, the team compared swabs and saliva samples from patients. They needed only a few drops of saliva for their test, an advantage for people who may have trouble producing more. Thinking about a favorite meal can often do the trick, said Anne Wyllie, the Yale teams leader.
The swabs are known to produce false negatives perhaps in part because of errors by health care workers under stress. The saliva test appeared to be more consistent and accurate over a longer period of time, detecting infections even after the amounts of the virus have waned, than the swab.
The nasopharyngeal swab is subject to so much more variability in how well its obtained, Dr. Wyllie said. A saliva test is definitely more reliable.
In one case, the team found a health care worker who twice tested negative using a nasopharyngeal swab before finally testing positive on a third day. But the workers saliva tested positive all three days, Dr. Wyllie said. She underlined the risks of asymptomatic health care workers getting a false negative and continuing to care for patients. You can imagine the implications, she said.
While the Yale team did not compare saliva tests with the shorter swabs used in some tests, Dr. Wyllie said she expected that saliva tests would prove superior there as well. Most people with Covid-19 do not have runny noses, which might influence how much virus a short swab can collect, she said.
Saliva tests would also be a preferred choice for at-home tests, Dr. Adalja added. A saliva test for H.I.V. is the only at-home test approved for an infectious disease, he said, but before the pandemic, the federal Biomedical Advanced Research and Development Authority had funded two companies to develop at-home nasal swab tests for influenza.
Its not a high bar to repurpose home testing for the coronavirus, he said. Its not something thats out of reach.
There is little respite for the nurses working with coronavirus patients at N.Y.U. Langone Health.
Inside the recently opened Kimmel Pavilion in Manhattan, hundreds of patients rest in rooms designed to minimize infection. When the nurses do take a break, a soundtrack of wailing sirens reminds them what lies ahead on their return.
On March 10, N.Y.U.s medical center had just two coronavirus patients. Today, patients are spread over every floor of both Kimmel and nearby Tisch Hospital, said Robert Magyar, a hospital spokesman. The medical staff is weary, but many said they were relieved to have the supplies and protective gear that are in short supply at so many other institutions.
There are days where you feel great and ready to conquer the world, and there are days where you break down and feel really vulnerable, said Gabrielle Barshay, a senior staff nurse at Kimmel whose floor was the first to accept coronavirus patients. Its just difficult seeing these patients. A lot of them are alone, and they dont have their families. Sometimes its a lot of burden on one nurse.
For now, this tight-knit group of mostly 20-something nurses has each other, sharing the emotional burden of working, hoping and waiting.
These interviews have been edited for length and clarity.
It feels like a year already, like one long day thats never-ending.
Ive never had more anxiety in my entire four years of nursing. I feel like Im a new nurse again. Youre constantly on edge, your adrenaline is always pumping, you really dont know whats going to happen next. Overall, I think were just scared.
I change into normal clothes when I leave work, which I never did before. Now I wont even bring my scrubs inside my house. They literally sit in my backyard and they go to a laundromat. I dont even wash my scrubs inside my house anymore. I dont even wear the same shoes home, my shoes from work stay at work.
When people are visibly scared of us because were nurses, its kind of upsetting. Its hard because you kind of get where theyre coming from. But at the same time were putting our lives at risk everyday and were doing our best we can for you. Its a little insulting.
The patients have panic in their eyes.Meghan Curtin, 25, senior staff nurse
I have not seen my dad, who is diabetic, ever since our unit became Covid. Its scary knowing that with my direct exposure, I could potentially be inflicting this virus on one of my family members who would get really sick from it. I think its a tough spot to put anyone in.
The patients have panic in their eyes. Along with the anxiety that comes with not being able to have adequate oxygen and breathe, comes that panic of them saying, Am I going to die? Am I ever going to see my family again? Its very emotional for them and for us.
To think about having to have this lifestyle for a full year, it would be very difficult.
I try to numb my feelings as much as I can and honestly just focus on work.Vicky Jang, 26, senior staff nurse
I do hear concerns about racism from my mom and my dad especially. When this whole thing started and they were hearing all these stories about racism that was happening in the subways and the streets, they were more afraid of that than the infection itself. Which kind of prevented them from stepping outside.
My family and their friends, their community of Korean-Americans, are essential workers. They open up the laundromats and the dry cleaners in the city. So they have to go to work, they have to take public transportation, and they get dirty looks from all these people.
At this point Im just trying to numb my feelings. My brain is so focused on work that I dont have the capacity in myself to think about the future of how Im dealing with it in my home. I try to numb my feelings as much as I can and honestly just focus on work.
I cant just give up on being a nurse, and this is the time that they need us.Christine Ziobro, 38, senior staff nurse
I have four kids I have to go home to. I cant be separated. Im still breastfeeding my daughter, and its a lot of wear and tear on my body on top of me working the night shift taking care of these really sick patients. And Im worn out, but I have to keep going. I cant just give up on being a nurse.
This morning a patient was really sick, and shes dying alone and here I have to make the choice of whether or not I take an extra 10 minutes in the room with my P.P.E. on holding her hand, or just letting her die alone. Im a nurse for 12 years now. It didnt sit well with me to have her die alone and not have any family near her. Its been a really hard thing for a lot of us. These patients are really on their own and theyre counting on the nurses and doctors to make decisions for them.
I dont ever really cry because were taught to separate work and family. But sometimes it just gets [to be] too much. This morning I looked up and the doctor resident was bawling, crying in his mask, and I started crying and the other nurse started crying. Were all human, you know, theres only so much we can take.
This is something that is going to define who we are as health care workers in this generation.Steven Cabrera, 28, assistant nurse manager
The Covid-19 pandemic is our generations defining moment.
The mood quickly changed from this is a health scare to this is something that is going to define who we are as health care workers in this generation. We knew that this was going to become a war. It is kind of, in a mental sense, a war, because it really has become something that day in and day out is a battle to keep these patients safe and keep them healthy from such an aggressive virus.
While at one end were stressed, were anxious, were working our hardest to keep people safe and stable, the reflective part of me says, once this is said and done we can say that we were part of a collective force that overcame something huge. We were the ones that answered the call.
Each day you come in and the protocol has changed.Jessica Riney, 26, staff nurse
I was there the first day. It was my first day back from vacation. It was very hard, because this is not something weve dealt with before. As a new nurse, its very scary each time you get something youve never had before. As you go on, you kind of get your footing and you kind of understand OK, pneumonia, Ive seen this before, I know how to handle this.
Then here comes coronavirus. And we dont really know what this is. So from a nursing standpoint its scary, because each day you come in and the protocol has changed. And youre trying to catch up and trying to treat your patients the best you can.
What are we going to do if all the health care workers get sick? Whos going to take care of anyone when health care workers go down because they didnt have the proper supplies and equipment? I did not think our country would be running out of supplies. You look at pictures of nurses in other countries, and theyre in full hazmat suits, and then to hear stories about, you know, a nurse wearing a trash bag to protect herself, I mean thats dystopian.
Now that its happened it seems like we should have been prepared for something like this.Anna Howard, 23, staff nurse
I hit my sixth month working as a nurse at the beginning of March. So, I am still very new to all this. Its interesting to know that right now Im experiencing something that hopefully I wont ever experience again in my work as a nurse. But Ive seen a debate in the nursing community where some people say This is what we signed up for, this is what is expected of us.
To some extent, yes.
But on the flip side I think that not having the right supplies, that is not what we signed up for.
Having a national or global shortage of supplies and equipment is something I didnt foresee happening. It seems like no one really did. But now that its happened it seems like we should have been prepared for something like this.
We were learning in nursing school about disaster preparedness, different emergency protocols and stuff. And I thought Oh, OK, we have to learn about this, whatever, this isnt going to be something that I really use. I didnt really take it that seriously. And now here I am a year later in the middle of it.
I dont feel like Im fully there for the patient, and I feel like thats taking a toll on my nursing.Gabrielle Barshay, 29, senior staff nurse
Im an oncology nurse, so building a rapport with my patient and making them feel good and distracting them from their disease is something Im used to. Now, I go into the room and Im rushed to get out. I dont feel like Im fully there for the patient, and I feel like thats taking a toll on my nursing.
On a regular day I always ask the patient, Where are you from, wheres your family from? I would always talk to the families. Now when the patient asks me to stay and I end up having to stay in the room longer, I almost get angry. How are they not understanding that theyre risking my life? I hate that feeling because its not who I am.
Part of nursing is compassion, and I feel like because of the virus a lot of us are starting to lose that a bit and its very scary.
It breaks my heart, because I just want to hang out with you for a little bit longer and hold your hand, but I really shouldnt.
I would never want to put my child at risk.Madina Rizaeva, 25, senior staff nurse
I feel really grateful for the people that I work with, for the place where I work. And feel very strongly about my team, theyre really capable of a lot of things. Strong, smart individuals, very resilient.
I think that if we make it through this were definitely always going to remain a part of each others lives. These are uncertain, very difficult times that were going through, and it matters whos with you during these moments.
Im not seeing my 2-year-old son, so that part has been really difficult. I would never want to put my child at risk. I FaceTime him everyday, but my mom sometimes thinks its not such a great idea, because then he walks around the house calling my name and looking for me. Sometimes I think that maybe its easier if I let him forget about me, but I dont know how long this whole situation is going to last, and I dont want him to forget me.
