This Q&A was published in the summer of 2020. While much of the information is still relevant and helpful, some of the answers contain information that’s still evolving.
Editor’s Note:
From the many questions received, I’ve combined some and edited others in order to best prevent redundancies. If you asked a question but don’t see it here, email me at LisaHayes3212@gmail.com and I’ll point you to where the answer can be found on this page, or find an answer for you.
Glossary
The definitions below use several sources, in addition to the scientists who answered our questions. I’ll simply list the websites here for efficiency. If time permits, I’ll come back through and cite exactly which element of each definition comes from which source.
WHO.int, CDC.gov, dictionary.cambridge.org, healthline.com, npr.org, nature.com
Coronavirus:
A type of common virus that infects humans, typically leading to an upper respiratory infection.
Coronaviruses are named for the crown-like spikes on their surface. There are four main sub-groupings of coronaviruses, known as alpha, beta, gamma, and delta.
Human coronaviruses were first identified in the mid-1960s. There are seven coronaviruses that infect people.
The Novel Coronavirus:
A novel coronavirus is a new coronavirus that has not been previously identified. THE Novel Coronavirus is a common name for SARS-CoV-2, the virus causing coronavirus disease 2019 (COVID-19). The novel coronavirus is not the same as other coronaviruses that commonly circulate among humans and cause mild illness, like the common cold.
There are many types of human coronaviruses including some that commonly cause mild upper-respiratory tract illnesses.
SARS-CoV-1:
Also called SARS, SARS coronavirus, SARS-CoV, and the original SARS, this is a virus identified in 2003 thought to be an animal virus from an as-yet-uncertain animal reservoir, perhaps bats, that spread to other animals (civet cats).
SARS-CoV-2:
The virus that causes the disease COVID-19.
COVID-19:
The disease caused by the SARS-CoV-2 virus. The new name of this disease is coronavirus disease 2019, abbreviated as COVID-19. In COVID-19, ‘CO’ stands for ‘corona,’ ‘VI’ for ‘virus,’ and ‘D’ for disease. Formerly, this disease was referred to as “2019 novel coronavirus” or “2019-nCoV”.
Seasonal Influenza:
Also called the flu and the seasonal flu, seasonal influenza is an acute respiratory infection caused by influenza viruses which circulate in all parts of the world.
Contagious:
Contagious diseases (such as the flu, colds, or strep throat) spread from person to person in several ways. One way is through direct physical contact, like touching or kissing a person who has the infection. Another way is when an infectious microbe travels through the air after someone nearby sneezes or coughs.
Sometimes people get contagious diseases by touching or using something an infected person has touched or used — like sharing a straw with someone who has mono or stepping into the shower after someone who has athlete’s foot. And sexually transmitted diseases (STDs) are spread through all types of sex.
Infectious:
Infectious refers to diseases that are contracted through the environment, caused by bacteria or viruses. Infectious diseases that spread from person to person are said to be contagious.
Communicable:
A communicable disease is a contagious one. The effect is external. If someone catches the illness, they can get sick and spread the pathogen—be it a cold, virus, or some other disease-causing agent—onto the next person. This can lead to small, isolated outbreaks or full-scale pandemics.
Antibody:
A protein produced in the blood that fights disease by attaching to harmful viruses and bacteria so they are no longer functional and can be removed by other immune cells.
Antibody Test:
Antibody tests identify people who have previously been infected with the coronavirus. They do not show whether a person is currently infected. Antibody tests should not be used to diagnose COVID-19.
PCR:
PCR, or polymerase chain reaction, is a process that enables the exponential amplification of small amounts of genetic material until it can be detected with different tools in the laboratory. This technique has been used for decades in the study of DNA and RNA.
qPCR:
Quantitative PCR or “Real-Time PCR” was developed as a method to estimate amounts of DNA or RNA in a biological sample. This technique is based on traditional Polymerase Chain Reaction (PCR).
Tests that rely on this technique can detect the merest traces of SARS-CoV-2 genetic material.
Virus:
A virus is an infectious agent that can only replicate within a host organism.
Viral Load: A measure of how much virus is present in a person, once the person has been infected and the virus has had time to replicate in their cells. This amount changes over time, rising as infection progresses and declining as the person recovers.
R0 (or R naught):
A mathematical term that indicates how contagious an infectious disease is. It’s also referred to as the reproduction number. As an infection is transmitted to new people, it reproduces itself.
R0 tells you the average number of people who will contract a contagious disease from one person with that disease. It specifically applies to a population of people who were previously free of infection and haven’t been vaccinated.
For example, if a disease has an R0 of 18, a person who has the disease will transmit it to an average of 18 other people. That replication will continue if no one has been vaccinated against the disease or is already immune to it in their community.
Three possibilities exist for the potential transmission or decline of a disease, depending on its R0 value:
If R0 is less than 1, each existing infection causes less than one new infection. In this case, the disease will decline and eventually die out.
If R0 equals 1, each existing infection causes one new infection. The disease will stay alive and stable, but there won’t be an outbreak or an epidemic.
If R0 is more than 1, each existing infection causes more than one new infection. The disease will be transmitted between people, and there may be an outbreak or epidemic.
Importantly, a disease’s R0 value only applies when everyone in a population is completely vulnerable to the disease. This means:
High Risk:
High risk refers to people who are more likely to become severely ill if they are infected. For COVID-19, this is older adults and people with underlying medical conditions.
Vulnerable Population:
Depending on the context, vulnerable populations in health care and research include the economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, children, prisoners, and people with chronic health conditions including severe mental illness and cognitive impairment.
Differentially Exposed Individuals:
Those people impacted by social and institutional forces in ways that make them exposed to COVID-19 at rates that generally lead to the worst health outcomes. This term should be used in place of inaccurate yet frequently used terms like “harder-hit communities” and “high-risk communities.”
How do viruses work, and how do our bodies react to create symptoms?
Patrick Bardill, Ph.D.:
Viruses are infectious agents that can only replicate inside a living host cell. They consist of genetic material wrapped in protein and sometimes lipid membranes. This genetic material can be RNA or DNA, depending on the type of virus. A virus enters a host cell and uses the machinery in that cell to create more copies of itself. New viruses leave the host cell by either pushing through the host membrane, which leaves the new virus with a lipid membrane, or when the host cell dies and ruptures.
Viruses can cause symptoms through stimulation of the immune system or damaging tissues in your body. It is usually a combination of these processes that produce disease pathology and symptoms.
For example, fever is a reaction from your body that raises your internal temperature to fight an infectious agent. However, in some individuals, the immune response can get out of control and be harmful to the person.
Jack Lipton, Ph.D.:
First thing to know is that viruses are not fully alive. A virus needs a living cell in order to reproduce and complete its function, which is to make more viruses.
When I was in high school, viruses were explained to me like this:
A virus is like a robot on a motorcycle.
The robot goes into a factory — a cell — and it takes it over. It changes around the machinery so that factory only produces robots and motorcycles. Then, after it uses up all the materials in the factory, it releases all of the robots on all of the motorcycles that the factory made, and they go to other factories to do the same thing all over again.
When we think of the illnesses that are produced by viruses, most of the symptoms you would associate with the illness come from your body’s immune response to this foreign invader. When your body finds a foreign invader – bacterium, virus – it uses the immune system to clean things up.
To do that, it uses chemicals that signal immune cells to move to the area. The process of releasing clean-up substances, which are toxic to the bacterium or virus, produces inflammation as a by-product. A fever is your body changing its thermostat setting to create an inhospitable place for invaders to live, but that process makes you feel sick. So your own immune system in its battle against invaders makes you feel sick. We call the by-products of these battle tactics symptoms.
The severity of someone’s illness from something like the flu or a coronavirus is often related to the magnitude of their immune response to the invader. If you have a very active immune system, you’ll produce a huge response to the infectious agent, and in the process of doing that, you’ll have worse symptoms.
How do we get to herd immunity?
Felicia Wu, a John A. Hannah Distinguished Professor at Michigan State University, said in this great article:
The Los Alamos study estimated that 82% of the community needs to be immune to the novel coronavirus before all public health restrictions can be lifted, because their estimated R0 for SARS-CoV-2 is so high. The United States has a population of approximately 328 million people, so about 268 million people would have to develop immunity to the novel coronavirus in order to safely go out in society. Herd immunity for the seasonal flu is 55%.
Why did the SARS-CoV-2 virus become a pandemic, when other viruses don't?
Patrick Bardill, Ph.D.:
Generally speaking, there are a few properties of SARS-CoV-2 that contributed to it becoming a pandemic. It is a respiratory virus and easily transmitted through coughing or sneezing. It also appears to usually produce a very mild disease, with some people not realizing they are infected. Those people then interact with other individuals, passing the virus on without realizing they are sick. Finally, SARS-CoV-2 is a new virus for humans, meaning that before the present pandemic, no one had immunity to it from a previous infection.
How infectious is Covid-19?
Patrick Bardill, Ph.D.:
When compared to more familiar diseases, this is much less contagious than measles, but more contagious than seasonal flu or norovirus.
This comparison is based on R-nought, or basic reproduction number. R0 is what R is at the start of an outbreak, before immunity or interventions. R0 more closely reflects the power of the virus itself, but it still changes from place to place. For example, R0 is higher in dense cities than sparse rural areas. R0 for seasonal flu is about 1.28; estimates of R0 for SARS-CoV-2 range from 2.2 to 5.7. Measles has an R0 of 18.
R0 and R are different but have been conflated in most reporting. This has caused much confusion about what these numbers mean.
This resource has a very good explanation of R nought and R: https://ncase.me/covid-19/
Jack Lipton, Ph.D.:
It’s pretty infectious, from what we understand. At first, people were worried about it on surfaces. It doesn’t appear that touching a common surface is a particularly significant way for the virus to transmit. Some viruses are more hearty than others; their packaging are more conducive to living on surfaces.
For example, cold viruses are mild but are very infectious because they can last on door handles and other common touch areas. There is evidence that touch is important with coronaviruses, but more of the risks are associated with sharing air in the same space for an extended period of time with someone who is infected. That is because of microscopic droplets, which is why we’re all supposed to wear masks.
Can you address the concept of viral load, with real-world examples?
... In particular, how the virus can be present but not necessarily in an amount that would cause someone to get sick. I’m thinking about how much is aerosolized and how long someone would have to be breathing it, or how much would need to be on a countertop and then picked up on hands then put into eyes/nose/mouth. Can you compare this to more familiar viruses, so laypeople might put the SARS-CoV-2 virus into context?
Chris Kemp, M.S.:
Viruses consist of little particles (singularly known as virions), and a certain number of them (the infectious dose) need to enter our system for us to get sick. At the moment, the infectious dose for SARS-CoV-2 is not known, but virologists are assuming the number is quite low, since it seems very transmissable. For context, the infectious dose for Hepatitis A is estimated at 10-100 particles, and the estimates for Norovirus are also in the 10-100 particle range. Most likely, SARS-CoV-2 is in this range too. But it's simply not known. When you think about infection, a sustained period of time in an enclosed space with an infected person dramatically increases the chance of infection. It's likely that, at some point, you've been around SARS-CoV-2 virions, but you need to get that infectious dose to become infected.
Alison Bernstein, Ph.D.:
There are many pieces to this question so I’m going to break it down into the individual topics.
Every pathogen has an infectious dose. For a virus, this is the number of individual viruses needed to infect someone. So for the virus to infect you, you need to be exposed to at least this amount of virus for the virus to take hold in your cells. Viral load is a measure of how much virus is present in a person. It is the amount of virus present once a person has been infected. This changes over time - going up as infection progresses and the virus replicates in your cells and then declining as, hopefully, you recover.
In general, the higher your viral load, the worse your symptoms and the more contagious you are because you shed more whole viruses. However, there is a lot about this we don’t know for SARS-CoV-2 yet. Answers to questions about viral load, how it relates to how infectious SARS-CoV2 is, and how contagious someone is at any given point in the COVID-19 disease course are still unclear. However, scientists expect the infectious dose for SARS-CoV2 is low, based on how easily it seems to spread through interpersonal contact. The scientific uncertainty on those details doesn’t change what we already know about this virus or the recommendations that we know can stop the spread of the disease: masks, diligent hygiene and physical distancing.
Droplets and aerosols refer to the respiratory particles we produce every time we talk, cough, sneeze, or sing. These can range from fine aerosols (less than 5 microns in size, also sometimes called droplet nuclei or small droplets) to medium or large droplets (more than 5 microns in size). Medium and large droplets are thought to fall to the ground or nearest surface and diseases transmitted via droplets are spread through close person-to-person contact (usually less than 6 feet). Fine aerosols can stay suspended in the air for longer. When someone is infected with a virus, these respiratory particles may contain infectious virus.
Airborne transmission occurs when viruses in these fine aerosols remain infectious over distance and time. Viruses that are spread by fine aerosols may be spread by airborne transmission. However, particle size is only one factor that contributes to potential airborne transmission. Other factors about the virus and the environment play a role in determining whether airborne transmission happens.
The question of whether SARS-CoV2 is transmitted via the larger droplets or airborne transmission of fine aerosols is important for which type of mask is needed. Wearing surgical or cloth masks can slow the spread of droplets. If long-range airborne transmission occurs, a mask with a tight seal and better filtering than a cloth mask, like an N95, is necessary to stop airborne transmission. Evidence from the previous SARS epidemic and the current pandemic indicates that SARS-CoV2 is transmitted via droplets and close person-to-person contact; there is no evidence to date of airborne transmission.
Resources:https://www.statnews.com/2020/04/14/how-much-of-the-coronavirus-does-it-take-to-make-you-sick/https://www.vox.com/science-and-health/2020/5/22/21265180/cdc-coronavirus-surfaces-social-distancing-guidelines-covid-19-risks
Is Covid-19 airborne? What are aerosols?
There's some great new coverage on these questions, some of which I'll link to and excerpt below.
What does it mean for a virus to be airborne?
For a virus to be airborne means that it can be carried through the air in a viable form. For most pathogens, this is a yes-no scenario. H.I.V., too delicate to survive outside the body, is not airborne. Measles is airborne, and dangerously so: It can survive in the air for up to two hours.
For the coronavirus, the definition has been more complicated. Experts agree that the virus does not travel long distances or remain viable outdoors. But evidence suggests it can traverse the length of a room and, in one set of experimental conditions, remain viable for perhaps three hours.
How are aerosols different from droplets?
Aerosols are droplets, droplets are aerosols — they do not differ except in size. Scientists sometimes refer to droplets less than five microns in diameter as aerosols. (By comparison, a red blood cell is about five microns in diameter; a human hair is about 50 microns wide.)
From the start of the pandemic, the W.H.O. and other public health organizations have focused on the virus’s ability to spread through large droplets that are expelled when a symptomatic person coughs or sneezes.
These droplets are heavy, relatively speaking, and fall quickly to the floor or onto a surface that others might touch. This is why public health agencies have recommended maintaining a distance of at least six feet from others, and frequent hand washing.
But some experts have said for months that infected people also are releasing aerosols when they cough and sneeze. More important, they expel aerosols even when they breathe, talk or sing, especially with some exertion.
Scientists know now that people can spread the virus even in the absence of symptoms — without coughing or sneezing — and aerosols might explain that phenomenon.
Because aerosols are smaller, they contain much less virus than droplets do. But because they are lighter, they can linger in the air for hours, especially in the absence of fresh air. In a crowded indoor space, a single infected person can release enough aerosolized virus over time to infect many people, perhaps seeding a superspreader event.
What does airborne transmission mean for reopening schools and colleges?
This is a matter of intense debate. Many schools are poorly ventilated and are too poorly funded to invest in new filtration systems. “There is a huge vulnerability to infection transmission via aerosols in schools,” said Don Milton, an aerosol expert at the University of Maryland.
Most children younger than 12 seem to have only mild symptoms, if any, so elementary schools may get by. “So far, we don’t have evidence that elementary schools will be a problem, but the upper grades, I think, would be more likely to be a problem,” Dr. Milton said.
College dorms and classrooms are also cause for concern.
Dr. Milton said the government should think of long-term solutions for these problems. Having public schools closed “clogs up the whole economy, and it’s a major vulnerability,” he said.
“Until we understand how this is part of our national defense, and fund it appropriately, we’re going to remain extremely vulnerable to these kinds of biological threats.”
What are some things I can do to minimize the risks? Do as much as you can outdoors. Despite the many photos of people at beaches, even a somewhat crowded beach, especially on a breezy day, is likely to be safer than a pub or an indoor restaurant with recycled air.
But even outdoors, wear a mask if you are likely to be close to others for an extended period.
When indoors, one simple thing people can do is to “open their windows and doors whenever possible,” Dr. Marr said. You can also upgrade the filters in your home air-conditioning systems, or adjust the settings to use more outdoor air rather than recirculated air.
Public buildings and businesses may want to invest in air purifiers and ultraviolet lights that can kill the virus. Despite their reputation, elevators may not be a big risk, Dr. Milton said, compared with public bathrooms or offices with stagnant air where you may spend a long time.
If none of those things are possible, try to minimize the time you spend in an indoor space, especially without a mask. The longer you spend inside, the greater the dose of virus you might inhale.
Excerpted from: Airborne Coronavirus: What You Should Do Now
See also: Is Covid-19 Transmitted by Airborne Aerosols?Flushing the Toilet May Fling Coronavirus Aerosols All OverFour New Insights About the Coronavirus: Listen Infection rates broke records across the United States over the holiday weekend, with many of the most severe surges in areas that reopened fastest. One thing that seems to have played a factor: transmission indoors, such as in restaurants and bars. We break down the risk, and look at what else scientists have learned about the coronavirus and how it spreads.
Could you explain fomites - the objects that may transmit a virus?
I’m unclear on fomites. I’ve read that transmission through touch is low because a particular series of events has to happen for the virus to be transmitted this way, but in a NYTimes survey of epidemiologists, a surprising percentage take precautions when handling their mail. I was sanitizing all packaged groceries until a month ago when I read that there’s likely no need to, but with the current surge where I live (Austin), I’m wondering if I should start again and be more cautious regarding other fomites.
Alison Bernstein, Ph.D.:
Fomites are inanimate objects that may transmit a virus, such as a doorknob. If a sick person touches a doorknob they may place viral particles onto it. Then, a healthy person could touch the doorknob and potentially transfer the virus to themselves. For transfer to occur, the virus needs to be able to survive for some time on the surface.
Several studies have examined how long SARS-CoV-2 can survive on objects. Depending on what the surface is - plastic, cardboard, metal - we know that RNA from the virus can last between a few hours and a few days. What we don’t know is whether this means there is infectious virus present and if that is enough to infect you. So it is possible to transmit Covid-19 through a fomite, but this will depend on how much virus is present and how much time it has been there.
A good precaution that gets around all the uncertainty about how long SARS-CoV2 can survive on surfaces is to wash your hands well after coming into contact with something that may have been contaminated.
Chris Kemp, M.S.:
Fomites are inanimate objects that can become contaminated with virus, so think: elevator buttons, door handles, etc. The field is still undecided on whether fomites are a major source of infection, but several recent papers do still consider them a possible secondary source of infection, far behind the much likelier route of airborne transmission. According to the CDC, the virus generally does not survive well on paper or cardboard. It lasts longest on steel but even then, its half-life on steel is around 5 hours or so. Short story: you're not likely to become infected from mail or groceries, and even less likely if you can leave them in a little quarantine spot for a few hours, or a day. For perishables, wipe them down if it makes you feel happier.
Can asymptomatic people spread the disease?
I’ve heard that young people are asymptomatic, so they shouldn’t be worried about gathering. Can asymptomatic people spread the disease? Is this only theoretical, or are we seeing it happen?
Alison Bernstein, Ph.D.:
Young people do tend to have milder cases of Covid-19 than older people. However, young people may still develop serious or fatal cases of Covid-19.
Yes, people without symptoms can spread the disease, as even if they do not feel sick they are able to shed the virus. Multiple studies have documented spread from people without symptoms and estimates for it are that as much as half of the cases of Covid-19 were from people who were not showing symptoms of the disease.
The use of the words asymptomatic and presymptomatic has caused a lot of confusion, because these are words that are used differently by scientists and lay people. Regardless of which word is correct, what we need to know as people trying to make our way through this pandemic is that you cannot rely on your perception of health as an indicator that you are not infected. This is why it is important to wear masks, practice good hygiene and physical distance even if you feel healthy.
Irving Vega, Ph.D.:
The main reason for our lack of clarity on asymptomatic spreaders is that COVID-19 testing has been directed at symptomatic individuals.
Interestingly, in the same households you can find asymptomatic and symptomatic individuals. In my lab’s community testing study, we identified asymptomatic individuals. Upon testing their significant other, we found that they were infected too. This was true for all asymptomatic cases we tested.
Comprehensive and accurate contact tracing with universal testing is required to answer the question about the role that asymptomatic individuals play in the spread of COVID-19.
Resources:
What We Need to Understand About Asymptomatic Carriers if We’re Going to Beat Coronavirus: ProPublica’s health reporter Caroline Chen explains what the conversation around asymptomatic coronavirus carriers is missing, and what we need to understand if we’re going to beat this nefarious virus together. April 2, 2020
I’m not high-risk. Are essential workers, who are at higher risk of exposure due to their jobs, increasing my risk even when they’re wearing a mask?
Jack Lipton, Ph.D.:
Let’s be very clear: You are posing the risk to them. That they are there to help you is crucial to recognize.
When you show up without a mask and rely on elements of your privilege to protect you, you are exposing essential workers to the virus. You, and the next person, and the next person. That essential worker goes home to a household that is statistically more crowded and at higher medical risk. That essential worker does not have the same access to a physician or test that you do. That essential worker may not have the same access to health insurance that you do. The list goes on and on. So when you want to talk about sectors of our society that show higher rates of Covid-19, you’d better be prepared to talk about your role in risking their lives, not the other way around.
I keep hearing people say, “Once we get back to normal.” This really bothers me. How do public health departments deal with changing the way the general public thinks?
I keep hearing people say, “Once we get back to normal.” This really bothers me, because it seems like that implies they want to forget this ever happened and go back to the way things were — which in turn drives them to act more and more “normal” when it’s not immediately in front of their faces. (For example, everyone who started to go to bars as soon as the state began to reopen.) How do public health departments deal with changing the way the general public thinks? We all came around to seat belts and non-smoking bars somehow.
Chris Kemp, M.S.:
Public health departments can only communicate the risk, suggest the appropriate ways to respond, and hope that people comply with the recommendations. In this case, public health departments have been undermined by the federal response, and often by political leadership at the state level, too.
Jack Lipton, Ph.D.:
Public health departments attempt to communicate best practices for staying infection free, but government agencies are not the agents of change. People are. We need to accept that there will be a new normal. As an example, Dr. Fauci said he thinks shaking hands should stop — forever. Do you wonder, throughout human history, how many people have transmitted an infection by handshake, and how many people have died as a result?
Normal behavior is, by definition, the thing that most people do. Therefore, we are now in need of a new set of normal behaviors. How we greet each other, our hygiene, how close we stand to each other, and our wearing of PPE, for example. A new normal means changing some — not all — of our many, many behaviors. Yes, change can be uncomfortable. However, if we do not adapt to our new circumstances, people will die. The trade-off isn’t so significant — in fact, I would urge everyone to really think about this any time they encounter someone who pushes against these simple changes. Recall the many times we as a people have had to change several significant behaviors to accommodate wars, depression, technology, and so on. “Normal” does not grant us a lack of change — change will happen in some way. Developing a new normal gives us some measure of control over how that change happens. These adaptations are not hard, but they require making thoughtful choices.
I recently had someone reflexively reach out to shake my hand. If I had only reacted and hadn’t thought about it — if I hadn’t made a conscious choice to air-elbow-bump instead — I would have been perpetuating a behavior that needs to end. If I wear a mask to a market and other people aren’t wearing theirs, I might feel foolish for wearing mine. However, if I take my mask off, another person might feel foolish for keeping theirs on. I am then contributing to a normal that values remaining unchanged even if it means people die because of it.
Our state recently began its reopening process, and I am angry beyond measure when I see masked workers at restaurants, bars, and markets, while the patrons choose not to wear masks. I’m sick of being stuck at home, too; I want the economy to come back, too. However, the solution is not to “finally get back to normal.” If you go out, do it making conscious choices that create a new normal. Quit shaking hands. Wear your mask. Stay six feet apart. Your actions cascade others’ actions, and while they may seem small to you in the moment, every new behavior we can offer to one another means fewer people suffer the unimaginable, preventable change that comes from the death of someone we love.
Resources:
Felicia Wu, John A. Hannah Distinguished Professor at Michigan State University, explains the importance of adhering to public health guidelines: https://www.canr.msu.edu/news/msu-public-health-expert-discusses-practices-for-mitigating-spread-of-novel-coronavirus
What should we be thinking about regarding our two college students who will return to their dorms in the fall? (Both out of state.)
Alison Bernstein, Ph.D.:
Will everyone have a single? How can they have enough space for all the students if everyone is in a single? What are they doing for testing and tracing on campus? What is the plan if someone gets sick? Where will they quarantine people? Are students and professors required to wear masks in classrooms and other common areas? Will hand sanitizer and disinfectant be available in all bathrooms, entrances, and in the hallways of dorms? What are they doing about meal service?
These are just a few of the questions I would have if my kids were college-aged.
Jack Lipton, Ph.D.:
I think there’s a lot of risk for students going to or going back to college, particularly in high-density housing. Much like the cruise ships and aircraft carriers that saw Covid-19 rip through them, students in high-density housing will be at a high risk for transmission. That doesn’t necessarily mean they will become very ill, but they will endanger others who are susceptible to becoming very ill, including faculty, staff, and fellow students who are at a high risk of severe response to infection.
So what do we do?
The number one thing we can do is systematic screening. In order for us to be able to know where the infections are, we need to do interval screening on a regular basis. One of the options we’re examining at MSU is testing all of the people who fall into high-risk categories (students who live in dorms, Greek housing, and university apartments; athletes; faculty and staff, etc.) every two weeks, looking for trends in certain dorms, staff positions, dining halls, etc. This will help us to control what we can control. For example, it could tell us that the air supply system is particularly bad in one building compared to another; using that data, we can make adjustments that will help protect more people. We can also contact people who have spent a great deal of time there and send them out for clinical tests and employ contact tracing teams. When we test every person who lives in a high-density environment, along with every staff and faculty member, on a rolling, two-week basis, we’ll also identify the asymptomatic spreaders who might turn a campus into a hot spot.
Finally, one of the things that we must address is the personal responsibility of every student.
We know the frontal lobes of college students are not fully formed. Their propensity for risk-taking is very high. That can show up in risky behaviors without thinking of the consequences.
Addressing this issue as it relates to the SARS-CoV-2 virus requires an entire campus-wide campaign to educate and train students, getting them socially acculturated to doing the right thing, and minimizing their risk of hurting others. We have to help them make better choices that are based on their commitment and care for the entire campus community, not just themselves.
As a college professor, academic researcher, co-chair of MSU’s Return to Campus Testing Subcommittee, and parent, these are the things I would hope incoming students and their parents would be asking about.
How much of an issue might it be for kids to play with neighborhood friends or a select group of other friends outside?
Chris Kemp, M.S.:
All activities carry some risk, but some clearly carry more than others. Consider the risks carefully. The best approach to controlling the virus is still strict social distancing. If you have some trusted families that have been social distancing in the same way you have, and share your concerns, you might be able to make a more informed choice and arrange for the kids to enjoy some playtime that doesn't require physical closeness, like kicking a ball around or riding bikes. Otherwise the risks can outweigh the benefit.
Alison Bernstein, Ph.D.:
Outside is lower risk than inside. But this also depends on many things because the issue is really about close contact between people.
How are the kids playing? Are they playing close or can they play apart? Are they going on a bike ride together? This is less contact than playing basketball.
Is everyone wearing masks? If the kids are wearing masks, many of these other concerns are greatly reduced.
Are the kids playing everyday, all day, or for an hour? Exposure is also a function of time. The longer the interaction, the greater the risk. Making these events infrequent can reduce the risks of these interactions.
How is your community behaving?. Did your neighbors just take a trip to a state that is currently a hotspot like Florida or Arizona? If the people around you are wearing masks and abiding by physical distancing recommendations, their risk of transmitting the disease is lower and I would tolerate the risks of playing more. But if I knew that my neighbors were actively not doing all the thing they should be doing to protect our community, then I would be a lot less permissive in letting my kids play.
Unfortunately, as soon as school opens in the fall, I will no longer have this control and our success as a community will be dictated by the least compliant among us.
Good graphic here ranking activities. I’d put kids playing outside with friends between yellow and orange depending on the specifics: https://www.vox.com/science-and-health/2020/5/22/21265180/cdc-coronavirus-surfaces-social-distancing-guidelines-covid-19-risks
How much of an issue is a park playground?
Alison Bernstein, Ph.D.:
There are two pieces to this question. First, are the surfaces on the playground equipment contaminated and a potential source of infection? Second, how many people are at the playground and are they wearing masks?
Let’s tackle surfaces. All the data is in lab settings so we don’t really know what happens outside with rain and sun and the elements. CDC recommends that playgroup equipment be cleaned, but not disinfected. However, many municipalities don’t have the funds to do this. I would guess that the risk of getting COVID-19 from a playgroup surface is low, though. Of course, on a crowded playground with people not wearing masks, that risk goes up, because more people are potentially depositing virus on those surfaces.
The bigger concern to me, as with all things coronavirus, is people. Is the playground crowded? Can you and your kids maintain distance with the people who are there? If not, are people wearing masks? Did you bring your hand sanitizer to clean your and your kids’ hands regularly? This to me is the bigger concern and is highly dependent on the behavior of people around you.
This is complicated by kids being kids. Kids touch everything. They put things in their mouths. They will want to be close to their friends, especially after months apart. They might not leave their masks on or they will fall off as the play. All of these make this a complicated thing to assess.
Personally, I would go to the playground only if there were few people and we could mostly maintain distance, if all of those people were wearing masks, and if my kids let me sanitize their hands regularly and didn’t touch their faces. Fortunately, I live in the suburbs, have a nice backyard and my kids have mostly outgrown playgrounds. This calculation will be different for people who don’t have a yard or live in a city in small apartments with little access to the outdoors, but it is a calculation that should be made.
Good resource: https://www.nytimes.com/2020/06/11/parenting/playgrounds-reopen-safety-coronavirus.html
Chris Kemp, M.S.:
All activities carry some risk. You have to weigh the risk of the activity against the benefit. Outside time is really important. I see a lot of kids playing on my local park playground. From an abundance of caution, I have not allowed my own children to visit the playground yet and I'm not sure when I will. They're just as happy throwing a ball or riding a bike, both of which have almost zero risk.
What do you think the mitigation strategies should be for businesses and interactions that have a high potential for spread in a small space?
Throughout the text below you’ll find specific examples, including dating, yoga studios, auto shops, and bike shops.
Chris Kemp, M.S.:
What about hot yoga? We’ve been researching how the spread may multiply when in a room with a single speaker for over 30 minutes, and its potential exponential effects. A hot yoga class clearly represents a risk. It provides perfect conditions for viral transmission. I wouldn't consider it without at least knowing more about the studio's mitigation strategies in detail and, even then, I don't see how they're good enough. You'd need masks on everyone, social distancing, improved airflow, and pre-class symptom monitoring. Seems like an excessive risk in an environment that provides all the right conditions for infection.
Question on behalf of an auto repair shop wanting to minimize risk to workers and customers: What are the exposure risks inside of people’s cars? Is it necessary for the workers to wear a mask when inside customers’ vehicles? Sanitizing interiors could ruin leather and other surface materials, yet there are several points of contact (doors, steering wheel, seatbelt, etc.). Employees wash their hands before and after getting into a vehicle and they distance inside the shop, but we also have a combined office/waiting room where we cannot physically distance (same for many similar repair shops). I think it is necessary to wear masks inside customers' cars. The exposure risks are difficult to quantify, so rely on strategies that limit risk. Clorox wipes or an equivalent product should sanitize the surfaces you’re able to use them on adequately. My suggestion for waiting rooms is to close them temporarily, or strictly limit the number of people allowed in the waiting area at a time so that they can maintain social distancing. Yes, it's inconvenient but there are lots of inconveniences at this time, and some of them aren't worth ignoring.
At our bike shop, we’re taking a lot of time to sanitize after test rides, and are considering opening up the bike rental portion of our business. Can we realistically do this safely? All activities carry risk. Can you guarantee complete safety? Definitely not. Can you try to mitigate risk? Yes. Wear masks always, maintain social distance, try to make payment and all other aspects of the business contactless, thoroughly sanitize bikes between customers. Let your customers know what you’re doing, so they take some responsibility for the risk.
What’s the prediction on when we’ll be able to safely date? Should we plan for a “new dating normal,” and if so, what do you think it will look like? Unfortunately, activities like dating will really be impacted until we have a dependable vaccine to the virus, and any other answer is unrealistic. At the very least, the "new dating normal" should include real honest conversations about risk, concerns, and whether each of you is in the same place and taking the same approach to the virus regarding masks, and social distancing, and other measures. Not romantic, I know.
Alison Bernstein, Ph.D.:
The general guidelines apply in all these cases. There are good hygiene practice — wearing masks all the time and physical distancing as much as possible. Hygiene involves frequent cleaning and disinfecting of surfaces that may have been contaminated and frequent hand washing/sanitizing. Mandating mask wearing can be hard, even if your local or state government has already mandated this, because enforcement is difficult. But high compliance on mask wearing is one of our best defenses against this pandemic. Physical distancing should be practiced as much as possible, but needs for distancing can be reduced if compliance on everything else is high.
CDC has guidelines for a variety of specific activities and institutions here https://www.cdc.gov/coronavirus/2019-ncov/community/index.html
Hot Yoga: Personally, I cannot imagine going back to any sort of group fitness class any time soon. I normally do a yoga class once a week, and Orange Theory twice a week. I will not be going back to these in the near future. If they mandate masks and limit enrollment and our local R is below 1, I might be comfortable going back, but as of right now, you couldn’t pay me enough to take this risk.
Auto Repair Shops: Given everything we talked about with surfaces and fomites, the risk of exposure from the car interior is relatively low especially if the car sits for a while before an employee enters the car. Time is your friend here.
Points of high contact - steering wheels, seatbelts, door handles - should be wiped down. Even if disinfectant would damage surfaces, it is important to remember that soap is also effective at disrupting the coronavirus and the physical action of wiping can also remove viruses. If employees wear masks to protect each other and protect customers, wipe down surfaces when the car arrives, wash their hands after touching those high contact surfaces and avoid touching their faces, it seems possible to mitigate most of the risks.
The combined office/waiting room might need to be closed, access limited, or mask wearing and regular disinfecting strictly enforced. Thinking creatively about how to use these spaces is important at this time.
Bike Shops: I would rent a bike if everyone was wearing a mask and I could wipe down the bike before taking it out.
Dating: I think there will be a new normal for everything, including dating. It seems a lot to ask for a two-week quarantine prior to a first date, but in the absence of regular testing this is the only guarantee that one person is not infected. There might be a lot more getting to know each other remotely prior to meeting in person and a discussion of what measures you are each taking.
Date activities could be planned with the same concerns in mind as every other activity, according to the risk categories outlined in this Vox graphic: https://www.vox.com/science-and-health/2020/5/22/21265180/cdc-coronavirus-surfaces-social-distancing-guidelines-covid-19-risks
Perhaps a socially distanced walk with masks, a picnic. This is obviously easier in the summer and will be more difficult as the weather turns colder.
The question of physical intimacy is much more difficult because, by definition, this violates all rules of physical distancing. Ideally, dating interactions should be approached with the same precautions as all your other interactions. This obviously makes spontaneity difficult.
Are people who don’t wear masks endangering themselves?
Are people who don’t wear masks endangering themselves? I’m thinking particularly of the extreme ends of the spectrum – 20-somethings and senior citizens who feel that masks and stepped-up hygiene practices are unnecessary.
Alison Bernstein, Ph.D.:
People who don’t wear masks are endangering their friends, families, neighbors and communities. Your masks protects the people around you and their masks protect you. Eventually, this does come around to endangering themselves as their refusal to wear a mask will help the virus continue to spread throughout the community.
I think that appealing to civic duty, shared responsibility and protecting the people in your community who are high-risk or less able to physical distance because of their jobs or living situations may help to convince people to wear masks.
Why does Covid-19 affect kids, young adults, and older adults so differently? What about blood type?
Alison Bernstein, Ph.D.:
The reasons behind these differences remain unclear. There's a new study that looked at the cells in the lining of kids’ noses compared to adults. They found that in kids, these cells had less gene expression of the ACE2, which encodes the protein that SARS-CoV2 is thought to use to get into cells. So if kids, in general, have less of this protein, the virus might just not be able to get into the host cells. But this is very preliminary as they haven’t looked at actual protein levels or reduced activity of ACE2. Some people also suspect that the differences in adult and child immune systems might contribute. But the science in this area is still very new and developing.
It is also important to remember that risk is a population-based concept. So while more old people get severe cases and more young people have mild cases, there are also examples of mild cases in old people and severe cases in children. We just don’t have enough information to predict who those individuals within a population will be. This means we all have to be vigilant.
What’s the deal with blood types? Women vs. men?
This comes from preliminary data in a study by 23andMe. There may be a 9-18% reduction in risk for people with Type O blood. As they summarize on their website:
The change in risk is also very modest. When they graph the percentage of cases in each of the blood types, you can see this clearly: https://blog.23andme.com/23andme-research/23andme-finds-evidence-that-blood-type-plays-a-role-in-covid-19/
Again, a reminder that risk is population-based so even if you are in a lower risk group, you cannot know what your outcome would be. While this is intriguing scientifically, it seems of little use for the public at the moment.
Reference: https://jamanetwork.com/journals/jama/fullarticle/2766524
How should the average person weigh social connection against risk?
Chris Kemp, M.S.:
Very carefully. Everything carries some risk, so it's better to try to find ways to connect socially without adding unnecessary risk. We know enough about the virus that outdoor activities, while observing social distancing measures, are obviously much better than going to a crowded bar without a mask. If it feels risky, it is risky.
Alison Bernstein, Ph.D.:
Social isolation is not good for us. We need to find ways to have social connections while practicing good risk mitigation strategies. We know what needs to be done to allow us to be social without endangering our progress is slowing the spread.
Wearing a mask and frequent hand washing goes a long way to mitigate risk. Combined with sitting far apart if you can’t wear a mask (while eating for example), this can go a long way to mitigating risk to allow us to reconnect with friends.
An idea that is emerging is the quarantine bubble or “quaranteam,” where you talk frankly with friends about merging your bubble for a period of time. This requires trust and honesty.
Melissa Hawkins, an epidemiologist, writes about how to create your own:
"First, everyone must agree to follow the rules and be honest and open about their actions. Individual behavior can put the whole team at risk and the foundation of a quaranteam is trust. Teams should also talk in advance about what to do if someone breaks the rules or is exposed to an infected person. If someone starts to show symptoms, everyone should agree to self-isolate for 14 days.
"Second, everyone must decide how much risk is acceptable and establish rules that reflect this decision. For example, some people might feel OK about having a close family member visit but others may not. Our family has agreed that we only visit with friends outside, not inside, and that everyone must wear masks at all times.
"Finally, people need to actually follow the rules, comply with physical distancing outside of the quaranteam and be forthcoming if they think they may have been exposed.
"Additionally, communication should be ongoing and dynamic. The realities of the pandemic are changing at a rapid pace and what may be OK one day might be too risky for some the next."
This is explained in more detail in her recent article: https://theconversation.com/quarantine-bubbles-when-done-right-limit-coronavirus-risk-and-help-fight-loneliness-140134
Jack Lipton, Ph.D.:
Our mental health and our need for social interaction is extremely important. Children I’ve interacted with over the past few months — their response to isolation is deeply concerning. As we are safely able to do so, we should try to expand the group of people who can physically interact with our kids as long as they’re agreeing to some ground rules — and taking those ground rules seriously.
One of the main risks that we all take is interactions with our friends and family members whose exposure is unknown. We’ve all been isolating in place a long time, and if we want to expand our interactions, we can try to do so responsibly by making clear and defined agreements with others. My family has come up with The Circle, which sounds like it’s similar to a quaranteam.
As you make your own plan, consider that one person in a room by themselves all the time will not get sick. When you bring in another person, that person has to have a clear understanding of where they’ve been and what they’ve risked — whether it’s going to the market, an appointment, work, daycare, etc. Every person you bring into your circle should be very aware of and transparent with their personal level of interaction with others. Every person you bring in must also agree to the same precautionary practices, and every person must agree to isolate if they encounter an increased level of risk. If they cannot bring those elements to your circle, they can’t be in the circle — that’s it.
Even though it may seem too simple or awkward to do so, have a circle-wide conversation that covers the basics of the virus, the disease, the risks, and the plan.
If we get to a point where we’re regularly testing everyone, not only the symptomatic, then we won’t have to worry so much about this. Until then, figure out your circle or quaranteam. If someone wants to connect socially but they’re not able to follow the group’s rules, or you feel they’ll violate them despite agreeing to them, it’s a clear “no.” You can reconnect once it’s safer to do so.
I can’t stress enough how important it is to establish your boundaries now. In the moment is a terrible time to consider how you and your family should handle interactions during a pandemic. Defining them now will better prepare you to prepare others for when you say “no,” and it will help you have the language you need versus fumbling when it matters.
Why is testing important? What are the benefits of testing to the overall national Covid-19 response and strategy?
Joe Patterson, Ph.D.:
Other than personal responsibilities, such as wearing a mask, self-health assessments, isolation if needed, and minimizing potential points of exposure, testing and contact tracing are the most important things we can do.
Testing and detecting infected individuals early on, before they can spread COVID-19, is the best we can do without a vaccine or viable treatments. If we can detect the virus early and limit spread, we can start to contain and isolate hotspots across the country. This will also hopefully allow for resources to be diverted to these hotspots and hospitals in the area to prepare for a potential influx of COVID-19 patients.
What is the ideal testing scenario for the U.S.? How could we scale up from what we’re doing now to what the ideal scenario is?
...And are you worried about federal funding for testing ending on June 30?
Joe Patterson, Ph.D.:
In a perfect world, you would test everyone weekly, whether they are symptomatic or not, and alert them of their COVID-19 status. If positive, you would have them and those who have been in contact self-isolate for a few weeks. In this scenario, there would need to be job protection, financial compensation for hardships due to not working, and food/other supplies delivered to their homes so they don’t have to leave quarantine. We know that this would never happen in the U.S., since we have already seen people arming themselves and marching on the state Capitol over haircuts.
Realistically, the best we can do is increase testing and enhanced screening around the country for those who want it. This endeavor would need to involve hospitals, clinics, and local universities that have the resources to perform these tests. I would say, have anyone that is symptomatic immediately get a clinical test, and those who have no symptoms of COVID-19 can go through an enhanced screening (testing) process. The best way to screen as many people as possible and cut down on cost is to move to a pooling method of testing, where multiple people would be tested in a single assay. If a pool tests positive, the individual or individuals positive from the pool would be identified. This would work best with groups that are in continuous contact with each other, such as coworkers, students, etc. The key thing is that we need to do something. Sticking our heads in the sand and hoping it will just magically go away is not an option.
As for the loss of federal funding on June 30, it is very concerning. One of the worst things that can be done is reduced testing for COVID-19.
President Trump says that cases are going up because the U.S. does more testing than any other country. Is it true that rising numbers of Covid-19 nationwide are attributable only to more tests?
Joe Patterson, Ph.D.:
Blaming the increase in COVID-19 cases on testing is like saying there are more stars in the night sky when your eyes aren’t closed. There is an increase in the number of hospitalizations across the country due to COVID-19. Increased testing did not cause the increase in hospitalization, COVID-19 did. What increased testing does is put a name to the reason for the hospitalizations, help individuals and states prepare for what to expect, inform our understanding about the virus and disease, and hopefully lead to self-isolation of individuals who came in contact with the person who tests positive.
I think rather than blame increased testing, we should be looking at failures in personal responsibility present in the country, such as the resistance to wearing masks, engaging in high-risk behaviors, unnecessary travel, attending mass gatherings where proper social distancing is not enforced, and forgetting the pandemic is still here and going strong. I feel these are the real underlying cause of the increase in cases.
Are antibody tests accurate?
Joe Patterson, Ph.D.:
It’s important to remember what an antibody test is and isn’t, and how it works. An antibody test is not a test to determine if the individual currently has COVID-19, but rather, can give insight into if the individual has had COVID-19.
In an antibody test, a small amount of blood from the individual is used in the assay [an assay is an analysis or test]. The blood will be added to a substrate or media that contains a COVID-19 specific antigen or target for the antibody to bind to. This is followed by a chemical reaction with the bound antibody to determine if the individual has developed antibodies against COVID-19 due to a previous infection.
Antibody tests “can” be accurate. For the test to work properly, the person being tested has to have antibodies present at a sufficient level. The test also needs to be specific enough for antibodies against COVID-19, but not so specific that natural variation in how antibodies are produced from person to person cause a false negative. Unfortunately, there are many antibody tests out there that have received emergency use authorization, but are not very accurate.
What's an antibody? Could you explain how antibody tests for Covid-19 work, their accuracy, and their availability?
Nick Kanaan, Ph.D.:
An antibody is a protein (also referred to as an immunoglobulin) found in the blood that the body’s immune system creates to grab onto foreign substances, such as viruses like COVID-19, and help remove them from the body. Antibodies against COVID-19 are important in two ways. First, they are part of the body’s natural response to help fight off the infection of COVID-19. Second, they can be used to test whether a patient was infected with COVID-19 since antibodies stick around in the body even after the virus has subsided. The second feature is one of the advantages of serological or blood-based COVID-19 antibody tests.
Simply put, antibody tests are set up to show a positive signal if a patient’s blood sample contains antibodies against COVID-19. (Scroll down for a definition of antibody.)
Basically, the parts of the virus that the person’s antibodies bind to are used as bait to catch the person’s antibodies that specifically target COVID-19. Then the caught antibodies are detected, producing either a positive signal if indeed COVID-19 antibodies are present, or negative if the blood did not contain COVID-19 antibodies.
The sensitivity and specificity can vary from test to test depending on the platform used. For example, antibody tests that resemble pregnancy tests (typically called lateral flow tests) are generally less sensitive than other, more sophisticated forms of antibody tests, but they are very rapid and can be done on-site. More sophisticated forms of antibody tests are more sensitive and specific, but they take longer and typically require some specialized equipment. Depending on the antibody that the test detects, the sensitivity and specificity can vary from a moderate (~70%) to high (~100%) levels.
A large number of tests have hit the market recently, and this is a very active area of on-going research. Ideally, an antibody test will be relatively rapid and easy to implement, while also showing high sensitivity and specificity.
Antibody tests will likely be an instrumental component of the strategy for COVID-19. One difference between antibody tests and the nasal swab/saliva tests that detect the virus’s genes is that the antibodies will likely maintain a presence for some amount of time after the virus is gone. This can help to identify people that were infected. The exact amount of time that antibodies are present post-infection is still actively being investigated by many groups and some recent research suggests they may not remain in the body as long as initially thought. Much of our understanding of COVID-19 continues to shift as more research is being conducted daily across the globe.
More on antibody tests:
An antibody test is a screening for things called antibodies in your blood. Your body makes these when it fights an infection, like COVID-19. The same thing happens when you get a vaccine, like a flu shot. That’s how you build immunity to a virus.
You may also hear it called a serology test.
The antibody test isn’t checking for the virus itself. Instead, it looks to see whether your immune system -- your body’s defense against illness -- has responded to the infection.
Resources:
Flawed COVID-19 antibody tests shipped without FDA review: A 60 Minutes investigation has found that federal officials knew many COVID-19 antibody testing kits had flaws, but allowed them to enter the U.S. market. June 28, 2020
What to know before getting a COVID-19 antibody test: Doctors tell 60 Minutes that patients should get multiple antibody tests to ensure an accurate result, but testing positive for antibodies may not mean prolonged, or any, immunity. June 28, 2020
CNN Health: Beware of fake coronavirus antibody tests, the FBI warns. June 29, 2020
New Cochrane review assesses how accurate antibody tests are for detecting COVID-19. June 25, 2020
The Guardian: I'm a viral immunologist. Here's what antibody tests for Covid-19 tell us. June 25, 2020
The Guardian: Antibody test accuracy lower during first 14 days of Covid-19 symptoms. June 25, 2020
The Telegraph: Coronavirus antibody tests could do more harm than good by offering false hope, review warns. June 25, 2020
Reuters: Many studies of COVID-19 antibody test accuracy fall short: review. June 25, 2020
FBI.gov: FBI warns of potential fraud in Covid-19 antibody testing. June 26, 2020
Could you talk about a realistic Covid-19 vaccine?
What do you see in terms of a realistic Covid-19 vaccine timeline, and what would a vaccine offer in terms of protection/immunity? How can it possibly be safe? I assume it’s being rushed through the process – is that right?
Nick Kanaan, Ph.D.:
I would defer to the experts on a timeline, and would reiterate what Dr. Fauci and others with appropriate expertise are saying – 1-1.5 years. Of course, we all want one as soon as possible!
The effectiveness of the vaccine is hard to predict with certainty. Some anti-viral vaccines have completely eradicated their disease, but others (like vaccines against the common flu) are only somewhat effective due to natural changes in the virus over time. Optimistically, a COVID-19 vaccine that completely eradicates the disease would be the jackpot. In lieu of that result, I would consider it a significant win for all of us if a vaccine could minimize the effects of the virus to a level that dramatically reduces the mortality rate.
How — and When — Can the Coronavirus Vaccine Become a Reality?
Below are excerpts from ProPublica’s article, written by Caroline Chen and posted on June 17, 2020.
Let me tell you this up front: If you’re imagining there’ll be one golden day when a vaccine is approved and the pandemic will be over — Finally! We can all crowd into one another’s living rooms and resume choir practice again — I’m afraid it won’t be quite like that. But it will be the beginning of the end.
On a vaccine’s effectiveness:
One lucky break COVID-19 vaccine developers have had is that this coronavirus hasn’t mutated in any significant way so far, including, crucially, the part that is most visible to the immune system, that spike protein. So long as that remains true, the vaccine they make should match up with the virus that our bodies will encounter in the real world, meaning it’ll likely work as intended. Given the stability seen so far in the coronavirus’s genetic sequence, “I am hopeful that when we do develop a vaccine, it will provide long-term protection,” Kartsonis said.
On vaccine safety:
When experimental vaccines are tested, they usually go through three phases of clinical trials. The first phase is the smallest and focuses on safety, making sure that the product doesn’t have any dangerous health effects. The second is a little larger, continuing to gather safety data while testing if the vaccine can induce an immune response, producing antibodies in participants. The third trial is the largest, and it needs to be big enough to confirm that the vaccine is actually effective in the real world.
“If the data were clear that in 20,000 people it appears to be safe and highly efficacious, then you should get the vaccine, because if you’re choosing not to get a vaccine, you’re choosing to risk getting a natural infection, which could be fatal.”
On current trials:
Moderna Therapeutics is currently expected to be the first U.S. manufacturer to start a phase 3 trial. Candidates by AstraZeneca and Johnson & Johnson will follow, according to The Wall Street Journal. Moderna’s trial is planned to begin in July and will enroll about 30,000 participants.
The speed of the phase 3 trials depends on the rate of infection wherever people are enrolled. If there is a huge outbreak going on, people in the placebo group will get sick at a high rate, and the trial may be over in a matter of a few months. If infection rates are very low, however, the trial could drag on for months on end. Moderna hasn’t announced its trial sites yet, but it will have sites “well dispersed” in the U.S. and is considering international trials as well, according to a spokesman.
On availability:
Typically, drugmakers will manufacture only enough doses for clinical trials and make sure the trials are successful before starting mass production. Manufacturing at risk means that developers will instead begin mass production at the same time as clinical trials, which means that if a vaccine fails in human trials, they’ll have to throw away all the product they’ve made, wasting money and materials. But if a product is successful, it means that the minute its trial is completed, there’ll be millions of doses ready to go.
Manufacturing at a massive scale is no simple task. “If we’re going to immunize 300 million people in the U.S. — we don’t even do that with the flu vaccine every year — we need a lot of glass vials, we have to make sure we have printing supplies and paper to make the labels and package inserts, we need stoppers for the vials, and they all need to be made to a very high standard. All this in addition to the raw materials to the vaccine itself,” Schaffner said.
Pfizer and its partner, German company BioNTech, are planning to have a few million doses ready by the end of the year, and hundreds of millions of doses available in 2021, even though the first of their four vaccine candidates just began its first early-stage human trials in May.
There will need to be a prioritization, with the vaccine given first to those who need it most: essential workers and the elderly.
Distribution is going to be a massive challenge. “There’s a need to have in place a mechanism to ensure people who should get the vaccine get it,” Dr. Walter Orenstein, associate director of Emory University’s vaccine center, said. “We won’t have 8 billion vaccines. So who should get priority, and how should it get delivered? We will need to remove barriers to access, including cost and distance.”
Is it possible to be reinfected with the novel coronavirus?
Jack Lipton, Ph.D.:
If what we know about viruses applies to the novel coronavirus, then the risk of reinfection is primarily associated with either viral mutations or time since your prior infection.
Think about the flu. You can become reinfected with the flu every year. The flu frequently mutates, or changes*, each season. As a result, your body may not recognize it when it comes back around. Think of your body’s immune system like the face on a “Wanted” poster. Those posters are your immune system’s memory of prior infection, and it keeps information to protect it against a future infection. If the face or description on the Wanted poster doesn’t accurately match the criminal, law enforcement might not notice when they come back into town. Similarly, your body’s immune system may not react to a mutated form of a virus it has already been infected with if it looks too different from before. If this happens with the novel coronavirus, it is possible that people could become reinfected. The flu shot is given every year because of changes in strains and mutations that you may encounter each flu season. Based on the data so far, there have been mutations in the novel coronavirus, but it seems as though those changes have been infrequent.
The other challenge for reinfection is time. Think about those “Wanted” posters again, but this time think about them bleaching or fading away in the sun. Your body produces antibodies to a virus to fight off infection. Over time, your antibody response may slowly wane until your body is not able to mount a sufficient response to prevent a new infection, even for the exact same virus. This is the reason why you have to get booster shots of certain vaccines.
*As it reproduces — makes copies of itself — random errors occur in the copies, and those copies reproduce. The flu virus mutates frequently, so the chances that any of those mutations will be meaningful is higher.
WHAT ABOUT THE REPORTS OF PEOPLE WHO TESTED POSITIVE FOR COVID-19, THEN NEGATIVE, THEN POSITIVE AGAIN? Reports of a person testing positive, negative, and positive again are from tests performed on the same person over several weeks. Like everything, we don’t know for sure the reason for this right now, but it’s likely not a reinfection. It seems more likely that it has to do with two factors: the sensitivity of the PCR test and the qualities of the sample.
Imagine that you need a test, and you go to a testing site. The most common form of the SARS-CoV-2 test is done using a nasopharyngeal swab. The person performing the test — let’s say, Bill — swabs the back of your nasal cavity, which drains into the back of your throat. It’s not that comfortable, and you might have to work hard to hold steady for the test. Bill will work as quickly as he can in order to get a sample. Whatever Bill is able to get onto the swab becomes our sample. We use a PCR machine to test that sample for the virus.
When the infection begins, the respiratory tract is filled with viral particles, and it’s very easy for us to detect that with PCR. Let’s pretend your sample is positive for SARS-CoV-2.
As the disease progresses in your body over time, the virus is cleaned out by your immune system, and viral levels decrease. You get another test, this time by Sophía. Just like the first time, you might have to work hard to hold steady for the test, and Sophía will work as quickly as she can in order to get a sample. This time, the viral particles may be fewer on the sample, or maybe the particles in your nasal cavity weren’t in the spot Sophía was able to swab, since they’re no longer filling your respiratory tract like they were at the start of the infection.
A PCR has limits in its ability to detect very small amounts of virus, using the types of samples that are commonly used for this test. So over the course of the many weeks the virus could potentially be detected on a PCR machine, your tests might come back as positive, negative, and positive again. This may look like a re-emergence of infection, but it’s really a combination of what we get on your sample and the limits of a PCR’s ability to detect low levels of virus.
From Johns Hopkins Bloomberg School of Public Health:
Reinfection is always a possibility with a viral infection, particularly if you have a subclinical infection and don’t mount much of an immune response against it. Reinfection is also possible within the window after the first infection and before you develop antibodies. That window can vary from a couple of weeks to a few months, depending on how much your immune system was triggered.
We’ve now got a good population of people who have recovered from the virus. Serum samples from those patients can allow us to time exactly when they begin to develop antibodies and when they develop sufficient titers and neutralizing antibodies. This will help us determine what the window is for protection.
Before your immune system returns to normal, you can be infected by not just this virus, but by regular colds and flu. A couple of months may be a reasonable window of recovery, based on what we know right now.
Rachel Graham, PhD, is an assistant professor in the Department of Epidemiology in the UNC Gillings School of Global Public Health. She began actively studying coronaviruses just prior to the SARS-CoV pandemic in 2002–2003.
What are super spreaders and how can they affect the trajectory of an outbreak?
From Johns Hopkins Bloomberg School of Public Health:
Rather than using the term super spreaders (a person who infects a large number of people), we should think of them as super spreading events. Maybe a person is at the right time of infection and at the mall. Typhoid Mary infected many people because she was a cook.
Part of the reason we stopped SARS is that a lot of super spreading was happening in health care settings and when people really got their act together in terms of infection control and biocontainment, it nipped the epidemic in the bud.
Super spreading events have the largest influence an outbreak’s trajectory early on. If there’s only a few cases and one person then infects 10 others, it can make it start strong. Once an epidemic gets going and has 100 to 200 cases or more, the “law of large numbers” takes over—and it stops mattering so much.
Justin Lessler is an associate professor of Epidemiology at the Johns Hopkins Bloomberg School of Public Health.
Could you explain what is meant by “R value,” and why it’s important to our understanding of Covid-19?
Patrick Bardill, Ph.D.:
R stands for current reproduction number, and is a measure of how contagious a disease is.
R is the average number of people a person with the disease will infect before they recover or die.
For example, an R value of 5 means that, on average, each person with a disease infects five other people. If the R value is below 1, the number of cases of the disease should drop. If the R value is above 1 the number of cases of a disease will increase.
Note that both biological properties of an infectious agent as well as the behavior of people in an affected area influence the R value. Thus, it is possible for the exact same virus to have different R values in different areas depending on how people interact.
R can change over the course of an outbreak as people gain immunity and interventions change, as well. This is important with COVID-19, as practices such as scrupulous hygiene and social distancing can and have lowered the R value.
Like any disease, the R value of SARS-CoV-2 has varied. Before public health interventions in a variety of places, the R value was as high as 3 or 4. With interventions such as self-isolation of the sick and social distancing, the R value has been brought below 1 in some places.
Could you offer an up-to-date understanding of Covid-19 immunity?
Patrick Bardill, Ph.D.:
Scientists are still trying to understand immunity to SARS-CoV-2. Because this is a new virus, we aren’t exactly sure of the key parameters of immunity, such as the length of time a person is immune after having the virus or if it is possible to not develop immunity. However, SARS-CoV-2 is a coronavirus and we do know some things about immunity to coronaviruses in general. We can use that information to make some baseline guesses. With other human coronaviruses, people develop immunity for about two years after infection. At this point, it seems that people do mount immune responses to SARS-CoV-2 and, based on other coronaviruses, probably have some short-term immunity, but we do not know this for certain and we do not know yet how long that immunity might last.
Jack Lipton, Ph.D.:
We’ll only know with time. A year from now, we’ll only know if people who have it now are immune for one year, based on research. Everything else is speculation based on other human coronaviruses, which is very helpful, but not certain.
How safe is it to work a 12-hour day wearing a mask?
Alison Bernstein, Ph.D.:
Masks are not dangerous and are safe to wear. Any reports of masks’ limited air flow are false.
But I think by “safe” this question is asking if a mask at work will protect you from coronavirus. This very much depends on what you do for work.
For this answer, I’m talking about cloth masks since that is what most people have access to right now. You are protected by the masks of your co-workers, customers, and other people you interact with. If you wear a mask and they don’t, you are not protected from them. If everyone in your workplace wears a mask and adjustments can be made to maintain physical distancing and good hygiene practices are implemented, this reduces your risk as much as possible. Certain occupations and jobs are more conducive to implementing these practices.
What is the average person’s responsibility when professionals aren’t using their masks correctly, or aren’t using masks or sanitization practices at all?
What is the average person’s responsibility when professionals aren’t using their masks correctly, or aren’t using masks or sanitization practices at all? I don’t know all of the laws and rules off the top of my head for each industry, and to be honest I’m a little weirded out by asking a server to put on a mask, or pull it over their nose, etc., but I see this issue constantly.
Alison Bernstein, Ph.D.:
This is an ethical question, not a science question, so I will just provide my opinion. Personally, I would leave and tell them why. If we went to a restaurant to get take out and they were not masked, I would not get food from there again and would tell them why. If I went to a store where the staff was not masked, I would do the same. If you are in a place without a mask mandate from your local or state government, this is about all that is in your power to do. If there is a mask mandate, you have a bit more on your side to remind them of the law.
The best way around this, in my opinion, is to take enforcement of masking out of the hands of individuals and pass mask requirements and implement fines for non-compliance. I’m not sure about the legal issues surrounding passing such laws, though.
Chris Kemp, M.S.:
We all have a role to play in combating SARS-CoV-2. The correct approach is to wear a mask always when inside buildings (except your own home), wash your hands often, maintain social distance, and don't touch your face/mouth/nose/eyes. If a server isn't wearing a mask or wearing it improperly, either tell them to fix it, or leave the business. Those are really the only two options. Contact the restaurants after leaving to tell owners their staff is not wearing masks properly.
What do the terms “high-risk” and “vulnerable populations” indicate?
Alison Bernstein, Ph.D.:
High risk refers to people who are more likely to become severely ill if they are infected. For COVID, this is older adults and people with underlying medical conditions.
According to the CDC, people of any age with certain underlying medical conditions are at increased risk for severe illness from COVID-19. These include:
However, COVID-19 is a new disease. Currently there are limited data and information about the impact of underlying medical conditions and whether they increase the risk for severe illness from COVID-19. Based on what we know at this time, people with the following conditions might be at an increased risk for severe illness from COVID-19:
Depending on the context, vulnerable populations in health care and research includes the economically disadvantaged, racial and ethnic minorities, the uninsured, low-income children, the elderly, the homeless, those with human immunodeficiency virus (HIV), and those with other chronic health conditions, including severe mental illness, children, prisoners, those with cognitive impairment. Some of these populations are also at high risk for severe cases of COVID-19. Some of these populations are also more likely to be exposed for a wide range of sociological and economic reasons.`
Resource: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-increased-risk.html
What language can we give our kids to help them navigate those pressured situations when family and friends aren’t following the same rules?
What language can we give our kids to help them navigate those pressured situations when family and friends aren’t following the same rules? My kids are strong and smart, but I can’t help worrying about peer pressure once everyone is back to school.
Chris Kemp, M.S.:
I agree. It's difficult and I'm not sure there's an easy answer. Humans (especially children) are inherently social. This is what allowed the pandemic to develop in the first place. I think we need to keep encouraging our kids to be smart and thoughtful and to be the leaders in their communities by making good choices.
Alison Bernstein, Ph.D.:
This page from UAB has some specific recommendations about talking to kids about masks: https://www.uab.edu/news/youcanuse/item/11321-tips-for-children-wearing-masks-during-a-pandemic
About preparing your child to wear masks in public, they write:
"Before heading out in public, it is important to practice wearing the mask at home before you actually need to wear it. According to Smith, this will help the child get used to wearing the mask and learn how to wear it properly. A child may find covering their mouth and hiding part of their face very frightening, so caretakers may have to explain it a few times."
“Be OK with repetitive questions, and give them time to adjust,” Smith said. “Give them a mask to play with, as it may help decrease their fears.”
This Urgent Cares page provides language as well: https://www.lifespan.org/lifespan-living/wearing-face-masks-and-how-explain-it-kids
The mask is a way to help stop the spread of the coronavirus. Everyone is being asked to take steps to prevent spreading the virus from person to person. Physically distancing is one way to accomplish this, which means maintaining six feet of distance from others. We are all becoming aware of how stores are marking the floor/ground to help remind us and ensure appropriate physical distance. However, when you are in public places it may not be possible to keep that far apart from others. You may pass closely or interact with others in grocery stores, at gas stations, or in the park. In those cases, it makes sense to have a mask on, as well as do your best to physically distance.
Unfortunately I am not seeing anything about dealing with the peer pressure piece of this. But in my experience as a parent, I can offer some thoughts. For my kids, we will be tying this into some of our important Jewish values, like showing kindness to others, protecting people who are more vulnerable than you, and working to make your world better. We will also frame this as part of our responsibility within our community. I don’t know if masks will be required; I don’t know what compliance will look like in school even if it is mandatory. All I can do is work with my kids so they know why WE wear masks and be clear in our expectations that they wear them. We will also talk to them about what do about friends who don’t wear masks and have them practice these conversations, so they are using their own words.
We have shared some resources on SciMoms about talking to kids about the pandemic in general: https://scimoms.com/coping-with-coronavirus/
Here’s a good resource from the AAP on parenting in a pandemic: https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Parenting-in-a-Pandemic.aspx
What needs to happen to lessen the disparities in differentially exposed communities?
Irving Vega, Ph.D.:
We need to be better in recognizing how to protect everyone equally. In general, the government should re-define “disaster relief” to add a provision that includes health emergencies such as a pandemic. Covid-19 showed to all how ill-prepared we (both the government and the public) were to handle the social aspects related to a healthcare emergency. Part of redefining disaster relief includes:
How is it that Covid-19 affects some socio-economic groups and cultural communities more than others?
Irving Vega, Ph.D.:
COVID-19 unrooted health and healthcare disparities in our society due to socio-economic status. These disparities are founded on social determinants of health, which are driven by a lack of access to affordable health insurance, the impact of institutionalized racism, and a disparity in quality education and educational opportunities.
The result of social determinants of health is poor physical and mental health outcomes. Therefore, those at low socio-economic status tend to have higher prevalence of metabolic disorders and cardiovascular disease, which seem to increase the risk for worse health outcomes in COVID-19 infected individuals.
How can I help communities with higher levels of Covid-19?
As a person who is not in a position of governmental, policy, or other type of influence, is there anything that I can do to help reduce the disparity or otherwise help those communities with higher levels of Covid-19 risk? I feel like just one person can’t possibly make a difference.
Irving Vega, Ph.D.:
Speak up! Differentially exposed individuals are within our community because of social determinants of health, and institutionalized discrimination. We need to recognize our privileges and use them to give voice to underserved populations and be agents of change. To do that, you need to educate yourself about social determinants of health, health equity, implicit biases and institutional racism.
Resources: Find links here: https://lisahayes.work/covid-answers/2020/6/28/how-can-i-help-communities-with-higher-levels-of-covid-19
Many Latinos Couldn’t Stay Home. Now Virus Cases Are Soaring in Their Communities.
The American Medical Association’s Covid-19 Health Equity Resource List
The Health Equity Initiative
National Congress of American Indians Resource List
Resources for Immigrants During the Coronavirus
The African American Policy Forum Resource List
AXIOS: The coronavirus economy will devastate those who can least afford it
The Colorado Trust: Pandemics Thrive on Inequality
Centers for Disease Control and Prevention: Coronavirus: Resources for Homeless Shelters
Nonprofit Quarterly: COVID-19: Using a Racial Justice Lens Now to Transform Our Future
Health Affairs Blog: Health Justice Strategies To Combat COVID-19: Protecting Vulnerable Communities During A Pandemic
Health Equity: Responding to Healthcare Disparities and Challenges With Access to Care During COVID-19
Health Equity Initiative: COVID-19 Is a Health Equity Issue
Health Equity Initiative: Paid Sick Leave Policy and the Impact on Health Equity
Human Rights Watch: US: Address Impact of Covid-19 on Poor
Kaiser Family Foundation: Key Facts about the Uninsured Population
The Marshall Project: Tracking Prisons' Response to Coronavirus
Pew Research Center: As coronavirus spreads which U.S. workers have paid sick leave - and which don't
UN News: Racism and xenophobia are ‘contagious killers’ too
World Economic Forum: Coronavirus: A pandemic in the age of inequality
World Heart Federation: Preventing COVID-19 spread in poor areas
ReachMD: Not Just a Pandemic: Why COVID-19 Is a Health Equity Issue
Region 2 Public Health Training Center (PHTC): COVID19: Using a Health Equity and Human Rights Lens to Protect Vulnerable Populations during this Pandemic and Beyond
Could you help me understand what public health departments’ roles are in this pandemic?
Could you help me understand what public health departments’ roles are in this pandemic? Do they have the infrastructure and support they need to do their jobs right now?
Chris Kemp, M.S.:
Public health departments DO NOT have the infrastructure, support, or resources to respond appropriately to the pandemic. In an ideal world, a single positive case is reported to local health departments and begins a cascade of events that includes strict quarantine of the individual and comprehensive contact tracing, during which every person the positive individual came into close contact with (say, 15 minutes or more in an enclosed space) is identified, contacted and also quarantined.
As a society, we have failed to do this on every level, and we're still not doing it. For the first weeks/month of the pandemic, we didn't even have enough available tests. Other countries -- Iceland, New Zealand -- have shown that it is possible to respond appropriately by committing significant resources to the effort.
**Why do some groups of people get Covid-19 at a higher rate than others?
Why do some groups of people get Covid-19 at a higher rate than others? I’m thinking about communities of color in particular. Does it have to do with their actual immune response, or is it more about their access to resources, or… something else? **
Chris Kemp, M.S.:
Higher rates of infection in black communities are a true symptom of systemic inequality. It has nothing to do with their immune response.
Generally speaking (due to a history of systemic inequality), people of color disproportionately occupy lower socio-economic groups. As a result, they're more likely to live in communal housing and in multi-generational households, with fewer opportunities for social distancing.
Many of them are employed in jobs that provide fewer opportunities to work from home, or to stay home and receive sick pay when sick, and are less likely to have health insurance. They're more likely to rely on public transport where social distancing is difficult.
The risks of infection are also less likely to be communicated adequately to them. The resources they need to prevent infection — such as masks and sanitizers — are less readily available to them.
Finally, if they get sick, research shows they're less likely to receive adequate care.
What's more, the co-morbidities that increase the chances of a negative outcome, such as diabetes and obesity, have a higher incidence in black populations. Literally nothing is weighted in their favor during a pandemic.
Resources: Find the links here: https://lisahayes.work/covid-answers/2020/6/28/why-do-some-groups-of-people-get-covid-19-at-a-higher-rate-than-others
The American Medical Association’s Covid-19 Health Equity Resource List
The Health Equity Initiative
National Congress of American Indians Resource List
Resources for Immigrants During the Coronavirus
The African American Policy Forum Resource List
AXIOS: The coronavirus economy will devastate those who can least afford it
The Colorado Trust: Pandemics Thrive on Inequality
Centers for Disease Control and Prevention: Coronavirus: Resources for Homeless Shelters
Nonprofit Quarterly: COVID-19: Using a Racial Justice Lens Now to Transform Our Future
Health Affairs Blog: Health Justice Strategies To Combat COVID-19: Protecting Vulnerable Communities During A Pandemic
Health Equity: Responding to Healthcare Disparities and Challenges With Access to Care During COVID-19
Health Equity Initiative: COVID-19 Is a Health Equity Issue
Health Equity Initiative: Paid Sick Leave Policy and the Impact on Health Equity
Human Rights Watch: US: Address Impact of Covid-19 on Poor
Kaiser Family Foundation: Key Facts about the Uninsured Population
The Marshall Project: Tracking Prisons' Response to Coronavirus
Pew Research Center: As coronavirus spreads which U.S. workers have paid sick leave - and which don't
UN News: Racism and xenophobia are ‘contagious killers’ too
World Economic Forum: Coronavirus: A pandemic in the age of inequality
World Heart Federation: Preventing COVID-19 spread in poor areas
ReachMD: Not Just a Pandemic: Why COVID-19 Is a Health Equity Issue
Region 2 Public Health Training Center (PHTC): COVID19: Using a Health Equity and Human Rights Lens to Protect Vulnerable Populations during this Pandemic and Beyond
What are your thoughts on a safe return-to-school/work strategy?
See questions here and throughout the body of this text.
What are your thoughts on a safe return-to-school/work strategy? For example, much has been made about kids going back to school in staggered days (every other day, with half of the kids two days and the other half the other two days) – which seems to me like it won’t make anything but trouble for parents, will expose teachers and support staff, and overload teachers with in-person and online curricula, while only accomplishing a reduction of the number of kids in a classroom per hour.
Jack Lipton, Ph.D.:
Based on all of the plans I’ve read about so far, I don’t think there’s a “right” answer yet. A lot is still going to happen with this virus before school starts, so what I do feel that I know for sure is that it’s going to be problematic.
Developing hybrid or virtual learning is to reduce the risk of transmission from person to person. However, we’d be reducing the risk a little bit, and only for the students, not the teachers. The teachers will be the most vulnerable, and they’ll have a continuous parade of not only students but also support staff, and vice-versa. That means that for adults in the K-12 system, we’re only reducing risk through the use of PPE and distancing, as much as each is able to be used and practiced during their often unpredictable day-to-day interactions with children. The risk is not mitigated in a significant enough way to make that make sense for me.
At the same time, I think there are inherent problems with going fully online. Mental health responses in children in isolation — especially in high-stress situations — are severe. Plus, socioeconomic disparities and levels of technical competence will advantage the most well-off students, deepening the very inequities responsible for exposing those people at a disproportionate rate. I only have fears about this type of learning choice, though I’ll note that I’m a neuroscientist, and would defer to my colleagues in public health and education to come up with solutions that might be able to mitigate some of the losses.
I will say that this 4/10 model from Dr. Uri Alon seems particularly attractive to me.
Chris Kemp, M.S.:
Generally speaking, schools will have to remain flexible and respond to the data. School boards have made decisions already, but in August and September they'll need to practice some flexibility based on local data.
The health department reports cases and deaths every day around 4 p.m.; school boards and superintendents will base decisions on these tallies. Unfortunately, without some sort of surveillance testing, schools will only know a pupil is sick if the pupil is symptomatic, feels unwell, and then tests positive.
There is a chance we will see a return to lock-down and distance learning, or some combination of half days, or days on/days off, or staggered classes —several different approaches have been suggested. Prepare now to be flexible.
Important note: as a parent with elementary and middle school kids, I'm very encouraged by some early data that seem to suggest not only that kids aren't infected at anywhere near the rate adults are, but more importantly that kids don't transmit the virus to adults very often. Iceland beat the virus with some pretty extreme contact tracing that gave researchers insights into how the virus is transmitted. Very few cases seemed to pass from children to adults.
Resources: A paper in preprint: https://www.medrxiv.org/content/10.1101/2020.06.24.20138875v1.full.pdf
An article in the New Yorker about the virus dynamics in Iceland: https://www.newyorker.com/magazine/2020/06/08/how-iceland-beat-the-coronavirus
Is there an age when that changes? It seems like elementary schools might be able to breathe a sigh of relief here, but high schools might have to factor in more of a transmission factor.
It's hard to try to parse out the data but I think kids are much less likely to contract the virus all the way through their teenage years. Kent County Health Department lists data in age groups by decade, so 1-10 and 10-20, and so on. Both of those age groups show significantly lower, like much much lower, rates of infection and even lower levels of mortality. Phew. The CDC has even wider age brackets with all kids dumped in a 0-24yrs group. The mortality in that group is almost nonexistent. The one bright spot in this.
In our high school, we have lots of rooms without windows/fresh air. Is this an issue?
Yes, this is a potential issue. Prolonged periods in poorly-ventilated spaces do seem to be a factor in virus transmission.
Is band class an issue, with lots of students blowing air around?
I think bands should practice outside and maintain social distancing guidelines to whatever extent possible.
From The Atlantic, 7/9/2020: These 8 Basic Steps Will Let Us Reopen Schools Authored by Thomas R. Frieden, former director of the U.S. Centers for Disease Control and Prevention; Arne Duncan, former U.S. Secretary of Education; and Margaret Spellings, former U.S. Secretary of Education
Excerpts: We need to reopen schools this fall. But we have to do it carefully. If we move too fast, ignore science, or reopen without careful planning, this will backfire. We can reopen if we follow commonsense guidelines...
The single most important thing we can do to keep our schools safe has nothing to do with what happens in schools. It’s how well communities control the coronavirus throughout the community. Such control of COVID-19 requires adhering to the three W’s—wear a mask, wash your hands, watch your distance—and boxing in the virus with strategic testing, effective isolation, complete contact tracing, and supportive quarantine—providing services and, if necessary, alternative temporary housing so patients and contacts don’t spread disease others.
8 Basic Steps: First, shield the most vulnerable. Children, older staff, and those who have underlying health conditions that put them at high risk should not return to school in person unless there is little or no community transmission; the school system should enable them to participate remotely to the greatest extent possible.
Second, reduce risk wherever possible. Large in-person student assemblies will be out. Cafeterias may need to close, with students instead eating in classrooms. On-site food preparation may be replaced by prepackaged meals and disposable dishware. And schools can reduce the number of surfaces touched by multiple people, for example by keeping hallway doors open. Some essential services must continue—such as in-school meals which many students depend on. Others may need to be modified—libraries will likely need capacity restrictions.
Because group singing increases risk, large choir rehearsals will need to stop. In areas where the coronavirus is under good control, band and orchestra practice may be able to continue. Team sports may be too risky; clusters of cases have been reported among college and professional sports teams. Recess and physical-education classes are possible if students play outdoors in small groups, wear masks, and observe physical-distancing guidelines.
For older students who are able to tele-school—high schoolers and some middle schoolers—distance learning may be a safer option, unless there is little or no virus circulating in the community.
Third, keep the virus out. Schools should forbid nonessential visits and require everyone who enters the school—not only students and staff but also parents, delivery people, and maintenance workers—to wash their hands (or apply hand sanitizer) and wear a face mask. Families must understand that their children should not go to school when sick. Class attendance policies should be revised to reflect the urgency of staying home when ill, and absences should not require a doctor’s note. Every person who works at a school, including staff members, contractors, and maintenance workers, must be given paid sick leave. Paid sick leave has been demonstrated to significantly reduce the risk of ill people continuing to work and spreading infection to others.
Fourth, wear a mask. Students, teachers, and staff should all wear masks throughout the school day, although this may be challenging for younger children. Consider adopting reward systems to encourage mask wearing and hand-washing.
Fifth, reduce mixing among students and staff. Divide students into smaller cohorts, or pods, that stay together throughout the day, rather than mixing and re-forming different class units. Remaining primarily within a smaller unit reduces the risk of extensive disease spread and makes contact tracing easier if there are cases. Staff break rooms should be closed: In hospitals, many employees became infected while socializing with other employees.
Sixth, reduce occupancy, especially indoors. Classrooms may need to operate at reduced capacity to provide increased physical distance. Schools can alleviate overcrowding by moving to a split-shift schedule (incorporating morning and an afternoon session) or by alternating students between in-person and remote learning. Classrooms can be rearranged to reduce transmission, such as by placing desks facing the same direction. If conditions allow, holding class outdoors is safer.
Seventh, implement new health and safety protocols, such as more frequent and thorough cleaning and disinfecting, including of buses. Hand-washing and sanitizing stations should be installed; their use should be required. There will need to be more cleaning during the day, when classes are in session, as well as at the end of the day. That will require safe usage and storage of cleaning products, to protect children from exposure. Sharing of classroom supplies and other items should also be limited; when sharing is necessary, equipment should be disinfected after each use.
Eighth, prepare for cases. Despite precautions, there will inevitably be coronavirus cases at schools. Schools must function as if the virus could arrive at any moment, and operate so that they can reduce transmission and provide ongoing education when it occurs. Responding well can prevent outbreaks; detailed and rehearsed protocols will enhance readiness. Daily temperature symptom checks are advisable. Students or staff members who become sick must stay home in isolation until they have met the CDC’s criteria to return. All contacts of new cases must be traced and quarantined. Any classroom with a reported case will need to be thoroughly disinfected and, if necessary, closed temporarily. Schools should also prepare to close if necessary because of outbreaks or explosive spread in the community.
What is contact tracing, why is it important, and how is it done?
From Johns Hopkins Bloomberg School of Public Health:
Contract tracing is a core public health function that public health agencies have done for years. Diagnostic tests can confirm whether a person is infected with an illness. Contact tracing involves finding out who the infected person had contacts with so that those individuals can be alerted that they are at a risk of developing the illness and at risk of potentially infecting others in the community.During contact tracing, the contacts of the infected person are generally called up, asked if they're feeling sick, and advised to self-quarantine for a period of time. During the quarantine period, the health of the contacts can be monitored and health care or other services could be provided to them if they do develop symptoms. Also, it is important to make sure that people who have been exposed to the illness are not circulating in the community and further spreading the disease.
Anita Cicero, JD, is deputy director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health.
How related is Covid-19 to the flu?
Patrick Bardill, Ph.D.:
SARS-CoV-2 is not closely related to the influenza virus that causes the flu. They share some characteristics, as both are respiratory viruses with lipid membranes, but there are many differences based on other characteristics that indicate they are not closely related.
Jack Lipton, Ph.D.:
I think people associate Covid-19 and influenza for a couple of reasons.
One, diseases have cycles that start somewhere geographically and move somewhere geographically, and the annual flu migrates from East and Southeast Asia, and generally end up in Europe and the Americas several months later.
Two, there have been a lot of political discussions that connect the two based on fatality rates. The reality is that there is no relation between the two at all. It makes people comfortable to try to find equivalence, in order to better understand something unknown. In doing this with Covid-19 and influenza, people connect the two diseases in a manner that downplays the seriousness of Covid-19. Influenza sounds innocuous to them — and makes it feel less scary. This is ultimately detrimental to all of us, as it encourages others to take the novel coronavirus less seriously.
I have a condition, but it's under control. Am I still considered high risk?
I have epilepsy, and due to the meds I take I have to have a lot of bloodwork done on my liver and kidneys. With this info, would I be someone considered high-risk during the pandemic? They say people with high blood pressure, diabetes, COPD, etc. are high-risk, but are they high-risk if their conditions are treated and under control?
Alison Bernstein, Ph.D.:
CDC does not specifically mention epilepsy in their list of known or likely high-risk categories.
I think that people are still considered to be in a high-risk group even if symptoms are under control because the underlying condition is still present. It’s important to recognize that risk is a population-based measure so it doesn’t apply to an individual.
Learn more and see a graphic at: https://scimoms.com/population-risk-individual-risk/
What should we anticipate regarding flu season?
Alison Bernstein, Ph.D.:
This is hard to predict. It is possible that increased diligence on hygiene and masking will help to slow the spread of flu this fall. The same things that prevent spread of coronavirus also prevent spread of flu. But people have also delayed vaccinations during the pandemic so if fewer people get the flu vaccine this could push things in the other direction. Getting your flu vaccine is still important, because keeping people out of hospitals as much as possible will help us fight COVID.
Resources:
https://medicalxpress.com/news/2020-05-covid-flu-season.html
https://www.cdc.gov/flu/season/faq-flu-season-2020-2021.htm
What is most important to keep in the fronts of our minds about this virus, so we don’t fall back into easy routines?
Michigan has done well in flattening the curve. While that’s great, we see all around us that people have become complacent. It’s almost as if they don’t realize that the curve has flattened because we’ve been under stay-at-home and mask-use orders. Even in our vigilant family, I find us forgetting to carry masks and sanitizer lately. What is most important to keep in the fronts of our minds about this virus, so we don’t fall back into easy routines?
Alison Bernstein, Ph.D.:
This is hard balance between maintaining vigilance but also not allowing anxiety and fear to overtake your life. Checking the COVID modeling websites regularly should be enough to trigger fear and anxiety but this is not healthy. So the question becomes, how do we maintain vigilance but also take care of our mental health?
My opinion based on my personal experience and many years of therapy are that we make consistent changes by developing habits and making it easy to keep them. Put your masks in the same place every night, keep one in your purse or work bag, and in your car. Keep hand sanitizer in all those places. This makes it easier to remember and lowers the amount of effort required to maintain these habits.
Chris Kemp, M.S.:
It will be back.
Why are some regions of the country more affected than others?
Why are some regions of the country more affected than others? Beyond the obvious population density issue in places like NYC, it seems like some regions are simply not as hard-hit despite a lack of stay-at-home orders. I’ve read that it doesn’t have to do with warm weather, so what else is at work?
Chris Kemp, M.S.:
There are numerous possible explanations for the pattern of infection. Ultimately, all regions will likely be affected to the same degree.
Communities with more elderly demographics might see higher rates of mortality (see parts of Florida and New Jersey). Cities with very poorly-functioning infrastructures are going to see higher rates of transmission, fewer people obeying stay-at-home-orders, and higher rates of mortality (see Detroit and Flint). Even so, the likelier explanation is that states and regions with less robust testing record fewer cases ... but the cases are there, undetected.
As we've seen this week in Texas, California, and Florida, regions that were hit less hard to begin with will catch up given the chance.
The pandemic does also have a socio-political component. Research shows that blue states obeyed stay-at-home orders with more compliance than red states, and we're seeing the effects of some of those differences now.
What determines whether a virus disappears or becomes endemic?
From Johns Hopkins Bloomberg School of Public Health:
Two main clues help us predict whether a virus is going to stick around. First, we consider the virus’s origins. If it came from animals and could still be circulating in animals, then no matter how good we are at getting rid of it in humans, animals could always bring it back. That’s true with influenza: Even if a certain strain disappears, a new one might emerge from animals—as we’ve seen with avian viruses.
But with a major outbreak like COVID-19 already underway in humans, the big question is how good humans are at developing immunity. And, if they gain immunity, does it stick, or does it fizzle out over time—leaving the door open a crack for the virus to return? As the first cases get further and further out from the point of infection, that data will give us a better idea of what to expect.
Emily Toth Martin, PhD, MPH, is an associate professor of epidemiology at the University of Michigan School of Public Health.
What does “preparedness” in a country really mean?
From Johns Hopkins Bloomberg School of Public Health: Preparedness starts with funding. That’s how everything else gets done—by having resources available to prepare for these kinds of rare but highly impactful events.
Public health departments would use that money to ensure expertise in emergency and pandemic planning. That’s key not only for the public health preparedness, but for preparedness in hospitals and long-term care facilities as well.
The money could also be used for supplies. In the US, we’ve heard a lot of about the Strategic National Stockpile which contains critical medicines and supplies needed during public health disasters. Having the resources to ensure we have extra supplies on hand is crucial.
Preparedness also means having policies and guidance ready to pull off the shelf during crises, rather than starting from scratch. That could include telework policies at an institutional level, or advance thinking on actions like the triggers that would indicate a need to close or reopen schools.
Caitlin M. Rivers, PhD, MPH is a senior scholar with the Johns Hopkins Center for Health Security and an assistant professor in the Environmental Health and Engineering department of the Johns Hopkins Bloomberg School of Public Health.
How has The Circle been working out?
Lisa Hayes:
A few weeks ago, I wrote about our family’s Circle — the plan we have for reconnecting now that our state is opening up. Many people have asked how it’s been going, and the answer is — mostly fine. We didn’t assume it would be problem-free, and we’ve learned that what we thought would be the toughest parts are, in fact, the toughest parts. To me, that means it was a smart exercise to really think it through ahead of time and prepare ourselves for a little bit of stress. I’ll take that little bit of stress over the stress of not having a plan any day.
Here’s where it’s been tricky: People feeling awkward speaking up, and people feeling unwilling to truly commit to full caution in the moments when they want things to “be normal again.”
For example, my girls were at their dad’s house, and their grandparents — his parents — stopped by. Those grandparents don’t practice distancing, wearing masks, or increased hygiene, and they’ve been having a number of social interactions both in Florida and Michigan without using precautionary measures. Despite one of my kids saying she wasn’t going to fall into risky habits (she put on her mask and stayed six feet away), everyone else in the household (guiltily and awkwardly) allowed the grandparents to take over. Jack and I found out about this from the kids, after we’d already been with them for a few days — so we were all exposed to an unknown factor. We reached out to the other members of our Circle (whom we had not seen since before the exposure) to let them know we wouldn’t be getting together again until 14 days had passed or we had a negative test.
We’re also seeing incidents where Circle members want to “better enjoy” the moment. We all know our overall risk is low, so it’s tempting to give in to a happy hug or to leave the mask off during an encounter. It takes a lot of conscious choice-making in the moment, along with preparing ourselves prior to venturing out, to ensure we don’t break our Circle’s rules.
After being isolated for so long, these opportunities to connect with others are incredibly tempting for all of us, and we know we may not be perfect all the time. But as committed Circle members who truly love and care for one another, the best thing we can do is protect each other. This won’t last forever. The ramifications from getting and passing on Covid-19 just may.
Our takeaway after our first few weeks is that in order to keep our commitments to our Circle family, we have to all become more confident standing our ground. That means we’re role-playing what to say in those high-stress situations, we’re practicing extreme caution while out so we contribute to the “new normal,” and we’re staying informed so that we don’t become complacent.
Links to other articles that answer similar questions
Find them here: https://lisahayes.work/covid-answers/2020/6/28/links-to-other-articles-that-answer-similar-questions
FROM JOHNS HOPKINS BLOOMBERG SCHOOL OF PUBLIC HEALTH’S GLOBAL HEALTH NOW. Are smokers at greater risk of catching or becoming seriously ill from COVID-19, and how can they minimize their risk? By Nicholas Hopkinson
Can the bodies of COVID-19 victims transmit the virus, and what are the safest burial practices? By Tolbert G. Nyenswah
Is the use of tear gas or pepper spray during the COVID-19 pandemic extra dangerous? How can people protect themselves? By Sven-Eric Jordt
Could SARS-CoV-2 be transmitted sexually via semen? By Jim Hotaling
Could people who have taken antiviral drugs (such as HIV Protease Inhibitors, etc.) for many years recover faster? By David Riedel
Could air conditioning systems help spread the virus? By Ana M. Rule and Lesliam Quirós-Alcalá
Do we know if the virus can enter through the eye? By Alfred Sommer
What determines whether a virus disappears or becomes endemic? By Emily Toth Martin
What can we expect from the coronavirus circulating now? Will it change to become more lethal or more easily transmitted? By Ralph Baric
Will most of humanity be infected by the new coronavirus? By Justin Lessler
How does a virus shift from zoonotic to human-to-human transmission? By David Quammen
Does an overreaction by the immune system play a role in COVID-19 deaths, or are they caused strictly by damage inflicted by the virus itself? By Jay Bream
Is it possible to be reinfected with the novel coronavirus? By Rachel Graham
What is viral load, and does it mean doctors and nurses face greater risk of infection or getting more severely ill? By Ray Viscidi
Does COVID-19 pose a risk to blood donors or recipients? By Harpreet Sandhu
What is cryptic transmission, and what is its significance in the COVID-19 outbreak? By Ingrid Katz
Given that coronaviruses can cause the common cold, does that mean humans likely have some protection against this new virus? Or are we immunologically "naive"? By Angela Rasmussen
How do you go about creating a vaccine against a new virus? By Peter Hotez
How does this particular coronavirus compare with other coronaviruses like SARS and MERS? By Tom Frieden
Can SARS-CoV-2 be controlled, eliminated, or eradicated? By Jess Atwell
With a given number of confirmed Covid-19 cases in a community, is there a way to estimate the number of actual cases? By Ron Brookmeyer
There have been news reports that the coronavirus epidemic will last for 18 months or longer and come in multiple waves. If so, how long will social distancing be necessary in that situation? By Eric Toner
What’s the worst case scenario for this pandemic? By Laurie Garrett
How much will mortality rates vary from country-to-country given differing levels of health system preparedness and response resources? By Antonia Ho
When does an outbreak become a pandemic? By Eric Toner
Why are wild animals believed to be the source of this outbreak? By Sonia Shah
How do disease detectives find the source of an outbreak like this? By Michael Mina
What are super spreaders and how can they affect the trajectory of an outbreak? By Justin Lessler
What’s a reproductive number and what does it tell us about an outbreak’s future? By Michael Osterholm
What does successful risk communication look like? By Amanda McClelland
Could export goods transmit SARS-CoV-2 infection around the world? By Sulzhan Bali
What are some of the major challenges to global cooperation in this coronavirus outbreak? By Sarah McCool
What is contact tracing, why is it important, and how is it done? By Anita Cicero
Do health care workers present a risk to the community by returning home after work? By Marisa Holubar and Yvonne (Bonnie) Maldonado
Why will it likely take longer to develop a vaccine than a drug for COVID-19? By William Moss
Does the COVID-19 pandemic automatically mean setbacks for ongoing global health programs? By Loyce Pace
What’s the most important thing that WHO can do in the fight against COVID-19? By Ilona Kickbusch
How can public health advocates encourage citizens to trust their advice in countries roiled by attacks on science? By Keiji Fukuda
What does “preparedness” in a country really mean? By Caitlin Rivers
In the absence of approved treatments, what can health care providers do? By Nahid Bhadelia
What's the best way to counter misinformation in the media? By Amesh Adalja
What is it like inside a hospital biocontainment room? By Lauren Sauer
What’s the best way to respond to the coronavirus outbreak? By Tom Inglesby
Can travel restrictions and quarantines stem the spread of the coronavirus? By Jennifer B. Nuzzo
What should a country like the US be doing to prepare when an outbreak like this begins to spread globally? By Tom Frieden
Are strong national health systems all we need for pandemic preparedness? By Gavin Yamey
What do frontline health care workers need most when they face an outbreak like this? By Amanda McClelland
What are the ethical considerations of using quarantines? By Jeffrey Kahn
Are people who get early treatment more likely to recover faster or avoid severe illness, and how should that inform testing guidelines? By Nahid Bhadelia
If I have a heart condition what precautions should I take to avoid serious COVID-19 illness? By Shelley Hankins
Can COVID-19 spread through water in pools, hot tubs or water parks? When will it be safe to go to public swimming pools? By Ernest R. Blatchley III
If I take immune-suppressing medication, should I stop so I'll have a better chance of avoiding COVID-19 infection? By Andreas Kronbichler
Why is diabetes considered a risk for severe COVID-19? By Ranganath Muniyappa
Can my kids go and play with friends? By Crystal Watson
As COVID-19 symptoms mimic those of common cold and flu viruses, how do you know when you should seek testing or special care? By Preeti Malani
What should the average person in a non-outbreak area be doing to prepare? By Michael Osterholm
What precautions should I take when I have to go out to get food? By Crystal Watson
What are the special risks of COVID-19 to pregnant women? By David Baud
Could export goods transmit SARS-CoV-2 infection around the world? By Sulzhan Bali
Can the new coronavirus be transmitted via paper money? By Marilyn Roberts
Links to relevant articles & websites
Find them here: https://lisahayes.work/covid-answers/2020/6/28/links-to-relevant-articles-amp-websites
The Coronavirus Page: Come for the snark, stay for the science. News, science-based information, and public health policy about Covid-19.
I Will Not Stand Silent.' 10 Asian Americans Reflect on Racism During the Pandemic and the Need for Equality, Time, 6/25/20
Coronavirus, Racism And Kindness: How NYC Middle-Schoolers Built A Winning Podcast, WNYC, 6/17/20
Why I talk about bias I've faced when reporting on coronavirus-related hate: Reporter's Notebook, ABC News, 6/17/20
Not American Yet, New York Times, 6/17/20
Asian Americans invisible in COVID-19 data and in public health response, Chicago Reporter, 6/16/20
Pandemic Reduced Black Vote, Study Finds, Urban Milwaukee, 6/25/20
‘I Feel So Overwhelmed’: COVID-19 And Police Violence Takes A Toll On Black Health Care Workers, KPBS, 6/24/20
The Chronic Stress of Being Black in the U.S. Makes People More Vulnerable to COVID-19 and Other Diseases, Yes!, 6/23/20
Black Medicare Patients With COVID-19 Nearly 4 Times As Likely To End Up In Hospital, NPR, 6/22/20
Black workers more likely to face retaliation for raising coronavirus concerns, Amsterdam (NY) News, 6/21/20
An alley without exit.’ Experts worry COVID-19 among Latinos will get dire without support, The News & Observer, 6/19/20
COVID-19 and the physicians we need, San Francisco Examiner, 6/12/20
Education and Equity in a Post-COVID Society, NEA Today, 6/12/20
Latinos’ risk of getting COVID doubles in states with meat processing plant outbreaks, Fort Worth Star-Telegram, 6/10/20
Administration for Community Living: Coronavirus disease 2019 (COVID-19): What do Older Adults and People with Disabilities Need to Know?
AXIOS: The coronavirus economy will devastate those who can least afford it
The Colorado Trust: Pandemics Thrive on Inequality
Centers for Disease Control and Prevention: Coronavirus: Resources for Homeless Shelters
Centers for Medicare and Medicaid Services: Coronavirus (COVID-19) Partner Toolkit
Community Tool Box: Coronavirus Response Tool Box: Tools for Public Health and Community Action
Families Values@Work: COVID19: A Call to Action (tools to advocate for paid sick time for those dealing with coronavirus)
Health Affairs Blog: Health Justice Strategies To Combat COVID-19: Protecting Vulnerable Communities During A Pandemic
Health Equity: Responding to Healthcare Disparities and Challenges With Access to Care During COVID-19
Health Equity Initiative: COVID-19 Is a Health Equity Issue
Health Equity Initiative: Paid Sick Leave Policy and the Impact on Health Equity
Human Rights Watch: US: Address Impact of Covid-19 on Poor
Kaiser Family Foundation: Key Facts about the Uninsured Population
The Marshall Project: Tracking Prisons' Response to Coronavirus
National Alliance on Mental Illness (NAMI): NAMI Helpline Coronavirus Information and Resources Guide
National Association for the Advancement of People of Color: Coronavirus Emergency Tele-Town Hall, The Coronavirus: Protecting Our Community
Newton,P.N. and Bond, K.C. (2020), The Lancet Global Health: COVID-19 and risks to the supply and quality of tests, drugs, and vaccines
Nonprofit Quarterly: COVID-19: Using a Racial Justice Lens Now to Transform Our Future
The National Law Review: COVID-19 and International Travel: The Latest Immigration Consequences of the Coronavirus
Pew Research Center: As coronavirus spreads which U.S. workers have paid sick leave - and which don't
Pew Research Center: As schools close due to the coronavirus, some U.S. students face a digital ‘homework gap’
ReachMD: Not Just a Pandemic: Why COVID-19 Is a Health Equity Issue
Region 2 Public Health Training Center (PHTC): COVID19: Using a Health Equity and Human Rights Lens to Protect Vulnerable Populations during this Pandemic and Beyond (recorded webinar with Health Equity Initiative's Founder and Board President, Dr. Renata Schiavo)
Robert Wood Johnson Foundation: Handwashing to Slow the Coronavirus Pandemic (and how this may be difficult depending on living conditions)
Robert Wood Johnson Foundation: Library Collection: Coronavirus Pandemic (COVID-19)
Salud America: How Coronavirus Is Crippling Rural Health Care, Especially for Latinos
Salud America: What the New Coronavirus Law Means for Paid Sick Leave, Family Leave
The Solutions Journalism: Are people of color hit harder by COVID-19 in your state or city?
Tsay, J. and Wilson, M. (2020), The Lancet Public Health: COVID-19: a potential public health problem for homeless populations
UNICEF, WHO, and IFRCRC: Key messages and actions for coronavirus disease (COVID-19) prevention and control in schools
UNICEF: How to talk to your child about coronavirus disease 2019 (COVID-19) - 8 tips to help comfort and protect children
UN News: Racism and xenophobia are ‘contagious killers’ too
World Economic Forum: Coronavirus: A pandemic in the age of inequality
World Heart Federation: Preventing COVID-19 spread in poor areas
Graphics from the World Health Organization
Get them here: https://lisahayes.work/covid-answers/2020/6/28/who-graphics-for-public-use