Issue No. 8

As U.K. Cases Spike, Can the U.S. Be Far Behind?

Public health officials in the U.S. are looking to the U.K. with trepidation. Cases of COVID-19 there have soared from a seven-day average of 2,000 on May 4 to 37,000 on July 15, and the curve keeps rising almost vertically. U.K. Health Secretary Sajid Javid said on July 12 that cases could rise to 100,000 a day in the coming weeks, breaking the record of 60,000 set in January. The culprit, of course, is the highly contagious Delta variant.
What is disturbing for Americans is that the U.K. has actually been more successful vaccinating its residents than the U.S. has been. Some 52% of the population in the U.K. is fully vaccinated, compared with 48% in the U.S., and 69% of residents have received at least one dose, compared with 66% in the U.S. And the U.K. isn’t the only country with a recent spike despite an above-average vaccination rate. In Spain, where 48% of the public is fully vaccinated, cases have jumped 252% in two weeks to levels similar to those in January. Italy, France, and Germany, where vaccination rates are slightly lower, are also seeing significant increases.
 
The question now is whether American cases will follow the same pattern – that is, heading for another peak just when we thought that vaccines were depressing the virus for good.
 
Currently, U.S. cases are on the rise in every state – more than doubling over the past two weeks. Levels are still relatively low compared to the U.K., but it’s hard to tell what’s really happening because daily testing has dropped by half since April. Cases are rising especially in the South, and hospitalizations are up sharply in the last two weeks: more than tripling in Florida and doubling in Arkansas, Louisiana, and Missouri. The red counties in the map below indicate counties where hospitalizations have risen at least 20% in a week.

So far, the dramatic rise in cases in the U.K. has not caused a similar increase either in deaths or hospitalizations. During the last surge, deaths topped 1,000 a day; currently, deaths are fewer than 40 a day, though increasing. A high proportion of those getting sick from the SARS-CoV-2 virus are young people, nearly all of whom have not been vaccinated. Young people are less likely to get very sick and die from COVID-19, but, of course, they can spread the infection to more vulnerable seniors.
 
Despite all the cases, the U.K. dropped almost its legal COVID restrictions on July 19. Nightclubs, for example, were allowed to open for the first time since March 2020, and legal requirements for masking in enclosed public spaces were removed. Venues with crowds are being encouraged to require passports proving vaccination. There’s a growing belief globally that COVID is not going away any time soon.
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Dr. Birx Expresses Virus Worries to County Officials at DC Conference

In the U.S., we will know very soon whether a genuine surge is at hand or whether cases will rise, as they did in April, and then quickly fall again. Deborah Birx, the physician and research scientist who served as leader of the U.S. battle against global HIV/AIDS and then as Coronavirus Task Force Coordinator, is worried. She is particularly focused on what happens as Americans move indoors, as they are now doing in the South and Southwest as summer heat intensifies; then later when school openings begin in late August; and, finally, as temperatures cool and people crowd interior spaces all over the country.
 
Birx spoke July 9 at a conference center outside Washington to attentive local officials from throughout at the country who were hungry for information about the course of the virus. Her remarks came at a meeting of the National Association of Counties (NACo). Birx took a new role in March as chief medical and scientific advisor to ActivePure, the Dallas-based developer of technologies to make indoor air cleaner and safer. She is especially concerned about mitigating indoor spread, not just of the SARS-CoV-2 virus, but also of other respiratory pathogens.
County officials at the NACo conference were naturally focused on the American Rescue Plan, which became law in March and allocates $1.5 trillion in county-related funding (NACo provides a breakdown). Some $130 billion is going to help schools reopen in the fall, including by purifying classroom air. Separate funds can be used by state, county, large-city, and tribal governments for “prevention, mitigation or other services in congregate living facilities or schools” (again, including by purifying the air) and for the safety of air in “key settings like health care facilities.”
 
The county officials are trying conscientiously to find the most effective, safest technologies to mitigate SARS-CoV-2 and other pathogens, while also protecting the environment. But making the right choices is not easy. As we have previously noted, a good guide was provided in an article by former Acting Surgeon General Kenneth Moritsugu posited in an article we cited in our newsletter No. 6. The original piece appeared on the RealClearHealth site on May 20, and its aim was to help government and education officials, as well as owners of private businesses and facilities managers that have to decide the best way to mitigate the dangers of SARS-CoV-2 and other pathogens

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‘She Saved Thousands of Lives’
 
Dr. Birx was highlighted in an article in the latest issue of the academic journal Regulation by David Harrington, the Himmelright Professor in Economics at Kenyon College. Harrington wrote:
 
During the final months of [Donald Trump’s] presidency, [Birx] spent most of her time on the road, traveling from state to state, meeting with governors, university presidents, public health officials, and reporters. She delivered an urgent message to everyone who would listen: COVID is surging; it’s insidious and dangerous; and people need to start guarding against it now.

Her travels create a unique opportunity to estimate whether people were heeding her advice. More specifically, the variation in where and when she made her recommendations can be compared to outcome variables such as whether people were wearing masks. As you’ll see, the evidence convinces me that she saved thousands of lives.

Harrington referred to Birx as a kind of “Johnny Appleseed,” travelling to “nearly every state on the continent, enduring “danger and drudgery,” and offering “hard recommendations wrapped in compliments.”
 
His research found that “Birx nudged 14.5% of those reluctant to wear masks to do so. If someone like her was just as successful in nudging people to get vaccinated, the hesitancy rate in states Trump won would decrease from 21% to 18%.”
 
The Biden Administration, wrote Harrington should consider having someone like Birx “visiting with governors and the American people to talk about receiving the COVID vaccine and taking care not to relax mitigation strategies too rapidly as the virus’s infection and death tolls fall…. An official filling the role Birx did last year would certainly be helpful.”
 
Harrington warns that “there is still elevated public health risk, exacerbated both by virulent new strains of the disease and a significant chunk of the public’s hesitancy (and in some cases outright opposition) to receiving one of the vaccines.”
 
For her part, Birx is continuing to talk to state, local, and university officials, both at venues like the NACo conference and on dozens of Zoom calls

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A Respiratory Virus That Strikes Infants and Seniors Is Surging,
and It’s Not COVID
 
As masks come off, conventional respiratory infections are increasing. The Centers for Disease Control and Prevention (CDC) reports a huge spike, starting in mid-March, in cases of respiratory syncytial virus (RSV), which is especially dangerous for infants and older people.
 
Mask-wearing to protect against contracting COVID has been shielding us from other viruses, like the flu, as well. Now we are back where we started – in interior spaces where ventilation, even with filters, is inadequate protection.
 
Actually, we may be worse off. A July 8 article in The Guardian notes that hospital wards in New Zealand are being “flooded by babies with a potentially-deadly respiratory virus,” a reference to RSV. The reason is what’s called “immunity debt.” Children have not built up the usual protections because they “haven’t been exposed to a range of bugs due to lockdowns, distancing, and sanitizer, [so] their immune systems are suffering.”

The article points out that in New Zealand, “lockdowns last winter led to a 99.9% reduction in flu cases and a 98% reduction in RSV.” According to a May 2021 study of immunity debt by a group of French doctors, “This positive collateral effect in the short term is welcome, as it prevents additional overload of the healthcare system,” In the long term, however, says the Guardian article, “if bacterial and viral infections aren’t circulating among children, they don’t develop immunity, which leads to larger outbreaks down the line.”

Immunity debt will almost certainly lead not just to more infections but to confusion and deep concern when people come down with respiratory symptoms as the weather gets colder. They’ll wonder, even if they are vaccinated, whether they have COVID. One way to alleviate both the infections and the worries is by taking measures to reduce the spread of pathogens indoors through ventilation and air purification.

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Climate Endangered as HVAC Systems Draw More Power to Mitigate COVID, Writes Former Sierra Club Board Member
 
In an opinion piece in Newsweek on July 14, Michael Dorsey, an environmental scientist and former director of the Sierra Club, warned of the dangers to the climate from ramping up HVAC systems and adding high-efficiency filters to them in an effort to mitigate threats of COVID-19 indoors.
 
Instead, Dr. Dorsey, who is also a former director of Dartmouth College’s Climate Justice Research Project and earned his PhD in natural resource and environmental policy at the University of Michigan, recommends “advanced photocatalytic,” or AP, processes as “better solutions” for cleaning interior air while avoiding increased energy use. He writes that the AP “methodology uses sub-microscopic particles in a super-charged state” to deactivate pathogens, “avoiding massive energy consumption” that is caused “by the process of sucking air through a filter or using harmful ultraviolet light.”
 
Dr. Dorsey takes aim at ASHRAE, the American Society of Heating, Refrigerating and Air-Conditioning Engineers, whose advice, he writes, “is a recipe for driving up CO2 emissions, and simultaneously runs afoul of long-standing guidance for green buildings practices.” ASHRAE has urged property managers to consider keeping their HVAC systems running 24 hours a day. The group also recommends applying filters, which can cause major pressure drops to systems, in turn necessitating more power to maintain ventilation levels.
 
The article cites a piece last year in the Wall Street Journal with the headline, “Why Covid-19 Makes It Harder for Cities to Fight Climate Change.” The article noted, “In a recent study, real-estate technology company Enertiv found that HVAC costs in office buildings increased 36% during the pandemic” because of increased energy use.
 
The Journal article also stated:
 
Landlords in some cities face not just higher energy bills, but also steep fines. In New York, the country’s largest office market, the city council last year passed a bill that set emission caps for buildings with a goal of reducing carbon emissions 40% by 2030, compared with 2005 levels. Starting in 2024, some building owners that fail to reduce emissions face fines of as much as millions of dollars a year.
 
On the other hand, said the article, paraphrasing Brenden Millstein, CEO of Carbon Lighthouse, a firm that helps building owners cut emissions, “landlords face potential lawsuits if tenants in their buildings become infected and a court determines that negligence has occurred,” so “the key is finding a balance.”
 
Dorsey sees that balance being achieved, not through enhancement of HVAC systems but through adding technology like AP, which was developed by ActivePure, a Dallas-based company. The U.S. Food & Drug Administration last year cleared ActivePure’s Medical Guardian, a device that uses the same technology as its other products, as a Class II Medical Device.
 
The Newsweek article concludes:
 
We can’t roll back 50 years of progress in sustainable building practices by simply telling property owners to run their HVAC systems more…. Advanced photocatalytic technologies can give us the best of both worlds. If we pursue a smart approach, we can emerge from COVID-19 healthier, reducing emissions and ultimately [becoming] more sustainable.
 
In Newsletter No. 5, we cited an article in HPAC Engineering by Gary and Ken Elovitz, a father and son team with Energy Economics, a venerable consulting firm outside Boston. The authors are skeptical of ventilation -- that is, the exchange of indoor for outdoor air through a heating and cooling, or HVAC, system – as the sole method of mitigating the spread of the SARS-CoV-2 virus, which causes COVID-19. They write:
 
The biggest danger for COVID-19 infection is close-range contact with infected people who are talking loudly or are otherwise exhaling heavily for at least several minutes. The HVAC system does not have much effect on those conditions.
 
The authors use the Wells-Riley equation, which uses “infectious particle concentration, exposure time, and outside air ventilation” to come up with a prediction of the “likelihood that a person will be infected by a virus.” (Academic research shows that, if anything, Wells-Riley underestimates risk.) Plugging in the numbers, the Elovitzes conclude:
 
No practical amount of ventilation can be relied on or expected to protect occupants over long exposure times like the 6 or 8 hours people might spend together in an office or school classroom. Similarly, ventilation is unlikely to succeed as the prime means of protection for people in close contact in a small space like a private office.
 
The authors write that “improved filtration can reduce the risk of transmission by reducing the concentration of infectious particles in the air.” But that reduction is by no means complete. They write that, on average, “MERV 13 filters might be 60% to 70% efficient at removing particles that contain viral material.”
 
Like Dr. Dorsey, the authors also warn that higher-efficiency filters “have higher pressure drop,” which means reduced air flow and heating and cooling capacity. Bringing an HVAC system back up to its pre-filter levels of air flow requires an increased “motor load” – that is, a bigger-capacity system, which will use more energy and pose a greater threat to the environment.

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Study Finds Delta Variant ‘Highly Transmissible in Indoor Sports Settings’

The Tokyo Olympic Games begin on July 23, and, while spectators have been banned because of COVID-19 concerns, athletes are already testing positive. Indoor events could become breeding grounds.

On July 16, the CDC’s Mortality and Morbidity Weekly Reports (MMWR) presented an examination of an outbreak at a U.S. gymnastics facility caused by the B.!.617.2 Delta variant, which originated in India and has spread around the world. The study concluded that the variant is “highly transmissible in indoor sports settings and households.”

Researchers from the Oklahoma Department of Health found that 47 people were infected out of 194 people exposed in the April-May event, including both gymnasts and family members. Among the 133 gymnasts themselves, 26 were infected.
“Several potential risk factors for transmission were identified through household interviews and direct observations at facility A,” wrote the researchers, “including nonadherence to recommended quarantine and testing guidance; delayed recognition of infection because of mild symptoms or attribution of symptoms to other causes; not using masks among active participants, coupled with increased respiration during active sport participation.”
 
No doubt “increased respiration” will be hard to avoid when the Olympics begin. The researchers urged, in addition to vaccinations, “multicomponent prevention strategies (e.g., testing, symptom monitoring, and other setting-specific measures)…among persons participating in indoor sports and their contacts.”
 
There was no specific mention, however, of one of the best ways to prevent the spread of the virus indoors: steps to keep interior air clean and safe through, for example, ventilation coupled with advanced photocatalysis.

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Public Health Leaders Urge Expanded Testing and Research

Writing in JAMA on July 15, three public health leaders took issue with the decision of the CDC in May to focus “its surveillance efforts only on breakthrough infections that resulted in hospitalizations or deaths, and ceasing to document [other] asymptomatic or symptomatic breakthrough cases.” (The term “breakthrough” refers to a COVID-19 infection in someone who has been vaccinated.)
 
The authors -- David Holtgrave, dean of the School of Public Health at the State University of New York at Albany; Sten Vermund, dean of the School Public Health at Yale; and Leana Wen, former health commissioner of Baltimore – wrote that the CDC “should once again add symptomatic infections to its surveillance efforts for breakthrough infections.” Recording these cases will help policy makers learn the extent of “suboptimal” vaccine protection. “Such symptomatic cases are relevant to the nation and should be reported by CDC.”
 
The authors point out that vaccinated people who are infected “may have more potential to transmit SARS-CoV-2 to others.” This is precisely the problem we may see at the Olympics or in the U.S. as school begins and people go back to office work.
 
Breakthrough infections currently happen at a low rate. For example, a study of 1,843 health care personnel, published in the MMWR in May, found that, of 623 case patients with a positive COVID test, only 19, or 3%, had received two vaccine doses. But, write the authors, “given the very large number of vaccinated persons in the U.S., even a small fraction of a large population can still represent a moderate number of cases.”
 
While finding and publicizing even the small proportion of breakthrough cases could alarm the public, if the CDC does not look for those cases actively, it will not have much authority when it asserts that the cases are rare. The authors, therefore, urge the CDC to step up testing of both vaccinated and unvaccinated Americans, which, as we noted above, has trailed off at an alarming rate.
 
Holtgrave, Vermund, and Wen also call for more research to understand why the case fatality rate (CFR) has been flat over the past six months. CFR is the number of COVID-19 related deaths divided by cases – in other words, the chances that, if you get infected, you will die. Since December 2020, “the CFR for the U.S. has hovered at approximately 1.7%” (actually, it rose a bit to 1.8% in the second week of July) despite the fact that, “given the array of tests, vaccines, and treatments now available, the CFR might be expected to be declining over time.”
 
The authors write that it’s important to learn whether people receive a diagnosis early in their illness and whether they have access to the right treatments. They urge expanded research into the role that income inequities and other social determinants play in treatment.
 
They conclude, “The nation’s confidence in the overall COVID-19 response is only as strong as its COVID-19 surveillance system, which should continue to persistently and rigorously look for trouble even if everyone hope there is little trouble to be found.”