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INDIANAPOLIS, Ind. Governor Eric Holcomb provided the latest information about Indianas response to the COVID-19 pandemic Tuesday as the state continues to see cases spread across Indianas counties.
Among the updates, Governor Holcomb announced two new executive orders he would be signing.
The first executive order deals with the carryout-only order. The order would extend the policy through April 6.
The second executive order waives the statute to let e-notary rules take effect.
On Tuesday, state health officials say an additional 14 people died in Indiana from coronavirus-related illnesses. This brings the states total to 49.
Of the new COVID-19 deaths, five involved Indianapolis residents and four were from Lake County. Elkhart, Decatur, Hancock, Ripley and Warren Counties also reported a death.
Confirmed COVID-19 cases grew by 347 to 2,159. The virus has now been reported in 81 of Indianas 92 counties. Marion County continues to have the most new reported cases. The county now has 964 cases.
Dr. Kristina Box, State Health Commissioner for Indiana, says the numbers do not necessarily show the amount of new cases per day. IT is based on when the data is reported to them.
Dr. Box says the jump in deaths from March 14-March 21 is when tests were done through the state lab. She says it can take up to two weeks to get results, and that some patients may have died before their test result was available.
While the Indiana State Department of Health has been providing daily updates on the number of reported cases and deaths, Dr. Box says EMS needs more timely data to make real-time decisions.
The department will soon begin providing twice-daily updates to its coronavirus page, giving the latest information at peoples fingertips.
Another update provided in the briefing is that the Army Corps of Engineers has been called in for facility assessment and other planning help. This will help the state prepare to set up field hospitals in key areas of the state if it becomes necessary to address medical facility shortages.
The request was made through the state emergency operations center and FEMA.
Our hope is that we never need this, but we must prepare as if we will.
Governor Holcomb ended the main part of the address by thanking people for jumping in to help out with the COVID-19 response. He highlighted a COVID-19 Crisis Response Fund that will help those on the front lines.
Holcomb also mentioned sewing clubs from across the state that are producing masks for hospitals and other facilities in the state. An employer in Lebanon making a handheld disinfecting wand to send to food manufacturers and health care facilities. Holcomb said they are all examples of Hoosier hospitality at its finest.
ByHub staff report
In recent weeks, the epicenter of the novel coronavirus pandemic has moved from China and East Asia to Italy and other Western nations including the U.S. The particularly severe outbreak in Italy has centered on the country's northern regions, including the city of Bologna, which is home to the Johns Hopkins School of Advanced International Studies in Europe. While the SAIS Europe campus has closed, classes, research, and collaboration have continued remotely and online.
To learn more about the situation in Bologna and across Europe, the Hub reached out to Filippo Taddei, a Johns Hopkins associate professor of international economics and a faculty member at SAIS Europe. He offered insights into the immediate and future impacts of the COVID-19 pandemic on European and American economies, political climates, and international relations. This is the first of a three-part series. The conversation has been edited for length and clarity.
Well, in reality, things have been changing very quickly during the past few weeks, which is similar to what you're now seeing in the U.S.
Image caption: Filippo Taddei
As the Italian government has introduced even stricter rules on people's movement and interactions, we accordingly decided, unfortunately, to close our building and campus. Now we are interacting with our community, with our colleagues, students, and administrators, purely online. It poses a lot of challenges, of course, but like any challenge it also poses an opportunity to do better. In the long run it will help us to be more effective with our online resources, especially using these online resources to teach and conduct a beneficial exchange of ideas. We have the right technology and the skills to adapt to this new setting, if a little bit by brute force because of the country's strict and rapid lockdown.
We need to understand that, in Europe, the impact of the epidemic is currently different in different countries, and at the moment some are more affected than others. But even for less affected countries, the outbreak needs to be dealt with quickly because we are so tightly integrated socially and economically. The outbreak in a single region or country quickly becomes a common problem. What we have to do in the face of this widespread and common shock to our economic and health systems is to implement an equally common and uniform response.
At the moment, the U.S. has one advantage in responding to the shock in comparison with Europe. Some states, like some European countries, will need more support than others, but the U.S. federal government is more readily available to pick up some of the state-specific costs due to the global shock. In the European Union, this is more complicated because we don't have a federal fiscal authority remotely resembling the United States Treasury. Each country has its own government with its own responses, which poses a problem for acting uniformly.
Thinking about our value chainor the way industries produce goodsEuropeans are far more integrated with one another than they often think. If one European country is severely affected, then the problem transfers very quickly to everybody else. It's just bad policy to leave public health responses at the state level in the U.S. or the member country level in the EU. Look at the consequences for the Italian economy, for example. Even though some countries are not as heavily affected by the virus now, they will suffer consequences from a complete disruption of another country's economy, like what has happened in Italy.
Image caption: The Spanish Steps, a popular tourist destination in Rome, is nearly abandoned in mid-March as a result of mandatory lockdowns throughout Italy.
Image credit: Getty Images
It's hard to say. We're still in the middle of it. The more countries that are affected by this shock, the more likely it is that they'll be able to join together. Recent crises were mostly asymmetric: some countries were more affected than others. Now we're facing something differenta shock that is far more uniform than those before. The effect of the epidemic could be more widespread, and as a result we might have a stronger push toward economic and political integration for the EU. If, as in past crises, the effects continue to be substantially more severe in some countries than in others, traditionally that has provided a strong force for disunity and disintegration across the European continent.
From an economic and policy point of view, we in Italy, and in Europe more broadly, were convinced that we stood on higher ground in terms of the standards of our health system. There was a general sense that our health system, throughout Europe, was superior and more robust, which would make the virus easier to contain here in comparison with Asia. The problem is we completely underestimated how contagious COVID-19 is and the implications for our demographic structure, with higher numbers of elders. Moreover, we underestimated how a health system geared to address conventional health needs might be very poorly placed to deal with an epidemic.
For example, if you go to the emergency room in North America it's a much quicker experience, but in European national health systems, like in Italy, the emergency room is often an admission gate to hospital care, even for less urgent cases. This system, built on patient-centered care like most Western health systems, allows the time to work through a patient's health problems. During a pandemic like this one, though, this practice might become an issue because it keeps patients around when they shouldn't be, possibly intensifying the outbreak. There is an extremely interesting and moving account of this issue recently published in the New England Journal of Medicine.
We did not understand quickly enough that this virus was an unconventional event that couldn't be dealt with by the conventional standards of our health system. By changing the triage procedure we've adaptedthe time an Italian emergency room takes to process patients now is different, faster, and oriented to COVID-19. Things would have likely been different if we had started sooner.
There is general lesson for Europe and the U.S.: if you use conventional responses to an unconventional scenario like this one, then you're very likely to fail. Rather than containing the virus, we ended up spreading it. We learned this the hard way. We were the victims of our own successful health system in a way. What's especially interesting is that, in Italy, the contagion has been particularly strong in the regionsLombardia and Emilia Romagnawhere the Italian health system is the strongest. They took thorough care of people longer but, in some cases, they were not ready to isolate them promptly. In the middle of an epidemic, even short delays can prove very important in failing to contain the outbreak.
Patients that need hospital treatment for coronavirus may need a team of NHS staff to help them through.
Jessica Murray talks to the people who are key to such treatment from first responders to intensive care consultants to physiotherapists.
Were informed by the control centre whether the patient is query Covid-19, but were wearing protective equipment - mask and protective eyewear - for pretty much all jobs now. Were going into peoples houses and its an enclosed space so were not able to social distance.
Because people cant visit Covid patients in hospital, we facilitate the conversation so people can say their goodbyes, without being too explicit about it. We then advise them to take a phone with them if theyre able to, make sure theyve got a charger and if they dont know how to video call, we might quickly teach them how to use it before we set off.
We then take them to A&E but through a different door for Covid patients - although were finding the Covid side is busier than the normal side.
Then well deep clean the ambulance. We have to clean inside of our cab, around the steering wheel and all the stuff that we would touch, and its difficult because theres a lot of equipment and crevices in an ambulance.
What is Covid-19?
It is caused by a member of the coronavirus family that has never been encountered before. Like other coronaviruses, it has come from animals.
What are the symptoms this coronavirus causes?
The virus can cause pneumonia-like symptoms. Those who have fallen ill are reported to suffer coughs, fever and breathing difficulties.
In the UK, the National Heath Service has defined the symptoms as:
Should I go to the doctor if I have a cough?
Medical advice varies around the world - with many countries imposing travel bans and lockdowns to try and prevent the spread of the virus. In many place people are being told to stay at home rather than visit a doctor of hospital in person. Check with your local authorities.
In the UK, NHS advice is that anyone with symptoms should stay at home for at least 7 days. If you live with other people, they should stay at home for at least 14 days, to avoid spreading the infection outside the home.
How many people have been affected?
Chinas national health commission confirmed human-to-human transmission in January. As of 31 March, more than 780,000 people have been infected in more than 170 countries, according to the Johns Hopkins University Center for Systems Science and Engineering.
There have been over 37,800 deaths globally. Just over 3,200 of those deaths have occurred in mainland China. Italy has been worst affected, with over 11,500 fatalities, and there have been over 7,700 deaths in Spain. The US now has more confirmed cases than any other country - more than 164,000. Many of those who have died had underlying health conditions, which the coronavirus complicated.
More than 166,000 people are recorded as having recovered from the coronavirus.
We have the most patient contact out of any healthcare workers. [We] help the nurses with the really basic but essential tasks, such as washing and changing patients, helping them go to the toilet and helping them eat.
With the current coronavirus crisis, that role has expanded because we are so short-staffed - our ward is down 60% of staff at the moment. Were doing the Covid testing swabs and transferring positive patients around the hospital. I work on a trauma and orthopaedic ward, which is now on lockdown because we have so many confirmed cases.
With both suspected and confirmed patients, we are only wearing surgical masks, sleeveless, plastic aprons and gloves, so theres no eye protection and no arm protection. Today I worked a 13-hour shift with a patient who is confirmed positive, and Im still going in with basically nothing.
We also get a lot of the stress and abuse from patients who are scared and confused and dont know whats going on, because were the people they see most.
Were not classed as frontline workers even though we are very much on the frontline because every Covid-19 patient is coming to us. Medical staff dont know what theyre dealing with unless the patient comes through radiology.
You dont see Covid-19 in the lungs, so Im using the chest X-rays and CT scans to look for patches, mainly on the edges of the lungs, which suggest infectious changes. Were looking for pneumonia and fluid.
For ICU patients who are on a ventilator and not looking well, were likely to be down there at least daily, if not a couple of times a day, for chest X-rays. We have portable X-ray machines on wheels so we can go direct to the patients on the wards, but the CT scanner is a huge machine so they have to come to us for that one, which poses quite a logistical nightmare.
Were needed in A&E, across the wards and, in the ICU were used all the time. Weve also got a postmortem CT scanner so were anticipating Covid patients coming to us that way as well.
I care for some of the sickest patients in the hospital who have a chance of getting over their illness. If someone is in hospital with Covid-19 and their oxygen levels continue to deteriorate, they will often be transferred to intensive care as they might need a ventilator.
If that happens, a team of three or four of us will drift them off to sleep and put a breathing tube through their mouth into the airway. In some cases, we also turn them on to their front, for about 16-18 hours a day, because some Covid-19 studies suggest this can help with oxygenation. That takes at least five people.
We wear full PPE to go in and see patients, meaning a mask and either a visor and goggles or a full respirator helmet, as well as a gown, apron and three pairs of gloves. But we try to spend as little time in with them as possible to minimise our exposure.
I lead the ward rounds, and manage the whole patient - not just the lungs and the right amount of oxygen, but also the heart, the kidneys, and all the other organ systems. Covid-19 can affect the whole body, and many organs may need supporting.
Were seeing many patients stay on a ventilator for about seven to 10 days. After that, the hope is the oxygen levels have returned close enough to normal that patients can breath sufficiently on their own.
Its quite an invasive process coming to intensive care. You have quite a lot done to you. But thats because you need it.
In critical care theres a nurse by the bedside 24/7 - although obviously not the same nurse or we would burn out pretty fast. Other medical staff, like the consultants, physiotherapists and nutritionists, tend to go from patient to patient, so they rely an awful lot on the bedside nurses insight.
If someone is having breathing difficulties, we can reposition them, administer medicines, use oxygen masks, or maintain their ventilator. With breathing, you need to be pretty damn quick at reacting. If five or 10 minutes go by, bad stuff can happen.
We also do the things for the patients that they cannot do themselves. So well wipe their eyes, lubricate them, make sure their eyelids are shut, well brush their teeth, suction out any buildup of saliva and apply lip balm. Well use bedpans, well put in catheters and monitor those, well wash the patients, change their bedding and well regularly reposition them. Well also talk to them because were never quite sure what level of consciousness they have.
When the bedside nurse is in full protective equipment, they cant just nip away to pick up the medicine or a new set of linen. So you have someone who stays in the amber zone away from the patients, who can fetch stuff.
Another big part of my job is supporting family and friends, giving them updates and providing emotional support. In this current situation, were also exploring using FaceTime for patients to talk with their loved ones.
We help identify patients who need extra help breathing, and then help to maintain their chest and keep it clear of secretions. We are the people who are actually asking Covid patients to cough.
As theyre breathing out on the ventilator, we give their chest a really good shake with our hands. It just helps to clear the phlegm, because they cant cough as theyre paralysed and sedated. We do the cough for them, using our hands on their chest and tummy. Its a lot of very hands on treatment. Were then working with the nurses and medics to ultimately wean them off the ventilator.
We also do physical rehabilitation. It might be just sitting on the edge of the bed, but for somebody whos been tubed on intensive care, that is like running a marathon.
Covid-19 patients are probably going to be in intensive care for a little bit longer than were used to, so I think then we will also play a big role in rehabilitation. I think theres going to be a lot of post traumatic stress, and probably a lot of breathing pattern disorder.
*Name has been changed
AUGUSTA, Maine (WABI) A person has died from COVID-19 at the Alfond Center for Health in Augusta, marking the first death reported by MaineGeneral Health, and bringing the total number of virus related deaths in the state to five.
The other deaths reported include three in Cumberland County, and one in York County.
The newly reported deaths were that of two women both in their 80's, both died while in the hospital.
According to hospital officials, another person with the disease is hospitalized at that facility and a third patient was transferred to a different hospital due to their need for a higher level of care.
Two children have also tested positive for the virus, Dr. Nirav Shah says neither of those are school aged.
Tuesday morning the Maine CDC reported that there have now been 303 Mainers who have tested positive for the virus.
68 of those have recovered.
A total of 57 people are currently hospitalized.
Still showing with the largest number of patients with the illness are Cumberland and York counties.
Here is a breakdown of the numbers by county:
Androscoggin: 11Cumberland: 169Franklin: 2Kennebec: 12Knox: 5Lincoln: 8Oxford: 9Penobscot: 12Sagadahoc: 7Somerset: 1Waldo: 2York: 59
The counties of residence of six patients have yet to be identified.
The testing backlog is now is down to 600 tests, these are all tests of people in lowest risk category.
3 counties have more than ten cases, including Androscoggin, Penobscot, and Kennebec. This is one of two criteria used to determine if community transmission has occurred.
Officials are still working to confirm if community transmission exists in those areas.
Congregate settings are also of concern and remain a high priority for the CDC.
13 cases of COVID-19 are associated with congregate settings, one of those being a person who received services at a southern Maine homeless shelter.
On that note, Maine's Department of Corrections has tested 7 individuals. 4 of which have come back negative and 3 sets of results remain pending.
During Tuesday's briefing, Dr. Shah asked people to really consider how they are living their lives these days, "For the time being this uncertainty may be the new norm. I fully recognize that uncertainty is unsettling. I want to acknowledge that that feeling of uncertainty, those feelings of being unsettled are okay. We're all feeling it."
As to equipment, 90 of the 190 Intensive Care Unit beds remain available if conditions continue to escalate.
The majority of ventilators are also still available for patients experiencing severe respiratory distress, and a third shipment of personal protective equipment was delivered yesterday form the federal stockpile.
The state has ordered an additional piece of equipment that will help with providing faster test results- that is anticipated to arrive within the next two weeks.
With emergency response, Dr. Shah says it is always important to have a backup plan, as healthcare providers or laboratory staff are also at risk of becoming ill.
Part of that backup plan includes the use of an out of state lab that is assisting with testing.
As has been the situation, it is important to continue to listen to the officials who urge people to stay at home and practice social distancing, which has proven to be effective.
With schools closed and governments issuing orders for people to stay at home, a lot of kids have no choice but to turn to their screens for school and any kind of socializing. The debate over how much screentime is healthy is nothing new, but our devices have arguably never played as big a role in our lives as they do now when it comes to staying connected amid a global pandemic.
To understand how these changes might affect kids, The Verge spoke with Lloyda Williamson, a general and child psychiatrist and the chair of the psychiatry and behavioral sciences department at Meharry Medical College. This interview has been lightly edited for length and clarity.
Recent data shows that a majority of kids between the ages of six and 12 in the US are spending at least 50 percent more time in front of screens each day during the COVID-19 outbreaks. How might that affect kids development and mental health?
Its interesting because we have sort of mixed guidelines in terms of childrens exposure to digital technology. We of course have the educators that are really promoting the use of digital technology to help them to gain skills, to provide ways for them to be more engaged in science, technology, engineering, and math, and just help them to be prepared for a productive workforce in the future.
On the other hand, youve got the public health officials that are, I would say, not anti-digital but more cautious because of concerns about various aspects of health. One of the social concerns is that, of course, we have predatory individuals, theres cyberbullying. Some examples of emotional concerns might be just addictive behaviors toward digital technology and depression, as well as access to inappropriate content. With this increased time [on screens], a lot of times that means that these children are less active in terms of physical activity and exercise. And then, were understanding that theres a shortened or decreased attention span [when it comes to cognitive development].
Of course, as we look at digital technology were talking about lots of different platforms and types of media. And a lot of what were dealing with in terms of digital technology is new. So, what we have in terms of [studies on the effects of] screen time are primarily on television. And we realized that television is different than a lot of the platforms that we have where people are interacting in different ways. So I guess the short answer is we dont really know what the impact of digital technology is going to have, because it hasnt been out long enough to get these long-term studies.
What can parents and guardians do to counteract some of those potentially adverse effects? And how do we talk with kids about the pandemic?
One of the things that I think is very crucial, particularly since our children are at home, is the parental example of media use. One of the things we forget is that our children are watching us all the time. And so they see how much time were on social media using different digital media, and many times their behavior patterns and their patterns of use are patterned after us.
We have a thirst for news and as we are watching on the TV or listening on social media, our children are also exposed to that. That can be not only overwhelming for us, but also overwhelming for our children. So have some boundaries as to how much of this were going to watch and at what times of the day. Sometimes its just good to turn it off and do some other things instead of just keeping up with every news event.
As adults we do have to be aware of what our children are experiencing along with the increased tension in our community. Children are definitely aware that were experiencing a crisis. Many adolescents are resistant to staying at home and just really want to connect with their friends in person. And so, when those activities are restricted, that can bring out some feelings of sadness, depression, irritability, anger, frustration. For younger kids, when they realize that their lives are different, its a good opportunity for us to talk with them about whats going on. Have conversations about how theyre doing, what they miss about school, what they miss about having contact with their friends, and then just listening and giving them an opportunity to talk about their feelings.
I think its important to tell them facts according to their developmental level. Some people may say, Well, how do you talk about this coronavirus when people are dying? But we should be having some of these difficult conversations with children all along like being safe when you go out in public, not speaking to strangers and why thats important. We have these difficult conversations, and so this is another one: why its important to wash your hands, why its important for us to stay in our safe place at home during this time, and why, when people get ill, it can be very serious, to the point where some people are ending up in the hospital or maybe even die.
As parents are interacting with their children, they may want to know what are some signs of my child or my adolescent not doing well? Pay attention to changes in their behavior, changes in the way they communicate, and change in their personalities like theyre becoming more withdrawn, irritable, if theyre sleeping more, or if theyre arguing more. If it gets to the point that its really negatively impacting their ability to interact with the family, or where theyre not eating or sleeping, then they may want to reach out to their care provider and see if this may be a time that an evaluation needs to occur before it gets to the point that theres actually a serious psychiatric or mental health disorder.
With so many schools closed, how might online classes affect students learning?
We have more data in terms of college students, and we dont have as much of that data with younger children. And so I think were in a big experiment.
Its challenging for teachers to relate to different learning styles online. Different children learn differently. Some are more visual. Some are more auditory. Some have a mixed learning style. And then children have different levels of being able to be self motivated and participate in these online educational activities. There are a lot of different factors to consider, to see how people may respond positively or negatively or in mixed ways. But parents [can be] aware of their child, their childs learning style and personality, and check in with them.
Many parents have struggled with putting limits on screentime, even before outbreaks of COVID-19. Is that a good idea now, especially for kids who might feel like thats their only connection to the outside world while theyre stuck at home?
We dont want to do all or none. So we dont want to cut them off. Were looking for a sense of balance, in terms of communicating, learning, connecting. Lets also turn [screens] off for some time so they can connect together as a family and so that they can also perhaps engage in some other activities, whether its cooking, doing yard work outside, or drawing, or even interacting as a family with different games and things.
Theres so many resources out there, theres so many apps. I think the main thing is finding things that will help bring you a sense of peace, and using those things instead of things that would add more stress and more anxiety.
This version updates the 27 March publication by providing definitions of droplets by particle size and adding three relevant publications.
Respiratory infections can be transmitted through droplets of different sizes: when the droplet particles are >5-10 m in diameter they are referred to as respiratory droplets, and when then are <5m in diameter, they are referred to as droplet nuclei.1 According to current evidence, COVID-19 virus is primarily transmitted between people through respiratory droplets and contact routes.2-7 In an analysis of 75,465 COVID-19 cases in China, airborne transmission was not reported.8
Droplet transmission occurs when a person is in in close contact (within 1 m) with someone who has respiratory symptoms (e.g., coughing or sneezing) and is therefore at risk of having his/her mucosae (mouth and nose) or conjunctiva (eyes) exposed to potentially infective respiratory droplets. Transmission may also occur through fomites in the immediate environment around the infected person.8 Therefore, transmission of the COVID-19 virus can occur by direct contact with infected people and indirect contact with surfaces in the immediate environment or with objects used on the infected person (e.g., stethoscope or thermometer).
Airborne transmission is different from droplet transmission as it refers to the presence of microbes within droplet nuclei, which are generally considered to be particles <5m in diameter, can remain in the air for long periods of time and be transmitted to others over distances greater than 1 m.
In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation.
There is some evidence that COVID-19 infection may lead to intestinal infection and be present in faeces. However, to date only one study has cultured the COVID-19 virus from a single stool specimen.9 There have been no reports of faecaloral transmission of the COVID-19 virus to date.
To date, some scientific publications provide initial evidence on whether the COVID-19 virus can be detected in the air and thus, some news outlets have suggested that there has been airborne transmission. These initial findings need to be interpreted carefully.
A recent publication in the New England Journal of Medicine has evaluated virus persistence of the COVID-19 virus.10 In this experimental study, aerosols were generated using a three-jet Collison nebulizer and fed into a Goldberg drum under controlled laboratory conditions. This is a high-powered machine that does not reflect normal human cough conditions. Further, the finding of COVID-19 virus in aerosol particles up to 3 hours does not reflect a clinical setting in which aerosol-generating procedures are performedthat is, this was an experimentally induced aerosol-generating procedure.
There are reports from settings where symptomatic COVID-19 patients have been admitted and in which no COVID-19 RNA was detected in air samples.11-12 WHO is aware of other studies which have evaluated the presence of COVID-19 RNA in air samples, but which are not yet published in peer-reviewed journals. It is important to note that the detection of RNA in environmental samples based on PCR-based assays is not indicative of viable virus that could be transmissible. Further studies are needed to determine whether it is possible to detect COVID-19 virus in air samples from patient rooms where no procedures or support treatments that generate aerosols are ongoing. As evidence emerges, it is important to know whether viable virus is found and what role it may play in transmission.
Based on the available evidence, including the recent publications mentioned above, WHO continues to recommend droplet and contact precautions for those people caring for COVID-19 patients. WHO continues to recommend airborne precautions for circumstances and settings in which aerosol generating procedures and support treatment are performed, according to risk assessment.13 These recommendations are consistent with other national and international guidelines, including those developed by the European Society of Intensive Care Medicine and Society of Critical Care Medicine14 and those currently used in Australia, Canada, and United Kingdom.15-17
At the same time, other countries and organizations, including the US Centers for Diseases Control and Prevention and the European Centre for Disease Prevention and Control, recommend airborne precautions for any situation involving the care of COVID-19 patients, and consider the use of medical masks as an acceptable option in case of shortages of respirators (N95, FFP2 or FFP3).18-19
Current WHO recommendations emphasize the importance of rational and appropriate use of all PPE,20 not only masks, which requires correct and rigorous behavior from health care workers, particularly in doffing procedures and hand hygiene practices.21 WHO also recommends staff training on these recommendations,22 as well as the adequate procurement and availability of the necessary PPE and other supplies and facilities. Finally, WHO continues to emphasize the utmost importance of frequent hand hygiene, respiratory etiquette, and environmental cleaning and disinfection, as well as the importance of maintaining physical distances and avoidance of close, unprotected contact with people with fever or respiratory symptoms.
WHO carefully monitors emerging evidence about this critical topic and will update this scientific brief as more information becomes available.
World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care. Geneva: World Health Organization; 2014 Available from: https://apps.who.int/iris/bitstream/handle/10665/112656/9789241507134_eng.pdf?sequence=1
Liu J, Liao X, Qian S et al. Community transmission of severe acute respiratory syndrome coronavirus 2, Shenzhen, China, 2020. Emerg Infect Dis 2020 doi.org/10.3201/eid2606.200239
Chan J, Yuan S, Kok K et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020 doi: 10.1016/S0140-6736(20)30154-9
Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020; doi:10.1056/NEJMoa2001316.
Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395: 497506.
Burke RM, Midgley CM, Dratch A, Fenstersheib M, Haupt T, Holshue M,et al. Active monitoring of persons exposed to patients with confirmed COVID-19 United States, JanuaryFebruary 2020. MMWR Morb Mortal Wkly Rep. 2020 doi: 10.15585/mmwr.mm6909e1external icon
World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf
Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA. 2020 Mar 4 [Epub ahead of print].
Zhang Y, Chen C, Zhu S et al. [Isolation of 2019-nCoV from a stool specimen of a laboratory-confirmed case of the coronavirus disease 2019 (COVID-19)]. China CDC Weekly. 2020;2(8):1234. (In Chinese)
van Doremalen N, Morris D, Bushmaker T et al. Aerosol and Surface Stability of SARS-CoV-2 as compared with SARS-CoV-1. New Engl J Med 2020 doi: 10.1056/NEJMc2004973
Cheng V, Wong S-C, Chen J, Yip C, Chuang V, Tsang O, et al. Escalating infection control response to the rapidly evolving epidemiology of the Coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong. Infect Control Hosp Epidemiol. 2020 Mar 5 [Epub ahead of print].
Ong SW, Tan YK, Chia PY, Lee TH, Ng OT, Wong MS, et al. Air, surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from a symptomatic patient. JAMA. 2020
WHO Infection Prevention and Control Guidance for COVID-19 available at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control
Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Medicine DOI: 10.1007/s00134-020-06022-5 https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19
Interim guidelines for the clinical management of COVID-19 in adults Australasian Society for Infectious Diseases Limited (ASID) https://www.asid.net.au/documents/item/1873
Coronavirus disease (COVID-19): For health professionals. https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/health-professionals.html
Guidance on infection prevention and control for COVID-19 https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control
Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
Infection prevention and control for COVID-19 in healthcare settings https://www.ecdc.europa.eu/en/publications-data/infection-prevention-and-control-covid-19-healthcare-settings
Rational use of PPE for COVID-19. https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf
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WHO continues to monitor the situation closely for any changes that may affect this interim guidance. Should any factors change, WHO will issue a further update. Otherwise, this scientific brief will expire 2 years after the date of publication.
World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license.
WHO reference number: WHO/2019-nCoV/Sci_Brief/Transmission_modes/2020.2
CT Department of Public Health
The map of COVID-19 hospitalizations by county shows a migration to the east and north, roughly following the interstate highways.
Public health experts speak calmly of an approaching storm, one moving west to east, like most weather in New England. Dont forget your umbrella. The governor and hospital executives use more urgent language, warning of a surge, maybe even a tsunami. You can almost hear the distant wail of sirens.
The former police chief in charge of emergency services in Connecticut uses cop vernacular. James Rovella watches the novel coronavirus creep up I-684 to I-84 to Danbury and I-95 to Stamford and Norwalk, and he thinks of his experience with two less novel plagues, drugs and guns. He says, All they do is follow the highways.
The metaphors of the COVID-19 pandemic continue to evolve, as do the metrics and the statistical modeling guiding the governmental response.
The White House released statistical models Tuesday showing the U.S. can expect at least 100,000 deaths from COVID-19 in coming months, even factoring in the social distancing measures imposed by governors and mayors and strongly recommended by the president. Donald J. Trump no longer speaks of a return to normalcy by Easter.
I want every American to be prepared for the hard days that lie ahead, Trump said.
A dynamic forecasting tool developed by the Institute for Health Metrics and Evaluation at the University of Washington suggests the current death toll of 69 in Connecticut could jump sixfold in April, then plateau in May, about two weeks behind New York and a month ahead of the U.S. as a whole. The projections fluctuate as the states update their data.
CT Department of Public Health
The running tally of confirmed cases and fatalities by county.
The institute sees more than a tenfold increase in U.S. deaths in April, reaching 60,000.
Even before White House disclosed details of its model, Gov. Ned Lamont said Tuesday all the algorithms and models all point to the same conclusion: April will be a horrible month.
Connecticuts daily COVID-19 tally is posted on the Department of Public Health web site: The numbers of tests completed, cases confirmed, patients hospitalized, and the deaths. They are imperfect measures of what is happening on any given day and incomplete data sets feeding the forecasts of what is to come.
The DPH laboratory confirmed the states first two cases on March 9, none on March 10, then another on March 11.
The one-day total Tuesday was 557, and the state epidemiologist says the running total of confirmed cases, now 3,128, always will be just the tip of the iceberg. What lays unseen is much larger, perhaps by a magnitude of 10, perhaps more.
Our goal is to provide the maximum amount of data that we can, said Av Harris, the former public-radio reporter in charge of communications at the state Department of Public Health. Its not a simple process.
Connecticut publishes more details than some states, less than others. The contents of the daily update on the DPH web site was tweaked Monday and again Tuesday, offering clearer summaries and more data points. And over the weekend it shifted to hospitalization data gathered by the Connecticut Hospital Association, finding it more accurate.
We hear from a lot of different people who are stakeholders about what data they would like to see, Harris said. Were getting input from local public health departments, from legislators, from journalists, from the governors office.
There has been limited data on infections in nursing homes and none among hospital workers. And there are questions about the accuracy and timeliness of the death toll, given the death Thursday of 35-year-old Mike OBrien. It wasnt until Monday that the DPH summary statistics reflected the death of anyone under age 40.
On Monday, the death toll was 36. On Tuesday, the Lamont administration reported an additional 33 fatalities, a misleading measure of the diseases progress. Yes, there were a statistically significant 16 deaths in the previous 24 hours. But there also were 17 catchup deaths, ones that had not been previously reported by the DPH.
The DPH on Tuesday began offering some details on nursing home infections: 85 residents have been diagnosed with the disease; half have been hospitalized; and 11 have died. Thirty of the states 216 nursing homes have had at least one confirmed case, but the facilities have not been publicly identified since an initial outbreak in Stafford Springs.
With more private labs now conducting the tests, there is a noticeable lag in reporting some days. State law initially required private labs to only notify DPH of confirmed COVID-19 cases, not negative results. By executive order of Gov. Ned Lamont, the negatives are now reported.
As of Tuesday, there were 15,600 completed tests: 3,128 positive, about 20 percent of the total.
For the first time, the DPH put COVID-19 in a broader context on Monday, offering syndromic surveillance data that compares the percentage of people seeking care in hospital emergency departments for unexplained fever/flu symptoms this year against the past two flu seasons. It shows a dramatic spike, one indicator of the growing pressure on hospitals.
There is no fever graph showing how steeply the trajectory of confirmed cases or hospitalizations are pitching upward. But the numbers are there: hospitalizations nearly doubled overnight, from 205 on March 28 to 404 on the 29th and 517 on the 30th. On Tuesday, the number rose to 608.
We wanted to stay two and three and four weeks ahead, said Rovella, describing the states preparations to have sufficient hospital capacity. But I can hear the footsteps.
Hospitals in Fairfield County, the closest to New York, have the most COVID-19 patients, with 275; New Haven County has 202 and Hartford County, 110. Those statistics reflect where the patients are hospitalized, not where they are from.
Commissioner James RovellaDepartment of Emergency Services and Public Protection
An unknown numbers New Yorkers have taken shelter at second homes in Litchfield County or on the Connecticut shoreline. If they are tested positive while in Connecticut, the results will be reported and recorded in New York. There were no details on how many New Yorkers might be hospitalized in Greenwich, Stamford, Norwalk or Danbury hospitals.
At the insistence of Lamont, the hospitals are greatly expanding capacity. Less clear is how the staffing and related supplies, particularly personal protection equipment, can expand to serve patients who soon could be in beds in mobile hospitals, universities and exhibition halls at the Connecticut Convention Center and Mohegan Sun.
DPH officials declined to comment Tuesday on the latest projections released by the White House based on the administrations modeling.
The University of Washington forecasting tool was developed to give hospitals a sense of when to expect a surge of patients. While the death toll will not reach its apex until May, the peak demand on the hospitals is eight days away in New York and 12 in Connecticut.
Ryan Caron King :: Connecticut Public Radio
Members of the Connecticut National Guard unload equipment Tuesday for a 250-bed field hospital that will be staged at Southern Connecticut State University to facilitate overflow for regional hospitals.
The institute estimates the states overall hospital capacity can meet peak demand, but it will be short more than 100 intensive-care beds. It was described Monday by Wired in a deeply reported story as a data-crunching powerhouse with about 500 statisticians, computer scientists, and epidemiologists on staff.
Josh Geballe, the governors chief operating officer, said the University of Washington model is by far, the least severe of the ones reviewed by the state.He said modeling is an imperfect tool, given that the peak caseloads will not arrive uniformly, even in a small state like Connecticut.
The peak is going to happen at different places at different times. Fairfield County is going to go first, the second half of April the most likely peak, Geballe said. It will migrate to the north and east.
For many reasons, the true spread of a disease will remain one of educated conjecture for months.
Testing for active cases still falls short the demand, and no one is looking on a large scale yet for the antibodies that would show its reach across the state, as well as the level of community or herd immunity that might slow its spread.
A person infected by COVID-19 can have mild symptoms or be largely asymptomatic, one of the reasons why the state epidemiologist, Dr. Matthew Cartter, estimates the actual number of those infected is at least ten times larger than those with a laboratory-confirmed diagnosis.
Were only testing people with quite severe symptoms, said Manon Cox, a virologist and the former chief executive of Protein Sciences, where she learned first hand the difficulty of developing a vaccine for SARS, a severe respiratory disease caused by another coronavirus. Were not testing the many layers behind this.
Cox is skeptical about the likelihood of an effective COVID-19 vaccine being developed, and it ultimately might be shown to be unnecessary if the U.S. can widely test for antibodies through serology tests. Cox said antibody testing would be a boon to researchers struggling to precisely measure the spread of the disease and its mortality rate.
In the meantime, state officials say, the best they can do is prepare for scenarios outlined in the models, trying to match hospital capacity with the expected need.
If it turns out we didnt need it all, Geballe said, thats fine.
CT Department of Public Health
Stamford, Norwalk and Danbury have the most residents with laboratory-confirmed cases.
"Novel coronavirus" is the proper term for this brand-new virus wreaking havoc on our unprepared world.
But you can also call this nasty villain by its scientific name: severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2 for short.
Covid-19 seems to strike the elderly and immunocompromised the hardest, along with any of us with underlying health conditions such as diabetes, heart and lung disease. But the young shouldn't take anything for granted -- there have been numerous deaths among people aged 20 to 50, as well as a very few among children.
Covid-19 can also present with mild symptoms very similar to a typical cold or flu -- or no symptoms at all, which makes controlling the spread of the virus causing Covid-19 very difficult.
What is a coronavirus?
There they set up shop, producing millions of copies of themselves and causing those cells to rupture. Like the famous scene from the movie "Alien," the viral offspring shoot out into the bloodstream, with the goal of invading more and more cells.
As they multiply, humans began to spit them out into the universe with each exhalation, making us contagious days before we begin to cough, sneeze or have diarrhea -- all symptoms the virus creates to ensure it can leap from human to human, thus ensuring its survival.
This "virus zombie invasion" comes in all sort of shapes, sizes and genetic strategies. All coronaviruses are covered with pointy spires of protein, giving them the appearance of having a crown or "corona" -- hence the name. Coronaviruses use these spikes to latch onto and pierce our cells.
Coronaviruses are part of the RNA brigade of viruses, which are much less stable than their DNA-based comrades. Why is that important? Because instability leads to mistakes in copying genetic code.
That leads to mutations -- thousands, millions, billions of mutations. Sooner or later, one mutation hits pay dirt and allows the virus to cross the great divide between different species. A few million/billion/trillion more mistakes creates another mutation that allows that virus to spread easily. Now the virus is both in its new host and it is contagious.
It's that type of mutation which gives humanity viruses like SARS-CoV-2.
Where did the novel coronavirus come from?
Some of those coronviruses can cross species, such as between pigs, cats and dogs, but for the most part coronaviruses stay loyal to their original hosts. Until, of course, they become that lucky mutation.
"Usually viruses from one animal really don't effectively transmit to other animal species or even to people," said Dr. John Williams, chief of the division of pediatric infectious diseases at the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh.
"So usually if a virus goes from an animal to a human, it's sort of dead end. That person gets sick but it doesn't spread further," said Williams, who has studied coronaviruses for decades.
"MERS is extremely deadly, about 30% of people who are infected with MERS will die," Williams said. "So the virus got over one of the barriers -- it's able to infect humans, grow in them and cause disease -- but thankfully it really doesn't spread well person to person, other than very, very close contacts."
SARS has been more difficult to pin down.
"SARS caused death in about 10% of people that became infected and it did spread person to person but not super effectively," Williams said. "There weren't many people walking around without symptoms or with mild symptoms, who could be spreading it.
"This new virus, SARS-CoV-2, has overcome more barriers," Williams added. "It spreads easily person to person and a lot of people can have either mild disease or they might not even have symptoms, yet they can have the virus and spread it."
At this time, scientists don't know where the novel coronavirus began.
"These things are more difficult than [identifying] dinosaurs, because there's no fossil record of a virus," Williams said. "For example, the main virus I study, human metapneumovirus, is clearly a virus that has circulated in humans for decades if not a few centuries.
"However, when you look at the genetics of the virus, its closest genetic relative is a bird virus," he added. "So, did that virus jump to humans way back and become established? That's what we think. But it isn't impossible that a human virus jumped to birds and became established there."
Ventilators are one of the most important tools hospitals have for keeping Covid-19 patients in the most critical condition alive.
Between 21% and 31% of Covid-19 patients in the U.S. have required hospitalization, and 5% to 11% have required intensive care. Officials have not reported how many of these patients developed respiratory distress so severe they needed to be put on a ventilator, but among one group of patients in China, 12% did.
The number of Covid-19 cases is growing at such a rapid pace, it is possible that many hospitals will not have enough ventilators available for the patients that need them. If this happens, any patients who would otherwise survived their infections could die.
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In the video above, we look at how ventilators work, and how they are used to treat patients with Covid-19.
