with Paulina Firozi
Want more stories examining Washington and the world's reaction to the novel coronavirus? Sign up for this newsletter here.
It would be great news for the prospect of containing the coronavirus pandemic if only people with symptoms typically spread the virus, as the World Health Organization said yesterday.
But the WHO’s announcement was immediately met with skepticism and pushback from prominent health and medical experts – underscoring how the scientific community is still far from consensus over how the novel coronavirus operates.
The question of whether asymptomatic people were helping drive the virus's spread is critical – and a central argument for social distancing and lockdowns. Because most researchers believed this is a common way the virus circulates, even people at low risk for the disease or who were not showing symptoms were nonetheless warned to behave as though they were already infected.
Children and teenagers — rarely seriously stricken by covid-19 — were taken out of school for the remainder of the academic year and all people were advised to wear a mask in public places, for fear they could unknowingly transmit the illness to the elderly and others highly vulnerable to it.
But now the WHO says asymptomatic people are not a “main driver” of new infections.
Maria Van Kerkhove, head of the WHO’s emerging disease and zoonosis unit, didn’t entirely dismiss the idea that people without symptoms can spread the virus. But she did say contact tracing research from around the world suggests that it’s much rarer than previously thought.
“We have a number of reports from countries who are doing very detailed contact tracing,” Kerkhove said. “They’re following asymptomatic cases. They’re following contacts. And they’re not finding secondary transmission onward. It’s very rare.”
Kerkhove pointed to a paper published last week by the WHO, which updated previous guidance on mask-wearing based on the latest research about the virus. The report warns that studies on asymptomatic transmission are limited and small, but says available evidence suggests people without symptoms “are much less likely to transmit the virus than those who develop symptoms.”
The report noted several relevant studies. In one, just nine of 63 infected but asymptomatic individuals in China infected another person. Another study found no secondary transmission among 91 contacts of nine asymptomatic cases.
“If you actually go back and say how many of them are truly asymptomatic, we find out that many have really mild disease, very mild disease — they’re not ‘covid symptoms,’ meaning they may not have developed fever yet,” Kerkhove said.
But key experts in the United States say the WHO's conclusion presents some big problems.
It's not that asymptomatic people don’t spread the virus — but that contact tracing is simply bad at detecting it, they argue. The studies cited by WHO relied on only a small number of people in China who claimed to have gotten sick from someone who had symptoms – which is not exactly a rigorous scientific experiment.
They also worry that their findings will lead to confusion. There's a difference between people who truly never showed symptoms of coronavirus and people who were “pre-symptomatic," who had not yet developed symptoms but eventually would. Then, of course, there are “low-symptomatic” people who are experiencing effects of coronavirus so mild they might not be noticed.
Andy Slavitt, former head of the Centers for Medicare and Medicaid Services, said that in an email exchange with the WHO, the organization admitted to him it can't distinguish between asymptomatic and pre-symptomatic people.
When I discussed with scientists and doctors, each was in a bit of disbelief that this would put out. They pointed out:— Andy Slavitt @ 🏡 (@ASlavitt) June 8, 2020
-there are 4 studies which show asymptomatic spread
-people are not reliable reporters of whether they have symptoms
-by their own admission, they can’t be sure
Jeremy Faust, an emergency room doctor at Harvard Medical School:
What Dr. Van Kerkhove is really saying, I think, is that when WHO follows up with people who did contact tracing, they found that they could *not detect* a lot of asymptomatic spread of SARS-CoV-2.— Jeremy Faust MD MS (@jeremyfaust) June 8, 2020
How do we square that with articles like this? https://t.co/40yQ6LRAJP
The correct conclusion is NOT that the WHO has evidence that SARS-CoV-2 is not commonly spread asymptomatically. That’s possibly rather wrong.— Jeremy Faust MD MS (@jeremyfaust) June 8, 2020
The correct interpretation is more likely that CONTACT TRACING is woefully inadequate at finding asymptomatic spread.
The critics also noted that coronavirus infections have continued spreading even as people with symptoms were largely isolating at home – indicating that asymptomatic and pre-symptomatic people were spreading it.
Spreading was also traced to schools around the world, even though kids typically don't get symptoms or only mild ones.
The WHO’s statement doesn’t square with previous studies suggesting the virus is highly transmissible by people without symptoms.
Slavitt and others pointed to multiple studies showing asymptomatic spread of the virus.
For example, one study published on June 3 in the Annals of Internal Medicine suggested asymptomatic people seem to account for 40 to 45 percent of SARS-CoV-2 infections and they can transmit the virus to others for an extended period of time.
Ashish Jha, director of the Harvard Global Health Institute:
This from @WHO is getting a lot of attention and creating confusion.— Ashish K. Jha (@ashishkjha) June 8, 2020
I want to quickly share what I understand about this.
Bottom line question:
Are infected people without symptoms an important cause of spread?
My best guess: yes.
A thread https://t.co/NnLpf7kTVh
So what about the other 80% of people who do have symptoms?— Ashish K. Jha (@ashishkjha) June 8, 2020
Many of them are shedding virus BEFORE they develop symptomshttps://t.co/nG32PLkM4h
Technically, these folks are PRE-symptomatic, not asymptomatic
But they are asymptomatic at the time they are shedding virus
So – it might be @WHO is drawing a distinction between asymptomatic spread and pre-symptomatic spread.— Ashish K. Jha (@ashishkjha) June 8, 2020
And it may be there isn't a lot of asymptomatic spread but plenty of pre-symptomatic spread.
Would be helpful to get the full report that they are referencing.
Critics said the WHO communicated poorly about scientific findings.
The organization, already at the crosshairs of the Trump administration, has been frequently criticized by Republicans and conservatives throughout the pandemic for how it has handled information from China. But yesterday a broader section of experts criticized the WHO for making a firm yet unproven statement about asymptomatic spread, potentially prompting even more skepticism about measures like mask-wearing and social distancing.
Slavitt said the WHO made an “irresponsible statement.”
4. I think if your data is thin or not public or contradicted by lots of studies, making definitive statements is a mistake.— Andy Slavitt @ 🏡 (@ASlavitt) June 9, 2020
5. There are many capable of critiquing WHOs menthols (@CT_Bergstrom @DrEricDing). I don’t have the expertise but they do.
Doctor Eric Topol:
Unfortunately, as an outgrowth of a @WHO statement and @CNBC coverage today there is still significant confusion about the asymptomatic story. Conflation with pre-symptomatic status.— Eric Topol (@EricTopol) June 9, 2020
Let's first define these 2 groups pic.twitter.com/R52dsNSHB0
If the WHO conclusions were confirmed, it probably would reshape the pandemic response.
Public officials probably would feel that they have more flexibility in reopening places such as schools and summer camps. Mask-wearing might be seen as less essential. Contact tracers would operate under different assumptions.
Howard Forman, a trauma radiologist:
Brief thread:— (((Howard Forman))) (@thehowie) June 8, 2020
This is BIG news, but many questions.
Even if true, literally (as below), it is HUGE. It also would change how we manage this: from contact tracing to social distancing measures.
Baylor University professor Peter Hotez:
If this turns out to be true it would be a game-changer, but I think it would be really important for us to know whether CDC concurs?https://t.co/7aMEfvSiQ8— Prof Peter Hotez MD PhD (@PeterHotez) June 8, 2020
Ahh, oof and ouch
AHH: A new study suggests shutdown orders prevented major outbreaks.
Shutdowns and social distancing prevented about 60 million coronavirus infections in the United States and 285 million in China, according to a study led by researchers at University of California at Berkeley and published in the journal Nature.
Another study simultaneously published in the journal from epidemiologists at Imperial College London said the lockdowns saved about 3.1 million lives in 11 European countries.
The pair of reports “suggest that the aggressive and unprecedented shutdowns, which caused massive economic disruptions and job losses, were effective at halting the exponential spread of the novel coronavirus,” Joel Achenbach and Laura Meckler report.
“Societies around the world are weighing whether the health benefits of anti-contagion policies are worth their social and economic costs,” the Berkeley team wrote.
One notable finding was that school closures did not have a significant impact, “although the authors cautioned that their research on this was not conclusive and the effectiveness of school closures requires further study,” Joel and Laura write. “The findings could be instructive to states and school districts as they weigh when and how to reopen this fall."
OOF: Fewer than half of states are counting probable coronavirus cases and deaths.
But the Centers for Disease Control and Prevention wants them to.
Some of the largest states — California, Florida, North Carolina and New York — are among those not disclosing probable cases and deaths.
“That is one reason government officials and public health experts say the virus’s true toll is above the U.S. tally as of Sunday of about 1.9 million coronavirus cases and 109,000 deaths — benchmarks that shape policymaking and public opinion on the pandemic,” Beth Reinhard, Emma Brown, Reis Thebault and Lena H. Sun report.
An analysis by The Washington Post found at least 24 states are not following national guidelines on reporting this data, even weeks after guidance was issued for standardizing coronavirus reporting.
They add: “Officials in Montana, Rhode Island and the District of Columbia say they haven’t reported any probable cases or deaths because they have not had any, citing low numbers or the wide availability of testing. Seven states did not respond to The Post’s requests for a breakdown of cases and death counts. Five of those are not reporting probable cases or deaths, according to data the CDC began publishing June 2. South Dakota reports probable deaths but not cases.”
OUCH: There are new protections amid the pandemic shielding nursing homes from lawsuits.
In Connecticut, where one nursing home lost 1 in 3 residents to covid-19, Gov. Ned Lamont (D) issued an emergency order granting such facilities immunity from lawsuits.
“Similar to recent measures in about 20 other states, the Connecticut order has sweeping implications, depriving potential plaintiffs not only of financial recourse in the courts but the ability to uncover an accounting of their relatives’ last days in nursing homes,” Debbie Cenziper, Peter Whoriskey, Shawn Mulcahy and Joel Jacobs report. “The demand for information during the crisis has become particularly urgent: Since March, federal officials have curtailed routine inspections and restricted visitors in homes, leaving families to peer through windows or plead for information over the phone.”
Health-care associations have been pushing for such immunity.
“The groups also have appealed to Health and Human Services Secretary Alex Azar, House Speaker Nancy Pelosi (D-Calif.) and Senate Majority Leader Mitch McConnell (R-Ky.), who vowed on the Senate floor last month to extend new coronavirus-related protections to a number of groups, including the health-care industry,” our colleagues write.
McConnell and others say the measures are meant to protect front-line health workers. “But what plaintiffs’ lawyers and patient advocacy groups contest most is not whether immunity should be extended to health-care personnel, but whether those protections should also extend to nursing homes and their owners,” Debbie, Peter, Shawn and Joel write. “In their view, troubled facilities ought to remain subject to litigation resulting from life-threatening failures in infection control and patient care, and families offered a chance to pierce the layers of secrecy that often surround unexpected or unexplained deaths.”
In the states
Kentucky Gov. Andy Beshear (D) said he wants to provide health insurance for all of his state’s black residents.
He cited the racial disparities in health care that have been underlined in the state by the pandemic.
“In our health-care system, the inequalities have been laid bare and exposed by this covid-19 pandemic and the results of inequality in health care have been shown in depth,” Beshear said. “By allowing this type of inequality to exist for as long as it has, we see African Americans dying at twice the rate that they make up of the population … it shouldn't have taken this pandemic or these demonstrations for us to commit to ending it."
The announcement follows days of demonstrations in the state over police violence. Ava Wallace, Jesse Dougherty and Roman Stubbs wrote this week about how the coronavirus exposed the racial divide in Louisville.
“We are gonna begin an effort to cover 100 percent of our individuals in our black and African-American communities,” Beshear said. “We’re gonna be putting dollars behind it.”
“He did not share specifics on how they would be covered, but mentioned potentially using a mix of Medicaid, Medicare and private insurance,” the Louisville Courier Journal’s Olivia Krauth reports. “… The push was one of a handful of changes to combat racial inequities Beshear led off his Monday press conference with after days of unrest and protests against systemic racism and police brutality across the state.”
New York City is beginning to reopen.
The city that was once the epicenter of the pandemic in the United States is starting to ease out of its stay-at-home orders.
“Monday marked the first, limited phase of a four-part reopening plan. Wholesale sellers and manufacturers were allowed to resume business and the construction industry made its noisy return. Workers in hard hats swarmed a site in south Queens, installing walls and machinery within the skeleton of a tower that had been mostly hollow since March,” Ben Guarino and Shayna Jacobs report.
But New York City Health Commissioner Oxiris Barbot insisted the gradual reopening doesn’t mean the city is returning to pre-pandemic ways.
“She cautioned that people with weakened immune systems, the elderly and others who are at high risk for serious complications from the coronavirus should stay indoors as much as possible,” Ben and Shayna add. “She urged New Yorkers to wear face coverings outdoors, vigorously wash hands and use hand sanitizer.”
“We’re still in what I would say is a moderate transmission phase,” Barbot said. “There are still, on a daily basis, hundreds of people that are newly diagnosed with covid-19. ”
Arizona’s state health director called on hospitals there to “fully activate” emergency plans.
The number of coronavirus cases in the state have spiked, as have hospitalizations.
“Some experts say Arizona is experiencing a spike in community spread of COVID-19,” the Arizona Republic’s Stephanie Innes reports. “… As of Monday, Arizona cases of COVID-19, rose to 27,678 with 1,047 known deaths. Maricopa County has the 26th highest number of confirmed cases of any county in the U.S., according to Johns Hopkins University. The disease has caused 110,845 deaths in the U.S. and 404,304 worldwide, the Johns Hopkins data says.”
The June 6 letter from Cara Christ, Arizona Department of Health Services director, calls for reviewing standards “to make determinations for moving your facility from conventional care to contingency care and prepare for crisis care.”
Los Angeles County experienced its highest weekend total of deaths in over a month.
There were 81 coronavirus-related deaths over the weekend, officials said, following the 105 total weekend deaths reported April 18-19, the Los Angeles Times’s Colleen Shalby reports.
“Now, two weeks after Memorial Day weekend saw crowds gather at newly reopened beaches and just over a week since restaurants and most businesses were given the green light to resume operations, officials have reported that the transmission rate of the virus appears to have increased, an expected reality as activity rose,” Colleen writes.
Here are a few more stories to catch up on this morning:
Around the world:
- The WHO reported the number of new cases around the globe hit a record on Sunday. “Yesterday, more than 136,000 cases were reported — the most in a single day so far,” WHO Director General Tedros Adhanom Ghebreyesus said at a briefing. He said three-fourths of those cases came from 10 countries, mostly in South Asia and the Americas, as the New York Times reports.
It's still an election year:
- Joe Biden’s reemergence into the public has raised questions about what his campaign is doing to keep him safe from the coronavirus, Matt Viser reports.
- The president’s campaign said Trump is expected to start his rallies in upcoming weeks, Josh Dawsey and Felicia Sonmez report.
Crawling toward a new normal:
- The New York Times’s Margot Sanger-Katz, Claire Cain Miller and Quoctrung Bui surveyed more than 500 epidemiologists about when they expect to feel comfortable doing certain activities. For example, 52 percent said it may be a year or more before they stop routinely wearing a face covering. One-third said they would attend a dinner party at a friend’s house this summer.
The economic fallout:
- The United States official entered a recession in February, Rachel Siegel reports.
More from the states:
- A Pennsylvania county health department director is warning people to continue to practice social distancing after 11 new coronavirus cases were linked back to a New Jersey resident who attended several Jersey Shore gatherings in the last two weeks, Kareem Copeland reports for The Post’s live blog.