vox--2020-06-12--The emerging long-term complications of Covid-19, explained

At first , Lauren Nichols tried to explain away her symptoms .
In early March , the healthy 32-year-old felt an intense burning sensation , like acid reflux , when she breathed .
Embarrassed , she didn ’ t initially seek medical care .
When her shortness of breath kept getting worse , her doctor tested her for Covid-19 .
Her results came back positive .
But for Nichols , that was just the beginning .
Over the next eight weeks , she developed wide and varied symptoms , including extreme and chronic fatigue , diarrhea , nausea , tremors @ @ @ @ @ @ @ short-term memory loss .
“ The guidelines that were provided by the CDC [ Centers for Disease Control and Prevention ] were not appropriately capturing the symptoms that I was experiencing , which in turn meant that the medical community was unable to ‘ validate ’ my symptoms , ” she says .
“ This became a vicious cycle of doubt , confusion , and loneliness.
” As estimated 40 to 45 percent of people with Covid-19 may be asymptomatic , and others will have a mild illness with no lasting symptoms .
@ @ @ @ @ @ @ patients who are finding their recovery takes far longer than the two weeks the World Health Organization says people with mild cases can expect .
( The WHO says those with severe or critical cases can expect three to six weeks of recovery . )
Because Covid-19 is a new disease , there are no studies about its long-term trajectory for those with more severe symptoms ; even the earliest patients to recover in China were only infected a few months ago .
But doctors say the novel coronavirus can attach to human @ @ @ @ @ @ @ and penetrate many major organs , including the heart , kidneys , brain , and even blood vessels .
“ The difficulty is sorting out long-term consequences , ” says Joseph Brennan , a cardiologist at the Yale School of Medicine .
While some patients may fully recover , he and other experts worry others will suffer long-term damage , including lung scarring , heart damage , and neurological and mental health effects .
The UK National Health Service assumes that of Covid-19 patients who have required hospitalization , 45 percent will need @ @ @ @ @ @ @ require inpatient rehabilitation , and 1 percent will permanently require acute care .
Other preliminary evidence , as well as historical research on other coronaviruses like severe acute respiratory syndrome ( SARS ) and Middle East respiratory syndrome ( MERS ) , suggests that for some people , a full recovery might still be years off .
For others , there may be no returning to normal .
There ’ s a lot we still don ’ t know , but here are a few of the most notable potential long-term impacts that @ @ @ @ @ @ @ patients .
Melanie Montano , 32 , who tested positive for Covid-19 in March , says that more than seven weeks after she first got sick , she still experiences symptoms on and off , including burning in her lungs and a dry cough .
Brennan says symptoms like that occur because “ this virus creates an incredibly aggressive immune response , so spaces [ in the lungs ] are filled with debris and pus , making your lungs less pliable.
” On CT scans , while normal lungs appear black , Covid-19 @ @ @ @ @ @ @ patches , called “ ground-glass opacities ” — which may not heal .
One study from China found that this ground-glass appearance showed up in scans of 77 percent of Covid-19 patients .
In another study out of China , published in Radiology , 66 of 70 hospitalized patients had some amount of lung damage in CT scans , and more than half had the kind of lesions that are likely to develop into scars .
( A third study from China suggests this is not just for critically ill patients ; its @ @ @ @ @ @ @ , 95 percent also had evidence of these ground-glass opacities in their lungs .
More than a quarter of these individuals went on to develop symptoms within a few days . )
“ These kinds of tissue changes can cause permanent damage , ” says Ali Gholamrezanezhad , a radiologist at the Keck School of Medicine at the University of Southern California .
Although it ’ s still too early to know if patients with ongoing lung symptoms like Montano will have permanent lung damage , doctors can learn more about what to @ @ @ @ @ @ @ have recovered from SARS and MERS , other coronaviruses that resulted in similar lung tissue changes .
One small longitudinal study published in Nature followed 71 SARS patients from 2003 until 2018 and found that more than a third had residual scarring , which can mean reduced lung capacity .
MERS is a little harder to extrapolate from , since fewer than 2,500 people were infected , and somewhere between 30 and 40 percent died .
But one study found that about a third of 36 MERS survivors also had long-term lung damage @ @ @ @ @ @ @ review of SARS and MERS and says that for this subset of people , “ The pulmonary function never comes back ; their ability to do normal activities never goes back to baseline.
” Additionally , Covid-19 scarring rates may end up being higher than SARS and MERS patients because those illnesses often attacked only one lung .
But Covid-19 appears to often affect both lungs , which Gholamrezanezhad says escalates the risks of lung scarring .
He has already seen residual scarring in Covid-19 patients and is now designing a study to @ @ @ @ @ @ @ at higher risk of permanent damage .
He suspects having any type of underlying lung disease , like asthma , or other health conditions , like hypertension , might increase the risk of having longer-term lung issues .
Additionally , “ the older you are , probably the higher your chance of scarring , ” he says .
For people with this kind of lung scarring , normal activities may become more challenging .
“ Routine things , like running up a flight of stairs , would leave these individuals gasping for air @ @ @ @ @ @ @ hospitalized for Covid-19 are experiencing unexpectedly high rates of blood clots , likely due to inflammatory responses to the infection .
These can cause lung blockages , strokes , heart attacks , and other complications with serious , lasting effects .
Blood clots that form in or reach the brain can cause a stroke .
Although strokes are more typically seen in older people , strokes are now being reported even in young Covid-19 patients .
In Wuhan , China , about 5 percent of hospitalized Covid-19 patients had strokes , and a @ @ @ @ @ @ @ In younger people who have strokes , mortality rates are relatively low compared to those who are older , and many people recover .
But studies show only between 42 and 53 percent are able to return to work .
Blood clots can also cut off circulation to part of the lungs , a condition known as a pulmonary embolism , which can be deadly .
In France , two studies suggest that between 23 and 30 percent of people with severe Covid-19 are also having pulmonary embolisms .
One analysis found that @ @ @ @ @ @ @ and functional limitations are frequently reported by survivors.
” These include fatigue , heart palpitations , shortness of breath , marked limitation of physical activity , and inability to do physical activity without discomfort .
Blood clots in other major organs can also cause serious problems .
Renal failure has been a common challenge in many severe Covid-19 patients , and patients ’ clotted blood has been clogging dialysis machines .
Some of these acute kidney injuries may be permanent , requiring ongoing dialysis .
Clots outside organs can be serious , too @ @ @ @ @ @ @ , occurs when a blood clot forms in a vein , often the legs .
Nick Cordero , a Tony-nominated Broadway and television actor , recently had to have his right leg amputated after Covid-related blood clots .
Abnormal blood clotting even seems to be happening in people after they ’ ve appeared to recover .
One 32-year-old woman in Chicago , for example , had been discharged from the hospital for a week when she died suddenly with a severely swollen leg , a sign of deep vein thrombosis , according to @ @ @ @ @ @ @ Randle , a 49-year-old cardiologist in New Jersey , who was declared safe to go back to work after recovering from Covid-19 when he developed a vicious headache .
A CT scan confirmed he ’ d had a stroke .
Although there ’ s still a shortage of data , one study found that as many as 31 percent of ICU patients with Covid-19 infections had these kinds of clotting problems .
In the meantime , the International Society on Thrombosis and Haemostasis has issued guidelines that recovered Covid-19 patients should continue taking @ @ @ @ @ @ @ hospital .
Being critically ill , especially with low oxygen levels , puts additional stress on the heart .
But doctors now think that in Covid-19 patients , viral particles might also be specifically inflaming the heart muscle .
( The heart has many ACE2 receptors , which scientists have identified as an entry point for the SARS-CoV-2 virus . )
“ In China , doctors noted some people coming [ in ] with chest pain , ” says Mitchell Elkind , president-elect of the American Heart Association and professor of neurology and @ @ @ @ @ @ @ had a heart attack , and then developed Covid symptoms or tested positive after.
” One study from Wuhan in January found 12 percent of Covid-19 patients had signs of cardiovascular damage .
These patients had higher levels of troponin , a protein released in the blood by an injured heart muscle .
Since then , other reports suggest the virus may directly cause acute myocarditis and heart failure .
( Heart failure was also seen with MERS and is known to be correlated with even the seasonal flu . )
In March @ @ @ @ @ @ @ Covid-19 patients and found 19 percent showed signs of heart damage .
University of Texas Health Science Center researchers warn that in survivors , Covid-19 may cause lingering cardiac damage , as well as making existing cardiovascular problems worse , further increasing the risk for heart attack and stroke .
A pulmonary critical care doctor at Mount Sinai Hospital in New York City , for example , recovered from Covid-19 , only to learn she had developed cardiomyopathy , a condition where your heart has trouble delivering blood around your body .
Although @ @ @ @ @ @ @ work , she told NBC , “ I couldn ’ t run around like I always do.
” The specific consequences may vary depending on how the heart is affected .
For example , Covid-19 has been linked to myocarditis , a condition where inflammation weakens the heart , creates scar tissue , and makes it work harder to circulate the body ’ s oxygen .
The Myocarditis Foundation recommends these patients avoid cigarettes and alcohol , and stay away from rigorous exercise until approved by their doctor .
Covid-19 also seems to @ @ @ @ @ @ @ potentially long-lasting consequences .
In one study from China , more than a third of 214 people hospitalized with confirmed Covid-19 had neurological symptoms , including dizziness , headaches , impaired consciousness , vision , taste/smell impairment , and nerve pain while they were ill .
These symptoms were more common in patients with severe cases , where the incidence increased to 46.5 percent .
Another study in France found neurologic features in 58 of 64 critically ill Covid-19 patients .
As the pandemic goes on , Elkind says , “ We need @ @ @ @ @ @ @ neurocognitive problems.
” Looking back to SARS and MERS suggests that Covid-19 patients may have slightly delayed onset of neurological impacts .
Andrew Josephson , a doctor at the University of California San Francisco , wrote in JAMA , “ Although the SARS epidemic was limited to about 8,000 patients worldwide , there were some limited reports of neurologic complications of SARS that appeared in patients 2 to 3 weeks into the course of the illness.
” These included muscular weakness , burning or prickling , and numbness , and the breakdown of @ @ @ @ @ @ @ injuries , including impaired balance and coordination , confusion , and coma , were also found with MERS .
Long-term complications of Covid-19 — whether caused by the virus itself or the inflammation it triggers — could include decreased attention , concentration , and memory , as well as dysfunction in peripheral nerves , “ the ones that go to your arms , legs , fingers , and toes , ” Elkind says .
There are other cognitive implications for people who receive intensive treatment in hospitals .
For example , delirium — @ @ @ @ @ @ @ can result in confusion and seeing or hearing things that aren ’ t there — affects a third or more of ICU patients , and research suggests the presence of delirium during severe illness predicts future long-term cognitive decline .
Previous research on acute respiratory distress syndrome ( ARDS ) more generally may also provide clues to what neurological issues critically ill Covid-19 patients might see after leaving the hospital .
Research shows one in five ARDS survivors experiences long-term cognitive impairment , even five years after being discharged .
Continuing impairments can @ @ @ @ @ @ @ learning and executive function .
These can lead to challenges like difficulty working , impaired money management , or struggling to perform daily tasks .
ARDS survivors frequently have increased rates of depression and anxiety , and many experience post-traumatic stress .
Although it ’ s still too early to have much data on Covid-19 , during the SARS outbreak , former patients struggled with psychological distress and stress for at least a year after the outbreak .
“ I felt imprisoned within my body , imprisoned within my home , and tremendously @ @ @ @ @ @ @ , and even those closest to me , ” Nichols says about her battle with Covid-19 .
“ I feel incredibly alone.
” Jane , who prefers to use a pseudonym because she fears retribution at the hospital where she works , tested positive for Covid-19 more than a month ago .
She ’ s still struggling with fevers , heart issues , and neurological issues , but the most difficult part , she says , is how tired she is of “ being treated like I am a bomb that no one @ @ @ @ @ @ @ a nurse who cared for AIDS patients during the ’ 90s , says , “ This is exactly what those people went through .
There is a terrible stigma.
” In addition to the stigma , uncertainty has added to her mental health burden .
“ People need to know this disease can linger and wreck your life and health , ” she says .
“ And no one knows what to do for us.
” Childhood inflammation , male infertility , and other possible lasting effects The novel coronavirus continues to frustrate @ @ @ @ @ @ @ .
One of these is a small but growing number of children who recently began showing up at doctors ’ offices in Britain , Italy , and Spain with strange symptoms , including a rash , a high fever , and heart inflammation .
On May 4 , the New York City Health Department noted that at least 15 children with these symptoms had been hospitalized there , too .
These cases present like a severe immune response called Kawasaki disease , where blood vessels can begin to leak , and fluid builds @ @ @ @ @ @ @ organs .
Although only some of these children have tested positive for Covid-19 , Russell Viner , president of the Royal College of Pediatrics and Child Health , told the New York Times , “ the working hypothesis is that it ’ s Covid-related.
” Children who survive Kawasaki-like conditions can suffer myocardial and vascular complications in adulthood .
But it ’ s too early to know how Covid-related cases will develop .
Many of the small number of reported cases appear to be responding well to treatment .
Other researchers are suggesting @ @ @ @ @ @ @ men beyond their disproportionate mortality from the illness .
The testicles contain a high number of ACE2 receptors , explained researcher Ali Raba , in a recent letter to the World Journal of Urology .
“ There is a theoretical possibility of testicular damage and subsequent infertility following COVID-19 infection , ” he wrote .
Another study , looking at 38 patients in China who had been severely ill with Covid-19 , found that during their illness , 15 had virus RNA in their semen samples , as did two of 23 recovering @ @ @ @ @ @ @ RNA doesn ’ t necessarily indicate infectious capacity . )
Another recent study also showed that in 81 men with Covid-19 , male hormone ratios were off , which could signal trouble for fertility down the line .
The authors called for more attention to be paid , particularly on “ reproductive-aged men.
” An April 20 paper published in Nature went so far as to suggest , “ After recovery from COVID-19 , young men who are interested in having children should receive a consultation regarding their fertility.
” And we are @ @ @ @ @ @ @ what this complex infection means for other organ systems and their recovery .
For example , a recent preprint from Chinese doctors looked at 34 Covid-19 survivors ’ blood .
While they saw a difference between severe and mild cases , the researchers found that regardless of the severity of the disease , after recovered patients were discharged from the hospital , many biological measures “ failed to return to normal.
” The most concerning measures suggested ongoing impaired liver function .
What all of this means for survivors and researchers As all @ @ @ @ @ @ @ still in the early days of understanding what this virus might mean for the growing number of Covid-19 survivors — what symptoms they might expect to have , how long it might take them to get back to feeling normal ( if they ever will ) , and what other precautions they might need to be taking .
Many people aren ’ t even receiving adequate information about when it might be safe for them to stop self-isolating .
Nichols and other survivors report feeling better one day and terrible the next .
@ @ @ @ @ @ @ in the medical systems , survivors say it ’ s hard to get attention for their ongoing struggles .
“ The support and awareness is simply lacking , ” Nichols says .
“ It is a true roller coaster of symptoms and severities , with each new day offering many unknowns : I may feel healthier one day but may feel utterly debilitated and in pain the next.
” Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks .
Follow her Covid-19 @ @ @ @ @ @ @ day at Vox , we aim to answer your most important questions and provide you , and our audience around the world , with information that has the power to save lives .
Our mission has never been more vital than it is in this moment : to empower you through understanding .
Vox ’ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an economic downturn .
Your financial contribution will not constitute a donation , but @ @ @ @ @ @ @ to offer free articles , videos , and podcasts at the quality and volume that this moment requires .
Please consider making a contribution to Vox today .

At first, Lauren Nichols tried to explain away her symptoms. In early March, the healthy 32-year-old felt an intense burning sensation, like acid reflux, when she breathed. Embarrassed, she didn’t initially seek medical care. When her shortness of breath kept getting worse, her doctor tested her for Covid-19.
Her results came back positive. But for Nichols, that was just the beginning. Over the next eight weeks, she developed wide and varied symptoms, including extreme and chronic fatigue, diarrhea, nausea, tremors, headaches, difficulty concentrating, and short-term memory loss.
“The guidelines that were provided by the CDC [Centers for Disease Control and Prevention] were not appropriately capturing the symptoms that I was experiencing, which in turn meant that the medical community was unable to ‘validate’ my symptoms,” she says. “This became a vicious cycle of doubt, confusion, and loneliness.”
An estimated 40 to 45 percent of people with Covid-19 may be asymptomatic, and others will have a mild illness with no lasting symptoms. But Nichols is one of many Covid-19 patients who are finding their recovery takes far longer than the two weeks the World Health Organization says people with mild cases can expect. (The WHO says those with severe or critical cases can expect three to six weeks of recovery.)
Because Covid-19 is a new disease, there are no studies about its long-term trajectory for those with more severe symptoms; even the earliest patients to recover in China were only infected a few months ago. But doctors say the novel coronavirus can attach to human cells in many parts of the body and penetrate many major organs, including the heart, kidneys, brain, and even blood vessels.
“The difficulty is sorting out long-term consequences,” says Joseph Brennan, a cardiologist at the Yale School of Medicine. While some patients may fully recover, he and other experts worry others will suffer long-term damage, including lung scarring, heart damage, and neurological and mental health effects.
The UK National Health Service assumes that of Covid-19 patients who have required hospitalization, 45 percent will need ongoing medical care, 4 percent will require inpatient rehabilitation, and 1 percent will permanently require acute care. Other preliminary evidence, as well as historical research on other coronaviruses like severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), suggests that for some people, a full recovery might still be years off. For others, there may be no returning to normal.
There’s a lot we still don’t know, but here are a few of the most notable potential long-term impacts that are already showing up in some Covid-19 patients.
Lung scarring
Melanie Montano, 32, who tested positive for Covid-19 in March, says that more than seven weeks after she first got sick, she still experiences symptoms on and off, including burning in her lungs and a dry cough.
Brennan says symptoms like that occur because “this virus creates an incredibly aggressive immune response, so spaces [in the lungs] are filled with debris and pus, making your lungs less pliable.”
On CT scans, while normal lungs appear black, Covid-19 patients’ lungs frequently have lighter gray patches, called “ground-glass opacities” — which may not heal.
One study from China found that this ground-glass appearance showed up in scans of 77 percent of Covid-19 patients. In another study out of China, published in Radiology, 66 of 70 hospitalized patients had some amount of lung damage in CT scans, and more than half had the kind of lesions that are likely to develop into scars. (A third study from China suggests this is not just for critically ill patients; its authors found that of 58 asymptomatic patients, 95 percent also had evidence of these ground-glass opacities in their lungs. More than a quarter of these individuals went on to develop symptoms within a few days.)
“These kinds of tissue changes can cause permanent damage,” says Ali Gholamrezanezhad, a radiologist at the Keck School of Medicine at the University of Southern California.
Although it’s still too early to know if patients with ongoing lung symptoms like Montano will have permanent lung damage, doctors can learn more about what to expect from looking back to people who have recovered from SARS and MERS, other coronaviruses that resulted in similar lung tissue changes.
One small longitudinal study published in Nature followed 71 SARS patients from 2003 until 2018 and found that more than a third had reduced lung capacity. MERS is a little harder to extrapolate from, since fewer than 2,500 people were infected, and somewhere between 30 and 40 percent died. But one study found that about a third of 36 MERS survivors also had long-term lung damage.
Gholamrezanezhad has recently done a literature review of SARS and MERS and says that for this subset of people, “The pulmonary function never comes back; their ability to do normal activities never goes back to baseline.”
Additionally, Covid-19 scarring rates may end up being higher than SARS and MERS patients because those illnesses often attacked only one lung. But Covid-19 appears to often affect both lungs, which Gholamrezanezhad says escalates the risks of lung scarring.
He has already seen residual scarring in Covid-19 patients and is now designing a study to identify what factors might make some people at higher risk of permanent damage. He suspects having any type of underlying lung disease, like asthma, or other health conditions, like hypertension, might increase the risk of having longer-term lung issues. Additionally, “the older you are, probably the higher your chance of scarring,” he says.
For people with this kind of lung scarring, normal activities may become more challenging. “Routine things, like running up a flight of stairs, would leave these individuals gasping for air,” Brennan says.
Stroke, embolisms, and blood clotting
Many patients hospitalized for Covid-19 are experiencing unexpectedly high rates of blood clots, likely due to inflammatory responses to the infection. These can cause lung blockages, strokes, heart attacks, and other complications with serious, lasting effects.
Blood clots that form in or reach the brain can cause a stroke. Although strokes are more typically seen in older people, strokes are now being reported even in young Covid-19 patients. In Wuhan, China, about 5 percent of hospitalized Covid-19 patients had strokes, and a similar pattern was reported with SARS.
In younger people who have strokes, mortality rates are relatively low compared to those who are older, and many people recover. But studies show only between 42 and 53 percent are able to return to work.
Blood clots can also cut off circulation to part of the lungs, a condition known as a pulmonary embolism, which can be deadly. In France, two studies suggest that between 23 and 30 percent of people with severe Covid-19 are also having pulmonary embolisms.
One analysis found that after a pulmonary embolism, “symptoms and functional limitations are frequently reported by survivors.” These include fatigue, heart palpitations, shortness of breath, marked limitation of physical activity, and inability to do physical activity without discomfort.
Blood clots in other major organs can also cause serious problems. Renal failure has been a common challenge in many severe Covid-19 patients, and patients’ clotted blood has been clogging dialysis machines. Some of these acute kidney injuries may be permanent, requiring ongoing dialysis.
Clots outside organs can be serious, too. Deep vein thrombosis, for example, occurs when a blood clot forms in a vein, often the legs. Nick Cordero, a Tony-nominated Broadway and television actor, recently had to have his right leg amputated after Covid-related blood clots.
Abnormal blood clotting even seems to be happening in people after they’ve appeared to recover. One 32-year-old woman in Chicago, for example, had been discharged from the hospital for a week when she died suddenly with a severely swollen leg, a sign of deep vein thrombosis, according to local broadcaster WGN9. Or take Troy Randle, a 49-year-old cardiologist in New Jersey, who was declared safe to go back to work after recovering from Covid-19 when he developed a vicious headache. A CT scan confirmed he’d had a stroke.
Although there’s still a shortage of data, one study found that as many as 31 percent of ICU patients with Covid-19 infections had these kinds of clotting problems. In the meantime, the International Society on Thrombosis and Haemostasis has issued guidelines that recovered Covid-19 patients should continue taking anticoagulants even after being discharged from the hospital.
Heart damage
Being critically ill, especially with low oxygen levels, puts additional stress on the heart. But doctors now think that in Covid-19 patients, viral particles might also be specifically inflaming the heart muscle. (The heart has many ACE2 receptors, which scientists have identified as an entry point for the SARS-CoV-2 virus.)
“In China, doctors noted some people coming [in] with chest pain,” says Mitchell Elkind, president-elect of the American Heart Association and professor of neurology and epidemiology at Columbia University. “They had a heart attack, and then developed Covid symptoms or tested positive after.”
One study from Wuhan in January found 12 percent of Covid-19 patients had signs of cardiovascular damage. These patients had higher levels of troponin, a protein released in the blood by an injured heart muscle. Since then, other reports suggest the virus may directly cause acute myocarditis and heart failure. (Heart failure was also seen with MERS and is known to be correlated with even the seasonal flu.)
In March, another study looked at 416 hospitalized Covid-19 patients and found 19 percent showed signs of heart damage. University of Texas Health Science Center researchers warn that in survivors, Covid-19 may cause lingering cardiac damage, as well as making existing cardiovascular problems worse, further increasing the risk for heart attack and stroke.
A pulmonary critical care doctor at Mount Sinai Hospital in New York City, for example, recovered from Covid-19, only to learn she had developed cardiomyopathy, a condition in which your heart has trouble delivering blood around your body. Although previously healthy, when she returned to work, she told NBC, “I couldn’t run around like I always do.”
The specific consequences may vary depending on how the heart is affected. For example, Covid-19 has been linked to myocarditis, a condition where inflammation weakens the heart, creates scar tissue, and makes it work harder to circulate the body’s oxygen. The Myocarditis Foundation recommends these patients avoid cigarettes and alcohol, and stay away from rigorous exercise until approved by their doctor.
Neurocognitive and mental health impacts
Covid-19 also seems to affect the central nervous system, with potentially long-lasting consequences. In one study from China, more than a third of 214 people hospitalized with confirmed Covid-19 had neurological symptoms, including dizziness, headaches, impaired consciousness, vision, taste/smell impairment, and nerve pain while they were ill. These symptoms were more common in patients with severe cases, where the incidence increased to 46.5 percent. Another study in France found neurologic features in 58 of 64 critically ill Covid-19 patients.
As the pandemic goes on, Elkind says, “We need to be on the lookout for long-term neurocognitive problems.”
Looking back to SARS and MERS suggests that Covid-19 patients may have slightly delayed onset of neurological impacts. Andrew Josephson, a doctor at the University of California San Francisco, wrote in JAMA, “Although the SARS epidemic was limited to about 8,000 patients worldwide, there were some limited reports of neurologic complications of SARS that appeared in patients 2 to 3 weeks into the course of the illness.” These included muscular weakness, burning or prickling, and numbness, and the breakdown of muscle tissue into the blood. Neurological injuries, including impaired balance and coordination, confusion, and coma, were also found with MERS.
Long-term complications of Covid-19 — whether caused by the virus itself or the inflammation it triggers — could include decreased attention, concentration, and memory, as well as dysfunction in peripheral nerves, “the ones that go to your arms, legs, fingers, and toes,” Elkind says.
There are other cognitive implications for people who receive intensive treatment in hospitals. For example, delirium — an acutely disturbed state of mind that can result in confusion and seeing or hearing things that aren’t there — affects a third or more of ICU patients, and research suggests the presence of delirium during severe illness predicts future long-term cognitive decline.
Previous research on acute respiratory distress syndrome (ARDS) more generally may also provide clues to what neurological issues critically ill Covid-19 patients might see after leaving the hospital.
Research shows one in five ARDS survivors experiences long-term cognitive impairment, even five years after being discharged. Continuing impairments can include short-term memory problems and difficulty with learning and executive function. These can lead to challenges like difficulty working, impaired money management, or struggling to perform daily tasks.
ARDS survivors frequently have increased rates of depression and anxiety, and many experience post-traumatic stress. Although it’s still too early to have much data on Covid-19, during the SARS outbreak, former patients struggled with psychological distress and stress for at least a year after the outbreak.
“I felt imprisoned within my body, imprisoned within my home, and tremendously ignored and misunderstood by the general public, and even those closest to me,” Nichols says about her battle with Covid-19. “I feel incredibly alone.”
Jane, who prefers to use a pseudonym because she fears retribution at the hospital where she works, tested positive for Covid-19 more than a month ago. She’s still struggling with fevers, heart issues, and neurological issues, but the most difficult part, she says, is how tired she is of “being treated like I am a bomb that no one knows how to disarm.” Jane, a nurse who cared for AIDS patients during the ’90s, says, “This is exactly what those people went through. There is a terrible stigma.” In addition to the stigma, uncertainty has added to her mental health burden.
“People need to know this disease can linger and wreck your life and health,” she says. “And no one knows what to do for us.”
Childhood inflammation, male infertility, and other possible lasting effects
The novel coronavirus continues to frustrate scientists and patients alike with its mysteries. One of these is a small but growing number of children who recently began showing up at doctors’ offices in Britain, Italy, and Spain with strange symptoms, including a rash, a high fever, and heart inflammation.
On May 4, the New York City Health Department noted that at least 15 children with these symptoms had been hospitalized there, too. These cases present like a severe immune response called Kawasaki disease, where blood vessels can begin to leak, and fluid builds up in the lungs and other major organs. Although only some of these children have tested positive for Covid-19, Russell Viner, president of the Royal College of Pediatrics and Child Health, told the New York Times, “the working hypothesis is that it’s Covid-related.”
Children who survive Kawasaki-like conditions can suffer myocardial and vascular complications in adulthood. But it’s too early to know how Covid-related cases will develop. Many of the small number of reported cases appear to be responding well to treatment.
Other researchers are suggesting that Covid-19 may pose particular problems for men beyond their disproportionate mortality from the illness. The testicles contain a high number of ACE2 receptors, explained researcher Ali Raba, in a recent letter to the World Journal of Urology. “There is a theoretical possibility of testicular damage and subsequent infertility following COVID-19 infection,” he wrote.
Another study, looking at 38 patients in China who had been severely ill with Covid-19, found that during their illness, 15 had virus RNA in their semen samples, as did two of 23 recovering patients. (The presence of viral RNA doesn’t necessarily indicate infectious capacity.)
Another recent study also showed that in 81 men with Covid-19, male hormone ratios were off, which could signal trouble for fertility down the line. The authors called for more attention to be paid, particularly on “reproductive-aged men.” An April 20 paper published in Nature went so far as to suggest, “After recovery from COVID-19, young men who are interested in having children should receive a consultation regarding their fertility.”
And we are just at the beginning of figuring out what this complex infection means for other organ systems and their recovery. For example, a recent preprint from Chinese doctors looked at 34 Covid-19 survivors’ blood. While they saw a difference between severe and mild cases, the researchers found that regardless of the severity of the disease, after recovered patients were discharged from the hospital, many biological measures “failed to return to normal.” The most concerning measures suggested ongoing impaired liver function.
What all of this means for survivors and researchers
As all this preliminary research shows, we are still in the early days of understanding what this virus might mean for the growing number of Covid-19 survivors — what symptoms they might expect to have, how long it might take them to get back to feeling normal (if they ever will), and what other precautions they might need to be taking.
Many people aren’t even receiving adequate information about when it might be safe for them to stop self-isolating. Nichols and other survivors report feeling better one day and terrible the next.
But in the chaos Covid-19 has caused in the medical systems, survivors say it’s hard to get attention for their ongoing struggles. “The support and awareness is simply lacking,” Nichols says. “It is a true roller coaster of symptoms and severities, with each new day offering many unknowns: I may feel healthier one day but may feel utterly debilitated and in pain the next.”
Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.
Correction, June 23: This story previously misstated the amount of lung scarring in SARS patients.


vox--2020-06-12--Trump: “The concept of chokehold sounds so innocent, so perfect”

On Friday , Fox News released an interview with President Trump by journalist Harris Faulkner .
The interview was a disaster , a case study in why Donald Trump is not and can not be the person to handle this moment in time .
When asked about police use of chokeholds on suspects like George Floyd , who was killed after a Minneapolis officer pinned him by the neck with his knee for nearly nine minutes , Trump initially told Faulkner that “ I don ’ t like chokeholds , ” even saying that “ generally speaking , they should @ @ @ @ @ @ @ pretty quickly , saying that when you ’ ve got someone who is “ a real bad person ... what are you gon na do now — let go ?
” He even went further , saying that “ the concept of chokehold sounds so innocent , so perfect , ” if a lone police officer is attempting to detain someone .
His position , as far as I can tell , seems to be that maybe sometimes individual officers need to use chokeholds , but the more police there are , the @ @ @ @ @ @ @ need to use one : TRUMP : I think the concept of chokehold sounds so innocent , so perfect .
And then you realize , if it ’ s a one-on-one .
But if it ’ s two-on-one , that ’ s a little bit a different story .
Depending on the toughness and strength — you know , we ’ re talking about toughness and strength .
There ’ s a physical thing here too .
FAULKNER : If it ’ s a one-on-one for the [ officer ’ s ] life @ @ @ @ @ @ @ , that does happen .
You have to be careful .
The most relevant part here isn ’ t the president ’ s views on the details of self-defense tactics , but rather the lack of empathy in the way he talks about the issue .
The only world in which police using chokeholds could sound “ innocent ” or “ perfect ” is a world in which you don ’ t think about what happens to people when they ’ re literally being choked — or one where you assume that it @ @ @ @ @ @ @ you .
A recent LA Times investigation found that 103 people were “ seriously injured ” by police using “ carotid neck restraints ” in California between 2016 and 2018 .
Black people , who make up 6.5 percent of the state ’ s population , were 23 percent of those injured in such holds .
Trump ’ s thinking seems so deeply shaped by his sense of generalized police innocence , his unwillingness to really process the fact of racial discrimination in police use of force , that he ’ s capable @ @ @ @ @ @ @ “ innocent.
” Later in the interview , Trump claims that he ’ s done more for African Americans than “ any other president.
” Abraham Lincoln is , of course , the obvious counterexample — but Trump said he ’ s going to “ take a pass ” on him .
It ’ s remarkable to see how he replies to Faulkner , a black woman , responding to that by saying “ we are free ” — and to see Trump basically shrug off the point , to say that “ @ @ @ @ @ @ @ s presidency is “ always questionable ” : Bear in mind that this is a president who recently threatened to veto an annual defense spending bill if it included an amendment that would rename military bases named after Confederate generals .
It is also the same president under whose watch , less than two weeks ago , peaceful protesters in Washington , DC , were tear-gassed so he could attend a photo op .
A recent NPR poll found that 86 percent of black voters believe Trump has “ mostly increased racial tensions @ @ @ @ @ @ @ that 88 percent were planning to vote for presumptive Democratic nominee Joe Biden in November .
Under these circumstances , the president claiming to be the “ best ” president for black voters — to be unwilling to admit that the man who ended slavery in the US did more for African Americans — is absolutely astonishing .
There ’ s moment after moment like this in the Faulkner interview .
Trump denies that he got the phrase “ when the looting starts , the shooting starts ” from a segregationist police chief @ @ @ @ @ @ @ racist police chief who once unleashed dogs on black student demonstrators .
He claims that he can console hurt Americans right now through “ toughness , ” because “ by being soft and weak , you end up not being compassionate.
” He says that holding his first campaign rally of the summer on Juneteenth — the holiday commemorating the end of slavery — is not offensive attention-hogging , but rather “ a celebration.
” After a certain point , writing about Trump feels redundant .
The president is so violently self-absorbed , @ @ @ @ @ @ @ hatred for political gain , and so manifestly unfit for his serious responsibilities that pointing it out over and over again starts to feel pointless .
But at this moment in our history — a pandemic coinciding with a massive uprising in favor of racial equality — it feels especially important to state the baseline reality : The most important person in America ’ s political system is incapable of rising to the moment and being the person the country needs .
Any serious analysis of our current state of affairs needs to @ @ @ @ @ @ @ as this interview , like many before it , shows .
Every day at Vox , we aim to answer your most important questions and provide you , and our audience around the world , with information that has the power to save lives .
Our mission has never been more vital than it is in this moment : to empower you through understanding .
Vox ’ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an economic @ @ @ @ @ @ @ constitute a donation , but it will enable our staff to continue to offer free articles , videos , and podcasts at the quality and volume that this moment requires .
Please consider making a contribution to Vox today .

On Friday, Fox News released an interview with President Trump by journalist Harris Faulkner. The interview was a disaster, a case study in why Donald Trump is not and cannot be the person to handle this moment in time.
When asked about police use of chokeholds on suspects like George Floyd, who was killed after a Minneapolis officer pinned him by the neck with his knee for nearly nine minutes, Trump initially told Faulkner, “I don’t like chokeholds,” even saying that “generally speaking, they should be ended.” But he contradicted that pretty quickly, saying when you’ve got someone who is “a real bad person ... what are you gonna do now — let go?”
He even went further, saying that “the concept of chokehold sounds so innocent, so perfect,” if a lone police officer is attempting to detain someone.
His position, as far as I can tell, seems to be that maybe sometimes individual officers need to use chokeholds, but the more police there are, the less likely it is they’ll need to use one:
TRUMP: I think the concept of chokehold sounds so innocent, so perfect. And then you realize, if it’s a one-on-one. But if it’s two-on-one, that’s a little bit a different story. Depending on the toughness and strength — you know, we’re talking about toughness and strength. There’s a physical thing here too. FAULKNER: If it’s a one-on-one for the [officer’s] life ... TRUMP: And that does happen, that does happen. You have to be careful.
The most relevant part here isn’t the president’s views on the details of self-defense tactics, but rather the lack of empathy in the way he talks about the issue. The only world in which police using chokeholds could sound “innocent” or “perfect” is a world in which you don’t think about what happens to people when they’re literally being choked — or one where you assume that it won’t happen to people like you.
A recent LA Times investigation found that 103 people were “seriously injured” by police using “carotid neck restraints” in California between 2016 and 2018. Black people, who make up 6.5 percent of the state’s population, were 23 percent of those injured in such holds.
Trump’s thinking seems so deeply shaped by his sense of generalized police innocence, his unwillingness to really process the facts on racial discrimination in police use of force, that he’s capable of saying out loud that chokeholds sound “innocent.”
Later in the interview, Trump claims that he’s done more for African Americans than “any other president.” Abraham Lincoln is, of course, the obvious counterexample — but Trump said he’s going to “take a pass” on him. It’s remarkable to see how he replies to Faulkner, a black woman, responding to that by saying “we are free” — and to see Trump basically shrug off the point, to say that “the end result” of Lincoln’s presidency is “always questionable”:
Trump, who has repeatedly defended the Confederacy, says he's done more for black community than any president with possible exception of Abraham Lincoln but then adds of Lincoln: "He did good although it's always questionable, you know, in other words, the end result." #wut pic.twitter.com/nIuu6fRAM2 — Aaron Rupar (@atrupar) June 12, 2020
Bear in mind that this is a president who recently threatened to veto an annual defense spending bill if it included an amendment that would rename military bases named after Confederate generals. It is also the same president under whose watch, less than two weeks ago, peaceful protesters in Washington, DC, were tear-gassed so he could attend a photo op. A recent NPR poll found that 86 percent of black voters believe Trump has “mostly increased racial tensions” during the George Floyd protests and that 88 percent were planning to vote for presumptive Democratic nominee Joe Biden in November.
Under these circumstances, the president claiming to be the “best” president for black voters — to be unwilling to admit that the man who ended slavery in the US did more for African Americans — is absolutely astonishing.
There’s moment after moment like this in the Faulkner interview.
Trump denies that he got the phrase “when the looting starts, the shooting starts” from a segregationist police chief — crediting it instead to a different racist police chief who once unleashed dogs on black student demonstrators. He claims that he can console hurt Americans right now through “toughness,” because “by being soft and weak, you end up not being compassionate.” He says that holding his first campaign rally of the summer on Juneteenth — the holiday commemorating the end of slavery — is not offensive attention-hogging, but rather “a celebration.”
After a certain point, writing about Trump feels redundant. The president is so violently self-absorbed, so committed to fanning flames of racial hatred for political gain, and so manifestly unfit for his serious responsibilities that pointing it out over and over again starts to feel pointless.
But at this moment in our history — a pandemic combined with a massive uprising in favor of racial equality — it feels especially important to state the baseline reality: The most important person in America’s political system is incapable of rising to the moment and being the person the country needs. Any serious analysis of our current state of affairs needs to take that as its starting point — as this interview, like many before it, shows.


vox--2020-06-12--Why coronavirus is suddenly spiking again in parts of the US

In many parts of the United States , Covid-19 appears to be surging .
It is a grim reminder that the country has not beaten the coronavirus pandemic that has taken more than 110,000 American lives and locked down the country for much of the year .
The number of confirmed cases in the US has now exceeded 2 million , and while new cases nationwide appear to be flat , they ’ re not dropping .
Moreover , the national numbers obscure the state and local trends that have public health experts worried .
The original pandemic epicenters — @ @ @ @ @ @ @ and a couple neighboring states like New Jersey — have seen a steady decline in cases and deaths since a mid-April peak .
But new hot spots are emerging .
Arizona , for one , is seeing increased hospitalizations , more tests are coming back positive for Covid-19 , and the rate of new infections as a share of the state ’ s population is quite high .
Outbreaks are picking up in parts of the country that were spared the worst of the pandemic initially because , first , they were lucky @ @ @ @ @ @ @ and , second , they instituted social distancing policies before their outbreaks could grow out of control .
But even if lockdowns slowed the coronavirus , they could not stop it completely , and the virus continued to seep into more and more of the country .
Some states are starting to see a worrying combination of trends in their Covid-19 data : Not only are case numbers rising , but hospitalizations are increasing and the share of tests that come back positive has gone up , all of which suggest the coronavirus @ @ @ @ @ @ @ at the same time , states are relaxing their stay-at-home orders , businesses are opening , and people are socializing .
The protests against police violence could also have been vectors for Covid-19 spread , though it is still too early to be sure how significant their effect will be .
Renewed spread , in a country that seems committed to reopening its economy to alleviate the financial pain of the lockdowns , could put the US on a dangerous path .
“ In the face of increasing numbers of case counts , @ @ @ @ @ @ @ opportunity for community transmission , ” William Hanage , an epidemiologist at Harvard University , told me .
“ The virus is getting highways along which to transmit.
” There is not one coronavirus pandemic in the US but many .
Some places are finally seeing relief after the virus took a catastrophic toll .
But elsewhere , the situation appears to be getting worse .
Where coronavirus spread is getting worse Public health experts are worried about the trend lines in some areas because the coronavirus is perfectly built to cause a @ @ @ @ @ @ @ health systems are not yet in crisis mode .
Once people are infected with Covid-19 , it takes about a week for them to show symptoms .
But they are still contagious before then , unwittingly exposing more people to the virus .
And once the symptoms start — they get a fever or they develop a dry cough — it can take another week or so for them to be sick enough to be hospitalized .
Hospitalizations are , in other words , a lagging indicator .
But once hospitals exceed capacity @ @ @ @ @ @ @ ; they are effectively guaranteed to endure several difficult weeks after that point .
People arriving in hospitals were infected two weeks or so earlier .
The virus continued spreading in the interim , infecting more people .
It takes time for a case to become serious enough that the patient must be hospitalized .
So the next wave of those newly infected won ’ t show up at a hospital for a couple more weeks .
It ’ s a vicious cycle .
That ’ s why the public health community was @ @ @ @ @ @ @ system warned this week their ICU units were filling up and ventilator use had quadrupled since mid-May .
Arizona looks like the likeliest candidate to become a new Covid-19 hot spot .
The state ’ s new Covid-19 cases are up more than 200 percent over the last two weeks , according to the Covid Exit Strategy dashboard .
Some of that spike is probably the result of more testing .
But what ’ s so concerning is that the positive test rate is also increasing at the same time , up from @ @ @ @ @ @ @ of May to nearly 14 percent now .
As I wrote earlier this week , that trend “ suggests the virus is actually spreading , not just that more tests happen to be finding more cases.
” In new cases per million residents , another means of measuring whether spread is getting worse , Arizona has the highest rate in the country .
And hospitalizations are up .
On May 10 , 713 people were in the hospital in Arizona with Covid-19 , according to the University of Minnesota ’ s hospitalization tracking @ @ @ @ @ @ @ 1,300 people were .
The number of people currently on a ventilator is also higher ; it was less than 200 a month ago but today is approaching 300 .
Arizona might be the most extreme case in terms of worrying trends , but at least six other states share a similar profile : • Arkansas ( cases up 113 percent in two weeks , positive test rate increasing , current hospitalizations up from 64 on May 10 to 181 on June 10 ) • Florida ( cases up 87 percent in two @ @ @ @ @ @ @ the state does not report current hospitalizations ) • North Carolina ( cases up 62 percent in two weeks , positive test rate increasing , current hospitalizations up from 442 on May 10 to 780 on June 10 ) • South Carolina ( cases up 93 percent in two weeks , positive test rate increasing , the state does not routinely report current hospitalizations but there was a reported recent spike ) • Texas ( cases up 53 percent in two weeks , positive test rate increasing , current hospitalizations up from 1,626 @ @ @ @ @ @ @ 10 ) • Utah ( cases up 126 percent in two weeks , positive test rate increasing , current hospitalizations up from 93 on May 10 to 130 on June 10 ) This is not a second wave .
These places are experiencing their first significant upswing in Covid-19 cases because they had constrained the virus by adopting stay-at-home orders and other distancing measures before their outbreaks grew out of control .
Early research suggests that lockdowns have significantly suppressed Covid-19 ’ s spread .
Other states — California , Kentucky , and @ @ @ @ @ @ @ also have trends worth watching , but their signals are more mixed .
California , for example , has seen cases rise by 20 percent in two weeks , but the positive test rate is little changed and hospitalizations are actually flat from a month ago .
Oregon has seen a much steeper increase in cases , up 146 percent in 14 days , but its rate of new cases per million people is quite low ( 22 ) compared to Arizona ( 150 ) .
Kentucky ’ s positive test rate is @ @ @ @ @ @ @ people is mild despite a 62 percent jump in cases over the last two weeks .
While these places are seeing their cases climb , the national Covid-19 curve looks like a plateau , with 21,894 new cases on June 1 and 20,839 new cases on June 10 .
That ’ s because other parts of the country — particularly the Northeast , which endured the worst Covid-19 outbreak in the early weeks of the pandemic — are seeing their numbers drop .
But nobody should rest easy yet because even as cases @ @ @ @ @ @ @ the country is relaxing social distancing and reopening the economy .
Reopening the economy too quickly could worsen the coronavirus ’ s spread It is difficult to ignore that the places seeing surges in Covid-19 cases began to reopen businesses and other public spaces a few weeks ago .
Because of those reporting lags that are innate to the virus , any changes in spread would only become evident now .
“ The early opening with insufficient public concern for behavior change will undoubtedly lead to more problems ahead , ” David Celentano @ @ @ @ @ @ @ ’ s epidemiology department , told me .
Arizona rolled back its stay-at-home order on May 16 .
North Carolina relaxed its order on May 22 .
Some of the other emerging hot spots — Texas , Arkansas , etc .
— have been open for business since the beginning of May .
Experts point out we are now a few weeks out from Memorial Day , which may have served as an unofficial end to self-quarantine for many people in the states where shelter-in-place is no longer in effect .
We should @ @ @ @ @ @ @ a clear sign that reopening is increasing spread .
Correlation is not causation .
There are acute outbreaks in prisons and meat-packing plants that explain part of the spike .
And not every state that ’ s eased its distancing policies has seen a dramatic deterioration in its Covid-19 numbers .
Georgia , for example , seems to be holding up okay after allowing businesses to reopen ; cases and positive test rates are up slightly but not to the degree of Arizona or Utah .
People I spoke with in these states @ @ @ @ @ @ @ ; it might even be considered an acceptable trade-off for getting people back to work .
Hospital capacity may be down , but that partly reflects an increase in non-Covid-19 patients now that elective surgeries have resumed .
Experts are still concerned .
Texas has been seen as a leader in reopening ; it never had a statewide stay-at-home order and businesses began reopening on May 1 .
But whatever the exact cause , the new trends in the state are troublesome .
“ There is little doubt in my mind that the @ @ @ @ @ @ @ more community spread , ” Thomas Giordano , who leads the infectious disease program at the Baylor College of Medicine , told me .
“ We need to get this right , and currently the numbers aren ’ t looking so good.
” And to repeat one more time for good measure , Covid-19 data is always a week or more behind whatever the situation on the ground is .
Spread is increasing and social distancing is easing , which could accelerate spread even more before we realize the full extent of the @ @ @ @ @ @ @ worry about right now .
“ If cases are increasing under current conditions , you are not going to slow things down by giving the virus more opportunities , ” Hanage said .
It ’ s too soon to know how much the George Floyd protests spread Covid-19 The nationwide protests over George Floyd ’ s death , police violence , and structural racism have also been met with concerns that they would become superspreading events .
At the protests , thousands of people congregated in close quarters and , though mask-wearing was @ @ @ @ @ @ @ Many public health experts lent their support to the protests , citing the toll taken on black Americans ’ health across US history because of slavery and racism , but there seemed to be a real risk that these protests organized and attended by black activists would simply deepen the racial disparities in the coronavirus pandemic .
Black Americans are already getting sick and dying from Covid-19 at higher rates than white Americans .
According to the experts I spoke with , however , it is simply too early to know whether the @ @ @ @ @ @ @ protests .
And it is worth remembering the differences between outdoor and indoor exposure , the latter being much more dangerous ; it could end up being the case that people got infected because they were arrested and put into a police van or jail cell with other people , not because they were outside protesting in a big crowd .
Regardless , it ’ s only been about two weeks since the protests in Minneapolis grew into a national movement ; new cases and any other worrying trends in the data would @ @ @ @ @ @ @ may not be perceptible .
For now , the trend lines in Minnesota show new cases dropping and the positive test rate is down , according to the Covid Exit Strategy dashboard .
Even if some of the places with large protests see a spike in Covid-19 cases , it will be difficult to separate the effects of the demonstrations from the effects of reopening .
Minnesota , for example , relaxed its stay-at-home order on May 18 and started allowing restaurants to open again on June 1 , coinciding almost exactly with @ @ @ @ @ @ @ took about a month after opening to start to see a clear increase in cases , we probably expect that any uptick coming from the protests wouldn ’ t be visible for a few more weeks , ” Ellie Murray , an epidemiology professor at Boston University , told me .
“ But it ’ s also going to be difficult to tease out how much of any uptick is related to protesting versus other opening-related changes in behaviors.
” And as a matter of scale , widespread changes in social distancing policies @ @ @ @ @ @ @ to have a larger effect than the acute impact of a few days of protests .
“ As states open up , the total number of risky contacts that are made in the population as a whole will outnumber those made at the protests , ” Hanage said .
“ I expect there will be some retrofitting of disease in the future to the presence of a protest , but that ’ s not really responsible.
” The trend lines are real enough and worrying enough , in other words , without apportioning @ @ @ @ @ @ @ of risky behaviors are becoming more common .
The more people take precautions — wearing masks , washing hands , avoiding contact when possible — the more difficult it will be for the coronavirus to spread .
But it should be clear by now : The pandemic is not over .
Every day at Vox , we aim to answer your most important questions and provide you , and our audience around the world , with information that has the power to save lives .
Our mission has never been more vital than @ @ @ @ @ @ @ empower you through understanding .
Vox ’ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an economic downturn .
Your financial contribution will not constitute a donation , but it will enable our staff to continue to offer free articles , videos , and podcasts at the quality and volume that this moment requires .
Please consider making a contribution to Vox today .

In many parts of the United States, Covid-19 appears to be surging.
It is a grim reminder that the country has not beaten the coronavirus pandemic that has taken more than 110,000 American lives and locked down the country for much of the year. The number of confirmed cases in the US has now exceeded 2 million, and while new cases nationwide appear to be flat, they’re not dropping. Moreover, the national numbers obscure the state and local trends that have public health experts worried.
The original pandemic epicenters — namely, the New York City area and a couple neighboring states like New Jersey — have seen a steady decline in cases and deaths since a mid-April peak. But new hot spots are emerging.
Arizona, for one, is seeing increased hospitalizations, more tests are coming back positive for Covid-19, and the rate of new infections as a share of the state’s population is quite high. Outbreaks are picking up in parts of the country that were spared the worst of the pandemic initially because, first, they were lucky the virus did not arrive there early and, second, they instituted social distancing policies before their outbreaks could grow out of control.
But even if lockdowns slowed the coronavirus, they could not stop it completely, and the virus continued to seep into more and more of the country. Some states are starting to see a worrying combination of trends in their Covid-19 data: Not only are case numbers rising, but hospitalizations are increasing and the share of tests that come back positive has gone up, all of which suggest the coronavirus is spreading in the community.
Yet at the same time, states are relaxing their stay-at-home orders, businesses are opening, and people are socializing. The protests against police violence could also have been vectors for Covid-19 spread, though it is still too early to be sure how significant their effect will be.
Renewed spread, in a country that seems committed to reopening its economy to alleviate the financial pain of the lockdowns, could put the US on a dangerous path.
“In the face of increasing numbers of case counts, the continued relaxation will only provide more opportunity for community transmission,” William Hanage, an epidemiologist at Harvard University, told me. “The virus is getting highways along which to transmit.”
There is not one coronavirus pandemic in the US, but many. Some places are finally seeing relief after the virus took a catastrophic toll. But elsewhere, the situation appears to be getting worse.
Where coronavirus spread is getting worse
Public health experts are worried about the trend lines in some areas because the coronavirus is perfectly built to cause a health care crisis, even if local health systems are not yet in crisis mode. Once people are infected with Covid-19, it takes about a week for them to show symptoms. But they are still contagious before then, unwittingly exposing more people to the virus. And once the symptoms start — they get a fever, or develop a dry cough — it can take another week or so for them to be sick enough to be hospitalized.
Hospitalizations are, in other words, a lagging indicator. But once hospitals exceed capacity, it’s already too late; they are effectively guaranteed to endure several difficult weeks after that point. People arriving in hospitals were infected two weeks or so earlier. The virus continued spreading in the interim, infecting more people. It takes time for a case to become serious enough that the patient must be hospitalized. So the next wave of those newly infected won’t show up at a hospital for a couple more weeks.
It’s a vicious cycle. That’s why the public health community was so alarmed when a major Arizona hospital system warned this week their ICU units were filling up and ventilator use had quadrupled since mid-May.
Arizona seems the likeliest candidate to become a new Covid-19 hot spot. The state’s new Covid-19 cases are up more than 200 percent over the last two weeks, according to the Covid Exit Strategy dashboard.
Some of that spike is probably the result of more testing. But what’s so concerning is that the positive test rate is also increasing at the same time, up from less than 8 percent at the end of May to nearly 14 percent now. As I wrote earlier this week, that trend “suggests the virus is actually spreading, not just that more tests happen to be finding more cases.” In new cases per million residents, another means of measuring whether spread is getting worse, Arizona has the highest rate in the country.
And hospitalizations are up. On May 10, 713 people were in the hospital in Arizona with Covid-19, according to the University of Minnesota’s hospitalization tracking project. On June 10, nearly 1,300 people were. The number of people currently on a ventilator is also higher; it was less than 200 a month ago but today is approaching 300.
Arizona might be the most extreme case in terms of worrying trends, but at least six other states share a similar profile:
Arkansas (cases up 113 percent in two weeks, positive test rate increasing, current hospitalizations up from 64 on May 10 to 181 on June 10)
Florida (cases up 87 percent in two weeks, positive test rate increasing, the state does not report current hospitalizations)
North Carolina (cases up 62 percent in two weeks, positive test rate increasing, current hospitalizations up from 442 on May 10 to 780 on June 10)
South Carolina (cases up 93 percent in two weeks, positive test rate increasing, the state does not routinely report current hospitalizations but there was a reported recent spike)
Texas (cases up 53 percent in two weeks, positive test rate increasing, current hospitalizations up from 1,626 on May 10 to 2,153 on June 10)
Utah (cases up 126 percent in two weeks, positive test rate increasing, current hospitalizations up from 93 on May 10 to 130 on June 10)
This is not a second wave. These places are experiencing their first significant upswing in Covid-19 cases because they had constrained the virus by adopting stay-at-home orders and other distancing measures before their outbreaks grew out of control. Early research suggests that lockdowns have significantly suppressed Covid-19’s spread.
Other states — California, Kentucky, and Oregon, to name a few — also have trends worth watching, but their signals are more mixed. California, for example, has seen cases rise by 20 percent in two weeks, but the positive test rate is little changed and hospitalizations are actually flat from a month ago. Oregon has seen a much steeper increase in cases, up 146 percent in 14 days, but its rate of new cases per million people is quite low (22) compared to Arizona (150). Kentucky’s positive test rate is flat, and new cases per million people is mild despite a 62 percent jump in cases over the last two weeks.
While these places are seeing their cases climb, the national Covid-19 curve looks like a plateau, with 21,894 new cases on June 1 and 20,839 new cases on June 10. That’s because other parts of the country — particularly the Northeast, which endured the worst Covid-19 outbreak in the early weeks of the pandemic — are seeing their numbers drop.
States reported ~20k new cases again today.
The 7-day average of new cases has been between 20-23k cases for nearly a month. But the outbreak has shifted south and west. pic.twitter.com/Rk6zPi1mV0 — The COVID Tracking Project (@COVID19Tracking) June 11, 2020
But nobody should rest easy yet, because even as cases rise in some places, most of the country is relaxing social distancing and reopening the economy.
Reopening the economy too quickly could worsen the coronavirus’s spread
It is difficult to ignore that the places seeing surges in Covid-19 cases began to reopen businesses and other public spaces a few weeks ago. Because of those reporting lags that are innate to the virus, any changes in spread would only become evident now.
“The early opening with insufficient public concern for behavior change will undoubtedly lead to more problems ahead,” David Celentano, who leads the Johns Hopkins University’s epidemiology department, told me.
Arizona rolled back its stay-at-home order on May 16. North Carolina relaxed its order on May 22. Some of the other emerging hot spots — Texas, Arkansas, etc. — have been open for business since the beginning of May. Experts point out we are now a few weeks out from Memorial Day, which may have served as an unofficial end to self-quarantine for many people in the states where shelter-in-place is no longer in effect.
We should be cautious about interpreting the surges as a clear sign that reopening is increasing spread. Correlation is not causation. There are acute outbreaks in prisons and meat-packing plants that explain part of the spike.
And not every state that’s eased its distancing policies has seen a dramatic deterioration in its Covid-19 numbers. Georgia, for example, seems to be holding up okay after allowing businesses to reopen; cases and positive test rates are up slightly but not to the degree of Arizona or Utah.
People I spoke with in these states said some increase in spread was expected; it might even be considered an acceptable trade-off for getting people back to work. Hospital capacity may be down, but that partly reflects an increase in non-Covid-19 patients now that elective surgeries have resumed.
Experts are still concerned. Texas has been seen as a leader in reopening; it never had a statewide stay-at-home order and businesses began reopening on May 1. But whatever the exact cause, the new trends in the state are troublesome.
“There is little doubt in my mind that the recent increase is also a result of more community spread,” Thomas Giordano, who leads the infectious disease program at the Baylor College of Medicine, told me. “We need to get this right, and currently the numbers aren’t looking so good.”
And to repeat one more time for good measure, Covid-19 data is always a week or more behind whatever the situation on the ground is. Spread is increasing and social distancing is easing, which could accelerate spread even more before we realize the full extent of the problem. That is the danger experts worry about right now.
“If cases are increasing under current conditions, you are not going to slow things down by giving the virus more opportunities,” Hanage said.
It’s too soon to know how much the George Floyd protests spread Covid-19
The nationwide protests over George Floyd’s death, police violence, and structural racism have also been met with concerns that they would become superspreading events.
At the protests, thousands of people congregated in close quarters and, though mask-wearing was common, it was not universal. Many public health experts lent their support to the protests, citing the toll taken on black Americans’ health across US history because of slavery and racism, but there seemed to be a real risk that these protests organized and attended by black activists would simply deepen the racial disparities in the coronavirus pandemic. Black Americans are already getting sick and dying from Covid-19 at higher rates than white Americans.
According to the experts I spoke with, however, it is simply too early to know whether the coronavirus will spread widely because of the protests. And it is worth remembering the differences between outdoor and indoor exposure, the latter being much more dangerous; it could end up being the case that people got infected because they were arrested and put into a police van or jail cell with other people, not because they were outside protesting in a big crowd.
Regardless, it’s only been about two weeks since the protests in Minneapolis grew into a national movement; new cases and any other worrying trends in the data would just now be starting to surface and may not be perceptible. For now, the trend lines in Minnesota show new cases dropping and the positive test rate is down, according to the Covid Exit Strategy dashboard.
Even if some of the places with large protests see a spike in Covid-19 cases, it will be difficult to separate the effects of the demonstrations from the effects of reopening. Minnesota, for example, relaxed its stay-at-home order on May 18 and started allowing restaurants to open again on June 1, coinciding almost exactly with the protests.
“Given that it took about a month after opening to start to see a clear increase in cases, we probably expect that any uptick coming from the protests wouldn’t be visible for a few more weeks,” Ellie Murray, an epidemiology professor at Boston University, told me. “But it’s also going to be difficult to tease out how much of any uptick is related to protesting versus other opening-related changes in behaviors.”
And as a matter of scale, widespread changes in social distancing policies or people’s behavior are likely to have a larger effect than the acute impact of a few days of protests.
“As states open up, the total number of risky contacts that are made in the population as a whole will outnumber those made at the protests,” Hanage said. “I expect there will be some retrofitting of disease in the future to the presence of a protest, but that’s not really responsible.”
The trend lines are real enough and worrying enough, in other words, without apportioning blame on the protesters. All kinds of risky behaviors are becoming more common.
The more people take precautions — wearing masks, washing hands, avoiding contact when possible — the more difficult it will be for the coronavirus to spread. But it should be clear by now: The pandemic is not over.


vox--2020-06-12--“Totally predictable”: State reopenings have backfired

One month ago , I asked epidemiologist Tara Smith if she was worried about states loosening their stay-at-home orders , despite most not meeting the government ’ s criteria for doing so .
“ I am really fearful that by June 1 or June 15 , after we ’ ve seen a couple weeks to a month of [ state reopenings ] , that our cases are going to be climbing , ” said Smith , a professor at the Kent State University College of Public Health .
Well , here we are .
It ’ s June 12 , @ @ @ @ @ @ @ , the Carolinas , Utah , Arkansas , Texas , Tennessee , and perhaps Florida .
Those states are also seeing higher numbers of positive Covid-19 tests , as well as increases in the percentage of tests that come back positive .
This indicates that the higher case counts aren ’ t simply due to more widespread testing finding milder cases .
Call it a reopening backfire .
But really : No expert thought that reopening this quickly was going to work in the first place .
Many states opened up in early @ @ @ @ @ @ @ while a winning battle against Covid-19 continued apace .
Unfortunately , it ’ s now clear that in the areas where the virus has come roaring back , few gains against it were made in the last month .
“ We managed to disrupt our economy [ and ] skyrocket unemployment , and we didn ’ t control the damn virus , ” said Jeff Shaman , an infectious disease modeler at Columbia University .
“ This is totally predictable , and there have been many warnings , ” Sarah Cobey , an @ @ @ @ @ @ @ Chicago , said .
“ We ’ re seeing undeniable signals that prevalence is truly increasing in many states.
” Simply put , reopenings have led to more infections because more people are coming into contact with each other while there ’ s still a lot of virus around .
Mask use is inconsistent , and even when they ’ re worn properly , masks are not 100 percent effective at preventing transmission .
In Arizona , nursing and long-term care facilities are still hotbeds of transmission .
“ In Arizona , one @ @ @ @ @ @ @ case of Covid-19 , ” Vox ’ s Umair Irfan previously reported .
Most concerning , Cobey said , is the increased hospitalization rates in these states — a reminder that the virus can be very severe and deadly for some , and that deaths could also start climbing soon .
“ It ’ s a lagging signal , so what it ’ s really telling us is how transmission rates were changing closer to two weeks ago , ” Cobey added .
“ This implies that unless behavior — the primary driver @ @ @ @ @ @ @ meantime , the situation will continue to worsen for another few weeks.
” It ’ s too soon to know what impact the mass protests against police brutality will have on the pandemic .
( Many protesters know the risks and have thoughtful reasons for participating anyway . )
The spikes we ’ re seeing now result in actions and decisions that likely predate them .
How bad might things get in Arizona and other states ?
We don ’ t know yet .
It might not be a disaster .
These states @ @ @ @ @ @ @ being overwhelmed and keep the epidemic curve from spiking to uncontrolled levels .
Still , more cases likely means more deaths — some of which could have potentially been avoided .
Overall , though , the trends are not moving in a good direction , and we have yet to see the full Covid-19 consequences of reopening .
Not every place that ’ s reopening is seeing spikes .
Scientists aren ’ t sure why .
Ending or loosening lockdowns hasn ’ t led to Covid-19 spikes everywhere .
Georgia was one of @ @ @ @ @ @ @ like barber shops , on April 30 .
Since then , its Covid-19 cases have more or less remained flat .
“ Why didn ’ t Georgia go through the roof ?
And the answer is , ‘ We don ’ t know , ’ ” Shaman said .
The pandemic is “ a real patchwork ” in America , he added .
Similarly , Smith said she is “ a bit surprised that Ohio is doing as well as we are since reopening.
” Maskless armed protestors showed up at the Ohio @ @ @ @ @ @ @ the governor allow businesses to reopen .
“ We don ’ t have all the data right now to determine why some [ areas ] have increased and others have not , ” she said .
It could depend more on how individuals behave — for instance , whether they ’ re wearing masks — than on any broad policy the state may enact .
Scientists are still unraveling what makes the difference between a sprawling outbreak in one city and a more manageable one in another .
Some factors are policy , @ @ @ @ @ @ @ and individual behavior .
And some of it is just luck .
It ’ s important to remember : Though scientists can ’ t precisely predict which areas will be hit hardest by Covid-19 , they do understand the conditions under which the virus thrives .
And so they can predict , broadly , when social distancing isn ’ t replaced with another safeguard , cases will increase .
The main ingredient that leads to increased cases is more people being in close contact with one another out in public .
“ I @ @ @ @ @ @ @ in places like Arizona are likely the results of easing social-distancing restrictions too soon , ” Eleanor Murray , a Boston University epidemiologist , said .
These new spikes in cases appear to be occurring in places that have largely avoided the worst coronavirus outbreaks so far .
But it ’ s important to remember that even hard-hit places like New York City could still see new waves of infections .
There are still so , so many people out there who are not immune to the virus .
In the US , @ @ @ @ @ @ @ But a lot of that is due to the initial huge crisis in New York subsiding , obscuring the emergence of new hot spots .
What ’ s happening now in Arizona and elsewhere is the continuation of the first wave , or the first wave in those areas .
But “ waves ” might be the wrong metaphor to describe what ’ s going on .
Instead , I imagine a bunch of nuclear reactors spread out across the country .
Control rods have been taken out in many of these reactors @ @ @ @ @ @ @ and the reaction grows .
This disaster is maybe more like Chernobyl and less like a tsunami .
It ’ s our actions — both collective and individual — that determine the results .
Ultimately , there ’ s no quick , snappy metaphor that really gets at the complexity of how the virus spreads .
But at the same time , the story is simple : When you don ’ t do enough to stop people with no immunity from getting infected , transmissions occur .
Experts never said that eternal lockdowns @ @ @ @ @ @ @ combat the pandemic .
They argued that once areas got the initial case spikes under control through widespread social distancing ( with new cases decreasing over at least a two-week span ) , a new phase of control should begin with widespread testing and contact tracing .
The initial lockdown period avoided the worst possible scenario , but the US didn ’ t use that time to prepare for managing the pandemic into the future .
And now we ’ ve wasted the weeks that have passed since reopening .
“ As prevalence @ @ @ @ @ @ @ increase too , because there are more cases to track , ” Cobey said .
“ At some point it becomes more practical for governments to institute blanket interventions to reduce prevalence.
” That is , we may have no choice but to enter lockdowns again .
The scary thought : What if states or businesses aren ’ t willing to do it ?
How many people will die ?
How many hospital systems will be overwhelmed ?
Too many communities and states “ are acting like we ’ re done with it @ @ @ @ @ @ @ .
“ And we ’ re nowhere near done with this.
” Every day at Vox , we aim to answer your most important questions and provide you , and our audience around the world , with information that has the power to save lives .
Our mission has never been more vital than it is in this moment : to empower you through understanding .
Vox ’ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an @ @ @ @ @ @ @ not constitute a donation , but it will enable our staff to continue to offer free articles , videos , and podcasts at the quality and volume that this moment requires .
Please consider making a contribution to Vox today .

One month ago, I asked epidemiologist Tara Smith if she was worried about states loosening their stay-at-home orders, despite most not meeting the government’s criteria for doing so.
“I am really fearful that by June 1 or June 15, after we’ve seen a couple weeks to a month of [state reopenings], that our cases are going to be climbing,” said Smith, a professor at the Kent State University College of Public Health.
Well, here we are. It’s June 12, and Covid-19 hospitalizations are rising in Arizona, the Carolinas, Utah, Arkansas, Texas, Tennessee, and perhaps Florida. Those states are also seeing higher numbers of positive Covid-19 tests, as well as increases in the percentage of tests that come back positive. This indicates that the higher case counts aren’t simply due to more widespread testing finding milder cases.
Call it a reopening backfire. But really: No expert thought that reopening this quickly was going to work in the first place.
“This is totally predictable”
Many states opened up in early May, hoping the economy would recover while a winning battle against Covid-19 continued apace.
Unfortunately, it’s now clear that in the areas where the virus has come roaring back, few gains against it were made in the last month.
“We managed to disrupt our economy [and] skyrocket unemployment, and we didn’t control the damn virus,” said Jeff Shaman, an infectious disease modeler at Columbia University.
States reported ~20k new cases again today.
The 7-day average of new cases has been between 20-23k cases for nearly a month. But the outbreak has shifted south and west. pic.twitter.com/Rk6zPi1mV0 — The COVID Tracking Project (@COVID19Tracking) June 11, 2020
“This is totally predictable, and there have been many warnings,” Sarah Cobey, an infectious disease modeler at the University of Chicago, said. “We’re seeing undeniable signals that prevalence is truly increasing in many states.”
Simply put, reopenings have led to more infections because more people are coming into contact with each other while there’s still a lot of virus around. Mask use is inconsistent, and even when they’re worn properly, masks are not 100 percent effective at preventing transmission.
In Arizona, nursing and long-term care facilities are still hotbeds of transmission. “In Arizona, one in three nursing homes has had a case of Covid-19,” Vox’s Umair Irfan previously reported.
Most concerning, Cobey said, is the increased hospitalization rates in these states — a reminder that the virus can be very severe and deadly for some, and that deaths could also start climbing soon. “It’s a lagging signal, so what it’s really telling us is how transmission rates were changing closer to two weeks ago,” Cobey added. “This implies that unless behavior — the primary driver of transmission — has changed in the meantime, the situation will continue to worsen for another few weeks.”
It’s too soon to know what impact the mass protests against police brutality will have on the pandemic. (Many protesters know the risks and have thoughtful reasons for participating anyway.) The spikes we’re seeing now result from actions and decisions that likely predate them.
How bad might things get in Arizona and other states? We don’t know yet. It might not be a disaster. These states could avoid the worst-case scenario of hospitals being overwhelmed and keep the epidemic curve from spiking to uncontrolled levels. Still, more cases likely means more deaths — some of which could have potentially been avoided.
Overall, though, the trends are not moving in a good direction, and we have yet to see the full Covid-19 consequences of reopening.
Not every place that’s reopening is seeing spikes. Scientists aren’t sure why.
Ending or loosening lockdowns hasn’t led to Covid-19 spikes everywhere.
Georgia was one of the first states to reopen businesses, like barber shops, on April 30. Since then, its Covid-19 cases have more or less remained flat.
“Why didn’t Georgia go through the roof? And the answer is, ‘We don’t know,’” Shaman said. The pandemic is “a real patchwork” in America, he added.
Similarly, Smith said she is “a bit surprised that Ohio is doing as well as we are since reopening.” Maskless armed protesters showed up at the Ohio Statehouse for three weeks to demand that the governor allow businesses to reopen. “We don’t have all the data right now to determine why some [areas] have increased and others have not,” she said. It could depend more on how individuals behave — for instance, whether they’re wearing masks — than on any broad policy the state may enact.
Scientists are still unraveling what makes the difference between a sprawling outbreak in one city and a more manageable one in another. Some factors are policy, demographics, structural inequality and racism, and individual behavior. And some of it is just luck.
It’s important to remember: Though scientists can’t precisely predict which areas will be hit hardest by Covid-19, they do understand the conditions under which the virus thrives. And so they can predict, broadly, when social distancing isn’t replaced with another safeguard, cases will increase.
The main ingredient that leads to increased cases is more people being in close contact with one another out in public. “I believe the increases we’re seeing in places like Arizona are likely the results of easing social-distancing restrictions too soon,” Eleanor Murray, a Boston University epidemiologist, said.
These new spikes in cases appear to be occurring in places that have largely avoided the worst coronavirus outbreaks so far. But it’s important to remember that even hard-hit places like New York could still see new waves of infections. There are still so, so many people out there who are not immune to the virus.
Is this a “second wave”?
In the US, overall cases have been dropping slowly. But a lot of that is due to the initial huge crisis in New York subsiding, obscuring the emergence of new hot spots.
What’s happening now in Arizona and elsewhere is the continuation of the first wave, or the first wave in those areas.
Nationally there’s no “second wave.” There’s one long wave. We’ve been in a plateau of around 20,000 cases and 1,000 deaths a day, largely among minority and vulnerable populations. Reopening will cause spikes, but calling them a second wave denies the reality of what’s going on. pic.twitter.com/ivutKKYgF9 — James Hamblin (@jameshamblin) June 11, 2020
But “waves” might be the wrong metaphor to describe what’s going on.
Instead, I imagine a bunch of nuclear reactors spread out across the country. Control rods have been taken out in many of these reactors without being replaced by new controls, and the reaction grows. This disaster is maybe more like Chernobyl and less like a tsunami. It’s our actions — both collective and individual — that determine the results.
Ultimately, there’s no quick, snappy metaphor that really gets at the complexity of how the virus spreads. But at the same time, the story is simple: When you don’t do enough to stop people with no immunity from getting infected, transmissions occur.
Experts never said that eternal lockdowns were the only choice we had to combat the pandemic. They argued that once areas got the initial case spikes under control through widespread social distancing (with new cases decreasing over at least a two-week span), a new phase of control should begin with widespread testing and contact tracing. The initial lockdown period avoided the worst possible scenario, but the US didn’t use that time to prepare for managing the pandemic in the future. And now we’ve wasted the weeks that have passed since reopening.
“As prevalence rises, the demands on contact tracing increase too, because there are more cases to track,” Cobey said. “At some point it becomes more practical for governments to institute blanket interventions to reduce prevalence.”
That is, we may have no choice but to enter lockdowns again. The scary thought: What if states or businesses aren’t willing to do it? How many people will die? How many hospital systems will be overwhelmed?
Too many communities and states “are acting like we’re done with it,” Shaman said of the pandemic. “And we’re nowhere near done with this.”