A Disturbing Dearth Of Data

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I get it.  It's hard to worry about the creek rising when your house in on fire. And right now the flames of COVID-19 have everyone's attention.

But our world doesn't stop just simply because we are embroiled in a pandemic. 

The seasons inexorably change, migratory birds make their twice annual flight to and from their high latitude roosting areas, natural disasters occur, viruses and bacteria mutate and adapt, and some may even jump species or acquire increased virulence or transmissibility along the way. 

In the best of times, our visibility of what is going on with infectious diseases is limited. 

Despite the long-standing IHR 2005 international Health Regulations agreement where WHO member countries pledged to develop mandated surveillance and testing systems, and to report certain disease outbreaks and public health events in a timely manner - fewer than half the countries of the world self-report having met the core requirements.

And even those countries capable of reporting sometimes find economic or political reasons to hold back (or delay releasing) disease outbreak information - or refuse to share virus samples - violating both the letter and the spirit of this agreement (see Adding Accountability To The IHR).

But over the past 6 months, even the normally reliable surveillance and reporting systems around the globe have diverted their attentions away from old threats like seasonal influenza, MERS-CoV, avian flu, Monkeypox, and a host of other emerging infectious diseases. 

The graphic at the top of this blog compares the early August Influenza reporting by the WHO for 2019 vs. 2020. Except for North America, the 2020 map is blank. Some of this is undoubtedly due to  reduced influenza transmission around the world, due to COVID-19 social distancing, but certainly not all. 

From yesterday's bi-weekly flu report.

Influenza update - 373
03 August 2020 - Update number 373, based on data up to 19 July 2020

Information in this report is categorized by influenza transmission zones, which are geographical groups of countries, areas or territories with similar influenza transmission patterns. For more information on influenza transmission zones, see the link below:

Influenza Transmission Zones pdf, 659kb

Open map in new window png, 268kb

Summary

• The current influenza surveillance data should be interpreted with caution as the ongoing COVID-19 pandemic might have influenced to varying extents health seeking behaviours, staffing/routines in sentinel sites, as well as testing priorities and capacities in Member States. The various hygiene and physical distancing measures implemented by Member States to reduce SARS-CoV-2 virus transmission might also have played a role in mitigating influenza virus transmission.
• Globally, influenza activity was reported at lower levels than expected for this time of the year. In the temperate zones of the southern hemisphere, the influenza season has not commenced.
• In the temperate zone of the northern hemisphere, influenza activity remained at inter-seasonal levels.
• In the Caribbean and Central American countries, sporadic influenza detections were reported in most reporting countries. Severe acute respiratory infection (SARI) activity remained elevated in some reporting countries.
• In tropical South American and tropical Africa, there were no or sporadic influenza virus detections across reporting countries.
• In Southern Asia and South East Asia, no influenza detections were reported.
• Worldwide, seasonal influenza A viruses accounted for the majority of detections.

National Influenza Centres (NICs) and other national influenza laboratories from 59 countries, areas or territories reported data to FluNet for the time period from 06 July 2020 to 19 July 2020 (data as of 2020-07-31 04:23:14 UTC). The WHO GISRS laboratories tested more than 302586 specimens during that time period. A total of 45 specimens were positive for influenza viruses, of which 26 (57.8%) were typed as influenza A and 19 (42.2%) as influenza B. Of the 7 sub-typed influenza A viruses, 100% were influenza A(H1N1)pdm09. Of the 2 characterized B viruses, 100% belonged to the B-Victoria lineage.

WHO encourages the testing of routine influenza surveillance samples from sentinel and non-sentinel sources for SARS-CoV-2 virus where resources are available and invites all countries/areas/territories to report this information (ideally indicating which data are from sentinel sites) to routine, established regional and global platforms. (See the Operational considerations for COVID-19 surveillance using GISRS guidance)

          (Continue . . .  )

In the corresponding 2019 report (Aug 5th), 4322 positive influenza samples were submitted, 75 times greater than was submitted in this report.   

Whole regions of the world have apparently stopped submitting flu reports. The WHO EMRO Influenza weekly update from the Eastern Mediterranean region - which normally reports 52 weeks a year - last submitted a report in early March.

All of this matters because less than two weeks ago, in ECDC: Influenza virus characterisation - Summary Europe, June 2020,  we saw the first antigenic analysis of flu samples in the EU since  March, which suggested increasing poor reactivity to the 2019-2020 H1N1 vaccine virus, jumping from 9% of samples reported last March to 22% (22 of 99) in this month's report.

Similarly, 25% of the (69) Influenza B/Victoria viruses tested were not well recognized by antiserum raised against the vaccine virus for last year's northern hemisphere influenza season.

How much of a factor seasonal flu will be this fall is anyone's guess, but it is risky to take our eyes off the ball, particularly since decisions must be made in September for next year's Southern Hemisphere flu vaccine.  

But it isn't just seasonal flu.

 

Saudi Arabia hasn't updated their MERS-CoV surveillance page since late May, when they were reportedly dealing with a hospital outbreak (see WHO DON: Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia).

No other Middle Eastern countries have reported any MERS-CoV cases since March. While it is possible MERS-CoV activity has vanished, it isn't terribly likely.

 

Reports of novel flu around the world have declined since the pandemic began as well.  We've seen a handful of avian H9N2 cases reported in China, and a small number of swine variant flu infections (Brazil, Germany & Hawaii), but no H5Nx or H7N9 cases in 2020. 

If countries aren't robustly testing for seasonal flu - which they don't appear to be right now - they are unlikely to pick up very many novel flu infections. 

Only occasionally do we see bird flu reports, such as the recent H7N7 outbreak in Victoria Australia, or this report yesterday from Chelyabinsk Oblast, Russia describing bird deaths from H5N8.

Avian influenza was registered in the Chelyabinsk region

The Rosselkhoznadzor Administration for the Chelyabinsk region informs that an outbreak of bird flu has been registered in the region. The Rosselkhoznadzor Directorate and the Veterinary Directorate of the Regional Ministry of Agriculture are taking all measures to prevent the spread of this dangerous disease. The diagnosis made by the staff of the Uvelskaya Interdistrict Veterinary Laboratory and the Chelyabinsk Testing Laboratory was confirmed by the specialists of the Federal Center for Animal Health (FGBI ARRIAH) in Vladimir: the genetic material of the avian influenza virus subtype H5N8 was identified.

The bodies of birds found were examined (1 wild duck, 2 domestic and 2 domestic geese), selected on the shores of Peschanoe and Tabinsha lakes, Uvelsky district. All samples revealed material from the avian influenza virus subtype H5N8. In this regard, a registration of birds was carried out in these settlements. On the territory of disadvantaged settlements located near these lakes, quarantine has been established, epizootic foci and threatened zones have been identified. In disadvantaged areas, activities are carried out in accordance with the rules for combating avian influenza.

While not particularly ominous, over the winter of 2016/2017 a reassorted, and revitalized HPAI H5N8 virus arrived in Europe following a reassortment event the previous summer in Qinghai/ Ubsu-Nur, (see EID Journal: Reassorted HPAI H5N8 Clade 2.3.4.4. - Germany 2016), sparking perhaps the largest avian epizootic in European history.

 

A study, published in 2016 (see Sci Repts.: Southward Autumn Migration Of Waterfowl Facilitates Transmission Of HPAI H5N1), suggests that waterfowl pick up new HPAI viruses in the spring (likely from poultry or terrestrial birds) on their way to their summer breeding spots - where they spread and potentially evolve - and then redistribute them on their southbound journey the following fall.

Meaning that what we see this fall and  inter could well depend upon what avian viruses have been circulating among birds in the high latitudes over the summer, and will be carried south by migratory birds for the winter (see WHO: Migratory Birds & The Potential Spread Of Avian Influenza).

 

The disturbing question remains: If we aren't able to monitor seasonal flu effectively during this COVID pandemic, what else are we missing?

While I can't answer that question, I do know that being blindsided again is the absolute worst way to find out. 

WHO: Modelling Human-to-Human Transmission of Monkeypox

Geographic Range of Monkeypox - Credit WHO

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One of the emerging infectious disease threats we've  discussed often (see here, here, here) over the years is Monkeypox, which is endemic in the DRC and central Africa, with more more than 4,000 cases reported there in 2019, and currently over 2,500 cases (and 97 deaths), reported in the first 7 months of 2020. 

Nigeria reported its first Monkeypox outbreak in nearly 40 years in the fall of 2017, and while surveillance and reporting is limited, they continued to report cases up until December of 2019. Like with so many other diseases, reporting has dropped off since the start of the COVID-19 pandemic.  

Exported cases from Africa have turned up sporadically around the world. In September of 2018 the UK saw two imported cases from Nigeria (see Eurosurveillance Rapid Comms: Two cases of Monkeypox imported to the UK). A month later Israel: MOH Confirmed An Imported Monkeypox Case). And in 2019, Singapore reported an imported case.

In last year's CDC: 8 Zoonotic Diseases Of Most Concern In The United States, Monkeypox was ranked 29th; about halfway down their list. Similarly, in 2018's WHO List Of Blueprint Priority Diseases - while Monkeypox did not make the final list (n=8) - it was mentioned as a disease to watch.

Human monkeypox was first identified in 1970 in the DRC, and since then has sparked small, sporadic outbreaks in the Congo Basin and Western Africa. It produces a remarkably `smallpox looking' illness in humans, albeit not as deadly. The CDC's Monkeypox website states:

The name `monkeypox’ is a bit of a misnomer. It was first detected (in 1958) in laboratory monkeys, but further research has revealed its primary hosts to be rodents or possibly squirrels.

The illness typically lasts for 2−4 weeks. In Africa, monkeypox has been shown to cause death in as many as 1 in 10 persons who contract the disease.

Human-to-human transmission is also possible.  This from the CDC’s Factsheet on Monkeypox:

The disease also can be spread from person to person, but it is much less infectious than smallpox. The virus is thought to be transmitted by large respiratory droplets during direct and prolonged face-to-face contact. In addition, monkeypox can be spread by direct contact with body fluids of an infected person or with virus-contaminated objects, such as bedding or clothing.

According to the CDC there are two distinct genetic groups (clades) of monkeypox virus—Central African and West African. West African monkeypox - which has been spreading recently in Nigeria - is associated with milder disease, fewer deaths, and limited human-to-human transmission.

In October of 2018, in the WHO: Monkeypox Update & Risk Assessment - Nigeria, we looked at advice from the World Health Organization, and some studies that raise concerns over the future path of the Monkeypox virus.

For a more detailed look at the Monkeypox virus in Africa, and a limited 2003 outbreak in the United States - you may wish to revisit this blog from May of 2018.

MMWR: Emergence of Monkeypox — West and Central Africa, 1970–2017

Routine vaccination against smallpox - which supposedly provides about 85% protection against Monkeypox - ended in the 1970s. Today more than half of the world's population is unvaccinated, and the level of protection remaining among those vaccinated 50+ years ago is highly suspect.

A 2016 study (see EID Journal:Extended H-2-H Transmission during a Monkeypox Outbreak) looked at a large 2013 outbreak of Monkeypox in the DRC and suggested that the virus's epidemiological characteristics may be changing (possibly due to the waning smallpox vaccine derived immunity in the community).

The DRC had reported a 600% increase in cases over both 2011, and 2012.  The authors also cite a higher attack rate, longer chains of infection, and more pronounced community spread than have earlier reports.

Like all viruses, Monkeypox continues to evolve and diversify, as discussed in the 2014 EID Journal article Genomic Variability of Monkeypox Virus among Humans, Democratic Republic of the Congo, where the authors cautioned:

Small genetic changes could favor adaptation to a human host, and this potential is greatest for pathogens with moderate transmission rates (such as MPXV) (40). The ability to spread rapidly and efficiently from human to human could enhance spread by travelers to new regions.

All of which brings us to a new report, published by the Bulletin of the World Health Organization, that examines the growing threat of monkeypox as human immunity to smallpox continues to wane.

I've only selected some excerpts from a much longer report.  Follow the link to read it in its entirety. 

Modelling human-to-human transmission of monkeypox

Rebecca Grant,a Liem-Binh Luong Nguyena & Romulus Brebana a 

Institut Pasteur, Emerging Diseases Epidemiology Unit, 25-28 rue du Dr. Roux, 75015 Paris, France. Correspondence to Romulus Breban (email: romulus.breban@pasteur.fr). (Submitted: 5 August 2019 – Revised version received: 18 March 2020 – Accepted: 12 May 2020 – Published online: 8 July 2020) 

Monkeypox is an emerging infectious disease for which outbreak frequency and expected outbreak size in human populations have steadily increased.1 The geographic spread of monkeypox cases has expanded beyond the forests of central Africa, where cases were initially found, to other parts of the world, where cases have been imported.

This transmission pattern is likely due to the worldwide decline in orthopoxvirus immunity, following cessation of smallpox vaccination, once smallpox was declared eradicated in 1980. Monkeypox could therefore emerge as the most important orthopoxvirus infection in humans.2 We use mathematical modelling to argue that, in a population with diminishing herd immunity against orthopoxvirus species, the epidemic potential of monkeypox will continue increasing.    

(SNIP)

The clinical presentation of monkeypox facilitates outbreak investigations around incidentally imported cases. The incubation period of monkeypox is 5–21 days, followed by clinical onsets for up to 21 days. Monkeypox is not considered contagious during its incubation period and asymptomatic monkeypox infection has not been documented.

Transmission occurs through fluids secretion, mainly from the  respiratory tract or skin lesions. The distinctive symptoms of human monkeypox greatly aid in its early detection and containment. Nevertheless, secondary transmission from imported cases is possible, as evidenced by the case of nosocomial transmission to a health-care worker in the United Kingdom of Great Britain and Northern Ireland in 2018.12 Under stringent infection prevention and control measures, including case isolation, hand hygiene, use of personal protective equipment to avoid direct contact with patients and the use of standard, contact and droplet precautions, the likelihood that an imported case triggers an epidemic can be
expected to be low.

Yet, with increasing importation rate, monkeypox outbreak investigations may become a costly and poorly effective strategy, to prevent endemic disease.

We conclude that circulation of smallpox, followed by worldwide smallpox vaccination, have previously protected human populations from monkeypox epidemics. We combined historical data on smallpox and monkeypox with mathematical modelling to estimate the basic reproduction number of monkeypox, and found out that monkeypox has epidemic potential. This finding may explain the increasing number of monkeypox outbreak reports, resulting in endemic monkeypox in central African countries. Moreover, with declining immunity to orthopoxvirus species, monkeypox can pose an ever-increasing threat for health security.

NHC: T.S Isaias Expected To Regain Hurricane Strength - Heading For Carolinas

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Florida was largely spared this weekend as wind shear weakened Tropical Storm Isaias stayed off the east coast, keeping the `dirty' side of the storm well out to sea. 

Although only expected to become a minimal hurricane before landfall, the NE quadrant of the storm will come into play when it makes landfall along the Carolina coast in about 18 to 20 hours. 

While unlikely to be a big wind maker, Isaias could produce life-threatening surge along the Carolina coastline, particularly north of where the center crosses.  Small tornadoes are possible, along with inland flooding due to heavy rain, as the storm treks north along the eastern seaboard (see 5am Key Messages)

People tend to dismiss the impact of tropical storms, and minor hurricanes, believing their low wind speeds render them fairly benign. But few realize that over a 3 decade period (1970-2000), the the leading cause of death in the United States from hurricanes was due to fresh water flooding. 

By the end of the first 2 months of the Atlantic Hurricane season, there have already been 9 Tropical storms (2 becoming hurricanes).  Although the impact on land has been minimal (so far), more than 2 dozen deaths (mostly in Mexico) and nearly $2 billion dollars in damage have been reported. 

But historically, the heart of hurricane season doesn't really begin until the middle of August - peaking around September 10th - and running to late October. Hurricane season doesn't officially end until the last day of November.

 

While early season storms tend to form in the Gulf of Mexico or Caribbean (see July Tropical Climatology), as ocean temperatures rise late in summer, and winds aloft become more favorable, hurricanes tend to form farther to the east, giving them more time grow before encountering land (see below).

Although September is regarded as the peak of the season, August has a history of producing some very large, and infamous, storms including Harvey (2017), Katrina (2005), Charley (2004), Andrew (1992), and Camille in 1969. Hurricane Donna (1960) - the first storm I can personally remember - formed in August but wasn't upgraded to a hurricane until Sept 1st.

You can find much more on Hurricane Climatology at NOAA’s Tropical Cyclone Climatology page.

 

With the forecast calling for an active season ahead and a concurrent pandemic to complicate matters,  this year - perhaps more than any other - it is important to be prepared before the next storm threatens (see Why Preparing For This Year's Hurricane Season Will Be `Different').

You'll find some excellent internet hurricane resources online (along with some very sketchy ones), but the two I heartily recommend are Mark Sudduth's excellent YouTube channel and http://hurricanetrack.com/ - and for true weather nerds like me - Mike's Weather page is a daily stop.

But your primary source of forecast information should always be the National Hurricane Center in Miami, Florida. 

These are the real experts, and the only ones you should rely on to track and forecast the storm.

If you are on Twitter, you should also follow @FEMA, @NHC_Atlantic, @NHC_Pacific and @ReadyGov and of course take direction from your local Emergency Management Office.

To help you get ready, below is a list of this year's hurricane preparedness blogs:

Hurricane Preparedness Week: Day 7 - Complete A Written Plan

Hurricane Preparedness Week: Day 6 - Help Your Neighbors

Hurricane Preparedness Week: Day 5 - Strengthen Your Home

Hurricane Preparedness Week: Day 4 - Get An Insurance Check-up

Hurricane Preparedness Week: Day 3 - Assemble Disaster Supplies

Hurricane Preparedness Week: Day 2 - Develop An Evacuation Plan

National Hurricane Preparedness Week: Day 1 - Determine Your Risk

Hurricane Preparedness Week 2020

NIOSH & FDA Updates On Counterfeit N95 Respirators & Ineffective and/or Dangerous Hand Sanitizers

N95 NIOSH Approved Markings

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Unless and until a safe and effective COVID-19 vaccine can be developed, our best protection against infection are NPIs - Non-pharmaceutical Interventions - like social distancing, rigorous hand hygiene, and the wearing of face covers and/or masks (see Two Studies (The Lancet & EID Journal) On The Impact Of NPIs On COVID-19 Spread).

Unfortunately, for months we've seen numerous reports of fake and/or counterfeit N95 respirators flooding the market, which endanger not only the Health Care Workers who wear them, but potentially anyone they come in contact with. 

In early June the FDA issued a letter to healthcare providers warning:

Certain Filtering Facepiece Respirators from China May Not Provide Adequate Respiratory Protection

While some Chinese manufacturers appear to be producing reasonably reliable products, others are clearly not. On June 9th the FDA issued a letter listing 66 manufacturers of N95/KN95 masks that are no long authorized by the EUA.

Since then, we've twice visited the NIOSH website which listed dozens of fake and/or counterfeit N95 respirators being sold as `NIOSH Approved', complete with bogus NIOSH certification numbers. 

Since then NIOSH has updated their page, adding newly reported `fake' or substandard N95 respirators to their list.  While these masks are arguably `better than nothing', those who use them in high-risk environments need to be aware of their limitations. 

Counterfeit Respirators / Misrepresentation of NIOSH-Approval

Updated July 27, 2020

Counterfeit respirators are products that are falsely marketed and sold as being NIOSH-approved and may not be capable of providing appropriate respiratory protection to workers.

When NIOSH becomes aware of counterfeit respirators or those misrepresenting NIOSH approval on the market, we will post them here to alert users, purchasers, and manufacturers.

How to identify a NIOSH-approved respirator:

NIOSH-approved respirators have an approval label on or within the packaging of the respirator (i.e. on the box itself and/or within the users’ instructions). Additionally, an abbreviated approval is on the FFR itself. You can verify the approval number on the NIOSH Certified Equipment List (CEL) or the NIOSH Trusted-Source page to determine if the respirator has been approved by NIOSH. NIOSH-approved FFRs will always have one the following designations: N95, N99, N100, R95, R99, R100, P95, P99, P100.

• Signs that a respirator may be counterfeit:
• No markings at all on the filtering facepiece respirator
• No approval (TC) number on filtering facepiece respirator or headband
• No NIOSH markings
• NIOSH spelled incorrectly
• Presence of decorative fabric or other decorative add-ons (e.g., sequins)
• Claims for the of approval for children (NIOSH does not approve any type of respiratory protection for children)
• Filtering facepiece respirator has ear loops instead of headbands

Additional Tips for Spotting Counterfeit Respirators Before You Buy

 

Of perhaps even greater concern to the general public, scores of brands of hand sanitizer being sold in the United States have been found to contain dangerous levels of methanol (see  CDC HAN #00434: Serious Adverse Health Events Associated with Methanol-based Hand Sanitizers). 

Methanol (wood alcohol) has a long, and tragic history of being used to fortify bootleg liquor, and when ingested even in small quantities converts to formic acid, which can cause permanent blindness or even death.  It has legitimate industrial uses (as solvents, pesticides, and alternative fuel sources), but is not meant to be ingested. 

Every once in awhile we hear of mass poisonings (see Methanol contamination in traditionally fermented alcoholic beverages) - often involving scores or even hundreds of people - who consumed improperly distilled spirits. 

Methanol is toxic in very low doses, and the CDC warns :

METHODS OF DISSEMINATION:

• Indoor Air: Methanol can be released into indoor air as a liquid spray (aerosol).
• Water: Methanol can be used to contaminate water.
• Food: Methanol may be used to contaminate food.
• Outdoor Air: Methanol can be released into outdoor air as a liquid spray (aerosol).
• Agricultural: If methanol is released into the air as a liquid spray (aerosol), it has the potential to contaminate agricultural products.

ROUTES OF EXPOSURE: Methanol can be absorbed into the body by inhalation, ingestion, skin contact, or eye contact. Ingestion is an important route of exposure.

On Friday the FDA updated their growing list of methanol-contaminated products, and added warnings about some hand sanitizers that - despite the claims on their labels - don't contain enough active ingredient to effectively kill viruses. 

7/31/2020: UPDATE - FDA continues to find issues with certain hand sanitizer products.

[7/31/2020] FDA continues to find issues with certain hand sanitizer products. FDA test results show certain hand sanitizers have concerningly low levels of ethyl alcohol or isopropyl alcohol, which are active ingredients in hand sanitizer products. The agency urges consumers not to use these subpotent products and has expanded its list to include subpotent hand sanitizers, in addition to hand sanitizers that are or may be contaminated with methanol

The agency continues to add certain hand sanitizers to import alert to stop these products from legally entering the U.S. market.

 

FDA reminds consumers to wash their hands often with soap and water for at least 20 seconds, especially after going to the bathroom; before eating; and after coughing, sneezing, or blowing one’s nose. If soap and water are not readily available, the Centers for Disease Control and Prevention (CDC) recommend consumers use an alcohol-based hand sanitizer that contains at least 60 percent ethanol (also referred to as ethyl alcohol).

 

Additionally, FDA reminds consumers that no drugs, including hand sanitizers, are approved to prevent the spread of COVID-19.

 

FDA encourages health care professionals, consumers and patients to report adverse events or quality problems experienced with the use of hand sanitizers to FDA’s MedWatch Adverse Event Reporting program (please provide the agency with as much information as possible to identify the product):

Complete and submit the report online; or

Download and complete the form, then submit it via fax at 1-800-FDA-0178

It wouldn't hurt to check any hand sanitizer you have on hand against the list, regardless of where you purchased it.  And check back every couple of weeks, since additional brands may be added over time. 

 

MMWR: SARS-CoV-2 Transmission At A Summer Day Camp - Georgia, June 2020

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With schools in many parts of the country preparing to re-open this fall, the debate over the susceptibility of children and adolescents to infection with SARS-CoV-2, their risks of experiencing serious illness, and their ability to transmit the virus on to others has taken center stage. 

Very early on in this pandemic, there were hopes - based on reports of low hospitalization rates - that children were largely immune to infection. More recent studies suggest they are equally susceptible to infection, but in general, tend to experience milder illness.

Serious illness has been reported in children and adolescents (see  Multisystem Inflammatory Syndrome in Children (MIS-C), although younger cohorts are statistically far less likely to experience serious COVID-19 illness than older adults.

The notion that children are less likely to spread the virus - either to other children, or to potentially vulnerable adults at school or home - has come under scrutiny recently as well (see yesterday's JAMA PEDS: Nasopharyngeal Viral RNA Higher In Young Children Than Adults).

Since schools closed quickly last spring, we really haven't seen very many real-world examples of SARS-CoV-2 transmissions among school-aged children in the United States. 

During the brief early summer decline in COVID-19 cases, however,  a few summer camps opened briefly.  One camp in Georgia - highlighted yesterday in an MMWR Early Release - provides us with evidence that even when following many (but not all) of the CDC Suggestions for Youth and Summer Camps, the pandemic virus spread efficiently among camp goers. 

This report also reinforces the idea that young children are every bit as susceptible to infection as older cohorts, and suggests they likely play a major role in the transmission of the virus to others.

I've posted the full text of the report below.  Follow the link to access supplementary information and download the PDF. 

SARS-CoV-2 Transmission and Infection Among Attendees of an Overnight Camp — Georgia, June 2020

Early Release / July 31, 2020 / 69

Christine M. Szablewski, DVM1,2; Karen T. Chang, PhD2,3; Marie M. Brown, MPH1; Victoria T. Chu, MD2,3; Anna R. Yousaf, MD2,3; Ndubuisi Anyalechi, MD1; Peter A. Aryee, MBA1; Hannah L. Kirking, MD2; Maranda Lumsden1; Erin Mayweather1; Clinton J. McDaniel, MPH2; Robert Montierth, PharmD2; Asfia Mohammed1; Noah G. Schwartz, MD2,3; Jaina A. Shah1; Jacqueline E. Tate, PhD2; Emilio Dirlikov, PhD2; Cherie Drenzek, DVM1; Tatiana M. Lanzieri, MD2; Rebekah J. Stewart, MSN, MPH2 (View author affiliations)

Limited data are available about transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), among youths. During June 17–20, an overnight camp in Georgia (camp A) held orientation for 138 trainees and 120 staff members; staff members remained for the first camp session, scheduled during June 21–27, and were joined by 363 campers and three senior staff members on June 21.

Camp A adhered to the measures in Georgia’s Executive Order* that allowed overnight camps to operate beginning on May 31, including requiring all trainees, staff members, and campers to provide documentation of a negative viral SARS-CoV-2 test ≤12 days before arriving. Camp A adopted most† components of CDC’s Suggestions for Youth and Summer Camps§ to minimize the risk for SARS-CoV-2 introduction and transmission. 

Measures not implemented were cloth masks for campers and opening windows and doors for increased ventilation in buildings. Cloth masks were required for staff members. Camp attendees were cohorted by cabin and engaged in a variety of indoor and outdoor activities, including daily vigorous singing and cheering. On June 23, a teenage staff member left camp A after developing chills the previous evening. The staff member was tested and reported a positive test result for SARS-CoV-2 the following day (June 24). Camp A officials began sending campers home on June 24 and closed the camp on June 27. On June 25, the Georgia Department of Public Health (DPH) was notified and initiated an investigation. DPH recommended that all attendees be tested and self-quarantine, and isolate if they had a positive test result.

A line list of all attendees was obtained and matched to laboratory results from the State Electronic Notifiable Disease Surveillance System¶ and data from DPH case investigations. A COVID-19 case associated with the camp A outbreak was defined as a positive viral SARS-CoV-2 test** in a camp A attendee from a specimen collected or reported to DPH from the first day at camp A (June 17 for staff members and trainees; June 21 for campers) through 14 days after leaving camp A (trainees left on June 21; staff members and campers left during June 24–June 27). Out-of-state attendees (27) were excluded from this preliminary analysis. Attack rates were calculated by dividing the number of persons with positive test results by the total number of Georgia attendees, including those who did not have testing results, because negative test results are not consistently reported in Georgia.

A total of 597 Georgia residents attended camp A. Median camper age was 12 years (range = 6–19 years), and 53% (182 of 346) were female. The median age of staff members and trainees was 17 years (range = 14–59 years), and 59% (148 of 251) were female. Test results were available for 344 (58%) attendees; among these, 260 (76%) were positive. 

The overall attack rate was 44% (260 of 597), 51% among those aged 6–10 years, 44% among those aged 11–17 years, and 33% among those aged 18–21 years (Table). Attack rates increased with increasing length of time spent at the camp, with staff members having the highest attack rate (56%). During June 21–27, occupancy of the 31 cabins averaged 15 persons per cabin (range = 1–26); median cabin attack rate was 50% (range = 22%–70%) among 28 cabins that had one or more cases. Among 136 cases with available symptom data, 36 (26%) patients reported no symptoms; among 100 (74%) who reported symptoms, those most commonly reported were subjective or documented fever (65%), headache (61%), and sore throat (46%).

The findings in this report are subject to at least three limitations. First, attack rates presented are likely an underestimate because cases might have been missed among persons not tested or whose test results were not reported. Second, given the increasing incidence of COVID-19 in Georgia in June and July, some cases might have resulted from transmission occurring before or after camp attendance.†† Finally, it was not possible to assess individual adherence to COVID-19 prevention measures at camp A, including physical distancing between, and within, cabin cohorts and use of cloth masks, which were not required for campers.

These findings demonstrate that SARS-CoV-2 spread efficiently in a youth-centric overnight setting, resulting in high attack rates among persons in all age groups, despite efforts by camp officials to implement most recommended strategies to prevent transmission. 

Asymptomatic infection was common and potentially contributed to undetected transmission, as has been previously reported (1–4). This investigation adds to the body of evidence demonstrating that children of all ages are susceptible to SARS-CoV-2 infection (1–3) and, contrary to early reports (5,6), might play an important role in transmission (7,8).

The multiple measures adopted by the camp were not sufficient to prevent an outbreak in the context of substantial community transmission. Relatively large cohorts sleeping in the same cabin and engaging in regular singing and cheering likely contributed to transmission (9). Use of cloth masks, which has been shown to reduce the risk for infection (10), was not universal. An ongoing investigation will further characterize specific exposures associated with infection, illness course, and any secondary transmission to household members. Physical distancing and consistent and correct use of cloth masks should be emphasized as important strategies for mitigating transmission in congregate settings.

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The very good news is that most of the kids who became infected at this day camp had either mild or asymptomatic infections.  The risk of serious illness in children - while not trivial - continues to be far less than in older populations. 

But their ability to act as vectors of virus - particularly to older, more vulnerable adults (teachers, cafeteria workers, parents, grandparents, etc.)  - continues to be a big concern. 

While older children and adolescents can probably be taught to wear masks, wash their hands, keep their hands away from their eyes and nose, and maintain social distance in classrooms - thereby lowering their risks - those are unrealistic expectations for many children under the age of 8 or 9.  

While I'm not sure how to mitigate those risks for younger kids who attend school this fall, I can safely say that hoping for the best is not a plan. 

CDC Updated (July 31st) COVID-19 Forecasts: Cumulative Deaths & Hospitalizations

#15,394

The CDC continues to expand, and hopefully improve, their (4 week) forecasts for COVID-19 deaths and hospitalizations. The CDC's Forecasts of COVID-19 Deaths this week incorporates a record 32 different modeling groups, and adds a new feature; forecasts of new deaths in addition to forecasts of total deaths.

Their 4 week hospitalization forecast - which is newer, and less robust than the deaths forecast - utilizes just 8 modeling groups, and continues to produce a wider range of results. 

All of these models are based on different assumptions about social distancing, disease transmission rates, and local compliance with recommended control measures, and therefore often come up with widely varying `solutions'.  

Rather than trying to pick a winner, the charts below show the individual model ranges, along with a `consensus'  forecast by the CDC. These weighted averages, while useful, should nonetheless be taken with a sizable grain of salt. 

 

While important metrics, deaths and hospitalizations don't begin to tell the full story of the impact of COVID-19.  We are increasingly seeing reports of very slow return to usual health, and potentially permanent heart and lung damage, among some `recovered' COVID cases. 

 

Our first stop today, the CDC's forecast on COVID-19 Deaths:

 

Forecasts of COVID-19 Deaths

Updated July 31, 2020

As of July 31, 2020, the Forecasts of COVID-19 Deaths webpage includes forecasts of new deaths in addition to forecasts of total deaths.

Observed and forecasted new and total reported COVID-19 deaths as of July 27, 2020.

Interpretation of Forecasts of New and Total Deaths

• This week CDC received forecasts of national COVID-19 deaths over the next 4 weeks from 32 modeling groups. Those forecasts predict:

• The number of new COVID-19 deaths reported each week (31 forecasts), which indicates how reported deaths are likely to increase or decrease in the coming weeks
• The total number of COVID-19 deaths reported by the end of each week (31 forecasts), which helps us understand the likely overall impact of the pandemic in the coming weeks

Of the 32 modeling groups, 30 provided forecasts of both new and total deaths, one provided a forecast of new deaths only, and one provided a forecast of total deaths only.

• This week’s national ensemble forecast predicts that weekly reports of new COVID-19 deaths may increase over the next month, with 5,000 to 11,000 new deaths reported during the week ending August 22. The ensemble forecast predicts that 168,000 to 182,000 total COVID-19 deaths will be reported by August 22. 
• State-level ensemble forecasts predict that the number of reported new deaths per week may increase over the next four weeks in: Alabama, Kentucky, New Jersey, Puerto Rico, Tennessee, and Washington.

National Forecast

 

• The top row of the figure shows the number of new COVID-19 deaths reported in the United States each week from May 16 through July 25 and forecasted new deaths over the next four weeks, through August 22.
• The bottom row of the figure shows the number of total COVID-19 deaths in the United States each week from May 16 through July 25 and the forecasted number of total COVID-19 deaths over the next four weeks, through August 22.

Models make various assumptions about the levels of social distancing and other interventions, which may not reflect recent changes in behavior. See model descriptions below for details.

State Forecasts

State-level forecasts figures show observed and forecasted state-level new and cumulative COVID-19 deaths in the US. Each state forecast uses a different scale, due to differences in the numbers of COVID-19 deaths occurring in each state.

Forecasts fall into one of two categories:

• The CMU, DDS, Columbia-UNC, ERDC, ESG, Geneva, GT-DeepCOVID, ISU, Karlen, LANL, LNQ, LSHTM, MIT-CovAlliance, MIT-ORC, MOBS, Oliver Wyman, NotreDame-Mobility, QJHong, STH, UA, UCM, UM, UMass-MB, USC, and UT forecasts assume that existing control measures will remain in place during the prediction period.
• The Columbia, COVID19Sim, GT-CHHS, IHME, JCB, JHU, NotreDame-FRED, PSI, UCLA, and YYG forecasts make different assumptions about how levels of social distancing will change in the future.

Download state forecasts {29 pages] 

Download forecast data  [1 sheet]

Additional forecast data and information on forecast submission are available at the COVID-19 Forecasting Hub

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As mentioned earlier, hospitalization forecasting is less mature, and tends to produce a wider range of `solutions'.  

In fairness, however, knowing the number of people hospitalized today helps enormously in calculating future deaths, while projecting the number of hospitalizations a month from now is based largely upon social distancing compliance by the general public. 

This week, expected hospitalizations 4 weeks from now range anywhere from 2,000 to 13,000 per day. 

Hospitalization Forecasts

Updated July 29, 2020

 

Interpretation of Forecasts of New Hospitalizations

This week, five national forecasts predict a likely increase in the number of new hospitalizations per day over the next four weeks, one forecast predicts a likely decline, and two forecasts predict stable numbers. For August 24, the forecasts estimate 2,000 to 13,000 new COVID-19 hospitalizations per day.

State-level forecasts also show a high degree of variability, which results from multiple factors.  Hospitalization forecasts use different sources of data for COVID-19 cases or deaths, with different limitations, and make different assumptions about social distancing.

National Forecasts

National Forecast for 7-27-2020

 

• The eight national forecasts show the predicted number of new COVID-19 hospitalizations per day for the next four weeks in the United States.
• The forecasts make different assumptions about hospitalization rates and levels of social distancing and other interventions and use different methods to estimate the number of new hospitalizations. See models below for details. 

State Forecasts

Nine state-level models predicting the number of new hospitalizations were submitted this week. These forecasts show the predicted number of new COVID-19 hospitalizations per day for the next four weeks in each state. Each state forecast uses a different scale, due to differences in the number of new COVID-19 cases occurring per day in each state.

Download state forecasts [1 MB, 7 pages]1

Download forecast data  [2 MB]

Additional forecast data and information on forecast submission are available at the COVID-19 Forecasting Hub .

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