The prevalence of these effects is too great to attribute them solely to the cytokine storm, a powerful immune-system response that attacks the body, causing severe damage, doctors and researchers said.
Almost half the people hospitalized because of covid-19 have blood or protein in their urine, indicating early damage to their kidneys, said Alan Kliger, a Yale University School of Medicine nephrologist who co-chairs a task force assisting dialysis patients who have covid-19.
Even more alarming, he added, is early data that shows 14to 30percent of intensive-care patients in New York and Wuhan, China birthplace of the pandemic have lost kidney function and require dialysis, or its in-hospital cousin, continuous renal replacement therapy. New York intensive care units are treating so much kidney failure, he said, they need more personnel who can perform dialysis and have issued an urgent call for volunteers from other parts of the country. They also are running dangerously short of the sterile fluids used to deliver that therapy, he said.
Thats a huge number of people who have this problem. Thats new to me, Kliger said. I think its very possible that the virus attaches to the kidney cells and attacks them.
But in medicine, logical inferences often do not prove true when research is conducted. Everyone interviewed for this story stressed that with the pandemic still raging, they are speculating with much less data than is normally needed to reach solid clinical conclusions.
Many other possible causes for organ and tissue damage must be investigated, they said, including respiratory distress, the medications patients received, high fever, the stress of hospitalization in an ICU and the now well-described impact of cytokine storms.
It does raise the very clear suspicion that at least a part of the acute kidney injury that were seeing is resulting from direct viral involvement of the kidney, which is distinct from what was seen in the SARS outbreak in 2002, said Paul M. Palevsky, a University of Pittsburgh School of Medicine nephrologist and president-elect of the National Kidney Foundation.
One New York hospital recently had 51 ICU patients who needed 24-hour kidney treatment but had just 39 machines to do it, he said. The hospital had to ration the care, keeping each patient on the therapy less than 24 hours a day, he said.
The virus also may be damaging the heart. Clinicians in China and New York have reported myocarditis, an inflammation of the heart muscle, and, more dangerous, irregular heart rhythms that can lead to cardiac arrest in covid-19 patients.
They seem to be doing really well as far as respiratory status goes, and then suddenly they develop a cardiac issue that seems out of proportion to their respiratory issues, said Mitchell Elkind, a Columbia University neurologist and president-elect of the American Heart Association. This seems to be out of proportion to their lung disease, which makes people wonder about that direct effect.
One review of severely ill patients in China found that about 40percent suffered arrhythmias and 20percent had some form of cardiac injury, Elkind said. There is some concern that some of it may be due to direct influence of the virus, he said.
The new virus enters the cells of people who are infected by latching onto the ACE2 receptor on cell surfaces. It unquestionably attacks the cells in the respiratory tract, but there is increasing suspicion that it is using the same doorway to enter other cells. The gastrointestinal tract, for instance, contains 100 times more of these receptors than other parts of the body, and its surface area is enormous.
If you unfurl it, its like a tennis court of surface area this tremendous area for the virus to invade and replicate itself, said Brennan Spiegel, co-editor in chief of the American Journal of Gastroenterology.
In a subset of covid-19 cases, researchers have found, the immune system battling the infection goes into hyperdrive. The uncontrolled response leads to the release of a flood of substances called cytokines that, in excess, can result in damage to multiple organs. In some severely ill covid-19 patients, doctors have found high levels of a pro-inflammatory cytokine called interleukin-6, known by the medical shorthand IL-6.
The unfettered response, also called cytokine release syndrome, has long been recognized in other patients, including those with autoimmune diseases such as rheumatoid arthritis or in cancer patients undergoing certain immunotherapies.
For covid-19 patients, cytokine storms are a major reason that some require intensive care and ventilation, said Jeffrey S. Weber, deputy director of the Perlmutter Cancer Center at NYU Langone Medical Center.
When your cytokines are systemically out of control, bad stuff happens, he said. It can be a complete disaster. It isnt clear why cytokine storms occur in some patients and not others, though genetic factors may play a role, some doctors say.
To treat cytokine storms, some doctors are using anti-IL-6 drugs such as tocilizumab, which is approved for cancer patients who develop cytokine storms as a result of immunotherapy.
Another odd, and now well-known, symptom of covid-19 is loss of smell and taste. Claire Hopkins, president of the British Rhinological Society, said studies of patients in Italy and elsewhere have shown that some lose their sense of smell before they show signs of being sick.
The coronavirus can actually attack and invade olfactory nerve endings, Hopkins said. When these aroma-detecting fibers are disrupted, they cant send odors to the brain.
Anosmia the medical term for the inability to smell was not initially recognized as a symptom of covid-19, Hopkins said. Doctors were so overwhelmed by patients with severe respiratory problems, she said, that they didnt ask the question.
But subsequent data from a symptom-tracking app has shown that 60percent of people later diagnosed with covid-19 reported losing their senses of smell and taste. About a quarter of participants experienced anosmia before developing other symptoms, suggesting it can be an early warning sign of infection.
Intriguingly, Hopkins said, people who lose their sense of smell dont seem to develop the same severe respiratory problems that have made covid-19 so deadly. But a very small number of patients have experienced confusion, low blood oxygen levels and even lost consciousness a sign that the virus may have traveled along their olfactory nerve endings straight to the central nervous system.
Why you get this different expression in different people, nobody knows, she said.
There are also reports that covid-19 can turn peoples eyes red, causing pinkeye, or conjunctivitis, in some patients. One study of 38 hospitalized patients in Hubei province, China, found that a third had pinkeye.
But like many of the non-respiratory effects of the virus, this symptom may be relatively uncommon and may develop only in people already severely ill. The fact that the virus has been found in the mucus membrane that covers the eye in a small number of patients, however, does suggest that the eye could be an entryway for the virus and is one reason that face shields and goggles are being used to protect health-care workers.
The virus also is having a clear impact on the gastrointestinal tract, causing diarrhea, vomiting and other symptoms. One study found that half of covid-19 patients have gastrointestinal symptoms, and specialists have coined a Twitter hashtag, #NotJustCough, to raise awareness of them.
Studies suggest that patients with digestive symptoms will also develop a cough, but one may occur days before the other.
The question is, is it kind of behaving like a hybrid of different viruses? Spiegel said. What were learning is, it seems anyway, that this virus homes in on more than one organ system.
Reports also indicate that the virus can attack the liver. A 59-year-old woman in Long Island came to the hospital with dark urine, which was ultimately found to be caused by acute hepatitis. After she developed a cough, physicians attributed the liver damage to a covid-19 infection.
Spiegel said he has seen more such reports every day, including one from China on five patients with acute viral hepatitis.
A particular danger of the virus appears to be its tendency to produce blood clots in the veins of the legs and other vessels, which can break off, travel to the lung and cause death by a condition known as pulmonary embolism.
Across New York City, blood thinners are being used with covid-19 patients much more than expected, said Sanjum Sethi, an interventional radiologist and assistant professor of medicine at Columbia Universitys Irving Medical Center.
Were just seeing so many of these events that we have to investigate further, he said.
The IRS declined to comment about whether the payments to the deceased would have to be repaid to the government. Generally the agency has said that recipients will not have to pay back any of the money.
Representative Thomas Massie, a Kentucky Republican, said he was alerted to the situation by a text message from a friend whose late father received a payment.
This stimulus program is ripe for waste, fraud and abuse and this dead person receiving a check is just the tip of the iceberg, Massie, one of the few lawmakers who opposed the $2.2 trillion economic rescue bill, said in an interview. He said the government should move away from stimulus payments and reopen the economy.
Errors such as payments to the recently departed are a consequence of lawmakers trying to balance accuracy with getting the money into bank accounts and mailboxes quickly, said Gordon Gray, director of fiscal policy at the American Action Forum, a conservative policy research group.
Congress erred on the side of speed, which nearly everyone agreed was the right answer in this case, said Gray, a former tax counsel in the U.S. Senate. The mechanisms we have to get money to people mean that some people have died since they last interacted with Treasury and as far as Treasury knows, that person should get a check.
Michael Zona, a spokesman for the Senate Finance Committee, said the panel was looking into the issue.
The payments to the deceased were one of the glitches with the program as the payments began hitting bank accounts and the IRS launched a web page to let recipients see when their money will be sent and whether they will receive it by direct deposit or a mailed check.
Phyllis Jo Kubey, a tax preparer in New York City, said several of her clients received error messages after trying to access the IRSs Get My Payment tool earlier Wednesday. The website said high demand was causing some delays.
The IRS said in a statement that the website is operating smoothly and more than 6.2 million taxpayers have successfully received their payment status while almost 1.1 million taxpayers have successfully provided banking information.
If the site volume gets too high, users are sent to an online waiting room for a brief period until space becomes available. The IRS said in a statement that the online tool will be updated once a day.
The IRS urges taxpayers to only use Get My Payment once a day given the large number of people receiving Economic Impact Payments, according to the statement.
The IRS began sending more than 80 million payments via direct deposit this week to middle- and low-income households. Mailed checks for those who dont have bank account information on file will start going out next week, but it could take months for all the payments to be distributed.
Individuals earning up to $75,000 or couples earning up to $150,000 are eligible for a $1,200 payment per adult and $500 per child under 17. The payments phase out above that income level, and individuals earning more than $99,000 or couples with a combined income of $198,000 dont get anything.
To see when payments will be sent, people will need to provide their Social Security number, date of birth and mailing address. Those wishing to submit bank account information also need to upload the adjusted gross income on their most recent tax return, as well as the amount of their most recent refund or amount owed.
People who filed tax returns in 2018 or 2019 can add bank account information to receive direct payments instead of waiting to receive a paper check.
The IRS released a separate website last week to allow people who arent required to file tax returns to provide their bank account information.
The agency will send recipients a notification about two weeks after they were scheduled to receive their payment with the details of how they should have received the money and how to report payments that dont arrive.
To see when payments will be sent, people will need to provide their Social Security number, date of birth and mailing address. Those wishing to submit bank account information also need to upload the adjusted gross income on their most recent tax return, as well as the amount of their most recent refund or amount owed.
People who filed tax returns in 2018 or 2019 can add bank account information to receive direct payments instead of waiting to receive a paper check.
The IRS released a separate website last week to allow people who arent required to file tax returns to provide their bank account information.
Trump Halts U.S. Funding of World Health Organization The New York Times
A priest in Innsbruck, Austria, views photographs of his absent congregation. Austria easedsocial distancing today.
By Kai KupferschmidtApr. 14, 2020 , 4:10 PM
Sciences COVID-19 reporting is supported by the Pulitzer Center.
The world is holding its breath.
After the novel coronavirus made its way from China around the world, one country after another adopted harsh measures to stop SARS-CoV-2 from spreading and overwhelming hospitals. They have hit the pause button on their economies and their citizens lives, stopping sports events, religious services, and other social gatherings. School closures in 188 countries affect more than 1.5 billion students. Borders are closed and businesses shuttered. While some countries are still seeing daily case numbers increase, othersfirst in Asia but increasingly in Europehave managed to bend the curve, slowing the transmission of COVID-19.
But what is the exit strategy? Weve managed to get to the life raft, says epidemiologist Marc Lipsitch of the Harvard T.H. Chan School of Public Health (HSPH). But Im really unclear how we will get to the shore.
As they seek a path forward, governments around the world must triangulate the health of their citizens, the freedoms of their population, and economic constraints. Could schools be reopened? Restaurants? Bars? Can people go back to their offices? How to relax the lockdown is not something around which there is a scientific consensus, says Caroline Buckee, an epidemiologist at HSPH. Most researchers agree that reopening society will be a long haul, marked by trial and error. Its going to have to be something that were going to have to take baby steps with, says Megan Coffee, an infectious disease researcher at New York University.
The number to watch in the next phase may no longer be the actual number of cases per day, but what epidemiologists call the effective reproduction number, or R, which denotes how many people the average infected person infects in turn. If R is above 1, the outbreak grows; below 1 it shrinks. The goal of the current lockdowns is to push R well below 1. Once the pandemic is tamed, countries can try to loosen restrictions while keeping R hovering around 1, when each infected person on average infects one other person, keeping the number of new cases steady.
To regulate R, Governments will have to realize that there are basically three control knobs on the dashboard, says Gabriel Leung, a modeler at the University of Hong Kong: isolating patients and tracing their contacts, border restrictions, and social distancing.
Singapore, Hong Kong, and South Korea have all managed to keep their epidemics in check through aggressive use of the first control. They identify and isolate cases early and trace and quarantine their contacts, while often imposing only light restrictions on the rest of society. But this strategy depends on massively scaling up testing, which has been hampered by a scarcity of reagents and other materials everywhere. The United States will be able to do millions of tests per week, says Caitlin Rivers of the Johns Hopkins Center for Health Security. Although our testing capacity has grown a lot in the last couple of weeks, we are not where we need to be yet, she says.
Contact tracing is another hurdle, and it is labor intensive. Massachusetts is hiring 500 contact tracers, buta recent report by Rivers and othersestimates that the United States as a whole needs to train about 100,000 people.
Mobile phone apps could help by automatically identifying or alerting people who recently had contact with an infected person. (Public health departments, not generally known anywhere in the world to be at the forefront of technological innovation, will have to adapt very quickly, Leung says.) But Western countries have yet to implement these systems. Google and Apple have teamed up to incorporate a contact tracing app in their operating systems. Germany, France, and other countries are developing apps based on a protocol calledPan-European Privacy Preserving Proximity Tracing. It relies on short-range Bluetooth signals to gauge the proximity between two devices without logging their exact locations, which helps sidestep some privacy concerns.
But short of making these technologies compulsory, as China has done, how can a country ensure that enough people download an app for it to provide reliable information and influence the spread of disease? And what exactly counts as a contact? If I live in a big apartment block, am I going to be getting dozens of notifications a day? asks epidemiologist Nicholas Davies of the London School of Hygiene & Tropical Medicine (LSHTM). Davies adds that widespread use of the apps will further drive up the demand for testing.
As to the second control knob, border restrictions, most countries have already banned entry to almost all noncitizens. Quarantining returning citizens, as New Zealand and Australia began to do in the past few weeks, further minimizes the risk of new introductions of the virus. Such measures are likely to remain in place for a while; the more a country reduces transmission domestically, the greater the risk that any new outbreaks will originate with travelers. And foreign visitors are generally harder to trace than citizens and more likely to stay at hotels and visit potential transmission hot spots, says Alessandro Vespignani, a disease modeler at Northeastern University. As soon as you reopen to travelers, that could be something that the contact tracing system is not able to cope with, he says.
The third dashboard dial, social distancing, is the backbone of the current strategy, which has slowed the spread of the virus. But it also comes at the greatest economic and social cost, and many countries hope the constraints can be relaxed as case isolation and contact tracing help keep the virus in check. In Europe, Austria took the lead by opening small shops today. Other stores and malls are scheduled to follow on 1 May, and restaurants maybe a few weeks later. A13 April report from the German National Academy of Sciencesargued for slowly reopening schools, starting with the youngest children, while staggering break times and making masks mandatory. But French President Emmanuel Macron has said Frances lockdown will remain in place until 11 May.
Choosing a prudent path is difficult, Buckee says, in part because no controlled experiments have compared the effectiveness of different social distancing measures. Because we dont have really strong evidence, she says, its quite hard to make evidence-based policy decisions about how to go back. But Lipsitch says that as authorities around the world choose different paths forward, comparisons could be revealing. I think theres going to be a lot of experimentation, not on purpose, but because of politics and local situations, he says. Hopefully the world will learn from that.
Lockdowns lower the number of new cases as well as R, the effective reproduction number. If R drops below 1, the epidemic shrinks.
Centre for mathematical modeling of infectious diseases/CC BY 4.0; ADAPTED BY X. LIU/SCIENCE
Finding out how any particular measure affects R is not straightforward, because infections that occur today can take weeks to show up in disease reports. In 2004, mathematician Jacco Wallinga of the Dutch National Institute for Public Health and the Environment and colleagues published a statistical method to estimate R in real time, which is now used around the world. Researchers are also incorporating data on mobility patterns and peoples behavior to make the estimates more accurate. Having real-time estimates of R is important, says Adam Kucharski, a modeler at LSHTM: If governments put a measure in or lift it, they can get a sense of what the immediate implications are, rather than having to wait, he says.
Theres one other, unknown factor that will determine how safe it is to loosen the reins: immunity. Every single person who becomes infected and develops immunity makes it harder for the virus to spread. If we get 30% or 40% of the population immune, that really starts to change that whole picture, it helps us a lot, because it would bring R down by the same percentage, says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities.
Immunity will inevitably build up as more people become infected, but some researchers argue for ramping up immunity more quickly, by letting the virus spread in younger people, who are less susceptible to severe illness, while cocooning more at-risk patients, such as the elderly. The United Kingdom floated this herd immunity idea in February but backed away from it, as did the Netherlands. If you get to herd immunity any way other than through widespread vaccination, it is devastating, says Jeremy Konyndyk, a senior policy fellow at the Center for Global Development. Even briefly considering it left the United Kingdom in a dramatically worse place than they needed to be, he says.
But some scientists say other countries should consider it once the strain that the first wave of cases has put on their health care systems eases. Is it better to have a controlled burn in younger populations right now than it is to prevent it? I think thats a very important conversation to have, Osterholm says.
Skeptics doubt that vulnerable populations could really be protected. In many countries, multiple generations live under one roof, and young people work at nursing homes. Nor are scientists certain that COVID-19 produces robust, long-lasting immunity. Several studies seek to address these questions.
For now, the most likely scenario is one of easing social distancing measures when its possible, then clamping down again when infections climb back up, a suppress and lift strategy that both Singapore and Hong Kong are pursuing. Whether that approach can strike the right balance between keeping the virus at bay and easing discontent and economic damage remains to be seen.
Even Singapore and Hong Kong have had to toughen some social distancing measures in recent weeks after a surge of cases, Lipsitch notes; Singapores social distancing regime is no longer very different from that in New York City or London. And both cities strategies are much harder to implement across a big country like the United States. We have to have every single town and city and county be as good as Singapore for this to work, he says.
Jeremy Farrar, head of the Wellcome Trust, says a path out of the dilemma now facing the world will come from research. It might take the form of an effective treatment for severely ill patients, or a drug that can prevent infections in health care workers, orultimatelya vaccine. Science is the exit strategy, Farrar says.
With reporting by Kelly Servick.
SAN FRANCISCO California has been ahead of the rest of America in confronting the coronavirus pandemic, locking down its citizens early and avoiding, so far, the worst-case scenarios predicted for infections and deaths.
But as the national conversation begins to shift to reopening and President Trump beats the drum of economic revival, Californias extremely cautious approach toward the virus is a measure of how complicated it will be to restart the country.
Were not going to flip the switch and suddenly have the economy return to what it was and everyone come out of their homes simultaneously, Mayor Eric Garcetti of Los Angeles said in an interview. Peoples physical interactions, peoples spatial understandings, peoples risk-taking will come slowly.
As Americas premier gateway to China, California was, early in the pandemic, seen as one of the most vulnerable states to the spread of the virus. In January, close to 600 direct flights from China carrying around 150,000 people landed in the state, more than twice as many as landed in New York.
But two and a half months after the first cases were detected in Southern California, scientists are scrambling to explain the California conundrum: The state, despite its large, globe-traveling population, ranks 30th in the nation in coronavirus deaths per capita and has a fraction of the mortality rate that New York and New Jersey have suffered. As of Monday, San Francisco had recorded 15 deaths.
Much remains unknown about the coronavirus, and experts are still trying to understand why it is affecting some areas more than others. But figuring out why it has spread much less intensely in Americas most populous state than initially feared will be important in planning next steps, experts say.
As it has with so many other policies, California went its own way on confronting the virus. In moving toward recovery its leaders are inching forward, having repeatedly said that success can quickly turn to failure.
How the nations largest economy calibrates the reopening will have huge ramifications for the rest of the country, providing examples of what works, and what does not, especially given limits on testing capacity.
Gov. Gavin Newsom said on Tuesday that the state would eventually replace its broad-based stay-at-home orders with more localized and less restrictive measures. But he did not give a time frame, saying he would revisit the question in two weeks.
Ask me the question then. I know you want the timeline but we cant get ahead of ourselves, Mr. Newsom said. Lets not make the mistake of pulling the plug too early.
We want to see hospitalization numbers flatten and start to decline, the governor said, adding that the state would also have to build up its testing capacity, better protect older and more vulnerable people and ensure that hospitals have enough supplies.
Face coverings will likely remain a feature of public life, at least for a time, he said. Patrons of restaurants will likely have their temperature taken before being seated, and servers will wear masks and gloves. Large gatherings over the summer were not in the cards, he said, and in the fall, students may attend school in shifts to avoid crowded classrooms.
Normal it will not be, he said.
The reasons for the early promising signs in California are numerous, experts say. The state was the first to issue stay-at-home measures, and even before the orders came down, Californians were beginning to keep their distance from one another, while New Yorkers were still packing bars and restaurants.
Other factors include a work-from-home culture at many companies, spurred by the tech industry; a dry and sunny February that brought people away from crowded spaces and into the outdoors; and even the fact that the San Francisco 49ers lost the Super Bowl, avoiding a crowded victory parade.
Californias deep experience confronting natural disasters has also helped it address the pandemic. Not only does the state have a vast government machinery in place to handle disasters, but its populace has experience following orders at a time of calamity.
Several experts are advancing another explanation, too: Features that have long been viewed as liabilities the states solitary car culture and traffic-jammed freeways, a dearth of public transportation and sprawling suburban neighborhoods may have been protective.
Life in California is much more spread out, said Eleazar Eskin, chair of the department of computational medicine at the University of California, Los Angeles. Single-family homes compared with apartment buildings, work spaces that are less packed and even seating in restaurants that is more spacious.
Many scientific studies have found a correlation between population density and the spread of flu and other infectious diseases, something that may exist for the coronavirus as well.
Moritz Kraemer, a scholar at Oxford University, conducted a study with 12 other scientists across the world that relies on data from China. The study, which has not yet completed peer review, shows that more crowded areas had both higher coronavirus infections per capita and more prolonged epidemics.
The more space you have, the less probability there is for transmission, said Dr. Kraemer, who is also leading a team of researchers in mapping the global spread of the virus.
But California still has numerous weak points, and experts stress that density is only one of many factors in the spread of a disease that is still poorly understood.
Nursing homes and other settings where people congregate have been hit hard. The authorities discovered 102 cases at a single homeless shelter in San Francisco.
Jeffrey Shaman, a professor of environmental health sciences at Columbia University, where he has been deeply involved in modeling the spread of the disease, said it was likely that some aspects of West Coast culture helped dampen the early spread of the virus. But that does not argue, he said, for car congestion as a cure-all.
Some experts like George Rutherford, a professor of epidemiology at the University of California, San Francisco, put more emphasis on early government action in mitigating the spread of the virus. Dr. Rutherford said the nations first stay-at-home orders by officials in the San Francisco Bay Area, led by the Santa Clara chief health officer, Dr. Sara Cody, were crucial.
Thats where the credit belongs, Dr. Rutherford said.
Dr. Rutherford pointed out that his commute on mass transit in the Bay Area resembled one in New York City more than in Los Angeles.
I easily come within six feet of 200 people a day, he said.
Yet even in San Francisco, the nations second-densest major city, cars are much more common than in New York. San Francisco has one vehicle for every two people while the ratio in New York is one to four, according to data from the Department of Motor Vehicles.
Experts say understanding the dynamics of spread will be crucial for the next phases of the pandemic, as the authorities look for ways to open up the economy while avoiding a wide-scale and deadly second wave of the disease.
Mr. Garcetti, the Los Angeles mayor, has been guided by history, spending his nights and weekends studying how California cities responded to the 1918 flu pandemic. One of his key takeaways is that acting too soon to reopen could be disastrous, citing a second wave of infections in 1918 that proved more deadly than the first.
In 1918, L.A. acted quickly and kept with it, he said. In contrast, San Francisco, he said, had also done really well but then came out of it too quick, and had a second spike in the short term, which killed a lot of people.
Epidemiologists say transmission dynamics will differ by state, city and neighborhood.
In a push to better understand the scope of peoples interactions, Dr. Eskin is leading a survey effort in California and beyond. The survey asks what symptoms the participant has experienced, if any, and the locations of the supermarkets and pharmacies where he or she goes.
We want to give the public health authorities the data that they need for them to make decisions on when they should let people go back to work or the kids go back to school, Dr. Eskin said.
But even as California officials consider data that shows the outbreak here is far less intense than initially feared, they are being cautious in predicting a loosening of restrictions anytime soon.
Mr. Garcetti, for instance, has been touting the idea of using wide-scale testing to determine who is immune, and then allowing those people to resume some measure of normal life.
The idea of folks having an immunity passport, or something that allows them to be able to work, certainly would accelerate for me our economic recovery and my ability as mayor to lift the orders for some people, he said recently.
But that plan would require wide-scale testing, which California does not have.
An immunity passport, Mr. Garcetti said, is still a while off.
Thomas Fuller reported from San Francisco and Tim Arango from Los Angeles. Adam Nagourney contributed reporting from Los Angeles and Matt Richtel from San Francisco. Susan C. Beachy contributed research.
Major League Baseball employees, from players to stadium workers to executives, are participating this week in a 10,000-person study aimed at understanding how many people in various parts of the United States have been infected with the coronavirus.
Each participant will have a finger pricked to produce blood that will be tested for the presence of antibodies, which indicates a past infection even in people who have never displayed symptoms of Covid-19, the disease caused by the coronavirus. The test for the virus itself can reveal only a current infection.
One of the biggest hurdles in determining when to reopen parts of the United States is the uncertainty about the number of people who have been infected over all and who, as a result, may now have some sort of immunity.
Teams of researchers from Stanford University, the University of Southern California and a prominent antidoping lab in Salt Lake City are collaborating on the study involving M.L.B. They believe it is the first and most extensive research of its kind in the United States.
This kind of study would have taken years to organize outside of this setting, said Dr. Jay Bhattacharya, a professor of medicine at Stanford who is leading the study. With the help of M.L.B., weve managed to do this in a matter of weeks.
As the coronavirus pandemic spread and sidelined sport after sport, Daniel Eichner, the president of the Sports Medicine Research and Testing Laboratory in Salt Lake City, realized that his facility would have few, if any, antidoping responsibilities for quite a while.
So, Eichner said, his laboratory redirected its focus and ordered large quantities of antibody tests that had been used successfully in some Asian countries.
To carry out representative testing, the researchers needed a large group of people who were spread all over the country. Bhattacharya said that he had reached out to an array of corporations, and that M.L.B., which already had a relationship with Eichner, was the quickest to agree. The major leagues, in response to the pandemic, shut down spring training on March 12 and have no specific plans to resume play.
Theres nothing in it for the teams or M.L.B. on this one, Eichner said. This is purely to drive public health policy.
Bhattacharya said M.L.B.s pool of employees offered a big swath of the American population. He added that nearly all of M.L.B.s 30 teams were participating and that it was up to each team to distribute the tests.
Because many M.L.B. employees and players live in areas with shelter-in-place rules in effect, many kits have been mailed to participants. The test can produce results in 15 minutes, Bhattacharya said, and photographs documenting the results can be submitted electronically to the researchers.
A spokesman for the baseball players union said the study was voluntary, strictly part of independent research aimed at gathering data its not connected to resumption of play and players identities will be separated from the data.
In addition to studying the M.L.B. populations, the researchers are using the tests Eichner provided to conduct antibody screening in Los Angeles and in Santa Clara County, Calif.
Bhattacharya said he hoped to analyze the data from M.L.B.s employees and players and write a paper as soon as possible, to help guide the easing of stay-at-home restrictions.
Id love to be able to go to Fenway Park someday again, he said. But thats not really the main purpose. The main purpose is so that we can inform nationwide policy in every community about how far along we are in this epidemic and if it is safe enough to open up the economy.
BERLIN Slowly, tentatively, a handful of European countries began lifting constraints on daily life this week for the first time since the start of the coronavirus crisis, providing an early litmus test of whether Western democracies can gingerly restart their economies and restore basic freedoms without reviving the spread of the disease.
On Tuesday, Italy, the epicenter of Europes crisis, reopened some bookshops and childrens clothing stores. Spain allowed workers to return to factories and construction sites, despite a daily death toll that remains over 500. Austria allowed thousands of hardware and home improvement stores to reopen, as long as workers and customers wore masks.
In Denmark, elementary schoolteachers readied classrooms so young children could return to school on Wednesday, while in the Czech Republic, a restless public relished the reopening of sports centers and some shops.
When Lukas Zachoval, a sales manager in the Czech Republic, lost a tennis match to his father this week in a 6-4, 6-3 drubbing defeat had seldom tasted sweeter. After all, it was his first match since the Czech government began lifting sweeping restrictions on society, including a ban on communal sports, that had been in place for nearly a month.
I cannot live without sports, Mr. Zachoval explained.
The easing of the lockdowns was watched with interest and trepidation across Europe and beyond, and posed profound and knotty questions.
How much are we willing to pay in order to save peoples lives? asked Jana Puglierin, director of the Berlin office of the European Council on Foreign Relations, an independent research group. And when do we do more damage when we keep the lockdown in place, or when we open it up early?
The fledgling, country-by-country loosening, enacted without any coordination between nations, underscored the absence of any common agreement, or even understanding, about the challenge of keeping economies alive while stemming the disease. The International Monetary Fund has warned that the global economy is headed for its worst performance since the Great Depression.
A similar debate over how to reopen society is taking place in the United States, where President Trump has insisted that he calls the shots on the matter, prompting objections from the leaders of several states. Mr. Trump, himself under fire and his poll numbers falling as the dispute intensified, said Tuesday that he would halt funding to the World Health Organization, which he accused of making mistakes that allowed the virus to spread.
As the slow, piecemeal approach in Europe suggests, restrictions on daily life will probably not end in one clean break. Instead, people can expect a series of staggered interventions and loosening, probably over a period of weeks or months, if not considerably longer.
At the start of the crisis, many people had the feeling that we could shut down Denmark for two to three weeks and then we could reopen, free of the virus, said Peter Munk Christiansen, head of political science at Aarhus University in Denmark.
But theres been a gradual realization that that wont happen, he said. People accept we have to have a gradual opening, and also that this wont have gone away by the summer. It will stay here perhaps for years.
On a continent where the supply chains are closely interconnected, economic gains may be slowed by the asymmetric approaches taken by European governments.
Relieved as Mr. Zachoval was by the easing of some measures in the Czech Republic, his income remains stymied by restrictions still in force elsewhere.
Like many Czech companies, Mr. Zachovals saw factory depends heavily on buyers in Western Europe. But most countries there have kept their borders shut, even as the Czech Republic partly opens its own, or their sales rooms closed, even as Mr. Zachoval hopes to step up production.
On Tuesday, Mr. Zachoval fielded a few orders from his home country, but nothing from his main markets in Germany, France and Italy.
A lot of other states are not working fully, Mr. Zachoval said in a telephone interview. And were an exporter, so we dont feel the change too much.
If it continues, he said, in a few weeks I think well have to stop production, because orders are just not coming.
At a summit meeting in late March, the 27 heads of states in the European Union acknowledged the need for their countries to emerge from their respective lockdowns in a coordinated exit strategy, and called on the blocs leadership to create a joint plan.
But so far, such a plan has yet to be agreed upon. Last week, the president of the blocs administrative arm, Ursula von der Leyen, postponed a news conference at which she had been expected to announce it.
The absence of a united approach has long-term implications for Europes economic revival, said Derek Beach, an academic who researches European integration at Aarhus University.
If Germany, for example, takes a different approach to constraining the virus than its neighbors, the government might not risk fully reopening its borders for fear of undermining its public health efforts. Yet without open borders, the Continents economy will not properly function.
The lack of coordination here is such a big issue, Professor Beach said. Unless you have a common strategy, you have to keep the borders closed. But if the borders are closed, then do the supply chains still work over an extended time period?
Even within individual countries, the easing of restrictions has lacked a cohesive approach.
In Spain, workers could nominally return to factories, but many were not needed because of a lack of demand. And those who did return were sometimes fearful for their health.
I dont agree with it, but what else can you do? said a 52-year-old electrician in Barcelona, who asked to be identified only by his first name, Jos. If my bosses call me, and I say no, they wont call me again.
In Italy, booksellers cited a lack of clarity about whether people could now travel from neighboring towns to visit their shops, or only from the surrounding district.
Mauro Marrani, who works at his wifes bookstore in Florence, said he had written to the president of his region for an answer. Mr. Marrani was also confused by a requirement that the bookshop provide customers with disposable gloves which are almost impossible to find.
Amid this uncertainty, he said, he had made only one sale in five hours.
Its all very vague, Mr. Marrani said. If it remains this way, I think were better off closing altogether, and waiting until all stores reopen.
Among economists, there were also questions on Tuesday about whether they wield the right tools to assess Europes post-lockdown economy.
Its a new world, said Carl-Johan Dalgaard, one of four Danish economics professors who form the presidency of the Danish Economic Councils, known informally as the Wise Men.
Denmarks decision to reopen some schools and kindergartens makes sense, said Professor Dalgaard, who teaches at the University of Copenhagen, since it should allow parents to be more professionally productive.
But in general, the relationship between how the economy functions and how the coronavirus spreads is not yet fully understood, he said.
There will need to be a conversation between epidemiologists and economists to understand this two-way street between the epidemiology and the economics, said Professor Dalgaard. These tools are not yet available.
Elisabetta Povoledo contributed reporting from Rome, Raphael Minder from Madrid, and Elian Peltier from Barcelona.
(Want to get this briefing by email? Heres the sign-up.)
Good morning.
Were covering President Trumps decision to withhold funding from the World Health Organization, the lifting of some coronavirus-related restrictions in parts of Europe, and Barack Obamas endorsement of Joe Biden.
Governors from both parties said on Tuesday that, while they were a long way from telling Americans to return to their normal lives, it was not too early to make plans.
Some states, like California, shut down early and entirely, while a few more rural states have yet to adopt stay-at-home orders. Its possible that reopening the country could be similarly ad hoc.
President Trump, who a day earlier made the widely rejected claim that he had total authority to reopen the economy, said on Tuesday that he would work with the states.
Here are the latest updates from the U.S. and around the world, as well as maps of the pandemic.
Were also tracking the viruss growth rate in U.S. metro areas.
In other developments:
Bill Gates, the Microsoft founder who has donated much of his fortune to public health initiatives, was among those who criticized Mr. Trumps decision to halt American funding for the World Health Organization, which the president accused of a series of mistakes over the virus. Last year, the U.S. contributed about $553 million to the W.H.O., which is part of the United Nations and has a two-year budget of about $6 billion.
The details: Weve compiled expert guidance on several subjects, including health, money and travel.
The Times is providing free access to much of our coronavirus coverage, and our Coronavirus Briefing newsletter like all of our newsletters is free. Please consider supporting our journalism with a subscription.
Dr. Helen Ouyang has recorded her experiences for The Times Magazine, starting at the beginning of March, when New York State recorded its first coronavirus case.
Six weeks later, amid daily conversations about death, she wrote: Ive never felt less useful as a doctor. The one thing I can do what I think will matter most, in the end is just to be a person first, for these patients and their families.
Related: New York City sharply increased its death toll on Tuesday, after officials said they would include over 3,700 people who were presumed to have died of the virus but had never tested positive for it. The new figures appeared to increase the overall U.S. death toll by 17 percent, to more than 26,000.
Closer look: One of our writers visited a 68-bed field hospital in Central Park operated by the evangelical Christian relief group Samaritans Purse. Its the organizations first medical deployment in the U.S.
Public health experts have encouraged people to stay six feet from others, which is supposed to be a safe distance if a cough or sneeze spreads droplets that may carry coronavirus particles.
While no scientists are suggesting that another distance is actually the right one, some say longer is better. Sneezes, for instance, can launch droplets a lot farther than six feet, according to a recent study.
Quotable: Dr. Michael Osterholm, at the University of Minnesota, said he had no doubt that the six-foot distance would clearly reduce the number of droplets you come in contact with. But, he added: The question is what does it take for you to get infected? And that I think is the trillion-dollar question.
Closer look: Our 3-D simulation helps show why distancing is so important.
Dr. Li Wenliang tried to warn China about the coronavirus but was silenced by the government authorities. He became a hero in the country when his warnings proved true, then a martyr when he died from the virus in February.
Today, people gather, virtually, at his last post on Weibo, the Chinese social media platform, to grieve and seek solace in the comments section.
Our columnist Li Yuan writes: In a largely atheist yet spiritual nation with little tradition of praying, the digital Wailing Wall allows the Chinese people to share their sadness, frustration and aspirations with someone they trusted and loved.
Barack Obamas invisible hand: Mr. Obama, who endorsed Joe Biden on Tuesday, had kept his political distance from his former vice president. But he has been much more engaged in the end of the Democratic presidential primary race than has been previously revealed.
Snapshot: Above, a 150-foot siphonophore a colony of cells that clone themselves to produce an extended, stringlike body spotted off the coast of Western Australia. It could be the longest marine creature on Earth.
Late-night comedy: After former President Barack Obamas endorsement, Jimmy Fallon said, Obama said he knew Biden was the right candidate once he was absolutely sure Michelle wasnt running.
What were reading: This ESPN article about the complex family ties between Bruce Buffer, a mixed martial arts announcer, and Michael Buffer, a boxing announcer. Taffy Brodesser-Akner, a Times Magazine writer, calls it a great story about two long-lost brothers who had the same calling, which was to call things honestly, I couldnt put this down.
Cope: Dont know about the two-hour workouts, but you may be interested in taking up Megan Rapinoes skin-care routine. Maybe a 30-minute workout, no skin care? Heres how to exercise outside while wearing a mask. And Jazmine Hughes discusses how to be your own bartender.
We have more ideas about what to read, cook, watch and do while staying safe at home.
William Broad, a science and health reporter, recently wrote about a decade of health disinformation promoted by President Vladimir Putin of Russia. We spoke to him about his article.
How did you become interested in this story?
Last year, I wrote about how Mr. Putin and his aides were doing their best to scare Americans into thinking the new cellphone technology known as 5G posed dire health threats. In researching that article, I noticed other areas in which the Kremlin was hypocritically ringing false alarms especially on health issues and started gathering string.
Mr. Putin seems to have spent some of his early career as a K.G.B. agent working on foreign disinformation campaigns.
Yes, no question. He was a K.G.B. officer who rose to the rank of lieutenant colonel and worked in foreign intelligence. American experts say such officers had to spend a quarter of their time conceiving and carrying out plans for sowing disinformation. So hes been at this game for a very long time something on the order of four decades.
What do you think have been the biggest successes of this effort?
The Kremlins anti-vaccine campaign has done much to drive Americans away from childhood immunizations, helping to stir a resurgence of measles, a disease once seen as defeated. Last year, the U.S. had 1,282 new cases, with 61 resulting in major complications such as pneumonia and encephalitis.
How might Putins campaign influence coronavirus misinformation?
At worst, it seems as if the false information on the coronavirus may help prolong the pandemic and contribute to new cases of incapacitation and death.
Thats it for this briefing.
Need a lift? Eighteen of our writers shared small moments that recently lightened their mood.
Have a good day, and well see you next time.
Chris
Thank youMelissa Clark provided the recipe, and Theodore Kim and Jahaan Singh provided the rest of the break from the news. You can reach the team at briefing@nytimes.com.
P.S. Were listening to The Daily. Todays episode is about a day in the life of a Brooklyn hospital during the coronavirus pandemic. Heres todays Mini Crossword, and a clue: Misbehave (five letters). You can find all our puzzles here. The editors of our Book Review wrote to those whose livelihoods depend on books: Our hearts go out to the debut authors of the season, many of whom spent years, perhaps a lifetime, waiting for the dream moment when their first book would make its way into the world.
The rule of thumb, or rather feet, has been to stand six feet apart in public. Thats supposed to be a safe distance if a person nearby is coughing or sneezing and is infected with the novel coronavirus, spreading droplets that may carry virus particles.
And scientists agree that six feet is a sensible and useful minimum distance, but, some say, farther away would be better.
Six feet has never been a magic number that guarantees complete protection. The Centers for Disease Control and Prevention, one of the organizations using that measure, bases its recommendation on the idea that most large droplets that people expel when they cough or sneeze will fall to the ground within six feet.
But some scientists, having looked at studies of air flow and being concerned about smaller particles called aerosols, suggest that people consider a number of factors, including their own vulnerability and whether they are outdoors or in an enclosed room, when deciding whether six feet is enough distance.
No scientists are suggesting a wholesale change in behavior, or proposing that some other length for separation from another human, like seven, or nine feet, is actually the right one.
Everything is about probability, said Dr. Harvey Fineberg, who is the head of the Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats at the National Academies of Sciences, Engineering and Medicine. Three feet is better than nothing. Six feet is better than three feet. At that point, the larger drops have pretty much fallen down. Maybe if youre out of spitting range, that could be even safer, but six feet is a pretty good number.
One complicating factor is that aerosols, smaller droplets that can be emitted when people are breathing and talking, play some role in spreading the new coronavirus. Studies have shown that aerosols can be created during certain hospital or laboratory procedures like when using nebulizers to help patients inhale medication, which makes such procedures risky for doctors who do them.
If the aerosols that people exhale in other settings are significant in spreading the disease, the six-foot distance would not be completely protective because those are carried more easily by air currents.
Aerosols are generally considered to be particles under 5 microns in diameter, about the size of a red blood cell, and can be spread in the environment by talking and breathing. But some researchers argue that this is a false dichotomy. Infectious droplets cant easily be divided into those that are big enough to fall to the ground quickly and those that stay aloft because so much depends on environmental conditions and how deeply they penetrate into the respiratory tract.
Its really a continuum, said Dr. Donald Milton, who studies bioaerosols at the University of Maryland School of Public Health.
Even without the launching power of a sneeze, air currents could carry a flow of aerosol sized virus particles exhaled by an infected person 20 feet or more away.
In any confined geometry like an office room, meeting room, department store, food store, said Eugene Chudnovsky, a physicist at the City University of New York. In a study not yet peer reviewed, he analyzed air flow and showed how, the vortices in the air are taking the virus to different places.
A preliminary study at the University of Nebraska Medical Center found evidence of coronavirus genetic material on various surfaces in isolation rooms where infected patients were being treated, including on air vents more than six feet from the patients. The research, which has not yet been peer reviewed, indicates that the virus can occasionally travel long distances.
The virus is so small, it can hitch a ride even on tiny, tiny particles, Dr. Fineberg said. But how important is each size and how well they can transmit disease is not fully understood.
It is also unclear how many virus particles it takes to start an infection, how long the viral particles remain viable or if studies like the one in Nebraska simply detected the genetic calling card the virus left behind.
Spacing is an effective solution because it also reduces the number of people in a confined space. That reduces the likelihood of an infected person being in the group. And if there is one, fewer other people might be infected.
Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, said the six-foot distance would clearly reduce the number of droplets you come in contact with. I have no doubt about that.
But, he said: The question is what does it take for you to get infected? And that I think is the trillion-dollar question we have.
He said, Maybe all it takes is an aerosol. You dont need any droplets at all. If thats the case, he said, then someone who is at high risk would not want to be in the same room with someone who is infected or might be infected.
Current guidelines already suggest that anyone at high risk should stay home and not be out in public in the first place. And they seem to be working. Places where people reduced travel and started social distancing weeks ago, especially in California, New York and Washington, are starting to show a reduction in the number of new coronavirus cases.
People still need to shop and take care of necessities, Dr. Osterholm said, but reducing the risk of exposure to all possible modes of transmission infected surfaces, droplets and smaller aerosols is important.
Your job is to limit it as much as you can.
Abbott Laboratories announced Wednesday the launch of its third test for the coronavirus and said it could be screening up to 20 million people for antibodies for Covid-19 by June.
Abbott said it plans to distribute 4 million of the new antibody tests by the end of this month, after an initial shipment of 1 million tests this week to US customers, beginning Thursday.
"Antibody testing is an important next step to tell if someone has been previously infected," Abbott said in a press release.
"It will provide more understanding of the virus, including how long antibodies stay in the body and if they provide immunity," the company said.
Abbott's two other coronavirus tests, which only recently were introduced, determine whether a person has Covid-19 now.
One of those tests can tell in 13 minutes or less if a person at a testing site is currently infected, while the other test is performed in labs.
The new antibody test announced Wednesday will reveal if a person also had been infected in the past, even if they were no longer sick.
Infectious disease experts have said that such antibody screenings, also called serological tests, will be needed to track the spread of the coronavirus in the United States and elsewhere, and to develop containment strategies.
"We continue to contribute in a significant and meaningful way by providing new solutions across our diagnostics testing platforms," Abbott CEO Robert Ford said in a statement.
"I'm extremely proud of the many Abbott people who are working around the clock to get as many tests as we can to healthcare workers and patients."
