Monthly Archives: June 2020

As stay-at-home orders ease and cities reopen for business, many doctors and hospital administrators are calling for a quick return of health care to pre-pandemic levels. For months now, routine care has been postponed. Elective procedures big moneymakers were halted so that hospitals could divert resources to treating Covid-19 patients. Routine clinic visits were canceled or replaced by online sessions. This has resulted in grievous financial losses for hospitals and clinics. Medical practices have closed. Hospitals have been forced to furlough employees or cut pay.

Most patients, on the other hand, at least those with stable chronic conditions, seem to have done OK. In a recent survey, only one in 10 respondents said their health or a family members health had worsened as a result of delayed care. Eighty-six percent said their health had stayed about the same.

Admittedly, postponing health care had terrible health consequences for some patients with non-Covid-19 illnesses, such as those with newly diagnosed cancers that went untreated because outpatient visits were canceled, or because patients avoided going to the hospital out of fear of contracting the coronavirus. The spike in deaths in major cities like New York during the crisis almost certainly includes such patients.

Still, a vast majority of patients seem to have fared better than what most doctors expected. It will probably take years to understand why. Perhaps patients mitigated the harm of delayed care by adopting healthful behaviors, such as smoking less and exercising more. Perhaps the huge increases in stress were balanced out by other things, such as spending more time with loved ones.

However, there is a more troubling explanation to consider: Perhaps Americans dont require the volume of care that their doctors are used to providing.

It is well recognized that a substantial amount of health care in America is wasteful, accounting for hundreds of billions of dollars of the total health care budget. Wasteful care is driven by many forces: defensive medicine by doctors trying to avoid lawsuits; a reluctance on the part of doctors and patients to accept diagnostic uncertainty (which leads to more tests); the exorbitant prices that American doctors and hospitals charge, at least compared to what is charged in other countries; a lack of consensus about which treatments are effective; and the pervasive belief that newer, more expensive technology is always better.

One of the most significant factors in wasteful health care is having too much supply of health care per capita in certain areas. In specialist-heavy Miami-Dade County, for example, Medicare spends more than twice per person what it spends in Santa Fe, N.M., largely because there is more per capita utilization of doctors services. Sadly, more care doesnt always result in better outcomes.

If beneficial routine care dropped during the past few months of the pandemic lockdown, so perhaps did its malignant counterpart, unnecessary care. If so, this has implications for how we should reopen our health care system. Doctors and hospitals will want to ramp up care to make up for lost revenue. But this will not serve our patients needs.

The start-up should begin with a renewed commitment to promoting beneficial care and eliminating unnecessary care. Most doctors recognize the importance of this distinction, even if we dont always act on it. In a survey a few years ago, two-thirds of doctors in the United States admitted that between 15 percent and 30 percent of health care is probably unnecessary.

Medical societies already produce lists of procedures that are essential and those that are better avoided. The latter include M.R.I. scans for most lower-back pain and nuclear stress tests when there are no signs of heart disease. As hospitals and clinics reopen for non-Covid-19 care, such lists should be more widely publicized.

Patients have an important role to play, too. Studies suggest that up to 20 percent of surgeries in some specialties are unnecessary. If your surgery was postponed because of the pandemic, it is worth having a conversation with your doctor about whether it is still needed. Despite the complexity of disease today, ailments sometimes do get better by themselves. And in some cases, scheduled surgeries werent necessary in the first place.

Many institutions are using this difficult time in our nations history to make changes. The health care system should do the same. The pandemic has given us a glimpse of a world in which business as usual in our health care system was upended. It has also provided an opportunity to start up again in a healthier and more financially responsible way. Reflexively returning to the status quo may be good for our bottom line, but it wont serve our patients well.

Sandeep Jauhar (@sjauhar) is a cardiologist, a contributing Opinion writer and the author, most recently, of Heart: A History.

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How Should We Reopen Hospitals That Closed Because of the Coronavirus? - The New York Times

The news in the US has been dominated by anti-racism protests for the past couple of weeks, but coronavirus is now back in the headlines.

Several states have seen a record number of cases in recent days, leading to fears that the country is experiencing a second wave of infections.

But Vice-President Mike Pence said those fears were "overblown" and accused the media of using "grim predictions" to scare the American people.

So what is going on in the US?

With more than two million coronavirus cases, the US has the highest number of confirmed infections in the world - about a quarter of the global total.

The situation got really bad in late March but by May, cases were declining and most states had begun to ease restrictions put into place to halt the spread of the virus.

The number of new cases rarely fell below 20,000 though, because as some states were bringing their outbreaks under control, others were only just beginning to see flare-ups.

For this reason, the top US health official for infectious diseases, Anthony Fauci, sees the current situation as a continuation of the initial outbreaks.

"People keep talking about a second wave," he told a reporter last week. "We're still in a first wave."

Spikes in cases in those new hotspots mean the country's overall seven-day average has now risen for several days in a row for the first time since cases peaked in early April.

The North East has been by far the worst-hit region, with about a quarter of all US cases and more than a third of all US deaths occurring in the states of New York and New Jersey. But in recent weeks, the region has brought its outbreaks under control.

The South and West of the country, on the other hand, have seen a big rise in the number of infections, according to data compiled by the COVID Tracking Project.

There's no debate over whether cases are going up again, but there is over why.

President Donald Trump blames it on increased testing, telling the Wall Street Journal he thinks "testing is overrated" because "in many ways, it makes us look bad."

The US has conducted more tests than any other country - about 25 million so far - so that does go some way to explaining why it has the highest number of cases in the world, although international comparisons are difficult to make for a number of reasons.

But there's plenty of evidence to suggest the recent rise in infections is down to more than just a higher number of people being tested.

Twice last week, Arizona saw more new cases on its own than the entire nine-state North East region and that's not just down to increased testing.

This is clear when you look at the rate of coronavirus tests that are coming back positive.

If lots of tests are being done and the spread of the virus has been reduced, then the positive case rate would go down too. If the virus is still being spread widely, it goes up.

At the moment the positive case rate is just below 5% nationally, which is the level the World Health Organization recommends countries be at or below for 14 days before they ease restrictions on movement.

But about a third of states are above that level, as the chart below shows, and all of them have reopened to some extent over the last month.

The number of people being hospitalised has also risen in a number of these states, including Texas, where some reopened bars and restaurants are now closing their doors again, reports the Texas Tribune, because of fears over a new surge of cases.

Faced with rising case numbers and an economy that desperately needs to get going again, many public officials are looking to facemasks to help slow the spread of the virus. California, North Carolina and several US cities mandated or urged their use last week.

But masks have become increasingly politicised in recent weeks, with President Trump saying some people wear them primarily to show opposition to him.

Amid all of the fears about new hotspots, the most positive news in the US at the moment is that daily deaths continue to fall.

They peaked back in May when the outbreaks in the Northeast were at their most intense, with New York state alone registering around 1,000 a day. This week, that figure is about 40 a day.

However, deaths is a metric that lags behind cases and hospitalisations because it can take several weeks for those who are worst-hit to die from the disease. That means the consequences of the current spikes in cases won't be seen for a couple of weeks at least.

If we do see the number of deaths edging up, there will likely be some pressure on governors to reintroduce restrictions but Dr Fauci doesn't think that will happen.

"I don't think we're going to be talking about going back to lockdown," he said last week. "I think we're going to be talking about trying to better control those areas of the country that seem to be having a surge of cases."

Researchers are racing to produce a vaccine but it's clear that Americans, and the rest of the world, are going to be living with the virus until next year at the earliest.

So far, the US has recorded about 120,000 coronavirus deaths - the highest death toll in the world.

But one forecasting model run by experts at the University of Washington, which has been cited by the White House in the past, predicts that number will have passed 200,000 by October - a month before the election.

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Coronavirus: Is the pandemic getting worse in the US? - BBC News

When a deluge of coronavirus cases threatened to overwhelm the NHS in March, Covid-19 was a brand new and little-understood disease, causing panic as well as deaths. Hospitals under huge pressure did all they could.

Next time round, if, as everyone supposes, there is a next time, it will be different. In a second wave, or even localised spikes across the nation, the health service will know more about what it is dealing with and will be better able to help people recover and send them home, say doctors.

First, two drugs have been shown to work to some extent, even though neither is a cure. Most exciting is the revelation that a 60-year-old steroid, dexamethasone, reduces deaths among those who are most sick saving one in eight lives among those on ventilators and one in 25 of those on other oxygen support. Remdesivir is also useful, reducing the length of the illness.

Mervyn Singer, a professor of intensive care medicine at University College London, is delighted with the dexamethasone result. Covid-19 causes inflammation in the lungs and steroids are already used to reduce inflammation, but he said medicine is conservative with a small c, and some clinicians worried that they suppress the immune system, so they have generally been used later rather than earlier. However, the Recovery trial, a global trial into possible treatments, showed how well low-dose dexamethasone works in Covid-19 and it will now become standard of care.

He thinks medical staff will next time feel less anxious carrying out procedures such as intubation, which carries the risk of viral particles shooting into the air. They will also be happier about chest compression and humidification ventilating patients in a way that allows water vapour to emerge when they breathe.

We have become more confident in dealing with it. I think wed be much less paranoid about the risk of infection. Obviously we wear PPE but the people looking after the patients in intensive care have had a low level of infection no different from the man in the street which I think is important because there was a lot of fear, said Singer.

What helps now is the reduced numbers of patients in intensive care with breathing problems. Even in bad flu outbreaks, it was never like the peak numbers for Covid-19. Normally wed have two to three of these patients in an intensive care unit. We got up to 62 at one time, Singer said.

When you have got one nurse to one patient doing everything we normally do, its a very different kettle of fish from one nurse to four patients.

Epidemics of infectious diseases behave in different ways but the1918 influenza pandemicthat killed more than 50 million people is regarded as a key example of a pandemic that occurred in multiple waves, with the latter more severe than the first. It has been replicated albeit more mildly in subsequent flu pandemics.

How and why multiple-wave outbreaks occur, and how subsequent waves of infection can be prevented, has become a staple of epidemiological modelling studies and pandemic preparation, which have looked at everything from social behaviour and health policy to vaccination and the buildup of community immunity, also known as herd immunity.

Is there evidence of coronavirus coming back in a second wave?

This is being watched very carefully. Without a vaccine, and with no widespread immunity to the new disease, one alarm is being sounded by the experience of Singapore, which has seen a suddenresurgence in infectionsdespite being lauded for its early handling of the outbreak.

Although Singapore instituted a strong contact tracing system for its general population, the disease re-emerged incramped dormitory accommodationused by thousands of foreign workers with inadequate hygiene facilities and shared canteens.

Singapores experience, although very specific, has demonstrated the ability of the disease to come back strongly in places where people are in close proximity and its ability to exploit any weakness in public health regimes set up to counter it.

In June 2020, Beijing suffered from a new cluster of coronavirus cases which caused authorities to re-implement restrictions that CHina had previously been able to lift.

What are experts worried about?

Conventional wisdom among scientists suggests second waves of resistant infections occur after the capacity for treatment and isolation becomes exhausted. In this case the concern is that the social and political consensus supporting lockdowns is being overtaken by public frustration and the urgent need to reopen economies.

The threat declines when susceptibility of the population to the disease falls below a certain threshold or when widespread vaccination becomes available.

In general terms the ratio of susceptible and immune individuals in a population at the end of one wave determines the potential magnitude of a subsequent wave. The worry right now is that witha vaccine still many months away, and the real rate of infection only being guessed at, populations worldwide remain highly vulnerable to both resurgence and subsequent waves.

Peter Beaumont

Early on, he and colleagues at UCL realised fewer patients needed ventilation than had been forecast. The assumption that the UK would need 18,000 ventilators when it had 8,000 was one of the reasons it was thought the NHS would be unable to cope with the epidemic and that led to the lockdown.

But only half of the sickest patients were intubated and put on a machine, while just as many have been given other help with their breathing, such as with the use of a Cpap (continuous positive airway pressure) mask. The long-term outcomes are better.

Clinicians also now have more idea of which patients are likely to become sickest. There was a lot of talk earlier on about the cytokine storm triggered by the patients immune system going into overdrive and attacking its own cells. If you look at the data, it isnt particularly high, Singer said.

There is a hyper-inflammatory reaction from the body, but it manifests in a different way and can be measured by a standard inflammatory marker called C-reactive protein, or CRP. Its part of the bodys host response. It goes up hugely in Covid, whereas cytokine levels dont go up very much, he said.

It means a patients CRP level can be checked on arrival in hospital. It is the patients who are more hyper-inflamed who are more likely to die. We can target those patients more or less as they come through the door, said Singer.

One of the big and alarming surprises has been the damage Covid-19 does to the heart and circulatory system. There is a really increased risk of clotting, probably due to damage to the blood vessels, said Prof Sir Nilesh Samani, the medical director of the British Heart Foundation.

The virus attacks the lining of the blood vessels and makes them more likely to clot.

People who have had heart attacks or strokes are more vulnerable to the virus, which can also cause them in sick patients. The heart attacks are peculiar, said Samani. It is the smaller arteries downstream that are affected, where the inflammation is more acute.

One small study looking at the lungs of people who died, published in the New England Journal of Medicine, found they had nine times as many blood clots as people who died from swine flu (H1N1).

Knowing the danger, many hospitals are now giving those at risk anticoagulants and antiplatelet therapy soon after admission. These are drugs that thin the blood, making clotting less likely.

The lesson we have learned is that we should treat these people before they have the clot, said Samani. The risk can be measured by looking at the levels of D-dimers in the blood. These are proteins the leftovers from the normal clotting of blood when people have a wound that heals, for instance. But high levels can indicate a clot is forming.

The British Heart Foundation, together with the governments National Institute for Health Research, is supporting six major research programmes to discover more about the effects of the virus. These will combine data from hospitals, information about our health and lifestyle, genetic studies, and imaging and artificial intelligence techniques.

That research, and much more in other fields, will help find the optimal way to treat Covid-19 patients and reduce the death rate when and if it returns.

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Why doctors say UK is better prepared for a second wave of coronavirus - The Guardian

As we see the return of the sunshine this week, and as the number of confirmed cases and deaths in the UK continues to fall, it can feel as if the worst of the pandemic is over.

Far from relaxing, the government should be using this respite to make long-term plans on how to coexist with the virus until a vaccine can be found. Time is running out when the cold and damp weather sets in, the virus will thrive. Test, trace and isolate schemes will be stretched as soon as flu symptoms rise and overlap with Covid-19 symptoms. Avoiding a second lockdown must be the imperative to ensure that the sacrifices made by the British public over the past 13 weeks do not go to waste.

Currently the governments drive to open up as quickly as possible bears a risk of another increase in infections, similar to what is being experienced in several US states such as Florida, Arizona and Texas, and in Iran. Ian Diamond, the UKs national statistician, warned that the UK currently faces 3,000-4,000 new infections per day and only a fraction of those are being picked up through the test and protect scheme. By allowing the virus to spread during the summer months the government is creating a ticking time bomb that will go off as autumn arrives.

Covid-19 is too dangerous to let spread through a population unchecked. Not only because of the difficulty of staying within health service capacity and overall mortality, but also because of the morbidity it entails. The FT has estimated that 65,000 excess deaths have occurred so far during the Covid-19 pandemic in the UK. In addition, an increasing number of long-term health complications are being seen in those who have recovered from the virus, and often in those who were healthy previously. Covid-19 is not the flu, but a multi-system disease that has surprised doctors in how it presents and how it develops within the human body. Important questions about immunity remain about whether re-infection is possible, or even immune enhancement where individuals get a more severe version of the same virus upon repeated exposure, such as with dengue fever.

That is not to say countries should remain in lockdown until a vaccine is discovered, given the economic and social costs. Instead, each country will need to find the least worst path out of this situation based on their populations, public health system and capacity. An increasing number of countries are trying to suppress the virus to a low level and, where possible, eliminate it before reopening their schools, shops and restaurants. Not only New Zealand, but also Australia, Thailand, Vietnam, the Faroe Islands, Iceland and countries in east Asia. Once the virus has all but disappeared, governments in these nations are able to identity imported cases such as the two British travellers who reintroduced Covid-19 to New Zealand and limit their spread. It is possible to both eliminate the virus and reopen economies but it has to be done cautiously and with close monitoring.

As an island, Great Britain is in a strong position to eliminate the virus and fully reopen schools, bars and theatres as well as bringing back sports matches and weddings, without pointless debates about 1 or 2 metre distancing measures. This would require mass testing to catch all symptomatic and asymptomatic carriers tracing of contacts and isolation for those individuals. The public needs to be convinced that the short-term pain is worth it, including continued physical distancing from others, use of face masks when distancing is not possible, and putting aside short-term self-interest for a few more months. Local dashboards should be created using the first part of postcodes, so individuals can understand transmission within their communities and ensure their behaviour contributes to a downwards push. Covid-19 will burn itself out if it has no other hosts to transmit it.

A clear push towards a zero coronavirus Britain should have been the priority when the country went into late lockdown on 23 March. And while other countries raced ahead with testing and tracing, and border control, and face masks, the UK government seemed to think that locking down alone was the solution, instead of a window of extremely costly time to aggressively go after the virus and drive it out. As a Chinese colleague told me in early March, implement key public health measures now and youll be out of the woods by mid-June.

The UK government has missed chance after chance to suppress this virus and reopen the economy as quickly as possible. The summer months offer it a narrow timeframe to reassess its overall strategy in managing this outbreak. It feels like decisions are being made based on polling to see how this affects government approval ratings, rather than based on what is needed to get through this crisis. Planning and leadership are required to look at where the country needs to be, then work back from that to implement the key measures to get there. All of our lives, jobs and futures depend on it.

Prof Devi Sridhar is chair of global public health at the University of Edinburgh

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The pandemic is not over we need to push now for a zero-coronavirus Britain - The Guardian

CLEVELAND, Ohio In Missouri, two hair stylists who tested positive for COVID-19 after working in close contact with 140 clients and six coworkers. Local health officials feared it would be the start of a major outbreak.

But it wasnt.

The reason? Employees and patrons at the Great Clips salon were required to wear masks, health officials said.

The result appears to be one of the clearest real-world examples of the ability of masks to slow the spread of the novel coronavirus, the Washington Post wrote this month. Local health officials are studying the details of the Springfield, Missouri, incident, including what types of face coverings were used and what other precautions were taken.

The fact that none of the exposed people became ill is something we need to think about, said Dr. Claudia Hoyen, director of pediatric infection control at University Hospitals Rainbow Babies and Childrens Hospital.

There are definite lessons we can learn from this, Hoyen said. This is a good example of why we all should be wearing masks.

The coronavirus that causes COVID-19 spreads when infected persons expel the virus in airborne droplets while talking or coughing. When people wear a mask, fewer droplet are released, and the ones that are released dont travel as far, Hoyen said.

I believe masks play a role in protecting people from the coronavirus, she said.

The salons policies of spreading out patrons chairs, staggering appointments and other measures, also helped prevent the spread of the disease, local health officials said.

When MetroHealth Systems Dr. Nick Dreher heard about what happened at the Great Clips hair salon, he wondered were they lucky, or were they smart?

There was some luck involved, but also smart choices in the form of social distancing, sanitizing tools and surfaces, and requiring masks, said Dreher, medical director of the Population Health Innovation Institute at MetroHealth.

They did a lot of things right, he said.

Social distancing and other measures dont afford 100% protection from COVID-19, but they do help, Dreher said.

All those who had close contact with the sick hair stylists in Missouri were offered free testing but only 46 agreed to be tested. Dreher called the incident a good outcome, not a perfect outcome, because not everyone in the pool of 140 people were tested.

While mask-wearing may have averted an outbreak in Missouri, the opposite happened recently in Florida.

A group of 16 friends tested positive for the illness after celebrating a birthday in a crowded bar. At least seven bar employees have also reportedly tested positive for the disease, according to news reports. Members of the birthday group said no one was wearing masks.

New research is also examining the effectiveness of wearing a face covering in slowing the spread of COVID-19.

Scientists at University of California, San Diego, Caltech and Texas A&M looked at the worlds three COVID-19 epicenters: Wuhan, China; Italy, and New York City. They saw that in Wuhan, where mask-wearing is part of the culture, the spread was relatively slow. But case numbers continued to climb in Italy and New York City, despite lockdown and stay-at-home orders.

A separate study funded by the World Health Organization and recently published in the journal Lancet reviewed more than 170 studies and found evidence that wearing face coverings reduces the risk of COVID-19 infection.

Hoyen hopes the examples in Florida and Missouri, combined with new research, make wearing a mask more acceptable.

If everybody wears masks, were all much more protected, she said.

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Two hair stylists with the coronavirus wore masks. So did their 140 clients. Of those tested, none got sick - cleveland.com

STATEN ISLAND, N.Y. -- According to an infectious disease expert in Italy, the coronavirus (COVID-19) has weakened over time and could die out before a vaccine is needed.

Prof. Matteo Bassetti, head of the infectious diseases clinic at the Policlinico San Martino hospital, says he believes COVID over the past month or so has been losing its virulence, the Sunday Telegraph reported.

He bases that theory in part on the fact patients who would previously have died are now recovering.

In March and early April the patterns were completely different, Bassetti said. People were coming to the emergency department with a very difficult to manage illness and they needed oxygen and ventilation; some developed pneumonia.

Now, in the past four weeks, the picture has completely changed in terms of patterns. There could be a lower viral load in the respiratory tract, probably due to a genetic mutation in the virus which has not yet been demonstrated scientifically. Also we are now more aware of the disease and able to manage it.

I think the virus has mutated because our immune system reacts to the virus and we have a lower viral load now due to the lockdown, mask-wearing, social distancing. We still have to demonstrate why its different now.

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Coronavirus could die out on its own, according to Italian expert: Report - silive.com

The latest on the coronavirus pandemic around the U.S. and the world.

ST. PETERSBURG, Fla. Coronavirus cases in Florida surpassed 100,000 on Monday, part of an alarming surge across the South and West as states reopen for business and many Americans resist wearing masks or keeping their distance from others.

The disturbing signs in the Sunshine State as well as places like Arizona, Alabama, Louisiana, Texas and South Carolina along with countries such as Brazil, India and Pakistan are raising fears that the progress won after months of lockdowns is slipping away.

It is snowballing. We will most certainly see more people die as a result of this spike, said Dr. Marc Boom, CEO and president of Houston Methodist Hospital, noting that the number of COVID-19 hospital admissions has tripled since Memorial Day to more then 1,400 across eight hospital systems in the Houston metropolitan area.

He predicted that in three weeks hospitals could be overwhelmed, and he pleaded with people to cover their faces and practice social distancing.

It is possible to open up at a judicious pace and coexist with the virus, but it requires millions and millions of people to do the right thing. Right now, we dont have that because people have let their guard down, Boom said.

The number of newly confirmed coronavirus cases across the country per day has reached more than 26,000, up from about 21,000 two weeks ago, according to an Associated Press analysis of data compiled by Johns Hopkins University. The analysis looked at a seven-day rolling average through Sunday.

Over 120,000 deaths in the U.S. have been blamed on the virus.

Read the full story here.

White House relaxes its own virus screening as D.C. hits phase two

The White House is cutting back on screening visitors for the coronavirus as President Donald Trump pushes to reopen the country.

In conjunction with Washington, D.C., entering Phase Two today, the White House is scaling back complex-wide temperature checks, White House spokesman Judd Deere said in a statement on Monday.

The White House had been conducting temperature checks in a makeshift medical tent at the press entrance since March. The tent was gone on Monday, as Washington entered its second phase of reopening, allowing the businesses such as restaurants and gyms to open under limited conditions.

In addition to social distancing, hand sanitizer, regular deep cleaning of all work spaces, and voluntary facial coverings, every staff member and guest in close proximity to the president and vice president is still being temperature checked, asked symptom histories, and tested for COVID-19, Deere said.

A notice posted in the briefing room lists symptoms of the virus and recommends social distancing.

On Saturday, Trump held his first rally since the pandemic began, drawing a crowd in Tulsa, Oklahoma, far smaller than he and his camaign had touted. Health experts had warned that a large indoor rally would fuel the viruss spread in Oklahoma.

The U.S. reported 33,894 new cases on Saturday, its highest total since May 1. About 120,000 people have died from the virus in the U.S.

Germany works to tame meatpacking outbreak

BERLIN German Chancellor Angela Merkels spokesman said everything needs to be done to contain an outbreak of the coronavirus linked to a large slaughterhouse where over 1,300 people have tested positive for COVID-19.

Steffen Seibert said 20 workers at the Toennies meat plant in the western Guetersloh region have been hospitalized and several are in intensive care.

We very much hope that all those who have fallen ill survive, Seibert told reporters in Berlin on Monday. This is an outbreak that needs to be taken very seriously.

Authorities have scrambled to stop the outbreak from spreading, by ordering mass tests of all workers and putting thousands of people into quarantine. The outbreak at Toennies, where many workers are migrants from Eastern Europe, has pushed up Germanys daily infection rate.

Authorities have dispatched virologists, contact tracing teams and the German army to help contain the outbreak.

Germanys disease control center says the country has seen 190,359 confirmed cases and 8,885 virus-related deaths about five times fewer deaths than in Britain.

Netherlands reports no deaths in last 24 hours

THE HAGUE, Netherlands The Dutch public health institute says that no COVID-19 deaths have been reported in the last 24 hours, the first time since March 12 that no new deaths have been seen.

The institutes Monday death tallies are sometimes lower than other days of the week due to weekend reporting lags.

The official Dutch death toll in the coronavirus pandemic stands at 6,090. The true toll is higher because not all people who have died with suspected COVID-19 were tested.

Tesla delays annual meeting until September

SAN FRANCISCO Due to coronavirus restrictions in Silicon Valley, Tesla Inc. is delaying its annual shareholders meeting from July 7 probably until Sept. 15.

The electric car and solar panel company announced the delay in a regulatory filing Monday after CEO Elon Musk revealed it overnight on Twitter.

The event likely will be combined with what Musk has touted as Battery Day, when the company is supposed to announce new battery technology that will work for 1 million miles and have longer range than current models.

In the filing with the U.S. Securities and Exchange Commission, Tesla said its board believes that stockholders appreciate the interpersonal connection and dynamic of an in-person annual meeting.

It reprinted Musks tweets saying Sept. 15 was a tentative date, and the meeting would be held at the companys factory in Fremont, California.

Croatia bans visits to nursing homes

ZAGREB, Croatia Croatian authorities have banned visits to nursing homes and hospitals in the Croatian coastal town of Zadar following an outbreak of the new coronavirus at an exhibition tennis tournament there.

Tennis players Grigor Dmitrov from Bulgaria, Borna Coric from Croatia and two more people have tested positive after participating in the Adria Tour event organized by top-ranked Novak Djokovic of Serbia.

Authorities said Monday that dozens more tests are underway in Zadar, while Croatias state HRT television reported that Prime Minister Andrej Plenkovic also will be tested after visiting the event.

Djokovics team said he has returned to Serbia and was tested there, while the event has been canceled.

Croatia has reopened in hopes of salvaging the summer tourism season along the Adriatic Sea coast. The European Union nation will hold a national election on July 5.

Seouls mayor fears virus resurgence

SEOUL, South Korea The mayor of South Koreas capital fears the country is losing control over a virus resurgence and said Seoul will reimpose stronger social distancing measures if the daily jump in infections doesnt come below an average of 30 over the next three days.

If Seoul gets penetrated (by the virus), the entire Republic of Korea gets penetrated, Park Won-soon said Monday in a televised briefing, referring to South Korea by its formal name.

He also lamented what he described as complacency of citizens in social distancing, citing an increase in public transportation usage that he says has been approaching last years levels in recent weeks.

Citing research by health experts, Park the country could be possibly reporting as much as 800 new cases a day a month from now if it fails to stem current trends in transmissions. He said the basic reproduction number of virus carriers, which measures the number of infections caused by an individual, has reached nearly 1.8 for the period between April 30 and June 11. Any number above 1 indicates a growing epidemic.

In a separate briefing, Jeong Eun-kyeong, director of the Korea Centers for Disease Control and Prevention, acknowledged that the country was now going through a second wave of the virus, following a surge in late February and March centered around the southeastern city of Daegu.

The country has been reporting around 40 to 50 new cases per day since late May, mostly from the Seoul metropolitan area, where about half of South Koreas 51 million people live.

South Korea was reported around 500 new case per day in early March but managed to control the outbreak with an active testing and contact tracing campaign.

UN warns pandemic could jeopardize supply of AIDS drugs to developing nations

LONDON The U.N. AIDS agency is warning that the coronavirus pandemic could jeopardize the supply of AIDS drugs in developing countries and could lead to deadly shortages in the next few months.

In a statement Monday, UNAIDS said a survey it recently conducted found that lockdowns and border closures to stop the spread of COVID-19 were affecting both the production and distribution of the medicines, which could result in higher costs and shortages in the next two months.

As of June 2019, UNAIDS estimated that more than 24 million people were on life-saving anti-retroviral drugs and that losing access now could risk their health and the further spread of HIV.

I call on countries and buyers of HIV medicines to act swiftly in order to ensure everyone who is currently on treatment continues to be on it, Winnie Byanyima, executive director of UNAIDS, said in a statement.

UNAIDS said the sharp reduction in air and sea transport was complicating the distribution of raw materials and that social distancing was reducing manufacturing capacity. This could lead to a shortage of medicines or price increases, with some of the treatment courses for children estimated to be those worst affected.

The UNAIDS analysis was based on information collected from eight generic manufacturers of AIDS drugs in India, who account for more than 80% of the generic anti-retroviral drug supply globally. Governments in seven other countries that produce generic AIDS medications were also surveyed.

Beijing officials say they have contained outbreak

BEIJING A Beijing government spokesperson said the city has contained the momentum of a recent coronavirus outbreak that has infected more than 200 people, after the number of daily new cases fell to single digits.

The situation is developing in a good direction but the prevention situation remains grave and complex, Xu Hejian said at a Monday news conference.

Xu spoke after the city reported nine new cases in the previous day, down from more than 20 daily for eight straight days. A massive testing campaign found 236 confirmed cases of COVID-19 and 22 more without any symptoms. China does not include the latter in its official case count.

The Transport Ministry said tests of more than 100,000 of the citys ubiquitous delivery drivers were expected to be competed Monday, as authorities expand testing to more groups.

The outbreak took hold in a huge wholesale food market crowded with workers and buyers. Additional cases traced to the same outbreak have been found in neighboring Hebei province and nearby Tianjin city.

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The Latest: Surge in U.S. virus cases raises fear that progress is slipping - Press Herald

The latest:

Alarming surges in coronavirus cases across the U.S.raised fears Monday that the outbreak is spiralling out of control and that hard-won progress against the scourge is slipping away because of resistance among many Americans to wearing masks and staying away from others.

Confirming predictions that the easing of state lockdowns over the past month-and-a-half could lead to a comeback by the virus, cases surpassed 100,000 in Florida, hospitalizations are rising dramatically in Houston, and a startling onein fiveof those tested in Arizona are proving to be infected.

Over the weekend, the virus seemed to be everywhere at once: Six staff members helping set up for President Donald Trump's rally in Tulsa, Okla., tested positive, as did 23 Clemson University football players in South Carolina.

At least 30 members of the Louisiana State University team were isolated after becoming infected or coming into contact with someone who was. Meatpacking plants were also hit with outbreaks.

PHOTOS | COVID-19 precautions at Tulsa Trump rally:

"It is snowballing. We will most certainly see more people die as a result of this spike," said Dr. Marc Boom, CEO and president of Houston Methodist Hospital, noting that the number of COVID-19 hospital admissions has tripled since Memorial Day to more than 1,400 across eight hospital systems in the Houston metropolitan area.

He predicted that in three weeks hospitals could be overwhelmed, and he pleaded with people to cover their faces and practise social distancing.

"It is possible to open up at a judicious pace and coexist with the virus, but it requires millions and millions of people to do the right thing. Right now, we don't have that" because people have let their guard down, Boom said.

Texas is among a number of states including Arizona, Alabama, Florida and South Carolina whose governors have resisted statewide mask requirements, leaving the matter to local authorities.

In Orlando, 152 coronavirus cases were linked to one bar near the University of Central Florida campus, said Dr. Raul Pino, a state health officer in the resort city.

"A lot of transmission happened there," Pino said. "People are very close. People are not wearing masks. People are drinking, shouting, dancing, sweating, kissing and hugging, all the things that happen in bars. And all those things that happen are not good for COVID-19."

Although he asked health officials to renew calls for people to wear masks and keep their distance, Gov. Ron DeSantis has not signalled he will retreat from reopening the state after three months of shutdowns that have damaged the economy.

In Louisiana, Gov. John Bel Edwards weighed whether to proceed with any further loosening of restrictions amid a spike in cases. Some businesses have closed again because of infections among staff members or patrons. And a cluster of bars near LSU reported at least 100 customers and employees tested positive.

Arizona, in particular, is seeing disturbing trends in several benchmarks, including the percentage of tests that prove positive for the virus. Arizona's is the highest in the nation.

The state's positive test rate is at a seven-day average of over 20 per cent, well above the national average of 8.4 per cent and the 10 per centlevel that public health officials say is a problem. When the positive test rate rises, it means that an outbreak is worsening not just that more people are getting tested.

At Maryland's Fort Washington Medical Center on the outskirts of the nation's capital, workers described a scramble to find new beds, heartbreaking encounters with family members of critically ill patients and their frustration with Americans who do not believe the coronavirus threat is real.

Meanwhile, New York City, once the most lethal hot spot in the U.S., lifted more of its restrictions, moving a big step closer to normal. Restaurants can serve diners outdoors, customers can browse through stores and get a haircut, and children can return to playgrounds.

In Illinois, museums, gyms and zoos can reopen on Friday with restrictions. Indoor dining can resume at 25 per cent capacity, and some places, such as the Lincoln Park Zoo, will require reservations.

Worldwide, ninemillion people have been confirmed infected by the virus and about 470,000 have died, according to a tally by Johns Hopkins University, though experts say the actual numbers are much higher because of limited testing and cases in which patients had no symptoms.

As of 5:45 p.m. ET on Monday, Canada had 101,605 confirmed and presumptive coronavirus cases, with the majority in Quebec and Ontario. Of those cases, 64,307 of the cases were listed as resolved or recovered. A CBC News tally of deaths based on provincial information, regional health data and CBC's reporting stood at 8,473.

Ontario reported 161 new cases on Monday, bringing the total number of cases in that province to 33,637 with 2,647 deaths.

Quebec reported 69 new cases, bringing the total number of cases there to 54,835 with 5,417 deaths.The daily figure is the lowest Quebec has seen since March 21, and the first time Quebec has had no new deaths to report since March 17, when the province reported its first COVID-19-related death.

Saudi Arabia says this year's hajj will not be cancelled, but due to the coronavirus, only "very limited numbers" of people will be allowed to perform the major Muslim pilgrimage.

The kingdom said Tuesday that only people of various nationalities already residing in the country would be allowed to perform the hajj. The government did not specify how many people would be permitted to take part.

The announcement came asSaudi Arabia ended its nationwide curfew over the weekend.

India reported a record number of newcases on Monday and the deaths of more than 400 people in the past 24 hours.

Nearly 14,000 people have died from the disease caused by the virus since India's first case in January. The death toll there remains low when compared to countries with similar numbers of cases but public health experts fear its hospitals will be unable to cope with a rise in cases.

Despite the peak of infections projected to be weeks if not months away Prime Minister Narendra Modi relaxed most curbs of a near three-month lockdown on June 8 in order to ease economic pain.

Brazil the country with the second-most infections and deaths in the world behind the U.S. has "certainly seen a spike in cases" in the last 24 hours, said the WHO's Mike Ryan, adding there were "worrying increases" throughout Latin America.

In the state of Rio de Janeirowhich has recorded almost 100,000 COVID-19 cases and 9,000 deaths the health secretariat in a statement on Monday confirmed Health Secretary Fernando Ferry has left the post, without providing a reason.

The state's governor, Wilson Witzel, fired his prior health secretary in mid-May after a failure to construct several promised field hospitals for treatment of COVID-19 patients.

WATCH | Brazil deeply affected by COVID-19 due to high population, WHO says:

Africa's reported cases of COVID-19 have surpassed 300,000 as the spread of the disease quickens across the continent.

The Africa Center for Disease Control and Prevention said Monday the continent now has 306,567 confirmed cases, including 8,115 deaths and 146,212 recoveries. It took more than 90 days for Africa's 54 countries to reach 100,000 cases, 19 days to reach 200,000 and now 12 days to go above 300,000. The actual number of cases is believed to be much higher because testing across the continent is low.

South Africa, with 97,302 cases, accounts for nearly a thirdof the continent's total cases. The country had initially hoped it could control the disease through testing and tracing. But despite conducting more than 1.3 million tests, the highest number in Africa, it currently takes an average of 12 days to get results, which medical experts say is much too long to do any effective tracking and quarantining.

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Coronavirus: What's happening around the world Monday - CBC.ca

Heres one more behavior to be hyper-aware of in order to prevent coronavirus transmission: what you do after you use the toilet.

Scientists have found that in addition to clearing out whatever business youve left behind, flushing a toilet can generate a cloud of aerosol droplets that rises nearly three feet. Those droplets may linger in the air long enough to be inhaled by a shared toilets next user, or land on surfaces in the bathroom.

This toilet plume isnt just gross. In simulations, it can carry infectious coronavirus particles that are already present in the surrounding air or recently shed in a persons stool. The research, published Tuesday in the journal Physics of Fluids, adds to growing evidence that the coronavirus can be passed not only through respiratory droplets, but through virus-laden feces, too.

And while it remains unknown whether public or shared toilets are a common point of transmission of the virus, the research highlights the need during a pandemic to rethink some of the common spaces people share.

The aerosols generated by toilets are something that weve kind of known about for a while, but many people have taken for granted, said Joshua L. Santarpia, a professor of pathology and microbiology at the University of Nebraska Medical Center who was not involved in the research. This study adds a lot of the evidence that everyone needs in order to take better action.

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Typically, the coronavirus is most at home in cells in the lungs and upper respiratory tract. But studies have found it can also dock to cell receptors in the small intestine. Patients have been reported to experience diarrhea, nausea and vomiting among other symptoms.

And researchers have found viable virus particles in patients feces, as well as traces of viral RNA on toilet bowls and sinks in their hospital isolation rooms, although experiments in the lab have suggested that material may be less likely to be infectious compared with virus that is coughed out.

A computer simulation of the toilet flushing mechanism showed that when water pours into the toilet and generates a vortex, it displaces air in the bowl. These vortices move upward and the centrifugal force pushes out about 6,000 tiny droplets and even tinier aerosol particles.

Depending on the number of inlets in the toilet, flushing can force anywhere from 40 to 60 percent of the produced aerosols high above the seat.

Its very alarming, said Ji-Xiang Wang, who studies fluid dynamics at Yangzhou University and was a co-author of the study.

Its virtually impossible to keep bathrooms sanitized all the time, and sharing a toilet may be unavoidable for family members, even when one person is sick and isolating in a separate room at home, Dr. Wang said.

As cities around the world navigate the reopening of restaurants, offices and other businesses, more and more people will also need to use public or shared restrooms. But while diners can be moved outdoors and employees spaced out, people may find it harder to practice social distancing in small bathrooms.

Aerosolized particles may still linger in single-use toilets, and bathrooms are frequently poorly ventilated spaces, which can increase the risk of exposure to infection. Users also have to consider risks from high-touch surfaces, like doorknobs and faucets.

Experience with other coronaviruses shows how quickly the fecal-oral route can lead to spread of disease. In March 2003, more than 300 people living in the Amoy Gardens apartment complex in Hong Kong got infected with the original SARS coronavirus because infectious fecal aerosols spread through faulty plumbing and ventilation systems.

While Dr. Wang acknowledged that scientists had yet to look at toilet aerosols in real-world situations involving the new coronavirus, other research has shown that viral RNA was found in shared toilet areas at one hospital in Wuhan, China.

But researchers do not know how much infectious virus is in aerosols or whether people with more severe cases of Covid-19 shed more virus than patients with milder illness, he said.

Thankfully, people can also easily prevent the spread of infections from the toilet plume.

Close the lid first and then trigger the flushing process, Dr. Wang said, which he acknowledged isnt always possible in public bathrooms.

Updated June 22, 2020

A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise comes with issues of potential breathing restriction and discomfort and requires balancing benefits versus possible adverse events. Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. In my personal experience, he says, heart rates are higher at the same relative intensity when you wear a mask. Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.

The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.

The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who dont typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the countrys largest employers, and gives small employers significant leeway to deny leave.

So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was very rare, but she later walked back that statement.

Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus whether its surface transmission or close human contact is still social distancing, washing your hands, not touching your face and wearing masks.

A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nations job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you arent being told to stay at home, its still a good idea to limit trips outside and your interaction with other people.

Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

If youve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

You should also wash your hands frequently and thoroughly, especially if youre using a shared restroom where the toilet doesnt have a lid or the flush is automatically triggered on standing up. Avoid touching your face, and keep your mask on in the bathroom, which could prevent some exposure to the coronavirus.

Dr. Wang hopes the new research will help lead to improvements in bathroom design, including increased attention to contactless dispensers for soap and paper towels, and toilets that flush only after they have been covered with a lid.

Other experts are already considering indoor ultraviolet lights and automated disinfectant sprays that will zap the coronavirus and relieve some of the pressure on keeping public toilets clean.

And Dr. Santarpia said that Dr. Wangs study could point to a way of monitoring coronavirus clusters.

You could simply monitor samples from a shared bathroom on a daily basis, he said. And if something were to come up positive, you could then go look at everyone who was there and who they had contact with, rather than testing everybody all the time.

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Flushing the Toilet May Fling Coronavirus Aerosols All Over - The New York Times