The Global Science and Politics of Covid-19 / SARS-CoV-2
A Self-induced Malthusian Catastrophe -- 17-10-20 -- Chris King -
Emeritus, University of Auckland
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The Covid-Climate Elucidation – Our Key to the Future PDF

This article provides a detailed real-time global research overview of the Covid-19 pandemic in its medical, social, economic and ecological aspects, including epidemic modelling, infection mechanisms, death rates, antiviral, antibody and vaccine treatments and the way in which humanity, despite clear prior warnings in other zoonotic corona virus outbreaks, allowed itself to get into this situation, through our impact on the biosphere and expores the lessons to be learned for humanity's future survival.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

Introduction: Don't destabilize the Symbiosis!

The key to the Covid-19 pandemic is that bats and corona viruses have evolved into a semi-symbiotic relationship in which the bats harbour the coronas and ensure their survival by a "super-immune" response using interferon mediated anti-viral modulation, but inhibiting inflammasomes, which precipitate the cytokine storms resuling in human casualties. Bats, instead of expresing inflammatory cytokines, generate a targeted set of antiviral factors which tune down the virus. Simultaneously, the virus also adapts to the bat host cells, while rapidly mutating specific genes. Consequently bat coronaviruses can persist in their natural bat host for at least four months of hibernation without harming the bat, as discovered in the case of MERS. When a bat experiences stress to their immune system, it disrupts this immune system-virus symbiosis and allows the virus to multiply. Wet markets and habitat destruction combine to stress the bats in cages in close proximity to other species which also carry other strains of corona virus, leading to zoonotic recombination and a new toxic chimera not yet adapted to any host, but potentially both highly infectious and lethal because its highly evolved nature may bind very strongly to certain receptors in the bat or intermediate host. So its not that there is a vicious RNA virus at work alone, but the exploitative stressing of wild ecosystems disrupting symbiotic relationships on which the corona depends. This is the invidious work of humanity bringing about our own misfortune, hence it is a classic Malthusian grim reaper.

Sars-CoV-2 is clearly an extremely infectious epidemic disease. It binds strongly to ACE-2 receptors in the alveoli where oxygen transfer occurs and where it can cause debilitating pneumonia leading to loss of oxygen absorption and blood-borne viremia through the presence of ACE-2 blood-pressure receptors lining all blood vessels. It also binds sufficiently in the upper respiratory tract to be easily transmissable. A model of exactly why this is and why it can be very severe goes something like this:

Phase 1: Humans are currently not resistant to the virus so it replicates exponentially without restraint for around a four to five day incubation period (Lauer et a 2020, Li et al 2020) with an exponentially increasing viral load. The virus is also stable for long periods on external surfaces leading to indirect transfer. This means that a person may become extremely infectious just as they begin to show symptoms and can infect a large number of people around them as a transient super-spreader, leading to large clusters being generated at social gatherings.

Phase 2: Once the immune system kicks in, the infectivity naturally diminishes, as the viruses are attacked and destroyed. However in some, particularly older, people a deterioration may set in, in the second week, where they get obstructed lungs and an inflammtory cytokine storm. It is likely this is because the bat-adapted virus inhibits the interferon response and inflammatory responses promote viral ploliferation. In 'wet lung', the tissues around the alveoli leak plasma into the lungs which fill with fluid and the virus can pass into the blood stream, resulting in viremia. At this point the virus can attack the kidneys, brain, heart and/or liver which also have ACE-2 blood pressure receptors and infectivity is likely to increase again, causing risk to medical personnel. These two phases of infectivity could select for differing evolutionary processes, the first towards less aggressive and the second to more aggressive strains.

Reactions both by the immune systems of infected people and the virus itself can lead to an unparalleled variety of outcomes. The key to asymptomatic spreading is that the corona virus, as noted aove, is an implicitly symbiotic virus (1, 2 and 3) that has got knocked off its perch to become a pandemic infection. Thus some people have no symptoms at all, but others end up getting killed in large numbers when the virus remains active and the immune mismatich runs riot.

Asymptomatic cases may arise either because of existing immunity due to other human corona viruses, or due to the initial interferon reaction curbing the viral explosion as occurs in bats. Immunity-mediated resistance is also a combination of humoral antibody-based immunity in which helper T-cells prime B-cells to produce antibodies, and direct cytotoxic responses from killer T-cells. Currently there are indications of a waning and highly variable humoral antibody response, depending on the severity of the infection, with direct killer T-cell activity showing high specificity for the virus. Cases of people catching two different forms of Covid-19 have also emerged. There is evidence of formation of memory cells in people who have had moderate infection severity, pointing to longer term immunity, but not in those who have died. In the most severe cases there is evidence for a misregulated immune response leading to cytokine storms and organ failure accompanied by inflammosomes.

Six months of coronavirus: the mysteries scientists are still racing to solve Nature 3-7-2020 Genetic differences in victims. How long does immunity last? Worrying mutations? Vaccine prospects. Origin fo the virus?

Profile of a killer: the complex biology powering the coronavirus pandemic Nature 4-5-2020 With 30,000 genetic bases, coronaviruses have the largest genomes of all RNA viruses. Their genomes are more than three times as big as those of HIV and hepatitis C, and more than twice influenza's. Coronaviruses are also one of the few RNA viruses with a genomic proofreading mechanism — which keeps the virus from accumulating mutations that could weaken it. That ability explains why common antivirals such as ribavirin, have failed to work on SARS-CoV-2, because the proofreader can weed out the mutations caused by these drugs. Coronaviruses also frequently recombine, swapping chunks of their RNA with other coronaviruses, giving them deadly variability.. Recombination happens often in bats and bat cells infected by viruses rapidly release a signal that may make them able to host the virus without killing it. The fact that both mutations and recombinations are at work complicates efforts to draw a family tree. Estimates for the birth of the first coronavirus vary widely, from 10,000 years ago to 300 million years ago. Evolutionary studies suggest that a SARS-CoV-2 related lineage has existed in an animal host for decades. The SARS-CoV-2 binding domain is particularly efficient, and differs in important ways from that of the Yunnan bat virus, which seems not to infect people, although they are 96% similar. The pangolin has been found to harbour a coronavirus with a receptor-binding domain almost identical to the human version, but is overall only 90% similar.

SARS-CoV-2, like human CoVs, can attack the upper airways, or like SARS the lungs – both very efficiently. This gives it two ways to get a foothold. Once it gets into the lungs, it appears to be just as deadly as SARS. SARS-CoV-2 is uniquely equipped for forcing entry into cells. Both SARS-CoV and SARS-CoV-2 bind with ACE2, but the receptor-binding domain of SARS-CoV-2 is a particularly snug fit. ACE2 is expressed throughout the body on the lining of the arteries and veins that course through all organs, but it is particularly dense on the cells lining the alveoli and small intestines. A SARS-CoV-2 infection can trigger an excessive a cytokine storm, which can lead to multiple organ failure and death. The virus can also infect the intestines, the heart, the blood, sperm, the eye and possibly the brain. It is 10–20 times more likely to bind ACE2 than is SARS-CoV. Although the exact mechanisms remain unknown, evidence suggests that after the virus attaches itself, the host cell snips the spike protein at one of its dedicated 'cleavage sites', exposing fusion peptides — small chains of amino acids that help to pry open the host cell's membrane so that the virus's membrane can merge with it. SARS-COV-2 like several lethal viruses, but not SARS, seems to make use of the enzyme furin from the host to cleave the viral spike protein. This is worrying, because furin is abundant in the respiratory tract and found throughout the body. It gives SARS-CoV-2 a 100–1,000 times greater chance than SARS-CoV of getting deep into the lungs. This particular set-up has never been found in any other coronavirus in any species.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

A: Origins in Sustained Human Misadventure

The corona virus pandemic is a classic case of Malthusian catastrophe, where a population fails to regulate its own reproduction to meet with its own natural environmental conditions and induces a mass mortality by epidemic plague famine, or violent conflict.


Fig 1: Racoon dogs are widely farmed in China, Bats in a market in Indonesia and a Pangolin, the world's 'most-trafficked' animal.

Rather than controlling our population and impact on the biosphere, humanity has continued on an ever exponentiating population curve, ever more completely impacting on wilderness habitats, driving species towards extinction and placing wildlife under stresses inconceivable in a natural environment. Increasing urbanization has concentrated huge populations in close proximity and human fluidity in global travel and mixing movement of supply chains and work mean the entire human population is an overlapping system at critical mass, completely vulnerable to a chain reaction of infection.

In addition, the proclavity for eating wild animals particularly in Asia, has resulted in global trafficing that puts unrelated species in close proximity, where a crate of trapped bats can drop huge viral loads on other species, such as bats to civets in SARS, bats to camels in MERS, and possibly in SARS-CoV-2 bats to pangolins, (or racoon dogs which are widely farmed in China), resulting in viral species transfer, giving rise to new viral genomes with newly lethal combinations of genes which would have never arisen without human misadventure. Bats form a reservoir. They have high corona virus loads because they congregate closely in huge colonies but have a high metabolic rate as a flying mammal and are not seriously affected.


Fig 2: SARS and MERS are both lethal zoonotic corona viruses. SARS was contained. MERS continues to circulate.

Corona viruses are renowned for their zoonotic transfer and a corona virus pandemic has been at the forefront of international health concerns, but has gone unheeded, despite two clear warnings from previous zoonotic corona virus crises, that the pressure on wildlife could directly result in a human pandemic.

The first was from SARS in 2002 (29 countries 8096 cases mortality rate 9.6% -- 55% in those over 65) and then MERS in 2014 (26 countries 2606 cases mortality rate 34%). Both of these had horrific death rates from extreme forms of pneumonia and SARS, although contained proved highly infectious, killing many medical professionals who were called to treat victims, spreading from China as far as Canada. The MERS outbreak remains ongoing and no successful vaccine has so far been developed. Neither the combination of antivirals and interferons (ribavirin + interferon alfa-2a or interferon alfa-2b), nor corticosteroids improved outcomes.

The SARS outbreak can be genetically traced to a colony of cave-dwelling horseshoe bats in China's Yunnan province. The epidemic appears to have started in Guandong, China, in November 2002. Chinese government officials did not inform the World Health Organization of the outbreak until February 2003. The epidemic spread to multiple countries including a significant outbreak in Canada. In 2003, studies were conducted using samples of wild animals sold as food in the local market in Guangdong, China. SARS coronavirus could be isolated from masked palm civets, even if they did not show clinical signs. The conclusion was the SARS virus crossed the xenographic barrier from asian palm civet to humans, and more than 10,000 masked palm civets were killed in Guangdong Province. The virus was also later found in raccoon dogs, ferret badgers, and domestic cats. In 2005, two studies identified a number of SARS-like coronaviruses in Chinese bats. Fear of contracting the virus from consuming infected wild animals resulted in public bans and reduced business for meat markets in southern China and Hong Kong. The World Health Organization declared severe acute respiratory syndrome contained on 5 July 2003. In the following years, four SARS cases were reported in China. There were also three laboratory accidents that resulted in infection, in one of which, an ill lab worker spread the virus to several other people.

A study performed between 2010 and 2013, in which the incidence of MERS was evaluated in 310 dromedary camels, revealed high titers of neutralizing antibodies to MERS-CoV in the blood serum of these animals. A further study sequenced MERS-CoV from nasalswabs of dromedary camels in Saudi Arabia and found they had sequences identical to previously sequenced human isolates. Some individual camels were also found to have more than one genomic variant in their nasopharynx.

All seven human corona virus infections, including SARS, MERS and SARS-CoV-2, which originate in bats, and the four human corona viruses causing colds also have zoonotic origins, with HKU1 and OC43 (hosts cattle) originating in mice, and NL63 and 229E (hosts camelids) in bats (see 9 below).

In the case of SARS-CoV-2 causing Covid-19, we have a Malthusian grim reaper that unless, contained worldwide, which is at face value highly improbable, could become a permanent feature of ongoing human epidemic disease. It combines two features, high infectivity even before symptoms arise and the ability in some 10% of cases to cause severe pneumonia ravaging the lungs, effectively acting as a human predator, killing off the elderly and vulnerable, rather than a parasite coexisting with its victims. It thus has both the features of demographic lethality and the capacity to produce continual epidemics without killing itself off by destroying its host or prey. Hence measures to eradicate it, rather than just suppress it, make long term health and economic sense, even if it may seem difficult or impossible.

  1. What bats can teach us about developing immunity to Covid-19 Financial Times 8-9-2020
  2. Why bats are not to blame, say scientists BBC 13-10-2020
  3. Why deforestation and extinctions make pandemics more likely Nature 7-8-2020
  4. Scientists call for pandemic investigations to focus on wildlife trade Nature 10-7-2020 The World Health Organization is sending scientists to China this weekend to investigate the origins of the COVID-19 outbreak. Researchers say the focus should be on activities linked to China's wildlife trade — both legal and illegal — including hunting areas, storage facilities, farms and markets. "All parts of the wildlife supply chain need to be investigated". Early in the pandemic, pangolins were thought to be a possible intermediate host of the SARS-CoV-2 virus when researchers detected related coronaviruses in pangolins that had been seized in southern China between 2017 and 2019.
  5. No evidence of coronaviruses or other potentially zoonotic viruses in Sunda pangolins (Manis javanica) entering the wildlife trade via Malaysia. bioRxiv19-6-2020 Pangolins probably catch the viruses during the process of being traded. The study looked at more than 300 pangolins in Malaysia, which the authorities seized or locals rescued while en route to China between 2009 and 2019, and found no coronaviruses.
  6. Origin and cross-species transmission of bat coronaviruses in China bioRxiv 31-5-2020 Our analyses identify the host taxa and geographic regions that define hotspots of CoV evolutionary diversity in China that could help target bat-CoV discovery for proactive zoonotic disease surveillance. Finally, we present a phylogenetic analysis suggesting a likely origin for SARS-CoV-2 in Rhinolophus spp. bats.
  7. PREVENTING THE NEXT PANDEMIC Zoonotic diseases and how to break the chain of transmission UN 2020 The world is treating the health and economic symptoms of the coronavirus pandemic but not the environmental cause, according to the authors of a UN report. As a result, a steady stream of diseases can be expected to jump from animals to humans in coming years, they say. The number of such "zoonotic" epidemics is rising, from Ebola to Sars to West Nile virus and Rift Valley fever, with the root cause being the destruction of nature by humans and the growing demand for meat, the report says.
  8. Pandemics result from destruction of nature, say UN and WHO Guardian 17-6-2020 Pandemics such as coronavirus are the result of humanity's destruction of nature, according to leaders at the UN, WHO and WWF International, and the world has been ignoring this stark reality for decades. The illegal and unsustainable wildlife trade as well as the devastation of forests and other wild places were still the driving forces behind the increasing number of diseases leaping from wildlife to humans, the leaders told the Guardian. They are calling for a green and healthy recovery from the Covid-19 pandemic, in particular by reforming destructive farming and unsustainable diets.
  9. 'We did it to ourselves': scientist says intrusion into nature led to pandemic 25-4-2020 Leading US biologist Thomas Lovejoy "the Godfather of Biodiversity" says to stop future outbreaks we need more respect for natural world. "This pandemic is the consequence of our persistent and excessive intrusion in nature and the vast illegal wildlife trade, and in particular, the wildlife markets, the wet markets, of south Asia and bush meat markets of Africa… It's pretty obvious, it was just a matter of time before something like this was going to happen," said Lovejoy, a senior fellow at the United Nations Foundation and professor of environment science at George Mason University.
  10. Global shifts in mammalian population trends reveal key predictors of virus spillover risk Royal Society B 13-3-2020 species scales positively with global species abundance, suggesting that virus transmission risk has been highest from animal species that have increased in abundance and even expanded their range by adapting to human-dominated landscapes. Domesticated species, primates and bats were identified as having more zoonotic viruses than other species. Among threatened wildlife species, those with population reductions owing to exploitation and loss of habitat shared more viruses with humans.
  11. 'Tip of the iceberg': is our destruction of nature responsible for Covid-19? Guardian / ENSIA 17-3-2020 As habitat and biodiversity loss increase globally, the novel coronavirus outbreak may be just the beginning of mass pandemics. A number of researchers today think that it is humanity's destruction of biodiversity that creates the conditions for new viruses and diseases like COVID-19, the viral disease that emerged in China in December 2019, to arise -- with profound health and economic impacts in rich and poor countries alike. "We invade tropical forests and other wild landscapes, which harbor so many species of animals and plants -- and within those creatures, so many unknown viruses," David Quammen, author of Spillover: Animal Infections and the Next Pandemic, recently wrote in the New York Times. "We cut the trees; we kill the animals or cage them and send them to markets. We disrupt ecosystems, and we shake viruses loose from their natural hosts."
  12. Animal source of the coronavirus continues to elude scientists Nature 18-5-2020
  13. The biggest mystery: what it will take to trace the coronavirus source Nature 5-6-2020
  14. Why do bats have so many viruses? Wash. Post 16-7-2020 Bats have highly poised interferons and suppress inflammatory reactions. Different species can harbour some of the most dangerous viruses from ebola and marburg, through SARs and MERS. It may be that their ability to fly, which invovles a 37 fold jump in metabolic energy causing reactive oxygen species, has tamped down inflammation for this reason and this has helped bats to be better able to tol;erate viral loads without sickness.
  15. Bats as Viral Reservoirs Annu. Rev. Virol. 2016
  16. Why coronavirus in China could help save the pangolin and other endangered species CBS 26-2-2020 The novel coronavirus outbreak in China may end up saving one of the world's most trafficked animals after Beijing announced a total ban on the sale and consumption of the pangolin.
  17. Hope for pangolins as protection boosted in China BBC 9-6-2020 China has removed pangolins from its official list of traditional Chinese medicine treatments, according to reports. The move comes after China raised the animal's protected status to the highest level last week.
  18. WHO slammed as Wuhan wet markets reopen NZ Herald 14-4-2020
  19. China's wet markets are not what some people think they are CNN 15-4-2020
  20. Chinese authorities' latest wildlife trade outrage is mindbogglingly reckless Syd. Morn. Herald 14-4-2020 The sale of wild animals such as bats, civets, snakes, monkeys, ostriches and pangolins, and rhino horns was prohibited in China itself on February 24 as a"potential risk to public health" in the words of China's state media. But Beijing is allowing its wildlife traders to sell these and other wild creatures to the world. And not only allowing it but promoting it using tax incentives.
  21. Vietnam bans wildlife trade over pandemic risk BBC 24-7-2020
  22. Bats and Coronaviruses Viruses 9-1-2019 Bats are believed to be reservoirs of several emerging viruses including coronaviruses (CoVs) that cause serious disease in humans and agricultural animals. These include severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), porcine epidemic diarrhea (PED) and severe acute diarrhea syndrome (SADS).
  23. Zoonotic origins of human coronaviruses Int. J. Biol. Sci. 13-3-2020 All seven HCoVs have a zoonotic origin from bats, mice or domestic animals. Multiple lines of evidence support an evolutionary origin of all HCoVs from bats, where viruses are well adapted and non-pathogenic but show great genetic diversity.
  24. Scientists trace 2002 Sars virus to colony of cave-dwelling bats in China Guardian 10-12-2017 Nature 2013 source article. Scientists have pinpointed a population of virus-infected horseshoe bats, which they have linked to the mysterious outbreak of Sars disease 15 years ago. Hundreds died as the virus spread around the globe but its source was never traced.
  25. Serological Evidence of Bat SARS-Related Coronavirus Infection in Humans, China Virologica Sinica 8-1-2018 Our study provides the first serological evidence of likely human infection by bat SARSr-CoVs or, potentially, related viruses. The lack of prior exposure to SARS patients by the people surveyed, their lack of prior travel to areas heavily affected by SARS during the outbreak, and the rapid decline of detectable antibodies to SARS-CoV in recovered patients within 2–3 years after infection strongly suggests that positive serology obtained in this study is not due to prior infection with SARS-CoV.
  26. Isolation and Characterization of Viruses Related to the SARS Coronavirus from Animals in Southern China Science 10-10-2003
  27. Scientists prove SARS-civet cat link China Daily 23-11-2006 A joint research team found a genetic link between the SARS coronavirus appearing in civet cats and humans, bearing out claims that the disease had jumped across species.
  28. SARS-CoV Infection in a Restaurant from Palm Civet CDC 12-2005
  29. Middle East respiratory syndrome coronavirus quasispecies that include homologues of human isolates revealed through whole-genome analysis and virus cultured from dromedary camels in Saudi Arabia. mBio 29-4-2014
  30. Middle East respiratory syndrome coronavirus in dromedary camels: an outbreak investigation Lancet 1-2-2002
  31. The next pandemic is already coming, unless humans change how we interact with wildlife, scientists say Wash Post 3-4-2020 pwd=Some 70 percent of emerging infectious diseases in humans are of zoonotic origin and nearly 1.7 million undiscovered viruses may exist in wildlife. Many researchers are searching for the ones that could cause the next animal-to-human spillover. The likeliest hot spots have three things in common, lots of people, diverse plants and animals, and rapid environmental changes. They also are home to many of the likeliest zoonotic disease hosts: rodents and bats.
  32. Susceptibility of ferrets, cats, dogs, and different domestic animals to SARS-coronavirus-2 BioRxiv 31-3-2020 Science We found that SARS-CoV-2 replicates poorly in dogs, pigs, chickens, and ducks, but efficiently in ferrets and cats. We found that the virus transmits in cats via respiratory droplets.
  33. COVID-19 detected on four mink farms Wangenin Univ. 20-5-2020 Several mink have tested positive with COVID-19 at four mink farms in the Netherlands. The mink showed various symptoms including respiratory problems. Some employees had symptoms of the coronavirus at both companies. Pneumonia was seen in sections on mink and SARS-CoV-2 was detected in organs and throat swabs. Based on the variations in the genetic codes of the virus, it could be concluded that mink farms have transmitted the virus to each other. It is also plausible that one of the employees has been infected by mink. Virus RNA has been detected in dust particles in the stables, which indicates that people in the stables with infected minks can be exposed to coronavirus.
  34. A million mink culled in Netherlands and Spain amid Covid-19 fur farming havoc Guardian 17-7-2020 Seven workers tested positive for Covid-19. Officials have since carried out a string of PCR tests which showed that 87% of the mink were infected.
  35. Extreme genomic CpG deficiency in SARS-CoV-2 and evasion of host antiviral defense Mol. Bio. Evol. 14-4-2020 The zinc finger antiviral protein (ZAP) binds specifically to CpG dinucleotides and recruits other proteins to degrade a variety of viral RNA genomes. SARS-CoV-2 has the most extreme CpG deficiency in all known Betacoronavirus genomes. This suggests that SARS-CoV-2 may have evolved in a new host (or new host tissue) with high ZAP expression. A survey of CpG deficiency in viral genomes identified a virulent canine coronavirus (Alphacoronavirus) as possessing the most extreme CpG deficiency, comparable to that observed in SARS-CoV-2.
  36. Selection of viral variants during persistent infection of insectivorous bat cells with Middle east respiratory syndrome coronavirus Sci. Repts. 2020 doi:10.1038/s41598-020-64264-1 When exposed to the MERS virus, bat cells adapt -- not by producing inflammation-causing proteins that are hallmarks of getting sick, but rather by maintaining a natural antiviral response, a function which shuts down in other species, including humans. Simultaneously, the MERS virus also adapts to the bat host cells by very rapidly mutating one specific gene. Operating together, these adaptations result in the virus remaining long-term in the bat but being rendered harmless until something -- such as disease or other stressors -- upsets this delicate equilibrium. SARS-CoV-2 is thought to operate in the same way. The mechanism shows how human stresses to the bat immune system including abusive practices inculding crowding different species in wet-markets can be directly responsible for a zoonotic transfer and a resulting human corona virus pandemic.
  37. How China's 'Bat Woman' Hunted Down Viruses from SARS to the New Coronavirus Sci. Am. 27-4-2020 Wuhan-based virologist Shi Zhengli has identified dozens of deadly SARS-like viruses in bat caves, and she warns there are more out there.
  38. Origin and evolution of pathogenic coronaviruses Nature Rev. Microbiol. 3-2019
  39. Bat Coronaviruses in China Viruses 29-1-2019
  40. Discovery of a rich gene pool of bat SARS related coronaviruses provides new insights into the origin of SARS coronavirus Plos Pathogens 20-11-2017
  41. How China muzzled its Bat Woman: Beijing authorities hushed up the findings of Shi Zhengli who unlocked the genetic make-up of the coronavirus within days of the outbreak - which is vital for tests and vaccines. Daily Mail 12-4-2020 The virologist was called back as deputy director to her high security laboratory in Wuhan at the end of last year after a mysterious new respiratory condition in thecity was identified as a novel coronavirus – and within three days she completed its gene sequencing. Shi told the respected science journal Scientific American last month of her relief when, having checked back through disposal records, none of the genome sequences matched their virus samples.
  42. Comparison of SARS-CoV-2 spike protein binding to human, pet, farm animals, and putative intermediate hosts ACE2 and ACE2 receptors bioRxiv 8-5-2020
  43. Are pangolins the intermediate host of the 2019 novel coronavirus (SARS-CoV-2)? Plos Pathogens 14-5-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

B: First Awareness

These few papers give a scattering of awareness about the initial situation leading to the outbreak and ensuing pandemic, with further details in sections C and F.

  1. Cause of Wuhan's Mysterious Pneumonia Cases Still Unknown, Chinese Officials Say Scientific American 6-1-2020
  2. US intel agencies find Wuhan officials kept Beijing in the dark for weeks about coronavirus CNN 21-8-2020
  3. Cremation based estimates suggest significant under- and delayed reporting of COVID-19 epidemic data in Wuhan and China medRxiv 6-6-2020 Our study indicates a significant under-reporting in Chinese official data on the COVID-19 epidemic in Wuhan. The magnitude of discrepancy between our estimates based on cremation related data and Chinese official figures in early February, the critical time for response to the COVID-19 pandemic, suggests the need to reevaluate official statistics from China and consider all available and reasonable data sources for a better understanding of the COVID-19 pandemic.
  4. California coronavirus cluster: 40 deaths to be re-examined News AU 24-6-2020 Up to 40 cases of people who passed away in California from as early as December are now being re-examined to see if coronavirus played a role in their deaths. A Paris man complained of a dry cough and trouble breathing just after Christmas. He hadn't travelled but did work at a supermarket close to one of the city's major airports where travellers often shopped. A swab taken at the time was looked at again and his COVID-19 infection confirmed. Doctors said that would have meant he was infected anytime from mid-December onwards. Samples of sewage in the Italian cities of Milan and Turin – two places hit hard by the pandemic – have also shown the virus that causes COVID-19 was present in December.
  5. Sentinel surveillance of SARS-CoV-2 in wastewater anticipates the occurrence of COVID-19 cases medRxiv 13-6-2020 SARS-CoV-2 was detected in Barcelona sewage in March 2019 long before the declaration of the first COVID-19 case, indicating that the infection was present in the population before the first imported case was reported. 
  6. Analysis of hospital traffic and search engine data in Wuhan China indicates early disease activity in the Fall of 2019 Harvard Dash 6-2020 We observe an upward trend in hospital traffic and search volume beginning in late Summer and early Fall 2019. While queries of the respiratory symptom "cough" show seasonal fluctuations coinciding with yearly influenza seasons, "diarrhea" is a more COVID-19 specific symptom and only shows an association with the current epidemic. The increase of both signals precede the documented start of the COVID-19 pandemic in December. Questions raised BBC 13-6-2020
  7. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Lancet 24-1-2020
  8. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster Lancet 24-1-2020
  9. China delayed releasing coronavirus info, frustrating WHO CNN 1-6-2020
  10. Medical journal says Trump is 'factually incorrect' about when it first published coronavirus reports CNN 19-5-2020
  11. Birth of a pandemic: inside the first weeks of the coronavirus outbreak in Wuhan Guardian 10-4-2020
  12. Beijing tightens grip over coronavirus research, amid US-China row on virus origin CNN 13-4-2020
  13. The WHO v coronavirus: why it can't handle the pandemic Guardian 9-4-2020
  14. Why US outsourced bat virus research to Wuhan Asia Times 22-4-2020 US-funded $3.7 million project approved by Anthony Fauci in 2015 after US ban imposed on 'monster-germ' research.


Fig 2b Left: Top left : Nucleotide and amino acid divergences between Cov-2 and rat and pangolin covs). Lower: Amino acid comparisons on key parts of the spike protein. Top right: Key unique binding motifs of each. Right: Two troubling features of Sars-Cov-2. Top unusual inserts of basic amino acids inconsistent with corresponding bat corona viruses. Lower left: Sars-Cov-2 still has no clear zoonotic origin, while the evolutionary descent of both Sars-Cov epidemics is clear. Lower right: Sars-Cov-2 appears pre-adapted to humans while Sars-Cov showed clear evolutionary adaption.

C: Uravelling the Viral Transmission Event

The overriding feature of covid-19 is that rather than affecting the sinuses and upper airways as human corona viruses do, the zoonotic transfer has resulted in binding deep in the lungs, potentially destroying the alveoli esential for breathing and in the second week fulminating to the point of complete immunity crisis and organ or heart failure due to obstruction of the blood supply through the lungs.

Researchers have found the RBD portion of the SARS-CoV-2 spike proteins have evolved to effectively target a molecular feature on the outside of human cells called ACE2 - a receptor involved in regulating blood pressure. It turned out to mostly resemble related viruses found in bats and pangolins - scaly-skinned mammals that are prized delicacies in China.

That led scientists to suspect one of two possible scenarios. In one scenario, the virus evolved to its current state through natural selection in an animal host and then jumped to humans, as happened with Sars-CoV and Mers-CoV. They proposed bats were the most likely reservoir for SARS-CoV-2, as it was very similar to a bat coronavirus. Yet there were no documented cases of direct bat-human transmission, suggesting that an intermediate host was likely involved between humans.

In this scenario, both of the distinctive features of SARS-CoV-2's spike protein - the RBD portion that binds to cells and the cleavage site that opens the virus up - would have evolved to their current state before entering humans. In this case, the current epidemic would probably have emerged rapidly as soon as humans were infected, as the virus would have already evolved the features that made it pathogenic, or able to spread between people. In the other proposed scenario, a non-pathogenic version of the virus jumped from an animal host into humans and then evolved to its current state within the human population. A coronavirus from a pangolin could possibly have been transmitted to a human, either directly or through an intermediary host such as civets or ferrets. After that, the other distinct spike protein characteristic of SARS-CoV-2 - the cleavage site - could have evolved within a human host, or possibly among a group of people, before the outbreak kicked off.

While Sars-Cov-2 has 96% homology with the closest bat corona virus, the spike protein contains high homology with a pangolin corona virus spike protein.The broad scientific consensus remains that the virus emerged naturally due to zoonotic transfer from bats to humans via a second species, e.g. a pangolin or civet, and that there is no clear evidence of a lab origin, but two lines of genetic evidence below disagree with this. In May a paper (4) noted the highly evolved adaption to humans from the outset (see also 3). In June, a second paper (2) claiming furin-cleavage site inserts consistent with engineering are key components of the spike protein infectivity supported also by detailed structure of inserts, accompanied by media claims from an ex-head of UK MI6 (1) suggesting the virus was an (accidental) lab release. This claim needs careful comparison with the claim that the spike protein in a Malaysian pangolin is virtually identical to Sars-Cov-2, thus resulting from recombination of a bat corona virus in the pangolin see also the papers in fig 2b. A now somewhat notorious experiment in 2015 engineered a mouse-adapted Sars virus with bat spike proteins, co-authored by "Bat Woman" Shi Zhengli-Li Deputy Director of the Wuhan lab, as well as a US team, engineered a mouse-adapted Sars virus with bat spike proteins. Shi has sworn on her life that Cov-2 is not homologous to any of the viruses in her lab and the critical work seems to have all been done in the US.

A Smoking Gun? See also: The Corona Virus Lab Origin Papers

  1. How Covid-19 has perplexed scientists everywhere NZ Herald 25-3-2020
  2. Chinese lab conducted extensive research on deadly bat viruses, but there is no evidence of accidental release Wash Post 1-5-2020
  3. Mystery deepens over animal source of coronavirus Nature 1-4-2020 Initially researchers said they had found a coronavirus in smuggled pangolins that was a 99% genetic match to the virus circulating in people on the receptor-binding domain. However more recent whole genome samples in frozen cells from illegally trafficked pangolins shared between 85.5% and 92.4% of their DNA with the virus found in humans. Two other papers found the viruses were 90.23% and 91.02% similar, respectively, to the virus that causes COVID-19. But these figures are not high enough. The SARS virus shared 99.8% of its genome with a civet coronavirus, which is why civets were considered the source.
  4. 'Trump owes us an apology.' Chinese scientist at the center of COVID-19 origin theories speaks out Science 24-7-2020 Full Statement
  5. Norwegian virologist claims coronavirus is 'chimera' made in Chinese lab Taiwan News 10-6-2020
  6. Virus began as 'accident' in Chinese lab, ex MI6 boss says NZ Herald 7-6-2020
  7. Lab-Made? SARS-CoV-2 Genealogy Through the Lens of Gain-of-Function Research Medium 23-4-2020 This is a very detailed analysis of the lab claims and gain of function corona virus research where new spike proteins are added and furing cleavage sites have been inserted. These have invlolved both Chinese and US researchers in very dubious attempts to create enhanced infectivity vectors, ostensibly to research corona virus threats. It also includes a discussion of how such enhanced vectors could give rise to the serious organ failures seen in seriously ill covid-19 patients. PDF mirror
  8. A Candidate Vaccine for Covid-19 (SARS-CoV-2) Developed from Analysis of its General Method of Action for Infectivity QRB Discovery 28-5-2020 We show the non-receptor dependent phagocytic general method of action to be specifically related to cumulative charge from inserted sections placed on the SARS-CoV-2 Spike surface in positions to bind efficiently by salt bridge formations.
  9. In silico comparison of spike protein-ACE2 binding affinities across species; significance for the possible origin of the SARS-CoV-2 virus arXiv 13-5-2020 Overall, the data indicates that SARSCoV2 is uniquely adapted to infect humans, raising questions as to whether it arose in nature by a rare chance event or whether its origins lie elsewhere.
  10. Virus didn't come from animals in Wuhan market NZ Herald 17-5-2020
  11. SARS-CoV-2 is well adapted for humans. What does this mean for re-emergence? bioRxiv 2-5-2020 Our observations suggest that by the time SARS-CoV-2 was first detected in late 2019, it was already pre-adapted to human transmission to an extent similar to late epidemic SARS-CoV. However, no precursors or branches of evolution stemming from a less human-adapted SARS-CoV-2-like virus have been detected.
  12. Director of Wuhan Institute of Virology says 'let science speak' CGTN 23-5-2020 We have three strains of live viruses. One of them has the highest similarity, 96 percent to the SARS virus. But their highest similarity to SARS-CoV-2 only reaches 79.8 percent. The bat coronavirus which has a 96.2 percent genomic similarity to SARS-CoV-2 is called RaTG-13. But coronavirus have the largest genomes with 30000 bases. It would take about 50 years for RaTG-13 to naturally evolve to SARS-CoV-2, given 1100 base differences. Many people might misunderstand that since our institute reported the RaTG-13's genomic similarity to SARS-CoV-2, we must have the RaTG-13 virus in our lab. In fact, that's not the case. When we were sequencing the genes of this bat virus sample, we got the genome sequence of the RaTG-13 but we didn't isolate nor obtain the live virus of RaTG-13. Thus, there is no possibility of us leaking RaTG-13.
  13. Chinese scientist claims Covid-19 started in 'military lab' after fleeing to US Stuff/Fox 11-7-2020
  14. 'Heinous!': Coronavirus researcher shut down for Wuhan-lab link slams new funding restrictions Nature 21-8-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 4: Pollution reduction: A Scintillating day in LA 12 Apr, NO2 reduction in China, Himalayas visible for the first time in decades in Indian Jalandhar (Punjab) .

D: Environmental Cultural and Economic Consequences

The world shutdown has alleviated both CO2 and NO2 emssions and cleared pollution over much of Asia and Europe, but lessons need to be learned that the covid crisis is as much a product of human impact denial as is the failure to deal with biodiversity and climate crisis. Wild animals are taking advantage of the reduced human presence, entering cities and lying on roadways, while there has been a collapse in the price of oil and wild swings in the financial markets, with mass unemployment and huge financial subsidies during lockdowns affecting up to half the world's population. The fact that a viral mutation can threaten to decimate the world's population and the planet's 'economic engine' can grind to a standstill through lack of foresight for obvious risks already clear from SARS and MERS, and the way the world economy depends on ongoing activity to avoid collapse due to debt crisis, all indicates a complete lack of long-term resilience in business-as-usual attitudes of short-term venture capitalism, unmoderated by any effective long-term view of human sustainability. While we are clearly failing to address the more gradual crises of climate change, habitat destruction and loss of biological diversity, one has to hope that the fact this crisis has brought the world to a standstill will teach us that long-term survival depends on getting our own house in order and preserving our increasingly fragile biosphere before we bring about a more apocalyptic scenario with no exit strategy.

  1. Coronavirus could cause fall in global CO2 emissions
  2. Lockdowns trigger dramatic fall in global carbon emissions Guardian 19-5-2020
  3. How the coronavirus pandemic slashed carbon emissions — in five graphs Nature 20-5-2020
  4. India's carbon emissions fall for first time in four decades BBC 12-5-2020
  5. Coronavirus pandemic leading to huge drop in air pollution
  6. Climate vs coronavirus: Why massive stimulus plans could represent missed opportunities Nature 3-3-2020
  7. Ten EU countries urge bloc to pursue 'green' coronavirus recovery Reuters 10-4-2020
  8. Coronavirus forces postponement of COP26 meeting in Glasgow BBC 1-4-2020
  9. What Coronavirus Could Mean for the Global Economy Harvard Business Review 3-3-2020
  10. Coronavirus: who will be winners and losers in new world order? Guardian 10-4-2020
  11. Coronavirus: The world in lockdown in maps and charts BBC 13-4-2020
  12. With South Africa in lockdown, the lions are taking it very easy CNN 19-4-2020
  13. Emboldened wild animals venture into locked-down cities worldwide Guardian 18-4-2020
  14. US oil prices turn negative as demand dries up BBC 20-4-2020 CNN 20-4-2020
  15. Renewable power surges as pandemic scrambles global energy outlook Science 30-4-2020
  16. Coronavirus is causing a flurry of plastic waste. Campaigners fear it may be permanent CNN 5-5-2020
  17. Clean air in Europe during lockdown 'leads to 11,000 fewer deaths' Guardian 30-4-2020
  18. Coronavirus pandemic 'will cause famine of biblical proportions' Guardian 21-4-2020 Governments must act now to stop 265 million starving, warns World Food Programme boss
  19. Covid-19 has nothing on what's coming Newsroom 20-4-2020 The current nationwide pause in NZ as a result of Covid-19 is an extraordinary opportunity, and probably the only one we will get, to redesign our economy so that it no longer threatens life on this planet.
  20. Include the true value of nature when rebuilding economies after coronavirus Nature 12-5-2020
  21. Covid-19 has changed everything. Now we need a revolution for a born-again world Guardian 24-5-2020


Fig 4b: Left Previous epidemics have had only a temporary impact on the economy.
Right: Variations in social distancing policies and lockdowns in Europan countries.

For estimates of their governments' actions up to 3-Jun see fig16d.

Economies tend to rebound in a V-shaped recovery (fig 4b left) after a pandemic if the majority of the population survives, so temptations to act callously about human life throughfear of threats to the world economy remain insufficient to justify sacrificing older people to Malthusian catastrope to prop up the GDP. Only the Black Death where there was severe population decline, did the downturn last for decades.

Major Donors and Those Making a Fortune

  1. The billionaire trying to stop coronavirus (and fix China's reputation) BBC 26-4-2020
  2. Jack Dorsey Vows to Donate $1 Billion to Fight the Coronavirus NYT 7-4-2020
  3. What the 50 richest Americans have given for covid-19 relief Wash Post 4-6-2020
  4. Ruffer Investment, which was founded by multimillionaire financier Jonathan Ruffer, told clients it had made $2.6bn (£2.4bn)during the coronavirus pandemic-induced global stock market collapse after a series of cheap "protective investment" bets on market volatility delivered huge returns.
  5. A tail-risk hedge fund advised by Nassim Taleb, author of "The Black Swan," described by The Sunday Times as one of the twelve most influential books since World War II, returned 3,612% in March, paying off massively for clients who invested in it as protection against a plunge in stock prices. Spitznagel included a chart in his letter showing that a portfolio invested 96.7% in the S&P 500 and 3.3% in Universa's fund would have been unscathed in March, a month in which the U.S. equity benchmark fell 12.4%. The same portfolio would have produced a compounded return of 11.5% a year since March of 2008 versus 7.9% for the index.

  6. Fig 4c Left: The US stock market is atypical in rising before the pandemic's effect has abated, suggesting: (a) Hope for a V-shaped recovery desipte the confounding evidence from other measures, (b) lack of alternative avenuse to hold assets due to low bond yields and (c) unremitting FOMO greed overtakes fear.
    Right: Quarterly fall in the GDP collides with stock market expectations.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 5: Left: Figure from key IHME report Sep11 showing projected 450000 US deaths by December. Centre: Animation of US epidemic to 13th June.
'Unfathomable': US death toll from coronavirus hits 200,000 accounting alone for 22% of world deaths when it is only 4% of the world population.
Trump said it was "a shame" the U.S. reached that number. "I think if we didn't do it properly and do it right, you'd have 2.5 million deaths." Trump once joked that he could shoot someone in New York’s Fifth Avenue and not lose any support. For the first time in his life, he was guilty of understatement. In reality, he has directly contributed to the deaths of more than 200,000 people and paid barely any political price with base support still around 42% of the electorate.


E: Modeling Pandemic Strategies

SARS was a very lethal and highly infectious disease whose lethality motivated a strong response to contain it and the epidemic died out after several months. Sars-Cov-2 has even greater infectivity because asymptomatic or incipiently symptomatic people may be at the exponential peak of infectivity and so can transmit to many more people than Sars-Cov where a high proportion of those effected became stricken with severe pneumonia. This can lead to a doubling inthe number infected people every a 2-5 days. Therefore in the absence of an effective vaccination or a magic bullet, both physical distancing and very high rates of testing and isolation of positives are necessary to avoid an ongoing world threat to human health, which could otherwise decimate the population over 60.

Pandemics are measured by the reproduction coefficient R0 – how many people an aveage person infects and the serial interval I – how long the virus takes to become infectious. The current estimates of R0 = 5.7 and a serial interval of I = 6 days, gives a doubling time of 6*log(2)/log(5.7) = 2.39 days, very close to the trajectories in fig 9. However, there is another factor, the dispersion factor k , the proportion of people that are superspreaders, causing clusters if they are in a gathering of people. Sars-Cov-2 appears to have a k around 0.1, meaning 9/10 people will infect hardly anyone but 1/10 will be super infectious, particularly in an indoor space with enclosed air or circulating air conditioning, with some large clusters indicating airborne rather than droplet-borne spread (see article ).

The first few articles below show both that social distancing and lockdowns prevented a catastrophic epidemic and that levels of immunity remain well below herd immunity levels.


Fig 5b: Left: Posterior model estimates of percentage of total population infected as of 28th March 2020
Right: Effects on the modelled R0 from partial and complete lockdown (Germany).

  1. How the pandemic might play out in 2021 and beyond Nature 5-8-2020
  2. COVID-19 herd immunity in the Brazilian Amazon medRxiv 21-9-2020 From the proportion of donors who tested positive for antibodies, the authors estimate that about 66% of the population had been infected by early August — months after the epidemic in Manaus peaked in May.
  3. Would herd immunity stop the spread of coronavirus? Guardian 10-10-2020 Even if achievable, the strategy would kill too many people, say scientists. Scientists also point out that Manaus in Brazil suffered a devastating wave of Covid-19 cases that killed more than 3,000 people earlier this year. Then virus levels subsided and claims were made that the city had achieved herd immunity. However, cases have now started to surge again in Manaus, suggesting the city failed to achieve herd immunity despite its high death toll.
  4. The effect of temperature on persistence of SARS-CoV-2 on common surfaces Virol J. 7-10-2020 With initial viral loads broadly equivalent to the highest titres excreted by infectious patients, viable virus was isolated for up to 28 days at 20°C from common surfaces such as glass, stainless steel and both paper and polymer banknotes. Conversely, infectious virus survived less than 24 h at 40°C on some surfaces.
  5. Phylogenetic analysis of SARS-CoV-2 in the Boston area highlights the role of recurrent importation and superspreading events medRxiv 25-8-2020 We studied two superspreading events covered by the data, events that led to very different outcomes because of the timing and populations involved. One produced rapid spread in a vulnerable population but little onward transmission, while the other was a major contributor to sustained community transmission, including outbreaks in homeless populations, and was exported to several other domestic and international sites. One superspreading event at Biogen may be connected to about 20,000 Covid-19 cases in the Boston area, a researcher said on Tuesday.
  6. New research finds it could take a month for Covid-19 patients to clear the virus CNN 1-9-2020
  7. 70 of 92 coronavirus cases in Massachusetts linked to Biogen employees after biotech firm's Boston meeting CNN 11-3-2020
  8. Four months into the COVID-19 pandemic, Sweden's prized herd immunity is nowhere in sight Journal of the Royal Society of Medicine 2020
  9. Social and behavioral consequences of mask policies during the COVID-19 pandemic PNAS 22-7-2020 Serial crosssectional data (April 14 to May 26, 2020) from nearly 7,000 German participants demonstrate that implementing a mandatory policy increased actual compliance despite moderate acceptance; mask wearing correlated positively with other protective behaviors. A preregistered experiment (n = 925) further indicates that a voluntary policy would likely lead to insufficient compliance, would be perceived as less fair, and could intensify stigmatization. A mandatory policy appears to be an effective, fair, and socially responsible solution to curb transmissions of airborne viruses.
  10. Pediatric SARS-CoV-2: Clinical Presentation, Infectivity, and Immune Responses J Pediatr. 29-7-2020 This study reveals that children may be a potential source of contagion in the SARS-CoV-2 pandemic in spite of milder disease or lack of symptoms, and immune dysregulation is implicated in severe post-infectious MIS-C.
  11. Age-Related Differences in Nasopharyngeal Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Levels in Patients With Mild to Moderate Coronavirus Disease 2019 (COVID-19) JAMA Pediatr. 30-7-2020 Here, we report that replication of SARS-CoV-2 in older children leads to similar levels of viral nucleic acid as adults, but significantly greater amounts of viral nucleic acid are detected in children younger than 5 years.
  12. SARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp — Georgia, June 2020 CDC 31-7-2020 After a teenage staff member developed symptoms, subsequent testing showed 344 attendees, 260 were found to be positive. Contrary to earlier theories about the spread of the disease in children – younger children, as well as those who spent longer at the camp, appeared more likely to be infected. This suggests children – even asymptomatic cases – may play an important role in community transmission of Covid-19 affecting others.
  13. New IHME COVID-19 Forecasts See Nearly 300,000 Deaths by December 1, However, Consistent Mask-Wearing Could Save about 70,000 Lives 7-8-2020 The US forecast totals 295,011 deaths by December.
  14. Variation in government responses to COVID-19 Oxford Univ. 5-2020 Calculation and presentation of the Government Stringency Index 4.0
  15. It is Time to Address Airborne Transmission of COVID-19 Clin. Infect. Dis.6-6-2020 Somne 239 scientists in 32 countries outlined evidence that they say shows floating virus particles can infect people who breathe them in. Because those smaller exhaled particles can linger in the air, the scientists in the group had been urging WHO to update its guidance. Historically, there has been a fierce opposition in the medical profession to the notion of aerosol transmission, and the bar for proof has been set very high. A key concern has been a fear of panic.
  16. Reconstruction of the full transmission dynamics of COVID-19 in Wuhan Nature 16-7-2020 Accounting for presymptomatic infectiousness,time-varying ascertainment rates, transmission rates and population movements, we identify two key features of the outbreak: high covertness and high transmissibility.
    We estimate 87% (lower bound 53%) of the infections before March 8 were unascertained, potentially including asymptomatic and mild-symptomatic cases; and a basic reproduction number R0 of 3.54 in the early outbreak, much higher than for SARS and MERS. We observe that multi-pronged interventions had considerable positive efects on controlling the outbreak, decreasing the reproduction number to 0.28 and by projection reducing the total infections in Wuhan by 96.0% as of March 8. We furthermore explore the probability of resurgence following lifting of all interventions after 14 days of no ascertained infections, estimating it at 0.32 and 0.06 based on models with 87% and 53% unascertained infections, respectively, highlighting the risk posed by unascertained cases in changing intervention strategies.
  17. 'Superspreading' events, triggered by people who may not even know they are infected, propel coronavirus pandemic Wash. Post 19-7-2020
  18. Estimating the establishment of local transmission and the cryptic phase of the COVID-19 pandemic in the USA medRxiv 7-7-2020 Modeling results indicate international travel as the key driver of the introduction of SARS-CoV-2 in the West and East Coast metropolitan areas that could have been seeded as early as late-December, 2019. For most of the continental states the largest contribution of imported infections arrived through domestic travel flows.
  19. Prevalence of SARS-CoV-2 in Spain (ENE-COVID): a nationwide, population-based seroepidemiological study Lancet 6-7-2020 Only 3-10% of the Spanish population is seropositive to SARS-CoV-2 infection, even in hotspot areas. Most PCR-confirmed cases have detectable antibodies, but a substantial proportion of people with symptoms compatible with COVID-19 did not have a PCR test and at least a third of infections determined by serology were asymptomatic.
  20. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Geneva, Switzerland (SEROCoV-POP): a population-based study Lancet 11-6-2020 These results suggest that most of the population of Geneva remained uninfected during this wave of the pandemic, despite the high prevalence of COVID-19 in the region (5000 reported clinical cases over <2·5 months in the population of half a million people). Assuming that the presence of IgG antibodies is associated with immunity, these results highlight that the epidemic is far from coming to an end by means of fewer susceptible people in the population. Further, a significantly lower seroprevalence was observed for children aged 5–9 years and adults older than 65 years, compared with those aged 10–64 years.
  21. The effect of large-scale anti-contagion policies on the COVID-19 pandemic Nature 8-6-2020 We estimate that early infections of COVID-19 exhibit exponential growth rates of roughly 38% per day. We find that anti-contagion policies have significantly and substantially slowed this growth. We estimate that across six countries, interventions prevented or delayed on the order of 62 million confirmed cases, corresponding to averting roughly 530 million total infections.
  22. Estimating the number of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries Imperial College 30-3-2020 Nature 8-6-2020 We estimate that there have been many more infections than are currently reported. The high level of under-ascertainment of infections that we estimate here is likely due to the focus on testing in hospital settings rather than in the community. Despite this, only a small minority of individuals in each country have been infected, with an attack rate on average of 4.9% [1.9%-11%] with considerable variation between countries (Fig 5b). Our estimates imply that the populations in Europe are not close to herd immunity (~50-75% if R0 is 2-4). Further, with Rt values dropping substantially, the rate of acquisition of herd immunity will slow down rapidly. This implies that the virus will be able to spread rapidly should interventions be lifted.
  23. IHME models show second wave of COVID-19 beginning September 15 in US A total of 169,890 deaths are forecast by October 1, now revised upward to 201,129.
  24. COVID-19 case clusters offer lessons and warnings for reopening Sci. News 18-6-2020
  25. What settings have been linked to SARS-CoV-2 transmission clusters? Wellcome Open Res. 11-6-2020
  26. Preliminary analysis of SARS-CoV-2 importation & establishment of UK transmission lineages Virology 8-6-2020 A massive number of viral imports seeded the UK outbreak. The new coronavirus has jumped into the United Kingdom more than 1,300 times — mostly from France and Spain, despite early headlines focusing on infected travellers from China and other parts of Asia.
  27. Report 23: State-level tracking of COVID-19 in the United States Imperial College 21-5-2020 The estimates(fig 5) suggest that the epidemic is not under control in much of the US: As of 17 May 2020, the reproduction number is above the critical threshold (1.0) in 24 states. Higher reproduction numbers are geographically clustered in the South and Midwest, where epidemics are still developing, while we estimate lower reproduction numbers in states that have already suffered high COVID-19 mortality (such as the Northeast). These estimates suggest that caution must be taken in loosening current restrictions if effective additional measures are not put in place. We predict that increased mobility following relaxation of social distancing will lead to resurgence of transmission, keeping all else constant. We predict that deaths over the next two-month period could exceed current cumulativedeaths by greater than two-fold, if the relationship between mobility and transmission remains unchanged.
  28. UK lockdown a week earlier could have halved COVID-19 death toll, scientist says Reuters 10-6-2020 Britain has an official death toll from confirmed COVID-19 cases of over 40,000, rising to over 50,000 cases when deaths from suspected cases are included.
  29. The emergence of SARS-CoV-2 in Europe and the US bioRxiv 23-5-2020 Here, we elucidate when, where and how the earliest sustained SARS-CoV-2 transmission networks became established in Europe and the United States (US). Our results refute prior findings erroneously linking cases in January 2020 with outbreaks that occurred weeks later. Instead, rapid interventions successfully prevented onward transmission of those early cases in Germany and Washington State. Other, later introductions of the virus from China to both Italy and Washington State founded the earliest sustained European and UStransmission networks. Our analyses reveal an extended period of missed opportunity when intensive testing and contact tracing could have prevented SARS-CoV-2 from becoming established in the US and Europe.
  30. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period Science 14-4-2020 Prolonged or intermittent distancing may be necessary into 2022. Expanded critical care and an effective therapeutic would improve success. Longitudinal seriological studies are needed to determine the extent of immunity. A resugence is possible as late as 2024.
  31. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study Lancet 27-4-2020 The team found that 7% of close contacts younger than age 10 became infected — roughly the same as in the population overall. The researchers also found that just 9% of original cases were responsible for 80% of infections detected in close contacts. Such 'superspreading' events could lead to "large COVID-19 clusters".
  32. Expert report predicts up to two more years of pandemic misery CNN 30-4-2020 CIDRAP Report 30-4-2020 The new coronavirus is likely to keep spreading for at least another 18 months to two years—until 60% to 70% of the population has been infected, a team of longstanding pandemic experts predicted in a report released Thursday. They recommended that the US prepare for a worst-case scenario that includes a second big wave of coronavirus infections in the fall and winter.
  33. High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice — Skagit County, Washington, March 2020 Morb. Mortal Wkly. Rep. 69, 606–610 2020 A single ill person who attended a choir practice in Washington State led to the probable infection of more than 50 choir members, including 2 who died. Of the other 60 people in attendance, 32 became ill with confirmed COVID-19 and an additional 20 became ill with probable infections.
  34. Why do some COVID-19 patients infect many others, whereas most don't spread the virus at all? Science 19-5-2020
  35. Modeling the impact of social distancing, testing, contact tracing and household quarantine on second-wave scenarios of the COVID-19 epidemic medRxiv 6-5-2020
  36. Coronavirus has brought US 'to its knees', says CDC director Guardian 23-6-2020
  37. CDC chief says coronavirus cases may be 10 times higher than reported Wash. Post 25-6-2020 "Our best estimate right now is that for every case that was reported, there actually were 10 other infections," Redfield told reporters on Wednesday. This was because testing was restricted to people with symptoms and asymptomatic carriers were not tested, he said. "We probably recognized about 10% of the outbreak by the methods that we use to diagnosis between the March, April and May." He said that between 5% and 8% of the population had been exposed to the virus meaning 92-95% are still vulnerable and urged Americans to keep social distancing, wearing masks and washing hands. The estimate was based on the 2.4m known cases in the US, multiplied by the average rate of antibodies seen from the serology tests, about an average of 10 to one.
  38. New research explores how conservative media misinformation may have intensified the severity of the US pandemic Wash. Post 25-6-2020 The US response to the pandemic has faltered include four reasons (1) lack of a cohesive federal policy, (2) missteps on testing and tracing, both contributed to by Donald Trump's mismanagement, (3) a national culture emphasising individualism, and (4) active misinformation from conservative media outlets. Four studies paint a picture of a conservative media ecosystem that amplifies misinformation, entertains conspiracy theories and discourages audiences from taking concrete steps to protect themselves and others:
    (a) A peer-reviewed APPC/Univ.Illinois study has found that people who got most of their information from mainstream print and broadcast outlets tended to have an accurate assessment of the severity of the pandemic and their risks of infection. But those who relied on conservative sources, such as Fox News and Rush Limbaugh, were more likely to believe in conspiracy theories or unfounded rumors, and that the U.S. Centers for Disease Control and Prevention exaggerated the pandemic's threat "to damage the Trump presidency."
    (b) A paper posted by the National Bureau of Economic Research in May found that even when accounting for individual viewers differences, a 10% increase in Fox News viewership within a Zip code reduced its residents' propensity to stay home, in compliance with public health guidelines, by about 1.3 percentage points. Given total stay-at-home behavior increased by 20 percentage points during the study period, this is comparable to Fox's persuasive effect on voting behavior, as identified in another 2017 paper.
    (c) A third Univ. Chicago paper, similarly finds that Fox News viewers are less likely to comply with public health guidelines than consumers of other media. It finds that within Fox viewers, fans of some media personalities act distinctly from others and provides evidence that those behavioral differences are contributing to the spread of the coronavirus and mortality rate of covid-19.
    (d) A fourth paper from the Annenberg Public Policy Center attributes similar trends to social media including Twitter.
  39. WHO unsure antibodies protect against COVID, little sign of herd immunity Reuters 18-4-2020 "A lot of preliminary information coming to us right now would suggest quite a low percentage of population have seroconverted (to produce antibodies). The expectation that ... the majority in society may have developed antibodies, the general evidence is pointing against that, so it may not solve the problem of governments."
  40. What Immunity to COVID-19 Really Means Sci. Am. 10-4-2020 Immunity to seasonal coronaviruses (such as those that cause common colds), for example, starts declining a couple of weeks after infection. Antibody testing shows SARS-CoV immunity peaksat around four months and offers protection for roughly two to three years.
  41. A Coronavirus Death in Early February Was 'Probably the Tip of an Iceberg' NYT 22-4-2020 "This offers evidence of what many of us in the field had been saying," said Dr. Adalja, the infectious disease specialist. "That restricting testing was going to miss cases that could have a chain of transmission that ended up with somebody dying." NYT 23-4.
  42. BLACK LIVES MATTER PROTESTS, SOCIAL DISTANCING, AND COVID-19 Nat. Bur. Econ. Res. 23-6-2020 Event-study analyses provide strong evidence that net stay-at-home behavior increased following protest onset, consistent with the hypothesis that nonprotesters' behavior was substantially affected by urban protests. This effect was not fully explained by the imposition of city curfews. Estimated effects were generally larger for persistent protests and those accompanied by media reports of violence. Furthermore, we find no evidence that urban protests reignited COVID-19 case growth during the more than three weeks following protest onset. We conclude that predictions of broad negative public health consequences of Black Lives Matter protests were far too narrowly conceived.
  43. First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment Lancet 8-4-2020 " Findings: In all selected cities and provinces, the Rt decreased substantially since Jan 23, when control measures were implemented, and have since remained below 1. The cCFR (confirmed case fatality risk) outside Hubei was 0·98%, which was almost five times lower than that in Hubei (5·91%). Relaxing the interventions (resulting in Rt>1) when the epidemic size was still small would increase the cumulative case count exponentially as a function of relaxation duration, even if aggressive interventions could subsequently push disease prevalence back to the baseline level. Interpretation: The first wave of COVID-19 outside of Hubei has abated because of aggressive non-pharmaceutical interventions. However, given the substantial risk of viral reintroduction, particularly from overseas importation, close monitoring of Rt and cCFR is needed to inform strategies against a potential second wave to achieve an optimal balance between health and economic protection." Lockdowns can't end until Covid-19 vaccine found, study says Guardian 9-4-2020
  44. High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2 CDC 7-4-2020 Assuming a serial interval of 6–9 days, we calculated a median R0 value of 5.7 (95% CI 3.8–8.9). We further show that active surveillance, contact tracing, quarantine, and early strong social distancing efforts are needed to stop transmission of the virus.
  45. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand Neil Ferguson Imperial College 16-3-2020 Key paper determining the consequences of containment vs mitigation or doing nothing thatinfluenced the UK and US to change course toward containment.
  46. COVID-19: on average only 6% of actual SARS-CoV-2 infections detected worldwide Uni Gottingen 9-4-2020 Based largely on paper 3 in mortality rates.
  47. White House projects that shutting down the US to stop the coronavirus could save 2 million lives Business Insider 1-4-2020 As many as 2.2 million people in the US are predicted to die from COVID-19 if the disease is not mitigated, according to an analysis that the White House is using to guide its response, which was released Tuesday. But as many as 240,000 people are still predicted to die, even with shutdowns and stay-at-home orders.
  48. The Global Impact of COVID-19 and Strategies for Mitigation and Suppression Imperial College COVID-19 Response Team 26-3-2020 Follow up confirming 40 million people could have died without a global response. The analysis says that introducing social distancing, testing and isolating infected people would cut worldwide deaths to 1.9 million, if carried out when a each country's fatality rate is 0.2 per 100,000 people per week. Implementing these measures only when the death rate reaches 1.6 per 100,000 people per week leads to 10.5 million lives lost globally, it finds. According to Nature's analysis of death rates from Our World in Data -- counting each day at the centre of a rolling weekly window of deaths -- Italy hit this threshold on 2-3 March, the United Kingdom on 17 March, and the United States on 22 March.
  49. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study 25-3-2020 This paper suggests that if controls in Wuhan had been relaxed in early March, when case numbers dramatically dropped, the city would already be ramping up towards a fresh outbreak in June, placing constraints on any quick escape from containment.
  50. Using ILI surveillance to estimate state-specific case detection rates and forecast SARS-CoV-2 spread in the United States medRxiv 3-4-2020 Here, we show how publicly available CDC influenza-like illness (ILI) outpatient surveillance data can be repurposed to estimate the detection rate of symptomatic SARS-CoV-2 infections. We find a surge of non-influenza ILI above the seasonal average and show that this surge is correlated with COVID case counts across states. By quantifying the number of excess ILI patients in March relative to previous years and comparing excess ILI to confirmed COVID case counts, we estimate the symptomatic case detection rate of SARS-CoV-2 in the US to be 1/100 to 1/1000.
  51. Estimating the generation interval for COVID-19 based on symptom onset data MedRxiv 5-3-2020 The exponential growth of a pandemic depends on two parameters, the generation interval and the infectious reproduction rate R0. For example with covid-19 there is an average incubation time of around 4.7 days and an infection rate averaging around 2.5 to 1. Therefore the case numbers will be around 2-3 times as many in around 4-5 days, or perhaps a little faster as we have seen -- in an exponential runaway.
  52. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application An. Int. Med. 5-5-2020 This work provides additional evidence for a me- dian incubation period for COVID-19 of approximately 5 days, similar to SARS.
  53. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia NEMJ 26-3-2020 The mean incubation period was 5.2 days, with the 95th percentile of the distribution at 12.5 days.
  54. Impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study Lancet 17-4-2020 We estimated the daily effective reproduction number (Rt) for COVID-19 and influenza A H1N1 to estimate changes in transmissibility over time.
  55. Differential Effects of Intervention Timing on COVID-19 Spread in the United States medRxiv 20-5-2020 One week earlier would have cut 65307 recorded deaths to 3 May, to 29410 and two weeks earlier to 11253.
  56. Effect of non-pharmaceutical interventions to contain COVID-19 in China Nature 4-5-2020
  57. Changes in contact patterns shape the dynamics of the COVID-19 outbreak in China 29-4-2020 Daily contacts were reduced 7-8-fold during the COVID-19 social distancing period, with most interactions restricted to the household. We find that social distancing alone, as implemented in China during the outbreak, is sufficient to control COVID-19. While proactive school closures cannot interrupt transmission on their own, they can reduce peak incidence by 40-60% and delay the epidemic.
  58. Suppression of COVID-19 outbreak in the municipality of Vo', Italy medRxiv 18-4-2020 We collected information for 85.9% and 71.5% of the population of Vo at two consecutive time points. On the first survey, which was conducted around the time the town lockdown started, we found a prevalence of infection of 2.6%. On the second survey, which was conducted at the end of the lockdown, we found a prevalence of 1.2%. Notably, 43.2% of the confirmed SARS-CoV-2 infections detected across the two surveys were asymptomatic. The mean serial interval was 6.9 days. We found no statistically significant difference in the viral load of symptomatic versus asymptomatic infections. Contact tracing of the newly infected cases and transmission chain reconstruction revealed that most new infections in the second survey were infected in the community before the lockdown or from asymptomatic infections living in the same household.
  59. Fundamental principles of epidemic spread highlight the immediate need for large-scale serological surveys to assess the stage of the SARS-COV-2 epidemic. MedRxiv 26-3-2020 We calibrate a susceptible-infected-recovered (SIR) model to data on cumulative reported SARS-CoV-2 associated deaths from the United Kingdom (UK) and Italy under the assumption that such deaths are well reported events that occur only in a vulnerable fraction of the population.
  60. The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission PNAS 4-5-2020 Highly sensitive laser light scattering observations have revealed that loud speech can emit thousands of oral fluid droplets per second. In a closed, stagnant air environment, they disappear from the window of view with time constants in the range of 8 to 14 min, which corresponds to droplet nuclei of ca. 4 μm diameter, or 12- to 21-μm droplets prior to dehydration. These observations confirm that there is a substantial probability that normal speaking causes airborne virus transmission in confined environments
  61. Airborne transmission of COVID-19: epidemiologic evidence from two outbreak investigations Res. Gate 4-2020 Airborne transmission of COVID-19: epidemiologic evidence from two outbreak investigations. In the first outbreak, 126 passengers took two buses (59 from Bus 1 and 67 from 2) on a 100-minute round trip to attend a 150-minute worship event. The source patient was a passenger on Bus 2. We compared risks of COVID-19 among individuals taking Bus 1 and Bus 2, and among all other individuals (n=172) attending the worship event. Passengers in Bus 2 had a 41.5 times higher risk of getting COVID-19 compared to those in Bus 1, and 11.4 times higher risk compared to all other individuals attending the worship event. Within Bus 2, passengers in high-risk zones had moderately, but non-significantly, higher risk for COVID-19 compared to those in the low-risk zones. The second outbreak occurred among 30 trainees attending a 3-day workshop in several conference rooms. The overall attack rate was 48.3%. In both buses and conference rooms, central air-conditioners were in indoor re- circulation mode. Conclusion: Airborne spread of COVID-19 appears to at least partially explain the high attack rates in the exposed bus and conference rooms.
  62. Airborne transmission of SARS-CoV-2: The world should face the reality Envt. Int. 6-2020 Science explains the mechanisms of such transport and there is evidence that this is a significant route of infection in indoor environments. Despite this, no countries or authorities consider airborne spread of COVID-19 in their regulations to prevent infections transmission indoors.
  63. SARS-CoV-2 in environmental samples of quarantined households medRxiv 2-6-2020 26 of all 43 tested adults (60.47 %) tested positive by RT-PCR. All analysed air samples tested negative for SARS-CoV-2. Only 3.36 % of all object samples tested positive: one remote control, two metallic door knobs and one wooden stove overlay. 15.15 % of all wastewater samples (washbasin, showers and toilets) tested positive.This study supports the hypothesis that indirect environmental transmission may only play a minor role, which needs clarifications in further studies.
  64. Coronavirus was already in Italy by December, waste water study finds BBC 19-6-2020 Italian scientists say sewage water from two cities contained coronavirus traces in December, long before the country's first confirmed cases. The National Institute of Health (ISS) said water from Milan and Turin showed genetic virus traces on 18 December. It adds to evidence from other countries that the virus may have been circulating much earlier than thought.
    Chinese officials confirmed the first cases at the end of December. Italy's first case was in mid-February.
  65. Virological assessment of hospitalized patients with COVID-2019 Nature 4-2020 Here we report a detailed virological analysis of nine cases of COVID-19 that provides proof of active virus replication in tissues of the upper respiratory tract. Pharyngeal virus shedding was very high during the first week of symptoms, with a peak at 7.11 × 10^8 RNA copies per throat swab on day 4.
  66. Report into a nosocomial outbreak of coronavirus disease 2019 (COVID-19) at Netcare St. Augustine's Hospital Univ. Kwazulu-Natal 15-5-2020 On 9 March, a patient who had recently traveled to Europe and had symptoms of COVID-19 visited the emergency department of St. Augustine's, a private hospital in Durban, South Africa. Eight weeks later, 39 patients and 80 staff linked to the hospital had been infected, and 15 patients had died—fully half the death toll in KwaZulu-Natal province at that time. Scientists at the University of KwaZulu-Natal have published a detailed reconstruction of how the virus spread from ward to ward and between patients, doctors, and nurses, based on floor maps of the hospital, analyses of staff and patient movements, and viral genomes.
  67. Full genome viral sequences inform patterns of SARS-CoV-2 spread into and within Israel medRxiv 22-5-2020 An "extremely high level" of viral superspread helped to seed the new coronavirus across Israel, according to the authors of a genomic analysis. Researchers sequenced and analysed more than 200 SARS-CoV-2 genomes from people across Israel. The results show that only 1–10% of infected people caused 80% of the next wave of cases, illustrating the power of superspreaders in viral transmission.
  68. An investigation of transmission control measures during the first 50 days of the COVID-19 epidemic in China Science 31-3-2020
  69. The effect of human mobility and control measures on the COVID-19 epidemic in China Science 25-3-2020
  70. How an Austrian ski resort helped coronavirus spread across Europe CNN 24-3-2020
  71. What the cruise-ship outbreaks reveal about COVID-19 Nature 26-3-2020
  72. EU Chief: Social Isolation for Elderly May Last Until Year's End  AFP 12-4-2020
  73. Covid-19: UK starts social distancing after new model points to 260000 potential deaths BMJ
  74. Covid-19: experts question analysis suggesting half UK population has been infected BMJ 25-3-2020
  75. Covid-19: identifying and isolating asymptomatic people helped eliminate virus in Italian village BMJ
  76. What China's coronavirus response can teach the rest of the world Nature 26-3-2020
  77. 'We need to be alert': Scientists fear second coronavirus wave as China's lockdowns ease Nature 30-3-2020
  78. The United States leads in coronavirus cases, but not pandemic response Science 1-4-2020
  79. Whose coronavirus strategy worked best? Scientists hunt most effective policies Nature 27-4-2020

    Navigation

    A: Origins in Sustained Human Misadventure
    B: First Awareness
    C: Uravelling the Viral Transmission Event
    D: Environmental and Economic Consequences
    E: Modeling Pandemic Strategies
    F: Genetic and Evolutionary Analysis
    G: World Incidence Statistics

    H: Coronavirus Tests and Tracing
    I: Mechanisms of Infection
    J: Viral Loads & Asymptomatic Spread
    K: Antibody Responses and Reinfection
    L: Clinical Features
    M: Blood Clotting and Nervous System
    N: Lung Damage
    W:The Bradykinin Hypothesis

    O: Antiviral Drugs
    P: Antibody Treatments
    Q: Vaccines and Gene Therapies
    R: Mortality Rates
    S: Comparison with other Pandemics
    T: The New Zealand Situation
    U: World Comparisons
    V: Covid Politics


Fig 6: Next Strain evolutionary tree of CoV-2 infection, eLife genetic profile and full-length genome Corona virus tree. For the evolutionary tree of the spike protein see fig 10b.

F: Genetic and Evolutionary Analysis

Corona viruses are the most sophisticated RNA viruses with the largest genomes. Sars-CoV-2 has 29000 bases, Influenza 15700, HIV 13500, Hepatitis C 9,600, and Ebola 18500. This means greater sophistication and greater capacity to mutate, although corona viruses including Sars-CoV have an error correcting enzyme, reducing mutation rates enough to allow such a large genome. The articles below include multiple lines of evidence that the pandemic of Covid-19 has resulted in diverse evolutionary strains with different levels of infectivity and aggression towards human and animal hosts by a factor of 270. Evolving differences in the strains may thus explain some of the huge differences in mortality rates between some European countries and the Eastern US by comparison with lower rates in other places such as California and Australia.

While there has been debate about the precise origin of Sars-CoV-2, the paper below on Malaysian pangolins now leads stronger support than previously to an origin due to recombination between a Pangolin-CoV-like virus and a Bat-CoV-RaTG13-like virus.

Corncern has been raised about the emergence of a new mutation D614G, conferring increased human infectivity.

  1. Next StrainEvolutionary Trees of the Viral Genome
  2. SARS-CoV-2 (COVID-19) by the numbers eLife Genetic and epidemic data.
  3. Molecular Architecture of Early Dissemination and Massive Second Wave of the SARS-CoV-2 Virus in a Major Metropolitan Area medRxiv 23-9-2020 Scientists in the US have released a study of more than 5,000 genetic sequences of the coronavirus, which reveals the virus's continual accumulation of mutations, one of which may have made it more contagious. That mutation is associated with a higher viral load among patients upon initial diagnosis, the researchers in Houston found.
  4. The coronavirus is mutating — does it matter? Nature 8-9-2020
  5. More infectious G-strain takes over Wash. Post 29-6-2020
  6. Tracking changes in SARS-CoV-2 Spike: evidence that D614G increases infectivity of the COVID-19 virus Cell 26-6 G-strain more infectious, suggestive of higher upper respiratory tract viral loads, but not more lethal.
  7. Spike mutation pipeline reveals the emergence of a more transmissible form of SARS-CoV-2 30-4-2020 The mutation Spike D614G is of urgent concern; it began spreading in Europe in early February, and when introduced to new regions it rapidly becomes the dominant form. Also, we present evidence of recombination between locally circulating strains, indicative of multiple strain infections. These finding have important implications for SARS-CoV-2 transmission, pathogenesis and immune interventions.
  8. Spike mutation D614G alters SARS-CoV-2 fitness and neutralization susceptibility 2-9-2020
  9. The pandemic virus is slowly mutating. But is it getting more dangerous? Science 14-7-2020
  10. Effects of a major deletion in the SARS-CoV-2 genome on the severity of infection and the inflammatory response: an observational cohort study Lancet 18-8-2020 Researchers in Singapore identified a cluster of COVID-19 cases caused by a SARS-CoV-2 variant missing a chunk of DNA that spanned two genes, ORF7b and ORF8. None of the 29 people whose viruses had the mutation needed supplemental oxygen, but 26 of the 92 people whose viruses lacked the mutation did. SARS acquired a similar deletion in the ORF8 gene, suggesting that this might be an important adaption to infecting humans.
  11. Implications of SARS-CoV-2 Mutations for Genomic RNA Structure and Host microRNA Targeting Int. J. Mol. Sci. 2-7-2020 We have analysed subsets of genomes from SARS-CoV-2 isolates from around the globe and show that several mutations introduce changes in Watson–Crick pairing, with resultant changes in predicted secondary structure. Filtering to targets matching miRNAs expressed in SARS-CoV-2-permissive host cells, we identified ten separate target sequences in the SARS-CoV-2 genome; three of these targets have been lost through conserved mutations. A genomic site targeted by the highly abundant miR-197-5p, overexpressed in patients with cardiovascular disease, is lost by a conserved mutation. Our results are compatible with a model that SARS-CoV-2 replication within the human host is constrained by host miRNA defences.
  12. The D614G mutation in the SARS-CoV-2 spike protein reduces S1 shedding and increases infectivity Scripps 13-6-2020 SARS coronavirus 2 (SARS-CoV-2) isolates encoding a D614G mutation in the viral spike (S) protein predominate over time in locales where it is found, implying that this change enhances viral transmission. We therefore compared the functional properties of the S proteins with aspartic acid (SD614) and glycine (SG614) at residue 614. We observed that retroviruses pseudotyped with SG614 infected ACE2- expressing cells markedly more efficiently than those with SD614.This greater infectivity was correlated with less S1 shedding and greater incorporation of the S protein into the pseudovirion.
  13. Isolation of SARS-CoV-2-related coronavirus from Malayan pangolins Nature 7-5-2020 In this study, one coronavirus isolated from a Malayan pangolin showed 100%, 98.6%, 97.8% and 90.7% amino acid identity with SARS-CoV-2 in the E, M, N and S genes, respectively. In particular, the receptor-binding domain within the S protein of the Pangolin-CoV is virtually identical to that of SARS-CoV-2, with one noncritical amino acid diference. Results of comparative genomic analysis suggest that SARS-CoV-2 might have originated from the recombination of a Pangolin-CoV-like virus with a Bat-CoV-RaTG13-like virus. The Pangolin-CoV was detected in 17 of 25 Malayan pangolins analyzed.
  14. Emergence of SARS-CoV-2 through recombination and strong purifying selection Sci. Adv. 29-5-2020 We show evidence of strong purifying selection around the receptor binding motif (RBM) in the spike and other genes among bat, pangolin, and human coronaviruses, suggesting similar evolutionary constraints in different host species. We also demonstrate that SARS-CoV-2's entire RBM was introduced through recombination with coronaviruses from pangolins, possibly a critical step in the evolution of SARS- CoV-2's ability to infect humans.
  15. NIH's axing of bat coronavirus grant a 'horrible precedent' and might break rules, critics say Science 30-4-2020 The research community is reacting with alarm and anger to the National Institutes of Health's (NIH's) abrupt and unusual termination of a grant supporting research in China on how coronaviruses—such as the one causing the current pandemic—move from bats to humans. "This is a horrible precedent. This is cutting off your face to spite your nose. This is the worst kind of thing that political interference can cause in a democracy."
  16. Evolutionary origins of the SARS-CoV-2 sarbecovirus lineage responsible for the COVID-19 pandemic bioRxiv 31-3-2020 RaTG13 is the closest available bat virus to SARS-CoV-2; a sub-lineage of these bat viruses is able to infect humans. Two sister lineages of the RaTG13/SARS-CoV-2 lineage infect Malayan pangolins. The sarbecoviruses show a pattern of deep recombination events, indicating that there are high levels of co-infection in horseshoe bats and that the viral pool can generate novel allele combinations and substantial genetic diversity; the sarbecoviruses are efficient 'explorers' of phenotype space. The SARS-CoV-2 lineage is not a recent recombinant, at least not involving any of the bat or pangolin viruses sampled to date. Non-recombinant regions of the sarbecoviruses can be identified, allowing for phylogenetic inference and dating to be performed. We constructed three such regions using different methods. We estimate that RaTG13 and SARS-CoV-2 diverged 40 to 70 years ago (1948 to 1982). There is a diverse unsampled reservoir of generalist viruses established in horseshoe bats. While an intermediate host responsible for the zoonotic event cannot be ruled out, the relevant evolution for spillover to humans very likely occurred in horseshoe bats.
  17. The Molecular Biology of Coronaviruses Adv. Vir. Res. 1-3-2008 Coronaviruses are single-stranded, positive-sense RNA viruses and have the largest genomes known (around 30 kilobases) among RNA viruses.
  18. Engineering the largest RNA virus genome as an infectious bacterial artificial chromosome PNAS 9-5-2000 In the present study, we report the recovery of infectious transmissible gastroenteritis coronavirus TGEV from cloned cDNA and show that this procedure can be used to generate a genetically modified TGEV.
  19. Structural and molecular basis of mismatch correction and ribavirin excision from coronavirus RNA PNAS 9-1-2018 Coronaviruses (CoVs) stand out among RNA viruses because of their unusually large genomes (∼30 kb) associated with low mutation rates. CoVs code for nsp14, a bifunctional enzyme carrying RNA cap guanine N7-methyltransferase (MTase) and 3′-5′ exoribonuclease (ExoN) activities. ExoN excises nucleotide mismatches at the RNA 3′-end in vitro, and its inactivation in vivo jeopardizes viral genetic stability. Here, we demonstrate for severe acute respiratory syndrome (SARS)-CoV an RNA synthesis and proofreading pathway through association of nsp14 with the low-fidelity nsp12 viral RNA polymerase. Through this pathway, the antiviral compound ribavirin 5′-monophosphate is significantly incorporated but also readily excised from RNA, which may explain its limited efficacy in vivo.
  20. Emerging SARS-CoV-2 mutation hot spots include a novel RNA-dependent-RNA polymerase variant Sci. Trans. Med. 22-4-2020 Sci. Trans. Med. These findings suggest that the virus is evolving and European, North American and Asian strains might coexist, each of them characterized by a different mutation pattern. The contribution of the mutated RdRp to this phenomenon needs to be investigated.
  21. The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2
  22. Severe acute respiratory syndrome coronavirus 2 isolate Wuhan-Hu-1, complete genome NCBI / Nature
  23. Emergence of genomic diversity and recurrent mutations in SARS-CoV-2 Infection, Genetics and Evolution 24-4-2020 We identify regions of the SARS-CoV-2 genome that have remained largely invariant to date, and others that have already accumulated diversity. By focusing on mutations which have emerged independently multiple times (homoplasies), we identify 198 filtered recurrent mutations in the SARS-CoV-2 genome. Nearly 80% of the recurrent mutations produced non-synonymous changes at the protein level, suggesting possible ongoing adaptation of SARS-CoV-2. Three sites in Orf1ab in the regions encoding Nsp6, Nsp11, Nsp13, and one in the Spike protein are characterised by a particularly large number of recurrent mutations (>15 events) which may signpost convergent evolution and are of particular interest in the context of adaptation of SARS-CoV-2 to the human host.
  24. Phylogenetic network analysis of SARS-CoV-2 genomes PNAS 8-4-2020 In a phylogenetic network analysis of 160 complete human severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) genomes, we find three central variants distinguished by amino acid changes, which we have named A, B, and C, with A being the ancestral type according to the bat outgroup coronavirus. The A and C types are found in significant proportions outside East Asia, that is, in Europeans and Americans. In contrast, the B type is the most common type in East Asia, and its ancestral genome appears not to havespread outside East Asia without first mutating into derived B types, pointing to founder effects or immunological or environmental resistance against this type outside Asia.
  25. Patient-derived mutations impact pathogenicity of SARS-CoV-2 medRxiv 19-4-2020 The ability of the new coronavirus to mutate has been vastly underestimated and different strains may account for different impacts of the disease in various parts of the world. Within a small pool of patients we found many mutations not previously reported. These mutations included changes including tri-nucleotide mutations so rare that scientists had not considered they might occur. The coronavirus changes at an average speed of about one mutation per month. By Monday, more than 10,000 strains had been sequenced by scientists around the globe, containing more than 4,300 mutations.They also confirmed for the first time with laboratory evidence that certain mutations could create strains deadlier than others, demonstraitng that Sars-CoV-2 has acquired mutations capable of substantially changing its pathogenicity. The deadliest mutations in the Zhejiang patients had also been found in most patients across Europe, while the milder strains were the predominant varieties found in parts of the United States, such as Washington state, according to their paper. The disparity between New York, with 55 deaths per 100,000 people, and California, with 2, for instance, has been widely attributed to the imposition of earlier stay-at-home orders in California, which already had a work-at-home culture prepared to embrace the restrictions. A separate study had found that New York strains had been imported from Europe. The death rate in New York was similar to that in many European countries. Some of these mutations could lead to functional changes in the virus' spike protein. Computer simulation predicted that these mutations would increase its infectivity. To verify the theory, Li and colleagues infected cells with strains carrying different mutations. The most aggressive strains could generate 270 times as much viral load as the weakest type. These strains also killed the cells the fastest.
  26. Introductions and early spread of SARS-CoV-2 in the New York City area medRxiv 8-4-2020 Phylogenetic analysis of 84 distinct SARS-CoV2 genomes indicates multiple, independent but isolated introductions mainly from Europe and other parts of the United States. Moreover, we find evidence for community transmission of SARS-CoV2 as suggested by clusters of related viruses found in patients living in different neighborhoods of the city.
  27. Genotype and phenotype of COVID-19: Their roles in pathogenesis J. Microbiol 22-3-2020 A typical CoV contains at least six ORFs in its genome. All the structural and accessory proteins are translated from the sgRNAs of CoVs. Four main structural proteins are encoded by ORFs 10, 11 on the one-third of the genome near the 30-terminus. The genetic and phenotypic structure of COVID-19 in pathogenesis is important. This article highlights the most important of these features compared to other Betacoronaviruses.
  28. The genetic sequence, origin, and diagnosis of SARS-CoV-2 Eur. J. of Clin. Microbiol & Infect. Dis. 7-4-2020
  29. The proximal origin of SARS-CoV-2 Nature Medicine 13-3-2020 Our analyses clearly show that SARS-CoV-2 is not a laboratory construct or a purposefully manipulated virus. It was clear almost overnight that the virus wasn't human-made. Anyone hoping to create a virus would need to work with already known viruses and engineer them to have desired properties. But the SARS-CoV-2 virus has components that differ from those of previously known viruses, so they had to come from an unknown virus or viruses in nature. The researchers review what can be deduced about the origin of SARS-CoV-2 from comparative analysis of genomic data.They offer a perspective on the notable features of the SARS-CoV-2 genome and discuss scenarios by which they could have arisen. The scientists found that the RBD portion of the SARS-CoV-2 spike proteins had evolved to effectively target a molecular feature on the outside of human cells called ACE2, a receptor involved in regulating blood pressure. The SARS-CoV-2 spike protein was so effective at binding the human cells, in fact, that the scientists concluded it was the result of natural selection and not the product of genetic engineering. This evidence for natural evolution was supported by data on SARS-CoV-2's backbone -- its overall molecular structure. If someone were seeking to engineer a new coronavirus as a pathogen, they would have constructed it from the backbone of a virus known to cause illness. But the scientists found that the SARS-CoV-2 backbone differed substantially from those of already known coronaviruses and mostly resembled related viruses found in bats and pangolins.
  30. No credible evidence supporting claims of the laboratory engineering of SARS-CoV-2 Emerging Microbes & Infections 2-3-2020
  31. Supporting pandemic response using genomics and bioinformatics: a case study on the emergent SARS‐CoV‐2 outbreak Transbdry. & Emerg. Dis. 19-4-2020 We discuss the currently chosen SARS‐CoV‐2 strains for international coronavirus disease (COVID‐19) models in the context of their phylogeny as well as in a novel alignment‐free bioinformatics approach. Unlike phylogenetic trees, which focus on individual shared mutations, this new approach assesses genome‐wide co‐developing functionalities and hence offers a more fluid view of the "cloud of variances" that RNA viruses are prone to accumulate. Genomic Signature analysis of SARS-CoV-2 visualisation platform.
  32. On the origin and continuing evolution of SARS-CoV-2 National Science Review OUP 29-2-2020 Population genetic analyses of 103 SARS-CoV-2 genomes indicated that these viruses evolved into two major types (designated L and S), that are well defined by two different SNPs that show nearly complete linkage across the viral strains sequenced to date. Although the L type (∼70%) is moreprevalent than the S type (∼30%), the S type was found to be the ancestral version. Whereas the L type was more prevalent in the early stages of the outbreak in Wuhan, the frequency of the L type decreased after early January 2020. Human intervention may have placed more severe selective pressure on the L type, which might be more aggressive and spread more quickly. On the other hand, the S type, which is evolutionarily older and less aggressive, might have increased in relative frequency due to relatively weaker selective pressure.
  33. Isolation and characterization of a bat SARS-like coronavirus that uses the ACE2 receptor Nature 2013 Here we report whole-genome sequences of two novel bat coronaviruses from Chinese horseshoe bats in Yunnan, China: RsSHC014 and Rs3367. These viruses are farmore closely related to SARS-CoV than any previously identified bat coronaviruses, particularly in the receptor binding domain of the spike protein.
  34. Engineered bat virus stirs debate over risky research Nature Discusses the claim SARS-CoV-2 was engineered.
  35. A SARS-like cluster of circulating bat coronaviruses shows potential for human emergence Nature Medicine 2015 In 2015, the University of North Carolina at Chapel Hill and Wuhan Institute of Virology conducted research showing the virus could be made to infect the human HeLa cell line, through the use of reverse genetics to create a chimeric virus consisting of a surface protein of SHC014 and the backbone of a SARS virus. However, it has been shown to differ in over 5,000 nucleotides from SARS-CoV-2, the cause of a human pandemic in 2019-2020.
  36. A comparison of bats and rodents as reservoirs of zoonotic viruses: are bats special? Proc. Roy. Soc. B 10-1-2013 Bats are the natural reservoirs of a number of high-impact viral zoonoses. We found that bats host more zoonotic viruses per species than rodents, and we identified life-history and ecological factors that promote zoonotic viral richness.
  37. Accelerated viral dynamics in bat cell lines, with implications for zoonotic emergence eLife 3-2-2020 Bats host virulent zoonotic viruses without experiencing disease. In general, heightened immune responses limit pathogen-induced cellular morbidity, which can facilitate the establishment of rapidly-propagating persistent infections within-host.
  38. A pneumonia outbreak associated with a new coronavirus of probable bat origin Nature 3-2-2020 Here we report the identification and characterization of a new coronavirus (2019-nCoV), which caused an epidemic of acute respiratory syndrome in humans in Wuhan, China. The sequences are almost identical and share 79.6% sequence identity to SARS-CoV. Furthermore, we show that 2019-nCoV is 96% identical at the whole-genome level to a bat coronavirus.
  39. Probable Pangolin Origin of SARS-CoV-2 Associated with the COVID-19 Outbreak Cur. Biol. 6-4-2020 Pangolin-CoV is 91.02% identical to SARS-CoV-2 at the whole-genome level. Pangolin-CoV is the second closest relative of SARS-CoV-2 behind RaTG13. Five key amino acids in the RBD are consistent between Pangolin-CoV and SARS-CoV-2. Only SARS-CoV-2 contains a potential cleavage site for furin proteases.
  40. Complete Genomic Sequence of Human Coronavirus OC43: Molecular Clock Analysis Suggests a Relatively Recent Zoonotic Coronavirus Transmission Event J. Virol 16-9-2004
  41. A decade after SARS: strategies for controlling emerging coronaviruses Nature Microbiol. Rev. 11-11-2013 In this Review, we describe the emergence and identification of novel human coronaviruses over the past 10 years, discuss their key biologicalfeatures, including tropism and receptor use, and summarize approaches for developing broadly effective vaccines.
  42. About three-in-ten Americans believe COVID-19 was created in a lab Pew Research 7-4-2020
  43. Statement in support of the scientists, public health professionals, and medical professionals of China combatting COVID-19 Lancet 18-2-2020 We stand together to strongly condemn conspiracy theories suggesting that COVID-19 does not have a natural origin.
  44. Rapid reconstruction of SARS-CoV-2 using a synthetic genomics platform Nature 4-5-2020
  45. Viral Counterpoint of the Coronavirus Spike Protein (2019-nCoV) 14-3-2020 Musical encoding of the protein sequence.
  46. How sick will the coronavirus make you? The answer may be in your genes Science 27-3-2020 Some killed by the disease are previously healthy and even relatively young. Researchers are now gearing up to scour the patients' genomes for DNA variations that explain this mystery. The findings could be used to identify those most at risk of serious illness and those who might be protected, and they might also guide the search for new treatments.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 6b: Left cumulative deaths, right daily cases. World cases pass 11 million with 536 thousand deaths by 6/7/2020 and 37 million with over 1 million deaths by 10/10/2020. Most testing is taking place in developed countries, so the number of cases and deaths remain unclear.

G: World Incidence Statistics and Reference Sites

  1. Worldometer Corona World Pandemic Charts by Country
  2. Coronavirus COVID-19 Global Cases Center for Systems Science and Engineering
  3. Coronavirus Disease (COVID-19) – Statistics and Research Our World in Data
  4. Download today's data on the geographic distribution of COVID-19 cases worldwide ECDC
  5. 2019 Novel Coronavirus COVID-19 (2019-nCoV) Data Repository by Johns Hopkins CSSE
  6. Our World in Data Covid Testing Rates by Country
  7. https://www.customs.govt.nz/covid-19/more-information/passenger-statistics/
  8. https://ourworldindata.org/grapher/covid-stringency-index
  9. The Covid Tracking Project Atlantic
  10. Google Mobility Reports by Country
  11. Epiforecasts world global covid-19 pandemic modelling
  12. 2019 Novel Coronavirus Research Compendium (NCRC) JH-Bloomberg
  13. John Campbell's Research Reviews
  14. WHO Covid-19
  15. IHME COVID-19 Projections
  16. ncov.io Comparative R0 and death rate for human infectious diseases
  17. CDC Death Counts
  18. CIDRAP: Center for Infectious Disease Research and Policy
  19. COVID Projections Tracker
  20. Tracking Covid-19 cases in the US CNN
  21. COVID-19 research community Res. Gate
  22. Mary Ann Liebert, Inc., publishers Coronavirus Resource Center


Fig 7: Left: PCR Testing procedure (click to enlarge). Right: Decentralized proximity tracing.

H: Coronavirus PCR Tests, Antibody tests and Contact Tracing

PCR testing and Contact Tracing

The current covid-19 tests as in fig 7 use PCR -- polymerase chain reaction -- on the viral RNA to convert it to DNA which is sampled by binding to specific viral sequences. Flu tests don't use PCR. Instead, they detect proteins on the surface of the influenza virus. While the test is quick and cheap, it's also not nearly as sensitive as PCR in picking up infections, especially early on before the virus has a chance to replicate, he says. By the CDC's estimates, rapid influenza tests may miss 50 percent to 70 percent of cases that PCR can detect. An additional benefit of a PCR test is that it may be able to detect viruses earlier in an infection than a flu-style test can, perhaps not in the first day, but a couple of days into an infection when the virus is replicating strongly, but the body's immune system hasn't yet begun to fight and produce symptoms.

  1. Predicting infectious SARS-CoV-2 from diagnostic samples Clin. Infect. Dis. 22-5-2020 The researchers found that RNA-positive samples collected more than eight days after a person's symptoms began did not infect the cells — suggesting that people who test positive for viral RNA are not necessarily infectious.
  2. Test sensitivity is secondary to frequency and turnaround time for COVID-19 surveillance medRxiv 27-6-2020 The researchers found that weekly surveillance testing, paired with case isolation, would limit an outbreak even if the testing method was less sensitive than qPCR. By contrast, surveillance testing done every 14 days would allow the total number of infections to climb almost as high as if there were no testing at all.
  3. First CRISPR test for the coronavirus approved in the United States Nature 8-5-2020
  4. How countries are using genomics to help avoid a second coronavirus wave Nature 27-5-2020 Scientists in New Zealand, the United Kingdom and other places are using sequence data to track new infections as lockdowns ease.
  5. Ethical guidelines for COVID-19 tracing apps Nature 28-5-2020
  6. Point-of-care testing for COVID-19 using SHERLOCK diagnostics Science 7-5-2020 The team's CRISPR-based protocol can be performed by a layperson in an hour with access to a sous vide cooker, a piece of kitchen equipment that is commonly available for less than US$40.
  7. Will antibody tests for the coronavirus really change everything? Nature 18-4-2020 Touted as society's way out of widespread lockdowns, scientists say the true potential of these rapidly-developed tests is still unknown. A high-quality test should achieve 99% or more sensitivity and specificity, turning up only about 1 false positive and 1 false negative for every 100 true positive and negative results. But some commercial antibody tests have recorded specificities as low as 40% early in the infection. In an analysis of 9 commercial tests available in Denmark, 3 lab-based tests had sensitivities ranging 67–93% and specificities of 93–100%. In the same study, five out of six point-of-care tests had sensitivities ranging 80–93%, and 80-100% specificity, but some kits were tested on fewer than 30 people.
  8. LAMP-Seq: Population-Scale COVID-19 Diagnostics Using a Compressed Barcode Space BioRxiv 8-4-2020 Here we propose LAMP-Seq, a barcoded Reverse-Transcription Loop-mediated Isothermal Amplification (RT-LAMP) protocol that could dramatically reduce the cost and complexity of population-scale testing. In this approach, individual samples are processed in a single heat step, producing barcoded amplicons that can be shipped to a sequencing center, pooled, and analyzed en masse.
  9. A coronavirus test can be developed in 24 hours. So why are some countries still struggling to diagnose? CNN 25-3-2020
  10. SARS-COV2 Diagnostic Pipeline Proof of principle tests and antibody tests
  11. Diagnostic detection of 2019-nCoV by real-time RT-PCR WHO 17-1-2020
  12. Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing Science 31-3-2020 We conclude that viral spread is too fast to be contained by manual contact tracing, but could be controlled if this process was faster, more efficient and happened at scale. A contact-tracing App which builds a memory of proximity contacts and immediately notifies contacts of positive cases can achieve epidemic control if used by enough people.
  13. Decentralized Privacy-Preserving Proximity Tracing GitHub 3-4-2020 There is growing political and epidemiological interest in deploying technological approaches to help individuals and countries navigate the COVID-19 pandemic. One approach has been to make use of low-powered Bluetooth sensors on smartphones to inform users when they have been in contact with individuals who have since tested positive, and to support epidemiologists with modelling efforts. Designs with centralized components, where a single actor, such as a server or a state, can learn a great deal about individuals and communities, need specific attention because if they are attacked, compromised or repurposed, they can create greater harm. In order to address these issues, we instead realise the same task using a decentralized design that does not require the centralized collection and processing of information on users.

Antibody and Sewage Testing Results and Community Spread

Although the three antibody test studies reported below are consistent and may well prove to be correct, suggesting far more people have been infected than direct PCR tests of active infection have shown, thus implying the death rates are much lower overall than the 2-5% and 12% in older people based of death rates of positive cases: (a) the reported infection rates remain far below herd immunity levels of 60% , even in NY city, and only 5% in Spain. (b) the actual covid-19 death rates are significantly under-reported (c) the death rates are already excessive, with over 2400 per million in NYC (fig 13b), and (d) we still don't know a positive antibody test prevents reinfection, so can't assess future impact on emergency care once constraints are relaxed.

  1. Italy survey suggests coronavirus six times more prevalent than official data Reuters 3-7-2020 Almost 1.5 million people in Italy or 2.5% of the population have developed coronavirus antibodies. Lombardy, where the epidemic first broke out in February, showing 7.5% of the population had tested positive for coronavirus antibodies compared to just 0.3% in the southern region of Sicily.
  2. Antibody study shows just 5% of Spaniards have contracted the coronavirus El Pais15-5-2020 Only 5% of Spaniards have been infected with the coronavirus, according to the preliminary results of a study by the Carlos III public health institute, which took blood samples from nearly 70,000 participants. One out of every three people who tested positive for antibodies was asymptomatic and did not realize they had contracted the virus. The director of the National Epidemiology Center, Marina Pollán, also noted that 43% had experienced a sudden loss of the sense of smell. Five percent is the equivalent of 2,350,000 cases. If there were around 27,100 deaths, that means that the fatality rate is between 1 and 1.2%. In Spain, if we add another 5,900 suspicious but untested cases to the total number of infections, the fatality rate grows to 1.3%. If the percentage of infected people who eventually die is around 1.1%, as the study suggests, the cost in human lives of herd immunity would be between 200,000 and 300,000, making the method unacceptable, extrapolating to nearly 60 million deaths worldwide.
  3. Seroprevalence of anti-SARS-CoV-2 IgG antibodies in Kenyan blood donors medRxiv 29-7-2020 After testing more than 3000 blood donors, Uyoga and colleagues estimated in a preprint last month that one in 20 Kenyans aged 15 to 64—or 1.6 million people—has antibodies to SARS-CoV-2, an indication of past infection. That would put Kenya on a par with Spain in mid-May when that country was descending from its coronavirus peak and had 27,000 official COVID-19 deaths. Kenya's official toll stood at 100 when the study ended. And Kenya's hospitals are not reporting huge numbers of people with COVID-19 symptoms.
  4. COVID-19 Antibody Seroprevalence in Santa Clara County, California MedRxiv 11-4-2020 The unadjusted prevalence of antibodies to SARS-CoV-2 in Santa Clara County was 1.5% , and the population-weighted prevalence was 2.81% . Under the three scenarios for test performance characteristics, the population prevalence of COVID-19 in Santa Clara ranged from 2.49% to 4.16% . These prevalence estimates represent a range between 48,000 and 81,000 people infected in Santa Clara County by early April, 50-85-fold more than the number of confirmed cases at the time (1000 odd). However, even with the adjusted rate of infection as found by the study, only 3% of the population has coronavirus – that means 97% does not. To reach herd immunity 50% or more of the population would have to be infected and recovered from coronavirus. Participants were recruited through Facebook ads, which would attract many people likely to be positive who have had symptoms and want to know if the coronavirus was the reason. Some neighbourhoods also had way more participants than others, and "hot spots" within the county might have made infections seem more common than they are elsewhere.
  5. Seroprevalence of SARS-CoV-2 Specific Antibodies Among Adults in Los Angeles County Out of 863 adults tested in LA County, 35 or 4.06% tested positive. The weighted proportion of participants who tested positive was 4.14% . After adjusting for test sensitivity and specificity, the unweighted and weighted prevalence of SARSCoV-2 antibodies in our sample was 5.13% and 5.23%, respectively. Our estimates represent the cumulative incidence of COVID-19 in Los Angeles County on April 9. Given that Los Angeles County's adult population is about 7.9 million, our weighted adjusted estimate implies that between 280,000 to 547,000 adults had been infected with SARS-CoV-2 by April 9, which is 35 to 68 times higher than the 7,995 cumulative number of confirmed infections in the County on that date.
  6. 1 in 5 New Yorkers May Have Had Covid-19, Antibody Tests Suggest NYT 22-4-2020 Almost 14 percent of those tested in New York were positive, according to preliminary results from the state survey, which sampled approximately 3,000 people over two days at grocery and big-box stores. NBC notes New York City had a higher rate of antibodies (21.2 percent) than anywhere else in the state and accounted for 43 percent of the total tested. Cuomo was quick to caution that the death toll was higher than even the state's own official report -- it counts deaths in hospitals and nursing homes, but not at-home deaths or other "probable" cases.
  7. Are SARS-CoV-2 seroprevalence estimates biased? OSF 31-5-2020 Most antibody tests have been validated using blood samples from people hospitalized with severe disease. But these individuals, who make up only a small fraction of infected people, might have higher levels of antibodies circulating in their body than have people with mild or no symptoms. The researchers say more detailed studies are needed to assess how well antibody tests detect previous infection in people who had mild disease.
  8. Experts demolish studies suggesting COVID-19 is no worse than flu Are Tech. 25-4-2020 The lead researchers n the Santa Clara and LA studies had previously published in STAT and the Wall Street Journal that the death rates were vastly overinflated.
  9. Antibody surveys suggesting vast undercount of coronavirus infections may be unreliable Science 21-4-2020
  10. How sewage could reveal true scale of coronavirus outbreak Nature 3-4-2020 More than a dozen research groups worldwide have started analysing wastewater for the new coronavirus as a way to estimate the total number of infections in a community, given that most people will not be tested. The method could also be used to detect the coronavirus if it returns to communities, say scientists. de Roda Husman's group detected traces of SARS-CoV-2 in wastewater at Schiphol Airport in Tilburg only four days after the Netherlands confirmed its first case of COVID-19 using clinical testing. To quantify the scale of infection in a population from wastewater samples, the groups will need to find out how much viral RNA is excreted in faeces, and extrapolate the number of infected people in a population from concentrations of viral RNA in wastewater samples and ensure the samples are representative and sensitive to low levels.
  11. Metropolitan Wastewater Analysis for COVID-19 Epidemiological Surveillance medRxiv 24-4-2020
  12. Some scientists are using sewage to measure the prevalence of coronavirus in their communities CNN 26-4-2020 In its pilot 24-hour test, Biobot estimated there were 15,200 cases of Covid-19 in New Castle County Delaware alone. Those results would far outpace the 4,034 estimated number of confirmed cases in the state, according to Johns Hopkins University data.
  13. Coronavirus Antibody Tests: Can You Trust the Results? NYT 24-4-2020 Of the 14 tests, only three delivered consistently reliable results. While false positives are rare, false negatives are too common. SARS-CoV-2 Serology Manuscript
  14. New blood tests for antibodies could show true scale of coronavirus pandemic Science 19-3-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 8 Left: SARS-Cov-2 Viron. See also corona virus cellular replication and expression.
Right: Receptor binding in SARS-Cov-2. Click image to view moving gif (@Steve_Harborne).

I: Mechanisms of Infection

The fact that it seems to bind to both our upper and lower respiratory tracts is perhaps also a reason why people are spreading it so easily. Sars-CoV-2 is spread through droplets -- of which a single cough could create 3000, and a sneeze could produce as many as 10,000. There is still debate over whether these can evaporate into airborne virus. The reason people get very sick with it is it also gets into that lower respiratory tract, and it basically strips your lungs.

The target of SARS-CoV-2 is ACE-2, which is also the target of SARS and human respiratory coronavirus NL63. However the affinity of the spike proteins for this receptor and the ACE-2 receptors in the organs clearly differs enough to make these three diseases very distinct variations of corona virus infection. SARS has proven capable of infecting multiple organs and invade immune system cells and Sars-Cov-2 appears to do likewise. There is now evidence also that interferon immune response to viral attack promotes ACE-2 expression (see section K), giving aggressive corona virus strains a trojan horse to open up the host to life-threatening attack, mild remaining mildly or cryptically infectious in many younger people.

  1. Complete mapping of mutations to the SARS-CoV-2 spike receptor-binding domain that escape antibody recognition bioRxiv 10-9-2020
  2. Genome-wide CRISPR screen reveals host genes that regulate SARS-CoV-2 infection bioRxiv 17-6-2020
  3. Neuropilin-1 is a host factor for SARS-CoV-2 infection bioRxiv 5-6-2020 Researchers have found a second protein that SARS-CoV-2 uses to enter human cells, potentially offering a new target for vaccines and drugs.
  4. Neuropilin-1 facilitates SARS-CoV-2 cell entry and provides a possible pathway into the central nervous system bioRxiv 10-6-2020
  5. The sprint to solve coronavirus protein structures — and disarm them with drugs Nature 15-5-2020 Overview of the scientific cooperation to analyse protein structures to facilitate both vaccines and antiviral drugs.
  6. Structures and distributions of SARS-CoV-2 spike proteins on intact virions Nature 17-8-2020
  7. The Architecture of SARS-CoV-2 Transcriptome Cell 14-5-2020 We provide a high-resolution map of SARS-CoV-2 transcriptome and epitranscriptome. The transcriptome is complex owing to numerous discontinuous transcription events. In addition to 10 canonical RNAs, SARS-CoV-2 produces RNAs encoding unknown ORFs. We discover at least 41 potential RNA modification sites with an AAGAA motif. The transcriptome is highly complex owing to numerous discontinuous transcription events. In addition to the canonical genomic and 9 subgenomic RNAs, SARSCoV-2 produces transcripts encoding unknown ORFs with fusion, deletion, and/or frameshift. Using nanopore direct RNA sequencing, we further find at least 41 RNA modification sites on viral transcripts, with the most frequent motif, AAGAA. Modified RNAs have shorter poly(A) tails than unmodified RNAs, suggesting a link between the modification and the 30 tail.
  8. Proteomics of SARS-CoV-2-infected host cells reveals therapy targets Nature 17-5-2020 We determined the SARS-CoV-2 infection profle by translatome and proteome proteomics at diferent times afterinfection. These analyses revealed that SARS-CoV-2 reshapes central cellular pathways, such as translation, splicing, carbon metabolism and nucleic acid metabolism. Small molecule inhibitors targeting these pathways prevented viral replication in cells.
  9. SARS-CoV-2 entry factors are highly expressed in nasal epithelial cells together with innate immune genes Nature Medicine 23-4-2020 Two cell types in the nose have been identified as likely initial infection points for COVID-19 coronavirus. Goblet and ciliated cells in the nose have high levels of the entry proteins that the COVID-19 virus uses to get into cells. The binding affinity of the S protein and ACE2 was found to be a major determinant of SARS-CoV replication rate and disease severity. Viral entry also depends on TMPRSS2 protease activity. It was previously shown that SARS-CoV-2 could enter TMPRSS2− cells using cathepsin B/L. The study also predicts how a key entry protein is regulated with other immune system genes and reveals potential targets for the development of treatments to reduce transmission.
  10. SARS-CoV-2 Reverse Genetics Reveals a Variable Infection Gradient in the Respiratory Tract Cell 20-5-2020 High-sensitivity RNA in situ mapping revealed the highest ACE2 expression in the nose with decreasing expression throughout the lower respiratory tract, paralleled by a striking gradient of SARS-CoV-2 infection in proximal (high) vs distal (low) pulmonary epithelial cultures. These findings highlight the nasal susceptibility to SARS-CoV-2 with likely subsequent aspiration-mediated virus seeding to the lung in SARS-CoV-2 pathogenesis.
  11. Phylogenetic Analysis and Structural Modeling of SARS-CoV-2 Spike Protein Reveals an Evolutionary Distinct and Proteolytically Sensitive Activation Loop J.Mol. Biol. 2020
  12. Crystal structure of SARS-CoV-2 main protease provides a basis for design of improved α-ketoamide inhibitors Science 20-3-2020
  13. Structure of the RNA-dependent RNA polymerase from COVID-19 virus Science 15-5-2020
  14. Deep mutational scanning of SARS-CoV-2 receptor binding domain reveals constraints on folding and ACE2 binding bioRxiv 17-6-2020 Most mutations are deleterious for RBD expression and ACE2 binding, and we identify constrained regions on the RBD’s surface that may be desirable targets for vaccines and antibody-based therapeutics. But a substantial number of mutations are well tolerated or even enhance ACE2 binding, including at ACE2 interface residues that vary across SARS-related coronaviruses. 
  15. Comparative dynamic aerosol efficiencies of three emergent coronaviruses and the unusual persistence of SARS-CoV-2 in aerosol suspensions medRxiv 18-4-2020 SARS-CoV-2 virus was "remarkably resilient" in the air when aerosolised into smaller particles compared with SARS and MERS. After 16 hours, particles of the new virus could still infect cells in a dish and looked intact under the microscope.
  16. ACE-2: The Receptor for SARS-CoV-2 R&D Systems (see fig 3) Angiotensin converting enzyme 2 (ACE2) is an enzyme attached to the outer surface (cell membranes) of cells in the lungs, arteries, heart, kidney, and intestines. ACE2 lowers blood pressure by catalysing the cleavage of angiotensin II (a vasoconstrictor peptide) into angiotensin 1–7 (a vasodilator).
  17. Cryo-EM structure of the 2019-nCoV spike in the prefusion conformation Science 13-3-2020
  18. Structure, Function, and Antigenicity of the SARS-CoV-2 Spike Glycoprotein Cell 16-4-2020
  19. The spike glycoprotein of the new coronavirus 2019-nCoV contains a furin-like cleavage site absent in CoV of the same clade Antivir. Res. 8-2-2020 Despite a high similarity with the genome sequence of SARS-CoV and SARS-like CoVs, we identified a peculiar furin-like cleavage site in the Spike protein of the 2019-nCoV, lacking in the other SARS-like CoVs.
  20. ACE2 Receptor Expression and Severe Acute Respiratory Syndrome Coronavirus Infection Depend on Differentiation of Human Airway Epithelia J. Virol 2005 Angiotensin converting enzyme 2 (ACE2), the receptor for both the SARS-CoV and the related human respiratory coronavirus NL63, was expressed in human airway epithelia as well as lung parenchyma. The results indicate that infection of human airway epithelia by SARS coronavirus correlates with the state of cell differentiation and ACE2 expression and localization. These findings have implications for understanding disease pathogenesis associated with SARS-CoV and NL63 infections.
  21. Coronavirus could attack immune system like HIV by targeting protective cells, warn scientists Sth. China Morn Post 12-4-2020 Researchers in China and the US find that the virus that causes Covid-19 can destroy the T cells that are supposed to protect thebody from harmful invaders. Concern is growing in medical circles that effect could be similar to HIV.
  22. Structure of replicating SARS-CoV-2 polymerase 27-4-2020 bioRxiv Here we present the cryo-electron microscopic structure of the SARS-CoV-2 RdRp in its replicating form.
  23. The Novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Directly Decimates Human Spleens and Lymph Nodes MedRxiv 31-3-2020 Through careful inspection of the spleens and lymph nodes (LNs) from six cases with postmortem examinations, we observed that SARS-CoV-2 could directly infect secondary lymphoid organs to induce cell death. Immunohistochemistry demonstrated ACE2 (angiotensin-converting enzyme 2), the potential receptor of SARS-CoV-2, expresses on tissue-resident CD169+ macrophages in spleens and LNs.
  24. Multiple organ infection and the pathogenesis of SARS J. Exper. Med. 1-8-2005 SARS viral particles and genomic sequence were detected in a large number of circulating lymphocytes, monocytes, and lymphoid tissues, as well as in the epithelial cells of the respiratory tract, the mucosa of the intestine, the epithelium of the renal distal tubules, the neurons of the brain, and macrophages in different organs. SARS virus seemed to be capable of infecting multiple cell types in several organs; immune cells and pulmonary epithelium were identified as the main sites of injury. A comprehensive theory of pathogenesis is proposed for SARS with immune and lung damage as key features.
  25. Structural basis of receptor recognition by SARS-CoV-2 Nature16-2-2020 Sars-CoV-2, behaves very differently to Sars (fig 8). In particular, Sars-Cov-2 efficiently infects the throat and the nose, causing mild cold-like symptoms, whereas Sars almost always replicated in the lungs. The Sars-CoV-2 surface spike protein is able to bind more efficiently to the cell-surface protein, ACE-2, which acts as the doorway for these viruses to enter into the cell. This improved binding might allow the virus to infect the nose and the throat more efficiently, where the levels of ACE-2 are thought to be lower.
  26. SARS-CoV-2 receptor ACE2 and TMPRSS2 are primarily expressed in bronchial transient secretory cells EMBJ 4-4-2020 SARS-CoV-2 was reported to enter cells via binding to ACE2, followed by its priming by TMPRSS2. Here, we investigate ACE2 and TMPRSS2 expression levels and their distribution across cell types in lung tissue and in cells derived from subsegmental bronchial branches by single nuclei and single cell RNA sequencing, respectively. While TMPRSS2 is expressed in both tissues, in the subsegmental bronchial branches ACE2 is predominantly expressed in a transient secretory cell type.
  27. T Cell Responses to Whole SARS Coronavirus in Humans J Immunol. 15-10-2008 The serum cytokine profile during acute infection indicated a significant elevation of innate immune responses. Increased Th2 cytokines were observed in patients with fatal infection.
  28. Confronting the COVID-19 Pandemic with Systems Biology BioRxiv10-4-2020 Using a Systems Biology approach, we have integrated genomic, transcriptomic, proteomic, and molecular evolution data layers to understand its impact on host cells.
  29. COVID-19: Attacks the 1-Beta Chain of Hemoglobin and Captures the Porphyrin to Inhibit Human Heme Metabolism ChenRxiv 28-3-2020 In this study, conserved domain analysis, homology modeling, and molecular docking were used to compare the biological roles of certain proteins of the novel coronavirus. The results showed the ORF8 and surface glycoprotein could bind to the porphyrin, respectively. At the same time, orf1ab, ORF10, and ORF3a proteins could coordinate attackon the heme on the 1-beta chain of hemoglobin to dissociate the iron to form the porphyrin.
  30. Detection of SARS-CoV-2 in Different Types of Clinical Specimens JAMA 11-3-2020 Most of the patients presented with fever, dry cough, and fatigue; 19% of patients had severe illness. Bronchoalveolar lavage fluid specimens showed the highest positive rates (93%), followed by sputum (72%), nasal swabs (63%), fibrobronchoscope brush biopsy (46%), pharyngeal swabs (32%), feces (29%), and blood (1%). None of the 72 urine specimens tested positive.
  31. An Infectious cDNA Clone of SARS-CoV-2 Cell Host & Microbe 13-5-2020 We report a reverse genetic system for SARS-CoV-2. Seven complimentary DNA (cDNA) fragments spanning the SARSCoV-2 genome were assembled into a full-genome cDNA. RNA transcribed from the full-genome cDNA was highly infectious after electroporation into cells.
  32. The Global Phosphorylation Landscape of SARS-CoV-2 Infection Cell 23-6-2020 SARS-CoV-2 causes cells to put out filopodia -- projections that spread the virus, a study finds.
  33. Possible Vertical Transmission of SARS-CoV-2 From an Infected Mother to Her Newborn JAMA 12-5-2020
  34. Antibodies in Infants Born to Mothers With COVID-19 Pneumonia JAMA 26-3-2020
  35. Evidence 'strongly suggestive' of in utero vertical transmission of SARS-CoV-2 Healio 9-7-2020 Our results are strongly suggestive of vertical in utero SARS-CoV-2 transmission, in two cases out of 31.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 9: Pandemic spread: cumulative logarithmic trajectories, world infections and relative cases, from asymptomatic to mortality.

J: Viral loads and Asymptomatic Spread

One in four cases are now believed to be asymptomatic but may nevertheless be infectious. China is now registering asymptomatic individuals who test positive and recommendations for protection against infection from apparently healthy people need to be upgraded. Iceland doing randomized voluntary testing estimates that half the positives are asymptomatic indicating some testing is catching people before symptoms have developed.

Professor David Hayman has spent most of his career working on Ebola. In the public consciousness, few diseases are more feared. But he said he'd never been truly afraid of an Ebola pandemic, for the simple reason it could be contained. "People who are infectious are often always sick, so you can see the signs and isolate them." "The bigger fear was always something like this: not quite as lethal, but infectious well before the signs start. "It has this asymptomatic phase that makes it much harder to control. You never see it coming."

The key to asymptomatic spreading is that the corona virus is an implicitly symbiotic virus (1, 2 and 3) that has got knocked off its perch to become a pandemic infection. This means some people may have no symptoms at all because their immune systems react like the bats and damp down the virus without inflammation, but others will either get mild disease or end up getting killed in large numbers when the immune mismatch runs riot and blood born viremia ensues.

According to a WHO statement current unpublished work suggests completely asymptomatic individuals who never get sick may only rarely pass the virus on, but they have immediatley backtracked this to saying this situation is "unknown".

Nevertheless pre-symptomatic individuals who are currently asymptomatic and do not yet realize they are infected may shed very high viral loads before realising they feel sick, leading to the known very large clusters. This tallies with the dispersion factor for Covid being around 0.1 meaning 1/10 of individuals cause most of the new cases as "super-spreaders".

  1. The timing of COVID-19 transmission medRxiv 4-9-2020 Nearly half of coronavirus transmission is from people not yet feeling ill.
  2. Seasonal coronavirus protective immunity is short-lasting Nature Med. 14-9-2020 Natural immunity to coronaviruses that cause the common cold might last for only a few months after infection.
  3. Why the Coronavirus Is More Likely to 'Superspread' Than the Flu NYT 7-8-2020
  4. Wrong person, place and time: viral load and contact network structure predict 5 SARS-CoV-2 transmission and super-spreading events medRxiv 7-8-2020 SARS-CoV-2 super-spreader events 21 with over 10 secondary infections occur when an infected person is briefly shedding at a very 22 high viral load and has a high concurrent number of exposed contacts. The higher predisposition 23 of SARS-CoV-2 towards super-spreading events is not due to its 1-2 additional weeks of viral 24 shedding relative to influenza. Rather, a person infected with SARS-CoV-2 exposes more people 25 within equivalent physical contact networks than a person infected with influenza, likely due to 26 aerosolization of virus.
  5. Forty percent of people with coronavirus infections have no symptoms. Might they be the key to ending the pandemic? Wash Post 9-8-2020 New research suggests that some of us may be partially protected due to past encounters with common cold coronaviruses.
  6. Pre-existing immunity to SARS-CoV-2: the knowns and unknowns Nature Rev. Immun. 7-7-2020 T cell reactivity against SARS-CoV-2 was observed in unexposed people; however, the source and clinical relevance of the reactivity remains unknown. It is speculated that this reflects T cell memory to circulating 'common cold' coronaviruses. 
  7. Selective and cross-reactive SARS-CoV-2 T cell epitopes in unexposed humans Science 4-8-2020 Using human blood samples derived before the SARS-CoV-2 virus was discovered in 2019, we mapped 142 T cell epitopes across the SARS-CoV-2 genome to facilitate precise interrogation of the SARS-CoV-2-specific CD4+ T cell repertoire. We demonstrate a range of pre-existing memory CD4+ T cells that are cross-reactive with comparable affinity to SARS-CoV-2 and the common cold coronaviruses HCoV-OC43, HCoV-229E, HCoV-NL63, or HCoV-HKU1. Thus, variegated T cell memory to coronaviruses that cause the common cold may underlie at least some of the extensive heterogeneity observed in COVID-19 disease.
  8. The mystery of 'silent spreaders' BBC 30-5-2020
  9. The natural history and transmission potential of asymptomatic SARS-CoV-2 infection Clin. Infec. Dis. 4-6-2020 A massive coronavirus testing campaign in Vietnam has found evidence that infected people who never show any symptoms can pass the virus to others. Nasal swabbing showed that the infected but asymptomatic study participants had lower levels of viral RNA than infected people who felt ill at some point. But it's "highly likely" that two of the asymptomatic participants were the source of infection for at least two other people, the authors say.
  10. The implications of silent transmission for the control of COVID-19 outbreaks PNAS 23-6-2020 We evaluate the contribution of presymptomatic and asymptomatic transmission based on recent individual-level data regarding infectiousness prior to symptom onset and the asymptomatic proportion among all infections. We found that the majority of incidences may be attributable to silent transmission from a combination of the presymptomatic stage and asymptomatic infections. Consequently, even if all symptomatic cases are isolated, a vast outbreak may nonetheless unfold. We further quantified the effect of isolating silent infections in addition to symptomatic cases, finding that over one-third of silent infections must be isolated to suppress a future outbreak below 1% of the population. Our results indicate that symptom-based isolation must be supplemented by rapid contact tracing and testing that identifies asymptomatic and presymptomatic cases, in order to safely lift current restrictions and minimize the risk of resurgence.
  11. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV-2) Science 1-5-2020 We estimate that 86% of all infections were undocumented [95% credible interval (CI): 82–90%] before the 23 January 2020 travel restrictions. The transmission rate of undocumented infections per person was 55% the transmission rate of documented infections (95% CI: 46–62%), yet, because of their greater numbers, undocumented infections were the source of 79% of the documented cases. These findings explain the rapid geographic spread of SARS-CoV-2 and indicate that containment of this virus will be particularly challenging.
  12. Viral load of SARS-CoV-2 across patients and compared to other respiratory viruses medRxiv 15-7-2020 Early in the disease, people have high viral loads, which tend to decline gradually as the disease progresses. This later stage is typically characterized by inflammation. The decline of viral loads could thus serve as a cue to start treating infected people with anti-inflammatory drugs.
  13. Probability of symptoms and critical disease after SARS-CoV-2 infection arXiv 15-6-2020 5,484 contacts of SARS-CoV-2 index cases detected in Lombardy, Italy were analyzed, and positive subjects were ascertained via nasal swabs and serological assays. 73.9% of all infected individuals aged less than 60 years did not develop symptoms. The risk of symptoms increased with age. 6.6% of infected subjects older than 60 years had critical disease, with males at significantly higher risk.
  14. COVID-19: in the footsteps of Ernest Shackleton Thorax 18-5-2020 We describe what we believe is the first instance of complete COVID-19 testing of all passengers and crew on an isolated cruise ship during the current COVID-19 pandemic. The majority of COVID-19-positive patients were asymptomatic (81%, 104 patients). Of the 217 passengers and crew on board, 128 tested positive for COVID-19 on reverse transcription–PCR (59%). Of the COVID19-positive patients, 19% (24) were symptomatic; 6.2% (8) required medical evacuation; 3.1% (4) were intubated and ventilated; and the mortality was 0.8% (1).
  15. Household secondary attack rate of COVID-19 and associated determinants in Guangzhou, China: a retrospective cohort study Lancet 17-6-2020 After public-health officials had instituted isolation of infected individuals and quarantine of their contacts, people under the age of 20 had a 5.2% risk of being infected by a member of their household, compared with a 14.8% risk for people aged 20–59 and an 18.4% risk for people aged 60 and above.
  16. Could nearly half of those with Covid-19 have no idea they are infected? Guardian 30-5-2020 Raje, an oncologist, had been caring for her sick husband for a week before driving him to an emergency centre with a persistently high fever. But after she herself had a diagnostic PCR test she was astounded to find that the result was positive. "My husband ended up very sick," she says. "He was in intensive care for a day, and in hospital for 10 days. But while I was also infected, I had no symptoms at all." It took two months for Raje's husband to recover. Repeated tests, done every five days, showed that Raje remained infected for the same length of time, all while remaining completely asymptomatic. When they both took an antibody test earlier this month, Raje's husband showed a high level of antibodies to the virus, while Raje appeared to have no response at all. "The big question I have after my experience, is whether a vaccine will really work in all people," she says. "The vaccination approach is to create an immune response, which then protects you. But if asymptomatic people are not producing a normal antibody response to the virus, what does that mean?"
  17. COVID-19: PCR screening of asymptomatic health-care workers at London hospital Lancet 8-5-2020 Of the 44 HCWs who tested positive for SARS-CoV-2, 12 (27%) had no symptoms in the week before or after positivity.
  18. Coronavirus spread by people with no symptoms 'appears to be rare,' WHO official says CNN 8-6-2020 Expert backtracks Guardian 9-6-2020
  19. Temporal dynamics in viral shedding and transmissibility of COVID-19 Nature Med. 15-4-2020 We report temporal patterns of viral shedding in 94 patients with laboratory-confirmed COVID-19 and modeled COVID-19 infectiousness profiles from a separate sample of 77 infector–infectee transmission pairs. We observed the highest viral load in throat swabs at the time of symptom onset, and inferred that infectiousness peaked on or before symptom onset. We estimated that 44% (95% confidence interval, 25–69%) of secondary cases were infected during the index cases' presymptomatic stage, in settings with substantial household clustering, active case finding and quarantine outside the home. Disease control measures should be adjusted to account for probable substantial presymptomatic transmission.
  20. Karl Friston: 'Germany may have more immunological "dark matter"' Guardian 31-5-2020 The neuroscientist who advises Independent Sage on Covid-19 discusses the predictive power of his mathematical modelling and the risk of a second wave. Dynamic causal modeling, which is also applied to brain dynamics has proven accurate at making predictions of the case and death peaks and the degree to which social distancing can be relaxed.
  21. COVID-19 infection: the perspectives on immune responses Cell Death & Diff. 23-3-2020 SARS- CoV-2 infection can be roughly divided into three stages: stage I, an asymptomatic incubation period with or without detectable virus; stage II, non-severe symptomatic period with the presence of virus; stage III, severe respiratory symptomatic stage with high viral load.
  22. Viral load dynamics and disease severity in patients infected with SARS-CoV-2 in Zhejiang province, China, January-March 2020: retrospective cohort study BMJ 21-4-2020 In the mild group, the viral loads peaked in respiratory samples in the second week from disease onset, whereas viral load continued to be high during the third week in the severe group. Virus duration was longer in patients older than 60 years and in male patients.
  23. Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster BioRxiv 8-3-2020 People infected with the SARS-CoV-2 virus, which causes the disease, may test positive for the virus both before and after they have symptoms. But a new study of nine people who contracted the virus in Germany suggests that people are mainly contagious before they have symptoms and in the first week of the disease.
  24. The early phase of the COVID-19 outbreak in Lombardy, Italy An epidemiological analysis of Lombardy, the epicentre of the outbreak in Italy, reveals that the first onset of symptoms in the country occurred weeks before COVID-19, the disease caused by the virus, was reported there on 20 February.
  25. Iceland lab's testing of 5% of population suggests 50% of coronavirus cases have no symptoms CNN 3-4-2020 deCODE's screening program accepts everybody who is not showing symptoms and not currently in quarantine. Although fewer than 1% of the tests came back positive for the virus, around 50% of those who tested positive said they were asymptomatic, The screening is now randomized, but voluntary so there is some bias in the data. See fig 18.
  26. Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods Before and After Symptom Onset JAMA 1-4-2020 In this study, high transmissibility of COVID-19 before and immediately after symptom onset suggests that finding and isolating symptomatic patients alone may not suffice to contain the epidemic, and more generalized measures may be required, such as social distancing.
  27. Spread of SARS-CoV-2 in the Icelandic Population New. Engl. Med. J, 14-4-2020
  28. Coronavirus: many infections spread by people yet to show symptoms – scientists Guardian 12-3-2020 See fig 18.
  29. Coronavirus is most contagious before and during the first week of symptoms Science News 13-3-2020
  30. Covert coronavirus infections could be seeding new outbreaks Nature 20-3-2020
  31. Substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (SARS-CoV2) Science 16-3-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 9b: Left Covid-19 could hijack the interferon-mediated enhancement of ACE-2 receptors.
Right ACE receptors present in many/all organs (2).

K: Antibody Responses and Reinfection / Reactivation. See also: Antibody treatments and Vaccines

While those having recovered from Covid-19 infection do display antibodies to varying degrees, it remains unclear whether these confer long-term immunity to reinfection. Some of the immune response may be T-cell mediated rather than through circulating antibodies. There are also documented examples of reinfection which raise questions over sustained immunity of recovering patients, although these cases to not appear to be infectious. There is also evidence the virus inhibits interferon responses, driving the inflammatory responses instead, as seen in severe cases.

The declining response over a matter of weeks is a matter of concern, both for vaccine efficacy and for the risk of repeat bouts of infection and the capacity to ever reach herd immunity. However some studies do show development of T-cell activity even in family members of infected individuals who do not produce positive antibody tests, suggesting immunity could be spread without symptomatic infection or a positive antibody test. The Iceland study below shows persistance of antibodies four at least four months.

  1. The false promise of herd immunity for COVID-19 Nature 21-10-2020 Why proposals to largely let the virus run its course — embraced by Donald Trump's administration and others — could bring "untold death and suffering".
  2. Absence of SARS-CoV-2 neutralizing activity in pre-pandemic sera from individuals with recent seasonal coronavirus infection medRxiv 11-10-2020
  3. Inborn errors of type I IFN immunity in patients with life-threatening COVID-19 Science 24-9-2020 The team found that 3.5% of study participants had such mutations, which rendered them unable to manufacture type-1 interferons.
  4. Genomic evidence for reinfection with SARS-CoV-2: a case study Lancet 12-10-2020 A 25-year-old man had two positive tests for SARS-CoV-2, the first on April 18, 2020, and the second on June 5, 2020, separated by two negative tests done during follow-up in May, 2020. Genomic analysis of SARS-CoV-2 showed genetically significant differences between each variant associated with each instance of infection. The second infection was symptomatically more severe than the first.
  5. Reinfection with SARS-CoV-2 and Failure of Humoral Immunity: a case report medRxiv 25-9-2020 Low level immunity in both of two genetically distinct Cov-2 infections in a single patient.
  6. Auto-antibodies against type I IFNs in patients with life-threatening COVID-19 Science 24-9-2020 The researchers found that more than 10% of people with severe COVID-19 had autoantibodies that targeted type-I interferon activity, compared with 0.3% in the general population. Laboratory experiments confirmed that the auto-antibodies knocked out type-I interferon activity.
  7. Antigen-specific adaptive immunity to SARS-CoV-2 in acute COVID-19 and associations with age and disease severity Cell 11-9-2020 The team found that people whose immune systems failed to rapidly launch the entire adaptive immune system tended to have more severe disease than did people in whom all three arms ramped up production simultaneously. An uncoordinated response was particularly common among older people, and could indicate that both antibodies and T cells are important weapons against the coronavirus.
  8. Coronavirus reinfections: three questions scientists are asking Nature 4-9-2020
  9. Humoral Immune Response to SARS-CoV-2 in Iceland NEMJ 1-9-2020 Of the 1797 persons who had recovered from SARS-CoV-2 infection, 1107 of the 1215 who were tested (91.1%) were seropositive; antiviral antibody titers assayed by two pan-Ig assays increased during 2 months after diagnosis by qPCR and remained on a plateau for the remainder of the study. Of quarantined persons, 2.3% were seropositive; of those with unknown exposure, 0.3% were positive. We estimate that 0.9% of Icelanders were infected with SARS-CoV-2 and that the infection was fatal in 0.3%. We also estimate that 56% of all SARS-CoV-2 infections in Iceland had been diagnosed with qPCR, 14% had occurred in quarantined persons who had not been tested with qPCR (or who had not received a positive result, if tested), and 30% had occurred in persons outside quarantine and not tested with qPCR. Our results indicate that antiviral antibodies against SARS-CoV-2 did not decline within 4 months after diagnosis. A second wave of antibodies forms after a month or two into infection, and this seems more stable and long-lasting. Nearly a third of infections were in people who reported no symptoms.
  10. Scientists say Hong Kong man got coronavirus a second time Stuff 25-8-2020 Genetic tests (see next link) show a 33-year-old man returning to Hong Kong from a trip to Spain in mid-August had a different strain of the coronavirus than the one he'd previously been infected with in March. The man had mild symptoms the first time and none the second time. A patient in Netherlands and a patient in Belgium were also confirmed to have been reinfected with the virus. A mid-May survey by the doctors' information-sharing site Sermo found that 13 per cent of the 4,173 doctors responding believed that they had treated one or more patients who were reinfected.
  11. Nevada man may be first documented case of coronavirus reinfection in US Stuff 29-8-2020 A 25-year-old Reno man with mild COVID-19 symptoms initially was found to have the virus in April, recovered and tested negative twice, and then tested positive again in June. He was much sicker the second time, with pneumonia that required hospitalisation and oxygen treatment. Genetic tests from each episode showed that viruses were similar in major ways but differed in at least 12 spots that would be highly unlikely if the man had it continuously rather than being infected a second time.
  12. Loss of Bcl-6-Expressing T Follicular Helper Cells and Germinal Centers in COVID-19 Science 25-8-2020 To address the underlying etiology, we examined post mortem thoracic lymph nodes and spleens in acute SARS-CoV-2 infection and observed the absence of germinal centers and a striking reduction in Bcl-6+ germinal center B cells but preservation of AID+ B cells. Absence of germinal centers (needed for developing long-term immunity) correlated with an early specific block in Bcl-6+ TFH cell differentiation together with an increase in Tbet+ TH1 cells and aberrant extra-follicular TNF-a) accumulation. Parallel peripheral blood studies revealed loss of transitional and follicular B cells in severe disease and accumulation of SARS-CoV-2-specific ''disease-related'' B cell populations. These data identify defective Bcl-6+ TFH cell generation and dysregulated humoral immune induction early in COVID-19 disease, providing a mechanistic explanation for the limited durability of antibody responses in coronavirus infections, and suggest that achieving herd immunity through
    Q1 Q2 natural infection may be difficult.
  13. Deficiency of Tfh Cells and Germinal Center in Deceased COVID-19 Patients Curr. Med. Sci. 1-7-2020 We found a dominant presence of macrophages and a general deficiency of T cells and B cells in the lung tissues from deceased COVID-19 patients. In contrast to the FOP patients, Tfh cells and germinal center formation were largely absent in the draining hilar lymph nodes in the deceased COVID-19 patients. This was correlated with reduced IgM and IgG levels compared to convalescent COVID-19 patients. In summary, our data highlight a defect of germinal center structure in deceased COVID-19 patients leading to an impaired humoral immunity.
  14. COVID-19 re-infection by a phylogenetically distinct SARS-coronavirus-2 strain confirmed by whole genome sequencing Clin. Infect. Dis. 25-8-2020
  15. An Immune Protein Could Prevent Severe COVID-19—if It Is Given at the Right Time Sci. Am. 28-7-2020 The antiviral interferon might help early but exacerbate disease in later stages.
  16. COVID-19 poses a riddle for the immune system Nature 17-8-2020 It is unclear why people's immune response to the SARS-CoV-2 coronavirus varies so widely. Tracking patient responses over time sheds light on this issue, and has implications for efforts to predict disease severity.
  17. Going back in time for an antibody to fight COVID-19 Nature 22-7-2020
  18. Robust T cell immunity in convalescent individuals with asymptomatic or mild COVID-19 bioRxiv 29-6-2020 We systematically mapped the functional and phenotypic landscape of SARS-CoV-2-specific T cell responses in a large cohort of unexposed individuals as well as exposed family members and individuals with acute or convalescent COVID-19. Acute phase SARS-CoV-2-specific T cells displayed a highly activated cytotoxic phenotype that correlated with various clinical markers of disease severity, whereas convalescent phase SARS-CoV-2-specific T cells were polyfunctional and displayed a stem-like memory phenotype. Importantly, SARS-CoV-2-specific T cells were detectable in antibody-seronegative family members and individuals with a history of asymptomatic or mild COVID-19. Our collective dataset shows that SARS-CoV-2 elicits robust memory T cell responses akin to those observed in the context of successful vaccines, suggesting that natural exposure or infection may prevent recurrent episodes of severe COVID-19 also in seronegative individuals.
  19. Neutralizing antibodies correlate with protection from SARS-CoV-2 in humans during a fishery vessel outbreak with high attack rate medRxiv 14-8-2020 Just before the ship's departure, the researchers tested 120 of the 122 crew members and found that all were negative for SARS-CoV2, but an outbreak hit the ship soon after it left shore. Post-voyage testing showed that 104 members of the 122-person crew were infected. None of those who were infected and had been tested before embarking had shown neutralizing antibodies against SARS-CoV-2. But all three crew members who did have such antibodies before departure escaped infection.
  20. Functional SARS-CoV-2-specific immune memory persists after mild COVID-19 medRxiv 15-8-2020 We found that recovered individuals developed SARS-CoV-2-specific IgG antibody and neutralizing plasma, as well as virus-specific memory B and T cells that not only persisted, but in some cases increased numerically over three months following symptom onset. Furthermore, the SARS-CoV-2-specific memory lymphocytes exhibited characteristics associated with potent antiviral immunity: memory T cells secreted IFN-γ and expanded upon antigen re-encounter, while memory B cells expressed receptors capable of neutralizing virus when expressed as antibodies. These findings demonstrate that mild COVID-19 elicits memory lymphocytes that persist and display functional hallmarks associated with antiviral protective immunity.
  21. Imbalanced host response to SARS-CoV-2 drives development of COVID-19 Cell 1-5-2020 Final: 15-5-2020 SARS-CoV-2 infection induces low IFN-I and -III levels with a moderate ISG response. Strong chemokine expression is consistent across in vitro, ex vivo, and in vivo models. Low innate antiviral defenses and high pro-inflammatory cues contribute to COVID-19. Here, we compare the transcriptional response of SARS-CoV-2 to other respiratory viruses to identify transcriptional signatures that may underlie COVID-19 biology. In all, these data demonstrate that the overall transcriptional induction to SARS-CoV-2 is aberrant. Despite virus replication, the host response to SARS-CoV-2 fails to launch a robust interferon IFN-I/-III response, while simultaneously inducing high levels of chemokines needed to recruit effector cells. As a waning immune response would enable sustained viral replication, these findings may explain why serious cases of COVID-19 are more frequently observed in individuals with comorbidities.
  22. Impaired type I interferon activity and inflammatory responses in severe COVID-19 patients Science 13-7-2020 A unique phenotype was observed in severe and critical patients, consisting of a highly impaired interferon (IFN) type I response (characterized by no IFN-β and low IFN-α production and activity), associated with a persistent blood viral load and an exacerbated inflammatory response. Inflammation was partially driven by the transcriptional factor NF-κB and characterized by increased tumor necrosis factor (TNF)-α and interleukin (IL)-6 production and signaling. These data suggest that type-I IFN deficiency in the blood could be a hallmark of severe COVID-19 and provide a rationale for combined therapeutic approaches.
  23. Immunophenotyping of COVID-19 and influenza highlights the role oftype I interferons in development of severe COVID-19 Science Immun. 10-7-2020
  24. Structural basis for translational shutdown and immune evasion by the Nsp1 protein of SARS-CoV-2 Science 17-7-2020
  25. Prevalence of IgG antibodies to SARS-CoV-2 in Wuhan – implications for the ability to produce long-lasting protective antibodies against SARS-CoV-2 medRxiv 16-6-2020 Very few healthcare providers had IgG antibodies to SARS-CoV-2, though a significant proportion of them had been infected with the virus. After SARS-CoV-2 infection, people are unlikely to produce long-lasting protective antibodies against this virus. At least a quarter of the more than 23,000 samples tested could have been infected with the virus at some stage, according to the scientists. But only 4 per cent had developed antibodies as of April.
  26. SARS-CoV-2-reactive T cells in healthy donors and patients with COVID-19 Nature 29-7-2020 Here, we investigated SARS-CoV-2 spike glycoprotein (S)-reactive CD4+ T cells in peripheral blood of patients with COVID-19 and SARS-CoV-2-unexposed healthy donors (HD). We detected SARS-CoV-2 S-reactive CD4+ T cells in 83% of patients with COVID-19 but also in 35% of HD. S-reactive CD4+ T cells in HD reacted primarily to C-terminal S epitopes, which show a higher homology to spike glycoproteins of human endemic coronaviruses, compared to N-terminal epitopes. S-reactive T cell lines generated from SARS-CoV-2-naive HD responded similarly to C-terminal S of human endemic coronaviruses 229E and OC43 and SARS-CoV-2, demonstrating the presence of S-cross-reactive T cells, probably generated during past encounters with endemic coronaviruses.
  27. Longitudinal analyses reveal immunological misfiring in severe COVID-19 Nature 27-7-2020 We identify an association between early, elevated cytokines and worse disease outcomes. Following an early increase in cytokines, COVID-19 patients with moderate disease displayed a progressive reduction in type-1 (antiviral) and type-3 (antifungal) responses. In contrast, patients with severe disease maintained these elevated responses throughout the course of disease. Moreover, severe disease was accompanied by an increase in multiple type 2 (anti-helminths) efectors including, IL-5, IL-13, IgE and eosinophils. Unsupervised clustering analysis identifed 4 immune signatures, representing (A) growth factors, (B) type-2/3 cytokines, (C) mixed type-1/2/3 cytokines, and (D) chemokines that correlated with three distinct disease trajectories of patients. The immune profle of patients who recovered with moderate disease was enriched in tissue reparative growth factor signature (A), while the profle for those with worsened disease trajectory had elevated levels of all four signatures.
  28. Convergent antibody responses to SARS-CoV-2 in convalescent individuals Nature 18-6-2020 Plasmas collected an average of 39 days after the onset of symptoms had variable half-maximal pseudovirus neutralizing titres: less than 1:50 in 33% and below 1:1,000 in 79%, while only 1% showed titres above 1:5,000. Antibody sequencing revealed expanded clones of RBD-specifc memory B cells expressing closely related antibodies in diferent individuals. Despite low plasma titres, antibodies to three distinct epitopes on RBD neutralized at half-maximal inhibitory concentrations (IC50 values) as low as single digit nanograms per millitre. Thus, most convalescent plasmas obtained from individuals who recover from COVID-19 do not contain high levels of neutralizing activity. Nevertheless, rare but recurring RBD-specifc antibodies with potent antiviral activity were found in all individuals tested, suggesting that a vaccine designed to elicit such antibodies could be broadly effective.
  29. Concerns about Waning COVID-19 Immunity Are Likely Overblown Sci. Am. 31-7-2020 The decline seen in some studies is normal, experts say. But scientists must wait to see whether infection confers long-term protection
  30. Longitudinal evaluation and decline of antibody responses in SARS-CoV-2 infection medRxiv 11-7-2020 Blood tests revealed that while 60% of people marshalled a "potent" antibody response at the height of their battle with the virus, only 17% retained the same potency three months later. Antibody levels fell as much as 23-fold over the period. In some cases, they became undetectable.
  31. Clinical and immunological assessment of asymptomatic SARS-CoV-2 infections Nature Med. 6-2020 Forty percent of asymptomatic individuals became seronegative and 12.9% of the symptomatic group became negative for IgG in the early convalescent phase. In addition, asymptomatic individuals exhibited lower levels of 18 proand anti-inflammatory cytokines. These data suggest that asymptomatic individuals had a weaker immune response to SARS-CoV-2 infection. The reduction in IgG and neutralizing antibody levels in the early convalescent phase might have implications for immunity strategy andserological surveys. The study also found that asymptomatic people shed virus when infected, and did so for longer than those who had symptoms. About a third of the asymptomatic people had the "ground-glass opacities" characteristic of Covid-19 and abnormalities in the lungs and in cell types, however. The median duration of viral shedding in the asymptomatic group was 19 d. The asymptomatic group had a significantly longer duration of viral shedding than the symptomatic group).
  32. Rapid Decay of Anti–SARS-CoV-2 Antibodies in Persons with Mild Covid-19 NEJM 21-7-2020. A total of 31 of the 34 participants had two serial measurements of IgG levels, and the remaining 3 participants had three serial measurements. The first measurement was obtained at a mean of 37 days after the onset of symptoms (range, 18 to 65), and the last measurement was obtained at a mean of 86 days after the onset of symptoms (range, 44 to 119). Longitudinal Assessment of Anti–SARS-CoV-2 Receptor-Binding Domain IgG in Persons Who Recovered from Covid-19. The initial mean IgG level was 3.48 log10 ng per milliliter (range, 2.52 to 4.41). On the basis of a linear regression model that included the participants' age and sex, the days from symptom onset to the first measurement, and the first log10 antibody level, the estimated mean change (slope) was −0.0083 log10 ng per milliliter per day (range, −0.0352 to 0.0062), which corresponds to a half-life of approximately 36 days over the observation period (Figure 1A). The 95% confidence interval for the slope was −0.0115 to −0.0050 log10 ng per milliliter per day (half-life, 26 to 60 days). Our findings raise concern that humoral immunity against SARS-CoV-2 may not be long lasting in persons with mild illness, who compose the majority of persons with Covid-19.
  33. SARS-CoV-2 ORF3b is a potent interferon antagonist whose activity is further increased by a naturally occurring elongation variant bioRxiv 12-5-2020 ORF3b of SARS-CoV-2 and related bat and pangolin viruses is a potent IFN antagonist. SARS-CoV-2 ORF3b suppresses IFN induction more efficiently than SARS-CoV. The anti-IFN activity of ORF3b depends on the length of its C-terminus. An ORF3b with increased IFN antagonism was isolated from two severe COVID- 19 cases. The ORF3b proteins that were best at inhibiting the interferon response were from SARS-CoV-2 and closely related coronaviruses, although they were shorter (22-amino acids) than that of Sars-Cov (154 amino acids).
  34. SARS-CoV-2 receptor ACE2 is an interferon-stimulated gene in human airway epithelial cells and is detected in specific cell subsets across tissues Cell 20-4-2020 We identify ACE2 and TMPRSS2 co-expressing cells within lung type II pneumocytes, ileal absorptive enterocytes, and nasal goblet secretory cells. Strikingly, we discover that ACE2 is a human interferon-stimulated gene (ISG) in vitro using airway epithelial cells, and extend our findings to in vivo viral infections. Our data suggest that SARS-CoV-2 could exploit species-specific interferon-driven upregulation of ACE2, a tissue-protective mediator during lung injury, to enhance infection. The result suggests that the body's defences against viral attack drive the activation of the gene for ACE2.
  35. Receptors for SARS-CoV-2 Present in Wide Variety of Human Cells The Scientist 29-4-2020
  36. Convergent Antibody Responses to SARS-CoV-2 Infection in Convalescent Individuals bioRxiv 15-5-2020 Most people who have recovered from COVID-19 without hospitalization did not produce high levels of 'neutralizing antibodies'.
  37. Beyond the Spike: identification of viral targets of the antibody response to SARS-CoV-2 in COVID-19 patients medRxiv 2-5-2020 Our report provides an unbiased characterization of antibody responses to a range of SARS-CoV-2 antigens. The combination of 3 SARS-CoV-2 antibody LIPS assays, i.e. N, ORF3b, and ORF8, is sufficient to identify all COVID-19 patients of our cohort even at early time-points of illness, whilst Spike alone fails to do so. Furthermore, our study highlights the importance of investigating new immunogens NSP1, ORF3b, ORF7a and ORF8 which may mediate immune functions other than neutralization which may be beneficial or harmful to the patient.
  38. T cells found in COVID-19 patients -'bode well' for long-term immunity Science 14-5-2020
  39. Targets of T cell responses to SARS-CoV-2 coronavirus in humans with COVID-19 disease and unexposed individuals Cell 14-5-2020 Circulating SARS-CoV-2−specific CD8+ (killer) and CD4+ (helper) T cells were identified in ~70% and 100% of COVID-19 convalescent patients, respectively. CD4+ T cell responses to spike, the main target of most vaccine efforts, were robust and correlated with the magnitude of the anti-SARS-CoV-2 IgG and IgA titers. About half of the healthy people also had helper T cells that recognized bits of SARS-CoV-2, and about a third had the killer T cells. All of these people tested positive for antibodies that attach to two coronaviruses that cause common colds, a sign the participants had been previously infected by those viruses. This paper and the one following both suggest that some people may have pre-existing levels of immunity to Sars-Cov-2 resulting from other corona viruses.
  40. Presence of SARS-CoV-2 reactive T cells in COVID-19 patients and healthy donors medRxiv 22-4-2020 We demonstrate the presence of S-reactive CD4+ 52 T cells in 83% of COVID-19 patients, as well as in 34% of SARS-CoV-2 seronegative healthy donors (HD), albeit at lower frequencies. Strikingly, S-reactive CD4+ T cells in COVID-19 patients equally targeted N-terminal and C-terminal epitopes of S whereas in HD S-reactive CD4+ T cells reacted almost exclusively to the C-terminal epitopes that are a) characterized by higher homology with spike glycoprotein of human endemic "common cold" coronaviruses (hCoVs), and b) contains the S2 subunit of S with the cytoplasmic peptide (CP), the fusion peptide (FP), and the transmembrane
    domain (TM) but not the receptor-binding domain (RBD).
  41. Serologic responses to SARS-CoV-2 infection among hospital staff with mild disease in eastern France medRxiv 22-5-2020 Antibodies against SARS-CoV-2 were detected in virtually all hospital staff sampled from 13 days after the onset of COVID-19 symptoms. This finding supports the use of serologic testing for the diagnosis of individuals who have recovered from SARS-CoV-2 infection. The neutralizing activity of the antibodies increased over time.
  42. Susceptibility to and transmission of COVID-19 amongst children and adolescents compared with adults: a systematic review and meta-analysis medRxiv 24-5-2020 There is preliminary evidence that children and young people have lower susceptibility to SARS-CoV-2, with a 56% lower odds of being an infected contact. There is weak evidence that children and young people play a lesser role in transmission of SARS-CoV-2 at a population level. Our study provides no information on the infectivity of children.
  43. WHO warns against 'immunity passports' WHO 24-4-2020 The WHO has warned against governments issuing "immunity passports" to allow people who show antibodies for coronavirus to return to work. "There is currently no evidence that people who have recovered from Covid-19 and have antibodies are protected from a second infection," the WHO said. The health agency said it is reviewing the evidence on whether people who recover from Covid-19 become immune, but that there are no studies on whether the presence of antibodies indicates immunity in humans. However they later tweeted “We expect that most people who are infected with COVID19 will develop an antibody response that will provide some level of protection”.
  44. Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019 28-3-2020 Combining RNA and antibody detections significantly improved the sensitivity of pathogenic diagnosis for COVID-19 in the early phase of infection. A higher titer of Ab was independently associated with a worse clinical classification.
  45. Neutralizing antibody responses to SARS-CoV-2 in a COVID-19 recovered patient cohort and their implications MedRxiv 6-4-2020 Nearly a third of 175 patients studied produced low antibody levels. In 10 people, antibody levels were so low they could not be detected. Antibody levels seemed to rise dramatically 10 days after infection, reaching a peak five days later. Older patients seemed to produce higher levels of antibodies than younger patients. About a third of patients in the study developed antibody levels the researchers characterised as 'very low'. But all patients got over the virus and recovered just as quickly, no matter their subsequent antibody levels. That suggests the immune system is using a much wider arsenal of weapons to attack the virus, or that the markers used by the researchers didn't include all the effective antibody targets for the virus.
  46. Humoral immune response and prolonged PCR positivity in a cohort of 1343 SARS-CoV 2 patients in the New York City region medRxiv 5-5-2020 Here we show that the vast majority of confirmed COVID19 patients seroconvert, potentially providing immunity to reinfection. We also report that in a large proportion of individuals, viral genome can be detected via PCR in the upper respiratory tract for weeks post symptom resolution, but it is unclear if this signal represents infectious virus.
  47. Recovered coronavirus patients are testing positive again. Can you get reinfected? CNN 18-4-2020 At least 163 patients (2.1% retested positive) classed as having been cured in South Korea have tested positive again, with about 44% of them showing mild symptoms, the CDC said in a briefing. Rather than being infected again, the virus may have been reactivated in these people, given they tested positive again shortly after being released from quarantine, said Jeong Eun-kyeong, director-general of the Korean CDC. Bloomberg 9-4-2020, Reuters 10-2-2020, Reuters 13-4-2020. This is of serious concern, but may have been caused by false negatives as nasal swab can be negative when there is deep lung infection. Another plausible explanation is that the detected virus is an inactive genetic remnant, as attempts to culture it in three members of a family failed.
  48. New data suggest people aren't getting reinfected with the coronavirus Sci. News 19-5-2020 People who test positive after recovering from COVID-19 don't appear to carry infectious virus
  49. Recurrent recurrence of positive SARS-CoV-2 RNA in a COVID-19 patient Res. Squ. 15-4-2020 A 68-year-old man was initially diagnosed with COVID-19 according to two consecutive positive results for SARS-CoV-2 RNA plus clinical symptoms and chest CT findings, and was discharged from hospital when meeting the discharge criteria, including two consecutive negative results. He was tested positive for SARS-CoV-2 RNA twice during the quarantine and was hospitalized again. He was asymptomatic then, but IgG and IgM were both positive. He was discharged in the context of four consecutive negative test results for SARS-CoV-2 RNA after antiviral treatment. However, he was tested positive once again on the 3rd and 4th day after the second discharge, although still asymptomatic. IgG and IgM were still positive. After antiviral treatment, the results of SARS-CoV-2 RNA were negative in three consecutive retests, and he was finally discharged and quarantined for further surveillance.
  50. Clinical characteristics of severe acute respiratory syndrome coronavirus 2 reactivation J. Infect. 20-3-2020 All 55 patients had a history of epidemiological exposure to COVID-19, and 5 (9%) patients who discharged from hospital presented with SARS-CoV-2 reactivation. Among the 5 reactivated patients, other symptoms were also observed, including fever, cough, sore throat, and fatigue. One of the 5 patients had progressive lymphopenia and progressive neutrophilia. All 5 reactivated patients presented normal aminotransferase levels. Throat swab samples from the 5 reactivated patients were tested for SARS-CoV-2, indicating all positive for the virus. Findings from this small group of cases suggested that there was currently evidence for reactivation of SARS-CoV-2 and there might be no specific clinical characteristics to distinguish them.
  51. A single-cell atlas of the peripheral immune response to severe COVID-19 medRxiv 23-4-2020 Collectively, we provide the most thorough cell atlas to date of the peripheral immune response to severe COVID-19.
  52. Can Estrogen and Other Sex Hormones Help Men Survive Covid-19? NYT 27-4-2020 Men are more likely than women to die of the coronavirus, so scientists are treating them with female sex hormones. Last week, doctors on Long Island in New York started treating Covid-19 patients with estrogen in an effort to increase their immune systems, and next week, physicians in Los Angeles will start treating male patients with progesterone, which has anti-inflammatory properties and can potentially prevent harmful overreactions of the immune system.
  53. COVID-19 kills more men than women. The immune system may be why Sci. News 28-4-2020 One component of the innate immune system is called toll-like receptor 7. This protein can recognize molecules found on viruses, thereby outing the pathogens as foreign. The gene for toll-like receptor 7 resides on the X chromosome. Because females have two copies of the X, the body silences one (SN: 4/8/03), allowing for the right "dose" of X chromosome genes. But some genes escape the shut down, and there is evidence that this is true for the gene for toll-like receptor 7, researchers reported in Science Immunology in 2018. As the adaptive immune system gears up, the amount of antibody produced, as well as the quality of those antibodies, or the strength with which they bind to the virus, tends to be greater in females compared with males - more neutralizing antibodies — the type which stop an infection by preventing the virus from entering cells — and more total antibodies.
  54. Disappearance of Antibodies to SARS-Associated Coronavirus after Recovery New Eng. J. Med. 13-9-2007
  55. The time course of the immune response to experimental coronavirus infection of man Epidem. Infect. 10-5-1990 Detailed changes in the concentration of specific circulating and local antibodies were followed in 15 volunteers inoculated with coronavirus 229E. Although concentrations were still slightly raised 1 year later, this did not always prevent reinfection when volunteers were then challenged with the homologous virus.
  56. Lack of Reinfection in Rhesus Macaques Infected with SARS-CoV-2 bioRxiv 1-5-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

L: Clinical Features

It is becoming increasingly clear that, while many people have mild or even asymptomatic infections, once a person needs to seek hospital care, a series of life-threatentig process frequently occur leading to death in up to a third of admitted patients. These involve multiple factors including cytokine storms, microthromboses, organ failure probably due to viremia in which multiple organs also have ACE-2 receptors, and pneumonitis resulting in serum filling the lungs, leading to death by suffocation.

'How is this possible?' Researchers grapple with Covid-19's mysterious mechanism Guardian 2-5-2020 Something peculiar happens to a small group of Covid-19 patients on day seven of their symptoms:

"Up until the end of that first week, they're stable. And then suddenly, they have this hyper-inflammatory response. The proteins involved in that inflammation start circulating in the body at high levels." In these patients, the lungs begin to struggle. Blood pressure lowers. Other organs, including the kidneys, may begin to shut down. Blood clots form throughout the body. The brain and intestines may also be affected. Some suffer changes to their personality, suggesting brain damage.

"I think what is evolving is a very specific set of stages of disease and for some reason, not everyone goes through all of the stages," Darley says. "Some go through to the most severe stage and they require breathing support and oxygen. These patients who are severe tend to be older, they are more likely to be men, and also have other medical problems like diabetes, high blood pressure or cardiovascular disease." "The pathogenesis is not clear yet. We are observing brain inflammation in a subset of patients, and in those we are seeing agitation and a change in behaviour or personality. That's really interesting, and there are reports coming from elsewhere of some people, including younger patients, suffering stroke. It's unclear whether the virus is infecting the lining cells of blood vessels in the brain, or whether the patient's blood is excessively prone to clotting because of all the inflammation, leading to stroke."

"Bad oxygenation and good lungs tells me this must have something to do with the blood vessels. But these vessels are everywhere. In the brain. In the kidneys. So, in some patients, many organs are affected." "In thousands of experiments over the years trying to block inflammatory responses, we've only had a lot of poor results. Like many other things in medicine, we have to be patient."

  1. The major genetic risk factor for severe COVID-19 is inherited from Neanderthals Nature 30-9-2020 A recent genetic association study identified a gene cluster on chromosome 3 as a risk locus for respiratory failure upon SARS-CoV-2 infection. An early study identified two genomic regions associated with severe COVID-19: one region on chromosome 3 containing six genes and one region on chromosome 9 that determines ABO blood groups. Recently, a new dataset was released from the COVID-19 Host Genetics Initiative where the region on chromosome 3 is the only region significantly associated with severe COVID-19 at the genome-wide level. A new study comprising 3,199 hospitalized COVID-19 patients and controls finds that this is the major genetic risk factor for severe SARS-CoV-2 infection and hospitalization (COVID-19 Host Genetics Initiative). Here, we show that the risk is conferred by a genomic segment of ~50 kb that is inherited from Neanderthals and is carried by ~50% of people in South Asia and ~16% of people in Europe today.
  2. How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes Science 17-4-2020
  3. A race to determine what drives COVID-19 severity Nature 29-7-2020 Efforts are ongoing to find which human or viral factors underpin whether a person with COVID-19 will develop severe symptoms. Clinical evidence linked to two viral lineages now provides key insights into this enigma.
  4. COVID-19 Can Wreck Your Heart, Even if You Haven't Had Any Symptoms Sci. Am. 31-8-2020 Myocarditis can affect all ages including athletics and children as young as 12.
  5. Pericarditis and myocarditis long after SARS-CoV-2 infection: a cross-sectional descriptive study in health-care workers medRxiv 14-7-2020 In this study 139 health care workers who developed coronavirus infection and recovered It found that about 10 weeks after their initial symptoms, 37 percent of them were diagnosed with myocarditis or myopericarditis—and fewer than half of those had showed symptoms at the time of their scans.
  6. Sex differences in immune responses that underlie COVID-19 disease outcomes Nature 26-8-2020 By focusing our analysis on patients with moderate disease who had not received immunomodulatory medications, our results revealed that male patients had higher plasma levels of innate immune cytokines such as IL-8 and IL-18 along with more robust induction of non-classical monocytes. In contrast, female patients mounted significantly more robust T cell activation than male patients, which was sustained in old age. Importantly, we found that a poor T cell response negatively correlated with patients' age and was associated with worse disease outcome in male patients, but not in female patients. Conversely, higher innate immune cytokines in female patients associated with worse disease progression, but not in male patients.
  7. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China Lancet 24-1-2020
  8. Clinical Characteristics of Coronavirus Disease 2019 in China New England J. Med. 28-2-2020
  9. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study Lancet 15-6-2020 We estimated that 1·7 billion people, comprising 22% of the global population, have at least one underlying condition that puts themat increased risk of severe COVID-19 if infected (ranging from <5% of those younger than 20 years to >66% of those aged 70 years or older). We estimated that 349 million people (4% of the global population) are at high risk of severe COVID-19 and would require hospital admission if infected (ranging from <1% of those younger than 20 years to approximately 20% of those aged 70 years or older). We estimated 6% of males to be at high risk compared with 3% of females.
  10. Mini organs reveal how the coronavirus ravages the body Nature 22-6-2020
  11. Detectable 2019-nCoV viral RNA in blood is a strong indicator for the further clinical severity EMi 15-2-2020 Unexpectedly, the 2019-nCoV RNA was readily detected in the blood (6 of 57 patients) and the anal swabs (11 of 28 patients). Importantly, all of the 6 patients with detectable viral RNA in the blood cohort progressed to severe symptom stage, indicating a strong correlation of serum viral RNA with the disease severity.
  12. An Overlooked, Possibly Fatal Coronavirus Crisis: A Dire Need for Kidney Dialysis NYT 18-4-2020
  13. Antibiotic treatment for COVID-19 complications could fuel resistant bacteria Science 20-4-2020 Several recent studies from China suggest that nearly all serious cases of COVID-19 are treated with antibiotics, and anecdotally, many U.S. and European physicians say the same. But often the antibiotics are necessary, researchers say. Many COVID-19 patients die of secondary infections rather than the virus itself, growing evidence suggests.
  14. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area JAMA 22-4-2020 The initial release of this paper stated "Mortality for those requiring mechanical ventilation was 88.1%." This was replaced by: Among patients who were discharged or died (n = 2634), 14.2% were treated in the intensive care unit, 12.2% received invasive mechanical ventilation, 3.2% were treated with kidney replacement therapy, and 21% died. As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital.  Of those who died, 57 percent had hypertension, 41 percent were obese and 34 percent had diabetes.
  15. Obesity in patients younger than 60 years is a risk factor for Covid-19 hospital admission Clin. Infect. Dis. 9-4-2020 A cardiologist at Columbia University Medical Center, says his hospital is seeing a surprising number of younger patients with obesity, but no other conditions such as diabetes or high blood pressure. For obese patients, 'the prognosis is extremely grim'.
  16. Why children are not immune to Covid-19 BBC 1-4-2020 Data from the Chinese CDCP reported that children under 19 years of age comprised 2% of the 72,314 Covid-19 cases logged by February 20th, while a US study of 508 patients, reported no case fatalities among children, with this group accounting for less than 1% of the patients in hospital. Data from a Chinese study of Covid-19 in children confirmed slightly more than half showed mild symptoms of fever, cough, sore throat, runny nose, body aches and sneezing; while around a third showed signs of pneumonia, with frequent fever, a productive cough and wheeze but without the shortness of breath and difficulty breathing seen in more severe cases. But there are now several cases of children as young as 5 dying from Covid-19.
  17. National alert in UK as coronavirus-related inflammatory condition may be emerging in children HSJ 27-4-2020 Some of the children without existing conditions have died. Similar to Kawasaki disease.
  18. New York warns of children's illness linked to Covid-19 after three deaths 9-5-2020 Possible treatment IV immunoglobulins and aspirin.
  19. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study Lancet 13-5-2020 In the past month we found a 30-fold increased incidence of Kawasaki-like disease – Kawasaki disease shock syndrome (KDSS). Children diagnosed after the SARS-CoV-2 epidemic began showed evidence of immune response to the virus, were older, had a higher rate of cardiac involvement, and features of macrophage activation syndrome (MAS).
  20. New York's rising cases of mystery illness in children are "tip of the iceberg," Cuomo says CBS 19-5-2020 New York Governor Andrew Cuomo said Tuesday that the state has now confirmed 137 cases of a mystery illness in children connected to COVID-19. Cuomo said he believes the state's discovery is just the "tip of the iceberg" for the illness dubbed Pediatric Multisystem Inflammatory Syndrome  (PMIS).
  21. Young adults are also affected by Kawasaki-like disease linked to coronavirus Wash. Post 22-5-2020 Now called by the CDC multisystem inflammatory syndrome in children (MIS-C).
  22. 'Happy hypoxia': unusual coronavirus effect baffles doctors Guardian 3-5-2020 Covid-19 patients are talking and apparently not in distress, but who have oxygen levels low enough to typically cause unconsciousness or even death.
  23. Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease 2019 JAMA 7-5-2020 In this cohort study, we found that SARS-CoV-2 can be present in the semen of patients with COVID-19, and SARS-CoV-2 may still be detected in the semen of recovering patients. Owing to the imperfect blood-testes/deferens/epididymis barriers, SARS-CoV-2 might be seeded to the male reproductive tract, especially in the presence of systemic local inflammation. Even if the virus cannot replicate in the male reproductive system, it may persist, possibly resulting from the privileged immunity of testes.
  24. Circulating plasma concentrations of angiotensin-converting enzyme 2 in men and women with heart failure and effects of renin–angiotensin–aldosterone inhibitors European Heart Journal 2020 The fact that men have higher plasma concentrations of the ACE-2 enzyme circulating may explain why Covid-19 affects men more severely.
  25. 'Weird as hell': the Covid-19 patients who have symptoms for months Guardian 15-5-2020 Its effects can be agonisingly prolonged: in Garner's case for more than seven weeks.'The virus is causing lots of immunological changes in the body, lots of pathology that we don't yet understand. He had a muggy head, upset stomach, tinnitus, pins and needles, breathlessness, dizziness and arthritis in the hands. Each time Garner thought he was getting better the illness roared back.
  26. The Possible Role of Vitamin D in Suppressing Cytokine Storm and Associated Mortality in COVID-19 Patients 18-5-2020
  27. No evidence that vitamin D prevents coronavirus, say experts Guardian 29-6-2020
  28. UK public health bodies reviewing vitamin D's effects on coronavirus Guardian 17-6-2020 Public health officials are urgently reviewing the potential ability of vitamin D to reduce the risk of coronavirus. It comes amid growing concern over the disproportionate number of black, Asian and minority ethnic people contracting and dying from the disease, including a reported 94% of all doctors killed by the virus.
  29. Vitamin K found in some cheeses could help fight Covid-19, study suggests Guardian 5-6-2020
  30. A mouse-adapted SARS-CoV-2 model for the evaluation of COVID-19 medical countermeasures bioRxiv 7-5-2020
  31. Multiorgan and Renal Tropism of SARS-CoV-2 NEJM 13-5-2020 SARS-CoV-2 can be detected in multiple organs, including the lungs, pharynx, heart, liver, brain, and kidneys.
  32. A race to determine what drives COVID-19 severity Nature 29-6-2020
  33. Viral and host factors related to the clinical outcome of COVID-19 Nature 20-5-2020 Genomic sequences of SARS-CoV-2 assembled from 112 quality samples together with sequences in the Global Initiative on Sharing All Influenza Data (GISAID) showed a stable evolution and suggested two major lineages with differential exposure history during the early phase of the outbreak in Wuhan. Viral genomes from 6 people with established links to the Wuhan market cluster in clade I on the SARS-CoV-2 family tree, whereas the viral genomes of 3 cases without known links to the market cluster in clade II. These data support the idea that the market might not have been the origin of the pandemic. Instead, they suggest that clades I and II originated from a common viral ancestor and spread independently at the same time: clade I through the market and clade II outside it. Nevertheless, they exhibited similar virulence and clinical outcomes. Lymphocytopenia, especially the reduced CD4+ and CD8+ T cell counts upon admission, was predictive of disease progression. High levels of IL-6 and IL-8 during treatment were observed in patients with severe or critical disease and correlated with decreased lymphocyte count.
  34. Apoe e4 genotype predicts severe covid-19 in the UK biobank community cohort medRxiv7-5-2020 ApoE e4 allele increases risks of being hospitalized with covid-19, independent of pre-existing dementia, cardiovascular disease, and type-2 diabetes. ApoE not only affects lipoprotein function (and subsequent cardio-metabolic diseases) but also moderates macrophage pro-/anti-inflammatory phenotypes.
  35. Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19 NEMJ. 1-5-2020 Our studyconfirmed previous observations suggesting that underlying cardiovascular disease is associated with an increased risk of in-hospital death among patients hospitalized with Covid-19. Suspect article see Guardian.
  36. Why coronavirus hits men harder: sex hormones offer clues Science 3-6-2020 In the prostate, TMPRSS2 is produced when male hormones bind to the androgen receptor. An April study of 41 Spanish men hospitalized for COVID-19 found that 71% had male pattern baldness; the background rate in white men is estimated at 31% to 53%. A second study published last month found that 79% of 122 men in three Madrid hospitals with COVID-19 had male pattern baldness.
  37. Androgen-deprivation therapies for prostate cancer and risk of infection by SARS-CoV-2: a population-based study AnnalsOncol. 6-5-2020 Patients on androgen-deprivation therapy (ADT)—drugs that slash levels of testosterone—were only one-quarter as likely to contract COVID-19 as men with prostate cancer.
  38. The ABO blood group locus and a chromosome 3 gene cluster associate with SARS-CoV-2 respiratory failure in an Italian-Spanish genome-wide association analysis medRxiv 2-6-2020 The association signal at 9q34 was located at the ABO blood group locus and a blood-group-specific analysis showed higher risk for A-positive individuals (OR=1.45) and a protective effect for blood group O (OR=0.65).
  39. Inflammasomes and Pyroptosis as Therapeutic Targets for COVID-19 J. Immunol. 7-6-2020 We discuss available pharmaceutical agents that target a critical component of inflammasome activation, signaling leading to cellular pyroptosis, and the downstream cytokines as a promising target for the treatment of severe coronavirus disease 2019-associated diseases. The importance of NLRP3 in repressing SARS-CoV-2 virulence is emphasized in a study that demonstrated that significantly dampened NLRP3-mediated inflammation in bats conferred disease tolerance in these hosts, providing an ideal reservoir for a range of zoonotic viruses. Quercetin, a natural antioxidative flavonoid found in many plants, exhibited potent suppressive ability against inflammasomes, including NLRP3. Sassuria lappa, similarly suppressed NLRP3 inflammasome activity. Nonsteroidal anti-inflammatory drugs (NSAIDs) can also be repurposed to selectively inhibit NLRP3.
  40. Mounting clues suggest the coronavirus might trigger diabetes Nature 24-6-2020 Corona virus appears to be able to trigger type-1 diabetes by directly killing pancreatic β-cells. A patient who had no other symptoms when his parents became infected suddenly developed type-1 diabetes. The patient's blood didn't contain the types of immune cells that typically damage the pancreatic islets where the β-cells live. Various viruses, including the one that causes SARS, have been linked with autoimmune conditions such as type 1 diabetes. Diabetes is already known to be a key risk factor for developing severe COVID-19 and people with the condition are more likely to die and many organs involved in controlling blood sugar are rich in a protein called ACE2, which SARS-CoV-2 uses to infect cells.
  41. SARS-CoV-2 Infection in Children NEMJ 23-4-2020 Of 171 COVID+ children in this study (median age 7) 42% had fever; 33% w/features of sick lungs/signs of viral pneumonia; 6 w/low white blood count; 3 placed on ventilation (had pre-existing condition); one died.
  42. Symptom clusters in Covid19: A potential clinical prediction tool from the COVID Symptom study app medRxiv 16-6-2020
    Cluster 1: Mainly upper respiratory tract symptoms, such as a persistent cough, with muscle pain also present. About 1.5% of patients in this group required respiratory support, with 16% making one or more trips to hospital. This was the most common cluster of symptoms, affecting 462 participants.
    Cluster 2: Mainly upper respiratory tract symptoms, but also a greater frequency of skipped meals and fever. 4.4% required respiratory support, with 17.5% making one or more trips to hospital.
    Cluster 3: Gastrointestinal symptoms such as diarrhoea, but few other symptoms. While only 3.7% of patients in this group later needed respiratory support, almost 24% made at least one visit to hospital.
    Cluster 4: Early signs of severe fatigue, continuous chest pain and cough. 8.6% required respiratory support, with 23.6% making 1 or more trips to hospital.
    Cluster 5: Confusion, skipped meals and severe fatigue. 9.9% required respiratory support, with 24.6% making one or more trips to hospital.
    Cluster 6: Marked respiratory distress including early onset of breathlessness and chest pain, as well as confusion, fatigue and gastrointestinal symptoms. Almost 20% of this group needed respiratory support and 45.5% made one or more visits to hospital. But this was the least common symptom cluster, affecting 167 participants.
  43. SARS-CoV-2 and viral sepsis: observations and hypotheses Lancet 17-4-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons - Covid Politics

M: Microthromboses, Strokes and Effects on the Nervous System

Coronavirus blood-clot mystery intensifies Nature 8-5-2020 Studies suggest that clots appear in 20% to 30% of critically ill Covid-19patients. Blood thinners don't reliably prevent clotting in people with Covid-19, and young people are dying of strokes caused by the blockages in the brain. Many people in hospital have drastically elevated levels of a protein fragment called D-dimer, generated when a clot dissolves. High levels of D-dimer appear to be a powerful predictor of mortality in hospitalized patients infected with coronavirus. Researchers have also observed miniature clots in the body's smallest vessels. Lung and skin samples taken from three people infected with Covid-19 showed that the capillaries were clogged with clots. Other groups have reported similar findings.

One possibility is that SARS-CoV-2 is directly attacking the endothelial cells that line the blood vessels, which harbour the ACE2 receptor. And there is evidence that endothelial cells can become infected. Researchers have observed SARS-Cov-2 in endothelial cells inside kidney tissue. In healthy individuals, the blood vessel is a very smoothly lined pipe, which actively stops clots from forming. But viral infection can damage the lining, prompting the cells to churn out proteins that trigger the process. In some people, COVID-19 prompts immune cells to release a torrent of chemical signals that ramps up inflammation, which is linked to coagulation and clotting through a variety of pathways.

Hospitalized patients with COVID-19 on mechanical ventilation who received blood thinners had a lower mortality than those who weren't treated with them. But high doses of these drugs carry risks.

In addition to strokes in Covid-19 patients noted above, there are a number of manifestations including loss of tast and smell and some patients have neurological and behavioural signs suggesting viral encephalitis.

  1. How the Coronavirus Attacks the Brain NYT 9-9-2020
  2. How COVID-19 can damage the brain Nature 15-7-2020
  3. The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings Bain 8-7-2020
  4. Preventing dangerous blood clots from COVID-19 is proving tricky Sci. News. 23-6-2020 Why clotting can be a complication of a serious infection is rooted in its role in the immune system. Clots can also trap pathogens, preventing them from invading tissues and traveling throughout the body. Clotting in the tiny blood vessels associated with the alveoli, the little air sacs that allow the exchange of oxygen between the lungs and the blood, was widespread in the lungs of seven COVID-19 patients compared with the lungs of seven influenza patients.
  5. Blood vessel attack could trigger coronavirus' fatal 'second phase' Science 3-6-2020 When SARS-CoV-2 enters the lungs, it invades cells in the air sacs that transfer oxygen to the blood. Surrounding those sacs are capillaries lined like bricks with endothelial cells. The virus directly invades some of those cells and others become "activated," likely in response to signals from the invading virus and other damaged cells. Some infected cells likely commit suicide. All the contents leak out. Damage and other changes in the activated cells trigger vascular leakage, flooding the air sacs with fluid, a hallmark of ARDS. White blood cells swarm to the lungs. Together with the activated endothelial cells, the immune cells release a host of signaling molecules, including interleukins, which raise local blood pressure and weaken cell junctions. Damage to the endothelial cells also exposes the membrane underneath them. That exposed membrane in turn triggers uncontrolled clotting.
  6. Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Thrombosis Res.
  7. Pulmonary Embolism in COVID-19 Patients: Awareness of an Increased Prevalence
  8. D‐dimer levels on admission to predict in‐hospital mortality in patients with Covid‐19 BJH D-dimer levels were above the normal range in 67% of the total cohort on admission.
  9. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases Trans. Res.
  10. Covid-19 Coagulopathy in Caucasian patients
  11. Why children avoid the worst coronavirus complications might lie in their arteries Nature 11-6-2020 A large survey by the CDC, found that children aged 17 and under, who make up 22% of the US population, account for fewer than 2% of confirmed COVID-19 infections across the United States. And, of 2,572 children included in the survey, only 5.7% went to hospital and only three died. Endothelium is typically in much better condition in children than adults. The virus likely disrupts communication between the endothelial cells, the platelets and plasma components involved in clotting, and that this communication breakdown leads to excess clots forming.
  12. Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020 CDC
  13. Endothelial cell infection and endotheliitis in COVID-19 Lancet
  14. Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19 JACC
  15. A mysterious blood-clotting complication is killing coronavirus patients Wash Post 22-4-2020
  16. Microvascular Thrombosis as the unifying fatal insult in severe COVID-19 hypothesis. Microthrombosis is also a feature of skin injury from covid-19 (right).
  17. Covid-19 causes sudden strokes in young adults, doctors say CNN 22-4-2020 Case Report New. Eng. J. Med. 28-4-2020
  18. Young and middle-aged people, barely sick with covid-19, are dying of strokes Wash Post 25-4-2020 Doctors sound alarm about patients in their 30s and 40s left debilitated or dead. Some didn't even know they were infected.
  19. Lost Smell and Taste Hint COVID-19 Can Target the Nervous System The Scientist 24-3-2020
  20. Evidence of the COVID-19 Virus Targeting the CNS: TissueDistribution, Host−Virus Interaction, and Proposed Neurotropic Mechanisms ACS Chem Neutrosci. 1-3-2020 The lungs, heart, kidneys, intestines, brain, and testicles that are well-known toexpress ACE2 receptors and are possible targets of COVID-19 which may explain how viremia in the blood system may lead to organ failure and death.
  21. Human Coronaviruses and Other Respiratory Viruses: Underestimated Opportunistic Pathogens of the Central Nervous System? Viruses 20-12-2020 Herein, we present a global portrait of some of the most prevalent or emerging human respiratory viruses that have been associated with possible pathogenic processes in CNS infection, with a special emphasis on human coronaviruses.
  22. Association of chemosensory dysfunction and Covid‐19 in patients presenting with influenza‐like symptoms 12-4-2020 Smell and taste loss were reported in 68% and 71%of Covid‐19‐positive subjects, respectively, compared to 16% and 17% of Covid‐19‐negative patients. Smell and taste impairment were independently and strongly associated with Covid‐19‐positivity, whereas, sore throat was associated with Covid‐19‐negativity. Of patients who reported Covid‐19‐associated loss of smell, 74% (28/38) reported resolution of anosmia with clinical resolution of illness.
  23. Retinal findings in patients with COVID-19 Lancet 12-5-2020
  24. Neurological Implications of COVID-19 Infections Neurocrit. Care 28-4-2020
  25. Neurological and neuropsychiatric complications of COVID-19 in 153 patients: a UK-wide surveillance study Lancet 25-6-2020 Altered mental status was the second most common presentation, comprising encephalopathy or encephalitis and primary psychiatric diagnoses, often occurring in younger patients. Complete clinical datasets were available for 125 (82%) of 153 patients. 77 (62%) of 125 patients presented with a cerebrovascular event, of whom 57 (74%) had an ischaemic stroke, nine (12%) an intracerebral haemorrhage, and one (1%) CNS vasculitis. 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy and seven (18%) patients with encephalitis.
  26. The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings Brain SARS-CoV-2 infection is associated with a wide spectrum of neurological syndromes affecting the whole neuraxis, including the cerebral vasculature and, in some cases, responding to immunotherapies. The high incidence of acute disseminated encephalomyelitis, particularly with haemorrhagic change, is striking. This complication was not related to the severity of the respiratory COVID-19 disease.
  27. Some covid-19 patients taken off ventilators are taking days or even weeks to wake up Wash Post 8-6-2020 When they do regain consciousness, many face the need for months of cognitive and physical rehabilitation, and some might never return to their previous level of functioning.
  28. Trevena Announces Collaboration with Imperial College London to Evaluate TRV027 in COVID-19 Patients The drug (N-methylglycyl-L-arginyl-L-valyl-L-tyrosyl-L-isoleucyl-L-histidyl-L-prolyl-D-Alanine) is an angiotensin AT1 antagonist that may reduce clotting complications.
  29. The way the coronavirus messes with smell hints at how it affects the brain Sci. News. 12-6-2020 Recent studies have begun to identify the cells in the olfactory epithelium, a slender sheet of tissue that lines part of the nasal cavity, that seem vulnerable to SARS-CoV-2 infection. Smell-supporting cells called sustentacular cells are likely targets, scientists report in two new papers, one in ACS Chemical Neuroscience and the other posted at bioRxiv.org, a repository for research that hasn't been peer-reviewed by other scientists. Other research suggests that the virus is able to invade the brain. In one study, scientists put the virus in the noses of mice engineered to have the human form of ACE2 protein. Later, the virus had spread to the mice's lungs, trachea and brains, scientists report May 26 in Cell Host & Microbe. Studies on human brains are mixed. In postmortem studies of 10 people who died of COVID-19, none had SARS-CoV-2 in cerebrospinal fluid, suggesting that the virus wasn't in their brains. But an MRI of a young woman's brain turned up signs of SARS-CoV-2 infection in several areas involved in smell, including the olfactory bulb and a part of the brain called the right gyrus rectus, which helps process smell signals, scientists report May 29 in JAMA Neurology.
  30. Non-neuronal expression of SARS-CoV-2 entry genes in the olfactory system suggests mechanisms underlying COVID-19–associated anosmia Sci. Adv 31-7-2020 Bulk and single-cell RNA sequencing revealed that support and stem cells in the human and mouse olfactory epithelium and vascular pericytes in the mouse olfactory bulb express angiotensin-converting enzyme 2 (ACE2), which is essential for CoV-2 cell entry. In contrast, ACE2 was not detected in either olfactory sensory neurons or olfactory bulb neurons. Immunostaining confirmed these results and revealed pervasive expression of ACE2 protein in dorsally located olfactory epithelial sustentacular cells and mouse olfactory bulb pericytes. These findings suggest that CoV-2 infection of non-neuronal cell types leads to olfactory dysfunction in patients with COVID-19.
  31. Comparison of COVID-19 and common cold chemosensory dysfunction Rhinology 19-8-2020 Our results suggest that mechanisms of COVID-19 related olfactory dysfunction are different from those seen in an AC and may reflect, at least to some extent, a specific involvement at the level of central nervous system in some COVID-19 patients.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 10: Covid-19 Lung damage

N: Lung Damage

"What we know is primarily the coronavirus causes respiratory failure. So when it spreads to the lungs, it causes what we call a pneumonitis, where the lungs become very wet and waterlogged inside. So the normal mechanisms that keep fluid in the blood break down. The little membranes and tissues and the bases of the lungs become porous, and that allows fluid to leak in from the circulation into the lungs, almost like drowning. One of the things we provide with ventilators is pressure, which pushes some of that fluid out and helps to keep the lungs open. So people become exhausted because the work of breathing is so great that they basically become exhausted and die. What happens over time is people's levels of oxygen fall, the levels of carbon dioxide, which is a gas you normally breathe out, rise in the blood. That makes you even more drowsy. It has a narcotic effect. And then people will slowly develop worsening respiratory failure, and eventually they'll become unconscious and their breathing will get more shallow and they'll die. Patients also die from "multi-organ failure", as the kidneys, lungs, liver and even circulation progressively shut down. We've also seen patients who develop a thing called a myocarditis. Often when they're starting to recover, the heart can become very adversely affected and they develop heart failure. That's been probably the leading cause of death in the Covid patients we've seen" Dr David Hepburn, Royal Gwent Hospital.

“Although the majority of cases remain mild, almost 40% result in hospitalisation and 5% require intensive care. Among those who have lost their lives, two-thirds are male and 95% are over the age of 60." WHO regional director Hans Kluge. More recent study in the UK of 17,000 people shows a third of those requiring hospital care die.

Long road to recovery: The latest report into patients admitted into critical care for coronavirus in the UK showed that of 2,249 patients for whom data was available, only 344 (15%) had been discharged alive. A similar number had died (346 patients), while the remaining 70% (1,559) were still in critical care. Even discharged patients continue to experience severe ongoing breathing difficulties. Of those who have required ventilation in the UK so far, only a third (127 out of 388) have survived. Active ventillation also applies positive pressure to drive oxygen closer to the bloodstream and help unblock alveoli rather than the negative pressure of inhalation and can also cause lung damage and patients intubated have to be placed in a sedated coma. Among all Covid-19 patients for whom a critical care outcome has been recorded, 68% of those aged 70 or over died, compared with 46% of those aged 50 to 69 and 24% of patients aged 16 to 49.

Covid-19 can damage lungs of victims beyond recognition, expert says: "What you find in the lungs of people who have stayed with the disease for more than a month before dying is something completely different from normal pneumonia, influenza or the Sars virus. You see massive thrombosis. There is a complete disruption of the lung architecture – in some lights you can't even distinguish that it used to be a lung. There are large numbers of very big fused cells which are virus positive with as many as 10, 15 nuclei," he said. "I am convinced this explains the unique pathology of Covid-19. This is not a disease caused by a virus which kills cells, which had profound implications for therapy." This again suggests the virus is reverting to host coexistence, as in bats, after massive damage.

  1. Covid patients have lung damage 'weeks after leaving hospital' Guardian 6-9-2020
  2. AI tool predicts which coronavirus patients get deadly 'wet lung' Al Jazera 30-3-2020 The team applied a machine-learning algorithm to data from 53 coronavirus patients across two hospitals in Wenzhou, China, finding that changes in three features - levels of the liver enzyme alanine aminotransferase (ALT), reported body aches, and haemoglobin levels - were most accurately predictive of subsequent severe disease.
  3. Cigarette smoke triggers the expansion of a subpopulation of respiratory epithelial cells that express the SARS-CoV-2 receptor ACE2 BioRxiv 31-3-2020 Here, we show that cigarette smoke causes a dose-dependent upregulation of Angiotensin Converting Enzyme 2 (ACE2), the SARS-CoV-2 receptor, in rodent and human lungs. Using single-cell sequencing data, we demonstrate that ACE2 is expressed in a subset of epithelial cells that line the respiratory tract, including goblet cells, club cells, and alveolar type 2 cells. Chronic smoke exposure triggers a protective expansion of mucus-secreting goblet cells and a concomitant increase in ACE2 expression. Taken together, these results may partially explain why smokers are particularly likely to develop severe SARS-CoV-2 infections. Dev. Cell 16-5-2020
  4. Is There a Role for Tissue Plasminogen Activator (tPA) as a Novel Treatment for Refractory COVID-19 Associated Acute Respiratory Distress Syndrome (ARDS)? Trauma and Acute Care Surgery 20-3-2020 Acute Respiratory Distress Syndrome (ARDS) has no effective treatment besides supportive care. A consistent finding in ARDS is the deposition of fibrin in the airspaces and lung parenchyma, along with fibrin-platelet microthrombi in the pulmonary vasculature, which contribute to the development of progressive respiratory dysfunction and right heart failure. Similar pathologic findings have now been observed in lung specimens from patients infected with COVID-19. In 2001, Hardaway and colleagues showed that administration of either urokinase or streptokinase to patients with terminal ARDS reduced the expected mortality from 100% to 70% with no adverse bleeding events.
  5. Intensive Care Unit Management of Patients with Severe Pulmonary Hypertension and Right Heart Failure Conc. Clin. Rev. 4-6-2011 Herein we have developed an approach based on the current understanding of RV failure in PAH and have attempted to develop a treatment paradigm based on physiological principles and available evidence.
  6. Hypothesis for potential pathogenesis of SARSCoV-2 infection–a review of immune changes in patients with viral pneumonia Emerg. Micr. & Infect. 30-3-2020 This article reviews the immunological changes of coronaviruses like SARS, MERS and other viral pneumonia similar to SARS-CoV-2. Combined with the published literature, the potential pathogenesis of COVID-19 is inferred, and the treatment recommendations for giving high-doses intravenous immunoglobulin and low-molecular-weight heparin anticoagulant therapy to severe type patients are proposed.

The Bradykinin Hypothesis

This idea has come from running all the genetic variations of SARS-CoV-2 through the Summit super-computer at Oak Ridge (see eLife below). This resulted in a "eureka moment." The computer revealed a new theory about how Covid-19 impacts the body.

A Covid-19 infection generally begins when the virus enters the body through ACE2 receptors in the nose, (The receptors, which the virus is known to target, are abundant there.) The virus then proceeds through the body, entering cells in other places where ACE2 is also present: the intestines, kidneys, and heart. This likely accounts for at least some of the disease's cardiac and GI symptoms. But once Covid-19 has established itself in the body, things start to get really interesting.

Covid-19 isn't content to simply infect cells that already express lots of ACE2 receptors. Instead, it actively hijacks the body's own systems, tricking it into upregulating ACE2 receptors in places where they're usually expressed at low or medium levels, including the lungs. In this sense, Covid-19 is like a burglar who slips in your unlocked second-floor window and starts to ransack your house. Once inside, though, they don't just take your stuff — they also throw open all your doors and windows so their accomplices can rush in and help pillage more efficiently.

The renin–angiotensin system (RAS) controls many aspects of the circulatory system, including the body's levels of a chemical called bradykinin, which normally helps to regulate blood pressure. According to the team's analysis, when the virus tweaks the RAS, it causes the body's mechanisms for regulating bradykinin to go haywire. Bradykinin receptors are resensitized, and the body also stops effectively breaking down bradykinin. (ACE normally degrades bradykinin, but when the virus down-regulates it, it can't do this as effectively.) The end result is to release a bradykinin storm — a massive, runaway buildup of bradykinin in the body. According to the bradykinin hypothesis, it's this storm that is ultimately responsible for many of Covid-19's deadly effects.

  1. A Supercomputer Analyzed Covid-19 — and an Interesting New Theory Has Emerged Medium 1-9-2020
  2. A mechanistic model and therapeutic interventions for COVID-19 involving a RAS-mediated bradykinin storm eLife 7-7-2020
  3. A hypothesized role for dysregulated bradykinin signaling in COVID-19 respiratory complications FASEB 22-4-2020

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons - Covid Politics


Fig 10b: Targets for antiviral inhibition of the viral infection/replication cycle (Front. Microbiol.). Right evolution of the spike protein in corona viruses. For the evolutionary tree of the whole genome see fig 6.

O: Antiviral Drugs

A spectrum of anti-viral drugs has been tried but few have so far demonstrated any kind of magic bullet effectiveness, although several show borderline improvements if given early in the course of infection before serious symptoms arise. Currently the most promising of these isremdesivir, but even this has only a marginally significant effect so far.

  1. Repurposed antiviral drugs for COVID-19 – interim WHO SOLIDARITY trial results medRxiv 15-10-2020 Remdesivir, Hydroxychloroquine, Lopinavir and Interferon regimens appeared to have little or no effect on hospitalized COVID-19, as indicated by overall mortality, initiation of ventilation and duration of hospital stay.
  2. The Current and Future State of Vaccines, Antivirals and Gene Therapies Against Emerging Coronaviruses Front Microbiol. 24-4-2020 The authors review possible strategies against SARS-CoV-2, SARS-CoV-1, MERS-CoV as well as future coronaviruses including a comprehensive overview of possible antivirals and vaccines. They propose that the most promising approaches for fast progress are selected antivirals and gene therapy delivered through the adeno-associated virus (AAV). This would entail the fast, targeted delivery of antibodies, immunoadhesins, antiviral peptides, and immunomodulators to the upper airways, to give short-term protection.
  3. Structure-based design of antiviral drug candidates targeting the SARS-CoV-2 main protease Science 22-4-2020
  4. A SARS-CoV-2-Human Protein-Protein Interaction Map Reveals Drug Targets and Potential Drug Repurposing BioRxiv 27-3-2020 Nature 30-4-2020 A list of the human proteins affected by the SaRS CoV-2 virus offers a guide to potential treatments for infected people. A team engineered human cells to produce one of 26 proteins made by the coronavirus. This allowed the researchers to identify human proteins that physically interact with coronavirus proteins. Out of 332 interactions between human and viral proteins, the authors identified 67 that existing or candidate drugs could potentially disrupt. The researchers and their collaborators are now testing some of these compounds for antiviral activity and urge others to do the same. Intriguingly, dextromethorphan, actually has pro-viral activity.
  5. To counter the pandemic, clinicians bank on repurposed drugs PNAS 19-5-2020
  6. Coronavirus puts drug repurposing on the fast track Nature Biotechnology 27-2-2020
  7. Covid-19 Small Molecule Therapies Reviewed Science Transalational Medicine 6-3-2020
  8. Inhibition of SARS Coronavirus Infection In Vitro with Clinically Approved Antiviral Drugs 2004
  9. Use of antiviral drugs to reduce COVID-19 transmission Lancet 19-3-2020
  10. Repurposed drugs may help scientists fight the new coronavirus Science News 10-3-2020
  11. Therapeutic options for the 2019 novel coronavirus (2019-nCoV) Nature Reviews Drug Discovery 19-2-2020
  12. Discovery and Development of Safe-in-man Broad-Spectrum Antiviral Agents Preprints.org
  13. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro Cell. Res. 4-2-2020
  14. Medications for COVID-19 Drugs.com

Kaletra

Lopinavir / ritonavir is a fixed dose combination medication for the treatment and prevention of HIV/AIDS. One of the early research projects undertaken at the APS focused on proteins from the human immunodeficiency virus (HIV). Using the APS beam line for X-ray crystallography, researchers determined viral protein structures that allowed them to determine their approach to the development of HIV protease inhibitors, a key enzyme target that processes HIV polyproteins after infection, the function of which allows the lifecycle of the virus to proceed.

  1. Role of lopinavir/ritonavir in the treatment of SARS: initial virological and clinical findings Thorax 2003
  2. The Application of Lopinavir/Ritonavir for the Treatment of COVID-19 Pneumonia Monitored by Quantitative RT-PCR J Korean Med Sci. 17-2-2020
  3. A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19 New England J. Med. 18-3-2020 In hospitalized adult patients with severe Covid-19, no benefit was observed with lopinavir–ritonavir treatment beyond standard care.
  4. Triple combination of interferon beta-1b, lopinavir–ritonavir, and ribavirin in the treatment of patients admitted to hospital with COVID-19: an open-label, randomised, phase 2 trial Lancet 8-5-2020 The combination group had a significantly shorter median time from start of study treatment to negative nasopharyngeal swab (7 days) than the control group (12 days). No patients died during the study. Note: Sars-CoV-2 error correction can excise ribavarin.
  5. No clinical benefit from use of lopinavir-ritonavir in hospitalised COVID-19 patients studied in RECOVERY 29-6-2020

Remdesivir

Remdesivir is a nucleotide analog developed by Gilead Sciences as a treatment for Ebola virus disease and Marburg virus infections, though it subsequently was found to show antiviral activity against other single stranded RNA viruses such as respiratory syncytial virus, Junin virus, Lassa fever virus, Nipah virus, Hendra virus, and the coronaviruses (including MERS and SARS viruses). It is being studied for SARS-CoV-2 and Nipah and Hendra virus infections. Remdesivir is a prodrug that metabolizes into its active form GS-441524. An adenosine nucleotide analog, GS-441524 interferes with the action of viral RNA polymerase and evades proofreading by viral exoribonuclease (ExoN), causing a decrease in viral RNA production. Remesdevir has to be given by injection. There is continuing debate from preliminary studies (1-3) about its effectiveness. It probably needs to be given early in the course of the disease to reduce viral load before deleterious symptoms set in to be efective.

  1. Remdesivir may work even better against COVID-19 than we thought Sci. News 13-7-2020 Among severely sick people, the antiviral drug reduced the risk of dying by 62 percent compared with standard care, the Foster City, Calif., drugmaker Gilead Sciences Inc. reported at a virtual scientific conference on July 10. Gilead announced July 8 that it would begin a clinical trial to test the safety of an inhaled form of the drug. If the inhaled form is safe and effective, it might be used to treat people at home.
  2. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial Lancet 29-4-2020 Remdesivir use was not associated with a difference in time to clinical improvement, but patients receiving remdesivir had a numerically faster time to clinical improvement with symptom duration of 10 days or less. Adverse events were reported in 66% of 155 remdesivir recipients versus 64% of 78 placebo recipients. Remdesivir was stopped early because of adverse events in 12% patients versus 5% of patients who stopped placebo early.
  3. First trial for potential Covid-19 drug shows it has no effect Guardian 22-4-2020 In the trial, 158 patients were randomly assigned to be given remdesivir, while 79 others had standard care with a placebo instead. There was no difference between the groups with respect to recovery time. Just under 14% of those on remdesivir died, compared with nearly 13% of those not taking the treatment. Gilead subsequenty characterized this as a study terminated becouse of low enrollment (due to declining cases in China) and that it would undergo peer review (which it has above) CNN 24-4-2020. The following study is complete and randomised and shows improvements with remdesivir.
  4. Remdesivir for the Treatment of Covid-19 — Preliminary Report NEJM 23-5-2020 Preliminary results from the 1059 patients (538 assigned to remdesivir and 521 to placebo) indicated that those who received remdesivir had a median recovery time of 11 days, as compared with 15 days in those who received placebo. Mortality by 14 days were 7.1% with remdesivir and 11.9% with placebo. Serious adverse events were reported for 114 of the 541 patients in the remdesivir group and 141 of the 522 patients in the placebo group. Remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with Covid-19 and evidence of lower respiratory tract infection.
  5. Covid-19 patients recovering quickly after getting experimental drug remdesivir CNN 17-4-2020
  6. A new paper about a Gilead drug to combat coronavirus has some analysts skittish about success Statnews 13-3-2020
  7. First 12 patients with coronavirus disease 2019 (COVID-19) in the United States Based on our review of the clinical and virological courses, we believe remdesivir's contribution to efficacy remains unclear, and with a side-effect profile that may not be completely benign. Wecontinue to see a less than 50/50 possibility that the drug is ultimately proven effective."
  8. Structural Basis for the Inhibition of the RNA-Dependent RNA Polymerase from SARSCoV-2 by Remdesivir BioRxiv 9-4-2020 Remdesivir monophosphate (RMP) is covalently incorporated into the primer strand. Despite the presence of excess amount of RTP in complex assembly, only a single RMP is assembled into the primer strand. Thus, Remdesivir, like many nucleotide analog prodrugs, inhibits the viral RdRp activity indirectly through non-obligate RNA chain termination, a mechanism that requires the conversion of the parent drug to the active triphosphate form. The RMP position is at the center of the catalytic active site.
  9. Compassionate Use of Remdesivir for Patients with Severe Covid-19 New Eng. J. Med. 10-4-2020 A majority of a small group of patients showed improvements after being treated. At baseline, 30 patients (57%) were receiving mechanical ventilation and 4 (8%) were receiving extracorporeal membrane oxygenation. During a median follow-up of 18 days, 36 patients (68%) had an improvement in oxygen-support class, including 17 of 30 patients (57%) receiving mechanical ventilation who were extubated. A total of 25 patients (47%) were discharged, and 7 patients (13%) died; mortality was 18% (6 of 34) among patients receiving invasive ventilation and 5% (1 of 19) among those not receiving invasive ventilation. In this cohort of patients hospitalized for severe Covid-19 who were treated with compassionate-use remdesivir, clinical improvement was observed in 36 of 53 patients (68%). This was not a double-blind placebo-controlled trial which would offer more definitive evidence.
  10. Remdesivir inhibits SARS-CoV-2 in human lung cells and chimeric SARS-CoV expressing the SARS-CoV-2 RNA polymerase in mice Cell Rep. 21-4-2020

Avigan

Favipiravir In experiments conducted in animals Favipiravir has shown activity against influenza viruses, West Nile virus, yellow fever virus, foot-and-mouth disease virus as well as other flaviviruses, arenaviruses, bunyaviruses and alphaviruses. Activity against enteroviruses and Rift Valley fever virus has also been demonstrated. Favipiravir has showed limited efficacy against Zika virus in animal studies, but was less effective than other antivirals such as MK-608. The agent has also shown some efficacy against rabies, and has been used experimentally in some humans infected with the virus. In February 2020, Favipiravir was being studied in China for experimental treatment of the emergent COVID-19 (novel coronavirus disease). On March 17, Chinese officials suggested the drug had been effective in treating COVID in Wuhan and Shenzhen. The mechanism of its actions is thought to be related to the selective inhibition of viral RNA-dependent RNA polymerase. Other research suggests that favipiravir induces lethal RNA transversion mutations, producing a nonviable viral phenotype. It was never fully embraced by the medical community due to its known teratogenicity and embryotoxicity effects.

  1. Japanese flu drug 'clearly effective' in treating coronavirus, says China Guardian 18-3-2020 Patients who were given the medicine in Shenzhen turned negative for the virus after a median of four days after becoming positive, compared with a median of 11 days for those who were not treated with the drug, public broadcaster NHK said. In addition, X-rays confirmed improvements in lung condition in about 91% of the patients who were treated with favipiravir, compared to 62% or those without the drug. But a Japanese health ministry source suggested the drug was not as effective in people with more severe symptoms. "We've given Avigan to 70 to 80 people, but it doesn't seem to work that well when the virus has already multiplied".

Camostat

Camostat is a serine protease inhibitor of the enzyme transmembrane protease, serine 2 (TMPRSS2). Inhibition of TMPRSS2 partially blocked infection by SARS-CoV and Human coronavirus NL63 in HeLa cell cultures.[8] Another in vitro study showed that camostat significantly reduces the infection of Calu-3 lung cells by SARS-CoV-2, the virus responsible for COVID-19.

  1. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor Cell 5-5-2020
  2. Camostat mesylate inhibits SARS-CoV-2 activation by TMPRSS2-related proteases and its metabolite GBPA exerts antiviral activity bioRxiv 5-8-2020

Sofosbuvir plus Daclatasvir

Sovodak (Sofosbuvir plus Daclatasvir) is being trialled in Iran. The two have been previously combined as a treatment for hepatitis C. Doctors in Iran have commenced 109 clinical trials on treatments for COVID-19 and have recently announced that they have found a cure, where that cure looks like no ICU deaths and rapid recovery for patients - James Freeman.

  1. A prospective randomized controlled trial comparing Sovodak(Sofosbuvir plus Daclatasvir) in participants with moderate to severe Coronavirus disease (COVID-19) compared to standard of care treatment IRCT 1-4-2020

Galidesivir

Galidesivir (BCX4430, Immucillin-A)  is an adenosine analog originally intended as a treatment for hepatitis C, but subsequently developed as a potential treatment for deadly filovirus infections such as Ebola virus disease and Marburg virus disease. It also shows broad-spectrum antiviral effectiveness against a range of other RNA virus families, including bunyaviruses, arenaviruses, paramyxoviruses, coronaviruses, flaviviruses and phleboviruses.

  1. The New Zealand scientist behind one of the world's most promising COVID-19 treatments Newshub 24-4-2020

β-D-N4-hydroxycytidine

EIDD-2801 inhibits the coronavirus's self-copying operations in a manner that is different from remdesivir. While remdesivir brings that replication process to a full stop, EIDD-2801, like avigan, introduces mutations into the virus's RNA as it makes copies so that the viral RNA becomes so damaged that it cannot infect cells. This is a cytidine analogue that appears to selectively act to cause lethal viral mutations without serious mammalian ones. However it appears to have been studied only in tissue culture and animal studies. The safety of a mutational antiviral would thus have to be confirmed for human use, as cytidine is a unit in both RNA and DNA.

  1. An orally bioavailable broad-spectrum antiviral inhibits SARS-CoV-2 and multiple endemic, epidemic and bat coronavirus BioRxiv 20-3-2020 β-D-N4-hydroxycytidine has broad spectrum antiviral activity against SARS-CoV 2, MERS-CoV, SARS-CoV, and related zoonotic group 2b or 2c Bat-CoVs. In mice infected with SARS-CoV or MERS-CoV, both prophylactic and therapeutic administration of an orally bioavailable NHC-prodrug improved pulmonary function, and reduced virus titer and body weight loss. Decreased MERS-CoV yields in vitro and in vivo were associated with increased transition mutation frequency in viral but not host cell RNA, supporting a mechanism of lethal mutagenesis.
  2. Emails offer look into whistleblower charges of cronyism behind potential COVID-19 drug Science 13-5-2020 The Bright allegation addressed by Benford's email centers on a so-far unsuccessful effort by Florida-based Ridgeback Biotherapeutics to win new federal funding to develop EIDD-2801, a version of a 4-decade-old antiviral drug, into a treatment for COVID-19. Although the drug has shown potential against the coronavirus that causes the disease, Bright had opposed providing an immediate large funding boost. Some earlier studies suggested EIDD-2801 could cause harmful genetic mutations. Bright notes in his complaint that "similar experimental drugs in this class had been shown to cause reproductive toxicity in animals, and offspring from treated animals had been born without teeth and without parts of their skulls.
  3. β-d-N4-Hydroxycytidine Is a Potent Anti-alphavirus Compound That Induces a High Level of Mutations in the Viral Genome 22-11-2017
  4. Characterization of β-D-N4-Hydroxycytidine as a Novel Inhibitor of Chikungunya Virus 30-1-2017

Famotidine

Famotidine is the active compound in the over-the-counter heartburn drug Pepcid.

  1. New York clinical trial quietly tests heartburn remedy against coronavirus Science 26-4-2020 On 7 April, the first COVID-19 patients at Northwell Health in the New York City area began receiving famotidine intravenously, at nine times the heartburn dose. In reviewing 6212 COVID-19 patient records, the doctors noticed that many survivors had been suffering from chronic heartburn and were on famotidine rather than more-expensive omeprazole (Prilosec), the medicine of choice both in the United States and among wealthier Chinese. Hospitalized COVID-19 patients on famotidine appeared to be dying at a rate of about 14% compared with 27% for those not on the drug, although the analysis was crude and the result was not statistically significant. Subsequent modeling yielded several dozen promising hits that pharmaceutical chemists and other experts narrowed to three. Famotidine was one.
  2. Pepcid as a virus remedy? Trump admin's $21M gamble fizzled AP 23-7-2020

Chloroquine

Chloroquine is a medication primarily used to prevent and treat malaria in areas where malaria remains sensitive to its effects and for lupus. Chloroquine does have antiviral effects. It increases late endosomal and lysosomal pH, resulting in impaired release of the virus from the endosome or lysosome – release of the virus requires a low pH. The virus is therefore unable to release its genetic material into the cell and replicate. Chloroquine also seems to act as a zinc ionophore, that allows extracellular zinc to enter the cell and inhibit viral RNA-dependent RNA polymerase. However it can also leading to loss of hearing and/or vision and heart problems. The gold standard RECOVERYstudy(1) now shows it has no benefit. Neither do prophylactic studies nor other large gold standard studies with proper randomized trials. In all, at least six studies have uniformly found no significant benefit and significant potential harm including increased deaths from heart attack.

  1. FDA revokes emergency use authorization of chloraquine and hydroxychloraquine the drug Trump touted CNN 16-6-2020
  2. No clinical benefit from use of hydroxychloroquine in hospitalised patients with COVID-19 5-6-2020 Hydroxychloroquine does not work against Covid-19 and should not be given to any more hospital patients around the world, say the leaders of the biggest and best-designed trial of the drug, which experts will hope finally settle the question. The Recovery trial is a "gold standard" randomised controlled trial, designed to find an answer to a question by recruiting patients in similar circumstances either to take the drug or to take a placebo.
  3. Hydroxychloroquine or Chloroquine for Treatment or Prophylaxis ofCOVID-19: A Living Systematic Review An. Int. Med. 27-5-2020 Evidence on the benefits and harms of using hydroxychloroquine or chloroquine to treat COVID-19 is very weak and conflicting.
  4. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis Lancet 22-5-2020 96 032 patients (mean age 53·8 years, 46·3% women) with COVID-19 were hospitalised during the study period and met the inclusion criteria. We were unable to confirm a benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on in-hospital outcomes for COVID-19. Each of these drug regimens was associated with decreased in-hospital survival and an increased frequency of ventricular arrhythmias when used for treatment of COVID-19.
  5. Questions raised over hydroxychloroquine study which caused WHO to halt trials for Covid-19 Guardian 28-5-2020 Australian data shows inconsistencies with official figures.
  6. Governments and WHO changed Covid-19 policy based on suspect data from tiny US company Guardian 3-6-2020 Late on Tuesday, after being approached by the Guardian, the Lancet (1) released an "expression of concern" about its published study. The New England Journal of Medicine has also issued a similar notice over an article on cardiovascular risks.
  7. Hydroxychloroquine, a drug promoted by Trump, failed to prevent healthy people from getting covid-19 in trial Wash Post 4-6-2020
  8. Treatment with Hydroxychloroquine, Azithromycin, and Combination in Patients Hospitalized with COVID-19 Int. J. Infect. Dis. 29-6-2020 Overall crude mortality rates were 18.1% in the entire cohort, 13.5% in the hydroxychloroquine alone group, 20.1% among those receiving hydroxychloroquine plus azithromycin, 22.4% among the azithromycin alone group, and 26.4% for neither drug. But steroid use was also more double in the hydroxychloraquine group. Observational study with no controls The following three responses in the same journal stringly criticise this article.
  9. Problems with the analysis in "Treatment with Hydroxychloroquine, Azithromycin and Combination in Patients Hospitalized with COVID-19" Int. J. Infect. Dis. 9-7-2020
  10. Clarifying the record on hydroxychloroquine for the treatment of patients hospitalized with COVID-19 Int. J. Infect. Dis. 13-7-2020
  11. The continued dilemma about usage of Hydroxychloroquine: Respite is in randomized control trials Int. J. Infect. Dis. 29-7-2020
  12. Hydroxychloroquine with or without Azithromycin in Mild-to-Moderate Covid-19 NEJM 23-7-2020 Among patients hospitalized with mild-to-moderate Covid-19, the use of hydroxychloroquine, alone or with azithromycin, did not improve clinical status at 15 days as compared with standard care.
  13. A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19 NEJM 3-6-2020 We enrolled 821 asymptomatic participants. Overall, 87.6% of the participants (719 of 821) reported a high-risk exposure to a confirmed Covid-19 contact. The incidence of new illness compatible with Covid-19 did not differ significantly between participants receiving hydroxychloroquine (49 of 414) and those receiving placebo (58 of 407); the absolute difference was −2.4 percentage points (95% confidence interval, −7.0 to 2.2; P=0.35). Side effects were more common with hydroxychloroquine than with placebo (40.1% vs. 16.8%), but no serious adverse reactions were reported. After high-risk or moderate-risk exposure to Covid-19, hydroxychloroquine did not prevent illness compatible with Covid-19 or confirmed infection when used as postexposure prophylaxis within 4 days after exposure.
  14. FDA warns about use of hydroxychloroquine, which Trump promoted for treating COVID-19 CBS 25-4-2020 The FDA on Friday issued a warning against the widespread use of hydroxychloroquine, an antimalaria drug that President Trump repeatedly touted as a potential treatment for COVID-19. The warning comes just days after a study suggested the drug had no benefit for coronavirus patients, and was even associated with more deaths.
  15. Association of Treatment With Hydroxychloroquine or Azithromycin With In-Hospital Mortality in Patients With COVID-19 in New York State JAMA 11-5-2020 In a retrospective cohort study of 1438 patients hospitalized in metropolitan New York, compared with treatment with neither drug, the adjusted hazard ratio for in-hospital mortality for treatment with hydroxychloroquine alone was 1.08, for azithromycin alone was 0.56, and for combined hydroxychloroquine and azithromycin was 1.35. None of these hazard ratios were statistically significant. Those receiving hydroxychloroquine, azithromycin, or both were more likely than those not receiving either drug to have existing conditions or low oxygen. Primary outcome was in-hospital mortality. Secondary outcomes were cardiac arrest and abnormal electrocardiogram findings (arrhythmia or QT prolongation). The probability of death for patients receiving hydroxychloroquine + azithromycin was 25.7% hydroxychloroquine alone, 19.9% , azithromycin alone, 10.0% , and neither drug, 12.7%.
  16. Study finds no benefit, higher death rate in patients taking hydroxychloroquine for Covid-19 CNN 21-4-2020 Coronavirus patients taking hydroxychloroquine, a treatment touted by President Trump, were no less likely to need mechanical ventilation and had higher deaths rates compared to those who did not take the drug, according to a study of hundreds of patients at US Veterans Health Administration medical centers.
  17. Hydroxychloroquine and azithromycin plus zinc vs hydroxychloroquine and azithromycin alone: outcomes in hospitalized COVID-19 patients medRxiv 8-5-2020 This study provides the first in vivo evidence that zinc sulfate in combination with hydroxychloroquine may play a role in therapeutic management for COVID-19. Joseph Rahimian, a co-author of the study, pointed out that the study’s findings were limited to the possible promise of zinc, not of hydroxychloroquine.
  18. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro Cell discovery 18-3-2020 This suggests it might have a preventative action.
  19. Chloroquine hype is derailing the search for coronavirus treatments Nature 24-4-2020
  20. Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies Bioscience trends 19-2-2020
  21. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro Cell Discovery 2020
  22. Effects of chloroquine on viral infections: an old drug against today's diseases? Lancet 11-2003 Chloroquine exerts direct antiviral effects, inhibiting pH-dependent steps of the replication of several viruses including members of the flaviviruses, retroviruses, and coronaviruses. Moreover, chloroquine has immunomodulatory effects, suppressing the production/release of tumour necrosis factor α and interleukin 6 (IL-6), which mediate the inflammatory complications of several viral diseases.
  23. Targeting endosomal acidification by chloroquine analogs as a promising strategy for the treatment of emerging viral diseases Pharmacol Res Perspect. 5-2-2017
  24. Chloroquine Is a Zinc Ionophore PlosOne 10-9-2014
  25. Zn2+ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture Plos Pathogens 1-10-2010
  26. Chloroquine for COVID-19: Cutting Through the Hype The Scientist 20-3-2020
  27. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial Int. J. Antimic. Ag. 20-3-2020 In a non-randomised study of 36 patients, 6 were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms. Twenty cases were treated in this study and showed a significant reduction of the viral carriage at day 6 post inclusion compared to controls, and much lower average carrying duration than reported of untreated patients in the literature. Azithromycin added to hydroxychloroquine was significantly more efficient for virus elimination.
  28. Touting Virus Cure, 'Simple Country Doctor' Becomes a Right-Wing Star NY Times 2-4-2020 Experimental treatment consisting of hydroxychloroquine, the antibiotic azithromycin and zinc sulfate.
  29. Director of key federal vaccine agency says his departure was retaliation CNN 22-4-2020 The director of the office involved in developing a coronavirus vaccine says he was abruptly dismissed from his post in part because he resisted efforts to widen the availability of a coronavirus treatment pushed by President Donald Trump.
  30. Ventricular Arrhythmia Risk Due to Hydroxychloroquine-Azithromycin Treatment For COVID-19 Am. Coll. Cardiol. 29-3-2020 Chloroquine, hydroxychloroquine and azithromycin all prolong QT interval, raising concerns about the risk of arrhythmic death from individual or concurrent use of these medications.

Artemisinin

Artemisin is an antimalarial derived from Artemisia annua which acts by forming free radicals activated by heme which attack proteins and kill the parasite. The endoperoxide 1,2,4-trioxane  ring is responsible for the drug's mechanism of action. Artemisinin derivatives are known for their ability to suppress immune reactions such as inflammation. One derivative, SM934, was approved in 2015 by the China Food and Drug Administration for clinical trial as a drug for systemic lupus erythematosus. Experiments in animal models have given good results. It can regulate T cell subsets, inhibit the activation of B cells, block the production of inflammatory cytokines and NF-κB signal transduction pathway. A herbal artemisia drink is marketed in Madagascar.

Oleandrin

Oleandrin is a toxic cardiac glycoside found in the poisonous plant, oleander (Nerium oleander L.). During the COVID-19 pandemic, Donald Trump's Secretary of Housing and Urban Development Ben Carson, and MyPillow CEO Mike Lindell, a major Trump booster and an investor in a company that develops oleandrin, promoted oleandrin as a potential treatment of the disease in a July 2020 Oval Office meeting with Trump, who expressed enthusiasm for the substance. These claims were widely regarded by scientists as dubious, misleading, and alarming, as well as having no clinical proof of safety or effectiveness. However, on 14 August 2020, the FDA rejected the application for marketing an oleandrin dietary supplement by Phoenix Biotechnology, Inc. – the manufacturer of the product – due to concerns that oleandrin would not be safe to consume.

  1. Trump allies pitch extract from poisonous plant to fight Covid Guradian 25-8-2020

APN01 (hrsACE2)

  1. Inhibition of SARS-CoV-2 infections in engineered human tissues using clinical-grade soluble human ACE2 Cell 2-4-2020 Here we show that APN01 (human recombinant soluble angiotensin-converting enzyme 2 -- hrsACE2) -- soon to be tested in clinical trials by the European biotech company Apeiron Biologics, reduced SARS-CoV-2 recovery from Vero tissue culture cells isolated from kidney epithelial cells extracted from an African green monkey by a factor of 1,000-5,000. We also show that SARS-CoV-2 can directly infect engineered human blood vessel organoids and human kidney organoids, which can be inhibited by hrsACE2.

M pro Inhibitors and Ebsalen

Structure of Mpro from COVID-19 virus and discovery of its inhibitors Nature 9-4-2020 Mpro is a key CoV enzyme, which plays a pivotal role in mediating viral replication and transcription, making it an attractive drug target for this virus. Here, we identified a mechanism-based inhibitor, N3, by computer-aided drug design and subsequently determined the crystal structure of COVID-19 virus Mpro in complex with this compound. Next, through a combination of structure-based virtual and high throughput screening, we assayed over 10,000 compounds including approved drugs, drug candidates in clinical trials, and other pharmacologically active compounds as inhibitors of Mpro. Six of these compounds (ebsalen, disulfuram, tideglusib, carmofur, shikonin, PX-12) inhibited Mpro with IC50 values ranging from 0.67 to 21.4 μM. Ebselen also exhibited promising antiviral activity in cell-based assays.

Ivermectin

Ivermectin is an an anti-parasitic, killing nematode infections by disrupting the neuromuscular junction in invertebrates, including worms, mites and lice.

  1. The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro Antiviral Research 6-2020
  2. Ivermectin and COVID-19: A report in Antiviral Research, widespread interest, an FDA warning, two letters to the editor and the authors' responses 6-2020
  3. Surgisphere Sows Confusion About Another Unproven COVID-19 Drug The Scientist 16-6-2020

Immunosuppressives, Steroids and Anti-inflammatories

Dexamethasone

  1. Low-cost dexamethasone reduces death by up to one third in hospitalised patients with severe respiratory complications of COVID-19 16-6-2020 Dexamethasone reduced deaths by one-third in ventilated patients (rate ratio 0.65 [95% confidence interval 0.48 to 0.88]; p=0.0003) and by one fifth in other patients receiving oxygen only (0.80 [0.67 to 0.96]; p=0.0021). There was no benefit among those patients who did not require respiratory support (1.22 [0.86 to 1.75]; p=0.14). Based on these results, 1 death would be prevented by treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone.
  2. Drug recently shown to reduce coronavirus death risk could run out, experts warn Science 21-6-2020
  3. Steroids cut death rates among critically ill COVID-19 patients, major study finds Reuters 3-9-2020 Treating critically ill COVID-19 patients with corticosteroid drugs reduces the risk of death by 20%, an analysis of seven international trials found on Wednesday, prompting the World Health Organisation to update its advice on treatment. The analysis pooled data from separate trials of low dose hydrocortisone, dexamethasone and methylprednisolone - found that steroids improve survival rates of COVID-19 patients sick enough to be in intensive care in hospita from 60% to 68%l.
  4. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19
    A Meta-analysis
    JAMA 2-9-2020
  5. Psychiatric Adverse Effects of Corticosteroids Mayo Clinic 2006

General

  1. How does COVID-19 kill? Uncertainty is hampering doctors' ability to choose treatments Nature 9-3-2020 People infected with coronaviruses do not show symptoms until several days after infection. By then, collateral damage from the immune response often contributes to the illness as well as the effects of the virus itself. Steroids and other immune suppressants are already being tested against coronavirus in clinical trials. In March, UK researchers launched a clinical trial that will evaluate the steroid dexamethasone and other potential treatments for Covid-19. Evidence from previous outbreaks caused by related coronaviruses suggests that steroids hold little benefit, and might even delay the time it takes for patients to rid themselves of the virus. Although IL-6 levels are high in some acutely ill patients, viral loads are high as well, so reducing CD4 and CD8 T cells could undermine that response. Two specific IL-6 suppressing monoclonal antibodies are discussed in anntibidy treatments. But globally there is not enough of the drug to go round, and many clinicians are turning to steroids, which more broadly dampen the immune system. Steroids might significantly reduce the body's ability to fight infection overall. These drugs will not only suppress macrophages, but also CD4 T cells, crucial for initiating immune responses, and antiviral CD8 T cells, capable of destroying infected cells with more precision than macrophages.
  2. Anti-inflammatories may aggravate Covid-19, France advises Guardian 14-3-2020

Statins and Angiotensin inhibitors (ACEi / ARB)

  1. The effects of ARBs, ACEIs and statins on clinical outcomes of COVID-19 infection among nursing home residents medRxiv 11-5-2020 We found a statistically significant association between statin intake and the absence of symptoms during COVID-19 infection (unadjusted OR 2.91), which remained statistically significant after adjusting for age, sex, functional status, diabetes mellitus and hypertension. The strength of this association was considerable and clinically important. Although the effects of statin intake on serious clinical outcome (long-stay hospitalisation or death) were in the same beneficial direction, these were not statistically significant (OR 0.75; 62 CI 0.25-1.85; p=0.556). There was also no statistically significant association between angiotensin-converting enzyme inhibitors (ACEi), or angiotensin II receptor blockers (ARB) and asymptomatic status (OR 1.52) or serious clinical outcome (OR 0.79).
  2. Could Statins Reduce the Severity of COVID-19? The Scientist 12-6-2020
  3. Effect of Renin-Angiotensin-Aldosterone System inhibitors in patients with COVID-19: a systematic review and meta-analysis of 28,872 patients Current Atherosclerosis Reports 24-8-2020 Covid-19 patients with high blood pressure who were taking ACEi/ARB medications were 0.67 times less likely to have a critical or fatal outcome than those not taking these medications.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

P: Antibody Receptor and Interferon Treatments

Antibody treatments could provide short-term immunity and blunt the pandemic wave as well as saving lives in critical care, but there are also risks that incorrectly designed antibodies could exacerbate the infection as noted with dengue below (fig 13). Also anitbody treatments designed to reduce cytokine storm could also inhibit immune responses to accompanying bacterial or viral co-infection.

Receptor Protein Inhaler

  1. Covid 19 coronavirus: NZ-made 'virus decoy' proves promising NZ Herald 9-7-2020 To block the process, the team have made their own designer ACE2 proteins to use in an inhaler to lure the virus away from the actual receptors attached to sensitive cells.

Interferon Treatments Interferons, a subclass of cytokines, are produced in the body during illnesses such as influenza in order to help fight the infection. They are responsible for many of the symptoms of influenza infections. Interferon beta balances the expression of pro- and anti-inflammatory agents.

  1. Interferon fails the solidarity trial
  2. Prophylactic intranasal administration of a TLR2 agonist reduces upper respiratory tract viral shedding in a SARS-CoV-2 challenge ferret model bioRxiv 25-9-2020 By triggering the innate immune system this substance, called INNA-051, activates a number of processes including the release of signalling proteins called cytokines, which stimulate mechanisms that stop the virus replicating inside cells. The TLRs are key microbe-recognition receptors with a crucial role in activation of host defence. TLR2/6 agonists of the INNA compound series do not directly activate Type-1 interferons.
  3. 'Major' breakthrough in Covid-19 drug makes UK professors millionaires Guardian 24-7-2020 Synairgen's share price rises 540% on morning of news of successful drugs trial of interferon nebulizer.
  4. Synairgen announces positive results from trial of SNG001 in hospitalised COVID-19 patients Synairgen plc 20-7-2020 (1) Patients who received SNG001 had a 79% lower risk of developing severe disease compared to placebo. (2) Patients who received SNG001 were more than twice as likely to recover from COVID-19 as those on placebo.
  5. New Treatment for Covid-19 Shows Promise, but Scientists Urge Caution NYT 20-7-2020 Coronavirus attacks the body in part by blocking its natural interferon response, disarming cells that would otherwise be alerting neighboring cells to activate their own genes and fortify themselves against the invading virus. In theory, administering interferon to patients could invigorate its defenses in the early stages of illness. But giving patients interferon without eliciting serious side effects has proved challenging. The symptoms of a seasonal flu, for example, are largely produced by the mobilization of the body's interferon response, scientists said. The British drug company, Synairgen, tried to circumvent that problem by developing an inhaled form of interferon that directly targets cells in the lungs, rather than an injection, which can produce more intense side effects. It conducted a small, double-blind trial on patients hospitalized with Covid-19, the illness caused by the coronavirus, in nine British hospitals.
  6. Can boosting interferons, the body's frontline virus fighters, beat COVID-19? Science 8-7-2020
  7. An experimental trial of recombinant human interferon alpha nasal drops to prevent coronavirus disease 2019 in medical staff in an epidemic area medRxiv 7-5-2020 Results Among the 2944 subjects in our study, 2415 were included in the low-risk group, including 997 doctors and 1418 nurses with average ages of 37.38 and 33.56 years, respectively; 529 were included in the high-risk group, including 122 doctors and 407 nurses with average ages of 35.24 and 32.16 years, respectively. The 28-day incidence of COVID-19 was zero in both the high and low-risk groups. The 28-day incidence of new-onset clinical symptoms with negative images for pneumonia was also zero in both the high and low-risk groups.

Monoclonal and Engineered Antibodies

  1. Eli Lilly's Antibody Trial Is Paused Over Potential Safety Concern NYT 13-10-2020 The drugmaker's experimental antibody treatment is similar to the one President Trump received from Regeneron.
  2. SARS-CoV-2 neutralizing antibody structures inform therapeutic strategies Nature 12-10-2020 The structures discovered revealed that these neutralizing antibodies can be divided into several classes, according to which part of the spike protein’s cell-attachment region they recognize. Further experiments showed that mutations that allow viruses to evade one class of neutralizing antibody are unlikely to foil others.
  3. New antibody mix could form 'very potent' Covid-19 treatment, say scientists Guardian 22-7-2020Pharmaceutical company labs already manufacture antibodies in bulk, purifying them from cells that are grown in large fermenters. Estimates suggest that a dose of antibodies might cost $50 (£39) to produce.
  4. Antibody therapies could be a bridge to a coronavirus vaccine — but will the world benefit? Nature 12-8-2020 Monoclonal antibodies are complex and expensive to produce, meaning poor countries might be priced out.
  5. Potent neutralizing antibodies directed to multiple epitopes on SARS-CoV-2 spike Nature 22-7-2020 . Here we report the isolation of 61 SARS-CoV-2-neutralizing monoclonal antibodies from 5 infected patients hospitalized with severe disease. Among these are 19 antibodies that potently neutralized the authentic SARS-CoV-2 in vitro, 9 of which exhibited exquisite potency, with 50% virus-inhibitory concentrations of 0.7 to 9 ng/mL. Epitope mapping showed this collection of 19 antibodies to be about equally divided between those directed to the receptor-binding domain (RBD) and those to the N-terminal domain (NTD), indicating that both of these regions at the top of the viral spike are immunogenic. In addition, two other powerful neutralizing antibodies recognized quaternary epitopes that overlap with the domains at the top of the spike. Cryo-electron microscopy reconstructions of one antibody targeting RBD, a second targeting NTD, and a third bridging two separate RBDs revealed recognition of the closed, "all RBD-down" conformation of the spike. Several of these monoclonal antibodies are promising candidates for clinical development as potential therapeutic and/or prophylactic agents against SARS-CoV-2.
  6. REGN-COV2 antibody cocktail prevents and treats SARS-CoV-2 infection in rhesus macaques and hamsters bioRxiv 3-8-2020 We previously described Regeneron's REGN-COV2, a cocktail of two potent neutralizing antibodies (REGN10987+REGN10933) targeting non-overlapping epitopes on the SARS-CoV-2 spike
    protein.
  7. Regeneron's regn-cov2 antibody cocktail reduced viral levels and improved symptoms in non-hospitalized covid-19 patients 29-9-2020
  8. Antibody cocktail to SARS-CoV-2 spike protein prevents rapid mutational escape seen with individual antibodies Science 15-6-2020
  9. Coronavirus Antibody Therapies Raise Hopes—and Skepticism Sci. Am. 29-5-2020
  10. A coronavirus vaccine is still months away, but an antibody treatment could be closer CNN 26-6-2020
  11. Cross-neutralization of SARS-CoV-2 by a human monoclonal SARS-CoV antibody Nature 18-5-2020 One antibody, named S309, potently neutralizes SARS-CoV-2 and SARS-CoV pseudoviruses as well as authentic SARS-CoV-2 by engaging the S receptor-binding domain.
  12. Escape from neutralizing antibodies by SARS-CoV-2 spike protein variants bioRxiv 22-7-2020 Using a recombinant chimeric VSV/SARS-CoV-2 reporter virus, we show that functional SARS-CoV-2 S protein variants with mutations in the receptor binding domain (RBD) and N-terminal domain that confer resistance to monoclonal antibodies or convalescent plasma can be readily selected. Notably, SARS-CoV-2 S variants that resist commonly elicited neutralizing antibodies are now present at low frequencies in circulating SARS-CoV-2 populations.
  13. Tocilizumab (Actemra) By Roche Emerging As The Best Drug Candidate For Treating Covid-19 So Far While Others Are Simply Misleading Thai Med News 30-3-2020 Studies found that in Covid-19 in patients facing severe conditions leading to sepsis, organ failure and death, it was the 'cytokine storms' of the body's immune system that was causing the problems with increased inflammation even in the lungs. It was found by controlling or inhibiting the release of a protein called IL-6, many patients went into quicker recovery. Almost 95% percent of patients treated that way recovered faster. Tocilizumab, also known as atlizumab, is an immunosuppressive drug, mainly for the treatment of rheumatoid arthritis (RA) and systemic juvenile idiopathic arthritis, a severe form of arthritis in children. It is a humanized monoclonal antibody against the interleukin-6 receptor (IL-6R).
  14. Efficacy of Tocilizumab in Patients Hospitalized with Covid-19 JAMA 21-10-2020 Tocilizumab was not effective for preventing intubation or death in moderately ill hospitalized patients with Covid-19.
  15. Global trial to evaluate Kevzara (sarilumab) as COVID-19 therapy initiated EPR 30-3-2020 Kevzara is a fully-human monoclonal antibody (mAb) that inhibits the interleukin-6 (IL-6) pathway by binding and blocking the IL-6 receptor. IL-6 may play a role in driving the overactive inflammatory response in the lungs of patients who are severely or critically ill with COVID-19 infection. The role of IL-6 is supported by preliminary data from a single-arm study in China using another IL-6 receptor antibody.
  16. Baricitinib as potential treatment for 2019-nCoV acute respiratory disease Lancet 3-2-2020 Together with customisations bespoke to 2019-nCoV, we used BenevolentAI to search for approved drugs that could help, focusing on those that might block the viral infection process. We identified baricitinib, which is predicted to reduce the ability of the virus to infect lung cells.
  17. Cuba credits two drugs with slashing coronavirus death toll Reuters 22-5-2020 They appear to help calm a cytokine storm. One is itolizumab, a monoclonal antibody produced in Cuba and elsewhere. The other is a peptide that Cuba says its biotech industry discovered and has been testing for rheumatoid arthritis in Phase II clinical trials.
  18. COVID-19: combining antiviral and anti-inflammatory treatments Lancet 27-2-2020 Comparison of the properties of the three best candidates are shown in the table. Baricitinib, fedratinib, and ruxolitinib are potent and selective JAK inhibitors approved for indications such as rheumatoid arthritis and myelofibrosis. The most significant side-effect seen in clinical trial programmes used for European Medicines Agency registration was a small increase in upper respiratory tract infections (similar to that observed with methotrexate).
  19. A human monoclonal antibody blocking SARS-CoV-2 infection bioRxiv preprint 11-3-2020 We report a human monoclonal antibody that neutralizes SARS-CoV-2 (and SARS-CoV). This cross-neutralizing antibody offers potential for prevention and treatment of COVID-19. Coronavirus neutralizing antibodies primarily target the trimeric spike (S) glycoproteins on the viral surface that mediate entry into host cells. The S protein has two functional subunits that mediate cell attachment (the S1 subunit, existing of four core domains S1A through S1D) and fusion of the viral and cellular membrane (the S2 subunit). Potent neutralizing antibodies often target the receptor interaction site in S1, disabling receptor interactions. The spike proteins of SARS-CoV-2 (SARS2-S; 1,273 residues, strain Wuhan-Hu-1) and SARS-CoV (SARS-S, 1,255 residues, strain Urbani) are 77.5% identical by primary amino acid sequence, are structurally very similar and commonly bind the human angiotensin coverting enzyme 2 (ACE2) protein as a host receptor. The human 47D11 antibody, discovered through searching for cross-reactivity in animal models, binds to cells expressing the full-length spike proteins of 60 SARS-CoV and SARS-CoV-2 The 47D11 antibody was found to potently inhibit infection in vitro.
  20. Human monoclonal antibodies block the binding of SARS-CoV-2 spike protein to angiotensin converting enzyme 2 receptor Cellular & Molecular Immunology 20-4-2020 We have successfully cloned two human blocking mAbs using SARS-CoV-2 RBD-specific memory B cells isolated from recovered COVID-19 patients. These two mAbs can specifically bind to SARS-CoV-2 RBD, block the interaction between SARS-CoV2 RBD and hACE2 receptor, and lead to efficient neutralization of SARS-CoV-2 S protein pseudotyped virus infection.
  21. 'Pandemic' scientist says his team has discovered potential cure for COVID-19 CBS8 30-3-2020 We took a series of five antibodies from around 2002 that were able to neutralize SARS. We were able to use technology in our laboratories to evolve those antibodies against SARS to adapt them to recognize COVID-19.
  22. A highly conserved cryptic epitope in the receptor-binding domains of SARS-CoV-2 and SARS-CoV Science 3-4-2020 The study is the first to map a human antibody's interaction with the new coronavirus at near-atomic-scale resolution. Although the antibody was produced in response to an infection of SARS, it cross-reacts with SARS-CoV-2. The structural mapping revealed a nearly identical site on both coronaviruses to which the antibody binds, suggesting a functionally important and vulnerable site for this family of coronaviruses. The knowledge of conserved sites like this can aid in structure-based design of vaccines and therapeutics against SARS-CoV-2, and these would also protect against other coronaviruses -- including those that may emerge in the future.

Convalescent Sera, Stem Cells and Blood Filtration

People seriously ill with COVID-19 experienced striking improvement after receiving infusions of blood from disease survivors, according to two separate research teams.

  1. FDA Issues Emergency Use Authorization for Convalescent Plasma as Potential Promising COVID–19 Treatment FDA 23-8-2020
  2. FDA commissioner defends authorization of convalescent plasma CNN 25-8-2020 Hahn denied that his agency had been pressured by Trump to authorize the use of plasma, but apologized for how he characterized data used in the decision. The study, which has not yet been peer-reviewed, showed that 8.7% of patients who were treated within 3 days of diagnosis died, compared to 11.9% of patients who were treated 3 days or more after their diagnosis. Those treated with plasma containing the highest levels of antibodies had a 35% lower risk of dying within a week (8.9%) compared to those treated with less-rich plasma (13.7%). There was no placebo and 49.8% were treated with steroids and 30.1% with redesivir.
  3. Evidence lags behind excitement over blood plasma as a coronavirus treatment Nature 19-8-2020  Researchers call for more rigorous clinical trials as rumours abound that US regulators are considering widening access to the potential therapy but there’s little evidence that plasma actually helps patients, and the decision could confound efforts to study its effects.
  4. The feasibility of convalescent plasma therapy in severe COVID19 patients: a pilot study MedRxiv 23-3-2020 By the sixth day after the treatment, the virus that causes COVID-19 was undetectable in seven of the ten. The recipients experienced no significant side effects.
  5. Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma JAMA 27-3-2020 Symptoms dwindled in all five; within ten days of receiving the plasma, three recipients no longer needed ventilators.
  6. Uncertain Results in Study of Convalescent Serum for Covid-19 NYT 22-5-2020 Analyses like the following study - the most complete so far - are fraught with difficulties. The only way to know for sure if the treatment works is to randomly assign patients to receive antibodies or a placebo. And it can be impossible to find many patients who agree to have their treatment randomized to an unknown treatment.
  7. Convalescent plasma treatment of severe COVID-19: A matched control study medRxiv 22-5-2020 Convalescent plasma recipients were more likely than control patients to remain the same or have improvements in their supplemental oxygen requirements by post-transfusion day 14, with an odds ratio of 0.86. Convalescent plasma transfusion improved survival for non-intubated patients, but not for intubated patients. The death rates were 12.8 percent among those who got the antibodies, compared with 24.4 percent among the patients who did not get this treatment.
  8. The convalescent sera option for containing COVID-19 J. Clin. Investig 13-3-2020 Yesterday, a team at Johns Hopkins University led by Arturo Casadevall received FDA approval to try this technique. "This has a high probability of working, based on 100 years of experience in medicine," he says. Indeed, it was used successfully to treat Ebola in 2014.
  9. Blood from people who recover from coronavirus could provide a treatment Wash. Post 28-3-2020
  10. Are Mesenchymal Stem Cells a Promising Treatment for COVID-19? The Scientist 9-4-2020
  11. Transplantation of ACE2- Mesenchymal Stem Cells Improves the Outcome of Patients with COVID-19 Pneumonia Aging and Disease 13-3-2020
  12. Mesenchymal Stem Cell Therapy for COVID-19: Present or Future Stem Cell Revs. 13-4-2020
  13. ExThera's Affinity Blood Filter Is Used to Treat COVID-19 Patients March 26, 2020 In recent EU clinical cases improved lung function and rapid reduction of drug-resistant bacterial pathogens occurred with Seraph 100 treatment. Stabilization of blood pressure has also been observed, including during COVID-19 treatment. Another potential benefit of Seraph 100 treatment of COVID-19 is reduction in bloodborne virus/RNA, and the simultaneous treatment of bacterial and fungal 'secondary infections'.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 11: Left: Vaccines under development Nature. Right San Diego Tribune (click to enlarge).

Q: Vaccines and Virus Delivered Gene Therapies

Corona viruses appear to evolve only about half as fast as influenza viruses, so there is hope that a protective vaccine can be produced. However even after 20 years of a pandemic caused by HIV we still have not managed to produce an effective vaccine, so there is no guarantee. Furthermore attempts below to create a vaccine for closely-related SARS remain equivocal and there is still no vaccine for MERS.

  1. All eyes on a hurdle race for a SARS-CoV-2 vaccine Nature 19-10-2020 Leading COVID-19 vaccine candidates have progressed through laboratory tests at record speed. Two early clinical trials suggest that immunization delivers a favourable immune response and safety profile, but questions remain.
  2. How anti-ageing drugs could boost COVID vaccines in older people Nature 14-10-2020 COVID-19 poses the greatest threat to older people, but vaccines often don't work well in this group. Scientists hope drugs that rejuvenate the immune system will help.
  3. Pfizer says it will not have a coronavirus vaccine until late November, allaying fears of a rush for approval before Election Day Wash. Post 16-10-2020
  4. 2nd COVID-19 vaccine trial paused over unexplained illness AP 13-10-2020 A late-stage study of Johnson & Johnson's COVID-19 vaccine candidate has been paused while the company investigates whether a study participant's "unexplained illness" is related to the shot.
  5. White House Blocks New Coronavirus Vaccine Guidelines 5-10-2020 The F.D.A. proposed stricter guidelines for emergency approval of a coronavirus vaccine, but the White House chief of staff objected to provisions that would push approval past Election Day.
  6. FDA discloses vaccine guidelines blocked by White House AP 7-10-2020Vvaccine makers should follow trial participants for at least two months to rule out safety issues before seeking emergency approval. That requirement would almost certainly preclude the introduction of a vaccine before Nov. 3.
  7. Inside the Australian lab working round the clock to produce 100m doses Guardian 10-10-2020
  8. The race inside Russia's coronavirus vaccine laboratory CNN 5-10-2020
  9. Push to bring coronavirus vaccines to the poor faces trouble AP 1-10-2020 In one of the biggest obstacles, rich countries have locked up most of the world's potential vaccine supply through 2021, and the U.S. and others have refused to join the project, called Covax.
  10. Covax: Covid vaccine global effort gets China's support Guardian 9-10-2020
  11. Moderna chief says Covid-19 vaccine won't be widely available before late March CNN 2-10-2020
  12. Oxford University vaccine trial paused after participant falls ill BBC 9-9-2020 The New York Times is reporting a volunteer in the UK trial has been diagnosed with transverse myelitis, an inflammatory syndrome that affects the spinal cord and can be caused by viral infections. While her diagnosis had not been confirmed yet, she was improving and was due to be discharged from hospital this week. The woman had been injected with AstraZeneca's vaccine, not a placebo. This isn't the first time the company's vaccine trial has been halted due to the health of a participant. The clinical trial was stopped in July after another participant experienced neurological symptoms also claimed to be transverse myelitis. On further investigation though, the participant was diagnosed with multiple sclerosis with health authorities deeming it unrelated to the coronavirus vaccine. However this can also be caused by a virus. Trial recontinued 12-9-2020
  13. COVID-vaccine results are on the way — and scientists' concerns are growing Nature 25-9-2020 Researchers warn that vaccines could stumble on safety trials, be fast-tracked because of politics or fail to meet the public's expectations.
  14. NIH 'very concerned' about serious side effect in AstraZeneca coronavirus vaccine trial CNN 15-9-2020
  15. Internal AstraZeneca safety report sheds light on neurological condition suffered by vaccine trial participant CNN 17-9-2020
  16. Facial Masking for Covid-19 — Potential for "Variolation" as We Await a Vaccine NEMJ 12-9-2020
  17. What the immune response to the coronavirus says about the prospects for a vaccine Nature 18-8-2020
  18. The unequal scramble for coronavirus vaccines — by the numbers Nature 24-8-2020
  19. What if the First Coronavirus Vaccines Aren't the Best? NYT 27-8-2020
  20. Vaccine CEOs issue safety pledge amid Trump's quest for pre-election approval Wash Post 8-9-2020 Nine chief executives issued an extraordinary joint statement Tuesday seeking to bolster faith in coronavirus vaccine. BBC Source Statement
  21. CDC tells states: Be ready to distribute vaccines on Nov. 1 AP 3-9-2020 The timeline raised concern among public health experts about an "October surprise" - a vaccine approval driven by political considerations ahead of a presidential election, rather than science. "The COVID-19 vaccine landscape is evolving and uncertain, and these scenarios may evolve as more information is available," the document reads. Another of the documents says that limited COVID-19 vaccine doses may be available by early November and that supply will increase substantially in 2021. It also states that initially available vaccines will either be approved by the Food and Drug Administration or authorized by the agency under its emergency powers. Final stage trials of experimental vaccines are still recruiting, and are at best halfway through that process. Experts told the AP they did not understand how there could be adequate data on whether the vaccines work and are safe before Nov 1.
  22. Trump's vaccine chief sees a 'very, very low chance' of a vaccine by Election Day NYT 3-9-2020
  23. Past vaccine disasters show why rushing a coronavirus vaccine now would be 'colossally stupid' CNN 1-9-2020
  24. Scientists see downsides to top COVID-19 vaccines from Russia, China Reuters 31-8-2020 They are based on a common cold virus that many people have been exposed to, potentially limiting their effectiveness
  25. Elicitation of potent neutralizing antibody responses by designed protein nanoparticle vaccines for SARS-CoV-2 bioRxiv 12-8-2020
  26. Here's how the U.S. could release a COVID-19 vaccine before the election—and why that scares some Science 28-8-2020
  27. COVID-19 vaccine trials should seek worthwhile efficacy Lancet 27-8-2020
  28. Trump, without evidence, accuses FDA of delaying coronavirus vaccine trials CNN 23-8-2020
  29. Alarm as FDA willing to issue Covid-19 vaccine before stringent safety testing Guardian 31-8-2020
  30. Trump aides, meeting with lawmakers, reportedly said a vaccine would be approved before the election NYT 24-8-2020 The move would be highly unusual and would most likely prompt concerns about whether the administration is cutting corners on approvals for political purposes.
  31. Oxford University Covid-19 vaccine firm says it is not in talks with Trump Guardian 24-8-2020 In a statement insisted it had "not discussed emergency use authorisation with the US government and it would be premature to speculate on that possibility. Llate stage phase 2/3 trials for [the vaccine] are ongoing in the UK and other markets globally, and we do not anticipate efficacy results until later this year". One option being explored by the Trump administration would involve the FDA awarding an EUA (emergency use authorisation) for the vaccine in October on the basis of the relatively small UK study. US government licensing rules usually require studies on up to 30,000 people – three times the scale of the UK testing already under way.
  32. 'Possible' Oxford vaccine data will be put before regulators this year Guardian 26-8-2020 Trials of the Oxford coronavirus vaccine may have gathered enough data to show whether it works and is safe by the end of the year – but it will then need to go through the regulatory process. Prof Andrew Pollard, the director of the Oxford Vaccine Group, said it is "just possible" that there may be enough clinical trial data on Oxford University's Covid-19 vaccine to put before the regulators this year.
  33. Dr Anthony Fauci warns against rushing out vaccine BBC 25-8-2020 "The one thing that you would not want to see with a vaccine is getting an EUA before you have a signal of efficacy," Reuters quoted Fauci as saying. "One of the potential dangers if you prematurely let a vaccine out is that it would make it difficult, if not impossible, for the other vaccines to enroll people in their trial."
  34. Top FDA official says would resign if agency rubber-stamps an unproven COVID-19 vaccine Reuters 21-8-2020
  35. Inside the company at the forefront of China's push to develop a coronavirus vaccine CNN 27-8-2020
  36. Russia approves coronavirus vaccine despite testing safety concerns Guardian 11-8-2020 Drug, given to one of Vladimir Putin's daughters, skipped large-scale safety trials
  37. 'They've jumped the gun': scientists worry about Russia's Covid-19 vaccine Guardian 12-8-2020 The vaccine could either induce ADE or not fully protect, resulting in resistant covid strains.
  38. Here's what we know about Russia's unverified coronavirus vaccine Sci. News 11-8-2020 The vaccine uses a two phase pair of innoculations. the two-part vaccine. Both parts start with viruses that cause the common cold. Those viruses, adenovirus 5 and adenovirus 26, were each engineered to make the coronavirus' spike protein. Because the body may develop antibodies to the adenovirus carrying the spike protein, a booster shot with that same virus might be rendered useless. The two-step inoculation with different adenoviruses may sidestep that issue. AstraZeneca uses a chimpanzee adenovirus. CanSino is based on adenovirus 5. Johnson & Johnson uses adenovirus 26 for its vaccine.
  39. Moderna's clinical trial numbers show there's 'no way' Trump can have a vaccine by Election Day CNN 10-8-2020 Phase 1 trial results
  40. A COVID-19 vaccine may come soon. Will the blistering pace backfire? Sci. News 10-7-2020
  41. Developing a SARS-CoV-2 Vaccine at Warp Speed JAMA 19-7-2020
  42. China's coronavirus vaccines are leaping ahead – but face challenges as virus wanes Nature 31-7-2020
  43. The potential danger of suboptimal antibody responses in COVID-19 Nature Revs. Imun. 6-2020 Although they could (1) provide resistance to Cov-2, they could also (2) facilitate virus entry, or (3)activate inflammatory cytokines.
  44. A perspective on potential antibody-dependent enhancement of SARS-CoV-2 Nature 13-7-2020 The possibility of antibody-dependent enhancement(ADE) of disease is a general concern for the development of vaccines and antibody therapies because the mechanisms that underlie antibody protection have the theoretical potential to amplify viral infections or trigger immunopathology. Observations relevant to the risks of ADE of disease require careful review at this critical point in the SARS-CoV-2 pandemic. At present, no clinical fndings, immunologic assays or biomarkers are known to diferentiate any severe viral infection from immune-enhanced disease, whether by antibodies, T cells or intrinsic host responses. In vitro systems and animal models do not predict the risk of ADE of disease, in part because protective and potentially detrimental antibody-mediated mechanisms are the same, and designing animal models depends on understanding how antiviral host responses may become harmful in people. The implications of our lack of knowledge are twofold. First, comprehensive studies are urgently needed to defne clinical correlates of protective immunity against SARS-CoV-2. Second, since we cannot predict ADE of disease reliably after either vaccination or treatment with antibodies, regardless of what virus is the causative agent, it will be essential to depend on careful analysis of safety in humans as immune interventions for COVID-19 disease move forward.
  45. Pfizer-BioNTech potential coronavirus vaccine shows promise in second early trial Reuters 20-7-2020
  46. A single-dose intranasal ChAd vaccine protects upper and lower respiratory tracts against SARS-CoV-2 Cell 14-8-2020 A candidate vaccine encoding the SARS-CoV-2 spike protein was given to a candidatevaccine encoding the SARS-CoV-2 spike protein. After being injected with the vaccine and then exposed to SARS-CoV-2, mice showed no infectious virus in their lungs — but their lungs did harbour small amounts of viral RNA. By contrast, mice that had the vaccine inserted up their noses before exposure had no measurable viral RNA in their lungs.
  47. An adenovirus-vectored COVID-19 vaccine confers protection from SARS-COV-2 challenge in rhesus macaques Nature Comm. 21-8-2020 The researchers found that both nasal and injected forms of the vaccine protected rhesus macaques (Macaca mulatta) from infection.
  48. Single-shot Ad26 vaccine protects against SARS-CoV-2 in rhesus macaques Nature 30-7-2020 The optimal Ad26 vaccine induced robust neutralizing antibody responses andprovided complete or near-complete protection in bronchoalveolar lavage and nasal swabs following SARS-CoV-2 challenge. Vaccine-elicited neutralizing antibody titres correlated with protective efficacy, suggesting an immune correlate of protection. These data demonstrate robust single-shot vaccine protection against SARS-CoV-2 in nonhuman primates. 
  49. Be prepared for Covid-19 vaccine side effects Stuff/Newsroom 24-7-2020
  50. An mRNA Vaccine against SARS-CoV-2 — Preliminary Report NEJM 14-7-2020 The vaccine developed by the biotechnology company Moderna in partnership with the National Institutes of Health has been found to induce immune responses in all of the volunteers who received it in a Phase 1 study. Yhe vaccine worked to trigger an immune response with mild side effects -- fatigue, chills, headache, muscle pain, pain at the injection site. The vaccine is expected to begin later this month a large Phase 3 trial -- the final trial stage before regulators consider whether to make the vaccine available.
  51. Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial Lancet 20-7-2020. There were no serious adverse events. In the vaccine group, spike-specific T-cell responses peaked on day 14 (median 856 spot-forming cells per million peripheral blood mononuclear cells). Anti-spike IgG responses rose by day 28 (median 157 ELISA units), and were boosted following a second dose (639 EU). Neutralising antibody responses against SARS-CoV-2 were detected in 32 (91%) of 35 participants after a single dose when measured in MNA80 and in 35 (100%) participants when measured in PRNT50. After a booster dose, allparticipants had neutralising activity (nine of nine in MNA80 at day 42 and ten of ten in Marburg VN on day 56). Neutralising antibody responses correlated strongly with antibody levels measured by ELISA.
  52. ChAdOx1 nCoV-19 vaccine prevents SARS-CoV-2 pneumonia in rhesus macaques Nature 30-7-2020
  53. CanSino's COVID-19 vaccine candidate approved for military use in China Reuters 29-6-2020
  54. Ensuring global access to COVID-19 vaccines Lancet 2-5-2020
  55. $2bn global coronavirus vaccine fund announced at Gavi summit Guardian 5-6-2020
  56. The COVID-19 vaccine development landscape Nature 9-4-2020 As of 8 April 2020, the globalCOVID-19 vaccine R&D landscape includes 115 vaccine candidates (fig 11), of which 78 are confirmed as active and 37 are unconfirmed (development status cannot be determined from publicly available or proprietary information sources). Of the 78 confirmed active projects, 73 are currently at exploratory or preclinical stages. The most advanced candidates have recently moved into clinical development, including mRNA-1273 from Moderna, Ad5-nCoV from CanSino Biologicals, INO-4800 from Inovio, LV-SMENP-DC and pathogen-specific aAPC from Shenzhen Geno-Immune Medical Institute. Novel platforms based on DNA or mRNA offer great flexibility in terms of antigen manipulation and potential for speed. Vaccines based on viral vectors offer a high level of protein expression and long-term stability, and induce strong immune responses. Finally, there are already licensed vaccines based on recombinant proteins for other diseases, and so such candidates could take advantage of existing large-scale production capacity.
  57. Coronavirus vaccine trial by Imperial College begins Guardian 16-6-2020 The Imperial vaccine uses synthetic strands of genetic code based on the genetic material of Sars-CoV-2.
  58. Warp-speed: Top U.S. scientists left out of White House selection of COVID-19 vaccine short list Science 4-6-2020
  59. Operation Warp Speed's opaque choices of COVID-19 vaccines draw Senate scrutiny Science 2-7-2020
  60. COVID-19 Vaccine Developers Search for Antibodies That 'First Do No Harm' Sci. Am. 28-5-2020 If some of the antibodies produced do not bind to the virus well enough — or are not present in the right concentration — they can latch onto it and exacerbate disease through a process known as antibody-dependent enhancement (ADE).
  61. Early results from Moderna RNA coronavirus vaccine trial show participants developed antibodies against the virus CNN 18-5-2020
  62. Moderna unveiled encouraging coronavirus vaccine results. Then top execs dumped nearly $30 million of stock CNN 22-5-2020 Some calling for an Investigation after second set of sales CNN 1-6-2020
  63. Linkage between endosomal escape of LNP-mRNA and loading into EVs for transport to other cells Nature Comm. 24-9-2019 The moderna vaccine is the RNA code for the spike protein encapsulated in LNPs (lipid nanoparticles).
  64. ChAdOx1 nCoV-19 vaccination prevents SARS-CoV-2 pneumonia in rhesus macaques bioRxiv 13-5-2020 While the Oxford vaccine was shown in a safety study to protect macaque monkeys against pneumonia, it did not stop infection – which could leave people liable to spread the virus, even if they do not get sick themselves. Their noses harboured as much virus as unvaccinated animals. The vaccine is a made of a chimpanzee virus that has been genetically altered to produce a coronavirus protein.
  65. AstraZeneca-Oxford trial COVID vaccine moves to crucial phase with $1 billion in U.S. backing CBS 22-5-2020 AZD1222 vaccine shows more promise than most. Trials will expand testing with the enrollment of more than 10,000 people, including children age 5 to 12, and people over 70.
  66. Development of an inactivated vaccine candidate for SARS-CoV-2 Science 6-5-2020 The Sinovac vaccine is comprised of chemically inactivated SARS-CoV-2 particles.
  67. DNA vaccine protection against SARS-CoV-2 in rhesus macaques Science 20-5-2020 Vaccinated animals developed humoral and cellular immune responses, including neutralizing antibody titers comparable to those found in convalescent humans and macaques infected with SARS-CoV-2. Following vaccination, all animals were challenged with SARS-CoV-2, and the vaccine encoding the full-length S protein resulted in reductions in median viral loads in bronchoalveolar lavage and nasal mucosa, respectively. Vaccine-elicited neutralizing antibody titers correlated with protective efficacy, suggesting an immune correlate of protection.
  68. Safety, tolerability, and immunogenicity of a recombinant adenovirus type-5 vectored COVID-19 vaccine: a dose-escalation, open-label, non-randomised, first-in-human trial Lancet 22-5-2020 The CanSino Biologics Ad5 vectored COVID-19 vaccine is tolerable and immunogenic at 28 days post-vaccination. Humoral responses against SARS-CoV-2 peaked at day 28 post-vaccination in healthy adults, and rapid specific T-cell responses were noted from day 14 post-vaccination.
  69. A Candidate Vaccine for Covid-19 (SARS-CoV-2) Developed from Analysis of its General Method of Action for Infectivity QRB Discovery 28-5-2020 We show the non-receptor dependent phagocytic general method of action to be specifically related to cumulative charge from inserted sections placed on the SARS-CoV-2 Spike surface in positions to bind efficiently by salt bridge formations.
  70. Coronavirus vaccine trials have their first results — but their promise is still unclear Nature 19-5-2020
  71. Doubts greet $1.2 billion bet by United States on a coronavirus vaccine by October Science 22-5-2020
  72. Why we might not get a coronavirus vaccine Guardian 22-5-2020
  73. The race for coronavirus vaccines: a graphical guide Nature 28-4-2020
  74. Five organisations in the race to develop a coronavirus vaccine Guardian 18-5-2020 Moderna, CanSino, Oxford University, Imperial College London and Inovio are all making progress
  75. Coronavirus: Kiwi company 'cautiously optimistic' on developing Covid-19 vaccine Stuff 23-5-2020
  76. The Current and Future State of Vaccines, Antivirals and Gene Therapies Against Emerging Coronaviruses Front Microbiol. 24-4-2020 The authors review possible strategies against SARS-CoV-2, SARS-CoV-1, MERS-CoV as well as future coronaviruses including a comprehensive overview of possible antivirals and vaccines. They propose that the most promising approaches for fast progress are selected antivirals and gene therapy delivered through the adeno-associated virus (AAV). This would entail the fast, targeted delivery of antibodies, immunoadhesins, antiviral peptides, and immunomodulators to the upper airways, to give short-term protection.
  77. COVID-19 Vaccine Frontrunners The Scientist 7-4-2020
  78. In quest for vaccine, US makes 'big bet' on company with unproven technology CNN 1-5-2020 On April 16, when the federal Biomedical Advanced Research and Development Authority (BARDA) awarded Moderna up to $483 million to accelerate the development and manufacturing of their RNA vaccine. That amounts to about half of what the federal agency has doled out, with Janssen Research & Development -- part of Johnson & Johnson -- receiving $456 million, and a third company, Sanofi, receiving up to $30 million. But Moderna's RNA vaccine is an unproven technology.
  79. Analysis of the mutation dynamics of SARS-CoV-2 reveals the spread history and emergence of 2 RBD mutant with lower ACE2 binding affinity BioRxiv 11-4-2020 The discrepant phylogenies for the spike protein and its receptor binding domain proved a previously reported structural rearrangement prior to the emergence of SARS-CoV-2. Despite that we found the spike glycoprotein of SARS-CoV-2 is particularly more conserved, we identified a mutation that leads to weaker receptor binding capability, which concerns a SARS-CoV-2 sample collected on 27th January 2020 from India. This represents the first report of a significant SARS-CoV-2 mutant, and raises the alarm that the ongoing vaccine development may become futile in future epidemic if more mutations were identified.
  80. No vaccine for coronavirus a possibility Professor Ian Frazer, the immunologist who co-invented the human papilloma virus (HPV) vaccine which prevents cervical cancer says COVID-19 may never have a preventive vaccine, but could possibly burn out. There is no vaccine for the common cold. It is tricky, making vaccines for upper respiratory tract diseases, because the virus lands on the outside of you. Coronavirus doesn't get into you, it stays on the surface cells in your lungs. Flu viruses get into you, so the body can fight and makes T cells.The wrong vaccine could make things worse so we have to be very selective about what part of the virus we want to attack. At the moment we don't know how to make a coronavirus vaccine work. That's why there are 100 vaccines under testing using every conceivable approach.
  81. Rapid development of an inactivated vaccine for SARS-CoV-2 bioRxiv 19-4-2020 Here we developed a pilot-scale production of a purified inactivated SARS-CoV-2 virus vaccine candidate (PiCoVacc), which induced SARS-CoV-2-specific neutralizing antibodies in mice, rats and non-human primates. These antibodies potently neutralized 10 representative SARS-CoV-2 strains, indicative of a possible broader neutralizing ability against SARS-CoV-2 strains circulating worldwide. COVID-19 vaccine protects monkeys from new coronavirus, Chinese biotech reports Science 22-4-2020
  82. The SARS-CoV-2 receptor-binding domain elicits a potent neutralizing response without antibody-dependent enhancement bioRxiv 12-4-2020 The SARS-CoV-2 spike (S) protein protein engages ACE2 through its receptor-binding domain (RBD). Here we show that immunization with the SARS-CoV-2 RBD elicits a robust neutralizing antibody response in rodents, comparable to 100 μg/ml of ACE2-Ig, a potent SARS-CoV-2 entry inhibitor. Importantly, anti-sera from immunized animals did not mediate antibody- dependent enhancement (ADE) of S-protein-mediated entry under conditions in which Zika virus ADE was readily observed.
  83. In Race for a Coronavirus Vaccine, an Oxford Group Leaps Ahead NYT 28-4-2020 As scientists at the Jenner Institute prepare for mass clinical trials, new tests show their vaccine to be effective in monkeys. They say their vaccine could be ready by September.
  84. With record-setting speed, vaccine makers take their first shots at the new coronavirus Science 31-3-2020 The vaccine Jennifer Haller, fig 11, volunteered to test is made by Moderna, a well-financed biotech that has yet to bring a product to market. No mRNA vaccine has yet reached a phase III clinical trial, let alone been approved for use. But producing huge numbers of vaccine doses may be easier for mRNA vaccines than for traditional ones, says Mariola Fotin-Mleczek of the German company CureVac, which is also working on mRNA vaccine for the new coronavirus. CureVac's experimental rabies vaccine showed a strong immune response with a single microgram of mRNA. That means 1 gram could be used to vaccinate 1 million people.
  85. Trial of Coronavirus Vaccine mRNA-1273 Made by Moderna Begins in Seattle NYT 16-3-2020 Despite the rapid progress, even if the vaccine is proved safe and effective against the virus, it will not be available for at least a year. Moderna uses messenger RNA to make vaccines. But no vaccine made with this technology has yet reached the market. Researchers at Moderna and the National Institute of Allergy and Infectious Diseases identified part of the sequence that codes for a spike-like protein on the surface of the virus that attaches to human cells, helping the virus to invade them. That spike sequence is the basis for the vaccine. Moderna does not use the virus to produce its vaccine, but synthesizes the stretch of RNA required for the vaccine and embeds it in a lipid nanoparticle.
  86. Single-Dose, Intranasal Immunization with Recombinant Parainfluenza Virus 5 Expressing Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Spike Protein Protects Mice from Fatal MERS-CoV Infection mBio 4-2020
  87. Microneedle array delivered recombinant coronavirus vaccines: Immunogenicity and rapid translational development EBioMedicine 18-3-2020 Here we describe the development of MNA delivered MERS-CoV vaccines and their pre-clinical immunogenicity. Specifically, MNA delivered MERS-S1 subunit vaccines elicited strong and long-lasting antigen-specific antibody responses. Building on our ongoing efforts to develop MERS-CoV vaccines, promising immunogenicity of MNA-delivered MERS-CoV vaccines, and our experience with MNA fabrication and delivery, including clinical trials, we rapidly designed and produced clinically-translatable MNA SARS-CoV-2 subunit vaccines within 4 weeks of the identification of the SARS-CoV-2 S1 sequence. Most importantly, these MNA delivered SARS-CoV-2 S1 subunit vaccines elicited potent antigen-specific antibody responses that were evident beginning 2 weeks after immunization.
  88. The $1 billion bet: Pharma giant and U.S. government team up in all-out coronavirus vaccine push Science 1-4-2020 Janssen's vaccine is built around an engineered version of adenovirus 26 (Ad26), which normally causes common colds but has been disabled so that it cannot replicate. Company scientists stich into this Ad26 "vector" a gene for the surface protein from the new coronavirus spreading around the world. Janssen is testing this same Ad26 platform in vaccines against Ebola, HIV, respiratory syncytial virus, and Zika.
  89. Coronavirus: Australian scientists begin tests of potential vaccines BBC 1-3-2020 Scientists in Australia have begun testing two potential coronavirus vaccines in "milestone" lab trials. The vaccines, made by Oxford University and US company Inovio Pharmaceutical, have been cleared for animal testing (in ferrets) by the World Health Organization. Australia's national science agency will assess if the vaccines work, and if they would be safe for humans. One option, developed by the University of Oxford, is a vector vaccine. It uses a "defective" virus to introduce the proteins of the coronavirus to the immune system and induce a response. The other vaccine - from Inovio - is designed to encode certain proteins of the coronavirus to the immune system, prompting the body's cells to generate those proteins before the immune system reacts to them.
  90. The timetable for a coronavirus vaccine is 18 months. Experts say that's risky CNN 31-3-2020 A messenger RNA vaccine has never been approved as a product for distribution. Developed by NIAID scientists at Moderna, unlike most other licensed vaccines it does not use any part of the live virus. Amesh Adalja notes: "It's a very elegant solution, and that's why they could go to vaccine trials so quickly, because all they need is a sequence of the virus." Still, he thinks the process will exceed 18 months. The typical vaccine takes between eight and 10 years to develop. Paul Offit, the co-inventor of the rotavirus vaccine, put it bluntly: "When Dr. Fauci said 12 to 18 months, I thought that was ridiculously optimistic and I'm sure he did, too". The rotavirus effort spanned 26 years. The trial period took 16 years. In 2019, WHO prequalified a vaccine for Ebola, so health officials could start using it in at-risk countries. WHO said the 5 years was the fastest licencing process it had ever conducted. It took 4 years for the mumps and measles vaccine to be approved. There are also huge risks. "You're giving this vaccine, likely, to healthy people -- who are not the people typically who are dying from this infection". In 1976, Gerald Ford's administration reacted at speed to a novel swine flu outbreak. After 45 million people were vaccinated, the flu turned out to be mild and a disproportionately high number of the vaccinated -- roughly 450 in all -- had developed Guillain-Barré syndrome, a rare disorder in which the body's immune system attacks the nerves, leading to paralysis. At least 30 people died. A crush of lawsuits against the federal government followed.
  91. COVID-19 Vaccines Are Coming, but They're Not What You Think The Atlantic on RNA vaccines and convalescent serum. Despite successes in animals, the RNA vaccine approach has never yielded a vaccine approved for human use.
  92. SARS vaccines: where are we? NCBI 2009 We discuss inactivated vaccines, virally and bacterially vectored vaccines, recombinant protein and DNA vaccines, as well as the use of attenuated vaccines. Data regarding the correlates of protection, animal models and the available evidence regarding potential vaccine enhancement of SARS disease are discussed. While there is much evidence that various vaccine strategies against SARS are safe and immunogenic, vaccinated animals still display significant disease upon challenge.
  93. Coronavirus treatment: Vaccines/drugs in the pipeline for Covid-19 Clinial Trials 20-3-2020
  94. Should scientists infect healthy people with the coronavirus to test vaccines? Nature 27-3-2020
  95. Human challenge studies to accelerate coronavirus vaccine licensure HarvardControlled human challenge trials of SARS-CoV-2 vaccine candidates could accelerate the testing and potential rollout of efficacious vaccines. By replacingconventional Phase 3 testing of vaccine candidates, such trials may subtract many months from the licensure process, making efficacious vaccines available more quickly. Obviously, challenging volunteers with this live virus risks inducing severe disease and possibly even death.However, we argue that such studies, by accelerating vaccine evaluation, could reduce the global burden of coronavirus-related mortality and morbidity.
  96. Can existing live vaccines prevent COVID-19? Science 12-6-2020 Oral poliovirus vaccine (OPV), comprising live attenuated viruses, can reduce the incidence of other infections. In 2014, an expert panel at the WHO reviewed the evidence for nonspecific effects of live vaccines and concluded that they reduced childhood mortality by more than would be expected through their effects on the diseases they prevent. Non-live (inactivated) vaccines do not seem to have the same effects, suggesting that replicating attenuated pathogens induce a broader immune response. Some of the nonspecific effects of vaccines may be mediated by interferons. However, the mechanism may be more complex and diverse. Numerous studies have shown that BCG activates the innate immune system, resulting in enhanced responsiveness to subsequent triggers, so-called "trained innate immunity".
  97. Preventative TB BCG vaccine trial for COVID-19 healthcare workers
  98. Correlation between universal BCG vaccination policy and reduced morbidity and mortality for COVID-19: an epidemiological study MedRxiv 28-3-2020 BCG vaccination has been reported to offer broad protection to respiratory infections. We compared large number of countries BCG vaccination policies with the morbidity and mortality for COVID-19. We found that countries without universal policies of BCG vaccination (Italy, Nederland, USA) have been more severely affected compared to countries with universal and long-standing BCG policies. Countries that have a late start of universal BCG policy (Iran, 1984) had high mortality, consistent with the idea that BCG protects the vaccinated elderly population. We also found that BCG vaccination also reduced the number of reported COVID-19 cases in a country. The combination of reduced morbidity and mortality makes BCG vaccination a potential new tool in the fight against COVID-19.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

R:Mortality Rates

Because around 85% of those contracting covid-19 may be asymptomatic although potentially shedding virus, the actual death rates may be several times lower than the figures shown below calculated from tested positives, but already world deaths are far in excess of those for SARS and MERS due to the much higher infectivity. However death rates ary extensively between different countries due to different testing rates and procedures and due to differing demographics. The nominal death rate -- the current ratio of positive cases to covid deaths is 4.4%. This is strongly biased by the growth rate of cases, cryptic transmission rates of asymptomatic people and other demographic factors. While initial estimates from China were around 3.7%, South Korea currently has a rate of 1.01% and Germany 0.057%, both of which had intensive early testing and follow up, in contrast with France at 5.8%, Spain with 7.5% and Italy, which has a death rate of 10.1%. Differences between Italy and South Korea are due both to very extensive testing in South Korea while Italy is overloaded and due to S Korea having a stronger demographic of young women who don't smoke as opposed to a demographc in Italy of old men in a polluted area who do smoke.

A more recent antibody test series in Spain calculates the current infection rate is 5%. Given the fact that the death rate is 570 per million, a herd immunity level of 60% would correspond to a death rate of 6,840 per million. On a worldwide basis, this would equate to 47 million mortalities, about the same as the 1918 flu. In the US, this would equate to 2.3 million deaths.


Fig 12: Mortality rate statistics

While some people infected with covid-19 have a transient viral infection, others in the second week go on to a severe illness accompanied by pneumonia and a developing immune storm.

  1. Features of 16,749 hospitalised UK patients with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol medRxiv 28-4-2020 The study tracked the outcomes of nearly 17,000 patients – around one-third of all those admitted to hospital in the UK – and found that 33% had died, 49% were discharged and 17% were still receiving treatment after two weeks. "Despite the best supportive care that we can provide, the crude case fatality rate for people who are admitted to hospital with severe Covid-19 is 35% to 40% which is similar to that for people admitted to hospital with Ebola." The most significant health risk factor was obesity, increasing risk of death by 37% – a greater amount than heart disease (31%), lung disease (19%) or kidney disease (25%). Of 4,122 deaths registered in the UK, 2,523 were men and 1,599 women.
  2. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients medRxiv 7-5-2020 There were 5683 deaths attributed to COVID-19. In summary after full adjustment, death from COVID-19 was strongly associated with: being male (hazard ratio 1.99); older age and deprivation (both with a strong gradient); uncontrolled diabetes (HR 2.36); severe asthma (HR 1.25); and various other prior medical conditions. Compared to people with ethnicity recorded as white, black people were at higher risk of death, with only partial attenuation in hazard ratios from the fully adjusted model (age-sex adjusted HR 2.17; fully adjusted HR 1.71); with similar findings for Asian people (age-sex adjusted HR 1.95; fully adjusted HR 1.62).
  3. Tissue-specific tolerance in fatal Covid-19 medRxiv 4-7-2020 Tissue inflammation and organ dysfunction in fatal Covid-19 do not map to the tissue and cellular distribution of SARS-CoV-2, demonstrating tissue-specific tolerance. We conclude that death in Covid-19 is primarily a consequence of immune-mediated, rather than pathogen- mediated, organ inflammation and injury.
  4. Pathogenic T cells and inflammatory monocytes incite inflammatory storm in severe COVID-19 patients National Science Review 13-3-2020 Here we show that after the SARS-CoV-2 infection, CD4+ T lymphocytes are rapidly activated to become pathogenic T helper (Th) 1 cells and generate GM-CSF etc. The cytokines environment induces inflammatory CD14+CD16+ monocytes with high expression of IL-6 and accelerate the inflammation. Given that large amount of inflammatory cells infiltrations have been observed in lungs from severe COVID-19 patients, these aberrant pathogenic Th1 cells and inflammatory monocytes may enter the pulmonary circulation in huge numbers and play an immune damaging role to causing lung functional disability and quick mortality. Our results demonstrate that excessive non-effective host immune responses by pathogenic T cells and inflammatory monocytes may associate with severe lung pathology. Thus, we suggest that monoclonal antibodies targeting GM-CSF or interleukin 6 may be effective in blocking inflammatory storms and, therefore, be a promising treatment of severe COVID-19 patients.
  5. Case-Fatality Risk Estimates for COVID-19 Calculated by Using a Lag Time for Fatality CDC We estimated the case-fatality risk for 2019 novel coronavirus disease cases in China (3.5%); China, excluding Hubei Province (0.8%); 82 countries, territories, and areas (4.2%); and on a cruise ship (0.6%). Lower estimates might be closest to the true value, but a broad range of 0.25%--3.0% probably should be considered.
  6. Estimates of the severity of coronavirus disease 2019: a model-based analysis Lancet 30-3-2020 Using data on 24 deaths that occurred in mainland China and 165 recoveries outside of China, we estimated the mean duration from onset of symptoms to death to be 17·8 days (95% credible interval [CrI] 16·9–19·2) and to hospital discharge to be 24·7 days (22·9–28·1). In all laboratory confirmed and clinically diagnosed cases from mainland China (n=70117), we estimated a crude case fatality ratio (adjusted for censoring) of 3·67% (95% CrI 3·56–3·80). However, after further adjusting for demography and under-ascertainment, we obtained a best estimate of the case fatality ratio in China of 1·38% (1·23–1·53), with substantially higher ratios in older age groups (0·32% [0·27–0·38] in those aged <60 years vs 6·4% [5·7–7·2] in those aged ≥60 years), up to 13·4% (11·2–15·9) in those aged 80 years or older. Estimates of case fatality ratio from international cases stratified by age were consistent with those from China (parametric estimate 1·4% [0·4–3·5] in those aged <60 years [n=360] and 4·5% [1·8–11·1] in those aged ≥60 years [n=151]). Our estimated overall infection fatality ratio for China was 0·66% (0·39–1·33), with an increasing profile with age. Similarly, estimates of the proportion of infected individuals likely to be hospitalised increased with age up to a maximum of 18·4% (11·0–7·6) in those aged 80 years or older.
  7. 5-year-old daughter of Detroit first responders dies after being diagnosed with coronavirus CNN 21-4-2020 Skylar Herbert died Sunday at Beaumont Royal Oak Hospital after being on a ventilator for two weeks, CNN affiliate WXYZ reported. She tested positive for coronavirus last month and developed a rare form of meningitis and swelling on the brain, according to WXYZ.
  8. 5-month-old daughter of a New York firefighter dies from coronavirus CNN 24-4-2020 The baby had a heart condition, so they were already concerned for her health.
  9. Maria Branyas: 'Oldest woman in Spain' beats coronavirus at 113 BBC 12-5-2020
  10. Possible Biological Explanations for Kids' Escape from COVID-19 The Scientist 16-3-2020
  11. Black people are more than four times more likely to die from Covid-19 Guardian 7-5-2020
  12. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients medRxiv 7-5-2020 People from Asian and black groups are at markedly increased risk of in-hospital death from COVID-19, and contrary to some prior speculation this is only partially attributable to pre-existing clinical risk factors or deprivation; further research into the drivers of this association is therefore urgently required. Deprivation is also a major risk factor with, again, little of the excess risk explained by co-morbidity or other risk factors.
  13. Host Response to the Dengue Virus One hypothetical explanation why older people are more seriously affected, in addition to the general decline of immune competence with age, is that their previous exposure to human corona viruses HKU1, NL63, OC43 and 229E may set off an enhancement of infectivity due to the antibodies aiding viral entry into monocytes rather than killing them, as shown in fig 13 for dengue fever.
  14. In developing world, virus is killing far more young people Wash. Post 22-5-2020 Fifteen percent of the dead in Brazil were younger than 50. That's more than 10 times the percentage in Italy or Spain. Nearly half of the dead in India were younger than 60. In Mexico, nearly one-fourth of the dead were aged between 25 and 49.


Fig 13: Although it typically causes flulike symptoms or none at all, severe cases of dengue fever can lead to hemorrhagic fever, shock, and even death. In dengue fever infection, antibody (Ab)-dependent enhancement of infection occurs when preexisting antibodies present in the body from a primary (first) dengue virus (DENV) infection bind to an infecting DENV particle during a subsequent infection with a different dengue serotype. The antibodies from the primary infection cannot neutralize the virus. Instead, the Ab–virus complex attaches to receptors called Fcγ receptors (FcγR) on circulating monocytes. The antibodies help the virus infect monocytes more efficiently. The outcome is an increase in the overall replication of the virus and a higher risk of severe dengue. With an initial dengue vaccine - Sanofi Pasteur Dengvaxia was it was found that for those not previously infected by dengue virus more cases of severe disease could occur following vaccination upon a subsequent dengue infection. There is now a tetravalent vaccine for all four types but safety remains a key concern.


Fig 13b: Left: World comparative cumulative deaths per million for Covid-19. The odd fluctuations in the UK and Spain death rates are due to very arbitary recalculations of the death rate down. In the UK this was caused by discounting deaths in England where the positive covid test was more than 28 days old. Right: US states and New York City, Chicago and Deroit. These figures compare with the epidemics of fig 13. Those to date for New York City are far higher than the frightening levels of Italy and Spain and worse than the highest peaks of the smallpox and scarlet fever epidemics. The European figures counting excess deaths for the period (fig 13c) are approximately twice as high, taking Spain close to 800 deaths per million only part way through the outbreak.

Emerging data modelling such as that in fig 5b does suggest a significant number of undetected infections which would lower the death rate by an order of magnitude, but the actual death rate in Italy and Spain per million population in fig 13b, demonstrates conclusively that at these countries have already passed the 300 per million milestone indicative of a seriously lethal pandemic. Taking the data in 5b of 9.8% currently affected rising to 60% and 8165 deaths as of 28-3-2020 we might expect a total of 49,990 deaths for Italy with a death rate per million of 827 close to the peaks of smallpox and scarlet fever in fig 13. The total deaths for Italy could amount to100,000 given the under-reporting noted in fig 13c. Extrapolating the data from Italy to the world population of 7776 million, we would expect 6.43-13 million casualties due to covid worldwide. Using combined figures of France, Spain and Italy as at 28-3-2020 we arrive at the more moderate figure of 4.48-9 million, however France's death rate has since shot up, however other countries and regions have sustained much lower death rates so far, so this may be an overestimate. Belgiu claims its high death rates are due to counting all suspected cases not leading to the missing death in fig 13c.

Research noted above suggests that the variations in death rates between Italy, Spain and New York and the much lower rates e.g in California may be partly due to evolving differences in the severity of emerging Covid-19 strains. Other factors cited are demographic differences in population age, sex, health risks due to pollution, smoking, or obesity, other existing conditions and adequacy of hospital care under the pressure of the pandemic.

The US figures also show just how high death rates can actually become, with that of New York citiy already passing 2400 per million, higher than any of the epidemics discussed in the next section .

An analysis of more than 3,000 fatalities in Italy found the average age of those who died was about 80, and that 96% had previous medical conditions. Nearly 60% had three or more illnesses.


Fig 13c: Left: Apparent under-reporting of covid-19 death in Italy and Spain (Economist), where the rates are already very high can be contrasted with much lower rates in Iceland, where extensive testing and tracing has resulted in a much lower death rate. Right: Population composition (Left) and expected deaths in population (Right) for Italy and Republic of Korea (Top) and Nigeria and Brazil (Bottom). Projections assume 10% population infection rate and current age−sex-specific case fatality rates from Italy (3).


Fig 13d: Top Left Estimated deaths in the UK due to covid-19 from all sources. Top Right Excesses of unreported deaths due to covid-19. Lower excess deaths in the US reported by CDC.

  1. FT analysis sees UK coronavirus death toll at 41,000 Reuters 21-4-2020 This is more than twice the current confirmed cases of 16509 from ECDC.
  2. 25,000 Missing Deaths: Tracking the True Toll of the Coronavirus Crisis NYT 21-4-2020 In New York City, the number is now four times the normal amount. In many European countries, recent data show 20 to 30 percent more people have been dying than normal. Istanbul recorded about 2,100 more deaths than expected from March 9 through April 12 -- roughly double the number of coronavirus deaths the government reported for the entire country in that period. The increase in deaths in mid-March suggests that many people who died had been infected in February, weeks before Turkey officially acknowledged its first case.
  3. U.S. Coronavirus Death Toll Is Far Higher Than Reported, C.D.C. Data Suggests NYT 29-4-2020 9,000 more deaths than were reported as of April 11 in official count. In New York City, the home of the biggest outbreak, the number of deaths over this period is more than three times the normal number.
  4. Demographic science aids in understanding the spread and fatality rates of COVID-19 PNAS 8-4-2020 Because deaths have been concentrated at older ages, we highlight the important role of demography, particularly, how the age structure of a population may help explain differences in fatalityrates across countries and how transmission unfolds (fig 13c right).
  5. More on Excess Mortality and COVID19's Hidden Toll TPM 15-4-2020 Data from Spain, Netherlands,UK and Italy show aconsistent pattern of excess deaths for the period being roughly twice as high as the actual covid-19 reported cases.UK 6082/3475 1.75 times,Netherlands approximately 2 times higher, Madrid 1/0.37 = 2.7 times higher and we have the Economist data (fig 13c left).
  6. Those covid-19 death figures are incomplete Wash Post 27-3-2020
  7. JD Vance Twitter thread on Republican discounting of Covid and Death Rates
  8. Excess U.S. deaths hit estimated 37,100 in pandemic's early days, far more than previously known Wash Post 2-5-2020 The Post reported — based on the Yale team's model — that the nation had recorded an estimated 15,400 excess deaths between March 1 and April 4. But more up-to-date NCHS data released Friday revealed that more than 5,000 additional people had died overall during that span — bringing the total estimated excess deaths to 20,500.On April 4, state health departments were reporting that about 8,100 people had died of covid-19, according to The Post's tally at the time. Those figures excluded deaths of people who probably died of covid-19, based on symptoms and exposure, but were never tested. They also excluded some deaths that had occurred but had not yet been publicly reported. NCHS corrects for those exclusions. On Sunday, it was reporting that as of April 4, about 10,500 people had died of covid-19. On Friday, after more backfilling with updated reports, that number stood at about 11,361 — more than 9,000 short of the estimated 20,500 excess deaths.

It is hard to determine at this point the overall direction of the evolutionary selection pressures on covid-19, because there is both evidence of cryptic asymptomatic transmission and high incidence of infections in hospital staff attending critically ill patients. These could correspond to the two evolutionary types aleady discussed above in Wuhan.


Fig 13e: Left: The US crosses a daily milestone. Critics have claimed this is incorrect because between January and April in 2018, more than 234,000 people in the United States died of heart disease and nearly 199,000 died of cancer, but that is a distortion because covid-19 was barely present in January and the peak has not yet been reached with 16,700 death as of 10 Apr. As daily figures, these are nevertheless valid estimates based on CDC figures. Right: Already by 16th April covid-19 is about to become the leading weekly cause of death.

S: Comparison with other Pandemics

Often referred to as simply "The Plague", the Black Death was one of the most devastating pandemics in human history, peaking in Europe between 1348 and 1350 with an estimated one-third of the continent's population ultimately succumbing to the disease. Historians estimate that it reduced the total world population from 475 million to between 350 and 375 million. In most parts of Europe, it took nearly 80 years for population sizes to recover, and in some areas more than 150 years.


Fig 13f: Four previous epidemic disease mortality trends

Other viral and bacterial epidemics have frequently killed 500 to 1000 people per million. Currently in Italy as of 26th March 2020 there have been 135 deaths per million, before a peak has been reached, suggesting a similar eventual death rate in the absence of effective antivirals or vaccines, to smallpox, scarlet fever, measles and pertussis (whooping cough) before antibiotics and vaccination cut their mortality.

  1. Ancient microbial arms race sharpened our immune system—but also left us vulnerable Science 24-7-2020
  2. Infectious Diseases and Human Population History OUP 1996
  3. The Spread New Yorker 6-4-2020 (password as in the title) A short history of previous world pandemics.
  4. How pandemics shape social evolution Nature 15-10-2019
  5. Influenza: A viral world war Nature 8-6-2017
  6. 'Pathetically understaffed and hopelessly complacent': Lessons from Black November Stuff 18-3-2020
  7. From Black Death to fatal flu, past pandemics show why people on the margins suffer most Science 14-5-2020
  8. The Spanish flu killed more than 50 million people. These lessons could help avoid a repeat with coronavirus CNN 16-4-2020
  9. In 1911, another epidemic swept through China. That time, the world came together CNN 19-4-2020 In 1910-11, lockdowns, quarantine measures, the wearing of masks, travel restrictions, the mass cremation of victims, and border controls were deployed to try to lower the infection rate of an outbreak of plague souced from Tarbagan marmots (Marmota sibirica). 63,000 people died in Manchuria, making it one of the world's largest epidemics at the time. When the disease was eventually brought under control, the Chinese government convened the International Plague Conference in the northern city of Shenyang -- close to the epicenter of the outbreak. In attendance were virologists, bacteriologists, epidemiologists and disease experts from many of the world's major powers -- the United States, Japan, Russia, the United Kingdom and France.
  10. Russia cracks down on marmot hunting after suspected bubonic plague cases Guardian 6-7-2020
  11. The history of measles: from a 1912 genome to an antique origin BioRxiv 30-12-2019 The family tree of the measles virus reveals that today's measles is descended from a rodent disease that jumped to cattle and subsequently to humans. Measles diverged from Rinderpest, a now-extinct cattle virus that is its closest relative, in the later first millennium BC, centering almost exactly on the moment in human history when the largest cities first passed the 'critical community size' of around 250,000 where measles will drive itself to extinction. What this alignment suggests -- disturbingly enough -- is that one of the most dangerous and distinctly human respiratory viruses emerged instantaneously with the rise of civilization itself. The broader implication is that human social development has stoked the evolution of our many pathogens, enabling them to avoid the hasty extinction that would have otherwise awaited them. Our very success in taking over the Earth and commandeering its resources has made us attractive hosts.

By comparison because covid-19 is highly infectious, if 60% of a population cought it, given even a 1% mortality rate, we would see a death rate of 6000 per million, corresponding for example to 2 million deaths in the US and 43 million worldwide. This figure has since been confirmed by the Imperial College report above.

By comparison due to reduced incidence and anti-retroviral drugs the estimated 770,000 [570,000−1,100,000] people dying from HIV globally in 2018 were 56% fewer than in the peak in 2004 and 33% fewer than in 2010 in spite of a period of substantial population growth in many high burden countries. According to the WHO, the estimated number of malaria deaths stood at 405,000 in 2018

Although SARS was both lethal with a mortality rate of 10% and highly infectious with an R0 of 2-5, MERS with a higher mortality rate of 34% had an R0 of 0.5 < 1 so hasn't lead to major epidemics. Ebola with a mortality rate of over 50% has an R0 of 2 but has to be spread by blood contact and infectious people are heamorrhagic, so can easily be identified. Hence it is much less likely to cause a pandemic. In the 2014-2016 outbreak, a total of 28,616 cases and 11,310 deaths were reported in Guinea, Liberia, and Sierra Leone. In December 2016, a study found the VSV-EBOV vaccine to be 70–100% effective against the Ebola virus.

The coronavirus may be deadlier than the 1918 flu: Here's how it stacks up to other pandemics CNBC 26-3-2020 The covid-19 death rate of 1-4% can be compared with various influenza epidemics. The 1918 epidemic had a mortality rate of 2.5%, but the virus has become less lethal, due to natural selection, in which milder strains are transferred more because people who are less sick move about infecting more people unlike the 1918 epidemic when sick soldiers from the war were returned back into society. Hence the 1957 epidemic had 0.6%, and 2009 H1N1 0.02%.

Swine flu • April 15, 2009 -- first infection detected • June 19, 2009 -- 21,449 cases, 87 deaths
Covid-19 • Jan. 20, 2020 -- first infection detected • March 25, 2020 -- 69,344 cases, 1,050 deaths

The Centers for Disease Control and Prevention estimated that from April 12, 2009, to April 10, 2010, there were 12,469 deaths in the United States because of the H1N1 (swine flu) virus. By the same calculation, we might thus ultimately expect 46547 US deaths, but this will depend on emergency ICU services not becoming overwhelmed as they already appear to be doing. But the White House modelling as already by April suggested 100,000 to 2 million deaths, showing how fast the perception of the severity of the pandemic has changed.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics


Fig 14: How New Zealand relied on science and empathy BBC 20-4-2020
Two approaches favoured by Jacinda Ardern and Ashley Bloomfield
Government response structure 22-8-2020 Jacinda Resurgence Progress 21-8-2020
New Zealand's Ardern to take time to decide on coalition after historic election win Reuters 18-10-2020

T: The New Zealand Situation

New Zealand has entered alert level 3 "lockdown" in Auckland and level 2 in the rest of the country 12-8-2020 after 4 in a family were discovered to be positive and four associates supected of Covid-19 unknown origin, just as we reached 100 days since there was a case of community transmission. This has resulted in a cluster of around 90 people affecting a number of sites pread across Auckland, including churches, schools, and work places, but with all but one case genomically linked to a single cryptic transmission. Despite the new outbreak, Jacinda Ardern retains 64% support as the best person to handle the crisis, down from 70% in july and 54 per cent of those surveyed saying Jacinda Ardern was the best leader to manage the economic recovery from Covid-19, compared with only 26% for Judith Collins.

The current August cluster has accumulated to around 100 cases in isolation with all close contasts also in quarantine. The August outbreak is B.1.1.1 which comes from Australia and the UK and other countries, but has no homolgy with any of the successfully sequenced cases detected at the border and only a few of the original wave had early forms of this strain so it is also doubtful that it comes from a smoldering first wave ember. The tentative conclusion since transmission in freight has also been ruled out, is that it originates from an incoming person who remained asymptomatic for 14 days before two-phase testing of all arrivals at days 3 and 12 became mandatory.

NZ made a key strategic shift from a strategy of mitigation to one of stamping it out and elimination finally today 8-6-2020 reverting to alert 1 consisting of no intetrnal restrictions and only border controls after no cases for 17 straight days and no remaining active cases. NZ's low death rate can be attributed to early action, a high incidence of youger people affected, older people avoiding social contact and contact tracing.

Previously David Skeggs, professor of epidemiology told Parliament's Epidemic Response Committee he believed the number of people who had the virus in New Zealand far exceeded the recorded cases, and officials had "no idea" of the extent of community transmission. But Dr Ashley Bloomfield disputed that. "We know where our cases of community spread are, we know we have these clusters, which are being investigated to see what the source of infection is. So we have some idea. The more testing we do, the more we will get a picture of community transmission." However the reporting had tended to identify all contact traced individuals as non-community spread identifying only 2% as community-derived and only clusters of over 10 people are publicly notified, so critical areas of the epidemic remain obscure. Nevertheless here we are after high levels of testing on a world basis fig 16d showing no positives in some 49488 tests in the last 93 days, despite NZers returning from overseas testing positive in quarantine on a daily basis.


Fig 14: Semi-log cumulative and daily confirmed and probable cases. Testing positive %age rates and overseas arrivals. The gap in testing rates constitutes a period where there were no local cases and overseas arrivals were quarantined but not tested. With the overseas travel ban, arrivals fell from figures around 25,000 a day to a few hundred. New Zealand went into alert 4 lockdown from early in the epidemic on 25-3-2020 with everyone in a bubble except for food buying except for essential services staff to try to hunt down any crypitic transmissions as advised by modelling experts and went from alert 4 to alert 3 on 28 April and to alert 2 on the 13th May and to level 1 where the only restrictions are at the border on Jun 8. NZ saw the virus eliminated from June (see below), except for around 30 cases recently imported from overseas, requiring the testing and isolating of hundreds of close contacts. But as of 25th July all NZers returning are tested on days 3 and 12 and isolated for 14 days and then tested at days 3 and 12 we had 95 days since the last community derived case until the August cluster emerged.

COVID-19 - current cases <> COVID-19 Modelling reports <> Covid NZ case incidence tracker <> Alert system overview

NZ Modelling Reports and News Updates

  1. What NZ can learn from Taiwan about pandemic preparedness Stuff 21-10-2020
  2. New Zealand's Covid-19 response the best in the world, say global business leaders Guardian 8-10-2020
  3. The NZ strains: Our second wave Newsroom 5-10-2020
  4. The three theories for August's Auckland outbreak NZ Herald 8-10-2020
  5. While Covid-19 takes lives around the world, New Zealand's response has led to fewer deaths from all causes Stuff 19-8-2020
  6. Time for a sea change in our COVID-19 management NZ Med. J. 21-8-2020
  7. Genomic epidemiology reveals transmission patterns and dynamics of SARS-CoV-2 in Aotearoa New Zealand medRxiv 7-8-2020 We generated 649 SARS-CoV-2 genome sequences from infected patients in New Zealand with samples collected between 26 February and 22 May 2020, representing 56% of all confirmed cases in this time period. Despite its remoteness, the viruses imported into New Zealand represented nearly all of the genomic diversity sequenced from the global virus population. The proportion of D614G variants in the virus spike protein increased over time due to an increase in their importation frequency, rather than selection within New Zealand. These data also helped to quantify the effectiveness of public health interventions. For example, the effective reproductive number, Re, of New Zealand's largest cluster decreased from 7 to 0.2 within the first week of lockdown. Similarly, only 19% of virus introductions into New Zealand resulted in a transmission lineage of more than one additional case. Most of the cases that resulted in a transmission lineage originated from North America, rather than from Asia where the virus first emerged or from the nearest geographical neighbour, Australia. Genomic data also helped link more infections to a major transmission cluster than through epidemiological data alone, providing probable sources of infections for cases in which the source was unclear. Overall, these results demonstrate the utility of genomic pathogen surveillance to inform public health and disease mitigation.
  8. New Zealand beat Covid-19 by trusting leaders and following advice – study Guardian 23-7-2020 The secrets to New Zealand's success at eliminating coronavirus has been revealed by university researchers, who have found compliance with basic hygiene practices and trust in authorities was at nearly 100%. Researchers at Massey University interviewed more than 1,000 people post-lockdown, to investigate how New Zealanders responded to the pandemic. "We came together as a country, in part because we believed in our political and health experts to deliver and they did," said Dr Jagadish Thaker, a senior lecturer at the school of communication, journalism & marketing at Massey University. "Simple, clear health messages, communicated with kindness and empathy, resonate with people, even when they are demanding tough changes."
  9. Aotearoa NZ Public Responses to Covid-19 Massey Univ. 23-7-2020
  10. NZ's "Team of 5 million" has achieved the lowest COVID-19 death rate in the OECD – but there are still gaps in our pandemic response Otago Pub. Health Exp. 22-7-2020
  11. Covid 19 coronavirus: Two new cases, Jacinda Ardern admits check system 'failure' Herald 16-6-2020
  12. New Zealand readers tell us how they want the country to change after Covid-19 Guardian 7-6-2020
  13. Five ways New Zealand can keep Covid-19 cases at zero Guardian 8-6-2020
  14. Coronavirus: NZ could be declared free of Covid-19 in 21 days Stuff 27-5-2020
  15. NZ's chief scientist - when can we re-open our borders? Herald 31-5-2020
  16. NZ vs UK < Video News > NZ vs Sweden
  17. When can COVID-19 be Declared Eliminated from NZ? New Modelling Study Pub. Health Exprt. 25-5-2020
  18. What we would like to see on the Ministry of Health's website to better inform progress on COVID-19 elimination 2-5-2020
  19. Crunching the coronavirus curve is better than flattening it, as New Zealand is showing Guardian 22-4-2020
  20. New Zealand's contact tracing system for Covid-19 was overloaded, audit finds Stuff 21-4-2020
  21. Testing for COVID-19 in NZ to Achieve the Elimination Goal 6-4-2020
  22. Modelled Estimates for the Spread and Health Impact of Covid-19 in New Zealand 27-2-2020
  23. Rationale for Border Control Interventions and Options to Prevent or Delay the Arrival of Covid-19 in New Zealand 6-3-2020
  24. Potential Age-Specific Health Impacts from Uncontrolled Spread of the COVID-19 Pandemic on the NZ Population16-3-2020
  25. Supporting the COVID-19 pandemic response: Surveillance and Outbreak Analytics 20-3-2020
  26. Potential Health Impacts from the COVID-19 Pandemic for New Zealand if Eradication Fails 23-3-2020
  27. Potential Worse Case Health Impacts from the COVID-19 Pandemic for New Zealand if Eradication Fails 24-3-2020


Fig 15: Key NZ stats during the first wave. The 20-29 year olds are a major covid vector with lower risk and highest impact. The August outbreak is B.1.1.1 which comes from Australia and the UK and other countries but has no homolgy with any of the cases detected at the border. The outbreak is centered on Americold, a cool store importing frozen food from Australia.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

U: World Comparisons

Countries are responding to the pandemic in diverse ways, some less effective than others. In each case, it poses a challenge to the particular society and its politics how to respond, forming a commentary on how human societies unused to pandemic crisis respond to protect their populations in the face of competing political and economic agendas and priorities.

Singapore kept cases low and deaths minimal (before the large spike when migrant dormitories became infected) by controlling the border, rigorous testing and follow-up and confining positive case to hospital while schools remained open until a second wave hit (fig 16). South Korea has had similar successes despite some huge clusters by relentless testing and isolation. Germany initially had good testing but European travel is now taking it's toll. France, Italy and Spain have serious outbreaks overwhelming the hospital systems and leading to high death rates but the downward curvature indicates the slowing due to containment and isolation. By contrast, the USA still looks like an unbridled catastrophe with little downturn as of 12- Apr although the death ratios are much smaller than the highs of Europe. The UK is little better although increases in testing rates may be hiking the later positives in both countries. Iceland has followed a successful strategy of testing up to 5% of the population after a number of cases from international travel. The policies of Norway and Sweden have diverged with measures in Sweden being largely voluntary and a significantly higher death ration. The Netherlands have likewise cited herd immunity and an increasing death rate. India is in the early stages while Australia has sent mixed messages and like the US has seen large beach gatherings but has tested extensively and retains a low death ratio. Canada has seen a spike in mortalities but has a similar current ratio to South Korea, although there is little sign of a slow down in cases. Iran has had an ongoing epidemic since February where there may be many undiagnosed cases. China's trend has become horizontal because all new reported cases are currently due to incoming travel.

Daily Statistics of the World Pandemic

The following sets of charts show unfolding pandemic and testing data for a selection of world countries and US states and cities, updated daily. Click the image and then scale it to see each in full detail.

Selected World Countries: semi-log cumulative, daily positives with R values, daily deaths with deaths/million.
Comparative Charts: Cumulative world positives, World and US states deaths per million, Testing rates
Selected US States and Cities: semi-log cumulative, daily positives with R values, daily deaths with deaths/million.


Fig 16: Cumulative semi-log plots of positive cases and deaths (click image for scalable svg). Exponential growth leads to a straight line and downward curvature indicates mitigation of the epidemic. Horizontal shows containment. D/P = Deaths/Positives D/M = Deaths per million people, T/M = Tests per million people. dx2 is the time to the next doubling if the graph continues at the same slope. This gives an indication of how safe, or not, it is to relax restrictions


Fig 16b: Daily cases linear (click image for scalable svg) Blue = daily cases, Red = deaths. Green = the qualitative stringency index of how many measures are in place to reduce viral transmission. This covers only restrictive measures: school, workplace closing, public events, gathering size, public transport, stay at home, internal movement, international travel and public information. It does not cover testing tracing, healthcare, or vaccine investment. D/M = Deaths per million people. Of all the statistics, the one that really indicates the severity of the pandemic in different countries is the total deaths per million people because this is the least subject to variations in testing. It is generally an underestimate because there are clear increses on net deaths in several of these countries that mean the true rate can be 2, as in the UK, or even 15 times higher, as claimed for Ecuador.

Understanding the R0 and Serial Interval

The pandemic model is generated as a time series like a brush fire, where a given infected person infects R0 people over a serial interval of Int days, but the person themselves becomes resistant and exits the pandemic like a small region of brush that has already burned out. The functional generating process is exponential, so the time series is also exponential. Our calculation first takes a moderately smoothed moving average log of the daily positives and calculates two slopes s0 and s1 by linear regression, one slope before the peak, or trend change, and the other after. This is clearly a difficult task for some of the very grainy and incomplete data sets above. This has the same effect of trying to fit exponentials to the original daily data. If R > 1 the time series has a net positive exponential because more people are infected in the next step than the people who became resistant and for R < 1, it has a shrinking one because fewer people are infected in each next step.

So we get an approximate calculation: R0 = exp(Int*s0) and R1 = exp(Int*s1), where Int = 6 days and the exponentials are inverting the effect of taking the slopes of the logarithm of the daily positives, thus fitting exponentials to the original daily data.

In an unmitigated epidemic, a feedback occurs when herd immunity of say 60% immune begins to reduce Rt because the pool of susceptible people becomes only a more thinly spaced 40% of the total. The unmitigated naked invasive Covid-19 R0 runs up to 5.7, but physical distancing reduces Rt by reducing opportunities for an infected person to infect others. The aim of a lockdown is to reduce Rt to less than 1, as many of the above R1values clearly are, although many countries having trouble still have R1 values too high for containment. This is also happening when, even when antibody testing shows many morepeople infected the number is still only a few percent, far below the herd immunity. We are also still unsure antibodies guarantee immunity from re-infection. Ultmately, if Rt is held below, 1 a disease can completely die out. That is vastly preferrable to repeated roundsof new waves of infection, fig 5, given our lack of a vaccine, or certainty about robust immunity amid continuing mortalities and serious health damage to many people who do survive.

The corresponding values for US states and cities, fig 16f has detailed polical implications in terms of whether a given state is in a reasonable position to relax social distancing provisions.

The outgoing Rt can also be used to extrapolate the graph forward using its outgoing trend to make a prediction of eventual total deaths, as the semi-log plot of the covid projections tracker for US death data shows, but these predictions do not take into account possible subsequent waves of epidemic if the majority of the population remains non-resistant and/or has not reached herd immunity, as is currently the case for all populations studied.


Fig 16c: Daily deaths (red) and cases (cyan) semi-log (log10n) Click image for scalable svg). D/M = Deaths per million people.The R0 and R1 (the outgoing Rt ) give the approximate number of people each positive person infects before social distancing and currently (the worst case over the last 20-50 days). All countries with R1 over 0.8 are still in active epidemic community spread.


Fig 16d: Left: Sample testing rates per person (total tests / population) across selected countries (OWID).
Right: Judgment by country about their government's response (Dalia)


Fig 16e: US Cumulative semi-log plots of positive cases and deaths (click image for scalable svg). Exponential growth leads to a straight line and downward curvature indicates mitigation of the epidemic. Horizontal shows containment. D/P = Deaths/Positives D/M = Deaths per million people. dx2 is the time to the next doubling if the graph continues at the same slope. This gives an indication of how safe, or not, it is to relax restrictions.


Fig 16f: US Daily cases and deaths with approximate R0 and R1 values. The R0 and R1 (the outgoing Rt ) give the approximate number of people each positive person infects before and after social distancing. D/M = Deaths per million people. R0 is the intial wave front and R1 the worst case over the last 20-50 days. D/M is cumulative deaths per million people. Seriously affected states such as New York have instituted measures containing their epidemic for now, while other states have not.


Fig 16f2: US Daily deaths with approximate R0 and R1 values. The R0 and R1 (the outgoing Rt ) give the approximate number of people each positive person infects before and after social distancing. D/M = Deaths per million people. R0 is the intial wave front and R1 the worst case over the last 10-35 days. D/M is cumulative deaths per million people. Seriously affected states such as New York have instituted measures containing their epidemic for now, while other states have not.


Fig 16g: US Daily cases (cyan) and deaths (red) semi-log (log10n) Click image for scalable svg. D/M = Deaths per million people. R0 is the intial wave front and R1 the worst case over the last 20-50 days. The R1 figures indicating current infectivity of 1 and above given the number of cases still have epidemic community spread (see fig 5), indicating nearly half the states are likely to experience a siginficant second wave if social distancing is significantly relaxed. This is now evidenced in runaway case numbers and increasing death rates particularly in Arizona, Florida, South Carolina,Texas and Virginia.



Fig 16h: Australian states showing Victorian epidemic. Canadian provinces show highly disparate infections, with Quebec having a severe death rate.


Fig 16i: Chinese provinces and Hong Kong showing how effective the shutdown has been in China.


Fig 16j: EU countriies showing divergent handling of the pandemic. Blue = daily cases, Red = deaths. Green = the qualitative stringency index of how many measures are in place to reduce viral transmission. This covers only restrictive measures: school, workplace closing, public events, gathering size, public transport, stay at home, internal movement, international travel and public information. It does not cover testing tracing, healthcare, or vaccine investment. D/M = Deaths per million people.


Fig 17: Google mobility data for a spread of countries during the first lockdowns, showing varying restrictions.

Navigation

A: Origins in Sustained Human Misadventure
B: First Awareness
C: Uravelling the Viral Transmission Event
D: Environmental and Economic Consequences
E: Modeling Pandemic Strategies
F: Genetic and Evolutionary Analysis
G: World Incidence Statistics

H: Coronavirus Tests and Tracing
I: Mechanisms of Infection
J: Viral Loads & Asymptomatic Spread
K: Antibody Responses and Reinfection
L: Clinical Features
M: Blood Clotting and Nervous System
N: Lung Damage
W:The Bradykinin Hypothesis

O: Antiviral Drugs
P: Antibody Treatments
Q: Vaccines and Gene Therapies
R: Mortality Rates
S: Comparison with other Pandemics
T: The New Zealand Situation
U: World Comparisons
V: Covid Politics

V: Covid Politics

Trump fiddling on Covid while People Die and Democracy Burns


Left centre: Trump's 4-8video interview with Jonathan Swan on the high Covid-19 death rate per head in the US. Left and Right: These charts compare cases and deaths per million in NZ, the EU and USA. The USA death rate is 44% higher than the EU and worsening, as the pandemic continues to rage in the US, as the Texas and Florida charts show. Trumps claim "I heard we have one of the lowest, maybe the lowest, mortality rate anywhere in the world," to Fox News host Chris Wallace 19th July - is a frank lie. Based on deaths/over tests, Singapore has 1.5% of the US rate and by deaths per million, New Zealand has only 0.9% of the US death rate. Slovakia, despite being land-locked within Europe, has only 37% of the US deaths/tests and only 1% of the US deaths per million. How can the president of the claimed "greatest nation on Earth" mouth such ignorant lies unchecked? Making the claim to Jonathan Swan that the critical measure of mortality – death rates per head of population – are "fake news", in the face of 170,000 US deaths, is a tacit confession that Trump himself is primarily responsible for this huge unparalelled loss of life, by negligence, contrivance, obfuscation and denial. This man is the most unfit for office of any president in US history. The fact that he still has any support while refusing to say if he will leave office if he loses the election in the same interviews, while ordering federal military onto the streets of Portland, shows just how deeply the US illusion of democracy has fallen.



"You see what's going on in New Zealand? They beat it they beat, it was like front page [news] they beat it because they wanted to show me something.
The problem is [there is a] big surge in New Zealand, you know it's terrible - we don't want that."
Trump Minnesota 17-8-2020
"Obviously it's patently wrong," NZ Prime Minister
Jacinda Ardern said when asked about Trump's comments.
"We are still one of the best-performing countries in the world when it comes to Covid and our workers are focused on keeping it that way."
NZ's current cluster has around 90 cases and 0 deaths. The US pandemic has had 5.4 million cases and 170,000 deaths overall.
On the day of Trump's statement NZ had 7 cases and 0 deaths. The US had 44091 cases - 120 times higher per million - and 1370 deaths.
But despite the fake news Trump was spawning, he just couldn't stop - Next day at the press conference:
"New Zealand, by the way, had a big outbreak, and other countries that were held up
to try and make us look not as good as we should look, and we've done an incredible job"
Third time lucky? Pennsylvavia rally - @Don the Emperor clearly has no clothes and no shame!
"They like to compare us to others, so they were talking about New Zealand, New Zealand, it's over, it's over for New Zealand,
everything's gone, they're beautiful'," he appeared to mock. "They had a massive breakout yesterday.
"
Ardern replied: "To give you just one example, the United States has 16,563 cases per million, we have 269 per million people."
Everyone can see in New Zealand we’ve got 11 cases, while the United States is dealing with over 40,000 cases.
But it’s not just whether you have cases, it’s how you choose to deal with them as a nation and I'm very proud how New Zealanders have taken to the battle with Covid-19.
"


Left: Nomination of Amy Coney Barrett (click to see infected). A super-spreader event was held there to make the most out of Trump’s nominating Amy Coney Barrett to the supreme court – exploiting the opportunity of Ruth Bader Ginsburg’s death, and then the president and his considerable entourage fanned out around the country in pursuit of campaign funds (Guardian). Centre: Trumps doctors at Walter Reed. Right: Trump takes a victory lap for supporters outside, risking secruty drivers and takes his mask off while stil infectious on return to the White House, wincing as he takes a breath, risking staff not already infected. His comments "Don’t be afraid of Covid. Don’t let it dominate your life" show nothing has changed from his mishandling of the pandemic or his illness. 

Trump tested positive and was taken to Walter-Reed Hospital. He has been given oxygen, both Regeneron antibodies and Remdesivir, and dexamethazone as well as zinc, vitamin D,
famotidine, melatonin and aspirin. None of the latter have been proven to be effective against COVID-19. Trump apparently is not receiving hydroxychloroquin (AP1, AP2, BBC).
Chief of staff Mark Meadows said during an interview with Fox News that Trump had a fever on Friday morning and his oxygen level had "dropped rapidly.".
A senior administration official told CNN's Jake Tapper that the cluster of coronavirus cases among top Republican officials probably began
at President Donald Trump's Rose Garden event announcing the nomination of Judge Amy Coney Barrett to the Supreme Court.
Trump's New Jersey event showed perilous neglect for his staff, supporters – and himself (Guardian)
.Analysis: Trump faces credibility crisis over health scare (AP).

"I feel great. I feel, like, perfect," the president says in his video. "I think this was a blessing from God, that I caught it. This was a blessing in disguise. I caught it, I heard about this drug,
I said let me take it. It was my suggestion." The president also promised to bring the drug to the American people free, hawking it – falsely – as a "cure". There is no cure for Covid-19. Guardian 8-10-2020

Trump Covid post deleted by Facebook and hidden by Twitter
He wrote the US had "learned to live with" flu season, "just like we are learning to live with Covid, in most populations far less lethal!!!".
'This is not a trivial disease': Fauci rebuffs Trump's attempt to downplay Covid-19.


  1. Totally Under Control 13-10-2020 puts a spotlight on the White House’s failed response to the global pandemic and how it could have been prevented.
  2. Prestigious medical journal calls for US leadership to be voted out over Covid-19 failure CNN 8-10-2020
  3. Dying in a Leadership Vacuum NEMJ 8-10-2020 When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.
  4. Reviving the US CDC Lancet 15-5-2020 Americans must put a president in the White House come January, 2021, who will understand that public health should not be guided by partisan politics.
  5. The Rage: Trump's historic dereliction of duty laid bare CNN 10-9-2020 While he told Woodward in a phone call "this is deadly stuff" and that the pathogen caused a viciously contagious illness much worse than the flu, Trump didn't level with the American people. In fact, he deliberately misled them and failed to prepare the government for a vast national effort. Worse, for weeks he continued to misinform the country about the severity of the pathogen that caused the worst global pandemic in 100 years. The 190,000 American families who lost loved ones and could never say goodbye, the millions of unemployed, the business owners who went bust, a generation of kids who haven't been in class for months and everyone else self-distanced from their regular lives now face the same question: How different would things have been had the President done his job properly?
  6. Trump contradicts CDC director on vaccine, masks AP 17-9-2020 Another presidential assault on science as fires and pandemic rage CNN 15-9-2020
  7. Trump less trusted internationally than Putin and Xi after Covid-19 response CNN 15-9-2020 Pew Research
  8. Germans fear Trump more than coronavirus, survey shows CNN 13-9-2020 The annual poll into the fears of people living in Germany shows that 53% of respondents are concerned by the consequences of ''a more dangerous world due to the politics of Trump," putting the US president at the top of their list of worries. The poll found that 32% of Germans worry about catching a serious illness -- compared to 35% in 2019 -- before the coronavirus outbreak began to spread.
  9. Why the United States is having a coronavirus data crisis Nature 25-8-2020 Political meddling, disorganization and years of neglect of public-health data management mean the country is flying blind.
  10. CDC was pressured 'from the top down' to change coronavirus testing guidance CNN 27-8-2020 A sudden change in federal guidelines on coronavirus testing to ignore asymptomatic individuals came this week as a result of pressure from the upper ranks of the Trump administration. Although White House Task Force officials claimed Anthony Fauci signed them off, he was being operated on at the time. "I am concerned about the interpretation of these recommendations and worried it will give people the incorrect assumption that asymptomatic spread is not of great concern. In fact it is," he said.
  11. Inside Trump's pressure campaign on federal scientists over a covid-19 treatment Wash. Post 31-8-2020
  12. U.S. would be lucky to see new coronavirus case numbers matching those of New Zealand or South Korea Wash Post. 20-8-2020
  13. Is New Zealand's coronavirus outbreak as 'terrible' as Trump says? CNN 18-8-2020
  14. Facebook removes Trump post over false Covid-19 claim Guardian 5-8-2020 Post included video in which Trump wrongly said that children were 'almost immune' from illness. Facebook and Twitter target Trump over virus claim BBC
  15. Two decades of pandemic war games failed to account for Donald Trump Nature 4-8-2020. The US was considered the most pandemic prepared country but no one could anticipate the current levels of dysfunction in the United States.
  16. The Unraveling of America Rolling Stone 6-8-2020 Anthropologist Wade Davis on how COVID-19 signals the end of the American era
  17. Task force reports show dire reality despite Trump's positive messaging CNN 31-8-2020
  18. WHO chief says our lack of concern shows 'moral bankruptcy' CNN 4-9-2020 WHO Director-General Tedros Adhanom Ghebreyesus said he had heard people describing high Covid-19 death rates among older people as "fine." "No, when the elderly are dying it's not fine. It's a moral bankruptcy," he told a news conference. "Every life, whether it's young or old, is precious and we have to do everything to save it."Almost 88% of all deaths in Europe were among people aged 65 and over and almost half of all deaths linked to Covid-19 globally have taken place in care homes. But despite vast numbers of elderly people dying of coronavirus -- and a significant drop in the quality of life of many of those forced to self-isolate -- the global response to the risks they face in the era of Covid-19 has often been chilling.

"You do more testing, you're going to find more cases"
Trump - Tulsa rally - 20 June 2020
"I don't kid, let me just tell you, let me make it clear ..."
Trump to reporter 22 June when asked "Was he kidding?"
"If we didn't do testing we'd have no cases"
Trump to Hannity 25 June 2020 -- US death toll 124,415

The Trump Administration says it will cease federal funding to 13 testing sites in five U.S. states,
including 3 major centres inTexas at the end of the month, one in Houston..
It is unclear how the state of Texas will take over the federal testing if the state's current testing is not even available.

Texas recorded an all time high of 5,996 COVID-19 cases Thursday, beating the previous single-day record set Wednesday.
In Houston , hospitals have already reached capacity with the children's hopsital converted to covid emergency cases.

"Honestly, it feels like this whole city is being hung out to dry."
A Houston small business owner and mother who has covid symptoms but can't get tested

Trump says hydroxychloraquine has been rejected as a Covid-19 treatment only because he has suggested using it: "When I recommend something, they like to say 'don't use it.'"
Of Fauci and Birx: "They're highly thought of but nobody likes me. It can only be my personality, that's all." 28 July 2020 .



Trump's handling of the crisis has faced increasing disapproval. Aggregated states with Democrat governors have had a more severe sudden onset R0=4.4>>1 with higher death rates per million D/M=467.3 involving large cities but are continued to keep the pandemic just in control R1=0.9<1, while states with Republican governors, which had an easier onset R0=1.5 but now substantial death rates per million are opening when the pandemic is not under control and their new cases are still climbing R1=1.4>1. The democrat states are also now becoming affected. Trump is banking on economic concerns to cause people to care less about people dying in large numbers.

World Leaders: Sex and Sensibility in Crisis and Chaos

  1. How Angela Merkel went from lame duck to global leader on coronavirus CNN 7-5-2020
  2. As governments fumbled their coronavirus response, these four got it right. Here's how CNN 16-4-2020
  3. Women leaders are doing a disproportionately great job at handling the pandemic CNN 15-4-2020
  4. Female world leaders hailed as voices of reason amid the coronavirus chaos Wash Post 20-4-2020
  5. Jacinda Ardern Sold a Drastic Lockdown With Straight Talk and Mom Jokes NYT 23-5-2020
  6. Are female leaders more successful at managing the coronavirus crisis? Guardian 24-4-2020 From Germany to New Zealand and Denmark to Taiwan, women have managed the coronavirus crisis with aplomb. Plenty of countries with male leaders – Vietnam, the Czech Republic, Greece, Australia – have also done well. But few with female leaders have done badly. Jacinda Ardern, 39, NewZealand's premier, has held Kiwis' hands through the lockdown. Her insistence on saving lives and her kindness-first approach – urging New Zealanders to look after their neighbours, take care of the vulnerable, and make sacrifices for the greater good – has won her many fans, while her emphasis on shared responsibility has united the country. Public trust in Ardern's government is greater than 80%. Thanks to extensive testing from the outset, plenty of intensive care beds, and the chancellor Angela Merkel's periodic forthright reminders that Covid-19 was "serious – so take it seriously", Germany has so far recorded fewer than 5,000 deaths, a far lower figure than most EU countries. In nearby Denmark, meanwhile, the prime minister, Mette Frederiksen, acted equally firmly. Frederiksen's no-punches-pulled speeches and clear instructions to the nation have been widely praised. Taiwan's president Tsai Ing-wen responded equally fast, activating the country's central epidemic command centre in early January and introducing travel restrictions and quarantine measures. Norway, with 7,200 cases and 182 deaths, this week began relaxing its restrictions by reopening kindergartens. The prime minister, Erna Solberg, told CNN she had made a point of "letting scientists make the big medical decisions", adding that she thought her country's early lockdown and thorough testing programme had been key. Meanwhile, Iceland, under the prime minister, Katrín Jakobsdóttir's, leadership, has offered free testing to all citizens, not only those with symptoms, and has recorded 1,800 cases and 10 deaths. Some 12% of the population has taken up the offer, and an exhaustive tracing system has meant the country has not had to close schools. The world's youngest head of government, Finland's prime minister, Sanna Marin, also moved decisively to impose a strict lockdown, including a ban on all non-essential travel in and out of the Helsinki region. This has helped her country contain the spread of the virus to just 4,000 cases and 140 deaths, a per-million toll 10 times lower than that of neighbouring Sweden. Jeong Eun-kyeong, the unflappable head of South Korea's centre for disease control, has become a national icon after overseeing a "test, trace, contain" strategy that has made the country the world's coronavirus role-model, with daily infections in single digits and a death toll of less than 250.
  7. When it comes to coronavirus response, superpowers may need to study smaller nations Wash Post 17-5-2020


Fire and Emergency Services workers decontaminate a road to limit the spread of the coronavirus in Ahmedabad city. A group of migrant workers which also included women and children sprayed with sodium hypochlorite in Uttar Pradesh causing burning sensations.

Asia

  1. China Concealed Extent of Virus Outbreak, U.S. Intelligence Says Bloomberg 2-4-2020 China isn't the only country with suspect public reporting. Western officials have pointed to Iran, Russia, Indonesia and especially North Korea, which has not reported a single case of the disease, as probable under-counts. Others including Saudi Arabia and Egypt may also be playing down their numbers.
  2. Lack of immunity means China is vulnerable to another wave of coronavirus, top adviser warns CNN 16-5-2020 He also confirmed that local authorities in Wuhan had suppressed key details about the magnitude of the initial outbreak. Zhong said three Chinese vaccines are under clinical trials in the country -- however a "perfect" solution was likely to be "years" away.
  3. Hong Kong appeared to have the coronavirus under control, then it let its guard down CNN 23-3-2020
  4. Why South Korea has so few coronavirus deaths while Italy has so many 17-3-2020
  5. South Korea's evolving strategy to prevent a coronavirus resurgence Reuters 15-4-2020
  6. Why Singapore's coronavirus response worked – and what we can all learn Stuff 18-3-2020 Note the emerging problems though in fig 16.
  7. Singapore had a model coronavirus response, then cases spiked. What happened? CNN 19-4-2020
  8. Coronavirus lockdown: Lessons from Hokkaido's second wave of infections BBC 16-4-2020
  9. Lessons from Abroad: Taiwan's Covid-19 Containment Model NZ Init 12-5-2020
  10. India coronavirus: Tablighi Jamaat leader on manslaughter charge over Covid-19 BBC 16-4-2020 The leader of a prominent Muslim group has been charged with manslaughter in India after a meeting it held in Delhi spawned numerous Covid-19 clusters. The event has been linked to 1,023 cases across 17 states - believed to have been spread by infected foreign attendees.
  11. Powered by Fear, Indians Embrace Coronavirus Lockdown NYT 19-4-2020
  12. India: The 'mystery' of low Covid-19 death rates BBC 28-4-2020
  13. How does India, a country of 1.3 billion people, have around 1,000 coronavirus deaths? CNN 29-4-2020
  14. The way these Indian states handled coronavirus shows where you live matters CNN 12-5-2020 With 35 million people, health minister KK Shailaja the "virus slayer" of Kerala kept cases low from the outset by proactive measures and deaths non-existant, but recently the flood of Indian cases has begun to swamp the state. As of 23-7 with 50,000 new cases a day in India, Kerala, earlier hailed as a success story and which has already imposed partial restrictions, may decide on Monday to impose a full statewide lockdown, reports said.
  15. Mumbai: How Covid-19 has ravaged India's richest city BBC 27-5-2020
  16. How Hong Kong contained its second wave of Covid-19 CNN 4-5-2020
  17. Shulan goes into lockdown as fears grow over China's northeast cluster CNN 18-5-2020
  18. Moscow defends methodology as low official death rate prompts scrutiny Guardian 14-5-2020
  19. How Vietnam managed to keep its coronavirus death toll at zero CNN 29-5-2020
  20. 'The epidemic is growing very rapidly': Indian government adviser fears coronavirus crisis will worsen Nature 26-6-2020 He also notes the death rate may be underestimated due to lack of death certificates, low rates of testing and the failure to ascribe a death to covid if testing does not take place.
  21. 'Patient 206': Man blamed for nearly half of all Sri Lanka's coronavirus cases speaks out LA Times 15-7-2020
  22. Iran cover-up of deaths revealed by data leak BBC 2-7-2020 deaths 3 times and cases 2 times higher than reported.
  23. N. Korea's escalating virus response raises fear of outbreak AP 5-8-2020
  24. India has one of the world's lowest Covid-19 mortality rates. But the numbers don't tell the whole story CNN 11-9-2020
  25. India's Covid crisis sees rise in child marriage and trafficking BBC 16-7-2020


Left: Nurses in Arizona, inspired by the Denver protest (right) do the same. Right: Lockdown protest in Denver after Trump urged protesters in a series of tweets “LIBERATE MINNESOTA!”, “LIBERATE MICHIGAN” and “LIBERATE VIRGINIA, and save your great 2nd amendment. It is under siege!” As protesters gathered outside the capitol steps and others assembled in their automobiles to ask the city to reopen for business, healthcare workers stood in the middle of the road in their scrubs. One protestor leaned out of her car window, wearing an American flag T-shirt, holding a placard that read “land of the free”. Then, she yelled to the protester wearing scrubs: “This is a free country. This is the land of the free. Go to China!”

USA

  1. Lockdown Delays Cost at Least 36,000 Lives, Data Show NYT 21-5-2020 One week earlier than mid-Mar would have cut 65307 recorded deaths to 3 May, to 29410 and two weeks earlier to 11253. Source paper.
  2. Hidden Outbreaks Spread Through U.S. Cities Far Earlier Than Americans Knew, Estimates Say NYT 23-4-2020 On 1 Mar when there were only a few confrmed cases: 1 in Boston, 13 in Seattle, 3 in Chicago, 5 in San Francisco and 1 in New York, the actual numbers according to a North Eastern Univ. estimate were 2300, 2300, 3300, 9300, and 10700.
  3. The U.S. Government Was Not Adequately Prepared for Coronavirus at Home or Abroad Amer. Diplom. 5-2020 While the Coronavirus outbreak and pandemic found nearly all countries unprepared, U.S. lapses in addressing major documented flaws in our preparedness contributed to breakdowns of international collaboration and solidarity as well as institutional conflicts and stress on our health system at home.
  4. Inside Trump's coronavirus meltdown Financial Times 14-5-2020 When the history is written of how America handled the global era's first real pandemic, March 6 will leap out of the timeline. That was the day Donald Trump visited the US Centers for Disease Control and Prevention in Atlanta. His foray to the world's best disease research body was meant to showcase that America had everything under control. It came midway between the time he was still denying the coronavirus posed a threat and the moment he said he had always known it could ravage America.
  5. Trump team failed to follow NSC's pandemic playbook Politico 25-3-2020 The 69-page document, finished in 2016, provided a step by step list of priorities – which were then ignored by the administration.
  6. The missing six weeks: how Trump failed the biggest test of his life Guardian 28-3-2020
  7. Barack Obama labels Donald Trump's coronavirus response a 'chaotic disaster' ABC 9-5-2020 "More than anything, this pandemic has fully, finally torn back the curtain on the idea that so many of the folks in charge know what they're doing. A lot of them aren't even pretending to be in charge." 16-5-2020
  8. Pandemic planning becomes political weapon as deaths mount AP 15-5-2020 Trump has devoted little attention to the 69-page "playbook" from the Obama administration about the threat of a viral outbreak that might include Ebola or an airborne respiratory illness like coronavirus. And the Obama administration could draw from a similar document written during the administration of George W. Bush in 2006.
  9. Intelligence report warned of coronavirus crisis as early as November: Sources "Analysts concluded it could be a cataclysmic event" ABC News 9-4-2020
  10. He Could Have Seen What Was Coming: Behind Trump's Failure on the Virus NYT 12-4-2020
  11. 'Crime against humanity': Trump condemned for WHO funding freeze Guardian 15-4-2020 Timing of move during Covid-19 crisis is deplored by UN chief and experts who say it will cost lives CNN 15-4-2020 Outright dangerous.
  12. Trump suggests injecting disinfectant and ultra violet light as treatments BBC 23-4-2020 "I see the disinfectant that knocks it out in aminute, one minute, and is there a way we can do something like that by injection inside, or almost a cleaning?" The federal government scrambled Friday to stave off a potential wave of public health emergencies sparked by President Trump's dangerous suggestion that injecting bleach or other household disinfectants into the body might cure people of the novel coronavirus and the Food and Drug Administration also warned Friday against the use of hydroxychloroquine — the anti-malarial drug that Trump has repeatedly promoted as a "game-changer" miracle cure.The world's largest manufacturer of disinfectants issued a stark rebuttal. "RB has been asked whether internal administration of disinfectants may be appropriate for investigation or use as a treatment for coronavirus (SARS-CoV-2). As a global leader in health and hygiene products, we must be clear that under no circumstance should our disinfectant products be administered into the human body (through injection, ingestion or any other route)". Maryland Emergency Management Agency on Friday warned residents "This is a reminder that under no circumstances should any disinfectant product be administered into the body through injection, ingestion or any other route" after a blitz of the most calls to its hotline the state has received on any single topic since the coronavirus pandemic began. "My concern is that people will die. People will think this is a good idea,"Craig Spencer, director of global health in emergency medicine. Trump's statement follows a letter to him from one of the chlorine bleach 'cures' barred by federal court order from selling "an unproven and potentially harmful treatment for Covid-19".
  13. US Covid 19 Projections "We made two key updates for the social distancing indicators included our models and visualization tool. First, New Zealand’s government published COVID-19 Alert Levels, categorizing different types of social distancingmeasures by their intensity and type of response. To better align with these alert categories – and reflect the types of policies needed to mitigate the novel coronavirus’s rapid spread – we re-reviewed every “nonessential business” closurepolicy currently implemented in theUS. Informed by the New Zealand framework, we applied more strict criteria for what is defined as the closure of nonessentialservices."
  14. What 5 Coronavirus Models Say the Next Month Will Look Like NYT 22-4-2020
  15. Coronavirus shakes the conceit of 'American exceptionalism' AP 23-4-2020
  16. Gretchen Whitmer remains popular despite protests Business Insider 21-4-2020 A poll released Monday found 57% of Michiganders approved of Whitmer's handling of the crisis compared to 37% who disapproved. Meanwhile, Michigan residents disapproved of the president's actions by a net negative margin of six percentage points, with 44% approving and 50% disapproving. Corona virus has hit Michigan with 308 deaths per million. The epidemic R1 value of 0.9 in fig 16f suggests her restrictions are essential to avoid a further wave. "I took actions to keep people safe, and they're more restrictive than other states, but I thought that it was absolutely essential. After a few weeks of the stay-at-home posture, we have seen our trajectory really start to flatten. We've saved lives." She pointed out that Michigan had the third-highest covid-19 death count in the nation. Armed Protests 30-4-2020 Forbes Guardian
  17. Michigan attorney general warns Ford over letting Trump go maskless CNN 21-5-2020 "The president is like a petulant child who refuses to follow the rules. This is not a joke."
  18. Dozens of Decomposing Bodies Found in Trucks at Brooklyn Funeral Home NYT 29-4-2020 50 bodies transfered.
  19. Trump administration draws up plans to punish China over coronavirus outbreak CNN 30-4-2020
  20. US intelligence debunks theory it was 'manmade' BBC 30-4-202, immediately contradicted by Trump CNN Five eyes intel refutes claims.
  21. WashPost-U. Md. poll: Americans widely oppose reopening most businesses, despite easing of restrictions in some states 5-5-2020
  22. Over 4,500 virus patients sent to NY nursing homes AP 22-5-2020under a controversial state directive that was ultimately scrapped amid criticisms it was accelerating the nation's deadliest outbreaks.
  23. Reopening too soon: Lessons from the deadly second wave of the 1918 flu pandemic Wash Post 24-5-2020 Cities that closed schools and banned public gatherings fared better against the flu. "They had both lower peak and total overall morbidity and mortality cases and deaths. Statewide orders making masks mandatory and shuttering nonessential businesses were widespread in 1918. San Francisco, for example, imposed fines on individuals failing to wear a mask in public, prompting protests. Philadelphia's infamous decision not to cancel its Liberty Loan parade in late September resulted in 1,000 deaths in the span of 10 days, making the city one of the hardest hit by the epidemic. Other cities like Denver lifted restrictions that November on Armistice Day to celebrate the end of the war, only to experience a deadlier spike. That fall marked the disease's second and deadliest wave in the United States.
  24. Coronavirus may never go away, even with a vaccine Wash Post 27-5-2020 Embracing that reality is crucial to the next phase of America's pandemic response, experts say.
  25. From 'We've shut it down' to 100,000 US dead BBC 27-5-2020
  26. They didn't all have to die -- a moment of reflection as US Covid deaths reach 100,000 CNN 27-5-2020
  27. Backlash after Trump signals US exit from WHO BBC 29-5-2020
  28. Trump campaign says it can't be held liable if rally attendees contract coronavirus CNN 12-6-2020 Trump says the virus is now reduced to just the "embers" and "ashes" of a spent pandemic as patience for nationwide lock downs fades and states aggressively open up. The facts say the opposite. Another 1,299 Americans died on Tuesday and more than 112,000 people in the US have died from the disease.
  29. Trump Claims He Instructed His Team To 'Slow Down' Coronavirus Testing Forbes 20-6-2020 Public health experts, including some from the Trump administration, had warned against the rally. Several events on Saturday, including six Trump staffers working on the rally testing positive for coronavirus and Tulsa County reporting its highest number of cases ever, seemed to confirm those fears.
  30. How Arizona 'lost control of the epidemic' Wash. Post 26-6-2020
  31. Coronavirus: US disease chief Dr Anthony Fauci calls White House attacks 'bizarre' BBC 15-7-2020
  32. Donald Trump vows not to order Americans to wear masks BBC 17-7-2020
  33. US tops 1,000 coronavirus deaths 4 days in a row as experts urge the country to shut down CNN 25--7-2020 On Thursday, more than 150 prominent medical experts, scientists, teachers, nurses and other experts signed a letter urging leaders to shut the country down and start over to contain the rampant spread of the virus. Despite the push to reopen schools, older children (between the ages of 10 and 19) can transmit the coronavirus within a household just as much as adults. Models project that there will be up to 175,000 deaths linked to the virus by August 15. "Right now, we are on a path to lose more than 200,000 American lives by November 1st. Yet, in many states people can drink in bars, get a haircut, eat inside a restaurant, get a tattoo, get a massage, and do myriad other normal, pleasant, but non-essential activities," the letter read, which was sent to the Trump administration, members of Congress and state governors.
  34. Trump criticizes Birx after she issues coronavirus warnings CNN 3-8-2020 Fauci Supports Birx's Assessment NYT 4-8-2020
  35. Chasm grows between Trump and government coronavirus experts AP 4-8-2020


Left: Effects of Social Distancing in the US March-May Right: Trump's Wuhan, or China virus finally becomes the "Trump virus".

Europe

  1. Everyone In Iceland Can Get Tested For The Coronavirus. Here's How The Results Could Help All Of Us Buzzfeed 17-3-2020
  2. Why Dutch lockdown may be a high-risk strategy BBC 5-4-2020
  3. Top UK Government scientist resigns after breaking lockdown laws to meet married lover Stuff 6-5
  4. Denmark to ease restrictions next week after coronavirus lockdown Reuters 7-4-2020
  5. Swedish PM warned over 'Russian roulette-style' Covid-19 strategy Guardian 23-3-2020
  6. Coronavirus: To Swedes, it's the rest of the world engaging in a reckless experiment Stuff 3-4-2020
  7. They are leading us to catastrophe': Sweden's coronavirus stoicism begins to jar Guardian 30-3-2020
  8. Sweden challenges Trump -- and scientific mainstream -- by refusing to lock down CNN 10-4-2020
  9. Sweden Continues With Controversial Coronavirus Strategy: Is It A Big Mistake? Forbes 10-4-2020
  10. Anger in Sweden as elderly pay price for coronavirus strategy Guardian 18-4-2020 Herd-immunity fails
  11. Sweden says its coronavirus approach has worked. The numbers suggest a different story CNN 28-4-2020
  12. Sweden Stayed Open. A Deadly Month Shows the Risks NYT 15-5-2020
  13. What's going wrong in Sweden's care homes? BBC 18-5-2020 Residents needing care are niether given oxygen nor sent to hospital.
  14. The Hidden Flaw in Sweden's Anti-Lockdown Strategy Foreign Policy 21-5-2020 A disproportionate number of immigrants, in particular from Somalia, Iraq, and Syria, were among the COVID-19 cases registered at Swedish hospitals. Somali Swedes make up just over half a percent of the national population, so far they make up nearly 5 percent of hospitals' confirmed cases. The Rinkeby-Kista district in the north was the worst affected, with the equivalent of 47 cases per 10,000 residents, which is more than three times higher than the regional average of 13 cases per 10,000 residents.
  15. Sweden is still nowhere near 'herd immunity CNN 21-5-2020 Sweden's Tegnell admits too many died BBC 4-6-2020
  16. Sweden's Covid-19 strategist under fire over herd immunity emails Guardian 17-8-2020
  17. Sweden records highest death tally in 150 years in first half of 2020 Guardian 19-8-2020 The economy of Finland also outperformed its larger neighbour in the second quarter, despite a tougher lockdown. Finland's gross domestic product shrank by 5% against an 8.6% contraction in Sweden from the previous three-month period.
  18. Why so many people are dying in Belgium BBC 2-5-2020
  19. Why Germany's coronavirus death rate is so much lower than other countries' rates Wash Post 24-3-2020
  20. A German Exception? Why the Country's Coronavirus Death Rate Is Low NYT 4-4-2020
  21. Germany's devolved logic is helping it win the coronavirus race Guardian 5-4-2020
  22. Germany says its outbreak is 'under control' BBC 17-4-2020
  23. In Belarus, Covid-19 is a modern-day Chernobyl CNN 12-4-2020
  24. France's first known case 'was in December' BBC 4-5-2020
  25. Baltic states open a pandemic 'travel bubble' BBC 15-5-2020 The Baltic countries of Estonia, Latvia and Lithuania have opened their borders to one another, creating a coronavirus "travel bubble". From midnight on Thursday, citizens and residents can move freely between the three EU nations. Anybody arriving from outside the zone however must self-isolate for 14 days.
  26. MPs hear why Hong Kong had no Covid-19 care home deaths Guardian 19-5-2020 Despite sharing a border with China, Prof Terry Lum, the head of social care policy at Hong Kong University, told the UK parliament's health and social care select committee that Hong Kong treated the outbreak like Sars, the killer virus that hit Asia in 2003, and saved lives. By contrast, the UK's response to coronavirus was based on planning for a flu pandemic.
  27. Why Spain is seeing second wave BBC 21-8-2020

MIddle East

  1. With weekend lockdowns and age-specific restrictions, Turkey takes a different coronavirus approach CNN 17-4-2020 Turkey also uses hydroxychloroquine and favipiravir, a Japanese antiviral, much earlier than other countries in the onset of Covid-19.
  2. Israel's Not-So-Secret Weapon in Coronavirus Fight: The Spies of Mossad NYT 12-4-2020


Left: The Amazon burning August 2019 (NASA). Mass graves in Manaus April 2020. Both due to human misadventure
against biodiversity, exacerbated by the confrontational politics of Jair Bolsanaro.

Central and South America

  1. Bolsonaro and Amlo slammed for snubbing coronavirus warnings Guardian 15-3-2020
  2. Brazil lockdowns, attacked by Bolsonaro, begin to slip Reuters 8-4-2020
  3. Brazil's Amazonas state warns its health system overwhelmed by coronavirus Reuters 9-4-2020
  4. Brazil's indigenous people are dying at an alarming rate from Covid-19 CNN 24-5-2020
  5. Inside Brazil's hospitals, doctors know the horrifying reality CNN 24-5-2020
  6. Bolsonaro dragging Brazil towards coronavirus calamity, experts fear Guardian 12-4-2020
  7. What Bolsonaro said as Brazil's coronavirus cases climbed CNN 28-5-2020
  8. Amazon city resorts to mass graves as Brazil COVID-19 deaths soar Reuters 30-4-2020
  9. 'Utter disaster': Manaus fills mass graves as Covid-19 hits the Amazon Guardian 30-4-2020
  10. Brazil condemned to historic tragedy by Bolsonaro's virus response – top doctor Guardian 5-6-2020
  11. Bodies are being left in the streets in an overwhelmed Ecuadorian city CNN 4-4-2020
  12. Ecuador sees massive surge in deaths in April BBC 17-4-2020 Ecuador's official coronavirus death toll is 403, but the government said 6,700 people died in Guayas province in the first two weeks of April, far more than the usual 1,000 deaths there in the same period.
  13. Ecuador's Death Toll During Outbreak Is Among the Worst in the World NYT 23-4-2020 A New York Times analysis suggests that Ecuador's death toll is 15 times higher than its official tally of coronavirus deaths, highlighting the damage the virus can do in developing countries.
  14. Peru's coronavirus response was 'right on time' – so why isn't it working? Guardian 20-5-2020
  15. The Amazon, Giver of Life, Unleashes the Pandemic NYT 25-7-2020
  16. Brazil Indian Group Celebraes 6 Months without Covid-19 AP 12-9-2020
  17. How the world's worst-hit city turned a bad situation into a 'calamity' NZ Herald 13-10-2020

Africa

  1. The world is scrambling to buy ventilators in the Covid-19 pandemic. One country has only four of them -- for 12 million people CNN 19-4-2020 There are fewer than 2,000 functional ventilators in 41 African countries, according to the WHO, while the total number of available intensive care unit beds in 43 countries on the continent is less than 5,000. This is about five beds per 1 million people, compared to 4,000 beds per 1 million people in Europe, the WHO reported last week. South Sudan has just four ventilators and 24 ICU beds for a population of 12 million people, according to data from the International Rescue Committee (IRC). Burkina Faso has 11 ventilators for 20.6 million, Sierra Leone 13 for 7 million, and Central African Republic 3 for 4 million. US hospitals could need as many as half a million additional ventilators for 328 million during the pandemic, according to the Johns Hopkins Center for Health Security.
  2. Coronavirus: South Africa deploys 70,000 troops to enforce lockdown BBC 22-4
  3. South Africa death toll could be 'far higher' BBC 23-7-2020
  4. Caution urged over Madagascar's 'herbal cure' BBC 22-4 Drink contains herbal artemesin another anti-marial.
  5. Madagascar president's herbal tonic fails to halt Covid-19 spike BBC 14-8-2020
  6. Night burials amid Tanzania's coronavirus defiance BBC 4-5-2020
  7. Tanzanian president promises to import Madagascar's 'cure' BBC 4-5-2020
  8. 'It's a disaster': Egypt's doctors plead for more PPE and testing Guardian 20-5-2020
  9. The pandemic appears to have spared Africa so far. Scientists are struggling to explain why Science 11-8-2020 MedRxiv


Jackalls in Tel Aviv, half humanity in lockdown, and messages on the pyramids of Egypt