tag:theconversation.com,2011:/global/topics/severe-acute-respiratory-syndrome-sars-81473/articlesSevere acute respiratory syndrome (SARS) – The Conversation2023-05-14T11:19:08Ztag:theconversation.com,2011:article/2052822023-05-14T11:19:08Z2023-05-14T11:19:08ZLearning from COVID-19: The global health emergency has ended. Here’s what is needed to prepare for the next one<figure><img src="https://images.theconversation.com/files/525793/original/file-20230512-21-xs50y1.jpg?ixlib=rb-1.1.0&rect=998%2C22%2C5682%2C3507&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The World Health Organization has declared an end to COVID-19's status as a public health emergency of international concern.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/learning-from-covid-19--the-global-health-emergency-has-ended--here-s-what-is-needed-to-prepare-for-the-next-one" width="100%" height="400"></iframe>
<p>When the World Health Organization formally <a href="https://doi.org/10.1038/d41586-023-01559-z">declared an end</a> to the COVID-19 pandemic’s designation as a Public Health Emergency of International Concern (PHEIC), it may seem to have had<a href="https://theconversation.com/covid-is-officially-no-longer-a-global-health-emergency-heres-what-that-means-and-what-weve-learned-along-the-way-205080">little, if any, perceivable impact</a> on the daily lives of most people. </p>
<p>However, it would be a mistake to assume that this is a mere formality.</p>
<p>A PHEIC, like the one <a href="https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">adopted for COVID-19 on Jan. 30, 2020</a>, is declared if a public health event is <a href="https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic">determined to constitute</a>:</p>
<ol>
<li>an extraordinary event; </li>
<li>a public health risk to other states through the international spread, and </li>
<li>potentially requiring a co-ordinated international response. </li>
</ol>
<p>Under the <a href="https://www.who.int/health-topics/international-health-regulations#tab=tab_1">International Health Regulations (IHR)</a> — a legally-binding agreement which commits governments to certain actions when responding to the international spread of disease — the declaration of a PHEIC permits the WHO to issue temporary recommendations to national governments to support a co-ordinated and effective global response to such events. </p>
<figure class="align-center ">
<img alt="A man with a moustache adjusts his glasses in front of a World Health Organization logo on a blue wall." src="https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, talks to the media at WHO headquarters in Geneva on Jan. 30, 2020, the day COVID-19 was declared a public health emergency or international concern.</span>
<span class="attribution"><span class="source">(Jean-Christophe Bott/Keystone via AP)</span></span>
</figcaption>
</figure>
<p>A PHEIC means the WHO is <a href="https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdf">sounding the loudest possible alarm</a> to national governments to act together with urgency. A total of seven <a href="https://doi.org/10.1093%2Fjtm%2Ftaaa227">PHEICS have been declared</a> since the IHR took effect in 2007: H1N1, Ebola, Polio, a second Ebola outbreak, Zika, COVID-19 <a href="https://www.who.int/europe/news/item/23-07-2022-who-director-general-declares-the-ongoing-monkeypox-outbreak-a-public-health-event-of-international-concern">and Mpox</a>. </p>
<p>However, the heightened state of emergency under a PHEIC is not meant to be sustained indefinitely. The recommendations are temporary and require review every three months.</p>
<h2>Significance of the end of the COVID-19 PHEIC</h2>
<p>The lifting of PHEIC status for COVID-19 is significant for two reasons. </p>
<p>First, ending the emergency stands down the WHO’s formal authority to guide national COVID-19 policies. While the acute phase of the pandemic appears to have passed, this must still be balanced with continued response efforts aligned with the <a href="https://doi.org/10.1126/science.adi5890">ongoing risk posed by the ever-evolving SARS-CoV-2</a>. </p>
<p>Moreover, the phrase “<a href="https://www.gavi.org/vaccineswork/no-one-safe-until-everyone-safe?gclid=Cj0KCQjwpPKiBhDvARIsACn-gzBnSxNtyGxTap5iEuFfiao9E2LqUxZvbVZbDeVhaPTcwixcTQEMJDkaAimnEALw_wcB">no one is safe until everyone is safe</a>” may have become a familiar tagline during the pandemic. Yet, many people, mostly in low- and middle-income countries, still <a href="https://data.undp.org/vaccine-equity/">struggle to access</a> COVID-19 vaccines, diagnostics and treatments. Others, such as the immuno-compromised, remain subject to severe health outcomes. </p>
<p>With the impact of COVID-19 continuing to disproportionately affect vulnerable populations worldwide, the pandemic remains far from over.</p>
<p>Second, the standing down of the PHEIC declaration is accompanied by an understandable desire — and necessity — to “move on” from COVID-19 after three difficult years. Many high-income countries have been steadily returning to <a href="https://www.nytimes.com/2023/05/05/health/covid-who-emergency-end.html">pre-COVID-19 life</a>. </p>
<figure class="align-center ">
<img alt="A row of five coronaviruses in different shades, changing from red to purple" src="https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=217&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=217&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=217&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=272&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=272&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=272&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">While the acute phase of the pandemic appears to have passed, this must still be balanced with continued response efforts aligned with the ongoing risk posed by the ever-evolving SARS-CoV-2 virus.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>However, the critical and challenging process of learning lessons from the pandemic — let alone addressing the shortcomings in the global response to COVID-19 — has just begun. Governments must ensure that “moving on” does not mean losing the opportunity to capture critical insights that will determine the effectiveness of future pandemic preparedness and response.</p>
<p>Perhaps the biggest lessons has been the failure of countries to co-ordinate on many aspects of the global COVID-19 response, such as access to vaccines and <a href="https://doi.org/10.1136/bmjgh-2020-004537">use of travel measures</a>. The lack of real-world authority by the WHO to enforce the legally binding IHR has become abundantly clear. </p>
<h2>Global co-ordination fell short</h2>
<p>The <a href="https://theindependentpanel.org/">Independent Panel for Pandemic Preparedness and Response</a>, convened by the WHO to review the global response to the pandemic, characterized February 2020 as a “<a href="https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdf">lost month</a>” due to the overwhelming inaction of many countries after the PHEIC was declared. </p>
<p>Governments eventually began to take emergency action but only after the WHO made the strategic decision in March 2020 to <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020">declare COVID-19 a pandemic</a>. Still, what ensued fell far short of a co-ordinated global effort.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-19-vaccine-inequity-allowed-omicron-to-emerge-173361">COVID-19 vaccine inequity allowed Omicron to emerge</a>
</strong>
</em>
</p>
<hr>
<p>The need for collective action during global public health emergencies like COVID-19 has only been reinforced by the past three years. Our research on the <a href="https://www.pandemics-borders.org/">use of travel measures in response to COVID-19</a> has identified key policy areas where improving effectiveness depends on how willing countries are to act in a co-ordinated way. </p>
<p>For example, the chaos caused by varied and changing use of travel measures was due in part to the lack of an agreed risk-based approach. Among those that applied risk analysis, <a href="https://www.migrationpolicy.org/research/risk-analysis-border-covid19">how risk was defined and approached varied substantially</a>.</p>
<p>Additionally, travel measures implemented in <a href="https://www.theglobeandmail.com/opinion/article-by-reducing-air-travel-within-canada-covid-19-has-opened-another/">response to COVID-19</a>, and in <a href="https://doi.org/10.1016/S0140-6736(15)00946-0">previous PHEICs</a>, fell inequitably upon different population groups. <a href="https://www.pandemics-borders.org/projects/equity-canada-us-border-measures">Further research</a> is needed to understand and mitigate unfair impacts. Once again, better risk-based public health responses with more equitable outcomes will require countries to renew their commitment to work together.</p>
<p>If future co-ordination efforts are to be successful, governments must begin by understanding and addressing the shortcomings of existing legal frameworks, including the PHEIC and IHR.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-whos-international-pandemic-treaty-meaningful-public-engagement-must-inform-canadas-negotiations-203747">The WHO’s international pandemic treaty: Meaningful public engagement must inform Canada's negotiations</a>
</strong>
</em>
</p>
<hr>
<p>Towards this end, WHO member states have begun simultaneous negotiation of <a href="https://www.who.int/news/item/21-04-2023-governments-hold-third-round-discussions-on-proposed-amendments-to-the-international-health-regulations-(2005)">IHR amendments</a>, alongside a <a href="https://www.who.int/news/item/03-03-2023-countries-begin-negotiations-on-global-agreement-to-protect-world-from-future-pandemic-emergencies">new pandemic legal instrument</a>. </p>
<p>Previous outbreaks of concern, <a href="https://www.canada.ca/en/public-health/services/reports-publications/learning-sars-renewal-public-health-canada.html">notably SARS-CoV-1</a> and <a href="https://www.phac-aspc.gc.ca/about_apropos/evaluation/reports-rapports/2010-2011/h1n1/pdf/h1n1-eng.pdf">H1N1</a>, initially prompted new attention and investments in pandemic preparedness. However, these efforts were not sufficiently sustained. Whether and to what extent current efforts will compel countries to act in the collective interest is the crux of the issue.</p>
<p>Meanwhile, a new pandemic may already be on the horizon as the global and interspecies spread of <a href="https://doi.org/10.1038/d41586-023-00201-2">highly pathogenic avian influenza</a> is raising growing alarm. The adoption and now lifting of the PHEIC declaration during the COVID-19 pandemic, and actions taken by governments in between, offer clear lessons if the world is willing to learn them.</p><img src="https://counter.theconversation.com/content/205282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julianne Piper is funded by the Pacific Institute on Pathogens, Pandemics and Society which receives funding from the BC Ministry of Health</span></em></p><p class="fine-print"><em><span>Kelley Lee receives funding from the Canadian Institutes of Health Research, New Frontiers for Research Fund, and Social Sciences and Humanities Research Council of Canada. The Pacific Institute on Pathogens, Pandemics and Society (PIPPS) receives funding from the BC Ministry of Health.</span></em></p>After previous public health emergencies likes SARS and H1N1, there was renewed investment in pandemic preparedness, but it was not sustained. We cannot make the same mistake after COVID-19.Julianne Piper, Research Fellow, Health Sciences, Simon Fraser UniversityKelley Lee, Professor and Canada Research Chair in Global Health Governance; Scientific Director, Pacific Institute on Pathogens, Pandemics and Society, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1760772022-02-21T15:54:56Z2022-02-21T15:54:56ZHave hybrid coronaviruses already been made? We simply don’t know for sure, and that’s a problem<p>At the end of 2021, the US Centers for Disease Control and Prevention (CDC) <a href="https://www.federalregister.gov/documents/2021/11/17/2021-25204/possession-use-and-transfer-of-select-agents-and-toxins-addition-of-sars-covsars-cov-2-chimeric">quietly added</a> “chimeric viruses” – viruses that contain genetic material derived from two or more distinct viruses – to its list of most dangerous pathogens. </p>
<p>The CDC designated this type of research as a “restricted experiment” that requires approval from the secretary of the Department of Health and Human Services – an executive branch department of the US federal government created to protect the health of Americans. The CDC believes that immediate regulatory oversight of these experiments is essential to protect the public from the potential consequences of a release of these viruses.</p>
<p>It is possible that <a href="https://www.federalregister.gov/documents/2021/11/17/2021-25204/possession-use-and-transfer-of-select-agents-and-toxins-addition-of-sars-covsars-cov-2-chimeric">at least one lab</a> in the US is interested in conducting experiments to produce a more dangerous version of SARS-CoV-2, the virus that causes COVID. The experiments would add genetic material from the original SARS virus, which first emerged in 2003, to the SARS-CoV-2 strain to create an aggressive “chimeric virus”. </p>
<p>We say it is “possible” that chimeric coronaviruses have been made because we simply do not know for sure. US labs are not obliged to publicly report, explain, or justify such experiments. And this highlights a larger issue. </p>
<p>The current approach to preventing high-risk pathogen research is piecemeal and reactive. It does not foster a larger public debate about whether the potential societal benefits of such research outweigh the very significant risks. The world lacks a comprehensive approach to biorisk management that incorporates biosafety, biosecurity and oversight of “dual-use research”, research that is intended to provide a clear benefit, but which could easily be misapplied to do harm.</p>
<h2>Not the only type of dangerous research</h2>
<p>Research with dangerous pathogens is just one of many kinds of life science research with high-risk consequences. As advances in science teach us more about the healthy functioning of humans, animals and plants, we are also inadvertently learning more about how these healthy functions could potentially be disrupted to deliberately cause harm. </p>
<p>For example, a <a href="https://www.who.int/publications/i/item/9789240036161">recent report</a> from the science division of the World Health Organization (WHO) identified several areas of the life sciences with misuse potential. These include gene therapy, viral vectors, genome editing, <a href="https://theconversation.com/gene-drives-accelerate-evolution-but-we-need-brakes-98401">gene drives</a> (a way of changing an entire population of a specific species by altering its genome), synthetic biology and neurobiology. </p>
<p>Risks of repurposing information, methods or technologies from these fields to deliberately cause harm are not adequately dealt with through current governance mechanisms and practices. Neither are the challenges from the life sciences <a href="https://www.sipri.org/publications/2019/other-publications/bio-plus-x-arms-control-and-convergence-biology-and-emerging-technologies">converging</a> with technologies like machine learning, artificial intelligence, robotics, nanotechnology and data analytics, that not only open new possibilities to enhance health, but also potentially enable greater harm to be caused more easily.</p>
<p>A 2021 <a href="https://www.ghsindex.org/">survey of biorisk management policies</a> around the world found that most countries do not have comprehensive, national systems for biosafety and biosecurity governance. Even countries, like the US, that scored high on biosecurity and biosafety have implemented these policies poorly in practice, as exemplified by <a href="https://thebulletin.org/2018/02/new-pathogen-research-rules-gain-of-function-loss-of-clarity/">questionable oversight</a> of gain-of-function research on potential pandemic pathogens funded by the National Institutes of Health. </p>
<p>Given the increasing number of countries conducting high-risk life science research and the potential global impact of accidental or deliberate misuse of the science, international standards, setting out expectations and responsibilities for safe, secure and responsible research, are urgently needed. </p>
<h2>Steaming ahead</h2>
<p>We are at a significant point in time, with high-risk life science research steaming ahead despite <a href="https://theconversation.com/fifty-nine-labs-around-world-handle-the-deadliest-pathogens-only-a-quarter-score-high-on-safety-161777">indicators</a> and <a href="https://www.science.org/stoken/author-tokens/ST-253/full">warning signs</a> that risk assessments are not conducted comprehensively and transparently. We cannot afford overconfidence in the safety and security practices of life scientists, their institutions, funders and publishers. </p>
<p>Knee-jerk regulatory responses to individual experiments, and treating safety, security and dual-use risks in isolation, must stop. It is high time for a new global architecture for life science governance that takes a comprehensive and coherent approach to biorisk management and that revisits how high-risk life sciences research, funding and publication processes are conducted. </p>
<p>The world must ensure basic and applied life science knowledge, materials and skills are used for peaceful purposes and for the betterment of humans and the health of the planet.</p><img src="https://counter.theconversation.com/content/176077/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gregory Koblentz receives funding from Effective Giving. He is is affiliated with the Center for Arms Control and Non-Proliferation, serves as a pro bono advisor to DARPA and the WHO, and is a member of the Biological Threat Advisory Board of Heat Biologics. </span></em></p><p class="fine-print"><em><span>Filippa Lentzos does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Risky life-science projects need global governance. Unfortunately, current standards and practices are not up to the task.Filippa Lentzos, Senior Lecturer in Science and International Security and Co-Director Centre of the Centre for Science & Security Studies, King's College LondonGregory D. Koblentz, Associate Professor and Director of the Biodefense Graduate Program, George Mason UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1746722022-01-19T13:46:08Z2022-01-19T13:46:08ZCORBEVAX, a new patent-free COVID-19 vaccine, could be a pandemic game changer globally<figure><img src="https://images.theconversation.com/files/440522/original/file-20220112-25-tuq2mh.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2191%2C1363&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">CORBEVAX uses recombinant DNA technology that many countries already have the infrastructure to produce.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/global-vaccination-of-planet-earth-royalty-free-illustration/1315224179">Artis777 via iStock/Getty Images Plus</a></span></figcaption></figure><p>The world now has a new COVID-19 vaccine in its arsenal, and at a fraction of the cost per dose.</p>
<p>Two years into the COVID-19 pandemic, the world has seen <a href="https://www.worldometers.info/coronavirus/">over 314 million infections and over 5.5 million deaths worldwide</a>. Approximately <a href="https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html">60% of the world population</a> has received at least one dose of a COVID-19 vaccine. But there is still a glaring and alarming gap in global access to these vaccines. As a <a href="https://www.rit.edu/ferranlab/maureen-ferran">virologist</a> who has followed this pandemic closely, I contend that this vaccine inequity should be of grave concern to everyone.</p>
<p>If the world has learned anything from this pandemic, it’s that viruses do not need a passport. And yet approximately 77% of people in high- and upper-middle-income countries have received at least one dose of the vaccine – and <a href="https://www.nytimes.com/interactive/2021/world/covid-vaccinations-tracker.html">only 10% in low-income countries</a>. <a href="https://www.washingtonpost.com/world/2021/11/12/coronavirus-vaccine-boosters-global/">Wealthy countries</a> are giving boosters, and even fourth doses, while first and second doses are not available to many worldwide. </p>
<p>But there is hope that a new vaccine called <a href="https://www.texaschildrens.org/texas-children%E2%80%99s-hospital-and-baylor-college-medicine-covid-19-vaccine-technology-secures-emergency">CORBEVAX</a> will help close this vaccination gap.</p>
<h2>How does the CORBEVAX vaccine work?</h2>
<p>All <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/how-they-work.html">COVID-19 vaccines</a> teach the immune system how to recognize the virus and prepare the body to mount an attack. The <a href="https://www.texaschildrens.org/texas-children%E2%80%99s-hospital-and-baylor-college-medicine-covid-19-vaccine-technology-secures-emergency">CORBEVAX vaccine</a> is a <a href="https://www.gavi.org/vaccineswork/what-are-protein-subunit-vaccines-and-how-could-they-be-used-against-covid-19">protein subunit vaccine</a>. It uses a harmless piece of the spike protein from the coronavirus that causes COVID-19 to stimulate and prepare the immune system for future encounters with the virus. </p>
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<figcaption><span class="caption">Recombinant vaccines commonly use yeast to produce the immune-stimulating proteins of a virus in the lab.</span></figcaption>
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<p>Unlike the three vaccines approved in the U.S. – <a href="https://theconversation.com/how-do-mrna-vaccines-work-and-why-do-you-need-a-second-dose-5-essential-reads-157198">Pfizer and Moderna’s mRNA vaccines</a> and <a href="https://theconversation.com/how-does-the-johnson-and-johnson-vaccine-compare-to-other-coronavirus-vaccines-4-questions-answered-155944">Johnson & Johnson’s viral vector vaccine</a>, which provide the body instructions on how to produce the spike protein – CORBEVAX delivers the spike protein to the body directly. Like those other approved COVID-19 mRNA vaccines, CORBEVAX also requires <a href="https://timesofindia.indiatimes.com/india/india-approves-corbevax-covovax-vaccines-for-emergency-use/articleshow/88555029.cms">two doses</a>.</p>
<h2>How was CORBEVAX developed?</h2>
<p>CORBEVAX was developed by the co-directors of the <a href="https://www.bcm.edu/departments/pediatrics/divisions-and-centers/tropical-medicine/research/vaccine-development">Texas Children’s Hospital Center for Vaccine Development</a> at Baylor College of Medicine, Drs. <a href="https://www.bcm.edu/people-search/maria-bottazzi-18431">Maria Elena Bottazzi</a> and <a href="https://www.texaschildrens.org/find-a-doctor/peter-jay-hotez-md-phd">Peter Hotez</a>. </p>
<p>During the <a href="https://www.cdc.gov/sars/about/fs-sars.html">2003 SARS outbreak</a>, these researchers created a similar type of vaccine by inserting the genetic information for a portion of the SARS virus spike protein into yeast to produce large amounts of the protein. After isolating the virus spike protein from the yeast and adding an <a href="https://www.thehindu.com/business/biological-e-to-use-dynavaxs-adjuvant-in-corbevax/article35179401.ece">adjuvant</a>, which helps trigger an immune response, the vaccine was ready for use.</p>
<p>The first SARS epidemic was short-lived, and there was little need for Bottazzi and Hotez’s vaccine – until the virus that causes COVID-19, SARS-CoV-2, emerged in 2019. So they dusted off their vaccine and updated the spike protein to match that of SARS-CoV-2, creating the <a href="https://www.texaschildrens.org/texas-children%E2%80%99s-hospital-and-baylor-college-medicine-covid-19-vaccine-technology-secures-emergency">CORBEVAX vaccine</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/UNXJHUnTCxE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">CORBEVAX received emergency use authorization in India on December 28, 2021.</span></figcaption>
</figure>
<p>Two large clinical trials of <a href="https://www.biologicale.com/news.html">over 3,000 people in India</a> found the vaccine to be safe, well-tolerated and <a href="https://www.texaschildrens.org/texas-children%E2%80%99s-hospital-and-baylor-college-medicine-covid-19-vaccine-technology-secures-emergency">over 90% effective at preventing symptomatic infections</a> from the original strain of COVID-19, and over 80% effective against the delta variant. The vaccine received <a href="https://www.texaschildrens.org/texas-children%E2%80%99s-hospital-and-baylor-college-medicine-covid-19-vaccine-technology-secures-emergency">emergency use authorization</a> in India, and other developing countries are expected to follow.</p>
<p>Interestingly, the group at Baylor was <a href="https://www.npr.org/sections/goatsandsoda/2022/01/05/1070046189/a-texas-team-comes-up-with-a-covid-vaccine-that-could-be-a-global-game-changer">not able to drum up interest or funding in the U.S.</a> for their vaccine. Instead, newer technologies such as mRNA vaccines raced ahead, even though Bottazzi and Hotez’s vaccine design was more advanced, thanks to their <a href="https://www.nbcnews.com/science/science-news/texas-india-patent-free-covid-vaccine-looks-bridge-equity-gaps-rcna10911">previous work during the 2003 SARS and 2012 MERS outbreaks</a>.</p>
<h2>A vaccine built for the world</h2>
<p>Protein subunit vaccines have an advantage over mRNA vaccines in that they can be readily produced using well-established <a href="https://dx.doi.org/10.1016%2Fj.addr.2021.01.001">recombinant DNA technology</a> that is relatively inexpensive and fairly easy to scale up. A similar protein recombinant technology that’s been around for 40 years has been used for the <a href="https://www.who.int/news-room/feature-stories/detail/the-novavax-vaccine-against-covid-19-what-you-need-to-know">Novavax COVID-19 vaccine</a>, which is <a href="https://www.cnbc.com/2022/01/10/novavax-ceo-covid-vaccine-could-be-cleared-in-multiple-countries-soon.html">available for use in 170 countries</a>, and the <a href="https://www.nature.com/articles/d42859-020-00016-5">recombinant hepatitis B vaccine</a>.</p>
<p>This vaccine can be produced at a much larger scale because <a href="https://www.nbcnews.com/science/science-news/texas-india-patent-free-covid-vaccine-looks-bridge-equity-gaps-rcna10911">appropriate manufacturing facilities are already available</a>. Also key to global access is that CORBEVAX can be <a href="https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/new-protein-based-covid-vaccine-doesnt-need-cold-storage-study/articleshow/87580913.cms">stored in a regular refrigerator</a>. Therefore, it is possible to produce millions of doses rapidly and distribute them relatively easily. In comparison, <a href="https://www.nytimes.com/interactive/2021/health/pfizer-coronavirus-vaccine.html">producing mRNA vaccines</a> is more expensive and complicated because they are based on newer technologies, rely on highly skilled workers and often require <a href="https://www.technologynetworks.com/biopharma/articles/covid-19-vaccine-storage-and-stability-349023">ultralow temperatures</a> for storage and transport.</p>
<p>Another major difference is that the CORBEVAX vaccine was developed with <a href="https://www.advancedsciencenews.com/corbevax-vaccine-offers-solution-to-global-vaccine-inequity/">global vaccine access in mind</a>. The goal was to make a low-cost, easy-to-produce and -transport vaccine using a well-tested and safe method. Key to this, the researchers were <a href="https://www.nbcnews.com/science/science-news/texas-india-patent-free-covid-vaccine-looks-bridge-equity-gaps-rcna10911">not concerned with intellectual property or financial benefit</a>. The vaccine was produced without significant public funding; the <a href="https://www.nbcnews.com/science/science-news/texas-india-patent-free-covid-vaccine-looks-bridge-equity-gaps-rcna10911">US$7 million</a> needed for development was provided by philanthropists. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding child gets vaccinated by a health care worker in India." src="https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440919/original/file-20220114-30-1l4ut2k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">India is the first country to grant emergency use authorization to CORBEVAX.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakIndiaVaccination/a7d7130831b6471ca08c028908d84745">Anupam Nath/AP</a></span>
</figcaption>
</figure>
<p>COBREVAX is currently <a href="https://www.advancedsciencenews.com/corbevax-vaccine-offers-solution-to-global-vaccine-inequity/">licensed patent-free</a> to Biological E. Limited (BioE), India’s largest vaccine maker, which plans to manufacture <a href="https://www.scientificamerican.com/article/a-covid-vaccine-for-all/">at least 100 million doses per month starting in February 2022</a>. This patent-free arrangement means that other low- and middle-income countries can produce and distribute this cheap, stable and relatively easy-to-scale vaccine locally.</p>
<p>Combined, this means that CORBEVAX is <a href="https://www.axios.com/india-authorizes-covid-vaccines-corbevax-novavax-795a5b7e-d9b7-4e8f-a1ec-bdaba5c5b13b.html">one of the cheapest vaccines currently available</a>. How well it works against the <a href="https://www.scientificamerican.com/article/a-covid-vaccine-for-all/">omicron variant</a> is under investigation. However, the CORBEVAX story can be <a href="https://www.nbcnews.com/science/science-news/texas-india-patent-free-covid-vaccine-looks-bridge-equity-gaps-rcna10911">used as a model</a> to address vaccine inequity when it is necessary to vaccinate the world population – against COVID-19 and other diseases on the horizon.</p>
<h2>The necessity of vaccine equity</h2>
<p>There are many reasons <a href="https://www.cgdev.org/debate/would-exempting-covid-19-vaccines-intellectual-property-rights-improve-global-access">global access to vaccines is inequitable</a>. For example, the governments of wealthy nations purchase vaccines in advance, which limits supply. While developing countries do have vaccine production capacity, low- and middle-income countries in Africa, Asia and Latin America still need to be able to afford the cost of placing orders.</p>
<p>The Indian government has ordered <a href="https://www.healio.com/news/infectious-disease/20220105/qa-unpatented-covid19-vaccine-could-finally-vaccinate-the-world">300 million doses of CORBEVAX, and BioE plans to produce more than 1 billion shots</a> for people in developing countries. For context, the U.S. and other G7 nations have pledged to donate <a href="https://launchandscalefaster.org/covid-19/vaccinedonations">over 1.3 billion doses of COVID vaccines, yet only 591 million doses have been shipped</a>. These numbers mean that if BioE is able to produce 1.3 billion doses of CORBEVAX as planned, this vaccine will <a href="https://www.healio.com/news/infectious-disease/20220105/qa-unpatented-covid19-vaccine-could-finally-vaccinate-the-world">reach more people than those vaccinated by what’s been donated and shipped by the wealthiest nations</a>.</p>
<p>[<em>Over 140,000 readers rely on The Conversation’s newsletters to understand the world.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140ksignup">Sign up today</a>.]</p>
<p>As the <a href="https://www.cdc.gov/coronavirus/2019-ncov/variants/omicron-variant.html">omicron variant</a> has shown, new variants can spread across the world quickly and are much more likely to <a href="https://www.healthline.com/health-news/unvaccinated-people-are-increasing-the-chances-for-more-coronavirus-variants-heres-how">develop in unvaccinated people</a> and <a href="https://www.msn.com/en-us/health/medical/expect-more-worrisome-variants-after-omicron-scientists-say/ar-AASOna4?li=BBnb7Kz">continue to emerge</a> as long as global vaccination rates remain low. It is <a href="https://www.theguardian.com/world/2022/jan/12/repeated-covid-boosters-not-viable-strategy-against-new-variants-who-experts-warn">unlikely that boosters</a> will end this pandemic. Rather, developing globally accessible vaccines like CORBEVAX represent an important first step in vaccinating the world and ending this pandemic.</p>
<p><em>Article updated to indicate percentage of people in low- and upper-middle to high income countries who have received at least one vaccine dose. Article also updated to note that clinical trials were performed in India and include more information on effectiveness against different strains.</em></p><img src="https://counter.theconversation.com/content/174672/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Ferran receives funding from The National Institutes of Health.</span></em></p>CORBEVAX is anticipated to significantly expand vaccine access to people in low- and middle-income countries.Maureen Ferran, Associate Professor of Biology, Rochester Institute of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1732042021-12-07T20:19:29Z2021-12-07T20:19:29ZWildlife trade poses health threats to humans, but Chinese wildlife farms are profiting<figure><img src="https://images.theconversation.com/files/435945/original/file-20211206-138695-16h9zx4.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6689%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">White raccoon dogs are prized for their unusual fur.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/wildlife-trade-poses-health-threats-to-humans--but-chinese-wildlife-farms-are-profiting" width="100%" height="400"></iframe>
<p>In November 2021, scientists from various disciplines published a “<a href="https://doi.org/10.1016/j.biocon.2021.109341">warning to humanity</a>” on wildlife trade because of the risk of “diseases transmitted from wildlife to humans.”</p>
<p>As COVID-19 swept across China last year, the Beijing government <a href="https://www.theguardian.com/environment/2020/feb/25/coronavirus-closures-reveal-vast-scale-of-chinas-secretive-wildlife-farm-industry">closed the live-animal sections of numerous markets and shut down 20,000 wildlife farms across the country</a>. Unknown to the outside world, however, three-quarters of the sector’s value comes from <a href="https://multimedia.scmp.com/infographics/news/china/article/3064927/wildlife-ban/index.html">breeding animals for fur, traditional medicine and entertainment purposes</a>. Many of those wildlife farms <a href="https://www.theguardian.com/environment/2020/feb/25/coronavirus-closures-reveal-vast-scale-of-chinas-secretive-wildlife-farm-industry">are still in business</a>.</p>
<p>These wildlife farms have become a focal point in the search for the origins of COVID-19, and a touchy issue for the Chinese — so much so that Beijing barred <a href="https://www.washingtonpost.com/world/asia_pacific/china-covid-bats-caves-hubei/2021/10/10/082eb8b6-1c32-11ec-bea8-308ea134594f_story.html">researchers, who were part of a mission organized by the World Health Organization (WHO), from visiting wildlife farms and bat caves in southern China</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-has-finally-made-us-recognise-the-illegal-wildlife-trade-is-a-public-health-issue-133673">Coronavirus has finally made us recognise the illegal wildlife trade is a public health issue</a>
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</p>
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<h2>Active sites</h2>
<p>In late 2020, researchers at the Belgium-based Humane Society International (HSI) <a href="https://www.hsi.org/news-media/fur-farm-investigation-reveals-distressed-foxes-raccoon-dogs-electrocuted-in-agony-and-fur-farm-carcasses-sold-for-human-consumption/">visited 13 fur farms across China</a>. The researchers found that not only were animals still being killed, but that <a href="https://www.hsi.org/news-media/fur-farm-investigation-reveals-distressed-foxes-raccoon-dogs-electrocuted-in-agony-and-fur-farm-carcasses-sold-for-human-consumption/">no measures were being taken to prevent the spread of COVID-19</a>:</p>
<p>“The fur farms we visited did not follow health and safety regulations,” says Wendy Higgins, director of international media at HSI. “Epidemic control rules were breached and our investigators were welcomed to the farms without having to follow basic biosecurity measures like disinfection stations at entry and exit points, wearing safety clothing, and having a quarantine area for ill animals,” says Higgins.</p>
<p>In March 2021, the WHO concluded that the novel coronavirus was most likely transmitted to humans through an “intermediary” rather than through <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/origins-of-the-virus">direct infection by bats, packaged food or a laboratory accident</a>. </p>
<p>The WHO researchers identified mink, civets and raccoon dogs as possible “<a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/origins-of-the-virus">intermediary host species</a>,” with mink being “highly susceptible” to COVID-19. While the focus so far has been on the risk posed by humans consuming meat from these animals, the WHO report notes that direct contact with infected animals or their body waste can also spread the virus.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/origin-of-the-covid-19-virus-the-trail-of-mink-farming-155989">Origin of the Covid-19 virus: the trail of mink farming</a>
</strong>
</em>
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<h2>Livestock or wildlife?</h2>
<p>Concerns about these animals’ role in spreading COVID-19 have been fuelled by <a href="https://doi.org/10.1126/science.abe3870">outbreaks at 431 mink fur farms across Europe and North America</a>. </p>
<p><a href="https://www.hsi.org/news-media/denmark-calls-for-total-mink-cull-on-all-fur-farms-amidst-covid-19-infections/">Denmark</a> <a href="https://www.ciwf.eu/news/2020/09/white-smoke-from-warsaw-poland-set-to-ban-fur-farming">and Poland</a>, the world’s top two fur-producing countries after China, have temporarily banned mink farming because of COVID-19 concerns. British Columbia will <a href="https://globalnews.ca/news/8353156/bc-mink-farm-industry-update/">phase out mink farming by 2025</a>, and France <a href="https://www.rfi.fr/en/france/20211118-france-approves-tough-new-laws-targeting-animal-cruelty-banning-wild-animal-entertainments">recently banned mink farming</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/gy-iUROpXfo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">B.C. plans to end mink farming by 2025.</span></figcaption>
</figure>
<p>China farmed an estimated <a href="https://www.independent.co.uk/stop-the-illegal-wildlife-trade/covid-fur-farms-china-b1855584.html">14 million foxes, 13.5 million raccoon dogs and 11.6 million mink in 2019</a>. But rather than ban fur farming, the Chinese government classified <a href="http://forestry.gov.cn/bwwz/2784/20200513/085630366321198.html">mink, foxes and raccoons as livestock</a>, explicitly excluding them from the wildlife ban.</p>
<p>“Virologists are concerned the virus can lay dormant at fur farms. The virus is capable of mutating so as we develop vaccines, new variants can emerge that are resistant. To leave such a potential threat untouched, just to boost the world of fashion, seems a far too great risk,” says Higgins.</p>
<p>In May 2020, Chinese authorities <a href="https://www.chinanews.com/gn/2020/05-16/9186245.shtml">offered buyouts to farmers who raise wildlife for food</a>, but the same incentive was not offered to fur farmers. Recent data is hard to come by, but in 2016, fur farming was valued at an <a href="https://multimedia.scmp.com/infographics/news/china/article/3064927/wildlife-ban/index.html">estimated 389 billion Chinese yuan (US$55 billion), as opposed to only 125 billion yuan (US$17 billion) for wildlife food production</a>.</p>
<h2>Luxury and profits</h2>
<p>As a result of the closure of fur farms in other parts of the world, Chinese producers <a href="https://www.reuters.com/article/us-health-coronavirus-china-mink-idUSKBN28D0PV">experienced a price hike of 30 per cent</a> in December 2020. </p>
<p>Wildlife is considered a luxury product affordable only to a small but <a href="https://www.brookings.edu/wp-content/uploads/2020/07/8_Felbab-Brown_China_final.pdf">growing segment of consumers</a>. A World Wildlife Fund survey found that <a href="https://globescan.com/wp-content/uploads/2021/05/WWF-GlobeScan-COVID19_One_Year_Later-Highlights_Report-May2021.pdf">in China, 10 per cent of respondents had purchased wild animals at an open market in 2019</a>. </p>
<p>Worryingly, scientists found that banning wildlife markets has “<a href="https://doi.org/10.1016/j.envres.2020.110439">not discouraged online wildlife trade</a>.”</p>
<p>Besides food and fur, wild animal parts are also used in traditional Chinese medicine, a growing market actively promoted by the government. Chinese consumers were <a href="https://www.theguardian.com/environment/2020/may/26/its-against-nature-illegal-wildlife-trade-casts-shadow-over-traditional-chinese-medicine-aoe">expected to spend US$420 billion annually on these items by the end of 2020</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="older women sit in front of a window display of a traditional Chinese medicine shop" src="https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436039/original/file-20211207-141178-gta8uc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A group of women sit in front of a window display of a traditional Chinese medicine shop. The growing demand for traditional Chinese medicine has fed the legal and illegal trade in exotic animal parts.</span>
<span class="attribution"><span class="source">(AP Photo/Ng Han Guan)</span></span>
</figcaption>
</figure>
<p>China legalized the use of <a href="https://www.nationalgeographic.com/animals/article/wildlife-watch-news-china-rhino-tiger-legal">rhino horn and tiger bone in traditional medicine in 2018</a>. It went further last year with a <a href="https://www.theguardian.com/world/2020/jun/03/beijing-draws-up-plans-to-outlaw-criticism-of-traditional-chinese-medicine">law criminalizing any public criticism of traditional medicine</a>. More recently, the government started <a href="https://www.nationalgeographic.com/animals/article/chinese-government-promotes-bear-bile-as-coronavirus-covid19-treatment">promoting the use of traditional medicine to cure COVID-19</a> without any evidence to that effect.</p>
<h2>Mitigation and policy</h2>
<p>The government’s policy towards wildlife farming echoes its actions during the SARS outbreak in 2003. It initially <a href="https://doi.org/10.1016/S1473-3099(06)70676-4">shut down wildlife markets</a> when the disease was traced to animals, but after two years, enforcement “<a href="https://www.brookings.edu/wp-content/uploads/2020/07/8_Felbab-Brown_China_final.pdf">lessened as the wildlife trade industry lobbied against it and pointed out the economic and job contributions to the country</a>.” </p>
<p>The WHO continues its search for the definitive origin of COVID-19. It recently announced the formation of a <a href="https://www.who.int/news-room/articles-detail/public-notice-and-comment-on-proposed-new-scientific-advisory-group-for-the-origins-of-novel-pathogens-(sago)-members">scientific advisory group to further the investigation</a>, and has <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/origins-of-the-virus">recommended conducting “targeted surveys of fur farms” as one line of inquiry</a>.</p>
<p>Despite close encounters with Ebola, SARS-CoV-1, Middle East Respiratory Syndrome and H1N1, and decades of warnings from <a href="https://doi.org/10.1089/vbz.2020.2652">infectious diseases specialists</a>, stricter regulation and additional mitigation strategies are needed.</p><img src="https://counter.theconversation.com/content/173204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anrike Visser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In China, the wildlife trade is thriving, driven by the increased demands for luxury goods and traditional medicine. But there is real concern about the threat of diseases that can cross over to humans.Anrike Visser, Dalla Lana Global Journalism Fellow, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1652952021-11-05T12:30:09Z2021-11-05T12:30:09ZThe US was not prepared for a pandemic – free market capitalism and government deregulation may be to blame<figure><img src="https://images.theconversation.com/files/430000/original/file-20211103-17-1fprqlu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2185%2C1370&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In reprioritizing public health, the U.S. limited its ability to respond quickly and effectively to the pandemic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/quarantine-1-dollar-banknote-with-medical-mask-the-royalty-free-image/1215055651">Anton Petrus/Moment via Getty Images</a></span></figcaption></figure><p>It’s unclear when the pandemic will come to an end. What may be an even more important question is whether the U.S. will be prepared for the next one. The past year and a half suggests that the answer may be no.</p>
<p>As a <a href="https://scholar.google.com/citations?user=YCsTY4sAAAAJ">medical anthropologist</a> who has spent the past 20 years studying how the Chinese government reacts to infectious disease, my research can provide insight into how countries, including the U.S., can better prepare for disease outbreaks.</p>
<p>Researchers agree that a good response starts with a <a href="https://doi.org/10.2105/AJPH.2020.305861">strong public health system</a>. But this is something that <a href="https://www.milbank.org/quarterly/opinions/us-health-care-in-our-neoliberal-era/">has been sidelined</a> by the United States’ <a href="https://theconversation.com/what-exactly-is-neoliberalism-84755">neoliberal system</a>, which places more value on free markets and deregulation than public welfare.</p>
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<figcaption><span class="caption">Neoliberalism promotes a free market accessible to the wealthy few, making essential services less free for everyone else.</span></figcaption>
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<h2>As US neoliberalism evolved, public health devolved</h2>
<p><a href="https://doi.org/10.1080/03085147.2015.1013356">Neoliberal economic policies</a> became popular in the 1980s during the Reagan and Thatcher eras. This new approach aimed to make government leaner and more efficient through measures like market deregulation, privatization and reduction of government provision of <a href="https://doi.org/10.1057/s41301-020-00255-z">public services</a> like health and education – resources that do not necessarily lend themselves to market production.</p>
<p>While neoliberal governments still work to promote the health, welfare and security of their citizens, they place the responsibility of providing those services in the hands of private entities like health insurance companies and nongovernmental organizations. This gives the government space to focus on economic performance.</p>
<p>But placing responsibility for a public good into the hands of a private corporation turns that good into a commodity that people need to buy, rather than a <a href="https://doi.org/10.1057/s41301-020-00255-z">service publicly available to all</a>.</p>
<p>Spending on health care in the U.S., including on hospitals, medications and private insurance, has <a href="https://www.brookings.edu/research/a-dozen-facts-about-the-economics-of-the-u-s-health-care-system/">more than tripled</a> in the past 60 years. But the public health system that helps the nation <a href="https://www.ucpress.edu/book/9780520295766/unprepared">prepare for the unexpected</a> has been neglected. </p>
<p>U.S. spending on the local health departments that help to avert epidemic outbreaks and protect the health of populations <a href="https://khn.org/news/us-public-health-system-underfunded-under-threat-faces-more-cuts-amid-covid-pandemic/">fell by 18%</a> between 2010 and 2021. Two and a half cents of every medical dollar goes toward public health, a figure that has fallen from <a href="https://www.theatlantic.com/health/archive/2021/09/america-prepared-next-pandemic/620238/">1930 levels</a> of 3.3 cents of every dollar. This has allowed the U.S. to manage health risks like <a href="https://www.dukeupress.edu/drugs-for-life">chronic diseases</a> that threaten individual’s health. But it leaves the nation inadequately prepared for population-level major health threats that have a much bigger effect on the economy and society.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1397318954360659969"}"></div></p>
<p>Public health cuts left the U.S with a skeletal workforce to manage the pandemic. Because of this, responsibility <a href="https://www.nytimes.com/2020/04/20/opinion/osha-coronavirus.html">fell to individuals</a>. For example, without mandatory workplace COVID-19 safety guidelines, essential workers faced daily exposure to the coronavirus with insufficient to no protective gear and sanitizing supplies. They had to protect both their own health and the health of their families when they returned home, a difficult task without proper resources and support.</p>
<p>And this was not unique to the U.S. There were similar COVID-19 outcomes in other neoliberal countries like the <a href="https://doi.org/10.13169/jglobfaul.7.1.0009">U.K.</a> and <a href="https://www.jacobinmag.com/2021/05/india-covid-19-neoliberal-state-narendra-modi-vaccine-bjp-austerity">India</a> that had shifted priorities away from public health.</p>
<h2>How Asian nations learned their lessons</h2>
<p>The story was different in many <a href="https://www.wsj.com/articles/how-asian-countries-are-keeping-covid-19-under-control-11603229882">Asian nations</a> where people enjoy the same types of individual liberties as those who live in neoliberal societies. The difference is a <a href="https://www.voanews.com/a/covid-19-pandemic_how-cultural-differences-help-asian-countries-beat-covid-19-while-us-struggles/6193224.html">collectivist</a> type of mindset that guides these societies and encourages people and government to take responsibility for one another. In her book <a href="https://www.dukeupress.edu/flexible-citizenship"><em>Flexible Citizenship</em></a>, anthropologist Aihwa Ong argues that this leads to a societal model where citizens can be independent and self-reliant while also able to rely on a state that supports the collective. Countries like <a href="https://www.cnbc.com/2020/07/15/how-taiwan-beat-the-coronavirus.html">Taiwan</a> and <a href="https://www.theatlantic.com/ideas/archive/2020/05/whats-south-koreas-secret/611215/">South Korea</a> may have been better prepared to respond to the pandemic because most people are accustomed to protecting themselves and their communities. </p>
<p>Like China, these countries also learned from their recent experience with a pandemic. In 2003, China and much of Asia were caught off guard with the emergence of <a href="https://dx.doi.org/10.3201%2Feid1011.040797_02">SARS</a>. Like the U.S., China’s public health system had <a href="http://hdl.handle.net/10419/148725">taken a backseat</a> to investment in market reforms for over 20 years. As a result, it <a href="https://dx.doi.org/10.2105%2FAJPH.2020.305654">couldn’t accurately track</a> individual cases of infections.</p>
<p>Following the end of the SARS outbreak, however, the Chinese government improved training for public health professionals and developed one of the most sophisticated <a href="https://doi.org/10.7208/chicago/9780226401263.003.0011">disease surveillance systems</a> in the world. This allowed China to respond more quickly to the 2009 H1N1 pandemic and late 2019 COVID-19 outbreaks, once it was able to get past the initial <a href="https://www.prcleader.org/yanzhong-huang">bureaucratic and political hurdles</a> that prevented local doctors and government officials from sounding the alarm. </p>
<p>Some have attributed this swift action to China’s <a href="https://thediplomat.com/2020/02/coronavirus-and-chinas-authoritarian-advantage/">authoritarian</a> form of government that allows for greater control over individual lives. But prioritizing public health is not new to China. This became official practice <a href="https://doi.org/10.1017/S0021911820002284">as early as 1910</a> when it adopted the methods of <a href="https://www.nytimes.com/2021/05/19/health/wu-lien-teh-china-masks.html">quarantine, surveillance and masking</a> to respond to an outbreak of pneumonic plague.</p>
<h2>Could this work in the US?</h2>
<p>Much like SARS did with China, COVID-19 has exposed huge holes in the American public health infrastructure. </p>
<p>Take for example <a href="https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-contact-tracing">contact tracing</a>. SARS taught China and other affected countries the importance of a robust system to identify and track people who may have been exposed to the COVID-19 virus. The Chinese government sent <a href="https://www.sciencemag.org/news/2020/03/china-s-aggressive-measures-have-slowed-coronavirus-they-may-not-work-other-countries">more than 1,800 teams of scientific investigators</a> to Wuhan to trace the virus, which helped their efforts to quickly bring the virus under control.</p>
<p>In the U.S., on the other hand, poorly funded and thinly staffed public health departments <a href="https://www.npr.org/sections/health-shots/2021/06/03/1002878557/why-contact-tracing-couldnt-keep-up-with-the-u-s-covid-outbreak">struggled to test and notify people</a> who had been in direct contact with infected individuals. This crippled the U.S.’s ability to prevent the spread of COVID-19.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person scans phone app used for contact tracing and has temperature checked by guard before entering a shopping area" src="https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/430018/original/file-20211103-27-4nm7vx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A widely adopted contact tracing system in China helped control the spread of COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-scans-her-health-code-app-used-for-contact-tracing-as-news-photo/1234662565">Kevin Frayer/Stringer via Getty Images News</a></span>
</figcaption>
</figure>
<p>In my home state of Massachusetts, the local government teamed up with the global health organization <a href="https://www.pih.org/ma-response">Partners in Health</a> to start a contact tracing operation. But even then, people were left to fend for themselves. This became all the more evident as people <a href="https://www.bostonglobe.com/2021/03/02/nation/those-frustrated-with-vaccine-system-crew-volunteers-is-ready-help/">scrambled for vaccines</a> after their initial approval, through Facebook groups and informal volunteer networks that worked to help people secure appointments. Those who had resources learned how to <a href="https://www.nytimes.com/2021/02/02/health/white-people-covid-vaccines-minorities.html">take advantage of the system</a> while <a href="https://www.pbs.org/newshour/health/older-adults-left-behind-in-desperate-dash-for-vaccine-shots">others were overlooked</a>.</p>
<p>This is typical of a U.S. <a href="https://www.nytimes.com/2020/05/06/opinion/coronavirus-health-care-market.html">health care system</a> that is consumer-oriented and market-based. Americans are often convinced that the solution to a health problem must be <a href="https://www.theatlantic.com/health/archive/2021/09/america-prepared-next-pandemic/620238/">technical and costly</a>. The focus was placed on developing vaccines and therapeutics, which are essential for ending the pandemic, while ignoring lower-cost solutions.</p>
<p>But <a href="https://www.nytimes.com/2021/05/19/health/wu-lien-teh-china-masks.html">masking</a> and <a href="https://healthblog.uofmhealth.org/wellness-prevention/people-gave-up-on-flu-pandemic-measures-a-century-ago-when-they-tired-of-them">social distancing</a> – non-pharmaceutical interventions that have long been known to save lives during disease outbreaks – fell by the wayside. Uptake of these simple interventions is dependent on strong and coordinated public health messaging. </p>
<p>As seen in several <a href="https://www.brookings.edu/techstream/lessons-learned-from-taiwan-and-south-koreas-tech-enabled-covid-19-communications/">Asian nations</a> like Taiwan and South Korea, a well-thought-out plan for public health communication is key to a unified response. Without clear, coordinated directions from a public health system, it becomes difficult to prevent the spread of an outbreak.</p>
<h2>What it takes to be prepared</h2>
<p>Anthropologist <a href="https://www.ucpress.edu/book/9780520295766/unprepared">Andrew Lakoff</a> describes preparedness as more than just having the tools. It’s also about knowing how and when to use them, and keeping the public properly informed. </p>
<p>Such preparedness can only happen in a coordinated fashion organized by national leadership. But the U.S. has seen little of this over the past year and a half, leaving pandemic response up to individuals. In an era where emergent viruses are an increasing threat to health and welfare, the individualism of neoliberal policies is not enough. While neoliberalism can be good for an economy, it’s <a href="https://doi.org/10.2190%2FHS.42.3.b">not so good for health</a>.</p><img src="https://counter.theconversation.com/content/165295/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elanah Uretsky does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While neoliberalism has allowed U.S. markets to grow, the resultant stunted public health system left Americans to figure out how to protect themselves from COVID-19 and its fallout on their own.Elanah Uretsky, Associate Professor of International and Global Studies, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1652102021-08-06T13:06:14Z2021-08-06T13:06:14ZWill mask wearing still be common in Britain after the pandemic is over?<p>Face masks have been a crucial part of the UK’s strategy to contain COVID-19, but have also evoked contradictory emotions and reactions. Some see masks as an important means to <a href="https://jamanetwork.com/journals/jama/fullarticle/2776536">halt the virus’s spread</a>, as well as a sign of <a href="https://theconversation.com/covid-masks-how-and-when-to-ask-someone-to-wear-one-without-getting-into-a-fight-164888">social consideration</a> and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30918-1/fulltext">altruism</a>. Others have politicised them, seeing mask mandates as <a href="https://theconversation.com/face-mask-rules-do-they-really-violate-personal-liberty-143634">trampling over their rights</a> as individuals.</p>
<p>But what will mask wearing in the UK look like in the long term? This is an intriguing question, and one that our <a href="https://gtr.ukri.org/projects?ref=AH%2FW003813%2F1">interdisciplinary team</a> is currently exploring as part of a larger project on the role that the media plays in influencing people’s decisions to wear masks. Our research covers what factors drive people to wear masks across different parts of the world, exploring the use and effects of media messaging in the UK in light of what happens elsewhere, such as in east Asia.</p>
<p>Globally, the UK sits somewhere between the politicisation of mask wearing <a href="https://www.theguardian.com/world/2020/jun/29/face-masks-us-politics-coronavirus">seen in the US</a> and the more communitarian mask wearing of east Asia. Importantly, the US and UK don’t have a history of mask wearing to build on, whereas many east Asian countries do.</p>
<p>People in east Asia have worn masks for a host of <a href="https://theconversation.com/a-brief-history-of-masks-from-the-17th-century-plague-to-the-ongoing-coronavirus-pandemic-142959">medical</a>, <a href="https://www.voanews.com/science-health/coronavirus-outbreak/not-just-coronavirus-asians-have-worn-face-masks-decades">cultural</a> and environmental reasons since at least the first half of the 20th century. Masks are worn out of courtesy, to avoid putting on makeup, to keep warm, to avoid attention and communication, and to protect against the sun. They’re also worn to protect against pollution (the <a href="https://www.iqair.com/world-most-polluted-cities">100 cities</a> worldwide with the worst air pollution are all in Asia), though people may <a href="https://www.nature.com/articles/d41586-019-02938-1">overestimate the protection they offer</a>.</p>
<p>The real turning point, though, came in 2002, with the outbreak of <a href="https://www.who.int/health-topics/severe-acute-respiratory-syndrome#tab=tab_1">severe acute respiratory syndrome</a> (Sars), which started in China before spreading to Singapore and Taiwan over the following year. As a result, masks grew in popularity, so much so that they came to be used day to day as <a href="https://qz.com/299003/a-quick-history-of-why-asians-wear-surgical-masks-in-public/">fashion accessories</a> as well as for protection. Could the same thing happen in the UK too?</p>
<h2>How masks became normal in Asia</h2>
<p>In several east Asian countries, the high uptake of mask wearing has been driven by government messaging. As a result of Sars and avian flu, for example, the government in Hong Kong <a href="https://link.springer.com/article/10.1007/s15010-008-7277-y">urged people</a> consistently, clearly and frequently to use face masks when they had flu-like symptoms, both to prevent illness and prepare for other future flu-like epidemics. Warnings were regularly broadcast on television and in train stations.</p>
<p>Meanwhile, in Japan over the past few decades the government has <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01466.x">stressed</a> that it’s up to individual citizens to lead a healthy lifestyle. In the early 2000s, <a href="https://www.med.or.jp/english/pdf/2003_02/047_049.pdf">public health programmes</a> and <a href="https://www.mhlw.go.jp/english/wp/wp-hw3/dl/2-063.pdf">laws</a> were introduced to get people to actively monitor and take care of their own health.</p>
<p>At the time of the 2009 swine flu epidemic, the Japanese government then relied on this sense of personal responsibility to help contain the virus. Campaign posters at the time <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01466.x">read</a>: “The spread of the influenza must be prevented by each individual!” This reflects the sense of duty to act for the “greater good” that exists in many Asian countries, and which manifests itself in people choosing to wear masks if they feel under the weather so they don’t pass any illness on.</p>
<p>The success of this tactic may be due to many of these countries – including <a href="https://www.hofstede-insights.com/country-comparison/china/">China</a> and <a href="https://www.hofstede-insights.com/country-comparison/japan/">Japan</a> – having what the anthropologist Geert Hofstede has defined as “<a href="https://geerthofstede.com/culture-geert-hofstede-gert-jan-hofstede/6d-model-of-national-culture/">low individualism</a>”. In such countries, the prevailing culture generally favours acting in the interests of the group. A strong motivation to adhere to social norms will therefore <a href="https://warwick.ac.uk/newsandevents/expertcomment/how_does_wearing/">influence people</a> to wear masks. The force of this may be so strong that <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01466.x">mask wearing moves</a> from being something targeted at specific health threats to a general practice, adhered to daily without a specific purpose. </p>
<p>The emergence of branded masks or masks as fashion statements reflects this. For example, in Japan, what is known as “<a href="https://www.asianstudies.org/wp-content/uploads/from-hello-kitty-to-cod-roe-kewpie-a-postwar-cultural-history-of-cuteness-in-japanA.pdf"><em>kawaii</em></a>” culture is strong. This encompasses a love for anime characters, cute animal mascots and colourful fashion, and masks have proven to be an easy home for this aesthetic. Masks becoming fashionable may then in turn influence behaviour, making the everyday wearing of them more popular.</p>
<h2>Will the same trends appear in the UK?</h2>
<p>In the short term, it’s unlikely that Britain’s mask wearing will mirror Japan’s or Hong Kong’s. In east Asia, there’s been almost two decades of experience with flu-like outbreaks, leading to repeated government messaging around mask wearing and personal responsibility. There just hasn’t been the same context in the UK.</p>
<p>There are cultural differences to consider too. Unlike in Britain, in Asia wearing a face covering is not only done by large numbers of people, but is also <a href="https://warwick.ac.uk/newsandevents/expertcomment/how_does_wearing/">socially approved of and expected</a>, with lower levels of individualism driving conformity with this norm. Britain, in contrast, <a href="https://www.hofstede-insights.com/country-comparison/the-uk/">scores much more highly</a> for individualism. Mask wearing, now that it’s broadly not mandatory in England, is therefore more likely to be seen as a matter of personal choice.</p>
<p>Current government messaging in England is also emphasising the rights of the individual (the branding of the lifting of restrictions as “<a href="https://theconversation.com/why-freedom-day-is-the-latest-example-of-covid-propaganda-164521">Freedom Day</a>” being the key example), and so stands in direct contradiction to supporting the greater social good through mask wearing. </p>
<p>Indeed, anecdotally it doesn’t seem that frequent exposure to people wearing masks – whether on TV or in the street – has resulted in the development of a continuous pro-mask attitude and lasting behaviour change in the UK, and <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/articles/twothirdsofadultsstillplantowearmasksinshopsandonpublictransport/2021-07-16">a third of people</a> have indicated that they won’t continue to wear masks now they don’t have to. However, one way this could change is if mask wearing continued to be <a href="https://www.mdpi.com/1660-4601/18/4/1879">depicted as normal across the media</a>, including in fictional settings – on TV and in films, music videos and so on.</p>
<p>If required for a healthier future, continuing to portray their use in this way could serve as a means to normalise them, beyond governmental campaigns. This, though, isn’t a public health tactic that has been tried extensively to date.</p><img src="https://counter.theconversation.com/content/165210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>All authors receive funding from the Arts and Humanities Research Council. Simon Willcock is affiliated with both Rothamsted Research and Bangor University.</span></em></p><p class="fine-print"><em><span> </span></em></p>In east Asian countries, past disease outbreaks have made face masks part of everyday life – but the social context supporting such behaviour isn’t present in the UK.Nathan Abrams, Professor of Film Studies, Bangor UniversityHayley Roberts, Senior Lecturer in Public International Law, Bangor UniversitySimon Willcock, Professor of Sustainability, Bangor UniversityThora Tenbrink, Professor of Linguistics, Bangor UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1639712021-07-18T20:05:14Z2021-07-18T20:05:14ZWe’ve become used to wearing masks during COVID. But does that mean the habit will stick?<p>Mask mandates are in place in <a href="https://www.coronavirus.vic.gov.au/face-masks">Victoria</a> and <a href="https://www.nsw.gov.au/covid-19/rules/face-mask-rules">New South Wales</a> as these states continue to see COVID cases in the community. And <a href="https://intouchpublichealth.net.au/2021/07/02/setting-australias-covid-immunisation-target-our-next-big-challenge/">public health experts</a> have argued face masks will continue to be an important measure in our fight against the virus for some time to come.</p>
<p>Evidence shows <a href="https://www.sciencedirect.com/science/article/pii/S0020748920301139?via%3Dihub">masks are effective</a> at <a href="https://gh.bmj.com/content/5/5/e002794.abstract">reducing the spread</a> of COVID-19 in the community.</p>
<p>However, masks won’t always be compulsory, particularly outside outbreak situations. In most Australian states and territories at present, masks are not mandatory but are recommended <a href="https://www.covid19.act.gov.au/stay-safe-and-healthy/protect-yourself#Face-masks">in certain settings</a>, such as where physical distancing is difficult.</p>
<p>But moving forward — as more people get vaccinated and outbreaks hopefully become fewer and smaller — is mask use likely to stick?</p>
<h2>Leaving it up to the public</h2>
<p>In recent weeks, we’ve seen announcements from the <a href="https://www.theguardian.com/world/2021/jul/05/lifting-covid-rules-england-what-boris-johnson-announced">United Kingdom</a> and <a href="https://www.abc.net.au/news/2021-07-04/singapore-considers-a-radical-new-approach-to-covid-19/100256272">Singapore</a> that they’re shifting their approach to COVID-19 restrictions, moving to a new way of “living with the virus”. </p>
<p>In the UK, along with the reopening of all businesses, and lifting of attendance caps at events, social distancing and mask wearing will become matters of personal responsibility. </p>
<p>Select authorities may still require people to wear masks in certain settings, such as in hospitals or on public transport. For example, masks <a href="https://www.bbc.com/news/uk-england-london-57826331">will remain compulsory</a> on London’s public transport network. </p>
<p>But <a href="https://www.bbc.com/news/health-51205344">from July 19</a>, the national legal requirement to wear a face covering in shops, on public transport and in other enclosed spaces will end. </p>
<figure class="align-center ">
<img alt="Cloth masks on a table." src="https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411384/original/file-20210715-19-vihfdz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Masks effectively reduce the spread of COVID-19 and other respiratory viruses.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/homemade-protective-mask-pieces-cloth-on-1683745294">Shutterstock</a></span>
</figcaption>
</figure>
<p>In Singapore and the UK, the governments have noted <a href="https://www.straitstimes.com/opinion/living-normally-with-covid-19">the community’s behaviour</a> will be part of the solution. </p>
<p>Authorities hope that even without mandates, people will continue to wear masks <a href="https://www.bbc.com/news/uk-england-london-57826331">in high-risk situations</a>, such as crowded and enclosed spaces.</p>
<h2>Will discretionary mask use work?</h2>
<p>While we know mandates <a href="https://www.sciencedirect.com/science/article/pii/S1201971221002745">increase mask use</a> substantially, the decision to wear a mask is <a href="https://journals.sagepub.com/doi/full/10.1177/1524839920983922">influenced by many factors</a> beyond whether or not there are penalties in place for non-compliance. A person’s age, level of income, where they live and cultural norms can all play a role. </p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293989/">review on mask use</a> to prevent respiratory infections, conducted before COVID-19, found people are more likely to wear a mask when they feel at increased risk of infection, or when they think the outcome of getting sick is severe.</p>
<p>Wearing a mask is also motivated by a shared sense of responsibility and by perceived social norms (those unwritten rules or beliefs we consider acceptable in our community). We often take cues from people we’re close to, especially in uncertain times. </p>
<p><a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05340-9">Our research</a> found perceived pressure from different avenues including employers, mass media, government and family can all play a role in increasing mask use. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/living-with-covid-is-now-the-right-time-for-england-to-lift-all-restrictions-164022">Living with COVID: is now the right time for England to lift all restrictions?</a>
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<p>It’s difficult to know whether as countries move away from mandates, and leave it up to individuals, we’re likely to see ongoing mask use in the community.</p>
<p>But it’s worth looking to the Asian experience. Some Asian countries have a longer history of wearing masks, both for protection against pollution and for protection against infection, especially <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-9566.2012.01466.x">since SARS</a> in 2003.</p>
<p>In <a href="https://pubmed.ncbi.nlm.nih.gov/15917041/">Hong Kong</a> after the outbreak, the proportion of people who reported wearing a mask when experiencing flu-like symptoms declined sharply from 74% in June 2003 to 39% in September 2003. But self-reported health-related behaviours, including mask use, were still much greater in the period after SARS compared to before it. </p>
<p>Researchers tracking these trends noted that in the face of SARS, people in Hong Kong came to accept mask use as part of their “<a href="https://pubmed.ncbi.nlm.nih.gov/14600111/">civic responsibility</a>”.</p>
<p>One <a href="https://academic.oup.com/jtm/article/27/8/taaa121/5881391?login=true">study</a> looking at photographs of settings such as grocery stores and markets in six different countries in early 2020 mapped huge variations in mask use. This ranged from a high of 97% in Phnom Penh, Cambodia (in Asia) through to 4% in Kinshasa, in the Democratic Republic of Congo. </p>
<p>In some of these countries the level of mask use may have been influenced by government recommendations or mandates in place at the time.</p>
<p>There is an element of doubt as to whether masks will continue to be used in countries with more individualist cultures such as the US and Australia (“I often do my own thing”), as opposed to <a href="https://www.pnas.org/content/118/23/e2021793118.short">collectivist cultures</a> like those found more often in Asia (“My happiness depends very much on the happiness of those around me”). </p>
<p>Vaccination status could also affect mask use in the community. People who are vaccinated against COVID-19 — as <a href="https://ourworldindata.org/covid-vaccinations">a high proportion are</a> in countries like the UK and Singapore — may be less inclined to wear a mask, compared to those who are unvaccinated. </p>
<h2>The new normal?</h2>
<p>If we’re trying to shift the social norm around masks, and encourage their ongoing use (without mandates), it’s important we evolve our messaging. This includes relevant reminders around times when masks would be most beneficial, such as: </p>
<ul>
<li><p>encouraging people to put a mask on straight away if they’re out in public and start to feel unwell</p></li>
<li><p>encouraging mask use in higher-risk locations such as on public transport and especially when visiting people in aged care and hospitals. </p></li>
</ul>
<p>Continuing to frame <a href="https://www.bmj.com/content/370/bmj.m3021">the use of masks</a> as a social behaviour is critical. We don’t send our kids to school with peanut butter sandwiches in case there’s someone with an allergy. Likewise, wearing a mask is a simple action we can take to protect those who may be vulnerable. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-scary-pumpkins-to-bridal-bling-how-masks-are-becoming-a-normal-part-of-our-lives-in-australia-148718">From scary pumpkins to bridal bling, how masks are becoming a normal part of our lives in Australia</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/163971/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Holly Seale is an investigator on a study funded by NHMRC and has previously received funding for investigator driven research from NSW Ministry of Health, as well as from Sanofi Pasteur and Seqirus. She is the Deputy Chair of the Collaboration on Social Science and Immunisation.</span></em></p><p class="fine-print"><em><span>Abrar Ahmad Chughtai had testing of filtration of masks by 3M for his PhD. 3M products were not used in his research. He also has worked with Paftec on research in respirators (no funding was involved).</span></em></p><p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and Medical Research Futures Fund. She has consulted for mask manufacturers Detmold, Atmos and Ascend in the past 12 months. </span></em></p>In Hong Kong, SARS created a new social norm, where people accepted mask use as part of their ‘civic responsibility’.Holly Seale, Associate professor, UNSW SydneyAbrar Ahmad Chughtai, Epidemiologist, UNSW SydneyC Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1613872021-06-07T12:34:25Z2021-06-07T12:34:25ZHow virus detectives trace the origins of an outbreak – and why it’s so tricky<figure><img src="https://images.theconversation.com/files/403850/original/file-20210601-23-kb2qfx.jpg?ixlib=rb-1.1.0&rect=0%2C12%2C8192%2C4549&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The prevention of future pandemics requires examining viral family trees.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/corona-virus-under-magnifying-glass-observation-royalty-free-image/1204860249?adppopup=true">Stockcrafter/iStock via Getty Images Plus</a></span></figcaption></figure><p>Every time there is a major disease outbreak, one of the first questions scientists and the public ask is: “Where did this come from?”</p>
<p>In order to predict and prevent future pandemics like COVID-19, researchers need to find the origin of the viruses that cause them. This is not a trivial task. The <a href="https://doi.org/10.1038/428820a">origin of HIV</a> was not clear until 20 years after it spread around the world. Scientists still don’t know the origin of Ebola, even though it has <a href="https://doi.org/10.15252/emmm.201404792">caused periodic epidemics since the 1970s</a>.</p>
<p>As an <a href="https://plantpath.psu.edu/directory/mjr25">expert in viral ecology</a>, I am often asked how scientists trace the origins of a virus. In my work, I have found many new viruses and some well-known pathogens that infect wild plants <a href="https://doi.org/10.1146/annurev-genet-110711-155600">without causing any disease</a>. Plant, animal or human, the methods are largely the same. Tracking down the origins of a virus involves a combination of extensive fieldwork, thorough lab testing and quite a bit of luck.</p>
<h2>Viruses jump from wild animal hosts to humans</h2>
<p>Many viruses and other disease agents that infect people originate in animals. These diseases are <a href="https://doi.org/10.4103/1995-7645.277535">zoonotic</a>, meaning they are caused by animal viruses that jumped to people and adapted to spread through the human population.</p>
<p>It might be tempting to start the viral origin search by testing sick animals at the site of the first known human infection, but wild hosts often don’t show any symptoms. Viruses and their hosts adapt to each other over time, so viruses often don’t cause obvious disease symptoms until they’ve <a href="https://doi.org/10.15252/embr.202051374">jumped to a new host species</a>. Researchers can’t just look for sick animals.</p>
<p>Another problem is that people and their food animals aren’t stationary. The place where researchers find the first infected person is not necessarily close to the place where the virus first emerged.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Researcher in PPE holding pipette in lab." src="https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/403854/original/file-20210601-23-1shk7oe.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A challenge in viral origin tracing is the wide range of human and animal samples that need to be collected and tested.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/researcher-working-in-a-biochemist-laboratory-royalty-free-image/1301584009?adppopup=true">LLuis Alvarez/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<p>In the case of COVID-19, bats were an obvious first place to look. They’re known hosts for many coronaviruses and are the probable source of other zoonotic diseases like SARS and <a href="https://www.cdc.gov/coronavirus/mers/index.html">MERS</a>.</p>
<p>For SARS-CoV-2, the virus that causes COVID-19, the nearest relative scientists have found so far is <a href="https://doi.org/10.1038/s41586-020-2012-70">BatCoV RaTG13</a>. This virus is part of a collection of bat coronaviruses discovered in 2011 and 2012 by virologists from the Wuhan Virology Institute. The virologists were looking for SARS-related coronaviruses in bats after the <a href="https://theconversation.com/the-mysterious-disappearance-of-the-first-sars-virus-and-why-we-need-a-vaccine-for-the-current-one-but-didnt-for-the-other-137583">SARS-CoV-1 pandemic in 2003</a>. They collected fecal samples and throat swabs from bats at a site in Yunnan Province about 932 miles (1,500 kilometers) from the institute’s lab in Wuhan, where they brought samples back for further study.</p>
<p>To test whether the bat coronaviruses could spread into people, researchers infected monkey kidney cells and <a href="https://osp.od.nih.gov/scientific-sharing/hela-cells-landing/">human tumor-derived cells</a> with the Yunnan samples. They found that a number of the viruses from this collection could <a href="https://doi.org/doi:10.1128/JVI.02582-15.">replicate in the human cells</a>, meaning they could potentially be transmitted directly from bats to humans without an intermediate host. Bats and people don’t come into direct contact very often, however, so an intermediate host is still quite likely.</p>
<h2>Finding the nearest relatives</h2>
<p>The next step is to determine how closely related a suspected wildlife virus is to the one infecting humans. Scientists do this by figuring out the genetic sequence of the virus, which involves determining the order of the basic building blocks, or <a href="https://www.nature.com/scitable/topicpage/the-order-of-nucleotides-in-a-gene-6525806/">nucleotides</a>, that make up the genome. The more nucleotides two genetic sequences share, the more closely related they are.</p>
<p>Genetic sequencing of bat coronavirus RaTG13 showed it to be over <a href="https://www.nature.com/articles/s41586-020-2012-7">96% identical</a> to SARS-CoV-2. This level of similarity means that RaTG13 is a pretty close relative to SARS-CoV-2, confirming that SARS-CoV-2 probably originated in bats, but is still too distant to be a direct ancestor. There likely was another host that caught the virus from bats and passed it on to humans.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person wearing respirator, gloves, and headlamp holding bat up to the light." src="https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404078/original/file-20210602-13-1wk0cse.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In order to find the intermediate host between bats and humans, researchers have to cast a large net and sample many different animals.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/APTOPIXBrazilRacingforaRemedy-NextPandemic/28c42902d3c8492096c99f2ad694a984/photo?boardId=58e13cbbaf024f5dbdb2431332c5a934&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=5&currentItemNo=2">AP Photo/Silvia Izquierdo</a></span>
</figcaption>
</figure>
<p>Because some of the earliest cases of COVID-19 were found in people associated with the wildlife market in Wuhan, there was speculation that a wild animal from this market was the intermediate host between bats and humans. However, researchers <a href="https://www.livescience.com/covid-19-did-not-start-at-wuhan-wet-market.html">never found the coronavirus</a> in animals from the market. </p>
<p>Likewise, when a related coronavirus was identified in <a href="https://doi.org/0.1038/s41586-020-2169-0">pangolins</a> confiscated in an anti-smuggling operation in southern China, many leaped to the conclusion that SARS-CoV-2 had jumped from bats to pangolins to humans. The <a href="https://doi.org/10.1371/journal.ppat.1008421">pangolin virus</a> was found to be only 91% identical to SARS-CoV-2, though, making it unlikely to be a direct ancestor of the human virus.</p>
<p>To pinpoint the origin of SARS-CoV-2, a lot more wild samples need to be collected. This is a difficult task – sampling bats is time-consuming and requires strict precautions against accidental infection. Since SARS-related coronaviruses are found in <a href="https://doi.org/10.1038/s41467-021-21240-1">bats across Asia</a>, including Thailand and Japan, it’s a very big haystack to search for a very small needle.</p>
<h2>Creating a family tree for SARS-CoV-2</h2>
<p>In order to sort out the puzzle of viral origins and movement, scientists not only have to find the missing pieces, but also figure out how they all fit together. This requires collecting viral samples from human infections and comparing those genetic sequences both to each other and to other animal-derived viruses.</p>
<p>To determine how these viral samples are related to each other, researchers use computer tools to construct the virus’s family tree, or <a href="https://dx.doi.org/10.1016%2FB978-0-12-801238-3.95723-4">phylogeny</a>. Researchers compare the genetic sequences of each viral sample and construct relationships by aligning and ranking genetic similarities and differences.</p>
<p>The direct ancestor to the virus, sharing the greatest genetic similarity, could be thought of as its parent. Variants sharing that same parent sequence but with enough changes to make them distinct from each other are like siblings. In the case of SARS-CoV-2, the <a href="https://www.who.int/en/activities/tracking-SARS-CoV-2-variants/">South African variant, B.1.351, and the U.K. variant, B.1.1.7</a>, are siblings.</p>
<p>Building a family tree is complicated by the fact that different analysis parameters can give different results: The same set of genetic sequences can produce two very different family trees.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Example of two different phylogenetic trees constructed for the same genetic sequences" src="https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404132/original/file-20210602-15-5xrxh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The nucleotide sequences of six fictional viruses are shown on the top. Below are two family trees of these viruses created using two different programs. The tree on the left uses only percent identity, while the tree on the right also considers whether the two sequences share similar characters.</span>
<span class="attribution"><span class="source">Marilyn Roossinck</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>For SARS-CoV-2, phylogenetic analysis proves particularly difficult. Though <a href="https://nextstrain.org/ncov/global">tens of thousands of SARS-CoV-2 sequences</a> are now available, they don’t differ from one another enough to <a href="https://doi.org/10.1093/molbev/msaa314">form a clear picture</a> of how they’re related to each other. </p>
<h2>The current debate: Wild host or lab spillover?</h2>
<p>Could SARS-CoV-2 have been released from a research lab? Although <a href="https://www.who.int/publications/i/item/who-convened-global-study-of-origins-of-sars-cov-2-china-part">current evidence</a> implies that this is not the case, 18 prominent virologists recently suggested that this question should be <a href="https://science.sciencemag.org/content/372/6543/694.1">further investigated</a>.</p>
<p>Although there has been speculation about SARS-CoV-2 being engineered in a lab, this possibility seems highly unlikely. When comparing the genetic sequence of wild RaTG13 with SARS-CoV-2, differences are randomly spread across the genome. In an engineered virus, there would be clear blocks of changes that represent <a href="https://doi.org/10.1016/j.meegid.2021.104812">introduced sequences</a> from a different viral source.</p>
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<p>There is one unique sequence in the SARS-CoV-2 genome that codes for a part of the spike protein that seems to play an important role in infecting people. Interestingly, a similar sequence is found in the MERS coronavirus that <a href="https://doi.org/10.21873/invivo.12384">causes a disease similar to COVID-19</a>.</p>
<p>Though it is not clear how SARS-CoV-2 acquired these sequences, viral evolution suggests they arose from natural processes. Viruses <a href="https://doi.org/10.1002/9780470015902.a0000436.pub3">accumulate changes</a> either by genetic exchange with other viruses and their hosts, or by random mistakes during replication. Viruses that gain a genetic change that gives them a <a href="https://doi.org/10.1002/9780470015902.a0000436.pub3">reproductive advantage</a> would typically continue to pass it on through replication. That MERS and SARS-CoV-2 share a similar sequence in this part of the genome suggests that it naturally evolved in both and spread because it helps them infect human cells.</p>
<h2>Where to go from here?</h2>
<p>Figuring out the origin of SARS-CoV-2 could give us clues to understand and predict future pandemics, but we may never know exactly where it came from. Regardless of how the SARS-CoV-2 jumped into humans, it’s here now, and it’s probably here to stay. Going forward, researchers need to continue monitoring its spread, and get as many people vaccinated as possible.</p><img src="https://counter.theconversation.com/content/161387/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marilyn J. Roossinck does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Bat hosts, lab leaks – tracing SARS-CoV-2 to its origins involves more than just tracking down patient zero.Marilyn J. Roossinck, Professor of Plant Pathology and Environmental Microbiology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1561692021-03-03T13:22:25Z2021-03-03T13:22:25ZTwo gaps to fill for the 2021-2022 winter wave of COVID-19 cases<figure><img src="https://images.theconversation.com/files/387358/original/file-20210302-13-m2e61t.jpg?ixlib=rb-1.1.0&rect=9%2C42%2C2019%2C1298&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A sign in County Kildare, Ireland. in March 2020. Epidemiologists around the world worked hard to try to stop big parties in the face of rising caseloads of what would come to be called COVID-19. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sign-anouncing-the-cancellation-of-a-st-patricks-day-parade-news-photo/1207443830?adppopup=true">Niall Carson/PA Images via Getty Images</a></span></figcaption></figure><p>Epidemiologists – like oncologists and climate scientists – hate to be proven right. A year ago this week, the communications rush began from epidemiologists in academia to the public and to local governments about the imminent dangers of the COVID-19 pandemic, in the face of a weak federal response. </p>
<p>St. Patrick’s Day parades were canceled with days to spare. Hospitals were turning suspected positive cases away because of a lack of tests. <a href="https://works.bepress.com/mcandrew/2/">Epidemiologists</a> <a href="https://www.cbsnews.com/news/coronavirus-infection-outbreak-worldwide-virus-expert-warning-today-2020-03-02/">predicted</a> <a href="https://theconversation.com/how-big-will-the-coronavirus-epidemic-be-an-epidemiologist-updates-his-concerns-133133">that</a> hundreds of thousands Americans would die over the following year, with the upper boundaries <a href="https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/covid-19/report-9-impact-of-npis-on-covid-19/">above a million</a>. This was our country’s biggest challenge since 1941, and we did not meet it. </p>
<p>Despite the stream of bad news, a major success of 2020 was the pace of vaccine development. A 10-month sprint ending with completed phase 3 clinical trials for two vaccine candidates (and a <a href="https://www.fda.gov/news-events/press-announcements/fda-issues-emergency-use-authorization-third-covid-19-vaccine">third one</a> last week) is an incredible achievement. Uncredited here is the <a href="https://doi.org/10.1080/21645515.2017.1306615">experience</a> <a href="https://www.who.int/immunization/sage/meetings/2019/april/1_CEPI_Summary_WHO_SAGE_Meeting_April.pdf">gained</a> by the global health community during the rollout of <a href="https://doi.org/10.1016/S0140-6736(15)61117-5">clinical trials</a> in the West African Ebola epidemic in 2014-2015. Science during a crisis is difficult, and the scientific community responded in 2020 with an all-hands effort to design and initiate scores of trials on a moment’s notice.</p>
<p>But amid the scientific progress, what did we scientists neglect or get wrong? What will haunt us in eight months, when SARS-CoV-2 cases begin surging again, and we wonder if the winter epidemic trajectory will bring 30,000 or 300,000 more deaths? If vaccine efficacy drops, high death rates are a real possibility. </p>
<p>Our two big misses in 2020 were in behavioral modeling and real-time <a href="https://link.springer.com/chapter/10.1007/978-1-4899-7448-8_4">seroepidemiology</a>, the study of antibody measurements in blood samples. As an <a href="https://www.huck.psu.edu/people/maciej-f-boni">epidemiologist</a> with experience in the field, lab and modeling aspects of pandemic response, I believe that we must address these two gaps for the U.S. to have better forecasting, better communication and better management next winter. Even with effective vaccines, the new coronavirus will be with us for many years.</p>
<figure class="align-center ">
<img alt="Two medical workers transport a deceased patient." src="https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/387337/original/file-20210302-17-m7c3a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Medical personnel move a deceased patient to a refrigerated truck serving as a makeshift morgue at Brooklyn Hospital Center on April 9, 2020, in New York City.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/medical-personnel-move-a-deceased-patient-to-a-refrigerated-news-photo/1209563693?adppopup=true">Angela Weiss/AFP via Getty Images</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Understanding human behavior</h2>
<p>First, scientists do not understand the general <a href="https://doi.org/10.1073/pnas.0810762106">feedback loop</a> between virus transmission and human behavior. When case and death numbers rise, people get fearful and comply more fully with common-sense recommendations like mask-wearing, distancing, hygiene, reduced contacts and no group events. But when these numbers fall, people feel safer and resume risky behavior, setting the stage for a new increase in cases.</p>
<p>In 2020, we public health experts missed an opportunity to quantify this dynamic and estimate the delay inherent in a population’s behavioral response. Even the recent decline in cases in January <a href="https://twitter.com/nataliexdean/status/1362100680492601350">was attributed</a> to behavioral change by process of elimination only: It did not seem to be caused by weather, vaccines or new restrictions and was thus credited to human behavior and social distancing. But we still lack statistical evidence for how or when this started.</p>
<p>Why did we miss this? Epidemiologists had been preparing for a deadly pandemic for two decades. Our anchoring bias came from experiences with past influenza pandemics and <a href="https://doi.org/10.1038/nature04017">hypothetical avian influenza pandemics</a>, which have <a href="https://twitter.com/SRileyIDD/status/1220464674476625921">infection fatality ratios</a> (IFR) of either a very low 0.05% or very high rates of more than 25%. No one prepared for an intermediate IFR of 0.5%, where a virus could circulate unnoticed long enough for researchers to miss the first clinical signals – or a virus not gruesome enough to induce an immediate state of emergency. </p>
<p>Throughout the COVID-19 pandemic in the U.S., society’s reaction has wavered from urgency to complacency and back. Epidemiologists were not able to accurately predict these trends.</p>
<p>Going forward, we must develop data-centered models of population behavioral responses that occur during COVID-19 epidemics. For example, does experience with wintertime influenza act as an anchor, driving people to be more or less cautious as case numbers rise above or below “normal” flu rates? If scientists and public health experts can understand this behavior, we will know better when and how to institute new nonpharmaceutical interventions, such as gathering size limits or work-from-home orders. Then we will have better and more scientific justifications for early lockdowns and early interventions, with public health messaging stating clearly that an early lockdown means a short lockdown.</p>
<p>Behavioral modeling can also unlock the power of <a href="https://doi.org/10.1126/sciadv.abd5393">rapid at-home tests</a>, a promising public health tool that received no coordinated support over the past year. How does someone react if others are infected? How do people <a href="https://doi.org/10.1073/pnas.2005241118">react</a> if they themselves are infected? Without the foundational behavioral analysis in place, we will not know how to deploy at-home tests to best facilitate more careful mixing behavior.</p>
<figure class="align-center ">
<img alt="A man getting a blood test for COVID-19." src="https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=370&fit=crop&dpr=1 600w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=370&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=370&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=465&fit=crop&dpr=1 754w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=465&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/387340/original/file-20210302-23-rupwk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=465&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A laboratory technician takes an antibody test for COVID-19 at a community care center in New York City.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/laboratory-technician-takes-an-antibody-test-for-covid-19-news-photo/1214741188?adppopup=true">Lev Radin/Pacific Press/LightRocket via Getty Images</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Faster processing of antibody data</h2>
<p>Our second big miss was in real-time analyses of antibody data to gauge how many Americans have been infected with the coronavirus. Real-time <a href="https://coronavirus.jhu.edu/map.html">case numbers</a>, <a href="https://covidtracking.com/">hospitalizations</a> and <a href="https://www.covid19mobility.org/">mobility</a> data have been crucial for understanding the different phases of the COVID-19 pandemic. </p>
<p>But serum collection was not preplanned, routine or processed quickly. Seroprevalence results then <a href="https://doi.org/10.1001/jamainternmed.2020.4130">came</a> <a href="https://doi.org/10.1016/S0140-6736(20)32009-2">months</a> <a href="https://doi.org/10.1001/jamainternmed.2020.7976">late</a>, appearing in publications and preprints, but not aggregated in an easy-to-understand database. </p>
<p>With no universal standardization, misinterpretation of assay validations and serological thresholds was common. Scientists debated cross-sectional serology results, and study designs had no approach to correct for <a href="https://www.buzzfeednews.com/article/stephaniemlee/stanford-coronavirus-study-bhattacharya-email">sampling biases</a> generated from correlations between past symptoms and study participation.</p>
<p>Today, we still lack confidence in estimates of the total number of Americans who have been infected, which complicates efforts to use the vaccine scale-up to accurately state what fraction of the country is now immune, or to plan for the inevitable outbreaks of new variants this spring and summer.</p>
<p>The key studies to prepare for next winter involve standardizing serological assays and estimating <a href="https://doi.org/10.1126/sciimmunol.abf8891">antibody</a> <a href="https://wwwnc.cdc.gov/eid/article/27/3/20-4543_article">waning</a> <a href="https://doi.org/10.1038/s41467-020-20247-4">rates</a> – that is, how quickly one’s antibody levels go down after infection. Measuring the post-infection waning of antibody concentrations allows us to define antibody thresholds for <a href="https://www.taylorfrancis.com/chapters/inferring-time-infection-serological-data-maciej-boni-k%C3%A5re-m%C3%B8lbak-karen-krogfelt/e/10.1201/9781315222912-15">particular time points</a> after infection. </p>
<p>That’s a lot of jargon. Put more simply, if we know that antibodies wane to level X after three months, we can use this X to determine who has been infected in the past three months. This is not a true seroprevalence or attack-rate measurement, and that’s fine. It is a measure of the three-month attack rate or the six-month attack rate, depending on the threshold chosen, and it gives us an estimate of recent population-level infection rates. This new definition resolves the arbitrary threshold problem in serology, and allows studies to report the amount of recent population immunity, which is useful for public health decisions.</p>
<p>In my view, we should have learned in 2020 that it is never too early to start preparations for epidemic control. Summer 2020 was a missed opportunity to revamp our approach to health care and epidemic response. The U.S. cannot again squander an entire summer and fail to prepare for the possibility that SARS-CoV-2 has one more nasty winter in store for us.</p><img src="https://counter.theconversation.com/content/156169/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maciej F. Boni receives funding from the National Institutes of Health and the Bill and Melinda Gates Foundation.. </span></em></p>The US was not ready for the coronavirus pandemic in 2020. What can public health leaders and policymakers do to make sure we don’t face another winter of rampant disease?Maciej F. Boni, Associate Professor of Biology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1487022020-12-08T16:28:21Z2020-12-08T16:28:21ZSARS didn’t prepare the hospitality industry for the prolonged impact of COVID-19<figure><img src="https://images.theconversation.com/files/373166/original/file-20201205-17-pvv2k1.jpg?ixlib=rb-1.1.0&rect=32%2C0%2C5400%2C3046&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Fairmont Royal York Hotel in Toronto. After the SARS pandemic in 2003, Toronto hotels faced a recovery period.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>A virulent virus, worried travellers and a tourism sector on the brink. Sounds like 2020? In fact, this was the experience in a few global cities in 2002 and 2003. </p>
<p>Toronto was one of them. The city’s battle against a deadly virus — and the struggle for the rehabilitation of its damaged tourism sector — offers lessons for cities wondering how they will navigate a post-COVID world. And even plan for the next crisis, whenever it arrives. </p>
<p>Hotels, as places of refuge, pleasure, business and also contagion, are important places to explore how the tourism sector pilots its way through pandemics. The experience with SARS offers sobering lessons for Toronto and urban tourist destinations globally.</p>
<h2>Similar impacts of SARS and COVID-19</h2>
<p>How are the tourism crises of 2002-03 and today similar, and how do they differ? Both public health crisis resulted in <a href="https://globalnews.ca/news/6710543/ontario-covid-19-measures-layoffs/">sudden, dramatic declines in hotel occupancy</a>. However, while all travel came to a sudden stop globally in 2020, the 2002-03 events centred on a few cities, with Toronto, Singapore and Hong Kong under the microscope. </p>
<p>Hotel occupancy rates in these cities recorded steep declines, as travellers headed elsewhere, businesses suspended events <a href="https://www.who.int/csr/sars/travel/airtravel/en/">and worried airlines and public health authorities</a> explored protocols such as the now-ubiquitous face masks.</p>
<p>The collapse in travel in winter 2020 occurred at a point when the overall economy and the travel sector were in robust shape and recording record profits. In 2002-03, circumstances were very different. Global travel had slowed due to the <a href="https://abcnews.go.com/Business/story?id=86672&page=1">Iraq War</a>. Increasing documentation requirements and lingering concerns over security after 9/11 reduced cross-border traffic between Canada and the United States. </p>
<h2>Toronto hotels and SARS</h2>
<p>The arrival of SARS dealt a body blow to Canada’s largest city.</p>
<p>Both SARS and COVID-19 have had a severe impact on tourism and travel. Hotels are barometers of Toronto’s economic condition, and reveal the unequal impacts pandemics have on employment. Marginally employed people — immigrants and low-income workers — are over-represented among hotel workers. They lose their jobs quickly in the face of reduced demand. </p>
<p>Seasonal employment prospects also dim in the face of disruption. As in summer 2020, student summer employment was impacted in 2003, especially as Toronto entered the crucial summer months back, briefly, on the <a href="https://www.cmaj.ca/content/cmaj/168/11/1434.full.pdf">World Health Organization’s SARS travel advisory</a>. The blow dealt to the tourism sector locally was hard but, as it turned out, by no means fatal.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in a black suit with a blue suitcase uses an Air Canada check-in kiosk at the airport. A sign with the text SARS is in the foreground." src="https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373205/original/file-20201206-19-1bowie8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A passenger checks in as a warning sign gives information about SARS at Pearson International Airport on May 30, 2003.</span>
<span class="attribution"><span class="source">CP PHOTO/Kevin Frayer</span></span>
</figcaption>
</figure>
<p>Toronto’s experience with SARS suggests that once a place appears safe, reassured travellers return — with some coaxing and a lot of co-ordinated planning. In late spring 2003, Toronto businesses developed a co-ordinated response to recovery. Travel packages that included accommodation, restaurant reservations, sporting events and theatre tickets began to lure tourists back. This promotion was accompanied by an aggressive and <a href="https://www.cbc.ca/news/business/gas-chains-cutting-prices-to-encourage-toronto-travel-in-anti-sars-promotion-1.411220">co-ordinated roll-back of gasoline prices</a>. </p>
<h2>After SARS, a celebration</h2>
<p>The SARS crisis also led to the creation of a body for the tourism and hospitality sector, chaired by Tourism Toronto, which aimed to restore the city’s reputation. Local and provincial governments committed funds for advertising to reassure prospective tourists that Toronto was safe. The federal government also announced additional funds to promote Canada as a destination in international markets. </p>
<p>The most famous part of the reputation rehabilitation strategy was the hosting of the July 30, 2003, SARS benefit concert. Several hundred thousand fans cheered a lineup of world-famous musicians, headlined by the Rolling Stones. The results of <a href="https://www.cbc.ca/archives/the-2003-concert-that-rocked-toronto-after-sars-1.5650768">that mega-event</a> are hard to measure in terms of impact, <a href="https://www.cbc.ca/news2/background/sarsbenefit/">despite the large and enthusiastic crowds that it drew</a>. Such an event is unimaginable today, with the timeline for the COVID-19’s defeat far off, and the certainty that doubts will linger about the wisdom of such boisterous, large-scale assemblies for a long time to come.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/qena0QraBHE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A CBC report on the 2003 SARS benefit concert.</span></figcaption>
</figure>
<p>In 2003, good news for the tourism sector arrived quickly. In fact, by late 2004, hotels were recording pre-SARS occupancy levels. It seemed as if the sector had dodged a bullet. But it had also dodged a critical opportunity to reflect on how new technologies and standards might reduce the impact of a future pandemic. And this is perhaps where the comparison proves most illuminating.</p>
<h2>After COVID-19?</h2>
<p>The hotel sector faces dramatically different conditions today. It is in the midst of a global pandemic affecting all sectors of the economy. SARS resulted <a href="https://www.who.int/csr/sars/country/2003_07_11/en/">in far fewer deaths</a>, over a shorter period of time, in a small number of major cities. </p>
<p>While the story of hotels’ recovery is inspiring, the pace was so fast that few paused to ask is larger lessons would be learned: What vulnerabilities might have been disguised in the rush to restore Toronto’s dynamic tourism sector? How could new technologies, systematic contingency planning and early detection systems might have become integrated into hotel management post-2003? </p>
<p>The greatest lesson of SARS may be how, amid the excited focus on recovery and a return to normalcy, so little thought was given to structurally prepare for the prospect of future crises. We need to keep these lessons in mind as we plan our emergence from COVID-19, and the resumption of travel.</p><img src="https://counter.theconversation.com/content/148702/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin James receives funding from the University of Guelph COVID-19 Research Development & Catalyst Fund.</span></em></p><p class="fine-print"><em><span>Jose Gabriel Alonzo receives funding from the University of Guelph COVID-19 Research Development & Catalyst Fund.</span></em></p><p class="fine-print"><em><span>Mark Holmes receives funding from the University of Guelph and SSHRC. Holmes is also a Board Member for the Canadian Travel and Tourism Research Association.</span></em></p>After SARS in 2003, an effort was made by Toronto’s tourism and hospitality industries to stimulate the sector’s recovery. But measures weren’t put in place for future pandemics.Kevin James, Professor, History, University of GuelphJose Gabriel Alonzo, Masters student, History, University of GuelphMark Holmes, Assistant Professor, Business and Economics, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1460662020-10-14T12:30:06Z2020-10-14T12:30:06ZHow do pandemics end? History suggests diseases fade but are almost never truly gone<figure><img src="https://images.theconversation.com/files/363208/original/file-20201013-21-59qpfn.jpg?ixlib=rb-1.1.0&rect=560%2C288%2C4627%2C3147&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The COVID-19 new normal might be here for quite some time.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/reflecting-on-her-day-royalty-free-image/1263884394">SolStock/E+ via Getty Images</a></span></figcaption></figure><p>When will the pandemic end? After all this time, you may be wondering, with increasing exasperation, how long this will continue.</p>
<p>Since the beginning of the pandemic, epidemiologists and public health specialists have <a href="https://doi.org/10.1038/s41591-020-0883-7">been using</a> <a href="https://doi.org/10.1001/jama.2020.6585">mathematical</a> <a href="https://doi.org/10.1073/pnas.2006520117">models</a> to forecast the future in an effort to curb the coronvirus’s spread. But infectious disease modeling is tricky. Epidemiologists warn that “<a href="https://doi.org/10.1038/d41586-020-01003-6">[m]odels are not crystal balls</a>,” and even sophisticated versions, like those that <a href="https://doi.org/10.1101/2020.08.19.20177493">combine forecasts</a> or <a href="https://covid19-projections.com/">use machine learning</a>, can’t necessarily reveal when the pandemic will end or <a href="https://covid19.healthdata.org/united-states-of-america?view=total-deaths&tab=trend">how many people will die</a>.</p>
<p>As a <a href="https://sc.edu/study/colleges_schools/artsandsciences/history/our_people/directory/nukhet.php">historian who studies disease and public health</a>, I suggest that instead of looking forward for clues, you can look back to see what brought past outbreaks to a close – or didn’t. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="people in line outside a COVID-19 testing site" src="https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363210/original/file-20201013-17-1d058b0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tens of thousands of new cases of COVID-19 are diagnosed in the U.S. every day.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/florida-miami-beach-covid-19-mobile-testing-facility-fdem-news-photo/1262330941">Jeff Greenberg/Universal Images Group via Getty Images</a></span>
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<h2>Where we are now in the course of the pandemic</h2>
<p>In the early days of the pandemic, many people hoped the coronavirus would simply fade away. Some argued that it would <a href="https://www.npr.org/2020/04/21/837348551/timeline-what-trump-has-said-and-done-about-the-coronavirus">disappear on its own</a> <a href="https://theconversation.com/coronavirus-may-wane-this-summer-but-dont-count-on-any-seasonal-variation-to-end-the-pandemic-136218">with the summer heat</a>. Others claimed that <a href="https://www.theatlantic.com/health/archive/2020/03/coronavirus-pandemic-herd-immunity-uk-boris-johnson/608065/">herd immunity</a> would kick in once enough people had been infected. But none of that has happened.</p>
<p>A combination of public health efforts to contain and mitigate the pandemic – from rigorous testing and contact tracing to social distancing and wearing masks – <a href="https://www.endcoronavirus.org/countries">have been proven to help</a>. Given that the virus has <a href="https://www.aljazeera.com/news/2020/09/14/which-countries-have-not-reported-any-coronavirus-cases/">spread almost everywhere in the world</a>, though, such measures alone can’t bring the pandemic to an end. The hope now is vaccines, which were developed at unprecedented speed.</p>
<p>Yet experts tell us that even with successful vaccines and effective treatment, <a href="https://www.theatlantic.com/health/archive/2020/08/coronavirus-will-never-go-away/614860/">COVID-19 may never go away</a>. Even if the pandemic is curbed in one part of the world, it will likely continue in other places, causing infections elsewhere. And even if it is no longer an immediate pandemic-level threat, the coronavirus will likely become endemic – meaning slow, sustained transmission will persist. The coronavirus will continue to cause smaller outbreaks, much like seasonal flu.</p>
<p>The history of pandemics is full of such frustrating examples.</p>
<h2>Once they emerge, diseases rarely leave</h2>
<p>Whether bacterial, viral or parasitic, virtually every disease pathogen that has affected people over the last several thousand years is still with us, because it is nearly impossible to fully eradicate them.</p>
<p>The only disease that has been <a href="https://www.cdc.gov/smallpox/history/history.html">eradicated through vaccination is smallpox</a>. <a href="https://theconversation.com/a-massive-public-health-effort-eradicated-smallpox-but-scientists-are-still-studying-the-deadly-virus-139468">Mass vaccination campaigns</a> led by the World Health Organization in the 1960s and 1970s were successful, and in 1980, smallpox was declared the first – and still, the only – human disease to be fully eradicated. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Children holding smallpox vaccination certificates" src="https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363213/original/file-20201013-15-e5td11.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Children in Cameroon show off their smallpox vaccination certificates in 1975.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/children-of-cameroon-with-their-vaccination-certificates-news-photo/509399448">Smith Collection/Gado via Getty Images</a></span>
</figcaption>
</figure>
<p>So success stories like smallpox are exceptional. It is rather the rule that diseases come to stay.</p>
<p>Take, for example, pathogens like <a href="https://www.sciencedaily.com/releases/2010/06/100617120718.htm">malaria</a>. Transmitted via parasite, it’s almost as old as humanity and still exacts a heavy disease burden today: There were about <a href="https://www.who.int/news-room/fact-sheets/detail/malaria">228 million malaria cases and 405,000 deaths</a> worldwide in 2018. Since 1955, global programs to eradicate malaria, assisted by the use of DDT and chloroquine, brought some success, but the disease is <a href="https://www.who.int/malaria/media/world-malaria-report-2018/en/">still endemic in many countries of the Global South</a>.</p>
<p>Similarly, diseases such as <a href="https://www.who.int/news-room/fact-sheets/detail/tuberculosis">tuberculosis</a>, <a href="https://doi.org/10.1126/science/1109759">leprosy</a> and <a href="https://doi.org/10.1126/science.368.6497.1324-o">measles</a> have been with us for several millennia. And despite all efforts, <a href="https://ourworldindata.org/eradication-of-diseases">immediate eradication is still not in sight</a>.</p>
<p>Add to this mix relatively younger pathogens, such as <a href="https://www.nature.com/articles/d42859-018-00008-6">HIV</a> and <a href="https://www.who.int/news-room/fact-sheets/detail/ebola-virus-disease">Ebola virus</a>, along with <a href="https://www.who.int/health-topics/influenza-avian-and-other-zoonotic#tab=tab_1">influenza</a> and <a href="https://www.niaid.nih.gov/diseases-conditions/coronaviruses">coronaviruses</a> including <a href="https://www.who.int/ith/diseases/sars/en/">SARS</a>, <a href="https://www.who.int/news-room/q-a-detail/middle-east-respiratory-syndrome-coronavirus-(mers-cov)">MERS</a> and <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses">SARS-CoV-2 that causes COVID-19</a>, and the overall epidemiological picture becomes clear. Research on the <a href="https://doi.org/10.1016/B978-012373944-5.00185-1">global burden of disease</a> finds that annual mortality caused by infectious diseases – most of which occurs in the developing world – is nearly one-third of all deaths globally.</p>
<p>Today, in an age of global air travel, climate change and ecological disturbances, we are constantly exposed to the threat of <a href="https://wwwnc.cdc.gov/eid/about">emerging infectious diseases</a> while continuing to suffer from much older diseases that remain alive and well.</p>
<p>Once added to the repertoire of pathogens that affect human societies, most infectious diseases are here to stay. </p>
<h2>Plague caused past pandemics – and still pops up</h2>
<p>Even infections that now have effective vaccines and treatments continue to take lives. Perhaps no disease can help illustrate this point better than <a href="https://www.visualcapitalist.com/history-of-pandemics-deadliest/">plague, the single most deadly</a> infectious disease in human history. Its name continues to be synonymous with horror even today. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="people excavating human skeletons from ground" src="https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=716&fit=crop&dpr=1 600w, https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=716&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=716&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=900&fit=crop&dpr=1 754w, https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=900&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/363217/original/file-20201013-13-ge9rvj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=900&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Archaeologists learn more about diseases of the past when they excavate mass graves like this one in Italy.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ItalyUffiziAncientCemetery/2f84d82d32cd4a22bd1a40347be5b61a">AP Photo/Francesco Bellini</a></span>
</figcaption>
</figure>
<p><a href="https://www.who.int/health-topics/plague#tab=tab_1">Plague</a> is caused by the bacterium <em>Yersinia pestis</em>. There have been countless local outbreaks and at least three documented plague pandemics over the last 5,000 years, killing hundreds of millions of people. The most notorious of all pandemics was <a href="https://www.livescience.com/what-was-the-black-death.html">the Black Death</a> of the mid-14th century.</p>
<p>Yet <a href="https://scholarworks.wmich.edu/medieval_globe/1/">the Black Death</a> was far from being an isolated outburst. Plague returned every decade or even more frequently, each time hitting already weakened societies and taking its toll during <a href="https://doi.org/10.1017/npt.2020.27">at least six centuries</a>. Even before the <a href="https://doi.org/10.1136/bmj.39097.611806.DB">sanitary revolution</a> of the 19th century, each outbreak gradually died down over the course of months and sometimes years as a result of changes in temperature, humidity and the availability of hosts, vectors and a sufficient number of susceptible individuals. </p>
<p>Some societies recovered relatively quickly from their losses caused by the Black Death. Others never did. For example, medieval <a href="https://utpress.utexas.edu/books/borbla">Egypt could not fully recover</a> from the lingering effects of the pandemic, which particularly devastated its agricultural sector. The cumulative effects of declining populations became impossible to recoup. It led to the gradual decline of the Mamluk Sultanate and its conquest by the Ottomans within less than two centuries.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>That very same state-wrecking plague bacterium remains with us <a href="https://www.cnn.com/2020/08/08/us/second-plague-death-new-mexico-man/index.html">even today</a>, a reminder of the very long persistence and resilience of pathogens.</p>
<p>Hopefully COVID-19 will not persist for millennia. But even with successful vaccines, no one is safe. Politics here are crucial: When vaccination programs are weakened, infections can come roaring back. Just look at <a href="https://www.cdc.gov/media/releases/2019/s0424-highest-measles-cases-since-elimination.html">measles</a> and <a href="https://www.nytimes.com/2019/07/15/health/polio-pakistan-afghanistan.html">polio</a>, which resurge as soon as vaccination efforts falter.</p>
<p>Given such historical and contemporary precedents, humanity can only hope that the coronavirus that causes COVID-19 will prove to be a tractable and eradicable pathogen. But the history of pandemics teaches us to expect otherwise.</p><img src="https://counter.theconversation.com/content/146066/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nükhet Varlik does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As ready as you are to be done with COVID-19, it’s not going anywhere soon. A historian of disease describes how once a pathogen emerges, it’s usually here to stay.Nükhet Varlik, Associate Professor of History, Rutgers University - NewarkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1463792020-10-12T17:56:14Z2020-10-12T17:56:14ZWhy males may have a worse response to COVID-19<figure><img src="https://images.theconversation.com/files/358471/original/file-20200916-24-1p1vlon.jpg?ixlib=rb-1.1.0&rect=22%2C22%2C5061%2C3359&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Is COVID-19 hitting men harder than women?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/wife-consoling-husband-in-hospital-royalty-free-image/76529620?adppopup=true">UpperCut Images/Getty Images</a></span></figcaption></figure><p>If you ask most women about how their male relatives, partners and friends respond to being sick, they’ll often tell you with an accompanying eye roll, “He’s such a baby.” “He’s extra whiny.” Or “he exaggerates so much.” But there may be a biological explanation for this behavior. </p>
<p>Dubbed the “man flu,” this phenomenon has <a href="https://doi.org/10.1136/bmj.j5560">been validated in a review</a> of previously published, large epidemiological studies, as well as in studies of influenza in animals. In these studies, males were sick longer, with more severe symptoms and had a weaker response to vaccination. Laboratory tests with animals infected with the influenza virus also underscore that there are sex-based differences in immune response that influence outcomes observed in humans. But are these more severe symptoms and outcomes unique to cold and flu?</p>
<p>As a <a href="https://scholar.google.com/citations?user=m8jGcjAAAAAJ&hl=en">respiratory toxicologist and researcher</a> investigating sex differences in the respiratory system, I was intrigued to read a <a href="https://doi.org/10.1038/s41586-020-2700-3">recent study</a> on sex-specific responses to COVID-19 that suggest that men are, actually, more vulnerable and suffer more from this disease.</p>
<h2>Sex differences in COVID-19</h2>
<p>These findings may apply to other respiratory viruses like SARS-CoV-2, which causes COVID-19. For example, reports of SARS-CoV-2 <a href="https://covid.cdc.gov/covid-data-tracker/?utm_source=morning_brew#demographics">infection rates are similar between males and females</a>, but male sex is a significant risk factor for more serious COVID-19 disease and death. In fact, one study revealed that men are <a href="https://doi.org/10.3389/fpubh.2020.00152">2.4 times more likely to die from COVID-19</a>. I find it interesting that higher death rates in men also occurred in other coronavirus diseases like <a href="https://doi.org/10.3389/fpubh.2020.00152">severe acute respiratory syndrome</a>, caused by SARS-CoV, and <a href="https://doi.org/10.4049/jimmunol.1601896">Middle East respiratory syndrome</a>. </p>
<p>Based on data from the Centers for Disease Control and Prevention as of Oct. 5, 2020, the risk of death from COVID-19 in men 30-49 years old was also <a href="https://covid.cdc.gov/covid-data-tracker/?utm_source=morning_brew#demographics">found to be more than twice that of females</a>. </p>
<p>In other age groups, the risk of COVID-19-related death in males was also higher than the same female age cohort. But it was not as high as in the 30- to 49-year-old age group. </p>
<p>This contrasts with almost equal rates of SARS-CoV-2 infection in those same age groups, leading scientists to wonder why might males be more susceptible. </p>
<h2>Study identifies why men may be more susceptible to COVID-19</h2>
<p><a href="https://doi.org/10.1038/s41586-020-2700-3">The recent report published in Nature explores</a> how males and females respond differently to COVID-19. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/362495/original/file-20201008-14-1kmgif1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The risk of death from COVID-19 in men of some age groups may be twice that of their female peers.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/concerned-man-getting-covid-19-nasal-swab-test-at-royalty-free-image/1256885999?adppopup=true">xavierarnau</a></span>
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<p>This study examined samples including nasal swabs, saliva, and blood, which were either collected from healthy individuals or COVID-19 patients. These samples were used to better understand what the immune response to the infection looks like and how it differs in people with more severe disease. </p>
<p>Similar to CDC data on infection rates, no sex difference in the concentration of virus or the amount of virus present was observed in either the nasal swab or the saliva. There were also no differences in antibody levels – a signal the body had identified the virus – detected in infected men and women.</p>
<h2>Males with SARS-CoV-2 show greater inflammation</h2>
<p>However, the authors identified major sex differences during the early immune response that occurs soon after someone is infected with the SARS-CoV-2 virus. </p>
<p>The blood samples were analyzed for a variety of cytokines – some of the first signaling molecules that help immune cells respond to pathogens. The levels of these signals rise and fall to provide an adequate response to fight an invading pathogen. But large quantities of these molecules can severely damage the body. This is the case in a <a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690">cytokine storm</a>.</p>
<p>The authors of the Nature report observed sex differences in the strength of the cytokine response. Men showed higher levels of cytokines that trigger inflammation, like IL-8 and IL-18, than women. Higher quantities of these cytokines are linked to more severe disease. In severe cases of COVID-19, <a href="https://dx.doi.org/10.1016%2Fj.cpcardiol.2020.100618">fluid builds up in the lungs</a>, reducing the oxygen available in the body for normal functions. This can lead to tissue damage, shock and potentially the failure of multiple organs. </p>
<h2>Females with SARS-CoV-2 are better prepared to eliminate the virus</h2>
<p>In addition to sex differences in cytokine levels, the authors also found sex differences in the function of immune cells. </p>
<p>Compared to men, women had a higher number of T cells – essential for eliminating the virus – that were activated, primed and ready to respond to the SARS-CoV-2 infection. Men with lower levels of these activated T-cells were more likely to have severe disease. </p>
<p>Thus, there are several aspects of the human immune response to SARS-CoV-2 that differ between men and women. Understanding these differences can inform how doctors treat patients and can help researchers develop sex-specific therapies.</p>
<h2>Increased COVID-19 susceptibility in men is likely biological</h2>
<p>These results contradict speculation that male susceptibility to SARS-CoV-2 infection is due to <a href="https://www.cdc.gov/pcd/issues/2020/20_0247.htm">more risky behaviors</a>. Those include downplaying the seriousness of the virus, joining large gatherings and ignoring social distancing guidelines, as well as lower rates of hand-washing and wearing masks. Instead, rates of infection are actually similar between males and females, while males are more at risk of serious COVI9-19 disease, suggesting biological differences in response to infection.</p>
<p>This paper is one of the first of its kind to delve into mechanisms of susceptibility sex differences. With greater innate biological risk for severe disease and death in men, this suggests that males might need to be hypervigilant about social distancing, hand-washing and mask-wearing. </p>
<p>Greater adherence to infection prevention protections, especially in men, would not only reduce their risk of infection, but also combat their increased risk of severe disease and death from COVID-19.</p>
<p>The take-home message of this new paper is that researchers need to consider strategies to ensure <a href="https://news.yale.edu/2020/08/26/sex-differences-covid-19-immune-responses-affect-patient-outcomes?utm_source=YaleToday&utm_medium=Email&utm_campaign=YT_Yale%20Today%20Parents_8-31-2020">treatments and vaccines are equally effective for both women and men</a>, especially when one is more susceptible than another.</p><img src="https://counter.theconversation.com/content/146379/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Meghan E. Rebuli does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A new study is the first to identify sex differences in inflammation and immune cell activation in response to SARS-CoV-2 infection, which causes COVID-19.Meghan E. Rebuli, Assistant Professor of Pediatrics, University of North Carolina at Chapel HillLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1466502020-10-07T20:11:19Z2020-10-07T20:11:19ZTraining our immune systems: Why we should insist on a high-quality COVID-19 vaccine<figure><img src="https://images.theconversation.com/files/361304/original/file-20201002-22-1m9w3ip.jpg?ixlib=rb-1.1.0&rect=28%2C14%2C9461%2C6302&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A worker inspects vials of a SARS CoV-2 vaccine for COVID-19 produced by SinoVac at its factory in Beijing on Sept. 24, 2020. </span> <span class="attribution"><span class="source">(AP Photo/Ng Han Guan)</span></span></figcaption></figure><p>Athletes understand that there are two very different approaches that can be taken when training their bodies. For example, lifting heavy weights is a great way to <a href="https://doi.org/10.14814/phy2.12472">achieve maximum strength</a>. In contrast, low-load high-repetition training is ideal for developing the <a href="https://www.verywellfit.com/what-is-muscular-endurance-3120360">stamina required for endurance sports</a>. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A round blue T cell with a rough surface against a black background" src="https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361282/original/file-20201002-16-1fv7rgh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Scanning electron micrograph of a human T lymphocyte (also called a T cell) from the immune system of a healthy donor.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Remarkably, our immune system can be trained in a somewhat similar fashion. It must choose between two different responses to dangerous pathogens, both of which lead to white blood cells called T cells and antibodies targeting the infecting microbe. However, <a href="https://doi.org/10.1126/science.1062060">the types of these T cells and antibodies</a> is different depending on whether the pathogen lives outside of our cells, as many bacteria do, or inside our cells, as viruses do.</p>
<p>Mounting an anti-bacterial response against a virus may not be an ideal way to clear a viral infection. In fact, the wrong kind of immune response can actually <a href="https://doi.org/10.4049/jimmunol.181.9.6337">exacerbate disease</a>, as was observed in vaccinated mice challenged with the severe acute respiratory syndrome coronavirus (SARS-CoV) identified in 2003. </p>
<p>Importantly, our first exposure to a pathogen, either naturally or via vaccination, can train our immune system to adopt one of these two biases when we respond in the future to the same or a similar pathogen for the rest of our lives. Immunologists call this “<a href="https://doi.org/10.1126/science.aaf1098">trained immunity</a>.”</p>
<h2>First exposure</h2>
<figure class="align-right ">
<img alt="Orange coronavirus particles lined up diagonally along the edge of a green cell, against a black background" src="https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=587&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=587&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=587&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=737&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=737&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361286/original/file-20201002-22-1a47rt3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=737&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Colourized transmission electron micrograph of the coronavirus that caused the 2003 severe acute respiratory syndrome (SARS) outbreak. Orange virus particles at the edge of a green infected cell.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Our research programs span the fields of viral transmission, immune responses to viruses, respiratory pathogens such as influenza viruses and vaccine development, including vaccines against SARS-CoV-2, which is the causative agent of the coronavirus disease that emerged in 2019, <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it">COVID-19</a>. </p>
<p>We would like to convey the importance of trained immunity in the context of COVID-19 vaccines since this can have implications for the ability of our immune systems to respond appropriately to highly pathogenic coronaviruses in the future.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three orange coronavirus particles surrounded by a ring of orange and purple against a black background" src="https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361296/original/file-20201002-17-15n80zt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Colourized transmission electron micrograph showing Middle East respiratory syndrome (MERS) coronavirus that emerged in 2012.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Over the past 17 years, there have been three major outbreaks of highly pathogenic coronaviruses: the original <a href="https://www.cdc.gov/sars/about/fs-sars.html">SARS-CoV</a> in 2003, <a href="https://www.cdc.gov/coronavirus/mers/about/index.html">Middle East Respiratory Syndrome coronavirus</a> in 2012 and now SARS-CoV-2. Based on this history of having a new highly pathogenic coronavirus emerge approximately every decade, we should expect to have to deal with more of these viruses in the future. That means that the current drive to develop vaccines for COVID-19 should consider future coronavirus outbreaks. </p>
<p>The way we train our immune systems now to respond to SARS-CoV-2 could impact how well our bodies can respond to future coronaviruses. Vaccines, if developed properly, provide an opportunity to induce the type of trained immunity that is optimal for mounting protective immune responses, not only against SARS-CoV-2, but also against future infections with coronaviruses and/or their associated vaccines.</p>
<h2>Tuberculosis response</h2>
<p>Interestingly, some scientists have proposed to harness the concept of trained immunity in a related context. Specifically, there is evidence to suggest that individuals who received a vaccine against tuberculosis may be <a href="https://doi.org/10.1016/S0140-6736(20)31025-4">partially protected</a> against SARS-CoV-2.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A cluster of pink rod-shaped bacteria on a black background" src="https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=514&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=514&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=514&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=646&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=646&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361277/original/file-20201002-18-lc394i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=646&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Scanning electron micrograph of Mycobacterium tuberculosis bacteria.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p><a href="https://www.cdc.gov/tb/topic/basics/default.htm">Tuberculosis</a> is a respiratory disease caused by a bacterium. In contrast to many bacteria, this one, like viruses, lives inside cells. The vaccine formulation uses a live, but attenuated (modified or weakened) bacterium that is very similar to the one that causes the disease. Since it is a live bacterium, it can infect cells in the same way that the disease-causing bacteria do. </p>
<p>The result is an appropriate immune response that happens to be of the same type that is optimal against viruses. Scientists have concluded, therefore, that the tuberculosis vaccine might be training the immune system in such a way that it can respond ideally to other pathogens that live inside cells, including viruses like SARS-CoV-2.</p>
<h2>Evaluating responses</h2>
<figure class="align-right ">
<img alt="A yellow coronavirus with orange corona against a black background" src="https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361285/original/file-20201002-19-1o2r3rd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Colourized transmission electron micrograph of SARS-CoV-2, the virus that causes COVID-19.</span>
<span class="attribution"><span class="source">(NIAID)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>A heavy emphasis is being placed on quantitative aspects of candidate COVID-19 vaccines, such as whether they generate high levels of antibodies. Many health regulatory agencies are poised to <a href="https://doi.org/10.1016/S0140-6736(20)31976-0">approve COVID-19 vaccines</a> that reduce the burden of disease but do not induce immunity to completely prevent infection and transmission. But they should be cautious and ensure that these vaccines do not train our immune system for a response that is not optimal.</p>
<p>By thoroughly evaluating the nature and duration of the immune response induced by a prospective COVID-19 vaccine, we can ensure specific, effective and sustained responses against SARS-CoV-2. Specifically, vaccine developers should be able to answer these questions: </p>
<ol>
<li><p>Did the vaccine induce an immune response that is optimal against viruses? A balanced antiviral response should include antibodies to prevent the virus from infecting host cells and replicating inside them, and T cells to kill viruses that get past the antibody barrier. Importantly, the antibodies should be of <a href="https://doi.org/10.3389/fimmu.2014.00520">antiviral types</a>. </p></li>
<li><p>Were there antibody responses in the respiratory tract, and do these antibodies efficiently neutralize the virus? There is significant focus placed on measuring antibody responses in the blood, but SARS-CoV-2 infects mucosal surfaces including the <a href="https://doi.org/10.1128/JVI.76.21.10972-10979.2002">respiratory tract</a>, and it is important to ensure that the vaccine induces antibodies at these relevant locations. Also, it must be noted that appropriate antibody responses against viruses are usually <a href="https://doi.org/10.1111/j.1600-065X.1988.tb00739.x">of much lower magnitude</a> than those directed against extracellular bacteria. A large quantity of antibodies may seem promising, but the amount is not nearly as important as the types and locations of these antibodies. </p></li>
</ol>
<p>The take-home message is that we should insist on maintaining a very high standard for a COVID-19 vaccine; one that will induce a qualitatively appropriate immune response that will protect us from infection with SARS-CoV-2. </p>
<p>Like an athlete, we need to avoid training our immune system in a way that contradicts the end goal. For long-term health, we must ensure that our immune systems are trained in a way that will allow us to respond most effectively against future highly pathogenic coronaviruses, some of which may prove to be more dangerous than the current one.</p><img src="https://counter.theconversation.com/content/146650/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Byram Bridle received funding from the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council of Canada, the Canada Foundation for Innovation, and Ontario COVID-19 Rapid Research Funding.</span></em></p><p class="fine-print"><em><span>Samira Mubareka receives funding from the Natural Sciences and Engineering Research Council of Canada, the Canadian Safety and Security Program, the Public Health Agency of Canada and support from Questcap through the Sunnybrook Foundation. </span></em></p><p class="fine-print"><em><span>Shayan Sharif receives funding from Canada's First Research Excellence Fund </span></em></p>Our first exposure to a pathogen, either naturally or via vaccination, can affect how our immune system responds in the future to the same or similar pathogens.Byram W. Bridle, Associate Professor of Viral Immunology, Department of Pathobiology, University of GuelphSamira Mubareka, Clinician-scientist, Laboratory Medicine and Pathobiology, University of TorontoShayan Sharif, Professor of Immunology and Associate Dean, Research and Graduate Studies, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1431762020-07-29T18:42:22Z2020-07-29T18:42:22ZThe road to COVID-19 testing: The role of a Canadian biotech pioneer<figure><img src="https://images.theconversation.com/files/349747/original/file-20200727-17-1rum1nv.jpg?ixlib=rb-1.1.0&rect=11%2C0%2C1899%2C1187&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The polymerase chain reaction, or PCR, is used to copy strands of DNA.</span> <span class="attribution"><span class="source">(Pixabay/PixxlTeufel)</span></span></figcaption></figure><p>Canadians are updated daily on the multi-faceted devastation caused by SARS-CoV-2 and on the results of COVID-19 testing from across the country. Few people may be aware that these tests are based on a method innovated by the <a href="https://ethw.org/First-Hand:Starting_Up_Cetus,_the_First_Biotechnology_Company_-_1973_to_1982">first-ever biotech company, Cetus</a>, co-founded in California by Canadian-born and educated <a href="https://www.eurekalert.org/pub_releases/2007-05/chf-rct050707.php">Ron Cape</a>. He was Cetus’s first president in 1971, and then chairman and CEO. </p>
<p>Biotech was nonexistent before this. <a href="https://www.mcgill.ca/biochemistry/about-us/history">Cape obtained his PhD at McGill in 1967</a> with John Spencer as his supervisor, who was one of the pioneers in DNA biochemistry. At the same time, Cape was <a href="https://digitalassets.lib.berkeley.edu/roho/ucb/text/cape_ron.pdf">president of the Professional Pharmaceutical Corporation</a> in Montréal.</p>
<figure class="align-left ">
<img alt="John Bergeron and Ron Cape standing side by side" src="https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=586&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=586&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=586&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=736&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=736&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348934/original/file-20200722-28-jyyvgf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=736&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">John Bergeron and Ron Cape at the joint congress of the Human Proteome Organization and the International Union of Biochemistry and Molecular Biology (IUBMB) in 2003. The IUBMB meeting was transferred from Toronto to Montréal because of SARS.</span>
<span class="attribution"><span class="source">(John Bergeron)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The method used globally to test for the presence of the SARS-CoV-2 virus that causes COVID-19 is known as the polymerase chain reaction or PCR. This revolutionary innovation was developed at Cetus by <a href="https://www.nobelprize.org/prizes/chemistry/1993/mullis/facts/">in-house scientist Kary Mullis</a>. Awarded the Nobel Prize in chemistry in 1993, Mullis received the only Nobel Prize for a discovery made by a biotech company.</p>
<p>DNA technology was the key strategy for Cetus’s business plan when the company was founded by Cape and his partners. In 1983, Kary Mullis discovered a method to exponentially amplify specific sequences of DNA in the test tube. He called it the polymerase chain reaction. </p>
<p>His key insight was to use an enzyme that was active at high temperature to copy DNA. This DNA-copying enzyme, known as Taq DNA polymerase, had itself been <a href="https://www.the-scientist.com/news/patent-wars-56233">discovered by David Gelfand and Susanne Stoffel at Cetus</a>.</p>
<h2>Amplifying DNA</h2>
<p>Biologist James Watson and physicist Francis Crick <a href="https://profiles.nlm.nih.gov/spotlight/sc/feature/doublehelix">described the structure of DNA in 1953</a>: two strands that are stable in a double helix structure. Each strand of DNA is aligned anti-parallel (parallel but running in opposite directions) with another complementary strand, held together by what are known as hydrogen bonds. These bonds are broken by heat.</p>
<p>Mullis wanted to find a way to make multiple copies of DNA that itself could be used to make the proteins that Cetus wished to commercialize as therapeutics for cancer. His insight was to design a method to do this using Taq DNA polymerase. </p>
<p>Mullis designed a protocol using varying temperatures and repeated cycles to amplify DNA. He first used a high temperature to separate the double strands of DNA. Lowering the temperature allowed the Taq DNA polymerase to copy and extend sequences along the DNA strands. Once a cycle of copying was done, the temperature was raised again to re-separate the strands allowing for continuation of another amplification cycle. </p>
<p>With Cetus, <a href="https://bitesizebio.com/13505/the-invention-of-pcr/">Mullis designed a machine</a>, the thermocycler, to enable the repeating of such cycles to make exponential amounts of DNA, much like a nuclear chain reaction — hence the term polymerase chain reaction.</p>
<h2>PCR and SARS-CoV-2 testing</h2>
<p>The genes in the SARS-CoV-2 virus are stored as RNA, not DNA. The standard testing protocol is to take a deep nasal swab from a patient. To detect the virus by PCR-based tests, the RNA of the virus is copied into DNA using another enzyme called reverse transcriptase. It is this copied DNA which is used for PCR amplification. </p>
<p>The urgency for a cure for COVID-19 has made science discoveries move at an accelerated pace. On Jan. 11, the gene sequence of the SARS-CoV-2 virus was made openly available from scientists in China. By Jan. 24, the World Health Organization made available <a href="https://www.who.int/publications/m/item/molecular-assays-to-diagnose-covid-19-summary-table-of-available-protocols">PCR-based protocols to test for SARS-CoV-2</a>.</p>
<p>The legacy of Montréaler Ron Cape and the first biotech company is the PCR test we use to detect COVID-19 disease. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/Vd38iS_W7ww?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Using Reverse Transcription Polymerase Chain Reaction (RT-PCR) in COVID-19 Testing.</span></figcaption>
</figure>
<p><a href="https://reader.elsevier.com/reader/sd/pii/S138665322030175X?token=419EA74A92A1227285904C3805A3BDD91321CD5DC2FD99D6A8429CF8FC03A3A4C7D9146A4586A40E89F75FA342F1CDD9">Canada’s National Microbiology Laboratory in Winnipeg</a> set up the SARS-CoV-2 test for COVID-19 based on the data distributed by WHO in January 2020 for PCR testing.</p>
<p>The <a href="https://www.canada.ca/en/public-health/corporate/mandate/about-agency/background.html">Public Health Agency of Canada</a> regulates the <a href="https://www.canada.ca/en/public-health/programs/national-microbiology-laboratory.html">National Microbiology Laboratory</a>. The PHAC was created in 2004 after the SARS outbreak of 2003, as a consequence of a devastating report written by David Naylor, who was then dean of medicine at the University of Toronto, regarding <a href="https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/publicat/sars-sras/pdf/sars-e.pdf">Canada’s lack of preparedness for the lethal SARS outbreak</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-taming-of-polio-and-the-challenge-of-the-flu-116100">The taming of polio and the challenge of the flu</a>
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<p>Sadly, many of the detailed recommendations to prepare for another lethal virus were never implemented. The last sentence of the 2003 report on page 221 is chilling to read today: “If not now, after SARS, when?”</p>
<h2>Advancing Canada’s testing expertise</h2>
<p>Testing is our only way to know who has been infected, where and when. <a href="https://www.ctvnews.ca/health/coronavirus/coronavirus-report-card-experts-give-canada-a-b-u-s-an-f-1.5035917">The lack of coherence and standardization of tests and the communication of the results</a> should be unacceptable today given the recommendations of the 2003 Naylor report on SARS.</p>
<p>Genome Canada harbours exceptionally talented scientists whose expertise is the mapping of genomes. <a href="https://www.genomecanada.ca/en/news/genomics-mission-meeting-covid-19-challenge">The agency is undertaking heroic efforts to help Canada’s COVID-19 response</a>.</p>
<p>Using Genome Canada’s testing expertise through its six genome centres could help address the gap in complete, accurate and permanent testing and reporting for the expected next SARS-CoV-2 surge, or the next pandemic.</p>
<p>If not now, after COVID-19, when?</p>
<p><em>John Bergeron gratefully acknowledges Kathleen Dickson as co-author.</em></p><img src="https://counter.theconversation.com/content/143176/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Bergeron does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>COVID-19 tests rely on a process developed at a biotech company co-founded by a Canadian. Canada’s current testing expertise needs to be channelled to prepare for the next wave, and the next pandemic.John Bergeron, Emeritus Robert Reford Professor and Professor of Medicine, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1409412020-07-02T04:11:59Z2020-07-02T04:11:59ZBorder closures, identity and political tensions: how Australia’s past pandemics shape our COVID-19 response<p>Tensions over border closures are in the news again, now states are gradually lifting travel restrictions <a href="https://www.abc.net.au/news/2020-06-30/sa-delays-victorian-border-reopening-amid-coronavirus/12405632">to all</a> <a href="https://thenewdaily.com.au/news/coronavirus/2020/06/30/queensland-border-victoria/">except Victorians</a>.</p>
<p>Prime Minister Scott Morrison says singling out Victorians is an overreaction to Melbourne’s coronavirus spike, <a href="https://www.theage.com.au/national/victoria/get-some-perspective-pm-calls-out-premiers-for-closing-borders-to-victoria-20200630-p557q4.html">urging</a> the states “to get some perspective”.</p>
<p>Federal-state tensions over border closures and other pandemic quarantine measures are not new, and not limited to the COVID-19 pandemic.</p>
<p>Our new <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/puar.13224">research</a> shows such measures are entwined in our history and tied to Australia’s identity as a nation. We also show how our experiences during past pandemics guide the plans we now use, and alter, to control the coronavirus.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/national-and-state-leaders-may-not-always-agree-but-this-hasnt-hindered-our-coronavirus-response-136152">National and state leaders may not always agree, but this hasn't hindered our coronavirus response</a>
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<h2>Bubonic plague, federation and national identity</h2>
<p>In early 1900, <a href="https://www.nma.gov.au/defining-moments/resources/bubonic-plague">bubonic plague</a> broke out just months before federation, introduced by infected rats on ships.</p>
<p>When a new vaccine was available, the New South Wales government planned to inoculate just front-line workers. </p>
<p>Journalists called for a broader inoculation campaign and the government soon faced a “melee” <a href="https://www.griffithreview.com/articles/learning-from-forgotten-epidemics/">in which</a>:</p>
<blockquote>
<p>…men fought, women fainted and the offices [of the Board of Health] were damaged. </p>
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<p>Patients and contacts were quarantined at the <a href="https://www.qstation.com.au/our-story.html">North Head Quarantine Station</a>. Affected suburbs were quarantined and sanitation commenced.</p>
<p>The health board <a href="https://hekint.org/2017/02/01/plague-sydney-1900/">openly criticised</a> the government for its handling of the quarantine measures, laying the groundwork for quarantine policy in the newly independent Australia.</p>
<p>Quarantine then became essential to a vision of Australia as an island nation where “island” stood for immunity and where non-Australians were viewed as “diseased”. </p>
<p>Public health is mentioned twice in the Australian constitution. <a href="http://classic.austlii.edu.au/au/legis/cth/consol_act/coaca430/s51.html">Section 51(ix)</a> gives parliament the power to quarantine, and <a href="http://classic.austlii.edu.au/au/legis/cth/consol_act/coaca430/s69.html">section 69</a> requires states and territories to transfer quarantine services to the Commonwealth.</p>
<p>The <a href="https://www.legislation.gov.au/Details/C2016C00597">Quarantine Act</a> was <a href="https://www.jstor.org/stable/40111469?seq=1">later merged</a> to form the <a href="https://www.legislation.gov.au/Details/C1901A00017">Immigration Restriction Act</a>, with quarantine influencing immigration policy. </p>
<p>Ports then became centres of immigration, trade, biopolitics and biosecurity.</p>
<h2>Spanish flu sparked border disputes too</h2>
<p>In 1918, at the onset of the Spanish flu, quarantine policy included border closures, quarantine camps (for people stuck at borders) and school closures. These measures initially controlled widespread outbreaks in Australia.</p>
<p>However, Victoria quibbled over whether NSW had accurately diagnosed this as an influenza pandemic. Queensland closed its borders, despite only the Commonwealth having the legal powers to do so.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/this-isnt-the-first-global-pandemic-and-it-wont-be-the-last-heres-what-weve-learned-from-4-others-throughout-history-136231">This isn't the first global pandemic, and it won't be the last. Here's what we've learned from 4 others throughout history</a>
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<p>When World War I ended, many returning soldiers broke quarantine. Quarantine measures were not coordinated at the Commonwealth level; states and territories each went their own way.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=380&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=380&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=380&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=477&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=477&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344957/original/file-20200701-54182-1xi9yxt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=477&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Quarantine camps, like this one at Wallangarra in Queensland, were set up during the Spanish flu pandemic.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/hwmobs/33951814795/in/photolist-TJcVFa-YhgcRx-atsaix-XTKch7-UaKNVR-V9MpKW-UP7JCA-MLhyLw-LRP6K1-MLhndw-HCnkAZ-HzYnQ7-HCmst8-GP2158-HCn2kF-Hjh81L-HCn4qH-GP1U5H-HFEyxo-GNWKdo-GNWpWY-bYHyHs-VzVoWC-WS74kD-MPhwS2-MFUxbv-azS5yy-aWj2ht-2eHp2Cd-iK4YSS-iK6XWw-js1RoA-2iRKFBT-2iErL2N-do1pQW-2iPBTMC-2iPxv95-dJogXQ-dJhQ6D-gaEtvV-wZtUUa-gYh1Qz-gaDNYg-gaDNsr-cN1cWE-cN1bV9-cN1cQS-cN1c6h-cN1d6C-gaDVZw">Aussie~mobs/Public Domain/Flickr</a></span>
</figcaption>
</figure>
<p>There were different policies about state border closures, quarantine camps, mask wearing, school closures and public gatherings. Infection spread and hospitals were overwhelmed.</p>
<p>The legacy? The states and territories ceded quarantine control to the Commonwealth. And <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1467-8500.1952.tb01591.x">in 1921</a>, the Commonwealth created its own health department.</p>
<h2>The 1990s brought new threats</h2>
<p>Over the next seven decades, Australia linked quarantine surveillance to national survival. It shifted from prioritising human health to biosecurity and protection of Australia’s flora, fauna and agriculture. </p>
<p>In the 1990s, new human threats emerged. <a href="https://wwwnc.cdc.gov/eid/article/5/2/99-0202_article">Avian influenza in 1997</a> led the federal government to recognise Australia may be ill-prepared to face a pandemic. <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-cditech-influenza.htm">By 1999</a> Australia had its first <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-cditech-influenza.htm/$FILE/influenza.pdf">influenza pandemic plan</a>.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/todays-disease-names-are-less-catchy-but-also-less-likely-to-cause-stigma-131465">Today's disease names are less catchy, but also less likely to cause stigma</a>
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<p><a href="https://www.cdc.gov/sars/about/fs-sars.html">In 2003</a>, severe acute respiratory syndrome (or SARS) emerged in China and Hong Kong. Australia responded by discouraging nonessential travel and started health screening incoming passengers.</p>
<p>The next threat, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5305a1.htm">2004 H5N1 Avian influenza</a>, was a dry run for future responses. This resulted <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/ohp-ahmppi.htm">in the 2008</a> Australian Health Management Plan for Pandemic Influenza, which included border control and social isolation measures.</p>
<h2>Which brings us to today</h2>
<p>While lessons learned from past pandemics are with us today, we’ve seen changes to policy mid-pandemic. March saw the formation of the <a href="https://theconversation.com/explainer-what-is-the-national-cabinet-and-is-it-democratic-135036">National Cabinet</a> to endorse and coordinate actions across the nation. </p>
<p>Uncertainty over border control continues, especially surrounding the potential for <a href="https://www.smh.com.au/national/australia-covid-19-death-toll-reaches-100-20200519-p54uhb.html">cruise</a> and <a href="https://www.theguardian.com/australia-news/2020/may/26/wa-premier-fears-more-covid-19-infections-after-six-test-positive-on-live-export-ship-in-fremantle">live-export ships</a> to import coronavirus infections.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/coronavirus-has-seriously-tested-our-border-security-have-we-learned-from-our-mistakes-134794">Coronavirus has seriously tested our border security. Have we learned from our mistakes?</a>
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<p>Then there are border closures between states and territories, creating tensions and a potential <a href="https://www.theguardian.com/australia-news/2020/may/28/clive-palmer-launches-high-court-challenge-to-queensland-coronavirus-border-closure">high court challenge</a>.</p>
<p>Border quibbles between states and territories will likely continue in this and future pandemics due to geographical, epidemiological and political differences.</p>
<p>Australia’s success during COVID-19 as a nation, is in part due to Australian quarantine policy being so closely tied to its island nature and learnings from previous pandemics.</p>
<p>Lessons learnt from handling COVID-19 will also strengthen future pandemic responses and hopefully will make them more coordinated.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/4-ways-australias-coronavirus-response-was-a-triumph-and-4-ways-it-fell-short-139845">4 ways Australia's coronavirus response was a triumph, and 4 ways it fell short</a>
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<img src="https://counter.theconversation.com/content/140941/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Moloney is Past President, Paediatrics & Child Health Division, The Royal Australasian College of Physicians (RACP).</span></em></p><p class="fine-print"><em><span>Kim Moloney does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australia’s island identity and attitude to border security was forged from handling pandemics since the time of federation. Here’s what we’ve learned along the way.Susan Moloney, Associate Professor, Paediatrics, Griffith UniversityKim Moloney, Senior Lecturer in Global Public Administration and Public Policy, Murdoch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1415132020-07-01T12:30:14Z2020-07-01T12:30:14ZWhich drugs and therapies are proven to work, and which ones don’t, for COVID-19?<figure><img src="https://images.theconversation.com/files/344835/original/file-20200630-103673-pcawdc.jpg?ixlib=rb-1.1.0&rect=0%2C10%2C6679%2C4426&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We are slowly figuring out which drugs and therapies are effective against the new coronavirus.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/china-wuhan-smartphone-with-aliepress-logo-with-royalty-free-image/1203497795?adppopup=true&uiloc=thumbnail_similar_images_adp">Anton Petrus / Getty Images</a></span></figcaption></figure><p><em>Leer <a href="https://theconversation.com/que-medicamentos-y-tratamientos-se-ha-demostrado-que-funcionan-y-cuales-no-para-la-covid-19-143395">en español</a></em></p>
<p><a href="https://uvahealth.com/findadoctor/profile/william-petri">I am a physician and a scientist</a> at the University of Virginia. I care for patients and conduct research to find better ways to diagnose and treat infectious diseases, including COVID-19. Here I’m sharing what is known about which treatments work, and which don’t, for the new coronavirus infection. </p>
<p>Keep in mind that this field of medicine is rapidly evolving as our understanding of the SARS-CoV-2 virus improves. So what I am writing today may change within days or weeks.</p>
<p>Below are the treatments that have been tried and for which we have the best knowledge.</p>
<h2>Hydroxychloroquine or chloroquine – no evidence they work</h2>
<p>There are <a href="http://doi.org/10.1126/science.abd2496">three randomized controlled trials</a> of hydroxychloroquine, all of which have failed to prove or disprove a beneficial or harmful effect on COVID-19 clinical course or clearance of virus. Given this current lack of evidence, these drugs, which normally are used to treat arthritis, should <a href="https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/#toc-5">only be used within the context of a controlled clinical trial.</a> </p>
<h2>Lopinavir/ritonavir – not helpful</h2>
<p>The drug Lopinavir is an inhibitor of an enzyme called HIV protease which is involved in the production of viral particles. Protease inhibitors for HIV were revolutionary, leading to our current ability to effectively treat HIV. Lopinavir also can inhibit enzymes that perform similar functions as the HIV protease in the <a href="https://www.niaid.nih.gov/diseases-conditions/covid-19">SARS and MERS coronaviruses</a>. Ritonavir increases the level of Lopinavir in the blood so the lopinavir/ritonavir combination was tested in a randomized controlled clinical trial for COVID-19. </p>
<p>Unfortunately, there was no impact on the levels of virus in the throat or duration of viral shedding, nor did patients’ clinical course or survival change. There therefore is <a href="http://doi.org/10.1056/NEJMoa2001282">no role for lopinavir/ritonavir in the treatment of COVID-19.</a></p>
<h2>Steroids – yes for almost all COVID-19 patients</h2>
<p>When a synthetic steroid hormone, called dexamethasone, was given to patients with COVID-19 the drug decreased <a href="https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1">28-day mortality by 17% and hastened hospital discharge</a>. </p>
<p>This work was performed in a <a href="http://www.ox.ac.uk/news/2020-06-16-low-cost-dexamethasone-reduces-death-one-third-hospitalised-patients-severe">randomized and controlled clinical trial</a> of over 6,000 patients, and while not replicated in another study or yet peer reviewed, is certainly enough evidence to recommend its use. </p>
<h2>Tocilizumab – too early to judge</h2>
<p>Tocilizumab is an <a href="https://theconversation.com/antibody-injections-could-fight-covid-19-infections-an-infectious-disease-expert-explains-the-prospects-139444">antibody</a>, that blocks a protein, called IL-6 receptor, from binding IL-6 and triggering inflammation. Levels of IL-6 are higher in many patients with COVID-19, and the immune system in general seems to be hyperactivated in those with the most severe disease. This leads many physicians and physicians to think that inhibiting the IL-6 receptor might protect patients from severe disease. </p>
<p>Tocilizumab is currently FDA approved for the treatment of rheumatoid arthritis and several other collagen-vascular diseases and for “<a href="https://theconversation.com/blocking-the-deadly-cytokine-storm-is-a-vital-weapon-for-treating-covid-19-137690">cytokine storm</a>” – a harmful overreaction of the immune system – that can be caused by certain types of cancer therapy and COVID-19.</p>
<p><a href="https://doi.org/10.1016/S2665-9913(20)30173-9">A retrospective observational study</a> found that COVID-19 patients treated with tocilizumab had a lower risk of mechanical ventilation and death. But we lack a randomized controlled clinical trial so there is no way to ascertain if this apparent improvement was due to tocilizumab or from the imprecise nature of retrospective studies.</p>
<h2>Convalescent plasma – too early to judge</h2>
<p>Convalescent plasma, the liquid derived from blood after removing the white and red blood cells, contains antibodies from previous infections that the plasma donor had. This plasma has been used to prevent infectious diseases including pneumonia, tetanus, diphtheria, mumps and chickenpox for over a century. It is thought to benefit patients because antibodies from the plasma of survivors bind to and inactivate pathogens or their toxins of patients. Convalescent plasma has now been used in thousands of COVID-19 patients. </p>
<p>However, the only randomized clinical trial was small and included just 103 patients who received convalescent plasma 14 days after they became ill. There was <a href="http://doi.org/10.1001/jama.2020.10044">no difference in the time to clinical improvement or mortality</a> between those who did and did not receive treatment. The encouraging news was that there was a significant decrease in virus levels detected by PCR. </p>
<p>It is therefore too early to tell if this will be beneficial and controlled clinical trials are needed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/344915/original/file-20200630-103636-1os1g3t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A nurse is collecting convalescent plasma from a recovered COVID-19 patient to help the healing process of other COVID-19 patients in Indonesia.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nurse-were-conducting-the-process-of-taking-a-plasma-news-photo/1223515838?adppopup=true&uiloc=thumbnail_more_search_results_adp">Budiono,/ Sijori images/Barcroft Media via Getty Images</a></span>
</figcaption>
</figure>
<h2>Remdesivir – yes, decreases hospital stay</h2>
<p><a href="https://theconversation.com/remdesivir-explained-what-makes-this-drug-work-against-viruses-137751">Remdesivir is a drug that inhibits the coronavirus enzyme</a> that makes copies of the viral RNA genome. It acts by causing premature stoppage or termination of the copying and ultimately blocks the virus from replicating.</p>
<p>Remdesivir treatment, especially for patients who required supplemental oxygen before they were placed on a ventilator <a href="http://doi.org/10.1056/NEJMoa2007764">reduced mortality and shortened the average recovery time</a> from 15 to 11 days. </p>
<h2>ACE inhibitors and ARBs – keep taking them</h2>
<p>There was a concern that drugs called <a href="https://www.webmd.com/heart-disease/guide/medicine-ace-inhibitors#:%7E:text=Angiotensin%2Dconverting%20enzyme%20(ACE),to%20lower%20your%20heart's%20workload.">ACE inhibitors</a> or angiotensin receptor blockers (ARBs), which are used to treat high blood pressure and heart failure, could increase levels of the ACE2 proteins, the receptor <a href="https://theconversation.com/what-is-the-ace2-receptor-how-is-it-connected-to-coronavirus-and-why-might-it-be-key-to-treating-covid-19-the-experts-explain-136928">for SARS-CoV-2,</a> on the surface of cells in the body. This would, physicians hypothesized, allow more entry points for the virus to infect cells and would therefore boost the severity of new coronavirus infections.</p>
<p>However, there is no evidence that this is the case. The American Heart Association, the Heart Failure Society of America and the American College of Cardiology all recommend that patients continue to take these medications during the pandemic as they are <a href="https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19">beneficial in the treatment of high blood pressure and heart failure</a>. </p>
<p>We have made amazing progress in the treatment of COVID-19. Two therapies – steroids and Remdesivir – have already been shown to help. Those who benefit from these treatments owe thanks to patients who volunteered to participate in controlled clinical trials, and the physicians and pharmaceutical companies that lead them. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/141513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Petri receives funding from the NIH and the Gates Foundation.</span></em></p>During the last six months, news reports have mentioned dozens of drugs that may be effective against the new coronavirus. Here we lay out the evidence and reveal which ones are proven to work. Or not.William Petri, Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1404532020-06-14T08:13:11Z2020-06-14T08:13:11ZSo you think investing in fever screening can curb the spread of COVID-19? Think again<figure><img src="https://images.theconversation.com/files/341201/original/file-20200611-80750-mdacqk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A security guard checks the body temperature of a motorcyclist as a preventive measure. </span> <span class="attribution"><span class="source">Risa Krisadhi/SOPA Images/LightRocket via Getty Images</span></span></figcaption></figure><p>As lockdowns are lifted, procedures are being put in place to reduce the spread of <a href="https://theconversation.com/africa/covid-19">COVID-19</a>. Along with physical distancing, hand sanitisation and <a href="https://theconversation.com/african-countries-are-moving-to-make-masks-mandatory-key-questions-answered-137516">wearing of masks</a>, <a href="https://www.nytimes.com/2020/05/11/technology/coronavirus-worker-testing-privacy.html">fever screening</a> is increasingly being set up as a requirement before entry is allowed into hospitals, shops, workplaces and schools. But there are physiological and clinical reasons why fever screening simply won’t work. </p>
<p>Andrea Fuller and Duncan Mitchell explain why fever screening is unlikely to reduce the spread of the virus. Their arguments are based on an understanding of the physiology of fever, body temperature measurement, and fever prevalence in people who transmit COVID-19. </p>
<hr>
<h2>What happens to your body when you have a fever?</h2>
<p>Fever is a temporary elevation of body core temperature. It is part of a <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159115004079?casa_token=7_0RxEml1XkAAAAA:BLgBVOlXpp6vZuDa5dwuIpbpsdNhIS0YbRX8Q7nI_0-MMw1GZzVz_WYtNCRq4Ue1qAEzwTIx7Mw">defensive response</a> to infection by a virus. </p>
<p>When you develop a fever, you feel cold, heat generation in your body increases (achieved by shivering) and heat loss decreases (achieved by seeking warmth, covering up and reducing the flow of warm blood to the skin). When a fever breaks, either naturally or because you have taken an antipyretic like paracetamol, you feel warm. Your reactions include increasing the flow of warm blood to the skin and sweating, which helps to bring the body’s core temperature back to normal.</p>
<h2>What are the limitations to infrared thermometers or thermal cameras detecting fevers?</h2>
<p>Detecting fever requires measuring body core temperature. To do that accurately, you need to put a thermometer into the body core. Temperature in the rectum and the mouth get close to body core temperature. </p>
<p>Needing to measure body core temperature raises the first problem with fever screening. Thermal cameras and infrared thermometers measure heat radiating from a surface – in other words surface temperature. They don’t measure body core temperature. </p>
<p>Measuring surface temperature has contributed usefully to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2907.2007.00111.x">healthcare and to biology</a>. For example, infrared cameras have shown whether <a href="https://www.plasticsurgery.theclinics.com/article/S0094-1298(11)00022-8/abstract">skin grafts are receiving blood</a>. On the biology front they have shown that toucans dump body heat <a href="https://science.sciencemag.org/content/325/5939/468?casa_token=8sYjYaq1yM8AAAAA:qxvgTZ4nHtC8xT3kpf8OxWTmeGxRQqsPy2O6WGpdj0QyYm2g-rVUVkPQ0E2Hao025n_5C7mE_HEhf-Y">through their bills</a>. </p>
<p>But the forehead skin or inner eye temperatures that infrared thermometers or thermal cameras usually measure in fever screening are not body core temperatures. </p>
<p>Human surface temperature is heavily <a href="http://www.uhlen.at/thermology-international/archive/Fever%20screening%20and%20infrared%20...pdf">influenced by environmental conditions</a>. In cool environments, surface temperatures can be much lower than body core temperature. And doing <a href="https://www.tandfonline.com/doi/full/10.1080/03091900600711381">exercise</a>, or being exposed to the sun, can raise the temperature on our foreheads above body core temperature. Thermal cameras screen for high skin temperature. They can and do find high face temperatures that have nothing to do with infections. Those <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2020.25.5.2000080;jsessionid=tf38nvbo2h6-at8kDrFqpbG6.i-0b3d9850f4681504f-ecdclive">“false positives”</a> waste time and money in unnecessary follow-up.</p>
<p>Another problem is that skin temperature does not rise during the developing phase of a fever. It falls, because warm blood is kept away from the skin. So your skin temperature changes in the opposite direction to your body core temperature. </p>
<p>Thermal cameras would declare you safe, because your skin temperature is low, but you could be in the most infectious phase of the fever. No surface temperature is a reliable indicator of fever.</p>
<h2>Could better fever screening detect COVID-19?</h2>
<p>Even if infrared thermometers could detect fever reliably, they could not detect COVID-19 reliably. Nor could any other thermometer. Patients with COVID-19 are not guaranteed to have a fever. </p>
<p>Recent <a href="https://www.theguardian.com/world/2020/may/30/could-nearly-half-of-those-with-covid-19-have-no-idea-they-are-infected">research</a> indicates that many people who test positive for COVID-19, and especially children, never have any detectable sign of illness, including fever. </p>
<p>Even people who later do show symptoms will not have a fever during COVID-19’s <a href="https://www.acpjournals.org/doi/full/10.7326/M20-0504">incubation phase</a>, which can last nearly two weeks. During this period, when they are asymptomatic, they <a href="https://wellcomeopenresearch.org/articles/5-58">can spread the virus</a>. The finding that infected people without symptoms shed virus is the <a href="https://www.nejm.org/doi/10.1056/NEJMe2009758">Achilles’ heel of controlling the current pandemic</a>.</p>
<p>To add to the problem, not all patients with symptoms will have a fever, at least on the basis of once-off measurement. Only <a href="https://jamanetwork.com/journals/jama/fullarticle/2765184">31% of patients</a> presenting at New York State hospitals with COVID-19 had fevers. </p>
<p>So, in addition to not measuring body core temperature well, infrared thermometers are being used to find a high temperature that many people exposed to COVID-19 won’t have.</p>
<h2>Has fever screening ever helped to prevent the spread of viruses?</h2>
<p>Thermal cameras were introduced at airports at the outbreak of the 2002/3 <a href="https://www.who.int/ith/diseases/sars/en/">Severe Acute Respiratory Syndrome</a> (SARS) pandemic. They were widespread in airports during the 2009 Influenza A (H1N1) pandemic. But for medical and technological reasons they have <a href="https://www.mdpi.com/1660-4601/16/23/4638">failed to prevent</a> the import of any virus causing respiratory disease. They have failed even in combination with other interventions like follow-up contact and health declaration questionnaires. For example, 930 people who presented as potentially infected candidates were picked out by thermal screening from over 9 million passengers entering Japan in 2009/2010. But <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-11-111">not one case of H1N1 influenza was diagnosed</a>. </p>
<p>The data from Ebola shows the same pattern. Not one case of Ebola virus infection was picked up in 166,242 airport passengers screened when entering and leaving Sierra Leone in the 2014/2016 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6930773/">outbreak</a>. </p>
<p>In the case of COVID-19, CNN has reported that <a href="https://edition.cnn.com/2020/02/19/health/coronavirus-airport-temperature-checks/index.html">no cases were detected</a> among the more than 30,000 passengers screened with thermal cameras at US airports by mid-February 2020 .</p>
<p>Some scientists have been forthright about the dubious value of fever screening, arguing that border screening for infectious diseases <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4313627/">should not be continued</a>. </p>
<h2>Is there any place for fever screening?</h2>
<p>Perhaps, there may be benefits. </p>
<p>Some people with viral infections who know they are sick attempt to conceal their illness. Travellers wanting to fly home are <a href="https://www.sciencedirect.com/science/article/pii/S1477893904001267?via%3Dihub">prone to do so</a>. Others take antipyretic drugs, hoping to avoid triggering thermal cameras. </p>
<p>Though there still is no scientific evidence, <a href="https://www.sciencemag.org/news/2020/03/why-airport-screening-wont-stop-spread-coronavirus">researchers have suggested</a> that the prospect of being caught by fever screening is a deterrent to such dishonesty. </p>
<p>But we do not believe that the potential benefit outweighs the negatives. Apart from fever screening being unreliable, infrared thermometry poses a risk to thermometer operators who are required to come up close to potentially infected persons. Successfully passing a fever screen can create a false sense of security. And the thermal cameras used for mass screening are costly. So are the personnel required for any fever screening.</p><img src="https://counter.theconversation.com/content/140453/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Fuller receives funding from the South African National Research Foundation.</span></em></p><p class="fine-print"><em><span>Duncan Mitchell is Adjunct Professor in the School of Human Sciences, University of Western Australia. In the past, he has received funding from the South African Medical Research Council and the South African National Research Foundation, for biomedical research, and has carried out contract research for Adcock Ingram Pharmaceuticals. </span></em></p>Detecting fever requires measuring core body temperature. Screening measures the body’s surface temperature.Andrea Fuller, Professor, School of Physiology; Director, Brain Function Research Group, University of the WitwatersrandDuncan Mitchell, Honorary Professorial Research Fellow, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1399502020-06-05T12:06:21Z2020-06-05T12:06:21ZA few superspreaders transmit the majority of coronavirus cases<figure><img src="https://images.theconversation.com/files/339938/original/file-20200604-67399-131jhv5.jpg?ixlib=rb-1.1.0&rect=218%2C223%2C3323%2C2392&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A few people in the crowd will be responsible for the bulk of a disease’s spread.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/commuters-wearing-protective-masks-wait-for-a-train-at-the-news-photo/1215807811">Pacific Press /LightRocket via Getty Images</a></span></figcaption></figure><p><em>The coronavirus has traveled the globe, infecting one person at a time. Some sick people might not spread the virus much further, but some people infected with the SARS-CoV-2 are what epidemiologists call “superspreaders.”</em> </p>
<p><em><a href="https://scholar.google.com/citations?user=k4UBB88AAAAJ&hl=en&oi=ao">Elizabeth McGraw</a>, the director of the <a href="https://www.huck.psu.edu/institutes-and-centers/center-for-infectious-disease-dynamics">Center for Infectious Disease Dynamics</a> at Pennsylvania State University, explains the evidence and why superspreaders can be crucial to a disease’s transmission.</em></p>
<h2>What is a superspreader?</h2>
<p>Early in the outbreak, researchers estimated that a person carrying SARS-CoV-2
would, on average, <a href="https://www.imperial.ac.uk/mrc-global-infectious-disease-analysis/news--wuhan-coronavirus/">infect another two to three people</a>. More recent studies have argued, however, that this number <a href="https://www.harvardmagazine.com/2020/05/r-nought">may actually be higher</a>.</p>
<p>As early as January, though, there were reports out of Wuhan, China, of a single patient who <a href="https://www.cnn.com/2020/01/23/health/wuhan-virus-super-spreader/index.html">infected 14 health care workers</a>. That qualifies him as a super spreader: someone who is responsible for infecting an especially large number of other people.</p>
<p>Since then, epidemiologists have tracked a number of other instances of SARS-CoV-2 superspreading. In South Korea, around <a href="https://www.livescience.com/coronavirus-superspreader-south-korea-church.html">40 people who attended a single church service</a> were infected at the same time. At a choir practice of 61 people in Washington state, <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e6.htm">32 attendees contracted confirmed COVID-19</a> and 20 more came down with probable cases. In Chicago, before social distancing was in place, one person that attended a dinner, a funeral and then a birthday party was <a href="https://chicago.suntimes.com/politics/2020/4/8/21214375/super-spreader-coronavirus-spread-chicago-patients-deaths-cdc-covid-19">responsible for 15 new infections</a>.</p>
<p>During any disease outbreak, epidemiologists want to quickly figure out whether superspreaders are part of the picture. Their existence can accelerate the rate of new infections or substantially expand the geographic distribution of the disease.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312664/original/file-20200129-92959-m1ltr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A connected world of international travelers sets the stage for geographic superspreading.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/contrail-dark-blue-sky-beautiful-show-9683023">aleksander hunta/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>What are the characteristics of a superspreader?</h2>
<p>Whether someone is a superspreader or not will depend on some combination of the pathogen, the patient’s biology and their environment or behavior.</p>
<p>Some infected individuals might shed more virus into the environment than others if their immune system has trouble subduing the invader. Additionally, <a href="https://theconversation.com/infected-with-the-coronavirus-but-not-showing-symptoms-a-physician-answers-5-questions-about-asymptomatic-covid-19-137029">asymptomatic individuals</a> – <a href="https://www.cnn.com/2020/04/01/europe/iceland-testing-coronavirus-intl/index.html">up to 50% of all those who get COVID-19</a> – will continue their normal activities, inadvertently infecting more people. Even people who ultimately do show symptoms are capable of <a href="https://doi.org/10.1038/s41591-020-0869-5">transmitting the virus during a pre-symptomatic phase</a>. </p>
<p>A person’s behaviors, travel patterns and degree of contact with others can also contribute to superspreading. An infected shopkeeper might come in contact with a large number of people and goods each day. An international business traveler may crisscross the globe in a short period of time. A sick health care worker might come in contact with large numbers of people who are especially susceptible, given the presence of other underlying illnesses.</p>
<p>Public protests – where it’s challenging to keep social distance and people might be raising their voices or coughing from tear gas – are <a href="https://theconversation.com/how-to-protest-during-a-pandemic-and-still-keep-everyone-safe-from-coronavirus-6-questions-answered-139978">conducive to superspreading</a>.</p>
<h2>How big a part of COVID-19 are superspreaders?</h2>
<p>Several recent preprint studies, which haven’t yet been peer-reviewed, have shed light on the role of superspreading in COVID-19’s dispersion around the globe.</p>
<p>Researchers in Hong Kong examined a number of disease clusters by using contact tracing to track down everyone with whom individual COVID-19 patients had interacted. In the process, they identified multiple situations where a single person was responsible for as many as six or eight new infections. </p>
<p>The researchers estimated that only 20% of all those infected with SARS-CoV-2 were <a href="https://doi.org/10.21203/rs.3.rs-29548/v1">responsible for 80% of all local transmission</a>. Importantly, they also showed that these transmission events were associated with people who had more social contacts – beyond just family members – highlighting the need to rapidly isolate people as soon as they test positive or show symptoms. </p>
<p>Another study by researchers in Israel took a different approach. They compared the genetic sequences of coronavirus samples from patients inside the country to those from other places. Based on <a href="https://theconversation.com/the-coronavirus-genome-is-like-a-shipping-label-that-lets-epidemiologists-track-where-its-been-136826">how different the genomes were</a>, they could identify each time SARS-CoV-2 entered Israel and then follow how it spread domestically.</p>
<p>These scientists estimated that <a href="https://doi.org/10.1101/2020.05.21.20104521">80% of community transmission events</a> – one person spreading the coronavirus to another – could be tracked back to just 1-10% of sick individuals.</p>
<p>And when another research group modeled the variation in how many other SARS-CoV-2 infections a single infected person tends to cause, they also found there were occasionally individuals who were very infectious. These people <a href="https://doi.org/10.12688/wellcomeopenres.15842.1">accounted for over 80% of transmissions</a> in a population.</p>
<h2>When have superspreaders played a key role in an outbreak?</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=636&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=636&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=636&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=800&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=800&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312638/original/file-20200129-92964-kxqly8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=800&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Officials quarantined ‘Typhoid’ Mary Mallon in a hospital.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Mary_Mallon_in_hospital.jpg">Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>There are a number of historical examples of superspreaders. The most famous is <a href="https://www.history.com/news/10-things-you-may-not-know-about-typhoid-mary">Typhoid Mary</a>, who in the early 20th century purportedly infected 51 people with typhoid through the food she prepared as a cook.</p>
<p>During the last two decades, superspreaders have started a number of measles outbreaks in the United States. Sick, unvaccinated individuals visited densely crowded places like schools, hospitals, airplanes and theme parks where they <a href="https://doi.org/10.1001/jamapediatrics.2019.4357">infected many others</a>.</p>
<p>Superspreaders have also played a key role in the outbreaks of other coronaviruses, <a href="http://www.taipeitimes.com/News/world/archives/2004/02/23/2003099824/1">including SARS in 2003</a> and <a href="https://doi.org/10.3947/ic.2016.48.2.147">MERS in 2015</a>. For both SARS and MERS, superspreading <a href="https://doi.org/10.1186/s12916-015-0450-0">mainly occurred in hospitals</a>, with <a href="http://www.cidrap.umn.edu/news-perspective/2016/07/patient-proximity-key-korean-mers-super-spreader-event">scores of people being infected at a time</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312662/original/file-20200129-92959-4qx7wt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Public health officials work to get the word out on how to protect yourself during an outbreak.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/South-Korea-China-Outbreak/9250d36b1f274996a9eb600a4af27dc7/1/0">AP Photo/Ahn Young-joon</a></span>
</figcaption>
</figure>
<h2>Can superspreading occur in all infectious diseases?</h2>
<p>Yes. Researchers have identified superspreaders in outbreaks of diseases caused by bacteria, <a href="https://doi.org/10.1186/s12879-019-3870-1">such as tuberculosis</a>, as well as those caused by viruses, <a href="https://doi.org/10.1038/nature04153">including measles</a> and <a href="https://www.eurekalert.org/pub_releases/2017-02/osu-dw021017.php">Ebola</a>. Just as appears to be the case with the coronavirus, some scientists estimate that in an outbreak of any given pathogen, 20% of the population is usually responsible for <a href="https://doi.org/10.1038/438293a">causing over 80% of all cases of the disease</a>.</p>
<p>The good news is that <a href="https://www.cdc.gov/foodsafety/outbreaks/investigating-outbreaks/investigations/control.html">the right</a> <a href="https://www.who.int/csr/disease/ebola/training/infection-prevention/en/">control practices</a> <a href="https://www.who.int/csr/bioriskreduction/infection_control/publication/en/">specific to how</a> <a href="https://www.who.int/ith/2020-24-01-outbreak-of-Pneumonia-caused-by-new-coronavirus/en/">pathogens are transmitted</a> – hand-washing, masks, quarantine, vaccination, reducing social contacts and so on – can slow the transmission rate and halt a pandemic.</p>
<p><em>This is an updated version of <a href="https://theconversation.com/what-is-a-super-spreader-an-infectious-disease-expert-explains-130756">an article</a> originally published on Jan. 30, 2020.</em></p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/139950/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth McGraw does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Epidemiological data suggests that 80% of COVID-19 cases can be traced to just 20% of those infected with SARS-CoV-2.Elizabeth McGraw, Professor of Entomology and Director of the Center for Infectious Disease Dynamics, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1381772020-06-05T10:20:21Z2020-06-05T10:20:21ZThe original Sars virus disappeared – here’s why coronavirus won’t do the same<p>British cancer doctor Prof Karol Sikora recently claimed that the current COVID-19 pandemic would <a href="https://www.mirror.co.uk/science/coronavirus-could-burn-out-naturally-22043575">“burn itself out”</a>. His thinking is that if there are more infections than we realise, and that those milder, unrecorded infections result in robust immunity, then this would quickly lead to “herd immunity”, leaving the virus nowhere to go but extinct. Extend this to the world’s population and the virus eradicates itself. </p>
<p>But the idea that letting the virus run wild would protect us is unlikely to be valid. The antibody results coming in suggest that only a small proportion of people have been infected by SARS-CoV-2. In the UK, only an <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/5june2020">estimated 6.8%</a> of people have had the virus; for France, the figure is <a href="https://science.sciencemag.org/content/early/2020/05/12/science.abc3517">just 4.4%</a>.</p>
<p>This means that we are far away from achieving herd immunity. It also suggests that the virus does indeed have the relatively high fatality rate that <a href="https://ourworldindata.org/grapher/coronavirus-cfr?country=%7EOWID_WRL">we’ve estimated</a>.</p>
<p>This raises doubts that letting the virus burn itself out would be a sensible, safe and ethical answer to the COVID-19 problem. It would be safer to imagine a future where we can live side by side with SARS-CoV-2. </p>
<p>Yet the virus that caused the original Sars disease – SARS-CoV-1 – no longer haunts us. What can its disappearance tell us about the likelihood of living in a world without SARS-CoV-2?</p>
<h2>Why the original Sars disappeared</h2>
<p>It was evident by early 2004 that the Sars outbreak <a href="https://apps.who.int/iris/bitstream/handle/10665/207501/9290612134_eng.pdf?sequence=1&isAllowed=y">had ended</a>. Starting in 2002, this epidemic lasted about one and a half years, infecting at least 8,000 people and killing 10% of them. Although it mostly affected east Asian countries, by its end Sars had spread worldwide. </p>
<p>In the midst of the turmoil, there were fears that Sars could become a serious pandemic. The virus was passed on by respiratory transmission, had spread internationally and had the ability to cause significant disease. </p>
<p>In its final days, the outbreak <a href="https://apps.who.int/iris/bitstream/handle/10665/207501/9290612134_eng.pdf?sequence=1&isAllowed=y">bounced between humans and animals in wet markets across China</a>. There would be a couple of smaller outbreaks linked to laboratory-acquired virus transmissions, but nobody would die from these.</p>
<p>Why did the original Sars epidemic come to end? Well, SARS-CoV-1 did not burn itself out. Rather, the outbreak was largely brought under control by simple public health measures. Testing people with symptoms (fever and respiratory problems), isolating and quarantining suspected cases, and restricting travel all had an effect. </p>
<p>SARS-CoV-1 was most transmissible when patients were sick, and so by isolating those with symptoms, you could effectively prevent onward spread. Nearly everybody on the planet would remain susceptible to Sars in the decades following its disappearance.</p>
<h2>Enter COVID-19</h2>
<p>It is clear that our response to SARS-CoV-1 led to the extinction of that lineage of viruses in humans. But we also knew that <a href="https://www.pnas.org/content/113/11/3048.long">very similar viruses continued to exist in bats</a>. It’s possible that a very closely related Sars-like virus could emerge in the not-too-distant future. </p>
<p>Of course, this is what happened in late 2019, when SARS-CoV-2 jumped into humans. In a few short months it had erupted into a pandemic, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7182753/">infecting millions of people worldwide and killing around 1% of those infected</a>. While this new human coronavirus is distinct from the original Sars virus, it is related.</p>
<p>In a similar timeframe to the original Sars, SARS-CoV-2 has proved to be more contagious but seemingly less deadly than its cousin was nearly 20 years ago. An additional – and critical – concern is that SARS-CoV-2 is efficiently spread <a href="https://science.sciencemag.org/content/368/6491/eabb6936">before people get sick</a>. This makes traditional symptomatic-based public health restrictions, which worked well for Sars, largely incapable of containing COVID-19.</p>
<h2>Challenges in eradication</h2>
<p>In essence, this ease of transmission means that SARS-CoV-2 is infinitely more challenging to control. We also have a poor understanding of whether catching and recovering from COVID-19 completely prevents you from catching the virus again and passing it on to others. Together, these factors mean that SARS-CoV-2 will most likely <a href="https://science.sciencemag.org/content/368/6493/860">settle into the human population, becoming an endemic virus</a> like its coronavirus cousins that are major causes of colds every winter.</p>
<p>While we haven’t been able to watch this “post-pandemic” scenario unfold for other human coronaviruses (although we strongly suspect this to have <a href="https://theconversation.com/coronaviruses-a-brief-history-135506">occurred in the not too distant past</a>), we have ample evidence that this occurs with other viral infections. Over the last 100 years or so we have had five influenza pandemics, and descendants of the most recent pandemic influenza virus (H1N1 from 2009) continue to circulate in the population more than a decade later.</p>
<p>Given that we do not know how long natural immunity to COVID-19 lasts, nor whether it is capable of blocking infection completely or only symptoms, it’s not clear that SARS-CoV-2 could ever burn itself out. Therefore, our only option remains to suppress COVID-19 as much as possible until we have a safe and effective vaccine available to the masses.</p><img src="https://counter.theconversation.com/content/138177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Connor Bamford receives funding from the Wellcome Trust. </span></em></p>The virus that caused the original Sars no longer haunts us, but the characteristics of today’s coronavirus mean it’s unlikely to disappear in the same way.Connor G G Bamford, Research Fellow, Virology, Queen's University BelfastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1390202020-05-21T12:26:26Z2020-05-21T12:26:26ZWhat the phase 1 trials of the first COVID-19 vaccine really mean<figure><img src="https://images.theconversation.com/files/336224/original/file-20200519-152292-wsnxr0.jpg?ixlib=rb-1.1.0&rect=7%2C51%2C4913%2C3223&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Moderna just released the results of a phase 1 trial for a COVID-19 vaccine.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-moderna-headquarters-are-seen-in-cambridge-news-photo/1213500091?adppopup=true">JOSEPH PREZIOSO/AFP via Getty Images</a></span></figcaption></figure><p><a href="https://investors.modernatx.com/news-releases/news-release-details/moderna-announces-positive-interim-phase-1-data-its-mrna-vaccine">Early morning on May 18, Moderna</a>, a biotechnology company, revealed the preliminary findings for the much anticipated phase I trial of an <a href="https://theconversation.com/coronavirus-a-new-type-of-vaccine-using-rna-could-help-defeat-covid-19-133217">mRNA COVID-19 vaccine</a>. The information sent Moderna’s stock soaring by more than <a href="https://www.wsj.com/articles/global-stock-markets-dow-update-05-18-2020-11589778000?mod=searchresults&page=1&pos=14">20% and helped fuel a rally on Wall Street</a>. </p>
<p>Although there was an enthusiastic response to the news, the purpose of all phase I trials is primarily to demonstrate safety and tolerability. While the early results are tantalizingly positive, what Moderna has not revealed is raising some <a href="https://www.statnews.com/2020/05/19/vaccine-experts-say-moderna-didnt-produce-data-critical-to-assessing-covid-19-vaccine/">doubts.</a></p>
<p><a href="https://www.vumc.org/ig-lab/person/sanjay-mishra">I am a data scientist</a> and was, until last month, working on vaccine development for Zika and dengue fever. Since the beginning of the COVID-19 pandemic, I have spearheaded building a consortium of more than 100 cancer centers to collect data about cancer patients who have been infected with COVID-19. The purpose of the <a href="https://ccc19.org/">COVID-19 and Cancer Consortium</a> is to rapidly collect and disseminate information about this especially vulnerable population. Having a background in vaccine development, I found Moderna’s press release lacking some key details.</p>
<h2>What is a vaccine?</h2>
<p>A vaccine imitates the infection to give the immune system a preview of the disease. Vaccination became a public health tool after Edward Jenner showed in 1796 that inoculation with the <a href="https://dx.doi.org/10.1080%2F08998280.2005.11928028">less virulent cowpox could prevent smallpox</a>. After his son’s death from smallpox, Benjamin Franklin <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653186/">regretted</a> his decision not to inoculate his son against it. Today <a href="https://dx.doi.org/10.1098%2Frstb.2013.0433">vaccines</a> are widely credited for the <a href="https://www.cdc.gov/vaccines/vpd/vaccines-list.html">prevention and eradication of many</a> of once feared deadly diseases. </p>
<p>Vaccines prepare the <a href="http://www.imgt.org/IMGTeducation/Tutorials/ImmuneSystem/UK/the_immune_system.pdf">immune system</a> by generating disease-fighting proteins called antibodies, which seek out and attack if the real infectious virus ever shows up. </p>
<p>Traditional vaccines against viruses are <a href="https://www.cdc.gov/vaccines/hcp/conversations/downloads/vacsafe-understand-color-office.pdf">either</a> weakened versions of the whole virus that are unable to cause disease; or they are made from signature viral proteins called antigens, that then spark an immune response. An antigen in the new coronavirus SARS-CoV-2 is the crown-like spike (S) protein through which the virus latches to the lung and respiratory cells. </p>
<p>However, developing vaccines based on the viral proteins is a <a href="https://doi.org/10.3389/fimmu.2018.01963">slow</a> process because of the difficulties in producing pure proteins at medical standards in large quantities. But now scientists have developed a different type of vaccine: <a href="https://theconversation.com/coronavirus-a-new-type-of-vaccine-using-rna-could-help-defeat-covid-19-133217">mRNA vaccines</a>. </p>
<p>Rather than giving a person a protein vaccine, researchers are giving them <a href="http://www.phschool.com/science/biology_place/biocoach/transcription/intro.html">mRNA,</a> which is the biological code that the cells read and translate to make their own proteins. So, instead of the traditional viral protein vaccines, an mRNA vaccine provides a synthetic copy of mRNA-encoding individual proteins from the virus, which the host body uses to produce the viral protein itself. As with other vaccines, the presence of the protein kicks off the body’s immune system to fight the virus.</p>
<p>A big advantage of mRNA vaccines is that scientists can skip the laboratory production of proteins by directly injecting the molecular instructions to make the protein into the human body itself. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336580/original/file-20200520-152338-1ypxjnd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Rather than provide a vaccine made from viral proteins, Moderna’s COVID-19 vaccine is composed of synthetic viral mRNA. These molecules are injected into people and cellular protein-making machines, called ribosomes, read and translate the mRNA. It’s these proteins that then trigger an immune response.</span>
<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Learning from previous cornovairus epidemics</h2>
<p>Massachusetts-based Moderna Inc. has fast-tracked development and testing of an experimental COVID-19 mRNA vaccine called mRNA-1273. Its collaborators at the <a href="https://www.niaid.nih.gov/">National Institute of Allergy and Infectious Diseases</a> (NIAID) were already working on experimental Middle East respiratory syndrome (MERS) <a href="https://doi.org/10.1038/ncomms8712">vaccines</a>, which targeted a closely related coronavirus spike protein. So as soon as the genetic sequence of SARS-CoV-2 became available, Moderna and its collaborators at NIAID got a head start. </p>
<p>With up to <a href="https://www.reuters.com/article/us-health-coronavirus-moderna-funding/moderna-receives-483-million-barda-award-for-covid-19-vaccine-development-idUSKBN21Y3E0">US$483 million</a> in federal funds to speed development of a coronavirus vaccine, Moderna began <a href="https://clinicaltrials.gov/ct2/show/NCT04283461">testing</a> the 2019-nCoV vaccine (mRNA-1273) on Feb. 25, 2020. </p>
<p>The phase 1 study of the investigational vaccine, <a href="https://www.niaid.nih.gov/news-events/nih-clinical-trial-investigational-vaccine-covid-19-begins">led</a> by the NIAID, part of the <a href="https://www.nih.gov/">National Institutes of Health</a> (NIH), was designed to assess the safety, tolerability and ability to induce an immune response at three dose levels – 25, 100 or 250 micrograms. </p>
<p><a href="https://investors.modernatx.com/news-releases/news-release-details/moderna-announces-positive-interim-phase-1-data-its-mrna-vaccine">On May 18, Moderna announced</a> the interim phase 1 data. mRNA-1273 was generally safe and well tolerated, except for minor redness and swelling at higher doses. </p>
<p>No volunteers faced any life-threatening events during the six weeks of study. </p>
<p>The mRNA-1273 produced antibodies which could bind the target spike protein at each of the injected doses, in all 45 volunteers (ages 18 to 55). The production of the binding antibodies response from mRNA-1273 injection was similar to the one found in patients who have recovered from previous SARS-CoV-2 infection. It is important to highlight, though, that even among the survivors of COVID-19, the antibody response is <a href="https://theconversation.com/can-you-get-the-covid-19-coronavirus-twice-137309">highly variable</a>.</p>
<h2>What has not been revealed</h2>
<p>Unconventional for a scientific study, data was given from only eight of the 45 volunteers — four each from the 25 and 100 microgram doses, who developed <a href="https://www.sciencedirect.com/book/9781455700905/vaccines">neutralizing antibodies</a>. </p>
<p>Neutralizing antibodies are essential for an effective long-lasting vaccine because they not only bind to the virus, but they block an infection. The age of the eight volunteers is not known. That is important information because COVID-19 is <a href="https://ourworldindata.org/mortality-risk-covid#case-fatality-rate-of-covid-19-by-age">far more deadly</a> for older patients. It’s important to know if this immune response was limited to the younger participants. </p>
<p>Also, the neutralizing antibody response in the remaining 37 volunteers was not disclosed. So it is impossible to know whether the mRNA-1273 was ineffective in them, or whether the results were not available at this point. </p>
<p>The <a href="https://investors.modernatx.com/news-releases/news-release-details/moderna-announces-ind-submitted-us-fda-phase-2-study-mrna">phase 2 trial</a> for mRNA-1273 has already been approved by the Food and Drug Administration. In this trial each subject will receive two vaccinations – prime and booster – of either a placebo, a 50 microgram, or a 250 microgram dose given 28 days apart. </p>
<p>The amended choice for a higher dose suggests that the lowest 25 microgram dose of phase 1 was not very effective. Moderna expects phase 3 trial to start in July and anticipates to produce <a href="https://cen.acs.org/business/outsourcing/Moderna-picks-Lonza-make-1-billion-doses-of-its-coronavirus-vaccine/98/web/2020/05">1 billion doses</a> of the vaccine soon thereafter.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/139020/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sanjay Mishra does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Results from phase 1 trials of a COVID-19 mRNA vaccine created a burst of optimism. But details the company failed to release suggest it is too early to speculate whether the vaccine is effective.Sanjay Mishra, Project Coordinator & Staff Scientist, Vanderbilt University Medical Center, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1382202020-05-17T08:50:17Z2020-05-17T08:50:17ZWhy more must be done to fight bogus COVID-19 cure claims<figure><img src="https://images.theconversation.com/files/334628/original/file-20200513-156637-1qlwfz7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A bottle of Covid Organics, a herbal tea that authorities in Madagascar gave to students.</span> <span class="attribution"><span class="source">Photo by Rijasolo/AFP via Getty Images</span></span></figcaption></figure><p>Fake and bogus cure claims are a longstanding, but neglected <a href="https://www.sciencedirect.com/science/article/pii/S016561470900203X">public health problem</a>. Throughout recorded history, plagues have inspired anxiety and desperation. Time and again, this public nervousness has proved a fertile ground for false cures and claimants to thrive. In this sense, recent claims of COVID-19 cures and antidotes are no exception.</p>
<p>During the Spanish flu, cure claims <a href="https://link.springer.com/chapter/10.1007/978-3-030-15346-5_8">generated a false sense of safety</a> that drove hundreds to defy closures and isolation. In the US, <a href="https://www.politico.com/news/magazine/2020/03/17/spanish-flu-lessons-coronavirus-133888">scores of bogus remedies</a> alleging to cure the flu were sold under upbeat labels that undermined preventive action. One ad boasted:</p>
<blockquote>
<p>When Vick’s VapoRub is applied over the throat and chest, the medicated vapors loosen the phlegm, open the air passages and stimulate the mucus membrane to throw off the germs.</p>
</blockquote>
<p>Fake and bogus cures caused the death of many as HIV swept around the world. In Nigeria, for instance, as early as the 1990s, Jeremiah Abalaka, a surgeon with fringe training in immunology, startled the world with his <a href="https://www.sciencedirect.com/science/article/pii/S0264410X04005018?via%3Dihub">HIV cure claim</a>. Many of the HIV patients who flocked to his private clinic reportedly died, including dozens of soldiers referred for treatment by the Nigerian government. </p>
<p>More recently, during both the Ebola and SARS epidemics, fake cure claims also circulated freely, with lethal consequences. For <a href="https://www.npr.org/sections/health-shots/2014/10/23/358318848/fda-cracks-down-on-fake-ebola-cures-sold-online">example</a>, salt solution, snake venom, vitamin C, Nano Silver and some herbs were all touted as cures for Ebola. At least two people died in Nigeria and about 20 more were hospitalised after drinking excessive amounts of salt solution to prevent Ebola infection.</p>
<p>Sadly, history is repeating itself in the context of COVID-19. False claims range from US president Donald Trump’s touting of anti-malaria drug <a href="https://theconversation.com/chloroquine-and-hydroxychloroquine-no-proof-these-anti-malarial-drugs-prevent-novel-coronavirus-in-humans-134703">hydroxychloroquine</a> as a miracle cure to Madagascar’s herbal <a href="https://www.sciencemag.org/news/2020/05/unproven-herbal-remedy-against-covid-19-could-fuel-drug-resistant-malaria-scientists">“cure”</a> promoted by President Andry Rajoelina. </p>
<p>In Ghana, a Pentecostal pastor launched and sold “Coronavirus Oil”, telling a packed church that it was effective against COVID-19. An American pastor also recently directed viewers to buy Optivida Silver Solution to prevent COVID-19. Its promoter had <a href="https://www.theguardian.com/us-news/2020/mar/09/jim-bakker-letitia-james-coronavirus-product-stop-promoting">falsely claimed</a> that the product was government-approved and has the ability to kill every pathogen it has ever been tested on, including SARS and HIV.</p>
<p>With growing global anxiety, many people are easy targets for cure scams and hucksters. Victims of fake cure claims are often among the world’s poorest and most vulnerable. Fighting these cure claims is integral to containing the COVID-19 pandemic. </p>
<p><a href="https://www.who.int/health-topics/coronavirus#tab=tab_1">Authorities</a> across the world are working hard to ensure that correct information and messages on the pandemic reach everybody. But there is room to do more. </p>
<h2>Why we must act now</h2>
<p>Cure claims are dangerous. They delay treatment-seeking and promote reckless behaviour that may result in deaths. At least 300 Iranians have <a href="https://academic.oup.com/alcalc/advance-article/doi/10.1093/alcalc/agaa036/5827425">died</a> from methanol poisoning after consuming alcohol to prevent COVID-19. Hours after Trump declared <a href="https://www.washingtonpost.com/business/2020/04/21/anti-malarial-drug-trump-touted-is-linked-higher-rates-death-va-coronavirus-patients-study-says/">hydroxychloroquine</a> as a miracle cure for COVID-19, people overdosed on it in Africa and Asia. In Arizona, a man died after <a href="https://www.livescience.com/coronavirus-chloroquine-self-medication-kills-man.html">reportedly</a> treating himself with a COVID-19 home therapy derived from the same anti-malarial drug that the US president touted as a wonder drug.</p>
<p>Health literacy – the ability of patients to read, comprehend and act on
medical instructions – remains weak in many contexts. Several millions of health-seekers around the world rely on informal or inexpert sources for their health information needs. Hard-to-reach and vulnerable groups and communities must be targeted through bespoke health promotion strategies.</p>
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Read more:
<a href="https://theconversation.com/false-information-fuels-fear-during-disease-outbreaks-there-is-an-antidote-131402">False information fuels fear during disease outbreaks: there is an antidote</a>
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<p>Online and traditional media offer immense potential to intensify public health education. They must maintain vigilance on COVID-19 cure scams and claimants as they emerge in diverse forms and places. However, merely identifying bogus COVID-19 cure claims or alerting the public about them is no longer enough.</p>
<p>Targeted seizure and destruction of unproven cures can deliver important results. In 2015, a global <a href="https://www.interpol.int/en/News-and-Events/News/2015/INTERPOL-coordinated-operation-strikes-at-organized-crime-with-seizure-of-20-million-illicit-medicines">crackdown</a> by Interpol seized nearly 21 million fake and illegal drugs, including fake cancer “cures”. </p>
<p>Governments must also implement community health outreach programmes that communicate clearly and accurately. Such programmes should have fit-for-purpose feedback systems to enable lay persons in multiple contexts to raise concerns, ask questions and swiftly receive answers. One size will not fit all at this time. Part of the success recorded in Nigeria during the Ebola outbreak has been attributed to the use of different media, including government-sponsored TV and radio messages, town-criers, social media campaigns, and experts to communicate health information to its citizens.</p>
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Read more:
<a href="https://theconversation.com/three-key-drivers-of-good-messaging-in-a-time-of-crisis-expertise-empathy-and-timing-135866">Three key drivers of good messaging in a time of crisis: expertise, empathy and timing</a>
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<p>Countries and national health bodies must integrate traditional healers, faith leaders and community principals in their COVID-19 response strategies. Several studies have documented proven <a href="https://theconversation.com/busting-coronavirus-myths-will-take-more-than-science-lessons-from-an-aids-study-136521">strategies</a> for effectively engaging lay and faith healers to offer correct support and <a href="https://theconversation.com/comics-and-cartoons-are-a-powerful-way-to-teach-kids-about-covid-19-137910">information</a> on epidemics. This is the time to bring these strategies to scale. </p>
<p>Robust mechanisms for holding scam COVID-19 cure claimants and hucksters accountable are also urgently needed. Currently, few countries have such mechanisms. But a good precedent exists in Australia, where a <a href="https://www.theguardian.com/australia-news/2020/may/13/healing-church-fined-150000-in-australia-over-selling-bleach-as-coronavirus-cure">“healing church”</a> that touted a bleach-based solution as a COVID-19 cure has been fined more than $150,000. Politicians and other thought leaders must also realise that their utterances and actions during this pandemic will have far-reaching health, social and economic consequences.</p><img src="https://counter.theconversation.com/content/138220/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chimaraoke Izugbara receives funding from the Hewlett Foundation, IDRC and the Ford Foundation</span></em></p><p class="fine-print"><em><span>Mary Obiyan receives funding from the Consortium for Advanced Research Training in Africa (CARTA). </span></em></p>Authorities around the world can do more to ensure that correct information and messages on the pandemic reach everybody.Chimaraoke Izugbara, Director, Global Health, Youth and Development, International Center for Research on Women (ICRW), USA & Visiting Professor, University of the WitwatersrandMary O. Obiyan, Senior Lecturer, Department of Demography and Social Statistics, Obafemi Awolowo UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1372092020-05-13T12:09:29Z2020-05-13T12:09:29ZCoronavirus vaccine: reasons to be optimistic<p>The first coronaviruses known to infect humans were <a href="https://www.cdc.gov/coronavirus/types.html">discovered more than half a century ago</a> – so why are there no vaccines against these viruses? Should we be optimistic that an effective vaccine will be developed now?</p>
<p>SARS-CoV-2, the recently discovered coronavirus that causes COVID-19, is similar enough to other coronaviruses, so scientists make predictions about how our immune system might deal with it. But its novelty warrants its own careful study. Similar to Sars and Mers that cause severe acute respiratory syndrome, the novel coronavirus has emerged from animals and can cause damage to the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102538/">lungs</a> and sometimes <a href="https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes#">other organs</a>.</p>
<p>Why don’t we have a vaccine against other human coronaviruses? The emergence of Sars and Mers, in 2002 and 2012 respectively, were either quashed relatively quickly or affected small numbers of people. Despite the interest from keen virologists, there was no economic incentive to develop a vaccine for these diseases as they posed a small threat at the time. Virologists with an interest in coronaviruses were struggling to secure funding for their research. </p>
<p>In contrast, COVID-19 has caused huge disruption around the world. As a result, <a href="https://www.nature.com/articles/d41586-020-01221-y">at least 90</a> vaccines are under development, with <a href="https://www.who.int/who-documents-detail/draft-landscape-of-covid-19-candidate-vaccines">some already in human trials</a>. </p>
<h2>How a vaccine works</h2>
<p>A vaccine gives our body a harmless flavour of the virus, alerting the immune response to generate antibodies and/or cellular immunity (T cells) ready to fight the infection. The idea is that we can then deploy a ready-made defence system next time we encounter the virus, and this spares us from severe symptoms. We know that most people who have recovered from COVID-19 <a href="https://www.ncbi.nlm.nih.gov/pubmed/32350462">have detectable antibodies</a> in their blood. </p>
<p>We don’t know if these antibodies are fully protective, but a vaccine still has the potential to elicit powerful neutralising antibodies and scientists will evaluate these following vaccination. Researchers will also look for potent T cell responses in the blood of vaccinated people. These measurements will help scientists predict the efficacy of the vaccine, and will be available before a vaccine is approved. </p>
<p>The best way to evaluate a vaccine, of course, is to judge how well it protects people from infection. But exposing vulnerable groups to the virus is far too risky, so most vaccines will be tested in younger people with no underlying health problems. There are <a href="https://academic.oup.com/jid/article/221/11/1752/5814216">ethical considerations</a> for deliberately infecting a healthy person with a potentially dangerous virus for a vaccine trial, and these need to be considered carefully. </p>
<p>In the course of a pandemic, a vaccinated volunteer may become infected with the novel coronavirus, especially if they are a healthcare worker. It will take time to gather data on protection following infection and compare them to people that received a placebo vaccine. </p>
<h2>Vaccine challenges</h2>
<p>The ideal vaccine should protect everyone and cause lifelong defences with a single dose. It would be quick to produce, affordable, easy to administer (nasal or oral administration) and wouldn’t need refrigeration, so non-specialists can distribute it to hard-to-reach parts of the world. In reality, we don’t fully understand how to produce a vaccine that induces long-lived protective immunity for different viruses. For some infections, we need to administer booster vaccinations. </p>
<p>Ageing comes with a tired immune system that struggles to respond to vaccination, and this is also the case for people with weakened immune systems, so it is difficult to protect the most vulnerable. Therefore, vaccination programmes that protect over 80% of the population can reduce the incidence of virus spreading and protect the vulnerable by proxy, through herd immunity. Currently, <a href="https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-cases">the percentage of people who may have had COVID-19 in different parts of the world varies</a>, but this is hard to estimate because of test availability.</p>
<p>Scientists test and confirm a vaccine’s safety before it is approved. We appreciate that in some viral infections, <a href="https://stm.sciencemag.org/content/5/200/200ra114?ijkey=3fd5153d1fd32d5c17c6395632928368e658b597&keytype2=tf_ipsecsha">existing antibodies from an earlier infection with the same type of virus</a> can cause more severe disease. However, there is no strong evidence for any adverse effects of antibodies for SARS-CoV-2 infection.</p>
<h2>Within reach</h2>
<p>Here are some reasons to be optimistic. One, this virus can be cured. Unlike some viruses such as HIV that embed their genome in our own and make fresh copies of themselves after immune elimination, we know that SARS-CoV-2 is <a href="https://www.ncbi.nlm.nih.gov/pubmed/32150748">unable to persist</a> in this way. </p>
<p>Two, most infected patients <a href="https://www.ncbi.nlm.nih.gov/pubmed/32350462">develop antibodies</a> and there is evidence of virus-specific <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683413/">T cell responses</a>. Although we don’t know if these responses are protective yet, these are precisely the responses that can lead to immunological memory, the cornerstone of vaccination. Vaccine products will be refined and enriched to induce more potent immune responses than natural infection. </p>
<p>Three, coronaviruses mutate <a href="https://www.livescience.com/coronavirus-mutation-rate.html">slower</a> than viruses such as influenza, and we know from Sars and Mers that antibodies can <a href="https://www.medscape.com/viewarticle/870592_1">persist</a> for at least one to two years following recovery. This is good news for an effective vaccine that may not require updating for quite some time. </p>
<p>There are more reasons to be upbeat. Scientists are <a href="https://www.nature.com/articles/d41586-020-01221-y">testing several approaches</a> so there is a higher probability of success, and pharmaceutical companies have been engaged early, scaling up production and working out logistics for distribution even before there is evidence the vaccine will work. This is worth the investment because resources can be quickly repurposed for the most promising vaccines following the first clinical trials. </p>
<p>A coronavirus vaccine is within our reach, and it is our best hope to stem transmission and generate herd immunity to protect the most vulnerable. Taking away its hosts for replication, we can eradicate this virus from the human population just as vaccination previously eradicated smallpox.</p><img src="https://counter.theconversation.com/content/137209/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zania Stamataki receives funding from the Medical Research Council, the Medical Research Foundation, the Birmingham Children's Hospital Research Foundation and the Canadian Government. Dr Stamataki collaborates with pharmaceutical companies on projects unrelated to vaccine research. </span></em></p>We don’t have vaccines for the Sars, Mers or the common cold. But that doesn’t mean scientists won’t crack it this time.Zania Stamataki, Senior Lecturer in Viral Immunology, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1383692020-05-12T14:08:49Z2020-05-12T14:08:49ZACE2: the molecule that helps coronavirus invade your cells<figure><img src="https://images.theconversation.com/files/334345/original/file-20200512-175241-1n8h2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>The more we learn about the science behind COVID-19, the more we are beginning to understand the vital role a single molecule in our bodies plays in how we contract the disease. </p>
<p>That molecule, angiotensin-converting enzyme 2, or ACE2, essentially acts as a port of entry that allows the coronavirus to invade our cells and replicate. It occurs in our lungs, but also in our <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/path.1570">heart, intestines, blood vessels and muscles</a>. </p>
<p>And it may be behind the vastly different death rates we are seeing between men and women. </p>
<h2>What is ACE2?</h2>
<p>ACE2 is an enzyme molecule that connects the inside of our cells to the outside via the cell membrane. </p>
<p>In normal physiology, another enzyme called ACE alters a chemical, angiotensin I, and converts it into angiotensin II, which causes blood vessels to constrict. The tightening of the blood vessels leads to an increase in blood pressure. </p>
<p>That’s when the ACE2 molecule comes in: to counteract the effects of ACE, causing blood vessels to dilate and lowering blood pressure.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334347/original/file-20200512-175268-dg3uio.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The spikes that make up the ‘crown’ of coronavirus bind to ACE2 enzymes to get into our cells.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>You may have seen illustrations of the virus that show distinct spikes around the surface of the virus, which form part of the “crown” or “corona” that gives the virus its name. These spikes are called <a href="https://www.uniprot.org/uniprot/P59594">S1 proteins</a>, and they are what bind to the ACE2 molecule on our cells.</p>
<p>The virus is then able to invade the cell by a process called endocytosis – where the cell membrane engulfs the virus and internalises it within a bubble called an endosome. </p>
<p>Once inside the cell, the virus interacts with the host cells’ genetic machinery, taking advantage of the existing structure to replicate extensively.</p>
<p>SARS-CoV-2, the virus behind COVID-19, has a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7164637/pdf/367_1260.pdf">high binding capacity</a> for ACE2 – between ten and 20 times more that of the original Sars virus. This means it is much easier for SARS-CoV-2 to get into human cells compared to the original coronavirus, making it more infectious overall.</p>
<h2>ACE2 and COVID-19</h2>
<p>But there is still conflicting evidence on the precise role ACE2 plays in coronavirus infections. </p>
<p>In some cases, it can actually be of benefit: ACE2 has been shown to <a href="https://physoc.onlinelibrary.wiley.com/doi/full/10.1113/expphysiol.2007.040048">reduce injury to the lung tissue</a> in cases of the original Sars virus in mice by doing its job and causing blood vessels to dilate. </p>
<p>In another mouse study, however, the binding of the Sars spike protein to ACE2 was shown to <a href="https://journals.lww.com/shockjournal/Fulltext/2016/09000/Pulmonary_Angiotensin_Converting_Enzyme_2__ACE2_.3.aspx">contribute to lung damage</a>. </p>
<p>When it comes to the current coronavirus, early studies have shown that the introduction of a human-made form of ACE2 to human cells can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7181998/pdf/main.pdf">block the early stages of infection</a> by binding the spike protein, preventing it from entering the cells. ACE2 thus acts both as an entry port to cells but also as a mechanism to protect the lung from injury. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=469&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=469&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=469&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=589&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=589&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334334/original/file-20200512-175235-iqlz4o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=589&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">The structure of the ACE2 molecule.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Protein_ACE2_PDB_1r42.png">Emw</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<h2>ACE2 and the male death toll</h2>
<p>It’s well established that COVID-19 affects men and women differently. Out of a representative sample of 1,099 patients in China, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2002032">58% were men and 42% were women</a>. Data from China has also shown that men die of COVID-19 at a <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2020.00152/full">rate two and a half times that of women</a>. </p>
<p>Similar figures have been observed in the <a href="https://www.nytimes.com/2020/04/07/health/coronavirus-new-york-men.html">US</a> and 60% of deaths in <a href="http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/weekly-surveillance-report">Europe</a> have been men.</p>
<p>We don’t yet fully understand why men die of COVID-19 in higher numbers than women, but it’s possible ACE2 plays a role. </p>
<p>A large study of two independent populations of heart failure patients was recently published in which ACE2 concentrations were found to be <a href="https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa373/5834647">significantly higher in men than in women</a>. This could explain why men may be more at risk than women of COVID-19 infection and of dying from the disease.</p>
<h2>ACE2 and other conditions</h2>
<p>The other important factor in the outcome of patients is the presence of <a href="https://jamanetwork.com/journals/jama/fullarticle/2762130">underlying health problems</a>.</p>
<p>Recently, ACE2 has been identified in different cells of the heart. There are a <a href="https://academic.oup.com/cardiovascres/article/doi/10.1093/cvr/cvaa078/5813131">greater number of ACE2 receptors</a> on the surface of cells in the heart muscle in people with established cardiovascular disease compared to those without disease. </p>
<p>This may result in a greater number of virus particles <a href="https://theconversation.com/coronavirus-severe-forms-of-the-disease-can-damage-the-heart-136352">entering the heart cells </a> in COVID-19 patients with established heart diseases.</p>
<p>Given the role ACE2 plays in regulating blood pressure, there are also concerns about how it affects COVID-19 patients with hypertension. Men are more likely to have hypertension than women, especially under the age of 50. </p>
<p>Two particular drugs to reduce hypertension also affect ACE and ACE2. These are angiotensin converting enzyme inhibitors, or ACEi, and angiotensin receptor blockers, known as ARBs. In animal studies, both of these drug types <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7095949/pdf/41591_2005_Article_BFnm0805821.pdf">increase the production of the ACE2 enzyme</a> and so may increase the severity of COVID-19 infection. </p>
<p>Small independent studies have examined the effect of these treatments on COVID-19 with <a href="https://journals.sagepub.com/doi/pdf/10.1177/2047487320918421">conflicting results</a>. However, a <a href="https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.120.317134">recent study</a> on the subject has demonstrated that COVID-19 patients with untreated hypertension have a higher risk of death compared to those being treated with ACEi or ARBs. </p>
<p>That’s why many <a href="https://www.acc.org/latest-in-cardiology/articles/2020/03/17/08/59/hfsa-acc-aha-statement-addresses-concerns-re-using-raas-antagonists-in-covid-19">professional societies</a> are <a href="https://www.ema.europa.eu/en/news/ema-advises-continued-use-medicines-hypertension-heart-kidney-disease-during-covid-19-pandemic">advising people</a> with high blood pressure to continue using their medicines during the crisis. </p>
<p>The role that ACE2 plays in COVID-19 is important in our understanding of the disease and could be used as a target for therapy. Drugs could be designed to block the receptor function of ACE2, but also there is promise in using the molecule itself in preventing entry of the virus into cells. </p>
<p>This would protect organs such as the lung, heart, kidney and intestine from extensive damage, and hopefully reduce mortality.</p><img src="https://counter.theconversation.com/content/138369/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David C Gaze is affiliated with The Association for Clinical Biochemistry and Laboratory Medicine; The American Association of Clinical Chemistry; Royal Society of Medicine; Pathological Society of Great Britain & Ireland; European Society of Pathology. </span></em></p>A molecule responsible for lowering our blood pressure also helps coronavirus get into our cells and replicate. And it occurs more in men than in women.David C. Gaze, Lecturer in Clinical Biochemistry, University of WestminsterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1375782020-05-06T12:21:30Z2020-05-06T12:21:30ZThe puzzling questions of the coronavirus: A doctor addresses 6 questions that are stumping physicians<figure><img src="https://images.theconversation.com/files/332508/original/file-20200504-83730-49tcx4.jpg?ixlib=rb-1.1.0&rect=8%2C17%2C2964%2C1976&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The typically crowded Brooklyn Bridge in New York City, now nearly desolate in the midst of the coronavirus outbreak. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-wearing-a-mask-walks-the-brooklyn-bridge-in-the-midst-news-photo/1207839451?adppopup=true">Getty Images / Victor J. Blue</a></span></figcaption></figure><p><em>Editor’s Note: As researchers try to find treatments and create a vaccine for COVID-19, doctors and others on the front lines continue to find perplexing symptoms. And the disease itself has unpredictable effects on various people. Dr. William Petri, a professor of medicine at the University of Virginia Medical School, answers questions about these confusing findings.</em></p>
<p><strong>Some evidence suggests that patients experience low oxygen saturation days before they appear in the ER. If so, is there a way to treat patients earlier?</strong></p>
<p><a href="https://doi.org/10.1016/S1473-3099(20)30086-4">Even before symptoms arise</a>, people infected with SARS-CoV-2 show damage to their lungs. This is likely why low oxygen saturation – that is, below-normal oxygen levels in their blood – occurs before the patient goes to the ER. Restoring those levels to normal is presumed, though not proven, to be beneficial; giving patients supplemental oxygen via a nasal cannula, a flexible tube that delivers oxygen, placed just inside the nostrils, <a href="https://science.sciencemag.org/content/sci/368/6490/455.full.pdf">will restore oxygen to normal levels</a> unless disease worsens to the extent that mechanical ventilation is needed.</p>
<p><strong>Young adults are having strokes with COVID-19. Does this suggest the illness is more of a vascular disease than a lung disease in that age group</strong>?</p>
<p>COVID-19 can be a devastating disease to multiple organs and systems in the body, including the vascular and immune systems. A lung infection <a href="http://shaleklab.com/publication/sars-cov-2-receptor-ace2-is-an-interferon-stimulated-gene-in-human-airway-epithelial-cells-and-is-detected-in-specific-cell-subsets-across-tissues/">is the primary cause</a> of disease and death. There are examples of the clotting system being activated and causing strokes, <a href="https://science.sciencemag.org/content/368/6490/473/tab-pdf">perhaps caused by</a> an immune system responding <a href="https://science.sciencemag.org/content/368/6490/473/tab-e-letters">abnormally to COVID-19</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332515/original/file-20200504-83764-w43zap.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A sign in a clothing store in Stuart, Florida warns shoppers to keep their distance. Retail stores, restaurants and beaches have now reopened in a majority of Florida counties.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/beth-beall-shops-at-the-tommy-bahamas-store-as-the-state-of-news-photo/1222825247?adppopup=true">Getty Images / Joe Raedle</a></span>
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<p><strong>The Centers for Disease Control and Prevention recently updated its official list of symptoms. Does this suggest anything unusual about COVID-19?</strong></p>
<p>This new information is due to a greater number of infected individuals <a href="https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html">being studied</a>. The update simply reflects a better understanding of the full spectrum of illness due to COVID-19, from asymptomatic to presymptomatic to severe and fatal
infections. </p>
<p><strong>How can so many people experience such mild symptoms and others quickly die from it?</strong> </p>
<p>One of the most fascinating aspects of these diseases is the huge difference that individuals experience with an infection. In our own research, we have found that many children in the U.S. infected with <a href="https://www.ncbi.nlm.nih.gov/pubmed/29897482">cryptosporidia</a> have no symptoms, yet this parasite is a major killer of infants in the developing world. After an infection of SARS-CoV-2, the severity of the illness is likely due in part to how the patient’s immune system responds; an overzealous immune response may cause death through what is called colloquially a “<a href="https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes">cytokine storm.</a>.” We do not know yet if cytokine storms occur more in one group than another – for example, older versus younger. </p>
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<img alt="" src="https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=366&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=366&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=366&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=460&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=460&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332517/original/file-20200504-83730-10xaf6r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=460&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Thousands of white markers on the grounds of the First Congregational Church in Greenwich, Connecticut. Each marker honors lives lost to the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/thousands-of-white-markers-are-seen-on-the-lawn-placed-by-news-photo/1211718340?adppopup=true">Getty Images / Timothy A. Clary</a></span>
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<p><strong>The disease appears now to affect various other organs – heart and kidney, for example. What does this suggest?</strong></p>
<p>What we know most clearly is that infection starts only in human cells with the ACE2 receptor – that is, in a cell that is capable of receiving the virus. That is present not only in the lungs, but in other cells as well, including those in the intestine and in the nasal mucosa, which lines the nasal cavity. When those cells are infected, the immune system is activated. A consequence is that both the heart and kidney are affected. </p>
<p><strong>Why are some countries not experiencing as much COVID-19 as the U.S., Europe and China?</strong></p>
<p>I think it’s too early in the pandemic to know if certain countries or populations are relatively less susceptible. The younger overall age of a population could be a primary factor. Or perhaps the virus, so far at least, has not had time to spread more widely in these countries. </p>
<p>[<em>You need to understand the coronavirus pandemic, and we can help.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-help">Read The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/137578/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Petri does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mysteries surround the coronavirus, but our expert is here to address some of the most perplexing issues.William Petri, Professor of Medicine, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1375832020-05-05T12:20:53Z2020-05-05T12:20:53ZThe mysterious disappearance of the first SARS virus, and why we need a vaccine for the current one but didn’t for the other<figure><img src="https://images.theconversation.com/files/332061/original/file-20200501-42956-1c2bgpo.jpg?ixlib=rb-1.1.0&rect=5%2C29%2C1949%2C1344&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Visitors look at new anti-SARS outfits for medical workers on display Thursday Nov. 6, 2003 in Shanghai, China, as the country braced for a resurgence. The disease never made a comeback.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Associated-Press-International-News-China-CHINA-SARS/c6c95c9e25e4da11af9f0014c2589dfb/133/0">AP Photo/Eugene Hoshiko</a></span></figcaption></figure><p>Some people question why the current coronavirus has brought the world to standstill while a previous deadly coronavirus, SARS, did not. </p>
<p>Others have questioned <a href="https://www.washingtonpost.com/politics/2020/04/17/laura-ingraham-fauci-interview/">why a vaccine is so urgently needed now</a> to stop the spread of the current coronavirus when a vaccine was never developed for SARS.</p>
<p>I study viruses and am so fascinated by their complexity that I have written a <a href="https://press.princeton.edu/books/hardcover/9780691166964/virus">book about them</a>. The tale of SARS and its new cousin that causes COVID-19, SARS-CoV-2, shows just how unpredictable viruses can be, particularly when they jump from animals to humans. Understanding emerging, infectious diseases needs to be a priority. SARS, which killed about <a href="https://doi.org/10.1046/j.1440-1843.2003.00518.x">one in 10 infected people</a>, turned out to be highly lethal but ultimately, and somewhat mysteriously, disappeared.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332038/original/file-20200501-42951-1ptz8k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Coronaviruses are a large family of viruses, ranging from the common cold to more severe diseases, including the novel coronavirus and SARS.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/coronavirus-structure-royalty-free-image/1203695052?adppopup=true">Getty Images / xia yuan</a></span>
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<h2>A virus takes hold</h2>
<p><a href="https://www.nejm.org/doi/10.1056/NEJMra032498">SARS, or severe acute respiratory syndrome</a>, was first noted in Guangdong province, China in November of 2002, when doctors there saw an unusual pneumonia. But the disease was not reported to the World Health Organization at that time. </p>
<p>In February of 2003, another outbreak occurred in Hanoi, Vietnam, and a WHO officer, who later died, examined a patient there and reported a large outbreak to the WHO main office on March 10, 2003.</p>
<p>Meanwhile, a doctor from Guangdong province traveled to Hong Kong and stayed at the <a href="https://www.cnbc.com/2020/02/14/hong-kong-hotel-hosted-super-spreader-in-the-2003-sars-outbreak.html">Metropol Hotel</a>, along with a number of other international travelers. The doctor was infected with what we now know as SARS-CoV-1. The virus was transmitted to at least a dozen other hotel guests. Two returned to Canada and took the virus there. One returned to Ireland, one to the United States. Three went to Singapore, and one to Vietnam. In addition, a few people were hospitalized in Hong Kong, leading to an outbreak in the hospital there. </p>
<p>From that point, SARS spread to much of the world, although most cases remained in Asia. The virus was aggressive and lethal. Patients typically showed symptoms within two to three days. There were few reports of any infections without symptoms, as there are with COVID-19. The masks came out, temperature scanners were placed in all major public gathering places in China and other parts of Asia, quarantines were implemented, the virus infection peaked in late May of 2003 and then it disappeared. The strict quarantine measures paid off, and by July 2003, the WHO declared the threat over. </p>
<p>In all there were just over 8,000 cases of SARS-CoV-1, and about 700 deaths. In the U.S. there were a <a href="https://www.cdc.gov/sars/about/fs-sars.html">total of just 29 confirmed cases</a>, and no deaths. The Hong Kong economy, with a large tourism component, was severely impacted by SARS in 2003, much as the U.S. tourism industry is currently one of the most heavily impacted parts of the economy due to SARS-CoV-2.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332040/original/file-20200501-42929-1d79q75.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">From 2003, in Hong Kong, people riding the subway during the SARS outbreak.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hong-kong-people-riding-subway-during-sars-outbreak-royalty-free-image/200509489-001?adppopup=true">Getty Images / xPacifica</a></span>
</figcaption>
</figure>
<h2>Killing cousins?</h2>
<p>SARS-CoV-1 and SARS-CoV-2 are closely related viruses. Scientists believe that both viruses originated in bats. The RNA genomes of the viruses are about 80% identical. What does that mean? </p>
<p>Our own genomes are over 98% identical to those of chimpanzees, so 80% seems a lot less similar. For a virus though, especially one with an RNA genome, this is actually very closely related.</p>
<p>That’s because viruses can mutate very rapidly. They make a lot of mistakes when they copy their genomes, and they make thousands of copies in a few hours.</p>
<p>The two viruses have very similar proteins on their exterior and use the same proteins, or receptors, on our cell surfaces to enter the cell. <a href="https://www.the-scientist.com/news-opinion/receptors-for-sars-cov-2-present-in-wide-variety-of-human-cells-67496">These receptors</a> are found in a lot of different cell types. </p>
<p>Most studies of SARS-CoV-1 focused on the lungs, because that is where the most severe disease occurred, but both viruses can infect a lot of different organs. We won’t know how often other organs are infected with SARS-CoV-2 until there is time to do proper autopsies and fully understand the way the virus causes disease.</p>
<p>How are they different, and how is that impacting the course of the pandemic? SARS-CoV-1 was more aggressive and lethal than SARS-CoV-2. However, SARS-CoV-2 spreads faster, sometimes with hidden symptoms, allowing each infected person to infect several others. The current estimate is <a href="https://doi.org/10.1016/j.bsheal.2020.03.004">about three</a>, but we scientists won’t know the real number until we can test a lot more people, and can understand the role of people without symptoms. </p>
<p>The most important difference is that contact tracing – or finding out who was exposed to someone infected with the virus – was relatively easy: Everyone had severe symptoms in two to three days. </p>
<p>With SARS-CoV-2, it takes about two weeks for symptoms to appear, and many people don’t have any symptoms at all. Imagine asking someone whom they had contact with for the last two weeks! You can accurately remember most people you had contact with for the past two days, but two weeks? This critical tool for pandemic control is very challenging to implement. This means that the only safe thing to do is to maintain quarantine of everyone until the pandemic is under control.</p>
<p>What about a SARS vaccine? Vaccine studies for SARS-CoV-1 were started and tested in animal models. An inactivated whole virus was used in ferrets, nonhuman primates and mice. All of the vaccines resulted in protective immunity, but there were complications; the vaccines resulted in an immune disease in animals. No human studies were done, nor were the vaccine studies taken further because the <a href="https://doi.org/10.1371/journal.pone.0035421">virus disappeared</a>. Many factors were involved in the end of SARS-CoV-1, perhaps including summer weather, and certainly strict quarantine of all those who had contact with infected individuals, but we don’t really know why the epidemic ended. Viruses are like that, unpredictable!</p>
<p>Many of the vaccines being developed for SARS-CoV-2 are quite different, and many use only small portions of the virus, or the <a href="https://www.sciencedirect.com/science/article/pii/S1074761320301205">virus RNA</a>. This may circumvent the problems with SARS-CoV-1 vaccines that used more of the virus. Vaccine development has a large experimental component; we just have to make educated guesses and try different things and see what works. Hence, many different avenues for vaccines are being tested by different labs around the world.</p>
<p>[<em>Get facts about coronavirus and the latest research.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=upper-coronavirus-facts">Sign up for The Conversation’s newsletter.</a>]</p><img src="https://counter.theconversation.com/content/137583/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marilyn J. Roossinck receives funding from National Fish and Wildlife Foundation; National Science Foundation; US Department of Agriculture. </span></em></p>COVID-19 and SARS are both deadly – but different. SARS symptoms were quick to appear, making it easier to contain. Because health officials were able to contain it, the virus died off.Marilyn J. Roossinck, Professor of Plant Pathology and Environmental Microbiology, Penn StateLicensed as Creative Commons – attribution, no derivatives.