a Covid news digest
for the two-week period of October 3 – October 16, 2020 FINAL EDITION
FRONT PAGE
- More on airborne transmission and institutional reliability. The CDC has finally issued what we hope will be a permanent warning about coronavirus aerosol risk.
- Racial and ethnic disparities in Covid case and death rates. A deeper look into Milwaukee’s racial and ethnic distribution of Covid infections reveals unusually responsive government leaders, political change, and viral mobility. And, a Latina business leader in California stricken with Covid confronts bias in the health system.
- Covid positivity and hospitalizations rise sharply in Indiana. Indiana made it into the Top Ten states for seven-day Covid ositivity rates last week and stayed there this week. Reported positive case rates are limited in accuracy to those people who get tested, leaving open the possibility that many others are infected but just don’t get tested. Hospitalization rates, on the other hand, are highly accurate because you are either occupying a hospital bed with Covid or not. Hospitalizations for Covid in Indiana have risen sharply in the past week. Increased infection rates mean your chances for a close encounter with the virus are higher. Keep that in mind when planning any social activities. The Governor eased business restrictions this week but continued the mask requirement. Wear a mask, keep your distance, limit exposure time especially in poorly ventilated indoor areas, and don’t let your guard down, especially when around friends.
- Free testing. No doctor referral needed for highly accurate PCR test at the Marion County Public Health Department or the state health department or CVS. To set up an appointment visit https://mcphdredcap.hhcorp.org/surveys/?s=A4F4NY3PDH (Marion County) or call 317.221.8967 or 317.221.5515.
FEATURE STORIES
I. Airborne transmission – CDC takes a stand, again
Summary. After issuing a policy statement on aerosol transmission in September, then retracting three days later, the CDC issued a statement last week clarifying that Covid can indeed be transmitted through the air in aerosol form that can linger airborne for an extended period.
“CDC continues to believe, based on current science, that people are more likely to become infected the longer and closer they are to a person with COVID-19. Today’s update acknowledges the existence of some published reports showing limited, uncommon circumstances where people with COVID-19 infected others who were more than 6 feet away or shortly after the COVID-19-positive person left an area. In these instances, transmission occurred in poorly ventilated and enclosed spaces that often involved activities that caused heavier breathing, like singing or exercise. Such environments and activities may contribute to the buildup of virus-carrying particles.”
The CDC emphasizes that, despite the updated policy statement, the same Covid preautions remain in effect: maintain a six feet distance from others, wear a mask, wash hands frequently, clean touched surfaces often, and stay home when sick.
The WHO has not updated its most recent statement on aerosol transmission of July 9, 2020 in which it acknowledges the possibility of aerosolized virus, but finds all research performed to that date to be insufficient to warrant a definitive policy declaration.
Outside of medical facilities, some outbreak reports related to indoor crowded spaces have suggested the possibility of aerosol transmission, combined with droplet transmission, for example, during choir practice, in restaurants or in fitness classes. In these events, short-range aerosol transmission, particularly in specific indoor locations, such as crowded and inadequately ventilated spaces over a prolonged period of time with infected persons cannot be ruled out. However, the detailed investigations of these clusters suggest that droplet and fomite transmission could also explain human-to-human transmission within these clusters. Further, the close contact environments of these clusters may have facilitated transmission from a small number of cases to many other people (e.g., superspreading event), especially if hand hygiene was not performed and masks were not used when physical distancing was not maintained.
An article in the journal Science states: “Individuals with COVID-19, many of whom have no symptoms, release thousands of virus-laden aerosols and far fewer droplets when breathing and talking. Thus, one is far more likely to inhale aerosols than be sprayed by a droplet, and so the balance of attention must be shifted to protecting against airborne transmission. In addition to existing mandates of mask-wearing, social distancing, and hygiene efforts, we urge public health officials to add clear guidance about the importance of moving activities outdoors, improving indoor air using ventilation and filtration, and improving protection for high-risk workers.”
Take-away. Major public health agencies agree that Covid can be spread through aerosols suspended in the air through breathing or talking. In addition to the standard precautions of wearing a mask, maintaining physical distance, and washing hands frequently, one should avoid or minimize time spent in indoor areas with inadequate ventilation.
References
CDC, October 5, 2020, Scientific brief: potential airborne transmission.
https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html
World Health Organization, July 9, 2020, Virus transmission mplications for infection prevention
Science, June 26, 2020, Reducing airborne transmission
https://science.sciencemag.org/content/368/6498/1443.9?rss=1&intcmp=trendmd-sci
II. How can Covid’s racial disparities be addressed? Two stories.
Milwaukee’s numbers improve
CovidGram previously reported (September 25-October 2 issue) a dramatic improvement in Covid case and death rates in Milwaukee’s black population since ProPublica published a story back in April about the disproportionately high Covid rates among black residents of that city. Current stats for black Milwaukee residents show a 24% share of all positive cases, down from a 49% share in early April, and deaths at 35% down from an April peak of 81%. Considering that the city’s population is 26% black, Milwaukee appeared to have fixed much of the steep disparity in the racial distribution of Covid’s toll. Black residents still account for more than their share of Covid deaths, but the downward trend is unmistakable.
What caused Milwaukee’s Covid rates to even out across racial groups?
Viral infection rates tend to fluctuate in waves within and across population subgroups, and Milwaukee’s rates have had particularly extreme peaks and valleys. “The city’s first Covid peak in late March and early April was concentrated in Milwaukee’s African-American community on the city’s northside” explained Darren Rausch, Covid data spokesperson for Milwaukee County. As that spike dissipated, another strong surge formed in the Hispanic community on Milwaukee’s westside in May. Over the summer, the virus migrated once again toward the white suburbs. That last geographic shift left the city with a racial distribution of positive Covid cases and deaths aligned much more closely with racial distribution of the city’s population.
Rausch credited the city’s rapid mobilization of free Covid testing by the National Guard and a unified command structure within the various public health agencies in the county with some of the early success in controlling the pandemic and reversing the April surge in the black community. But as the virus receded from black neighborhoods in the north, outbreaks in factories and meat processing plants caused a second Covid spike mainly in Hispanic neighborhoods to the west.
Standard public health measures including lockdown and information campaigns helped bring the second surge under control, but in June Republican legislators swayed the State Supreme Court to overturn Democratic Governor Tony Evers’s lockdown order. A third, summer Covid spike ensued, then resolved in August only to rev back up in September as many colleges opened to in-person instruction. The Covid roller coaster ride continued with a dip at the end of September followed immediately by a large spike early this month.
To sum things up, Rausch believes that the natural migration of the virus to new locales and unsuspecting populations affected the fluctuations across racial groups more than any governmental action or inaction. Another information source, a social activist in Milwaukee’s nonprofit sector, suggested that Dr. Jeanette Kowalik, Milwaukee’s former Commissioner of Health deserves much credit for various victories against the pandemic. Kowalik is black, young, and popular in social justice circles. She resigned in early September to take a health policy position in Washington, DC.
Healthcare bias in Northern California
As reported this week on NPR, Karla Monterroso, CEO of a racial interrelations consulting firm that serves the tech industry, is not someone who is easily pushed around because of her brown skin and Latina heritage. But when she developed a bad cough, heavy lung sensation, and fluctuating fever among other disturbing symptoms, she rushed to the ER where she put herself at the mercy of the medical staff. The ER doctor, also non-white, dismissed all of her symptoms, chastised her for having an assertive attitude, and sent her home without any testing or diagnosis. Not until her friends took her to UC-San Francisco, one of the pre-eminent research hospitals in the country, did she find emergency department staff who understood her concerns, diagnosed her Covid, and gave her the care she needed, which turned out, unfortunately, to require repeated care over several months.
In recounting her experience of implicit bias in health care, Monterroso succinctly described a situation that patients of all races encounter from the medical profession but which weighs hardest on people of color who have historically endured more extreme forms of bias. “Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate. And if we are not advocating for ourselves, we can be treated as invisible.”
Unfortunately, doctors who have difficulty reconciling their medical authority with their patients’ own medical perspective are commonly encountered. Such doctor-patient conflict can easily compromise the quality of medical care.
A short article in NCRC News recommends, in addition to increasing the racial diversity of hiring in health care fields, the practice of effective bystander intervention: “White caregivers and administrators must have the courage to intentionally call out White colleagues when witnessing unfair or incivil treatment towards patients and staff of color.”
Take-away. When it comes to health care situations, racial bias can have dangerous, even grave consequences. Both the Milwaukee Covid situation and the Bay Area emergency room case illustrate the need for better professional training and more responsive politics leading to more widespread understanding of the historical roots of racial bias and the imperative to speak out and act against it.
References
CRC, September 22, 2020, Addressing white privilege in health care practice
https://ncrc.org/white-accountability-health-equity/
NPR, October 15, 2020, Research shows that doctors’ unconscious bias affects quality of care
Glossary
R – effective reproduction number, defined as the average number of secondary infections caused by an infected person. R > 1 indicates a growing epidemic, whereas R < 1 is needed to achieve a decrease in transmission.
Incubation period – time between infection and onset of symptoms.
Serial interval – duration between symptom onset of successive cases in a transmission chain.
Notable regular or ongoing journal coverage of Covid
The Atlantic
New York Times
PLOS
The New Yorker
Washington Post
STAT News
Vox
Wall Street Journal
Science
CDC
WHO
Chest
JAMA
NEJM
NPR