Category: Covid-19

Survivors of COVID-19 who spent time on a ventilator may be at risk of long-term disability and illness.

By Kelly ServickApr. 8, 2020 , 10:50 AM

Sciences COVID-19 reporting is supported by the Pulitzer Center.

The next few months will be full of grim updates about the spread of the new coronavirus, but they will also be full of homecomings. Patients hospitalized with severe COVID-19, some having spent weeks breathing with the help of a mechanical ventilator, will set about resuming their lives. Many will likely deal with lingering effects of the virusand of the emergency treatments that allowed them to survive it.

The issue were all going to be faced with the most in the coming months is how were going to help these people recover, says Lauren Ferrante, a pulmonary and critical care physician at the Yale School of Medicine. Hospital practices that keep patients as lucid and mobile as possible, even in the throes of their illness, could improve their long-term odds. But many intensive care unit doctors say the pandemics strain on hospitals and the infectious nature of the virus are making it hard to stick to some of those practices.

While COVID-19 is sending even young, previously healthy people to the intensive care unit(ICU), older adults are at greatest risk of both severe disease and long-term impairment, says Sharon Inouye, a geriatrician at Harvard Medical Schools Hebrew SeniorLife health care system. Its taken us a long, long time to [develop] some best practices for geriatric care in the hospital and ICU, and I just see all of that being eroded during this crisis.

COVID-19s immediate assault on the body is extensive. It targets the lungs, but a lack of oxygen and widespread inflammation can also damage the kidneys, liver, heart, brain, and other organs. Although its too early to say what lasting disabilities COVID-19 survivors will face, clues come from studies of severe pneumoniaan infection that inflames the air sacs in the lungs, as COVID-19 does. Some of these infections progress to acute respiratory distress syndrome (ARDS), in which those sacs fill with fluid. That condition sometimes leads to scarring that can cause long-term breathing problems, Ferrante says, but studies show that most ARDS patients eventually recover their lung function.

After any severe case of pneumonia, a combination of underlying chronic diseases and prolonged inflammation seems to increase the risk of future illnesses, including heart attack, stroke, and kidney disease, says Sachin Yende, an epidemiologist and critical care physician at the University of Pittsburgh Medical Center. His team reported in 2015, for example, that people hospitalized for pneumonia have a risk of heart disease about four times as high as that of age-matched controls in the year after their release, and about 1.5 times as high in each of the next 9 years. COVID-19 might prompt a big increase in these sorts of events, he says.

Patients who spend time in an ICU, regardless of the illness that put them there, are also proneto a set of physical, cognitive, and mental health problems after leaving known as postintensive care syndrome. The new coronavirus might put ICU survivors at particular risk for some of these problems, says Dale Needham, a critical care physician at Johns Hopkins Universitys School of Medicine. One reason is the exceptionally severe lung injury it can cause, which leads many patients to spend prolonged periods on a ventilator under deep sedation. A patient with ARDS caused by other illnesses might rely on this life support for 7 to 10 days, Needham estimates, but some coronavirus patients require more than 2 weeks.

Many COVID-19 patients who need a ventilator never recover. Although survival rates vary across studies and countries, a report from Londons Intensive Care National Audit & Research Centre found that 67% of reported COVID-19 patients from England, Wales, and Northern Ireland receiving advanced respiratory support died. A study in a smaller patient group in China found that only 14% survived after going on a ventilator.

Those who survive a long period on a ventilator are prone to muscle atrophy and weakness. Keeping a critically ill patient movingraising their arms and legs, and eventually helping them sit up, stand, and walkcan reduce that weakness and get them off the ventilator faster. But because SARS-CoV-2is so infectious, bringing rehab specialists into patients rooms can be a challenge, Needham says.

In Needhams ICU at Johns Hopkins, these specialists are donning protective gear to help people on ventilators stay moving. But Ferrante says that at many major hospitals, including hers, a shortage of such equipment has kept physical therapists away from COVID-19 patients. And even when people are well enough to leave the ICU or the hospital, many still have the virus, she says, and may have to wait until theyre not contagious to get inhome care or visit a rehab facility.

Another risk for hospitalized patients is deliriuma state of confused thinking that can lead to long-term cognitive impairments such as memory deficits. What were finding in COVID is that theres a ton of delirium, says E. Wesley Ely, a pulmonologist and critical care physician at Vanderbilt University whose team is preparing to publish those findings. The virus itself is partly to blame, Ely says. He suspects this coronavirus, like the ones that cause severe acute respiratory syndrome(SARS) and Middle East respiratory syndrome, can directly infiltrate and damage the brain. And bodywide inflammation caused by the virus can also limit blood flow to the brain and kill brain cells.

Making matters worse, doctors commonly prescribe sedative drugs to suppress violent coughing and help patients tolerate the distress and discomfort of a breathing tube. But these drugs can increase the risk of delirium, Ely says. And as hospitals run short of the most commonly used sedatives, theyre turning to benzodiazepines, a class of drugs that can cause intense and prolonged delirium, he says.

Over the past 20 years, Ely and colleagues have developed a checklist, now adopted by many ICUs, to improve patient care and outcomes. Among its priorities: a daily interruption of narcotics and sedatives plus a decrease of ventilator pressure to test whether patients can wake up, breathe, and tolerate the ventilator without drugs. (If they cant, doctors are urged to restart these drugs at a lower dose.) But the practice requires close monitoring, and in ICUs overstretched by COVID-19, I think thats getting skipped, Ely says. Everybody out there is trying to do their best, he notes. But lets not throw out all the things weve learned in the last 20 years.

The threat of infection has limited the bedside interactions that can help patients stay calm and reduce the need for delirium-inducing drugs. If you could design a system to be bad for how you care for older adults, you would make it such that no one could go in the room, and the family would not be allowed to visit, and everyone has to go in with face masks and all gowned up, so theyre completely frightening, Inouye says. Doctors do need to sedate and restrain agitated patients to keep them from pulling out their IV or breathing tubes, she says. And yet Im wondering, could we possibly take 2 minutes to try to calm them, to have someone there whos gloved and masked, to hold their hand and stroke their arm?

Early reports from ICUs battling COVID-19 suggested patients should be put on ventilators early in the course of the disease, says C. Terri Hough, a pulmonary critical care physician at the University of Washington, Seattle. That was our approach here for our first handful of patients. Part of the logic was that a less invasive alternativedelivering a high flow of oxygen into the nosemight send the patients viral particles into the surrounding air, increasing the risk of infecting others. And if a patient declined quickly, doctors would be forced to do a riskier emergency intubation. But Houghs team quickly got worried about all the downsides of early ventilation, she says. She and her colleagues are now trying to tease apart subtypes of respiratory failure in coronavirus patients to help them decide which patients need ventilators and when. As we learn the faces of the disease, were seeing our practices shift, she says. If were putting more people on ventilators than maybe we need to, that certainly is going to affect the population health after recovery.

Poor survival odds and the potential for long-term complications force difficult conversations for older patients, families, and clinicians. I was initially really upset when I was hearing about the rationing of ventilators from older adults, Inouye says. But when COVID-19 broke out at her 91-year-old mothers assisted living facility, she and her sister made plans to tell hospital staff that if their mother got sick, she did not want to be kept on a ventilator when the hope of recovery was slight. (The facility has now passed 14 days without a new coronavirus case.)

Because of the decision-making about my moms case, and because of realizing how scarce the ventilators are, I do think we have to take it one-on-onewe have to go by what that persons wishes are and what their familys wishes are, she says.

As hospitals struggle through the current surge of cases, researchers are also trying to look ahead. Elys team is testing a tablet-based rehabilitation program for people who have cognitive impairment after being hospitalized for a critical illness, which he describes as Sudoku and Scrabble on steroids. Yendes team is piloting a care approach for discharged pneumonia and sepsis patients that includes monitoring them using computers and smartphones and visiting them at home or treating them remotely in hopes of preventing readmission to the hospital.

Others are preparing for a surge in mental health problems, among them anxiety, depression, and post-traumatic stress disorder following the psychological stress of severe disease. A study of people hospitalized for SARS found that more than one-third had moderate to severe symptoms of depression and anxiety 1 year later. Hough and her collaborators are testing a mobile app that promotes mindfulness and coping skills in people leaving the hospital.

The global emergency could lead to a stronger support system for survivors of any critical illness, Hough says. This were-all-in-this-together attitude around coronavirus may actually provide hope that wasnt there before.

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For survivors of severe COVID-19, beating the virus is just the beginning - Science Magazine

Doctors say its not uncommon for the coronavirus to spread quickly through a family. And thats hard on everyone involved.

Chanintorn Vanichsawangphan/Getty Images/EyeEm

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Chanintorn Vanichsawangphan/Getty Images/EyeEm

Doctors say its not uncommon for the coronavirus to spread quickly through a family. And thats hard on everyone involved.

Chanintorn Vanichsawangphan/Getty Images/EyeEm

Misty Donaldson-Urriola and Edgar Urriola of Raytown, Mo., are recently divorced. But they have remained close friends as they raise their three sons together.

They generally see each other every day.

That constant contact and proximity an aspect of family life is being put to the test by a disease that thrives when people are close together.

Misty says that just before St. Patricks Day, Edgar told her he had started feeling run down. He had a fever but no cough. They thought he had the flu.

Four days after that first fever, Edgar started experiencing shortness of breath. He went to an urgent care center the next morning.

From there, things spiraled quickly. Edgar had developed pneumonia. His oxygen levels were dangerously low. An ambulance raced him to a local hospital.

Within two hours, theyre like, Were going to intubate you. It was that fast, Misty says.

A selfie with the Urriola family in the foreground. Mistys two older children Erica Donaldson and Ryan Buller are in the back row.

Misty Donaldson-Urriola

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Misty Donaldson-Urriola

Edgar said he loves the kids, Misty recalls. He got to talk to the three boys, and then they sedated him.

That was the last time they spoke to Edgar. Doctors put him on a ventilator. And Misty was told she and her three boys needed to quarantine themselves.

But the coronavirus hadnt finished ripping through her family. The day after his father went into the hospital, 7-year-old Matthew spiked a fever overnight.

The next morning, Misty heard a big bang. I walked into the bathroom, she recounts. Hes laying on the floor, kind of twitching.

Matthew had passed out. Misty says he was talking gibberish and she was worried hed hit his head and had a concussion.

She called an ambulance, and when the paramedics arrived, she warned them that the family was under quarantine. At the hospital, doctors checked Matthew and gave him fluids for dehydration, then sent him home. They told Misty to bring him back if his symptoms worsened.

He had a fever that day, a little bit the next day, she says. We had a lot of sleep. Matthew hasnt had fever since then. So thank goodness, his mom says.

Matthews older brothers, Justin, 13, and Lucas, 14, have also shown signs of illness, such as headaches and fatigue. But with confirmatory tests still in short supply, theres no way to know for sure if they, too, were infected with the coronavirus.

Misty says she, too, has felt unwell.

I dont know if its stress, I dont know if its symptoms, she says. Its so scary. Its hard to say.

Doctors say its not uncommon for the coronavirus to spread quickly through a family. Dr. Vineet Chopra, a hospitalist and associate professor at the University of Michigan, says sometimes the virus can spread before anyone knows they are sick.

If you dont know you have it, theres not really much you can do to protect yourselves, he says.

But if someone in a household shows signs of illness, he says, its important to designate a room or space, as best youre able to, where they can be isolated from everyone else and, if it is possible, a designated bathroom where people dont share stuff with you.

Dr. Alex Isakov of Emory University adds that if you do need to share a bathroom, the person who is sick should disinfect it after every use if they can. If this is not possible, you, as the caregiver, should try to not enter the bathroom immediately. And when you do, wipe down frequently touched surfaces with a disinfectant before the next use, and wash your hands well afterward.

In fact, anyone living with someone who has symptoms of COVID-19 should be particularly careful to scrupulously wash their hands often and not touch their face the same general rules were all advised to follow now. Chopra suggests wearing gloves and a mask or face covering whenever interacting with someone who has symptoms, and keeping at least six feet away.

Were humans, were social creatures, Chopra says. We want to interact with our loved ones. But, you know, in a time when somebody has an infection, we really have to resist that urge and keep our distance from people.

Its been more than two weeks since Misty and the boys began their quarantine. Edgar is still on a ventilator. Misty says shes got no choice but to stay strong for her children, and for Edgar.

There was a time where I kind of wavered, like, Oh, this is it. Thinking the worst, Misty says. And that made stress and everything worse. I said, I cant think like that. Its hard, but were trying to stay positive.

Shes also trying to keep family life as normal as possible for the kids. That means a regular routine for meals, school work and family game nights and finding reasons to celebrate. Last week, Misty and Edgars youngest son, Matthew, turned 8. Friends and family stopped by to wish him well from a safe distance in the yard.

Meanwhile, the family is keeping hope alive that Edgar will be able to come home.

Were just trying to hang in there and hope hes still fighting, Misty says.

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A Father And Child Get COVID-19: How Families Cope And Provide Care : Shots - Health News - dineshr

In the Los Angeles area, at least two so-called "concierge doctors" tested hundreds of people, or provided them tests to take home, for between $250 and $600 per test.

The Medical Board of California is "aware of some doctors doing this" and is looking into the allegations, spokeswoman Veronica Harms told CNN.

"If we are made aware of any of our licensees engaging in such activities, whether it be a doctor, nurse, physician assistant, etc., we will investigate the situation and take appropriate action," Harms said in a statement.

The US Food and Drug Administration did not provide immediate answers to CNN's questions about the legality of selling tests or letting patients take tests home for later use.

Dr. Arthur Caplan, founder of the New York University School of Medicine's division of medical ethics, said no laws or regulations were necessarily violated, but the practice lays bare the vast inequality in the American health care system.

Describing it as "one of the grossest scandals of America that class drives access to resources in an epidemic," he said state and federal resources haven't properly been put into action.

"It's a system failure. It would also be nice if somebody in Washington (DC) had said, 'Here's how we're going to fairly distribute tests, ventilators, protective gear,' instead of left it up to the market," he said.

Doctor did nothing wrong, he says

Long before the novel coronavirus pandemic, Caplan said, there were people who were poor, didn't have insurance or had enormous co-pays for their insurance, "but now, people with insurance, people who are middle-class, they find themselves wondering, 'I wonder if the rich are gonna push me aside?' And the answer is: Yes, they can."

Where government is supposed to be accountable to the people, "the free market, the invisible hand, doesn't care who it kills, has no ethics," he said.

Dr. Jay Gordon, a Santa Monica pediatrician, insists he did nothing wrong by giving his patients tests to take home. In fact, he said, he believes he increased demand -- and thus production -- by selling tests to well-heeled patients.

"It's not that I took tests away from people because the tests weren't available to them," the doctor told CNN.

He doesn't know how many tests he sold -- at least 300 but maybe as many as 500 -- for $250 a pop, he said. The first 100 sold in 10 minutes, Gordon said. He's donating the profits to charity, he said.

"Use them if you have symptoms or if you have a problematic exposure," Gordon said he told his patients.

He further advised them to hold on to them and not to use them right away, he said.

$50 test, $600 bill

Dr. David Nazarian is a primary care physician who has a "concierge" practice in Beverly Hills offering "boutique" or "executive" health care to his patients.

"We try to provide the best care that we can. It's more of a one-on-one experience where we're there for patients when they need us," Nazarian said.

In February, when the coronavirus outbreak began making headlines, Nazarian contacted test manufacturers LabCorp and Quest Diagnostics to order Covid-19 test kits for his patients as part of his practice's role in anticipating "certain factors that may impact health care," he said.

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Amid a national shortage of Covid-19 tests, California's wealthy can still get tested - CNN

Yet Trump has churned through officials overseeing the very intelligence that might have helped understand the looming crisis. At Liberty Crossing, the headquarters of the Office of the Director of National Intelligence, the government will have been without a Senate-confirmed director for eight months as of next week; last summer, Trump accepted the resignation of Dan Coats and forced out the career principal deputy of national intelligence, Sue Gordon. Coats temporary stand-in, career intelligence official Joseph Maguire, then served so long that he was coming close to timing out of his rolefederal law usually lets officials serve only 210 days before relinquishing the acting postwhen Trump ousted him too, as well as the acting career principal deputy. In their place, at the end of Februaryweeks after the U.S. already recorded its first Covid-19 caseTrump installed U.S. Ambassador to Germany Richard Grenell as his latest acting director, the role that by law is meant to be the presidents top intelligence adviser. Grenell has the least intelligence experience of any official ever to occupy directors suite.

This Friday, the role of Homeland Security secretary will have been vacant for an entire year, ever since Kirstjen Nielsen was forced out over Trumps belief she wasnt tough enough on border security. DHS has numerous critical roles in any domestic crisis, but its acting secretary, Chad Wolf, has fumbled through the epidemic; in February, Wolf couldnt answer seemingly straightforward questions on Capitol Hill from Republican Senator John Kennedy of Louisiana about the nations preparednesswhat models were predicting about the outbreak, how many respirators the government had stockpiled, even how Covid-19 was transmitted. Youre supposed to keep us safe. And you need to know the answers to these questions, Kennedy finally snapped at Wolf. Wolf has been notably absent ever since from the White House podium during briefings about the nations epidemic response.

Actings often struggle to be successful precisely because theyre temporarytheir word carries less weight with their own workforce, with other government agencies or on Capitol Hilland they rarely have the opportunity to set and drive their own agenda, push for broad organizational change or even learn the ropes of how to be successful in the job given the usually brief period of their tenure. Anyone who has ever changed jobs or companies knows how long it can take to feel like you understand a new organization, a new culture or shape a new role.

And yet up and down the org chart at DHS, there are people still learning the ropes. DHS is riddled with critical vacancies; according to the Washington Posts appointment tracker, just 35 percent of its top roles are filled. Its chief of staff, executive secretary and general counsel are all acting officials, and theres no Senate-confirmed deputy secretary, no undersecretary for management, no chief financial officer, no chief information officer, no undersecretary for science and technology, nor a deputy undersecretary for science and technology.

Even as we face a global crisis with complex travel restrictions and health guidelines, there are no Senate-confirmed leaders of any of DHS three border and immigration agenciesCustoms and Border Protection, Immigration and Customs Enforcement or U.S. Citizenship and Immigration Services. Nor is there a deputy administrator at the Transportation Security Administration (TSA), as the airline industry faces an existential cutback to global travel.

Matthew Albence, acting head of ICE, which faces a growing Covid-19 problem in its national network of detention facilities, has been acting for so long that hes surpassed the 220 day-statutory limit for the role and instead is now technically the senior official performing the duties of the director, a legal term of art thats become all too common around the federal government as vacancies linger in the Trump era. Ken Cuccinelli, the similarly titled senior official performing the duties of the USCIS director, who is simultaneously also DHS temporary No. 2, the senior official performing the duties of the deputy secretary, is currently appealing a court ruling that hes not even legally serving at DHS.

When Trump turned to DHS Federal Emergency Management Agency last month to oversee the federal governments coronavirus response, the agency lacked Senate-confirmed officials in either of its deputy rolesincluding its deputy overseeing preparedness and continuity of government planning, a function that may become all-too-important in the days ahead if the virus sickens government leaders, as British Prime Minister Boris Johnson has already been hospitalized.

And the assistant secretary for countering Weapons of Mass Destructionthe person who oversees DHS chief medical officer, the doctor designated to advise the DHS secretary and the head of FEMA? That job is vacant, too. Meanwhile, in addition to its role serving the nation, DHS itself faces a growing number of Covid-19 infections in its own workforceup to 600 cases as of Mondays numbers, including 270 TSA employees and 160 CBP employees.

The effect of these vacancies ripple further than most people realize. Since vacant roles awaiting either an official appointment or a Senate-confirmed nominee are always filled by acting officials pulled from other parts of the organization or broader government, even more offices are understaffed as people do double-duty and as their own positions are filled with other actings behind them. Grenell, even as he fills in as director of National Intelligence, continues technically to be the U.S. ambassador to Germany, meaning that amid the huge economic uncertainty around Covid-19 epidemic the U.S. is without a high-level envoy to the largest economy in Europe. For the 14 months he was acting White House chief of staff, up until March 31another horse Trump changed midstream in the epidemicMick Mulvaney was still technically serving as the director of Office of Management and Budget, a normally critical role itself overseeing the nations spending. In Mulvaneys absence, Russell Vought, OMBs deputy, filled in as the acting directorleaving his own job, normally its own full-time role, to be filled in by others, and so on.

In government agencies, deputies are not like the vice presidenta spare role kept around, if needed. Often, the deputy role is the most important figure in the day-to-day operations of the department or agencythe person who runs the bureaucracy and organization while the principal (the secretary or director) attends to the policy and the politics. Robbing an agency or department of a principal and forcing the deputy to fill in means the organization will be running at reduced effectiveness, with less guidance, direction and oversight.

The vacancies at DHS and ODNI are hardly the whole story of how Trump has hampered the very jobs meant to protect the nation in crisis. While much attention has been focused on Trumps decision to shutter the National Security Councils pandemic unit, less attention has focused on an even more critical change in the NSCs structure. Another key post-9/11 reform was the creation of a White House homeland security adviser, a domestic equal to the national security adviser, a post created just days after 9/11 by President George W. Bush and filled at first by Tom Ridge, who would go on to be the first Homeland Security secretary. Presidents Bush and Obama for years had at their beck and call senior, sober homeland security advisers like Fran Townsend, Ken Wainstein, John Brennan and Lisa Monaco; Monaco helped oversee the nations response to Ebola and led the incoming Trump administration through a pandemic response exercise in the days before the inauguration to highlight how critical such an incident could be.

Over the course of his administration, Trump effectively has done away with the role of homeland security adviser; when John Bolton took over as national security adviser, one of his first acts was to fire Homeland Security Advisor Tom Bossert and downgrade the role in rank. Ever since, the Trump NSC has sidelined the officials who filled the role. In February, as Covid-19 loomed domestically, Trump actually even shuffled the Coast Guard official then filling the post out to a new job, overseeing Puerto Ricos disaster recovery.

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Trump Broke the Agencies That Were Supposed To Stop the Covid-19 Epidemic - POLITICO

People infected with COVID-19 may spread the disease when they speak and breathe, not only when they let out a hearty cough.

Although these modes of transmission could help to explain how asymptomatic and mildly infected people fuel the virus' spread, researchers don't yet know whether tiny particles expelled in breath infect more people than large droplets spewed through coughs, experts told Live Science.

"There's a possibility" that COVID-19 primarily spreads via fluid particles less than 0.0002 inches (5 microns) in diameter, known as aerosols, which can be emitted when people speak, said William Ristenpart, a professor of chemical engineering at University of California, Davis. "We just don't know," he said.

Related: Live updates on COVID-19

The World Health Organization still states that COVID-19 spreads mostly through direct contact with infected people and with infected large respiratory droplets, which measure more than 0.0002 inches in diameter. The hefty droplets fly from a person's mouth when they cough or sneeze, falling to the ground by the time theyve traveled only a few feet.

However, mounting evidence suggests that aerosols may spur transmission more than once thought, and these smaller particles "can remain aloft for a considerable amount of time," on the order of hours, said Jeffrey Shaman, an epidemiologist and head of the Climate and Health Program at Columbia University in New York City.

In one anecdotal account, dozens of choir members contracted COVID-19 after a rehearsal, despite members not reporting symptoms and keeping their distance from each other throughout rehearsal, the Los Angeles Times reported. In a study published in March in the New England Journal of Medicine, researchers described how aerosolized coronavirus particles can remain viable for up to three hours in the air, meaning they could infect a person hours after being expelled.

Shaman noted that the study authors sampled the air for just three hours, meaning the virus could potentially remain viable for longer. Until scientists learn more about the true viability of the virus in a variety of settings and conditions, they have to consider all potential routes of transmission in their attempts to slow transmission, he added. That means people should maintain strict social distancing and wear a mask when out, even if you don't feel ill.

"You have this issue where people are unwittingly spreading the virus around," Shaman told Live Science. Even imperfect homemade masks likely disrupt the movement of droplets and aerosols exiting your mouth, he said. "I would suspect that masks help."

The notion that the novel coronavirus SARS-CoV-2 might be "airborne" has been a point of contention throughout the pandemic, the journal Nature reported. Evidence suggests that the related virus SARS-CoV, which triggered outbreaks of severe acute respiratory syndrome in the early 2000s, likely spread through aerosols but only in health care settings and other specific scenarios, Live Science previously reported. But from the start of the COVID-19 pandemic, "people were getting up and saying definitively" that the disease mostly transmits through respiratory droplets, Shaman said.

Related: 20 of the worst epidemics and pandemics in history

In reality, no one knew that for sure, he said.

"We don't observe the transmission process We actually don't know how respiratory diseases are transmitted," Shaman said. While scientists understand the various routes by which respiratory viruses can enter the body, determining which route a pathogen prefers can be incredibly difficult, Ristenpart added. Although scientists have studied influenza for decades, its primary route of transmission remains a mystery, he said. That said, evidence does suggest that people emit aerosols while they speak and that the particles can shuttle viral material between hosts.

"The basic idea that speech releases aerosol particles has been known for decades," Ristenpart told Live Science. However, even within the medical community, speech often isn't acknowledged as a potential conveyer of infectious pathogens, he added. Many particles emitted through speech measure only a micron across, rendering them invisible to the naked eye. "When you sneeze, you see a spray," which may bias people towards thinking that respiratory droplets contribute heavily to spread, he said.

Related: 10 deadly diseases that hopped across species

Though less obvious than a wet sneeze, aerosols are still large enough to carry pathogens like the measles virus, influenza viruses and Mycobacterium tuberculosis, and they can be generated through speech in several ways, Ristenpart said. Mucus-like fluid that clings to thin blood vessels in the lungs can break off in droplets as people inhale and exhale, according to a 2011 study in the Journal of Aerosol Science, and the same can happen as the vocal cords vibrate, snapping open and closed to generate different sounds. People also expel "spittle" from their mouths as they speak, Ristenpart said. Both breath and speech generate aerosols in these ways, but speech can generate about 10 times more aerosols than breathing alone, according to a 2009 report in the same journal.

In a 2019 study in the journal Nature Scientific Reports, Ristenpart and his colleagues investigated how many of these tiny particles people let off in a normal conversation; they found that people expel between one and 50 aerosol particles per second as they speak, depending on their volume, or how loud they speak. A follow-up study published in January in the journal PLOS ONE revealed that certain units of sound generate more aerosols than others; for example, the "E" sound in "need" produces more particles than the "A" in "saw." But still, the sheer volume of a person's voice acts as the main determinant of whether someone emits many particles or few.

"The take-home message there is that the louder you speak, the more aerosol particles are generated," Ristenpart said. Certain individuals are so-called speech superemitters and give off about 10 times the number of particles as others, on average, although the reason remains unknown.

In the context of COVID-19, superemitters could potentially act as superspreaders, releasing thousands of infectious particles into the surrounding air in a matter of minutes. "A 10-minute conversation with an infected, asymptomatic superemitter talking in a normal volume thus would yield an invisible 'cloud' of approximately 6,000 aerosol particles," Ristenpart wrote in a report published April 3 in the journal Aerosol Science and Technology.

At this point, however, we don't know how infectious that aerosolized cloud might be, he said.

To determine how speech and breathing contribute to COVID-19 transmission, scientists must learn how much virus the average aerosol contains and how much virus one must inhale to become infected, Ristenpart wrote in Aerosol Science and Technology.

Tracking how the aerosols move in different environments, when subjected to different air flows, would also provide key clues about the risk of transmission, he noted. For instance, a turbulent air flow could carry an infectious cloud far away from the original speaker, but could also dilute the viral concentration to a relatively harmless level, he wrote.

Future research could also address how varying levels of humidity, wind and heat affect aerosols and the viruses held within them, Shaman said. More practically, until scientists can resolve these unknowns, "the need is to just distance ourselves so we can get everything in order right now," he added.

While the role of speech-generated aerosols in COVID-19 transmission remains hypothetical, for now, "unfortunately, I haven't seen any data that's inconsistent with that hypothesis," Ristenpart said.

Originally published on Live Science.

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COVID-19 may spread through breathing and talking but we don't know how much - Live Science

For Covid-19 patients who respond successfully to intensive care treatment and are able to be discharged from hospital, the road to recovery can still be a lengthy one.

The latest report into patients admitted into critical care for coronavirus so far in England, Wales and Northern Ireland showed that of 2,249 patients for whom data was available, only 344 (15%) had been discharged alive. A similar number had died (346 patients), while the majority the remaining 1,559 were still in critical care.

As it is early days in the spread of the virus, the figures from the intensive care national audit and research centre (IANARC) do not paint a complete picture. Additionally, little is known about what the recovery process looks like, but what is clear is that it will take time, even after leaving hospital.

Faiz Ilyas, 24, from Clayton near Bradford, was discharged from Bradford Royal Infirmary last week after eight days, including five in the hospitals intensive care unit (ICU). He was not on a ventilator (the most intensive treatment) but told the Guardian: When I get up and go to the bathroom or go to the garden, especially when I have a shower, I get really breathless afterwards. The doctors gave me exercises to utilise the whole of my lungs. They didnt give me any timeframe [for getting better].

It is a general rule that the sicker you are, the longer it will take to recover. As such, Covid-19 patients who have been on a ventilator will face the toughest convalescence.

The first step for those patients will be for their doctors to decide they can be taken off sedation and they will then try to get them breathing through the machine themselves. Only when the patient is able to do this will the clinicians remove the breathing tube, enabling the patients to speak, which in some cases depending on how long they have been intubated will be the first time in a while.

The ICNARC figures show that of those who have required ventilation in the UK so far, only a third (127 out of 388) have survived.

Among all Covid-19 patients for whom a critical care outcome (either discharged alive or died) has been recorded, 68% of those aged 70 or over died, compared with 46% of those aged 50 to 69 and 24% of patients aged 16 to 49. Men were also more likely to die than women, 52.2% compared with 44.6%.

Additionally, of those who were obese, 57.6% died compared with 45.8% who were overweight and 43.6% who were not overweight. While the findings are not conclusive, these risk factors are confirmed by data from other countries.

Even after coming off the ventilator, the patient will still need assistance getting enough oxygen and this is likely to be through a mask or, possibly, a continuous positive airway pressure ventilator (Cpap), which sits somewhere between a mask and ventilator on the intensity scale.

The patient will stay on the ICU until they are safe to move to a ward one intensive care doctor told the Guardian this would probably take one to three days after coming off ventilation where reduced intervention is needed.

But even then the struggle is still far from over. Dr David Hepburn, an intensive care consultant at the Royal Gwent hospital in Newport, wrote on Twitter: If you end up on ITU [intensive therapy unit] its a life-changing experience. It carries a huge cost even if you do get better. As our patients wake up, they are so weak they cant sit unaided, many cant lift their arms off the bed due to profound weakness. They need to be taught to walk again, breathe again, and have problems with speech and swallowing.

At the bare minimum, to leave the ICU, sedation will have to have worn off and their breathing must have improved to the necessary threshold. Once they are transferred on to a ward, where they are likely to spend a week or so, being able to breathe without oxygen assistance is a prerequisite for being discharged from hospital.

Work will also begin in hospital on remedying the rapid weight loss and resultant weakness the patient will have suffered through muscle wastage as the body went into crisis mode during ventilation. In the first week after ventilation even sitting up in a chair can be a major first step, but as movement increases the muscles improve and get stronger day by day.

When the patient leaves hospital they will still be restricted for weeks to months in terms of exercise, due to both the damage to their lungs and their muscles. This will be the same for patients such as Ilyas, who have not been on a ventilator but instead on a Cpap or high flow nasal oxygen therapy, but their recovery time will be shorter; Ilyas said he can already feel his breathing improving on a daily basis.

Wide ranging psychological problems, from depression to PTSD (post-traumatic stress disorder) are also associated with time spent in an ICU. Patients can also suffer from hallucinations coming out of sedation, which can cause problems such as flashbacks at a later date.

They get better in time but it may take a year and needs an army of physiotherapy, speech and language, psychology and nursing staff to facilitate this, said Hepburn. The few weeks on a ventilator are a small footnote in the whole process.

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Learning to breathe again: the long road to recovery from Covid-19 - The Guardian

Police: Shoplifter who says she has COVID-19 charged with knowingly exposing several people at Kroger  WXIX

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Police: Shoplifter who says she has COVID-19 charged with knowingly exposing several people at Kroger - WXIX

If millions of people were infected weeks ago without dying, the virus must be less deadly than official data suggest

Apr 11th 2020

ONE OF THE few things known for sure about covid-19 is that it has spread faster than official data imply. Most countries have tested sparingly, focusing on the sick. Just 0.1% of Americans and 0.2% of Italians have been tested and come up positive. In contrast, a study of the entire population of the Italian town of V found a rate of 3%.

The lack of testing has set off a hunt for proxies for covid-19 infection, from smart-thermometer readings to Google searches for I cant smell. A new paper by Justin Silverman and Alex Washburne uses data on influenza-like illness (ILI) to show that SARS-CoV-2 is now widespread in America.

Every week, 2,600 American clinicians report the share of their patients who have ILIa fever of at least 37.8C (100F) and a cough or sore throat, without a known non-flu reason. Unsurprisingly, ILI is often caused by flu. But many other ailments also produce ILI, such as common colds, strep throat and, now, covid-19. The authors assume that the share of these providers patients with ILI who do have the flu matches the rate of flu tests that are positive in the same state and week. This lets them estimate how many people have ILI seriously enough to call a doctor, but do not have the fluand how many more people have had non-flu ILI in 2020 than in prior years.

They find that non-flu ILI has surged. Its rise has the same geographic pattern as covid-19 cases: modest in states with few positive tests, like Kentucky, and steep in ones with big outbreaks, such as New Jersey. In total, estimated non-flu ILI from March 8th to 28th exceeded a historical baseline by 23m cases200 times the number of positive covid-19 tests in that period. This may overstate the spread of covid-19, since non-flu ILI has other causes. It could also be too low, because people with asymptomatic or mild covid-19 would not report non-flu ILI.

This sounds alarming, but should be reassuring. Covid-19 takes 20-25 days to kill victims. The paper reckons that 7m Americans were infected from March 8th to 14th, and official data show 7,000 deaths three weeks later. The resulting fatality rate is 0.1%, similar to that of flu. That is amazingly low, just a tenth of some other estimates. Perhaps it is just wrong, possibly because the death toll has been under-reported. Perhaps, though, New Yorks hospitals are overflowing because the virus is so contagious that it has crammed the equivalent of a years worth of flu cases into one week.

Sources: Using ILI surveillance to estimate state-specific case detection rates, by J. Silverman & A. Washburne; Johns Hopkins CSSE

This article appeared in the Graphic detail section of the print edition under the headline "Footprints of the invisible enemy"

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Why a study showing that covid-19 is everywhere is good news - The Economist

A tiger at New York Citys Bronx Zoo has tested positive for the novel coronavirus, officials at the US Department of Agriculture said Sunday, raising new questions about how the virus that causes Covid-19 spreads in animals, and whether other animals are at risk of becoming infected with the virus.

The Bronx Zoos tiger a 4-year-old Malayan tiger named Nadia is the first animal in the US and the first non-domesticated animal globally to have a confirmed Covid-19 case. At least two pets, a cat and a dog, were infected in Hong Kong; and a cat in Belgium is also believed to have had the virus. All of the pets were owned by people with confirmed Covid-19 cases.

Zoo officials believe the cat as well as her sister, two Amur tigers, and three African lions that are all exhibiting similar symptoms may have been infected by a caretaker who has the virus but is asymptomatic, given that the zoo has been closed to the public since March 16.

Its the first time, to our knowledge, that a [wild] animal has gotten sick from Covid-19 from a person, Paul Calle, chief veterinarian for the Bronx Zoo, said Sunday.

Calle added that his team took samples from Nadia that were sent to scientists and veterinarians at Cornell University, the University of Illinois, and the USDA National Veterinary Services Laboratory. All samples tested positive. Animal testing for Covid-19 in general requires a protocol that differs from the testing done in humans. For example, testing a tiger includes placing the big cat under anesthesia; the complexity of the procedure led zoo officials to decide only one cat should be tested.

The new confirmed case is a reminder that although scientists have worked rapidly to understand the new coronavirus there is still much that isnt known about how the virus can and cannot spread between species and how it spreads among animals that arent human.

Heres what we know and dont about Nadia, and how Covid-19 spreads in animals.

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What we know about the Bronx Zoo tiger with Covid-19, and how the disease affects other animals - Vox.com

Because of the coronavirus, mail volume is down, and the U.S. Postal Service says it may run out of money by this summer. Matt Rourke/AP hide caption

Because of the coronavirus, mail volume is down, and the U.S. Postal Service says it may run out of money by this summer.

Updated at 10:58 a.m. ET

If you've checked your mail lately, you may have noticed there's just not much of it.

The U.S. Postal Service could be another casualty of the coronavirus pandemic.

"A lot of businesses have ceased to do advertising through the mail," says Rep. Gerry Connolly, D-Va., "and as a result, mail volume has collapsed."

He says the decline could be as much as 60% by the end of the year, which he says would be "catastrophic" for the agency.

The $2 trillion emergency bill approved by Congress last month included a $10 billion loan for the Postal Service, but Connolly, who chairs the House Subcommittee on Government Operations, says that's not what the agency needs.

"The Postal Service is insolvent," he says. "It needs debt forgiveness, not debt extension. And it needs an infusion of capital right now."

The Postal Service's finances have long been in sorry shape, in part because of a requirement that the agency pre-fund the future retirement benefits of its employees. The agency says it lost $8.8 billion last fiscal year.

Yet during the coronavirus pandemic, its services, which have been deemed essential, are more vital than ever, says Mark Dimondstein, president of the 200,000-member American Postal Workers Union.

"Just think about: In this pandemic, information is going into people's homes on health. Medicines are going into people's homes through the post office," he says. "Even in ordinary times, there's 1.2 billion packages of medicine," and "just about all" of the VA's medicines go through the Postal Service.

The terms of the loan included in the last funding bill could give control of large parts of the agency to the Treasury Department, and Dimondstein says the Trump administration has made no secret of its desire to eventually privatize the Postal Service. "It's in writing," he says. "That's their plan."

He says the "small-'d' democratic right to have postal services, no matter who you are and where we live," would disappear or be severely diminished under the plan.

On Tuesday, President Trump revived a largely discredited claim that the Postal Service wouldn't be losing money if it charged more to Amazon and other internet companies for delivering their packages.

In a statement, U.S. Postal Service spokesman David Partenheimer said:

"The Postal Service appreciates the inclusion of limited emergency borrowing authority during this COVID-19 pandemic. However, the Postal Service remains concerned that this measure will be insufficient to enable the Postal Service to withstand the significant downturn in our business that could directly result from the pandemic. Under a worst case scenario, such downturn could result in the Postal Service having insufficient liquidity to continue operations."

In other words, the post office could soon run out of money.

Congressman Connolly says the next coronavirus rescue bill should provide a cash infusion of $25 billion to the Postal Service and forgive the agency's debts, which House Democrats had pressed for but failed to get in the last funding package, after objections by Senate Republicans and the White House. He notes that lawmakers provided about $50 billion in that bill to help the airline industry.

"The Postal Service has been struggling for 14 years, and it is an essential service we all count on," Connolly says. "And if the airline industry qualified for assistance, it is time for Congress and the White House to address their needs."

Without that assistance, he warns, the Postal Service could run out of cash by June.

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COVID-19 Is Harming The US Postal Service Too - NPR