Infectious diseases

What Can and Can’t Be Learned From a Doctor in China Who Pioneered Masks

May 19, 2021 by Staff Reporter

In late 1910, a deadly plague started spreading in the northeast reaches of China, reaching the large city of Harbin. Tens of thousands of people coughed up blood; their skin pruned and turned purple. They all died.

This outbreak sent the Qing government into a tailspin: They didn’t know what illness was causing these deaths, let alone how to control it. So they brought in one of the best trained doctors in Asia at the time, Dr. Wu Lien-Teh. After performing autopsies, Dr. Wu found Yersinia pestis, a bacterium similar to the one that had caused bubonic plague in the West. He recognized Manchuria’s plague as a respiratory disease and urged everyone, especially health care professionals and law enforcement, to wear masks.

Chinese authorities, heeding his call, coupled masking with stringent lockdowns enforced by the police. Four months after the doctor was summoned, the plague ended. Although often overlooked in Western countries, Dr. Wu is recognized in world history as a pioneer of public health, helping to change the course of a respiratory disease spread by droplets that could have devastated China in the early 20th century, and perhaps spread far beyond its borders.

While the Chinese of that era complied with these strategies, public health professionals in the United States and other Western countries have struggled to get people to listen to them during the Covid-19 pandemic. China, too, ran into challenges early on, but the country’s institutional memory from previous viral outbreaks helped turn the tide. And as many Americans abandon masking, push to restore normality in places where risks of infection remain high and hesitate to get vaccinated, some public health experts have looked to Dr. Wu’s success, seeking lessons on handling not only Covid, but also future epidemics.

masks became a political flash point in the United States and elsewhere during the Spanish flu pandemic, the idea of using them persisted in China, and gauze masks became an important tool in the political agenda of the Nationalist Party when it took over in 1928. Public health officials recommended all citizens wear gauze masks in public spaces during outbreaks of meningitis or cholera.

Kyle Legleiter, the senior director of policy advocacy at The Colorado Health Foundation.

Another factor that might have contributed to Dr. Wu’s success in China would be the reverence residents and officials had for him as a figure of authority, Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations, said.

In some ways, Dr. Anthony Fauci, the chief medical adviser on Covid to President Biden and a prominent public health figure since the 1980s, served in a role similar to the one Dr. Wu played in China, Dr. Huang said. But, his message perhaps didn’t always get through because Americans are more polarized in their political identities and beliefs.

Dr. Legleiter added that public health messaging only penetrates if the public identifies with or trusts that figure of authority.

“An individual person is a stand-in for a broader set of institutions or systems that they’re speaking on the behalf of,” Dr. Legleiter said. Those who lean conservative, for instance, may put Dr. Fauci and other scientists in the category of “the elites.” As such, they’re more likely to flout public health policies that such authority figures promote, and comply with proclamations from individuals they identify with the most.

Others say that public health is intrinsically tied to the legitimacy of the state promoting it. At the turn of the 20th century, China was in distress, Dr. Hanson said. Dr. Wu helped bring China out of a tumultuous period, and the enforcement of public health measures gave the country more legitimacy.

Similarly, because the current pandemic has laid bare shortcomings in the public health systems in the United States, Britain and other Western countries, some experts believe it can be a catalyst for change.

“Since the mid-19th century, the West has generally seen its ability to control infectious disease as a marker of their civilizational superiority over much of the rest of the world,” Dr. White said. While China was seen as the sick man of the world then, some commentators in China now attempt to brand the United States with that label.

Ruth Rogaski, a medical historian at Vanderbilt University who specializes in studying the Qing dynasty and modern China, believes that the coronavirus crisis similarly offers an opportunity for reflection, which can be very motivating.

“Epidemics can serve as inflection points,” Dr. Rogaski said. “Opportunities to rethink, retool and even revolutionize approaches to health.”

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An Updated Covid Guide

May 17, 2021 by Staff Reporter

3. Families with young children

These are some of the hardest cases, because children under 12 seem to be months away from being vaccinated.

There are a few reassuring facts for these families. First, in many of the places where children spend time, Covid transmission is uncommon. It is extremely rare outdoors, and springtime is a good time to be outdoors. The number of outbreaks in schools has also been quite low worldwide, perhaps because children may be less likely to infect others even when they have Covid.

Most reassuring is the fact that Covid is no more serious for children on average than the flu. I have written an article, with charts, that goes into more detail. As I explain, some parents may still choose to be extremely cautious, while others will be more comfortable with normalcy. Both decisions are defensible. Here’s an interview from that article:

Jennifer Nuzzo, an epidemiologist at Johns Hopkins, told me that she viewed decisions about children’s activities as a matter of personal choice that different parents would make differently. In her family, she said she was worried about how a year of pandemic life had hurt her children, by making them less comfortable in social situations. Once all the adults are vaccinated, she plans to restart more activities.

“I can accept the risks of my kids getting Covid, in part because I compare it to the risk of them getting other infectious diseases and the risk seems very, very small,” Dr. Nuzzo said. “I feel that if my kids were to get Covid, they would be OK. I also see the direct harms of their not having a normal life.”

4. The unvaccinated

About 40 percent of U.S. adults have not yet received a vaccine shot. For the country to reduce that number as rapidly as possible, it’s important to acknowledge reality: The vast majority are unvaccinated by choice.

They do not have health problems that prevent them from getting a shot, and they have not been stymied by the logistics of getting a shot. Yes, there are people in both of those groups, and they will need special help as society begins to reopen. Among other things, the Biden administration, state officials and employers will need to keep pushing to make vaccination even more convenient.

But the much larger issue is vaccine skepticism.

In the most recent poll by the Kaiser Family Foundation, 15 percent of adults said they did not want to get a shot until they knew more about how it affected other people. Another 6 percent said they would get a shot only if required (say, by their employer), and an additional 13 percent said they would definitely not get a shot. Put those three numbers together, and you get 34 percent — which, again, accounts for most of the unvaccinated 40 percent.

Unvaccinated people do face some additional risk from the hypothetical example that many people have been talking about since the C.D.C. changed its guidelines: the unvaccinated person who was wearing a mask in stores and avoiding restaurants until last week but no longer will.

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Why is Covid Killing So Many Young Children in Brazil? Doctors Are Baffled

May 16, 2021 by Staff Reporter

RIO DE JANEIRO — Fretting over a fever in her toddler that wouldn’t break, the mother took the young girl, Letícia, to a hospital. Doctors had worrisome news: It was Covid-19.

But they were reassuring, noting that children almost never develop serious symptoms, said the mother, Ariani Roque Marinheiro.

Less than two weeks later, on Feb. 27, Letícia died in the critical care unit of the hospital in Maringá, in southern Brazil, after days of labored breathing.

“It happened so quickly, and she was gone,” said Ms. Marinheiro, 33. “She was everything to me.”

Covid-19 is ravaging Brazil, and, in a disturbing new wrinkle that experts are working to understand, it appears to be killing babies and small children at an unusually high rate.

scientists say are leading to more severe cases of Covid in young, healthy adults and driving up death tolls in Brazil — on babies and children.

But experts say the variant appears to be leading to higher death rates among pregnant women. Some women with Covid are giving birth to stillborn or premature babies already infected with the virus, said Dr. André Ricardo Ribas Freitas, an epidemiologist at São Leopoldo Mandic College in Campinas, who led a recent study on the impact of the variant.

“We can already affirm that the P.1 variant is much more severe in pregnant women,” said Dr. Ribas Freitas. “And, oftentimes, if the pregnant woman has the virus, the baby might not survive or they might both die.”

Lack of timely and adequate access to health care for children once they fall ill is likely a factor in the death toll, experts said. In the United States and Europe, experts said, early treatment has been key to the recovery of children infected with the virus. In Brazil, overstretched doctors have often been late to confirm infections in children, Dr. Marinho said.

“Children are not being tested,” she said. “They get sent away, and it’s only when these children return in a really bad state that Covid-19 is suspected.”

study published in the Pediatric Infectious Disease Journal in January foundthat children in Brazil and four other countries in Latin America developed more severe forms of Covid-19 and more cases of multisystem inflammatory syndrome, a rare and extreme immune response to the virus, compared with data from China, Europe and North America.

Even before the pandemic began, millions of Brazilians living in poor areas had limited access to basic health care. In recent months, the system has been overwhelmed as a crush of patients have flooded into critical care units, resulting in a chronic shortage of beds.

“There’s a barrier to access for many,” said Dr. Ana Luisa Pacheco, a pediatric infectious diseases specialist at the Heitor Vieira Dourado Tropical Medicine Foundation in Manaus. “For some children, it takes three or four hours by boat to get to a hospital.”

The cases in children have shot up amid Brazil’s broader explosion in infections, which experts attribute to President Jair Bolsonaro’s cavalier response to the pandemic and his government’s refusal to take vigorous measures to promote social distancing. A lagging economy has also left millions without income or enough food, forcing many to risk infection as they search for work.

Some of the children who have died of the virus already had health issues that made them more vulnerable. Still, Dr. Marinho estimates that they represent just over a quarter of deaths among children under 10. That suggests that healthy children, too, seem to be at heightened risk from the virus in Brazil.

Letícia Marinheiro was one such child, her mother said. A healthy baby who had just started walking, she had never been sick before, Ms. Marinheiro said.

Ms. Marinheiro, who was infected along with her husband Diego, 39, believes Letícia might have lived if her illness had been treated with more urgency.

“I think they didn’t believe that she could be so sick, they didn’t believe it could happen to a child,” said Ms. Marinheiro.

She recalled pleading to have more tests done. Four days into the child’s hospitalization, she said, doctors had still not fully examined Letícia’s lungs.

Ms. Marinheiro is still unsure how her family got sick.

She had kept Letícia — a first child the couple had badly wanted for years — at home and away from everyone. Mr. Marinheiro, a supplier of hair salon products, had been cautious to avoid contact with clients, even as he kept working to keep the family financially afloat.

For Ms. Marinheiro, the sudden death of her daughter has left a gaping hole in her life. As the pandemic rages on, she says, she wishes other parents would quit underestimating the dangers of the virus that took Letícia away from her. In her city, she watches as families throw birthday parties for children and officials push to reopen schools.

“This virus is so inexplicable,” she said. “It’s like playing the lottery. And we never believe it will happen to us. It’s only when it takes someone from your family.”

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Nurses’ Union Condemns C.D.C.’s New Mask Advice

May 15, 2021 by Staff Reporter

The nation’s largest union of registered nurses condemned the Centers for Disease Control and Prevention on Saturday for lifting mask recommendations for vaccinated people and called on the agency to “do the right thing” and revise its guidance.

Bonnie Castillo, a registered nurse and executive director of the union, National Nurses United, said the most recent guidance, which was issued on Thursday and rolled back mask recommendations and other precautions for those who are fully vaccinated, “is not based on science.” Ms. Castillo said the new guidance would jeopardize the health of frontline workers and the general public and would disproportionately harm people of color.

“This is a huge blow to our efforts at confronting this virus and the pandemic,” said Ms. Castillo, whose union represents 170,000 nurses nationwide. Although vaccination is vitally important to stopping the virus’s spread, she noted that millions of Americans still had not been vaccinated.

“The mask is another lifesaving layer of protection for workers,” she said.

The union also criticized the C.D.C. for other actions, including its decision to stop monitoring breakthrough infections among vaccinated individuals and to investigate such cases only if they result in a hospitalization or death. The agency announced that, as of May 1, it would no longer track or investigate all infections among vaccinated people so that it could “maximize the quality of the data collected on cases of greatest clinical and public health importance.”

The nurses said that meant the C.D.C. would not gather the data necessary to understand whether vaccines prevent mild and asymptomatic infections, how long vaccine protection lasts and what role variants play in breakthrough infections.

The union also called on the agency, which recently recognized that the virus could be transmitted through aerosolized particles, to update its guidance about ventilation and respiratory protection accordingly. The union also called on the Occupational Safety and Health Administration to immediately issue emergency temporary standards on infectious diseases to protect people in the workplace.

The C.D.C. did not immediately respond to the criticisms. Introducing the new recommendations on Thursday, Dr. Rochelle P. Walensky, the C.D.C. director, cited two recent scientific findings as significant factors: Few vaccinated people become infected with the virus, and transmission seems rarer still; and the vaccines appear to be effective against all known variants of the coronavirus.

The union noted that more than 35,000 new cases of coronavirus were being reported each day and that more than 600 people were dying each day. “Now is not the time to relax protective measures, and we are outraged that the C.D.C. has done just that while we are still in the midst of the deadliest pandemic in a century,” Ms. Castillo said.

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Why Vaccinating the World Against Covid-19 Will Be Hard

May 15, 2021 by Staff Reporter

In delivering vaccines, pharmaceutical companies aided by monumental government investments have given humanity a miraculous shot at liberation from the worst pandemic in a century.

But wealthy countries have captured an overwhelming share of the benefit. Only 0.3 percent of the vaccine doses administered globally have been given in the 29 poorest countries, home to about 9 percent of the world’s population.

Vaccine manufacturers assert that a fix is already at hand as they aggressively expand production lines and contract with counterparts around the world to yield billions of additional doses. Each month, 400 million to 500 million doses of the vaccines from Moderna, Pfizer and Johnson & Johnson are now being produced, according to an American official with knowledge of global supply.

But the world is nowhere close to having enough. About 11 billion shots are needed to vaccinate 70 percent of the world’s population, the rough threshold needed for herd immunity, researchers at Duke University estimate. Yet, so far, only a small fraction of that has been produced. While global production is difficult to measure, the analytics firm Airfinity estimates the total so far at 1.7 billion doses.

dangerous new variants emerge, requiring booster shots and reformulated vaccines, demand could dramatically increase, intensifying the imperative for every country to lock up supply for its own people.

The only way around the zero-sum competition for doses is to greatly expand the global supply of vaccines. On that point, nearly everyone agrees.

But what is the fastest way to make that happen? On that question, divisions remain stark, undermining collective efforts to end the pandemic.

Some health experts argue that the only way to avert catastrophe is to force drug giants to relax their grip on their secrets and enlist many more manufacturers in making vaccines. In place of the existing arrangement — in which drug companies set up partnerships on their terms, while setting the prices of their vaccines — world leaders could compel or persuade the industry to cooperate with more companies to yield additional doses at rates affordable to poor countries.

Those advocating such intervention have focused on two primary approaches: waiving patents to allow many more manufacturers to copy existing vaccines, and requiring the pharmaceutical companies to transfer their technology — that is, help other manufacturers learn to replicate their products.

more than 100 countries in asking the W.T.O. to partially set aside vaccine patents.

But the European Union has signaled its intent to oppose waivers and support only voluntary tech transfers, essentially taking the same position as the pharmaceutical industry, whose aggressive lobbying has heavily shaped the rules in its favor.

Some experts warn that revoking intellectual property rules could disrupt the industry, slowing its efforts to deliver vaccines — like reorganizing the fire department amid an inferno.

“We need them to scale up and deliver,” said Simon J. Evenett, an expert on trade and economic development at the University of St. Gallen in Switzerland. “We have this huge production ramp up. Nothing should get in the way to threaten it.”

Others counter that trusting the pharmaceutical industry to provide the world with vaccines helped create the current chasm between vaccine haves and have-nots.

The world should not put poorer countries “in this position of essentially having to go begging, or waiting for donations of small amounts of vaccine,” said Dr. Chris Beyrer, senior scientific liaison to the Covid-19 Prevention Network. “The model of charity is, I think, an unacceptable model.”

halting vaccine exports a month ago. Now, as a wave of death ravages the largely unvaccinated Indian population, the government is drawing fire at home for having let go of doses.

poses universal risks by allowing variants to take hold, forcing the world into an endless cycle of pharmaceutical catch-up.

“It needs to be global leaders functioning as a unit, to say that vaccine is a form of global security,” said Dr. Rebecca Weintraub, a global health expert at Harvard Medical School. She suggested that the G7, the group of leading economies, could lead such a campaign and finance it when the members convene in England next month.

Pfizer expects to sell $26 billion worth of Covid vaccines this year; Moderna forecasts that its sales of Covid vaccines will exceed $19 billion for 2021.

History also challenges industry claims that blanket global patent rights are a requirement for the creation of new medicines. Until the mid-1990s, drug makers could patent their products only in the wealthiest markets, while negotiating licenses that allowed companies in other parts of the world to make generic versions.

Even in that era, drug companies continued to innovate. And they continued to prosper even with the later waivers on H.I.V. drugs.

“At the time, it rattled a lot of people, like ‘How could you do that? It’s going to destroy the pharmaceutical industry,’” recalled Dr. Anthony S. Fauci, President Biden’s chief medical adviser for the pandemic. “It didn’t destroy them at all. They continue to make billions of dollars.”

Leaders in the wealthiest Western nations have endorsed more equitable distribution of vaccines for this latest scourge. But the imperative to ensure ample supplies for their own nations has won out as the virus killed hundreds of thousands of their own people, devastated economies, and sowed despair.

The drug companies have also promised more support for poorer nations. AstraZeneca’s vaccine has been the primary supply for Covax, and the company says it has sold its doses at a nonprofit price.

stumbled, falling short of production targets. And producing the new class of mRNA vaccines, like those from Pfizer-BioNTech and Moderna, is complicated.

Where pharmaceutical companies have struck deals with partners, the pace of production has frequently disappointed.

“Even with voluntary licensing and technology transfer, it’s not easy to make complex vaccines,” said Dr. Krishna Udayakumar, director of the Duke Global Health Innovation Center.

Much of the global capacity for vaccine manufacturing is already being used to produce other lifesaving inoculations, he added.

But other health experts accuse major pharmaceutical companies of exaggerating the manufacturing challenges to protect their monopoly power, and implying that developing countries lack the acumen to master sophisticated techniques is “an offensive and a racist notion,” said Matthew Kavanagh, director of the Global Health Policy and Politics Initiative at Georgetown University.

With no clear path forward, Ms. Okonjo-Iweala, the W.T.O. director-general, expressed hope that the Indian and South African patent-waiver proposal can be a starting point for dialogue.

“I believe we can come to a pragmatic outcome,” she said. “The disparity is just too much.”

Peter S. Goodman reported from London, Apoorva Mandavilli from New York, Rebecca Robbins from Bellingham, Wash., and Matina Stevis-Gridneff from Brussels. Noah Weiland contributed reporting from New York.

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What Would It Take to Vaccinate the World Against Covid?