Virus World

JAKARTA, Indonesia (AP) — Indonesia surpassed 100,000 confirmed COVID-19 deaths on Wednesday, a grim milestone in a country struggling with its worst pandemic wave fueled by the delta variant, amid concerns the actual figure could be much higher.  It took 14 months for Indonesia to exceed the 50,000 death mark at the end of May, and just over nine weeks to double it. The Health Ministry recorded 1,747 new deaths of COVID-19 in the last 24 hours, bringing the total to 100,636. Those figures are believed to be an undercount. Since the beginning of June, more than 2,800 people have died during self-isolation at home, according to LaporCOVID-19, an independent virus data group that keeps track of deaths at home. Some of those deaths are reflected in official figures but others are not, he said. “They were rejected by the hospitals, so they went back home and did the self-isolation at home with limited access to medicine, no oxygen and no monitoring from doctors until they died,” said Ahmad Arif, one of the LaporCOVID-19 founders. WHO says hospitals are in need of isolation rooms, oxygen supplies, medical and personal protective equipment, as well as mobile field hospitals and body bags. Lia Partakusuma, secretary general of the Indonesia Hospital Association, said intensive care beds continue to be in very short supply, especially outside of Java, where she said her association has received many reports of people dying at home.

“It is very rare that patients come and get into the ICU directly,” she said. “Many of them refuse to wait in the emergency unit, maybe they feel uncomfortable, so they decide to go back home.” In Bogor, south of Jakarta, Pramirtha Sudirman’s infected brother and parents decided to isolate at home because local hospitals were too crowded in early July. They consulted with a doctor ahead of time and had a plan to rush to the hospital if the symptoms got worse, the 32-year-old said. “We knew the risk of doing self isolation,” she said. After seeming to be on the road to recovery, her father suddenly took a turn for the worse and died at home before they could get him to the emergency room. Her mother and brother have since recovered. “We tried our best. We do not have any regret as we also know that the hospital was full too,” she said. Indonesia, the world’s fourth most populous country, has recorded more than 3.5 million COVID-19 cases since March 2020. July was its deadliest month since the pandemic began, with more than 30,100 deaths — more than triple the 7,914 reported in June. Its current per capita death rate is one of the worst in the region, second only to Myanmar. In response, the government has stepped up its vaccination campaign, diverted most of the country’s industrial oxygen production for medical use, built more isolation centers and field hospitals, and has increased supplies of medicine to hospitals. The situation has eased somewhat in Jakarta, where patients were not being turned away like in the past, said Mahesa Paranadipa, the co-leader of the Risk Mitigation Team of the Indonesian Medical Association.

Following 803 pregnant and postpartum deaths, authorities have warned women to delay pregnancy as alarm rises.  This month should have been one of the happiest in Letícia Aparecida Gomes’s life. The pregnant 23-year-old Brazilian had been due to marry before delivering her baby, Elloah, in August. Instead, as the Covid-19 pandemic swept Gomes’s country claiming thousands of lives each day, she was taken to hospital having been infected herself. “I felt desperate when I realised it was serious because this is my first pregnancy, my first daughter,” said Gomes, a nursing technician from Maricá, a coastal city an hour’s drive east of Rio de Janeiro. Gomes was lucky. After an agonising week in intensive care, she was discharged and is now recovering at home and preparing to welcome her child.  Others have been far less fortunate. At least 803 pregnant and postpartum women have died from Covid-19 since the pandemic hit Brazil last February, according to a Brazilian taskforce that is studying Covid’s impact on pregnancy. More than half of those deaths, 432, happened this year as Brazil’s pandemic accelerated into by far its deadliest phase. In recent weeks Brazilian newspapers have filled with heartbreaking stories of young mothers killed by the disease including another 23-year-old, Maria Laura Prucoli, who died on Rio’s deprived outskirts last week after her daughter, Lavínia, was delivered by emergency C-section. On 3 April, three days before Gomes was admitted to hospital, a 20-year-old woman who was seven months pregnant died in the midwestern state of Mato Grosso after waiting four days for an intensive care bed.

Concern over the risk Covid poses to pregnant and postpartum women has been expressed around the world, including in the UK where doctors have reported an increase in intensive care admissions and the use of ventilators during the second wave. But experts and activists say the situation in Brazil is particularly alarming, with authorities recently urging women to delay having children until the country’s outbreak loses steam. “We are facing a calamity of maternal deaths here,” said Carla Andreucci, a Brazilian obstetrician and member of the pregnancy taskforce. “There are women dying without finding an ICU bed, without being offered ventilation, without being intubated … It’s like we’re just standing by and watching this happen.” Last July Andreucci’s group published a study suggesting 77.5% of the world’s Covid-related maternal deaths had occurred in the South American country, although they noted that some low-income countries did not release such data. Specialists say a range of factors help explain the high number of pregnant women falling severely ill and losing their lives to Covid in Brazil. They include the way in which the pandemic-induced healthcare collapse deepened historically high rates of maternal deaths. Inadequate access to prenatal care and family planning are longstanding challenges of Brazil’s public health system, with the country suffering rates of maternal deaths more than three times the average of OECD countries even before the pandemic. Some suspect new forms of coronavirus, such as the P1 variant linked to the Brazilian Amazon, may also be partly responsible although there is still no concrete evidence of this. “We don’t have genetic tests but we believe the outbreak of P1 in January played a role in this catastrophe,” Andreucci said, noting that the profile of victims had changed in recent months. Last year, most victims were non-white women from poor areas with risk factors such as diabetes, obesity and cardiovascular disease. This year, white women with no risk factors have been dying as well. Letícia Gomes had been enjoying a healthy pregnancy until she started experiencing coughing fits, tiredness and a temperature in late March and her oxygen levels fell to a worrying 83%. She suspects she was infected making the 20-minute bus journey from her house to the nursing home where she works. During her first night in hospital, Gomes remembered sharing a room with eight other patients: “It was nerve-racking because you saw people in need of oxygen, people dying in front of you, doctors having to choose who had priority.” The next day Gomes was transferred to a specialist unit for pregnant women with Covid at the State Public Servants Hospital in Rio. There, doctors reassured her the illness had not affected her child. “They made me listen to my baby’s heart, so I knew she was fine,” said Gomes, who recalled feeling overjoyed when she called home with news of her discharge over a week in the ICU.

“Everyone was surprised and cried. I cried too,” Gomes said. Her wedding will finally happen on 21 May. A domestic outcry over the plight of Brazilian pregnant and postpartum women saw the health ministry this week include them in the priority vaccination group. So far, however, fewer than 10% of Brazilians have received two doses meaning most pregnant women will face a long wait. In the meantime, the leftist congresswoman Sâmia Bomfim, who is seven months pregnant with her first child, is proposing new legislation that would allow expectant mothers to work from home during the pandemic. “I am able to socially isolate and work from home, but the majority of pregnant women in Brazil don’t have this privilege”, Bomfim said. A total of 8.5 million Brazilian women have left the workforce since the epidemic began last February. Raíssa Perlingeiro, an infectious disease specialist at the Covid centre in Rio, said that over the past three months, as Brazil’s outbreak intensified, her unit had become busier and their shifts more demanding. Patients were arriving with more serious conditions than before. “It is very tough work and it’s very hard to watch women go through this – particularly because I’m seven months pregnant myself,” Perlingeiro said. The 32-year-old doctor said she had decided to continue working at the unit after being vaccinated as part of a campaign to protect frontline healthworkers. “I couldn’t be away from work at such a difficult time, the team is already small,” Perlingeiro said. “I had to do my part.”

Over the past 10 months, the virus has taken more lives than H.I.V., malaria, influenza and cholera. And as it sows destruction in daily life around the globe, it is still growing quickly.  More than H.I.V. More than dysentery. More than malaria, influenza, cholera and measles — combined. In the 10 months since a mysterious pneumonia began striking residents of Wuhan, China, Covid-19 has killed more than one million people worldwide as of Monday — an agonizing toll compiled from official counts, yet one that far understates how many have really died. It may already have overtaken tuberculosis and hepatitis as the world’s deadliest infectious disease, and unlike all the other contenders, it is still growing fast. Like nothing seen in more than a century, the coronavirus has infiltrated every populated patch of the globe, sowing terror and poverty, infecting millions of people in some nations and paralyzing entire economies. But as attention focuses on the devastation caused by halting a large part of the world’s commercial, educational and social life, it is all too easy to lose sight of the most direct human cost More than a million people — parents, children, siblings, friends, neighbors, colleagues, teachers, classmates — all gone, suddenly, prematurely. Those who survive Covid-19 are laid low for weeks or even months before recovering, and many have lingering ill effects whose severity and duration remain unclear.  Yet much of the suffering could have been avoided — one of the most heartbreaking aspects of all “This is a very serious global event, and a lot of people were going to get sick and many of them were going to die, but it did not need to be nearly this bad,” said Tom Inglesby, the director of the Johns Hopkins Center for Health Security, which aims to protect people’s health from epidemics and disasters.

Places like China, Germany, South Korea and New Zealand have shown that it is possible to slow the pandemic enough to limit infections and deaths while still reopening businesses and schools. But that requires a combination of elements that may be beyond the reach of poorer countries and that even ones like the United States have not been able to muster: wide-scale testing, contact tracing, quarantining, social distancing, mask wearing, providing protective gear, developing a clear and consistent strategy, and being willing to shut things down in a hurry when trouble arises. No one or two or three factors are the key. “It’s all an ecosystem. It all works together,” said Martha Nelson, a scientist at the National Institutes of Health who specializes in epidemics and viral genetics, and who studies Covid-19. It comes down to resources, vigilance, political will and having almost everyone take the threat seriously — conditions harder to attain when the disease is politicized, when governments react slowly or inconsistently, and when each state or region goes its own way, advisable or not. “It’s one thing to have all the technical capabilities, but if our leaders undermine science, minimize the epidemic or falsely reassure people, we put everything else at risk,” Dr. Inglesby said. Time and again, experts say, governments reacted too slowly, waiting until their own countries or regions were under siege, either dismissing the threat or seeing it as China’s problem, or Asia’s, or Italy’s, or Europe’s, or New York’s.

Thomas R. Frieden, a former head of the U.S. Centers for Disease Control and Prevention, said that a major failing had been in governments’ communication with the public, nowhere more so than in the United States “You have standard principles of risk communication: Be first, be right, be credible, be empathetic,” he said. “If you tried to violate those principles more than the Trump administration has, I don’t think you could.” The world now knows how to bend the curve of the pandemic — not to eliminate risk, but to keep it to a manageable level — and there have been surprises along the way. Masks turned out to be more helpful than Western experts had predicted. Social distancing on an unheard-of scale has been more feasible and effective than anticipated. The difference in danger between an outdoor gathering and an indoor one is greater than expected...

More than 600,000 people in the U.S. have now lost their lives to COVID-19, a staggering toll that comes even as new infections and deaths steadily decline and much of the country attempts to return to pre-pandemic normal life.  The rate of severe illness and death has fallen dramatically as more and more people get vaccinated, but hundreds of people are still dying daily, offering a striking contrast with the joyous scenes of reopening. Worldwide, more than 176 million people have been diagnosed with the coronavirus, according to a Johns Hopkins University tracker, and more than 3.8 million have died from it.  The U.S. in late February became the first country to surpass a half-million coronavirus deaths. That it has taken more than three months to reach 600,000 deaths is a testament to the slowing pandemic — it took just a month for the U.S. to jump from 300,000 to 400,000 COVID-19 deaths. But it is also a sign that the virus is still circulating, and new variants pose an even greater threat to the remaining people who are unvaccinated. Nationally, 64.5 percent of people in America above age 18 have received at least one dose of vaccine, according to the Centers for Disease Control and Prevention (CDC).

President Biden has set a goal of vaccinating 70 percent of U.S. adults with at least one dose of a COVID-19 vaccine by July 4. While 13 states have reached that threshold, others are lagging behind, especially in the southeast, and the nation appears increasingly unlikely to meet Biden's benchmark. The vaccination rate in the U.S. fell by nearly half in the past few months. At its peak in mid-April, an average of nearly 3.4 million vaccines were being administered daily, according to CDC data, but by May about 1.8 million were being administered, a drop of 46 percent. The daily rate of vaccinations dropped below 1 million doses for the first time earlier this month. Experts say the effort has already reached the low-hanging fruit of people eager to get vaccinated, and the new phase needs to be much more individually focused. Racial and ethnic disparities persist, with access to a vaccine being reported as the most common impediment. However, there is also a significant political disparity, as white Republicans say they have no intention of ever getting vaccinated.  Officials have acknowledged that multiple states across the country have recently stopped asking for the full allotment of vaccines from the federal government. The federal government last week had to extend the shelf life of the Johnson & Johnson vaccine by six weeks, after multiple state officials warned their doses in storage would expire before the end of this month. Despite the drop in vaccine demand, the nationwide vaccination effort appears to be paying off, with the daily infection rate continuing to drop. In May, the number of new reported COVID-19 cases fell below 10,000 for the first time since March 2020. More than 33 million coronavirus cases have been reported in the U.S. so far.

The mortality rate among patients in the Democratic Republic of the Congo with severe or critical cases of COVID-19 is nearly 50%, according to a study in The American Journal of Tropical Medicine and Hygiene. The study was the first to explore the clinical characteristics and outcome management of COVID-19 patients in an African country. Jean Nachega, MD, PhD, MPH, FRCP, FAAS, associate professor of epidemiology, infectious diseases and microbiology at University of Pittsburgh and adjunct professor of medicine at Stellenbosch University in Cape Town, and colleagues conducted a retrospective cohort study using data from the Democratic Republic of the Congo (DRC) health ministry’s COVID-19 database that was collected between March 10, 2020, and July 31, 2020. The study included data from 766 patients with COVID-19 admitted to the seven largest health facilities in Kinshasa.

“Whilst it is generally thought that COVID-19 in Africa causes lower mortality rates than in Western countries, COVID-19 is an important disease and does cause mortality in elderly adults with comorbidities,” Sir Alimuddin Zumla, KBE, FRCP, FRCPath, FRSB, senior co-author and professor of infectious diseases and international health at University College London, told Healio. “Physicians should not become complacent.” Among the patients in the study, overall hospital mortality was 13.2% (95% CI, 10.9-15.8), with a higher rate of mortality among patients with severe and critical disease than those with mild or moderate disease (45% vs. 2.6%; P < .001). According to the study, 34.6% of patients had at least one comorbidity and 48.5% had more than one. The most common comorbidities were hypertension (25.4%) and diabetes (14%). Of the patients who died, four were children. “One surprising finding was the high COVID-19 death rate among young patients”— 11.8% among patients aged 20 years or younger — “when compared to the United States, where hospitalization rates and death rates in children and adolescents with COVID-19 are lower than those in adults,” Nachega, told Healio.

Published in American J. Topical Medicine and Hygiene (Oct. 2, 2020):

https://doi.org/10.4269/ajtmh.20-1240