Special Report: As world approaches 10 million coronavirus cases, doctors see hope in new treatments

By Nick Brown, Deena Beasley, Gabriela Mello and Alexander Cornwell

(Reuters) – Dr. Gopi Patel recalls how powerless she felt when New York’s Mount Sinai Hospital overflowed with COVID-19 patients in March.

Guidance on how to treat the disease was scant, and medical studies were being performed so hastily they couldn’t always be trusted.

“You felt very helpless,” said Patel, an infectious disease doctor at the hospital. “I’m standing in front of a patient, watching them struggle to breathe. What can I give them?”

While there is still no simple answer to that question, a lot has changed in the six months since an entirely new coronavirus began sweeping the globe.

Doctors say they’ve learned enough about the highly contagious virus to solve some key problems for many patients. The changes could be translating into more saved lives, although there is little conclusive data.

Nearly 30 doctors around the world, from New Orleans to London to Dubai, told Reuters they feel more prepared should cases surge again in the fall.

“​We are well-positioned for a second wave,” Patel said. “We know so much more.”

Doctors like Patel now have:

*A clearer grasp of the disease’s side effects, like blood clotting and kidney failure

*A better understanding of how to help patients struggling to breathe

*More information on which drugs work for which kinds of patients.

They also have acquired new tools to aid in the battle, including:

*Widespread testing

*Promising new treatments like convalescent plasma, antiviral drugs and steroids

*An evolving spate of medical research and anecdotal evidence, which doctors share across institutions, and sometimes across oceans.

Despite a steady rise in COVID-19 cases, driven to some extent by wider testing, the daily death toll from the disease is falling in some countries, including the United States. Doctors say they are more confident in caring for patients than they were in the chaotic first weeks of the pandemic, when they operated on nothing but blind instinct.

In June, an average of 4,599 people a day died from COVID-19 worldwide, down from 6,375 a day in April, according to Reuters data.

New York’s Northwell Health reported a fatality rate of 21% for COVID-19 patients admitted to its hospitals in March. That rate is now closer to 10%, due to a combination of earlier treatment and improved patient management, Dr. Thomas McGinn, director of Northwell’s Feinstein Institutes for Medical Research, told Reuters.

“I think everybody is seeing that,” he said. “I think people are coming in sooner, there is better use of blood thinners, and a lot of small things are adding up.”

Even nuts-and-bolts issues, like how to re-organize hospital space to handle a surge of COVID-19 patients and secure personal protective equipment (PPE) for medical workers, are not the time-consuming, mad scrambles they were before.

“The hysteria of who’d take care of (hospital staff) is not there anymore,” said Dr. Andra Blomkalns, head of emergency medicine at Stanford Health Care, a California hospital affiliated with Stanford University. “We have an entire team whose only job is getting PPE.”

To be sure, the world is far from safe from a virus that continues to rage. It is expected to reach two grim milestones in the next several days: 10 million confirmed global infections and 500,000 deaths. As of Thursday evening, more than 9.5 million people had tested positive for the coronavirus, and more than 483,000 had died, according to Reuters data. The United States remains the epicenter of the pandemic, and cases are rising at an alarming pace in states like Arizona, Florida and Texas.

There is still no surefire treatment for COVID-19, the disease caused by the new virus, which often starts as a respiratory illness but can spread to attack organs including the heart, liver, kidneys or central nervous system. Scientists are at least months away from a working vaccine.

And while medical knowledge has improved, doctors continue to emphasize that the best way for people to survive is to avoid infection in the first place through good hygiene, face coverings and limited group interaction.

Dr. Ramanathan Venkiteswaran, medical director of Aster Hospitals in the United Arab Emirates, said COVID-19 will likely result in permanent changes in medicine and for the general public on “basic things like social distancing, wearing of masks and hand washing.”

LEARNING ON THE FLY

In the medical field, change can be slow, with years-long studies often needed before recommendations are altered. But protocols for COVID-19 have evolved at lightning speed.

In Brazil, São Paulo-based Hospital Israelita Albert Einstein, one of the country’s leading private hospital networks, has updated its internal guidelines for treating coronavirus patients some 50 times since the outbreak began earlier this year, according to Dr. Moacyr Silva Junior, an infectious disease specialist at the center. Those guidelines govern questions such as which patients are eligible for which drugs, how to handle patients with breathing problems, and the use of PPE like masks, gowns and gloves.

“In only three months, a resounding amount of scientific work on COVID-19 has been published,” he said.

At Stanford Health Care, treatment guidelines changed almost daily in the early weeks of the pandemic, Blomkalns said. She described a patchwork approach that began by following guidelines established by the U.S. Centers for Disease Control and Prevention, then modifying them to reflect a shortage of resources, and finally adding new measures not addressed by the CDC, such as how to handle pregnant healthcare workers.

The new coronavirus has been particularly vexing for doctors because of the many and often unpredictable ways it can manifest. Most people infected experience only mild flu-like symptoms, but some can develop severe pneumonia, stroke and neurological disease. Doctors say the biggest advance so far has been understanding how the disease can put patients at much higher risk for blood clots. Most recently, doctors have discovered that blood type might influence how the body reacts to the virus.

“We developed specific protocols, such as when to start blood thinners, that are different from what would be done for typical ICU patients,” said Dr. Jeremy Falk, pulmonary critical care specialist at Cedars-Sinai Medical Center in Los Angeles.

Around 15% of COVID-19 patients are at risk of becoming sick enough to require hospitalization. Scientists have estimated that the fatality rate could be as high as 5%, but most put the number well below 1%. People with the highest risk of severe disease include older adults and those with underlying health conditions like heart disease, diabetes and obesity.

While rates of COVID-19 infection have recently been rising in many parts of the United States, the total number of U.S. patients hospitalized with COVID-19 has been steadily falling since a peak in late April, according to the CDC.

Many hospitals report success with guidelines for “proning” patients – positioning them on their stomachs to relieve pressure on the lungs, and hopefully stave off the need for mechanical ventilation, which many doctors said has done more harm than good.

“At first, we had no idea how to treat severely ill patients when we (ventilate),” said Dr. Satoru Hashimoto, who directs the intensive care division at Kyoto Prefectural University of Medicine in Japan. “We treated them in the fashion we treated influenza,” only to see those patients suffer serious kidney, digestive and other problems, he said.

Hospitals say increased coronavirus testing – and faster turnaround times to get results – are also making a difference.

“What has really helped us triage patients is the availability of rapid testing that came on about six weeks ago,” said Falk of Cedars-Sinai. “Initially, we had to wait two, three or even four days to get a test back. That really clogged up the COVID areas of the hospital.”

Faster, wider testing also helps conserve PPE by identifying the negative patients around whom doctors don’t have to wear as much gear, said Dr. Saj Patel, who treats non-critical patients at the University of California San Francisco Medical Center. “You can imagine how much PPE we burned through” waiting for test results, he said.

Hospitals around the world acted early to restructure operations, including floor layouts, to isolate coronavirus patients and reduce exposure to others. It wasn’t always smooth, but doctors say they’re figuring out how to do it more efficiently.

“Our hospital infrastructure, and the way that we … manage people coming through the door is a lot slicker than it was earlier in the epidemic,” said Dr. Tom Wingfield, a clinical lecturer at the Liverpool School of Tropical Medicine in Liverpool, England.

USING WHAT’S AT HAND

But even if hydroxychloroquine looks unlikely as an effective COVID-19 treatment, hospitals continue to try new medications – both by repurposing older drugs and exploring novel therapies. Patients are being enrolled in hundreds of coronavirus clinical trials launched in the past three months.

Many hospitals said they are seeing success with the use of plasma donated by survivors of COVID-19 to treat newly infected patients.

People who survive an infectious disease like COVID-19 are generally left with blood containing antibodies, which are proteins made by the body’s immune system to fight off a virus. The blood component that carries the antibodies, known as convalescent plasma, can be collected and given to new patients.

Early results from a study at New York’s Mount Sinai Hospital found that patients with severe COVID-19 who were given convalescent plasma were more likely to stabilize or need less oxygen support than other similar hospital patients. But results from other studies have been mixed, and doctors still await findings from a rigorously-designed trial. And availability of plasma varies between regions.

At Henry Ford Hospital in Detroit, Michigan, “anecdotally everyone can provide stories” of the benefits of plasma, said Dr. John Deledda, the hospital’s chief medical officer.

But in rural New Mexico, hospitals that care for largely underserved populations struggle to find it. “There’s a limited number of blood centers” that can provide plasma, said Valory Wangler, chief medical officer at Rehoboth McKinley Christian Health Care Services, in Gallup, New Mexico. Until trial data is more conclusive, plasma is “not something we’re pursuing actively,” she said.

Dr Abdullatif al-Khal, head of infectious diseases at Qatar’s Hamad Medical Corporation and a co-chair of the country’s pandemic preparedness team, said he saw patients improve after he started using donated plasma early in the course of COVID-19 before the patients deteriorated.

Qatar is also assessing a steroid known as dexamethasone to treat COVID-19. But Khal says he wants to wait for publication of clinical data behind a recent UK study suggesting that the steroid reduced death rates by around a third among the most severely ill COVID-19 patients.

In patients with severe COVID-19, the immune system can overreact, triggering a potentially harmful cascade. Steroids are an older class of drugs that suppress that inflammatory response. But they can also make it easier for other viral or bacterial infections to take hold – making doctors leery of their use in a hospital setting or in patients with early-stage COVID-19.

Some countries, including Bahrain and the United Arab Emirates, reported using HIV drugs lopinavir and ritonavir with some success. Clinical trials, though, have suggested little benefit, and they aren’t widely used in the United States.

MIDNIGHT DELIVERY

Many of the doctors who spoke with Reuters were bullish on the use of remdesivir, the only drug so far shown to be effective against the coronavirus in a rigorous clinical trial. The antiviral developed by California-based Gilead Sciences Inc <GILD.O> was shown to reduce the length of hospital stays for COVID-19 patients by about a third, but hasn’t been proven to boost survival.

Remdesivir is designed to disable the mechanism by which certain viruses, including the new coronavirus, make copies of themselves and potentially overwhelm their host’s immune system.

It is available under emergency approvals in several countries, including the United States. But Gilead’s donated supplies are limited, and distribution and availability are uneven.

Dr. Andrew Staricco, chief medical officer at McLaren Health Care, which operates 11 hospitals across Michigan, recalls the urgency to obtain remdesivir early on. He got an email from Michigan’s health department on May 9, a week after the U.S. Food & Drug Administration authorized the drug for use in treating COVID-19. The health department said it had received a small batch from the federal government, and planned to dole it out to local hospitals based on need. Staricco wrote back, saying he had 15 to 18 critically ill patients, but was given enough to treat just four.

The drug was so precious, he said, that state police troopers were responsible for transporting it to the hospital – which they did, dropping it off around 1 a.m. the next morning.

Health officials originally directed remdesivir for use on the most critically ill patients. But doctors later found they got the best results administering it earlier.

“We started finding that, actually, the sooner you get treated with it, the better,” Staricco said. “We’ve revisited our criteria for giving it to patients three different times.”

Data on the drug, he said, is still scarce. But his anecdotal observations on the benefits of early treatment were echoed by several U.S. doctors.

‘COPY-CATTING’

Gilead on Monday said it aims to manufacture another 2 million courses of remdesivir this year, but did not comment on how it plans to distribute, or sell, those supplies for use by hospitals. The company has licensed the antiviral to several generic drugmakers, who will be allowed to sell the medication in over 100 low-income nations.

Although much about the coronavirus remains unknown, a key reason hospitals say they now are more prepared owes to teamwork.

Many doctors described a kind of unofficial network of information sharing.

In hard-hit Italy, Dr. Lorenzo Dagna of the IRCCS San Raffaele Scientific Institute in Milan, organized conference calls with institutions in the United States and elsewhere to share experiences and anecdotes treating COVID-19 patients.

McLaren’s Staricco said the Michigan hospital chain adopted its policy on use of blood thinners by looking at peers at Detroit Medical Center and Vanderbilt University Medical Center.

As more institutions put their guidelines online, he said, there was “lots of copy-catting going on.”

(Reporting by Nick Brown in New York, Deena Beasley in Los Angeles, Gabriela Mello in São Paulo and Alexander Cornwell in Dubai.; Additional reporting By Alistair Smout in London, Matthias Blamont in Paris, Emilio Parodi in Milan, Lisa Barrington in Dubai, Rocky Swift in Tokyo and Sangmi Cha in Seoul.; Editing by Michele Gershberg and Marla Dickerson)

 

Explainer: Are asymptomatic COVID-19 patients safe or silent carriers?

By Cate Cadell and Roxanne Liu

BEIJING (Reuters) – China said 300 symptomless carriers of the novel coronavirus in Wuhan, the epicenter of the pandemic, had not been found to be infectious, in a bid to reassure people as countries ease restrictions. But some experts say asymptomatic infections are common, presenting a huge challenge in the control of the disease.

WHAT IS ASYMPTOMATIC AND PRE-SYMPTOMATIC?

The World Health Organization (WHO) defines https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200402-sitrep-73-covid-19.pdf asymptomatic cases as those who don’t show symptoms but have been confirmed infected through a lab test. WHO notes there are few reports of truly asymptomatic cases.

The incubation period, or the time a person takes to show symptoms after getting infected, is the pre-symptomatic phase, the WHO says. Carriers can infect others during this period.

Health experts are not yet sure whether asymptomatic or pre-symptomatic cases are infectious. Some say data so far suggests those cases are probably equally likely to be able to spread infection.

The WHO agrees that pre-symptomatic carriers are infectious, and adds that there is also a possibility – although little evidence so far – that people who are asymptomatic may also transmit the virus. The WHO had said in early April that there had been no documented asymptomatic transmissions.

WHAT ELSE DOES CHINA SAY?

China has reported around 83,000 cases of COVID-19, the disease caused by the new coronavirus. It does not include asymptomatic cases in that total official count, but began reporting them separately on a daily basis on March 31.

That has raised concerns about Beijing’s commitment to transparency, and some experts say it could also paint a misleading picture of how the virus spreads.

“If you watch (such asymptomatic cases) really closely, you would see something … that probably fits with a more realistic mild disease than a complete asymptomatic,” Ian Mackay, a virologist at the University of Queensland said.

“But the term is around now and it’s going to stick. It’s a nice piece of theatre, but I don’t think it’s going to give useful information.”

Asymptomatic cases under medical observation in China dropped to 357 as of Tuesday from 1,541 as of March 30.

Wuhan has tested almost its entire population of 11 million and found no new COVID-19 cases.

Wuhan’s low rate of symptomless carriers is in line with China’s previous reporting, said Zhong Nanshan, the government’s senior medical adviser, adding that the result showed that the country didn’t cover up the epidemic as some U.S. politicians claimed.

HOW ABOUT REST OF ASIA?

Some countries in Asia include asymptomatic carriers in their total confirmed cases.

In Vietnam, which has just over 300 COVID-19 cases, almost 37% were symptomless, according to health ministry data.

Researchers concluded that asymptomatic infection was common and found two asymptomatic patients had infected at least four other people.

South Korea, which had early success in taming the outbreak through aggressive testing, said 20%-30% were asymptomatic. A senior health official said the virus could be widely transmitted during the incubation period, but asymptomatic patients were less likely to transmit it.

Singapore, which has the highest number of cases in Southeast Asia, does not give data on asymptomatic cases but has said an overwhelming majority of positive cases in its crowded migrant workers’ dormitories show mild or no symptoms.

The Philippines said about 13% of its nearly 19,000 cases were asymptomatic. In India, some 28% of 40,184 people who tested positive between Jan. 22 and April 30 were asymptomatic, according to a study.

(Reporting by Cate Cadell and Roxanne Liu in Beijing; Additional reporting by Kate Kelland in London, John Mair in Sydney, James Pearson in Hanoi, John Geddie in Singapore, Neil Jerome Morales in Manila, Sangmi Cha in Seoul, Rocky Swift in Tokyo and Miyoung Kim in Singapore; Writing by Sayantani Ghosh in Singapore; Editing by Kim Coghill)

Your COVID-19 questions, answered

Your COVID-19 questions, answered
There is a lot of misinformation circulating about the coronavirus, so we took to Instagram, Twitter and Reddit to see what questions have been bugging you, our readers.Below are answers from several healthcare experts who have been following the outbreak. Please note that there is much we still don’t know about the new virus, and you should reach out to your own healthcare provider with any personal health concerns.

LIVING UNDER LOCKDOWN

What are good ways to maintain your mental health?

I would recommend the following:

1. Maintain a normal schedule if possible

2. Exercise (go for walk or run, do an online video)

3. Maintain social connections via FaceTime, Skype or phone calls

4. Limit time spent on the Internet and connected to the news

5. Have “virtual” dates with family and friends.

— Dr. Krutika Kuppalli, infectious disease researcher

How long will the U.S. really have to be on lockdown to successfully flatten the curve?

We’re still learning on a daily basis what the case count looks like in the U.S. We also need to consider that there could be a resurgence of cases once public health measures are loosened up.

— Dr. Krutika Kuppalli, infectious disease researcher

I defer to the epidemiologists here, but National Institute of Allergy and Infectious Diseases Director Anthony Fauci recently said that he’s confident in a range of four to six weeks to 3 months.

— Dr. Angela Rasmussen, virologist at Columbia University

Do I actually need to wear a mask?

The WHO advises that if you’re healthy, you need to wear a mask only when caring for an infected person or if you’re coughing, sneezing or showing symptoms.

TRANSMISSION

Is it fair to assume every American will be exposed to the coronavirus this year?

No, which is one of the reasons we have these current public health measures in place. We are trying to prevent further onward transmission of the disease.

— Dr. Krutika Kuppalli, infectious disease researcher

Is the coronavirus airborne in normal settings and if so, for how long?

According to our knowledge, it does not stay in the air in normal settings. Most evidence directs us to droplet transmission. Airborne precautions are required only for healthcare workers when undertaking aerosol producing procedures such as bronchoscopy/intubation.

— Dr. Muge Cevik, infectious diseases researcher at the University of St. Andrews

Is there potential exposure in elevators?

Coronavirus guidelines by the CDC are based on the fact that the virus is transmitted primarily via respiratory droplets, like a cough or sneeze. In droplet form, it’s airborne for a few seconds, but is only able to travel a short distance. In elevators, social distancing measures should be implemented with a max number of people inside at a time.

— Infectious Diseases Society of America

How worried should we be about fomite transmission?

We are still learning about fomite transmission. We know from an article in the New England Journal of Medicine that the virus is viable up to four hours on copper, 24 hours on cardboard, and two to three days on plastic and stainless steel.

— Dr. Krutika Kuppalli, infectious disease researcher

Can you spread the virus if you’re asymptomatic?

Yes, but it isn’t the main driver of transmission. This is also why it is extremely important to ensure you have washed hands before touching your face.

— Dr. Krutika Kuppalli, infectious disease researcher

What’s the typical timeline of symptoms?

From the time of exposure to symptoms it may take on average three to six days, which may be longer/shorter in some patients. Typically it starts with fever, dry cough, myalgia and flu-like illness, then progresses to shortness of breath and pneumonia in some patients.

— Dr. Muge Cevik, infectious diseases researcher at the University of St. Andrews

Is it possible that an infected person only has a mild cold before recovering?

Yes. The most common symptoms a person will have are fever, dry cough and muscle aches/fatigue.

— Dr. Krutika Kuppalli, infectious disease researcher

Should people be more concerned about eye protection?

We certainly use face shields to protect our eyes when in contact with patients.

— Dr. Isaac Bogoch, infectious disease researcher and scientist

Does getting vaccines increase your risk?

Getting any vaccines would not increase your risk for COVID-19. We’re recommending getting needed vaccines. We want people to get their influenza vaccines so they don’t end up with the flu and in the hospital.

— Dr. Krutika Kuppalli, infectious disease researcher

Do people have a natural immunity to this virus?

I am not aware of “natural immunity” since it is a new virus. We might find as serology testing is rolled out that people have been exposed and developed antibodies without having symptoms.

— Dr. Krutika Kuppalli, infectious disease researcher

Is it possible to get reinfected?

We’re not sure how immunity works or how long it lasts. The best guess is that people who are infected are likely to be protected over the short-to-medium term. We don’t know about longer yet.

— Dr. Eric Rubin, editor-in-chief, New England Journal of Medicine

TREATMENT

Is there a team working on an antibody test for the virus? If so, when might it be ready?

There are teams working on serological tests . Rolling out on a population scale will be an essential part of the long-term answer, but we need to get through the next month.

— Bill Hanage, associate professor at the Harvard T. H. Chan School of Public Health

When will a vaccine be ready?

Vaccine trials may take as long as 12 months. There are multiple clinical trials looking at different treatment options, but we currently don’t know whether this combination is effective and safe for patients.

— Dr. Muge Cevik, infectious diseases researcher at the University of St. Andrews

Scientists in Singapore are trying to fast-track the process.

What impact will warmer weather have on the spread?

I have yet to see convincing evidence on this, one way or the other. We are all hoping transmission will slow down with warmer weather in the northern hemisphere, and that warmer countries will be spared the worst. Not enough data yet to conclude.

— Dr. Suerie Moon, director of research at the Global Health Centre

I’ve seen several news sources report that experts from Johns Hopkins and other medical colleges are saying the virus can become less deadly as it spreads. Can you explain this phenomenon?

Yes, one theory for why many viruses become weaker over time is that viruses that kill their host don’t get very far. This pattern of weakening is seen with flu viruses, and many others, but not all. We’re not there yet with the current outbreak. Whether it’s weaker three or 10 years from now doesn’t change anything about today’s situation.

— Christine Soares, medical editor at Reuters

(Reporting by Lauren Young, Jenna Zucker, Beatrix Lockwood, Nancy Lapid, Christine Soares)

Arctic ‘doomsday’ food vault welcomes millionth seed variety

By Gwladys Fouche

OSLO (Reuters) – A vault in the Arctic built to preserve seeds for rice, wheat and other food staples contains one million varieties with the addition on Tuesday of specimens grown by Cherokee Indians and the estate of Britain’s Prince Charles.

The Svalbard Global Seed Vault, built on a mountainside in 2008, was designed as a storage facility to protect vital crop seeds against the worst cataclysms of nuclear war or disease and safeguard global food supplies.

Representatives from many countries and universities arrive in the Svalbard’s global seed vault with new seeds, in Longyearbyen, Norway February 25, 2020. NTB Scanpix/Lise Aserud via REUTERS

Dubbed the “doomsday vault”, the facility lies on the island of Spitsbergen in the archipelago of Svalbard, halfway between Norway and the North Pole, and is only opened a few times a year in order to preserve the seeds inside.

On Tuesday, 30 gene banks deposited seeds, also including offerings from India, Mali and Peru.

The Royal Botanical Gardens at Kew in Britain banked seeds harvested from the meadows of Prince Charles’ private residence, Highgrove.

The vault also serves as a backup for plant breeders to develop new varieties of crops. The world used to cultivate around 7,000 different plants but experts say we now get about 60% of our calories from three main crops – maize, wheat and rice – making food supplies vulnerable if climate change causes harvests to fail.

“The seed vault is the backup in the global system of conservation to secure food security on Earth,” Stefan Schmitz, executive director of the Crop Trust, the Bonn-based organization that manages the vault, told Reuters.

“We need to preserve this biodiversity, this crop diversity, to provide healthy diets and nutritious foods, and for providing farmers, especially smallholders, with sustainable livelihoods so that they can adapt to new conditions.”

One in nine people go to bed hungry globally, according to the United Nations’ World Food Programme, and scientists have predicted that erratic weather patterns could reduce both the quality and quantity of food available.

The vault was last opened in October. With Tuesday’s deposit, it contains one million different seeds, from almost all nations.

In 2015, researchers made a first withdrawal from the vault after Syria’s civil war damaged a seed bank near the city of Aleppo. The seeds were grown and re-deposited at the Svalbard vault in 2017.

In October, Norway completed an $11 million, year-long upgrade of the building, which was constructed at Svalbard because the Arctic’s cold climate means its contents will stay cool even if the power fails. But even the doomsday vault has been affected by climate change as an unexpected thaw of permafrost when it first opened let in water to the tunnel entrance, although no seeds were damaged.

(Additional reporting by Thin Lei Win in Rome; Editing by Susan Fenton and John Stonestreet)

Hunt on for ‘patient zero’ who spread coronavirus globally from Singapore

By John Geddie, Sangmi Cha and Kate Holton

SINGAPORE/SEOUL/LONDON (Reuters) – As lion dancers snaked between conference room tables laden with plastic bottles, pens, notebooks and laptops, some staff from British gas analytics firm Servomex snapped photos of the performance meant to bring good luck and fortune.

But the January sales meeting in a luxury Singapore hotel was far from auspicious.

Someone seated in the room, or in the vicinity of the hotel that is renowned for its central location and a racy nightclub in the basement, was about to take coronavirus global.

Three weeks later, global health authorities are still scrambling to work out who carried the disease into the mundane meeting of a firm selling gas meters, which then spread to five countries from South Korea to Spain, infecting over a dozen people.

Experts say finding this so-called “patient zero” is critical for tracing all those potentially exposed to infection and containing the outbreak, but as time passes, the harder it becomes.

“We do feel uncomfortable obviously when we diagnose a patient with the illness and we can’t work out where it came from…the containment activities are less effective,” said Dale Fisher, chair of the Global Outbreak Alert and Response Network coordinated by the World Health Organisation.

Authorities initially hinted at Chinese delegates, which included someone from Wuhan – the Chinese city at the epicentre of the virus that has killed over 1,350 people. But a Servomex spokesperson told Reuters its Chinese delegates had not tested positive.

Fisher and other experts have compared the Singapore meeting to another so-called “super-spreading” incident at a Hong Kong hotel in 2003 where a sick Chinese doctor spread Severe Acute Respiratory Syndrome around the world.

The WHO has opened an investigation into the Singapore incident, but said its “way too early” to tell if it is a super-spreading event.

SCARY AND SOBERING

It was more than a week after the meeting – which according to a company e-mail included Servomex’s leadership team and global sales staff – that the first case surfaced in Malaysia.

The incubation period for the disease is up to 14 days and people may be able to infect others before symptoms appear.

The firm said it immediately adopted “extensive measures” to contain the virus and protect employees and the wider community. Those included self-isolation for all 109 attendees, of whom 94 were from overseas and had left Singapore.

But the virus kept spreading.

Two South Korean delegates fell sick after sharing a buffet meal with the Malaysian, who also passed the infection to his sister and mother-in-law. Three of the firm’s Singapore attendees also tested positive.

Then cases started appearing in Europe.

An infected British delegate had headed from the conference to a French ski resort, where another five people fell ill. Another linked case then emerged in Spain, and when the Briton returned to his home town in the south of England the virus spread further.

“It feels really scary that one minute it’s a story in China… and then the next minute it is literally on our doorstep,” said Natalie Brown, whose children went to the same school as the British carrier. The school said in a letter that two people at the school had been isolated.

“It’s scary and sobering how quickly it seems to have spread,” said Brown.

TIME RUNNING OUT

Back in Singapore, authorities were battling to keep track of new cases of local transmissions, many unlinked to previous cases.

Management at the hotel – the Grand Hyatt Singapore – said they had cleaned extensively and were monitoring staff and guests for infection but did not know “how, where or when” conference attendees were infected. The lion dancers, who posted photos of the event on Facebook, said they were virus free.

“Everyone assumes it was a delegate but it could have been a cleaner, it could have been a waiter,” said Paul Tambyah, an infectious diseases expert at National University Singapore. He added it was “very important” to find “patient zero” to establish other possible “chains of transmission”.

But time may be running out.

Singapore health ministry’s Kenneth Mak said the government will continue to try and identify the initial carrier until the outbreak ends, but as days pass it will get harder.

“We might never be able to tell who that first patient is,” Mak said.

Meanwhile, the fallout from the conference continues to sow trepidation weeks after the event and thousands of miles away.

Reuters visited Servomex’s offices in the suburbs of South Korea’s capital, Seoul. It was closed and dark inside, and a building guard told Reuters employees were working from home.

A notice posted by building management stated a coronavirus patient had entered the complex, while several young women could be overheard in a nearby elevator discussing whether it had been used by the infected person.

“Do you think the patient would have gotten on this elevator or the other one?” one said.

(Reporting by John Geddie, Joe Brock and Keith Zhai in Singapore, Sangmi Cha and Josh Smith in Seoul, Kate Holton in London, and Joseph Sipalan in Kuala Lumpur; Editing by Raju Gopalakrishnan)

Cold, disease threaten more than half a million Syrians fleeing Idlib fighting

By Khalil Ashawi

AZAZ, Syria (Reuters) – Cold weather, disease and a lack of shelter and medicine threaten hundreds of thousands of civilians as they flee fighting in Idlib province, in one of the biggest upheavals of Syria’s nine-year civil war, aid groups and doctors said.

The migrants, their numbers swelling by the day, are trapped between advancing Syrian government forces, keen to crush the last significant opposition stronghold, and Turkey’s closed border.

Some are having to flee by foot, while many others are having to sleep in their cars, as Syrian and Russian warplanes bombard the highways leading north toward Turkey.

A U.N. official appealed for emergency financial assistance to help an estimated 800,000 people in northwest Syria to survive the coming months.

“People are facing a tragedy. For the last two weeks it’s been very, very cold. There is rain and mud, and influenza is spreading,” said Wassim Zakaria, a doctor who works in a clinic in Idlib city that closed on Monday due to heavy bombardment.

The numbers on the move have increased in recent days as the forces of Syrian President Bashar al-Assad advanced to within 8 km (5 miles) of Idlib city, said Selim Tosun, the Turkish Humanitarian Relief Foundation’s (IHH) media adviser in Syria.

“If the cold weather continues…there is a risk of epidemics as a large migrant flow is coming,” he said.

Since November, 692,000 people have abandoned towns south of Idlib city, Tosun said. The number “is rising every hour” and could reach 1 million, he added.

Zakaria said people had also started to flee from Idlib city but their options for shelter were limited, with people forced to sleep in cars or tents, many near the walled-off border which prevents Syrians taking refuge in Turkey.

“It’s like people are imprisoned here. Last week women and children demonstrated at the border, asking to be allowed across,” he said.

Turkey’s IHH is distributing urgent aid and blankets to those traveling on the highway from Idlib city and has set up 2,000 tents, with plans to put up another 1,500, Tosun said.

Some 700 breeze-block dwellings have also been built out of a total 10,000 which Turkey is planning to erect in the region south of its border, he said.

He added that many people were now seeking shelter beyond Idlib province, already home to waves of civilians displaced earlier in Syria’s civil war, and were heading toward Afrin and Azaz, areas just to the northeast under the control of Turkish-led Syrian rebel forces.

AID APPEAL

David Swanson, U.N. regional spokesperson for the Syria crisis, said $336 million was urgently needed to help those being displaced, with shelter a critical problem.

“This crisis continues to deteriorate by the minute. This is easily one of the largest waves of displacements since the (Syrian civil war) began in March 2011,” Swanson said.

“Hundreds of thousands of people are in now in urgent need of critical, life-saving assistance,” he said.

The United Nations has put the number of displaced from the Idlib fighting since Dec. 1 at 520,000, with a further 280,000 seen at “imminent risk of displacement”.

Many of the displaced are staying with host communities who themselves are struggling to cope, while others have sought shelter in schools or mosques, or are sleeping in their vehicles or in the open air, said Swanson.

“The humanitarian situation in Syria is more catastrophic than ever before. Who would have imagined that entire cities would be displaced in a single month?” said Atef Nanou, manager of Molham Volunteering Team, a relief group in northern Syria.

He said he had encountered families unable to get away from the bombing because they couldn’t afford fuel for their car or transportation costs.

“So they either stayed despite the bombing or went out on foot on the international road that the Syrian regime and Russian warplanes are bombing around the clock,” Nanou added.

(Additional reporting by Dominic Evans and Daren Butler in Istanbul and Eric Knecht in Beirut; Writing by Daren Butler; Editing by Gareth Jones)

Wider Image: The Indian children who need to take a train to get to water

By Rajendra Jadhav

MUKUNDWADI, India (Reuters) – As their classmates set off to play after school each day, nine-year-old Sakshi Garud and her neighbor Siddharth Dhage, 10, are among a small group of children who take a 14-km (9-mile) return train journey from their village in India to fetch water.

Their families are some of the poorest in the hamlet of Mukundwadi, in the western state of Maharashtra, a village that has suffered back-to-back droughts.

India’s monsoons have brought abundant rain and even floods in many parts of the country, but rainfall in the region around Mukundwadi has been 14% below average this year and aquifers and borewells are dry.

“I don’t like to spend time bringing water, but I don’t have a choice,” Dhage said.

“This is my daily routine,” said Garud. Their cramped shanty homes are just 200 meters (220 yards) from the train station. “After coming from school, I don’t get time to play. I need to get water first.”

They are not alone. Millions of Indians do not have secure water supplies, according to the UK-based charity, WaterAid. It says 12% of Indians, or about 163 million people, do not have access to clean water near their homes – the biggest proportion of any country.

For an interactive graphic on India’s depleting water resources, please click https://tmsnrt.rs/2mgof1L

Recognizing the issue, Indian Prime Minister Narendra Modi has promised to spend more than 3.5 trillion rupees ($49 billion) to bring piped water to every Indian household by 2024.

More than 100 families in Garud and Dhage’s neighborhood do not have access to piped water and many depend on private water suppliers, who charge up to 3,000 rupees ($42) for a 5,000-litre tanker during summer months.

But private water supply is something Garud and Dhage’s parents say they can not afford.

“Nowadays, I don’t get enough money to buy groceries. I can’t buy water from private suppliers,” said Dhage’s father, Rahul, a construction worker. “I am not getting work every day.”

PIPE DREAM

The children take the train daily to fetch water from the nearby city of Aurangabad.

The train is often overcrowded, so a group of small children jostling to get on board with pitchers to fill with water is not always welcome.

“Some people help me, sometimes they complain to railway officials for putting pitchers near the door. If we don’t put them near the door, we can not take them out quickly when the train stops,” Dhage said.

Garud’s grandmother Sitabai Kamble and an elderly neighbor help occasionally by pushing them on board in the face of irritable passengers.

“Sometimes they kick the pitchers away, they grumble,” Kamble said.

When the train pulls into Aurangabad thirty minutes later, they scramble to fill the pitchers at nearby water pipes. Garud can’t reach the tap, so she relies on her taller sister, Aaysha, 14, and grandmother.

Others, like Anjali Gaikwad, 14, and her sisters, also board the train every few days to collect water and wash clothes.

Their neighbor Prakash Nagre often tags along with soap and shampoo. “There’s no water to bathe at home,” he says.

When the train returns them to Mukundwadi, they have just under a minute to disembark. At times, Dhage’s mother, Jyoti, is waiting at the station to help.

“I’m careful, but sometimes pitchers fall off the door in the melee and our work is wasted,” she said, holding her infant in one arm and a pitcher in the other. “I can’t leave my daughter at home alone so I have to take her along.”

(Reporting by Rajendra Jadhav; Additional reporting by Francis Mascarenhas; Writing by Sankalp Phartiyal; Editing by Euan Rocha and Neil Fullick)

U.S. records 16 new measles cases as outbreak shows signs of slowing

FILE PHOTO: Materials are seen left at demonstration by people opposed to childhood vaccination after officials in Rockland County, a New York City suburb, banned children not vaccinated against measles from public spaces, in West Nyack, New York, U.S. March 28, 2019. REUTERS/Mike Segar/File Photo

(Reuters) – The United States recorded 16 new measles cases between July 18 and July 25, federal health officials said on Monday, as the spread of the disease, which has infected 1,164 people this year in the worst U.S. outbreak since 1992, shows signs of slowing.

The U.S. Centers for Disease Control and Prevention said the new cases represented a 1.4% increase in the number of cases of the highly contagious and sometimes deadly disease since the previous week.

In recent weeks, the CDC has reported smaller increases in the number of measles cases, compared with a surge of more than a hundred cases reported in a single week earlier this year.

The running tally of cases this year, which have popped up in 30 states, includes active cases and those that have since resolved. No fatalities have been reported.

Health experts say the virus has spread mostly among school-age children whose parents declined to give them the measles-mumps-rubella, or MMR, vaccine, which confers immunity to the disease. A vocal fringe of U.S. parents cites concerns that the vaccine may cause autism despite scientific studies that have debunked such claims.

Measles was declared eliminated in the United States in 2000, meaning there was no continuous transmission of the disease for a year. Still, cases of the virus occur and spread via travelers coming from countries where measles is common.

CDC officials have warned that the country risks losing its measles elimination status if the ongoing outbreak, which began in October 2018 in New York, continues until October 2019.

(Reporting by Gabriella Borter in New York and Ankur Banerjee in Bengaluru; editing by Maju Samuel and Jonathan Oatis)

Cholera cases jump to 138 in Mozambique’s Beira after cyclone

Medical staff wear protective masks at a cholera treatment centre set up in the aftermath of Cyclone Idai in Beira, Mozambique, March 29, 2019. REUTERS/Mike Hutchings

By Stephen Eisenhammer

BEIRA, Mozambique (Reuters) – The number of confirmed cases of cholera in the cyclone-hit Mozambican port city of Beira jumped from five to 138 on Friday, as government and aid agencies battled to contain the spread of disease among the tens of thousands of victims of the storm.

Cyclone Idai smashed into Beira on March 14, causing catastrophic flooding and killing more than 700 people across three countries in southeast Africa.

Many badly affected areas in Mozambique and Zimbabwe are still inaccessible by road, complicating relief efforts and exacerbating the threat of infection.

Although there have been no confirmed cholera deaths in medical centers in Mozambique yet, at least two people died outside hospitals with symptoms including dehydration and diarrhea, the country’s environment minister Celso Correia said.

A Reuters reporter saw the body of a dead child being brought out of an emergency clinic in Beira on Wednesday. The child had suffered acute diarrhea, which can be a symptom of cholera.

“We expected this, we were prepared for this, we’ve doctors in place,” Correia told reporters.

The government said for the first time that there had been confirmed cholera cases on Wednesday.

Mozambique’s National Disaster Management Institute said the local death toll from the tropical storm had increased to 493 people, from 468 previously.

That takes the total death toll across Mozambique, Zimbabwe and Malawi to 738 people, with many more still missing.

“Stranded communities are relying on heavily polluted water. This, combined with widespread flooding and poor sanitation, creates fertile grounds for disease outbreaks, including cholera,” the International Committee of the Red Cross said in a statement.

In Geneva, the World Health Organization’s Tarik Jasarevic said 900,000 doses of oral cholera vaccine were expected to arrive on Monday.

Cholera is endemic to Mozambique, which has had regular outbreaks over the past five years. About 2,000 people were infected in the last outbreak, which ended in February 2018, according to the WHO.

But the scale of the damage to Beira’s water and sanitation infrastructure, coupled with its dense population, have raised fears that another epidemic would be difficult to put down.

(Reporting by Stephen Eisenhammer in Beira and Stephanie Nebehay in Geneva; Writing Alexander Winning; Editing by Alison Williams)

After Venezuelan troops block aid, Maduro faces ‘diplomatic siege’

Venezuelan national guard members stand near a fire barricade, at the border, seen from in Pacaraima, Brazil February 24, 2019. REUTERS/Ricardo Moraes

By Angus Berwick, Sarah Marsh and Roberta Rampton

CARACAS/WASHINGTON (Reuters) – Venezuelan President Nicolas Maduro faced growing regional pressure on Sunday after his troops repelled foreign aid convoys, with the United States threatening new sanctions and Brazil urging allies to join a “liberation effort”.

Violent clashes with security forces over the opposition’s U.S.-backed attempt on Saturday to bring aid into the economically devastated country left almost 300 wounded and at least three protesters dead near the Brazilian border.

Juan Guaido, recognized by most Western nations as Venezuela’s legitimate leader, urged foreign powers to consider “all options” in ousting Maduro, ahead of a meeting of the regional Lima Group of nations in Bogota on Monday that will be attended by U.S. Vice President Mike Pence.

Pence is set to announce “concrete steps” and “clear actions” at the meeting to address the crisis, a senior U.S. administration official said on Sunday, declining to provide details. The United States last month imposed crippling sanctions on the OPEC nation’s oil industry, squeezing its top source of foreign revenue.

“What happened yesterday is not going to deter us from getting humanitarian aid into Venezuela,” the official said, speaking with reporters on condition of anonymity.

Brazil, a diplomatic heavyweight in Latin America which has the region’s largest economy, was for years a vocal ally of Venezuela while it was ruled by the leftist Workers Party. It turned sharply against Venezuela’s socialist president this year when far-right President Jair Bolsonaro took office.

“Brazil calls on the international community, especially those countries that have not yet recognized Juan Guaido as interim president, to join in the liberation effort of Venezuela,” the Brazilian Foreign Ministry said in a statement.

Colombia, which has received around half the estimated 3.4 million migrants fleeing Venezuela’s hyperinflationary economic meltdown, has also stepped up its criticism of Maduro since swinging to the right last year.

President Ivan Duque in a tweet denounced Saturday’s “barbarity”, saying Monday’s summit would discuss “how to tighten the diplomatic siege of the dictatorship in Venezuela.”

Maduro, who retains the backing of China and Russia, which both have major energy sector investments in Venezuela, says the opposition’s aid efforts are part of a U.S.-orchestrated coup.

His information minister, Jorge Rodriguez, during a Sunday news conference gloated about the opposition’s failure to bring in aid and called Guaido “a puppet and a used condom.”

Cuban President Miguel Diaz-Canel said on Sunday that Venezuela, the Caribbean island’s top ally, was the victim of U.S. imperialist attempts to restore neoliberalism in Latin America.

Venezuelan National Guards block the road towards the Francisco de Paula Santander cross border bridge between Venezuela and Colombia, in Urena, Venezuela February 24, 2019. REUTERS/Andres Martinez Casares

Venezuelan National Guards block the road towards the Francisco de Paula Santander cross border bridge between Venezuela and Colombia, in Urena, Venezuela February 24, 2019. REUTERS/Andres Martinez Casares

SMOLDERING BORDER AREAS

Trucks laden with U.S. food and medicine on the Colombian border repeatedly attempted to push past lines of troops on Saturday, but were met with tear gas and rubber bullets. Two of the aid trucks went up in flames, which the opposition blamed on security forces and the government on “drugged-up protesters.”

The opposition had hoped troops would balk at turning back supplies so desperately needed by a population increasingly suffering malnutrition and diseases.

Winning over the military is key to their plans to topple Maduro, who they argue won re-election in a fraudulent vote, and hold new presidential elections.

Though some 60 members of security forces defected into Colombia on Saturday, according to that country’s authorities, the National Guard at the frontier crossings held firm. Two additional members of Venezuela’s National Guard defected to Brazil late on Saturday, a Brazilian army colonel said on Sunday.

The Brazilian border state of Roraima said the number of Venezuelans being treated for gunshot wounds rose to 18 from five in the past 24 hours; all 18 were in serious condition. That was the result of constant gunbattles, which included armed men without uniforms, throughout Saturday in the Venezuelan town of Santa Elena, near the border.

The Venezuelan Observatory of Violence, a local crime monitoring group, said it had confirmed three deaths on Saturday, all in Santa Elena, and at least 295 injured across the country.

In the Venezuelan of Urena on the border with Colombia, streets were still strewn with debris on Sunday, including the charred remains of a bus that had been set ablaze by protesters.

During a visit to a border bridge to survey the damage, Duque told reporters the aid would remain in storage.

“We need everything they were going to bring over,” said Auriner Blanco, 38, a street vendor who said he needed an operation for which supplies were lacking in Venezuela. “Today, there is still tension, I went onto the street and saw all the destruction.”

MILITARY INVASION?

U.N. Secretary-General Antonio Guterres appealed on Sunday for “violence to be avoided at any cost” and said everyone should lower tensions and pursue efforts to avoid further escalation, according to his spokesman.

But U.S. Senator Marco Rubio, an influential voice on Venezuela policy in Washington, said the violence on Saturday had “opened the door to various potential multilateral actions not on the table just 24 hours ago”.

A car of the Brazilian Federal Police is seen at the border between Brazil and Venezuela in Pacaraima, Roraima state, Brazil February 24, 2019. REUTERS/Bruno Kelly

A car of the Brazilian Federal Police is seen at the border between Brazil and Venezuela in Pacaraima, Roraima state, Brazil February 24, 2019. REUTERS/Bruno Kelly

Hours later he tweeted a mug shot of former Panamanian dictator Manuel Noriega, who was captured by U.S. forces in 1990 after an invasion.

President Donald Trump has in the past said military intervention in Venezuela was “an option,” though Guaido made no reference to it on Saturday.

The 35-year old, who defied a government travel ban to travel to Colombia to oversee the aid deployment, will attend the Lima Group summit on Monday and hold talks with various members of the European Union before returning to Venezuela, opposition lawmaker Miguel Pizarro said on Sunday.

“The plan is not a president in exile,” he said.

(Reporting by Angus Berwick, Sarah Marsh, Brian Ellsworth and Vivian Sequera in Caracas; Roberta Rampton in Washington; Additional reporting by Ricardo Moraes and Pablo Garcia in Pacaraima, Brazil; Ana Mano in Sao Paulo; Nelson Bocanegra in Cucuta, Colombia; Anggy Polanco in Urena and Mayela Armas in San Antonio, Venezuela; Ginger Gibson in Washington; Editing by Daniel Flynn, Jeffrey Benkoe, Lisa Shumaker and Jonathan Oatis)