CHICAGO Covid-19 is surging around the United States again in what experts consider the most transmissible variant of the pandemic yet.
But something is different this time: The public health authorities are holding back.
In Chicago, where the countys Covid warning level was raised to high last week, the citys top doctor said there was no reason for residents to let the virus control their lives. The state health director in Louisiana likened a new rise in Covid cases there to a downpour a surge within a surge but characterized the situation as concerning but not alarming.
And the public health officer in King County, Wash., Dr. Jeffrey Duchin, said on Thursday that officials were discussing reissuing a mask mandate but would prefer that the public mask up voluntarily. Were not going to be able to have infinite series of mandates forcing people to do this, that and the other, he said.
The latest surge, driven by a spike of BA.5 subvariant cases in this country since May, has sent infections rising in at least 40 states, particularly in the Great Plains, West and South. Hospitalizations have climbed by 20 percent in the past two weeks, leaving more than 40,000 people in American hospitals with the coronavirus on an average day.
More than two years after the pandemic began, though, public health officials are sounding only quiet warnings amid a picture that they hope has been changed by vaccines, treatments and rising immunity. Deaths are rising, but only modestly so far in this new wave. And state and local public health officials say they also must now factor in a reality that is obvious along the streets from Seattle to New York City: Most Americans are meeting a new Covid wave with a collective shrug, shunning masks, joining crowds indoors and moving on from the endless barrage of virus warnings of months past.
I feel strongly that you cant just kind of cry wolf all the time, said Dr. Allison Arwady, the commissioner of the Chicago health department, who said she would wait to see whether hospitals become strained before considering another citywide mask mandate. I want to save the requirements around masks or updating vaccine requirements for when theres a significant change.
Complicating the countrys understanding of this BA.5 wave is a dearth of data. Not since the earliest months of the pandemic has there been so little precise information about the number of actual infections in the United States. As public testing sites have closed and at-home testing if people test at all has grown common, the publicly reported data has become scarce and spotty.
Still, experts say, the outlines of a new wave are undeniable.
You dont have to count every raindrop to know its raining, said Dr. Joseph Kanter, Louisianas state health officer and medical director. And its pouring right now.
In that state, the health department analyzes a wide range of data to track the spread of the virus, including case counts, samples from a growing network of wastewater testing sites, test positivity rate and hospitalization metrics.
The BA.5 subvariant, which was first detected in South Africa in January and spread to a number of European countries, was responsible for 1 percent of cases in the United States in mid-May but now represents at least two-thirds of new cases in the country.
Anita Kurian, an assistant director for the health department in San Antonio, said cases have been rising in the area for six weeks in a row. But some measures, like the low number of deaths so far, suggest that the nation is entering a newer and less lethal stage of the pandemic where vaccines and treatments have significantly improved chances of survival, she said.
We are nowhere at the level where we were with the previous surges, she said.
So far, the current waves toll of hospitalizations and deaths pales in comparison to previous spikes. During the peak of the Omicron surge in early 2022, close to 159,000 people were hospitalized on any given day.
Experts caution that predicting the months ahead is difficult, particularly given the high transmissibility of BA.5. Words of caution from national health leaders have slowly increased in intensity in recent weeks.
Still, even as federal health authorities reiterated calls for people to test for Covid before attending large indoor gatherings or visiting especially vulnerable, immunocompromised people, they are striking a delicate balance, telling Americans that while they do not need to upend their lives, they must pay attention to the Covid threat.
We should not let it disrupt our lives, Dr. Anthony S. Fauci, President Bidens chief medical adviser on the virus, said at a White House news briefing in which he added that new variants could continue to emerge. But we cannot deny that it is a reality that we need to deal with.
As health officials in many places have avoided issuing new virus restrictions during the latest surge, California has stood out as an exception. There, public health authorities have issued stark warnings and moved toward reimposing restrictions.
The warnings have been spurred by worrisome data, experts said. Walgreens said that more than half of the Covid tests administered at its California stores have returned with positive results. Surveys of wastewater in the Bay Area suggest this surge could be the biggest yet.
And the number of weekly deaths in Los Angeles County from the coronavirus has doubled from about 50 a month ago to 100 last week. The deaths are still below the levels of the winter Omicron surge, when more than 400 were dying weekly in the county.
Officials in Los Angeles say they plan to reinstate a countywide indoor mask mandate as early as the end of this month. Barbara Ferrer, the public health director in the county, said that even a slight increase in masking would help slow transmission of the virus.
Im like everyone else: I hate wearing that mask. But more than that, I hate the idea that I might accidentally transmit to somebody else, Ms. Ferrer said. Thats my biggest fear that were so anxious to be done with this virus that were getting complacent.
Charles Chiu, an infectious-disease specialist and virologist at the University of California, San Francisco, says data emerging from patients suggests that BA.5 does not cause more severe disease in patients than other Omicron variants. But he says he is concerned that the variant is so infectious and so able to evade the protections of vaccination and prior infection that it could be unstoppable.
It looks as if we are unable to control it, he said.
Dr. Chiu said he was sympathetic to the plight of government officials seeking to mitigate the spread of the virus. They are up against a public that chafes at renewed directives, even in parts of the country where people were previously most willing to go along. In places where Covid mitigation measures are mandatory, like on New York subways, adherence to masking rules is increasingly spotty.
Public health officers have an impossible task here, Dr. Chiu said.
In New York City, rates of positive tests, cases and hospitalizations are all rising. But health officials have resisted reissuing mask mandates, and many residents have said they were not worried, counting on vaccines, immunity from prior infections and antivirals for protection from severe illness. The city no longer has a contact tracing system in place or requires proof of vaccination to enter restaurants.
In Louisiana, officials have watched hospitalizations of people with Covid rise in the state, but they say those numbers are still far lower than in previous surges when more than 2,000 residents were at times hospitalized.
I feel much more empowered that we have the ability to protect ourselves, Dr. Kanter said.
During the height of the Delta wave in Louisiana in 2021, about 20 percent of hospitalized Covid patients were on ventilators, according to Dr. Kanter, the state health officer and medical director. That figure fell to 10 percent during the states initial Omicron surge and now is below 5 percent.
For people who are most at risk of severe illness from Covid, a sense that public health warnings have diminished was little comfort, and in fact made them worry more than ever about getting infected.
Neyda Bonilla, 48, of Mission, Texas, was diagnosed in April with breast cancer. With case counts rising in South Texas, she now fears that an infection as she undergoes chemotherapy could prove catastrophic for her health.
She has received all of the vaccines and boosters available to her, she said, and now wears a surgical mask in public and rarely leaves the house, except to work as an administrator at an ambulance company.
I hope that people open their eyes, she said. We should have never taken our masks off. This is not over.
Yet even in some cities whose residents have taken precautions against Covid throughout the pandemic, the latest surge has not caused widespread alarm.
In Berkeley, Calif., Jeff Shepler, the general manager of the Spanish Table, a specialty shop selling Iberian wine and food, said that he goes to Giants games across the Bay in San Francisco, recently attended a Pearl Jam concert at the Oakland Coliseum and does not hesitate to shake hands.
It got exhausting for me to wear a mask all day, every day, he said. Im at the point in my life where Ive got the vaccine and Ive had Covid. I figure Im fairly safe.
Julie Bosman reported from Chicago, Thomas Fuller from San Francisco, and Edgar Sandoval from San Antonio. Reporting was contributed by Soumya Karlamangla, Eliza Fawcett, Sarah Cahalan, and Holly Secon.
New coronavirus infections in parts of California may be surging even higher than winters Omicron wave, potentially explaining why so many people seem to be infected simultaneously.
The concentration of coronavirus levels in San Franciscos wastewater is at even higher levels than during the winter, according to data tweeted by Marlene Wolfe, an assistant professor in environmental health at Emory University.
Wastewater data for much of L.A. County Los Angeles city and a wide swath of eastern and southern L.A. County have been unavailable due to a supply chain shortage on testing supplies at the state level. But county Public Health Director Barbara Ferrer said last week that steady increases have been noted as of late in the Las Virgenes Municipal Water District that serves areas in and around Calabasas and the L.A. County Sanitation Districts treatment plant in Lancaster.
The wastewater data suggest many infections arent being recorded in officially reported coronavirus case counts. That is because so many people are using at-home over-the-counter tests, which can be more convenient than getting tested at a medical facility, where results are reported to the government.
When you look at the [coronavirus] case counts, theyre no longer reliable. There are tremendous undercounts, Dr. Robert Wachter, chair of the UC San Francisco Department of Medicine, said at a campus town hall Friday. And the number of cases now probably is not all that dissimilar to what we saw during the massive surge in December and January.
Thats why, Wachter said, he strongly recommends masking in indoor public settings in the face of immense numbers of cases.
At UC San Franciscos hospitals, 5.7% of asymptomatic patients are testing positive for the coronavirus, meaning 1 in 18 people who feel fine nonetheless have the coronavirus. In other words, in a group of 100 people, theres a 99.7% chance that someone there has the coronavirus and is potentially contagious. Think about that the next time you go into a crowded bar or get onto an airplane with 100 people, Wachter said.
I kind of wish the flight attendants would hold up a sign that says, I can guarantee to you that someone on this plane has COVID, he said. I think the rate of mask wearing would go up quite a bit.
The spread of illness caused UC Irvine on Monday to renew a mask mandate inside campus buildings, following the lead of other campuses such as UC Riverside and UCLA and school systems like San Diego Unified. In addition, the film industry has recently begun to require masking on film sets again around Los Angeles.
L.A. Countys coronavirus case rate continues to rise. L.A. County is now averaging about 6,900 coronavirus cases a day nearly double the peak case rate from last summers Delta surge, and 27% higher than the previous week. On a per capita basis, L.A. Countys case rate is 476 cases a week for every 100,000 residents; a rate of 100 or more is considered high. COVID-19 deaths in L.A. County have risen from 50 per week to between 88 to 100 fatalities per week over the past month.
California is recording about 21,000 coronavirus cases a day, up 16% over the prior week. On a per capita basis, the state is recording 368 cases a week for every 100,000 residents. California is recording roughly 255 COVID-19 deaths per week. Weekly deaths in the state have fluctuated from 200 to 300 deaths a week.
L.A. County is prepared to reinstate a universal mask mandate in indoor public spaces for those 2 and older as early as July 29 if the rate of new coronavirus-positive hospitalizations does not improve.
Worldwide, were clearly in the throes of the sixth wave of the COVID epidemic, UC San Francisco epidemiologist and infectious diseases expert Dr. George Rutherford said at the meeting. This has been prompted by worldwide circulation of the newer Omicron sublineages: BA.4, BA.5 and now BA.2.75.
This is my way of saying: Were not out of the woods yet, Rutherford said, adding that the World Health Organization recently said theres no reason to consider were anywhere near the end of this. Last week, he noted that COVID-19 remains a public health emergency of international concern.
Its unclear how long this wave will last. Dr. Robert Kosnik, director of UC San Franciscos occupational health program, said a current surge among employees and students has so far lasted twice as long as its fall-and-winter wave, which lasted about two months.
Its easy for COVID fatigue to set in, given the duration of this wave. But, Kosnik added, we still need to be vigilant.
That means not coming to work if you have symptoms, Kosnik said. At-home coronavirus tests can give negative test results for people on the first day or two of symptoms, even though they are contagious. It sometimes takes two or three days after symptoms begin for enough virus to have replicated in the body for the rapid test to turn positive.
The symptoms are quite devious in my mind, Kosnik said, with some people who dont know they are infected thinking symptoms are only from allergies or a cold.
If you have symptoms, and you test negative, you need to still assume you could have COVID, Wachter said.
The latest California models suggest the virus is spreading at even faster rates. As of Monday, the California COVID Assessment Tool, published by the state Department of Public Health, said the spread of the coronavirus is probably increasing, with every infected Californian likely spreading it to 1.15 other people.
BA.5, the Omicron subvariant driving this latest wave, is not exactly a brand-new ballgame, but its definitely a new inning and we have to take it seriously, Wachter said.
A challenge with COVID-19, he added, has been that once we learn a pattern of how the disease works, our brain locks in on those. And we kind of assume that they will continue to be true. And then when they turn not true, its a little bit hard for us to pivot.
Thats whats happening now, Wachter said. Some patterns are still similar new subvariants keep emerging that are even more contagious. Also, Omicron infections seem to cause less severe disease than Delta, the dominant coronavirus variant last summer. During Deltas peak, about 5.6% of coronavirus cases in L.A. County required hospitalization, but during the winters Omicron wave, only about 1.2% of cases did.
Regarding BA.5, what is different and this is where it is something of a game-changer is the level of immune escape, and particularly to the degree to which immunity from prior infection, including prior versions of Omicron, doesnt seem to count for as much, Wachter said.
So its wrong to think that if youve survived a coronavirus infection, you no longer have to worry about COVID-19 for perhaps three months, Wachter said.
We are seeing reinfections as early as a month after a prior infection, Wachter said. You cant count on COVID superpowers from your prior infection-plus-vaccination to make you completely free of risk for the next three or four months, which is really the way we used to think about this a few months ago.
Wachter said its unclear whether reinfections, on average, are more, less or the same severity as an earlier infection.
But he cited a recent preprint study from scientists with Washington University and the Veterans Affairs Saint Louis Health Care System suggesting that people who got reinfected did worse over the long haul. The study suggested that reinfected people have a higher long-term risk of death even after the acute infection has resolved besides other health problems.
Compared to people with first infection, reinfection contributes additional risks of all-cause mortality, hospitalization, and adverse health outcomes, the study said, including in organ systems affecting the cardiovascular, kidney, neurological and gastrointestinal systems and increasing risk of diabetes, fatigue and mental health disorders.
The risks were evident in not only unvaccinated people but also vaccinated people who got a booster shot. The risks were most pronounced in the acute phase, but persisted in the post-acute phase of reinfection, and most were still evident at six months after reinfection, the report said.
Its worth going with the assumption that getting reinfected is a bad thing that once youre infected, you have a little bit of additional immunity, but not that much. And you should go back to your prior position of trying to be careful, Wachter said.
Thats why its important to get up-to-date on vaccinations and boosters, Wachter said. Federal officials have said to not wait for an Omicron-specific booster that might come in the autumn; if youre eligible for a first or second booster, get it now and you can still get an Omicron-specific booster later.
The existing vaccines, even if not designed specifically against the latest subvariants, still help reduce the risk of hospitalization and death, even if theyre relatively less effective at preventing infection in the first place.
A report published by the U.S. Centers for Disease Control and Prevention on Friday found that vaccine effectiveness protecting against hospitalizations or emergency room visits declined five months after the second COVID-19 vaccine dose. Thats why it was so important to get a booster, and a second one, when eligible, the report said.
Second booster shots have been limited to people 50 and older and those who are immunocompromised age 12 and older. Wachter said that federal officials have been signaling that eligibility for a second booster will be coming soon.
Mike Stucka USA TODAY NETWORK| Montgomery Advertiser
White House issues warning on new COVID variants
The Biden administration is calling on people to exercise caution about COVID-19, emphasizing the importance of getting booster shots for those who are eligible and wearing masks indoors as two new transmissible variants are spreading rapidly. (July 12)
AP
New coronavirus cases leaped in Alabama in the week ending Sunday, rising 13.8% as 16,649 cases were reported. The previous week had 14,633 new cases of the virus that causes COVID-19.
Alabama ranked sixth among the states where coronavirus was spreading the fastest on a per-person basis, a USA TODAY Network analysis of Johns Hopkins University data shows. In the latest week coronavirus cases in the United States increased 29% from the week before, with 947,862 cases reported. With 1.47% of the country's population, Alabama had 1.76% of the country's cases in the last week. Across the country, 42 states had more cases in the latest week than they did in the week before.
The Fourth of July holiday disrupted who got tested, when people got tested and when both test results and deaths were reported. This may significantly skew week-to-week comparisons.
Montgomery County reported 1,112 cases and one death in the latest week. A week earlier, it had reported 1,219 cases and one death. Throughout the pandemic it has reported 60,757 cases and 959 deaths.
Elmore County reported 366 cases and two deaths in the latest week. A week earlier, it had reported 340 cases and zero deaths. Throughout the pandemic it has reported 25,160 cases and 352 deaths.
Autauga County reported 236 cases and zero deaths in the latest week. A week earlier, it had reported 239 cases and zero deaths. Throughout the pandemic it has reported 17,037 cases and 217 deaths.
Butler County reported 68 cases and zero deaths in the latest week. A week earlier, it had reported 78 cases and zero deaths. Throughout the pandemic it has reported 5,401 cases and 129 deaths.
Lowndes County reported 54 cases and zero deaths in the latest week. A week earlier, it had reported 52 cases and zero deaths. Throughout the pandemic it has reported 2,829 cases and 77 deaths.
Within Alabama, the worst weekly outbreaks on a per-person basis were in Dallas County with 602 cases per 100,000 per week; Wilcox County with 588; and Macon County with 565. The Centers for Disease Control says high levels of community transmission begin at 100 cases per 100,000 per week.
Adding the most new cases overall were Jefferson County, with 2,397 cases; Mobile County, with 1,428 cases; and Madison County, with 1,135. Weekly case counts rose in 51 counties from the previous week. The worst increases from the prior week's pace were in Mobile, Tuscaloosa and Madison counties.
This week in COVID: Officials beg eligible Americans to get second booster; CDC reports 'superbugs' made a comeback in pandemic
>> See how your community has fared with recent coronavirus cases
Across Alabama, cases fell in 15 counties, with the best declines in Montgomery County, with 1,112 cases from 1,219 a week earlier; in Baldwin County, with 735 cases from 760; and in Escambia County, with 111 cases from 135.
In Alabama, 36 people were reported dead of COVID-19 in the week ending Sunday. In the week before that, 27 people were reported dead.
A total of 1,390,333 people in Alabama have tested positive for the coronavirus since the pandemic began, and 19,822 people have died from the disease, Johns Hopkins University data shows. In the United States 89,542,107 people have tested positive and 1,023,799 people have died.
>> Track coronavirus cases across the United States
USA TODAY analyzed federal hospital data as of Sunday, July 17. Likely COVID patients admitted in the state:
Likely COVID patients admitted in the nation:
Hospitals in 36 states reported more COVID-19 patients than a week earlier, while hospitals in 27 states had more COVID-19 patients in intensive-care beds. Hospitals in 40 states admitted more COVID-19 patients in the latest week than a week prior, the USA TODAY analysis of U.S. Health and Human Services data shows.
The USA TODAY Network is publishing localized versions of this story on its news sites across the country, generated with data from Johns Hopkins University and the Centers for Disease Control. If you have questions about the data or the story, contact Mike Stucka at mstucka@gannett.com.
Mike Stucka USA TODAY NETWORK| The Gaston Gazette
New coronavirus cases increased 3.6% in North Carolina in the week ending Sunday as the state added 26,388 cases. The previous week had 25,462 new cases of the virus that causes COVID-19.
North Carolina ranked 21st among the states where coronavirus was spreading the fastest on a per-person basis, a USA TODAY Network analysis of Johns Hopkins University data shows. In the latest week coronavirus cases in the United States increased 29% from the week before, with 947,862 cases reported. With 3.15% of the country's population, North Carolina had 2.78% of the country's cases in the last week. Across the country, 42 states had more cases in the latest week than they did in the week before.
The Fourth of July holiday disrupted who got tested, when people got tested and when both test results and deaths were reported. This may significantly skew week-to-week comparisons.
Gaston County reported 587 cases and five deaths in the latest week. A week earlier, it had reported 554 cases and two deaths. Throughout the pandemic it has reported 70,076 cases and 871 deaths.
Within North Carolina, the worst weekly outbreaks on a per-person basis were in Graham County with 557 cases per 100,000 per week; Pamlico County with 471; and Surry County with 436. The Centers for Disease Control says high levels of community transmission begin at 100 cases per 100,000 per week.
Adding the most new cases overall were Mecklenburg County, with 3,112 cases; Wake County, with 2,994 cases; and Guilford County, with 1,039. Weekly case counts rose in 63 counties from the previous week. The worst increases from the prior week's pace were in Surry, Cumberland and Cabarrus counties.
>> See how your community has fared with recent coronavirus cases
Across North Carolina, cases fell in 36 counties, with the best declines in Wake County, with 2,994 cases from 3,442 a week earlier; in Buncombe County, with 527 cases from 617; and in Iredell County, with 362 cases from 419.
In North Carolina, 138 people were reported dead of COVID-19 in the week ending Sunday. In the week before that, 48 people were reported dead.
A total of 2,919,068 people in North Carolina have tested positive for the coronavirus since the pandemic began, and 25,395 people have died from the disease, Johns Hopkins University data shows. In the United States 89,542,107 people have tested positive and 1,023,799 people have died.
>> Track coronavirus cases across the United States
USA TODAY analyzed federal hospital data as of Sunday, July 17. Likely COVID patients admitted in the state:
Likely COVID patients admitted in the nation:
Hospitals in 36 states reported more COVID-19 patients than a week earlier, while hospitals in 27 states had more COVID-19 patients in intensive-care beds. Hospitals in 40 states admitted more COVID-19 patients in the latest week than a week prior, the USA TODAY analysis of U.S. Health and Human Services data shows.
The USA TODAY Network is publishing localized versions of this story on its news sites across the country, generated with data from Johns Hopkins University and the Centers for Disease Control. If you have questions about the data or the story, contact Mike Stucka at mstucka@gannett.com.
Gov. Ned Lamont and ConnecticutDepartment of Public Health Commissioner Manisha Juthani held a news conference Monday to provide an update on the COVID-19 situation in Connecticut.
They encouraged vaccinations for people who are eligible, including younger age groups that have recently been approved, to receive COVID-19 vaccinations.
While its summer and people are enjoying time outdoors now, Juthani said Fall and the school year are not too far away.
So there are a few key things I want people to remember. First of all, weve got about 50 percent of our children who are 5 to 11 years old currently vaccinated, she said.
However, that might be a long time ago, and everyone, from 5 years through adulthood are eligible for a booster shot, she said.
Were going into our first school season without a mask mandate in place and were able to do that because we have these tools at our disposal, specifically vaccinesfor the entire school-age age group, she said.
State officials are also urging adults to get vaccinated and urged everyone to get up to date with what they are eligible for.
Full coverage of the COVID-19 outbreak and how it impacts you
"If you are over 50 and haven't gotten vaccinated this calendar year, 2022, go get vaccinated," Lamont said.
Juthani said the BA.4 and 5 subvariants have gone up and are the majority of the cases health officials are seeing now. She added that there is also a slight uptick in hospitizations.
Coronavirus cases and hospitalizations are on the rise in North Texas.
Over the weekend, Dallas County's Public Health Committee moved their COVID-19 risk level from yellow to orange, which urges extreme caution.
The update comes after the Centers for Disease Control and Prevention placed Dallas, Tarrant and Collin counties in the high-risk or "red" category of COVID-19 spread on Thursday. Denton County is currently set at yellow.
The committee published a report on Saturday, saying the primary drivers of the increase in COVID-19 cases are inadequate/waning immunity and lack of masking.
Much of the population remains unvaccinated, un-boosted (have not received all recommended doses) with COVID-19 vaccine and are not up-to-date, the report states. Vaccines are our most powerful tools in protecting our residents and our economy as they prevent hospitalizations, long COVID-19, and death. Masking helps stop the spread. Individuals who received their primary series in 2021 and those who have had COVID-19 are facing significant waning immunity if they have not completed their vaccine series or been boosted.
The report states only 24% of eligible Dallas County residents have been boosted and 73% have received one vaccine.
Full coverage of the COVID-19 outbreak and how it impacts you
The Dallas County Public Health Committee said COVID-19 vaccine rates remain lower than what is needed to protect vulnerable and at-risk residents, especially children.
Data on the countys COVID-19 dashboard shows a daily average of about 570 cases over the past week. However, experts have said case counts are probably higher than what's reported as more people test themselves with at-home kits or skip testing altogether.
Hospitalizations have also increased by 45% in the last two weeks, according to the committees report.
At the high-risk level, the CDC is recommending that people wear a mask indoors, get vaccinated, increase ventilation indoors, and get tested if they have symptoms.
"As long as we do all of those things, we're going to be OK. So I don't believe that anyone needs to have an extreme amount of concern. But again, let's just be smart," said Dr. Joseph Chang, Parkland Memorial Hospital Chief Medical Officer.
Chang said that what we're seeing now is no cause for major concern yet.
"I think my concern level is greater than zero. But you know, on a scale of one to 10, it's not even close to five at this point, he told NBC 5.
According to the latest COVID-19 forecast by UT Southwestern Medical Center researchers, two omicron sub-variants, BA.4 and BA.5 make up more than 75% of samples that have been tested so far.
Researchers at UT Southwestern expect COVID hospitalizations to increase over the next several weeks. Their big concern right now is a steep rise in new patients over the age of 65. UTSW research also notes increased infection in 20 to 40-year-olds.
Chang said he is not expecting a dramatic surge in cases and hospitalizations, as seen with previous variants.
"I do not believe that we're going to have the same situation that we had with omicron and delta, and certainly not to the severity of disease that we saw. Now, we might see people get sick and they might have to stay home. But the severity is probably not going to be anywhere near what we saw before. That's the good part," he said.
Chang also stressed that getting the COVID-19 vaccine is the best way to avoid issues, especially for children, as hospitals keep an eye on the start of school in a month.
"I don't see big waves like omicron and delta again. Of course, the ultimate super spreader event is school, he said. [Kids] need to be vaccinated right away. Again, this is very basic, very simple, and very straightforward. I know there are a lot of folks with a lot of reasons why they don't want to get their kids vaccinated. But listen, it's just being smart. And if we don't do it, we're going to see some consequences.
It's still too early to say what protocols school districts will decide when that happens.
By Melissa Patrick
All but 14 of Kentuckys 120 counties have an elevated risk of coronavirus on the latest federal risk map, and Gov. Andy Beshear cautioned that the transmission rates are likely high in those counties too.
We know there is a lot more Covid that is out there, and people need to really think about what steps they want to take, or the repercussions of steps that they might not take, Beshear said at his weekly news conference. And while the latest dominant variant isnt nearly as deadly as recent ones, It still is harming and taking lives, he said, and we need to be wary of that.
This weeks Centers for Disease Control and Preventionrisk mapsays Kentucky has 61 orange counties, indicating a high level of risk. Thats a big increase from the 37 on last weeks map. Most of this weeks orange counties are in the east and west, with a string of them down the middle of the state.
Forty-five counties are yellow, indicating a medium level of risk. Last week 44 were yellow. The rankings are based on new coronavirus cases, hospital admissions and hospital capacity.
People in yellow counties who are immunocompromised, or at high risk for severe illness from the virus, should talk to a health-care provider about whether they need to wear a mask or take other precautions, the CDC says.
The statesweekly pandemic report,released Monday, showed Kentucky had an average of 1,564 new cases a day last week, 14.3 percent more than the week before. The positive-test rate increased to 16.96% and Covid-19 deaths jumped to 62 from 38 the prior week.
Hospitalizations, while still low, are on what Beshear called a legitimate increase, increasing enough to prompt him to urge caution for the first time in a long while.
People need to be wary, the governor said. And certainly, if people are in the groups that this virus harms the most, they should definitely think about taking extra steps.
Nine out of 10 Kentuckians under 60 who have died from Covid-19 in the past year were unvaccinated, and two-thirds of Kentuckians over 60 who died from Covid-19 in the past year were unvaccinated, Health Commissioner Steven Stack said.
Speaking to how contagious the Omicron BA.5 variant is, Stack said earlier variants resulted in one person possibly infecting three or more people, while one person with BA.5 could infect 18 or more people. The good news is that even as BA.5 causes more infections, it does not appear to cause increased hospitalizations or deaths.
Stack said we are solidly at a phase in the pandemic where individuals who are at higher risk from the virus such as people 50 and older and certainly over 60, anyone with major medical problems or compromised immune systems need to take extra precautions, which involves getting that second booster. If youre generally healthy, he said. I think you might be OK to see what happens in the fall, when the FDA is expected to approve a new version of the vaccine with broader protection.
We have all got to take this seriously, Stack said. That doesnt mean we dont go on with life, but this is this is here to stay, folks. So I think we all still should continue to treat it with a healthy dose of respect.
Stack praisedToyota Motor Manufacturings decision to require masks in its Georgetown factory, noting that while this variant isnt as dangerous as prior ones, it is highly contagious and causing people to get sick and stay home from work, potentially impacting a whole operation.
I think this is important . . . and encourage other employers to consider whats appropriate in your setting, Stack said.
New vaccine approved:TheU.S. Food and Drug Administrationapproved emergency use of a new Covid-19 vaccine called Novavax on Wednesday. The vaccine that is made with more traditional technologies than thePfizerandModernamRNA vaccines.
In the next few weeks or month, youll have another option if for some reason the two mRNA vaccines were not appealing to you . . . and I would encourage you to be open to it, Stack said.
This news comes as the administration works on strategies to be ready for the pandemics next phase, including having stockpiles of tests, personal protective equipment and updated vaccines, Stein reports.
That job has become much, much harder . . . because Congress has decided that they dont want to fund that kind of effort, Jha said. And so we are now trying to put together resources to make sure that we have at least some of the new vaccines, that we have at least some tests going into the fall. We are not going to have enough.
Stack said this lack of federal funding is already limiting access to monoclonal antibodies for Covid-19, a treatment that acts much like your own antibodies and can stop symptoms of the disease from getting worse and may prevent hospitalization caused by worsening symptoms.
Hopefully, he said, this wont happen with Covid-19 vaccines, but If Congress doesnt grant more money to the administration, the administration has said unequivocally, they will unfortunately not have the resources and then that means we wont be able to just tell every citizen in every Kentucky and you can just go and at no cost to yourself get a vaccine.
So I hope theyll take action, he said. But for right now, Vaccine is abundant. So if you are eligible, please go out and get it.
Background: The ongoing pandemic of coronavirus disease 2019 (COVID-19) has negatively impacted respiratory health worldwide. The severity of the disease varies considerably, and patients may present with bronchitis, pneumonia, and acute respiratory distress syndrome. This study aims toquantify the parameters of the pulmonary function test (PFT) with regard to the severity of COVID-19and understand the pattern of PFT in reference to the status of selected morbidities and body mass index.
Materials and methods: This is a hospital-based, comparative, cross-sectional study. A total of 255 COVID-19 survivors underwent clinical assessment, a PFT, and a 6-minutewalk test. Participants were divided into mild, moderate, and severe disease groups. The parameters were compared between these groups. The PFT and 6-minutewalk tests were conducted using an NDD Digital computerized spirometer (NDD Meditechnik AG., Switzerland) and a fingertip pulse oximeter(Hasely Inc., India), respectively.
Results: All PFT parameters showed significant differential distribution among the severity groups (p<0.001) except for forced expiratory volume in 1 s/ forced vital capacity (FEV1/FVC) and forced expiratory flow (FEF) during 25%-75% expiration and peak expiratory flow (PEF). Among severe category participants forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and FEV1/FVC, were significantly reduced as compared to mild and moderate. Severity wassignificantly affected by age >50 years. Severecategory participants were seen in 31% of normal, 58% of pre-obese, and 53% of obese participants; however, this difference was insignificant. A significant reduction in SPO2 on the 6-minutewalk test was observed in severely sick participants.
Conclusions: COVID-19 is associated with a mixed pattern of spirometry. Poor prognosis is associated with older age, obesity, and multimorbidity.
The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has affected >367 million individuals and resulted in >5 million deaths worldwide [1]. The disease primarily affects the lungs and other respiratory organs. Damage to the lungs results from a cytokine storm induced by the host's immune system. This immune response leads to acute inflammation and increased levels of inflammatory biomarkers, such as C-reactive protein, ferritin, and interleukin-6 (IL-6) [2]. Based on the widely documented lung injuries related to COVID-19, concerns are raised regarding assessing lung injury in discharged patients [3]. The severity of clinical manifestations ranges considerably, and patients present with bronchitis, pneumonia, and acute respiratory distress syndrome (ARDS). COVID-19-associated ARDS has been linked to poor prognosis [4]. A follow-up study of 81 patients with COVID-19 through computed tomography revealed a reticular pattern associated with bronchiectasis and irregular interlobular or septal thickening. These findings indicate the appearance of interstitial changes, suggesting the development of fibrosis [5].
Another follow-up study by Fumagalli et al. revealed deranged pulmonary functions in a restrictive pattern [6]. Nevertheless, Thomas et al. suggested that all spirometry parameters were normal except the changes were observed in diffusing capacity with a worse impact on those with severe disease[7]. Owing to the complex pathophysiology, the status of the lungs and degree of recovery remains unknown [8]. According to the available evidence on the COVID-19 pandemic, there is limited knowledge regarding the effects of the virus in terms of residual changes or long-term sequelae [9-12]. Notably, the pulmonary function test (PFT) and spirometry are important, reliable, and easy to perform tools for the diagnosis and management of respiratory disease in all age groups. Hence, they are used in the present study to screen residual pulmonary changes in COVID-19 survivors. Moreover, disease progression is a complex phenomenon and bi-directionally affected by protective (e.g., immune status, good nutrition) or deleterious (e.g., obesity, comorbidity) effects.
According to guidelines established by the World Health Organization, the presentation and progression of illness are categorized into the following groups: mild; moderate; and severe [13]. Moreover, it has been found that disease progression and severity are associated with the presence of comorbidities [14]. As obesity is one of the comorbidity conditions its high prevalence rate may directly or indirectly interfere with the treatment and prognosis of ARDS. This condition poses challenges due to its unique physiology in patients and, indirectly, is a risk factor for the development of chronic obstructive pulmonary disease (COPD) [15]. Hence, investigatingthe long-term sequelae of COVID-19 in survivors is urgently warranted [16]. Currently, evidence regarding the pattern of COVID-19 residual changes among survivors during the recovery phase, as well as its correlation with the comorbidity status and body mass index (BMI), is scarce [17-19].
Thus, the aim of this study was to analyze the patterns and trajectories of COVID-19 in pulmonary functions of survivors classified into different clinical categories.
This was a hospital-based, comparative, cross-sectional study. Ethical approval was obtained from the institutional ethical committee (approval number: IHEC-LOP/2020/EF0219). A total of 546 COVID-19 survivors were followed up at the Outpatient Department of the All India Institute of Medical Sciences (Bhopal, India). Of those, 255 provided written informed consent and met the inclusion criteria: age 18-65 years and discharge from hospital 2 weeks prior to inclusion in the study. Participants were enrolled between July 2021 and September 2021.
All the precautions related to the COVID-19 care protocol were implemented during this study. Clinicians performed PFTs after recording a detailed history of the patient and conducting a clinical assessment. Patient characteristics (e.g., body mass index {BMI}, comorbidity status, smoking habits, signs and symptoms, and other demographic information) were collected. Based on clinical and treatment history, and according to the World Health Organization performance scale, the enrolled COVID-19 survivors were divided into the following disease severity groups: mild; moderate; and severe. The enrolled survivors were categorized in accordance with the history of hospitalization, requirement of supplemental oxygen, and requirement for admission to the intensive care unit [13].
Clinical assessment included the 6-minute walk test (6MWT) using a fingertip pulse oximeter (Hasely Inc., India). This analysis was performed at room temperature under the supervision of a respiratory therapist. Oxygen saturation (SpO2) absolute values were categorized from 0 to 2, as per the relative capability to perform the 6MWT.
The BMI (weight/height {kg/m2}) of all enrolled survivors was also determined, and the patients were categorized as normal, obese, and pre-obese (18-21, <25, and 22-25 kg/m2, respectively) [20]. In addition, the presence of comorbidities (i.e., diabetes, hypertension, COPD, and multimorbidity) was evaluated.
PFT was performed in a sitting position using an NDD Digital computerized spirometer (NDD Meditechnik AG., Switzerland). Prior to undergoing the test, the participants were familiarized with the instrument and the procedure. PFT parameters were considered according to the maneuver-acceptable criteria established by the American Thoracic Society and the European Respiratory Society [21]. PFT parameters were recorded as best trial and percentage. PFT parameters included the following: forced vital capacity (FVC); forced expiratory volume in 1 s (FEV1); FEV1 as a percentage of the FVC; peak expiratory flow rate; forced expiratory flow rate during 25-75% of expiration (FEF25-75); and forced inspiratory vital capacity (FIVC).
Data were validated for redundancies and missing values, and they were descriptively summarized using the mean, median, and interquartile ranges (in the case of non-Gaussian distribution). Categorized PFT values were compared through an unpaired analysis of variance test to analyze the shift of categorized PFT distribution values from null parent distributions. Proportional stack diagrams were created to illustrate the effect of BMI categories on PFT values and the direction of possible interactions.
A total of 255 COVID-19 survivors were enrolled in this study (167 males and 88 females; mean age: 47.12 13.78 years). Of those, participants were classified into the mild, moderate, and severe disease groups as shown in Table 1. The distribution of the baseline characteristics of enrolled COVID-19 survivors was categorized according to disease severity presented as the mean (standard deviation) or numbers (%). The comorbidities mainly presented with diabetes and hypertensionwere found to be statistically significantlydistributed(p = <0.001), except for COPD (p=0.7). A significant distribution was also found with reference to their multimorbidity status.
All parameters exhibited a differential distribution among the disease severity groups. These differences were statistically significant, except for the FEV1/FVC ratio (p = 0.079). The mean values of FVC, FEV1, FEF25-75, PEF, FET, FIVC, and PIF parameters were lower in the disease severity group as compared to the mild and moderate groups, which suggests the restrictive pattern(Table 2).
All parameters showed a differential distribution among the disease severity groups. These differences were statistically significant, except for FEF25-75 (p = 0.2) (Table 3).
We further classified the enrolled COVID-19 survivors into binary groups by setting the cut-off value at 80% for FVC, FEV1, and the FEV1/FVC ratio. This classification represents the distribution of obstructive and restrictive changes according to the severity of the disease (Tables 4-6).
We observed an increase in the number of participants in the <80% group based on the disease severity. This may denote an association of severity with the parameters examined in this study.
We further investigated the potential effects of age and BMIon disease severity as per their category(Table 7) that suggested the presence of disease in severe form among higher age group individuals. The mean 6-minute walking distance SpO2 in all participants was above 96% except for the disease severity group who had a low 6MWDs SpO2 mean, 94.99 (3.29), and it was also statistically significant distributed (p = <0.001).
The effect of multimorbidity and BMI according to the PFT parameters of COVID-19 survivors areillustrated with the help of a stake diagram(Figures 1, 2).
Currently, there is a scarcity of large-scale studies focusing on changes in pulmonary function among COVID-19 survivors. Using spirometry, this study focused on patterns of changes in pulmonary functions in relation to morbidity and disease severity.
COVID-19 survivors aged 18-65 years were enrolled in the present study. Those in the older age group (i.e., >50 years)associated with severe disease are 76(66%) out of 115; moreover, 56 of the 131 severe cases (42%) required intensive care management. Hence, the findings were suggestive of a link between severe disease and advanced age. This association may be due to the higher rates of comorbid conditions present in older patients [22].
Our study also revealed that PFT parameters were significantly associated with disease severity. The detected changes were both obstructive and restrictive, suggesting a mixed pattern of long-term sequelae of COVID-19. Significant changes were not found in FEV1/FVC, FEF25-75, and peak expiratory flow. A similar study conducted by Fumagalli et al., involving a smaller sample size, suggested mainly restrictive changes in COVID-19 survivors [6].
In the present study, patterns of changes in PFT parameters were also studied using a binary category setting and a cut-off value of 80% [21]. Impairment of pulmonary function in the obstructive pattern (FEV1) was found in 177 (69%) participants out of 255. In the restrictive pattern (FVC), this rate was in 76% (19) of participants. In the obstructive form, 20 (48%) and 111 (85%) of the enrolled COVID-19 survivors presented mild and severe disease, respectively. In the restrictive changes, these rates were observed in 60% (25) and 91% (119) participants, respectively. This evidence indicates that the rate of restrictive changes was slightly higher than that of obstructive changes. The findings of our study are in coherence with the previously reported occurrence of progressive fibrosis as a consequence of ARDS [23].
Using computed tomography, Zhou et al. revealed that diffuse pulmonary dysfunction was common, with a high incidence of pulmonary sequelae regardless of disease severity [3]. This is attributed to diffuse alveolar damage, severe endothelial injury, widespread thrombosis with microangiopathy, alveolar septal fibrous growth, and pulmonary consolidation, as well as lower lung elasticity in critically ill patients.
According to the American Thoracic Society and the European Respiratory Society, the FEV1/FVC ratio is the most sensitive PFT parameter. In almost all COVID-19 survivors (97%) this ratio was >80%; 99% of these had severe disease [21]. This suggests that none of the enrolled COVID-19 survivors were in respiratory distress during the PFT. Alternatively, this result could be due to the fact that residual changes were slightly more restrictive than obstructive.
To verify this, we further investigated the results of the 6MWT and SpO2, which were analyzed using a score ranging from 0 to 2. We found a score of 2 and SpO2 >96%, which suggested that study participants were not in respiratory distress at the time of the study [24].
In the analysis of the PFT results, it was observed that 193 of 255 participants were hospitalized with comorbidities. The most frequent comorbidities were diabetes in 100 participants (39.21%), hypertension in 93 participants (36.47%), and multimorbidity in 61 participants (23.98%). We found a significant association of disease severity with diabetes and hypertension, but not COPD. Notably, participants with multiple comorbidities were at higher risk of severe COVID-19 versus those with single comorbidity [22].
Older participants and those with higher BMI were associated with a poor prognosis; thus, they require early and intensive care [25]. Of note, the effects of COPD and BMI were not significantly associated with pulmonary function. Importantly, there was a link between the long-term sequelae of COVID-19 and multimorbidity, particularly diabetes and hypertension.
The inferences drawn in this study were based on data derived from the disease severity groups and various PFT parameters. The participants were further classified into several groups to address the effect of possible confounders and effect modifiers. However, considering the limitations of cross-sectional studies,it may be difficult to comment with certainty. One should be cautious while drawing the causal inference for which serial measurements and adjustment through multivariate models might serve thepurpose.
Based on the present findings, we may conclude that COVID-19 is associated with a mixed pattern of spirometry. As measured by spirometry, older adults with diabetes Mellitus and hypertension are associated with deterioration in respiratory functions.We recommend that these patients must take extra precautions against COVID-19. Periodic follow-up for appropriate timely treatment and rehabilitation is advised in such patients. We recommend various multi-centric trialsregarding the role of rehabilitation programs in form of yoga/exercise in COVID-19 patients with various comorbidities.
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The median of the national-level daily search index for Covid-19 related terms was 4, 533 (IQR (Interquartile Range)=1, 301) before theCOVID-19 outbreak (January 1 2017 to December 30 2019), and 314, 718 (IQR=445, 074) after the outbreak (December 31 2019 to March 15 2021). The median of the provincial-level search index, ranged from 63 (IQR=7) in Tibet to 1138 (IQR=302) in Guangdong before COVOD-19, and ranged from 1386 (IQR=983) in Tibet to 38, 061(IQR=45, 784) in Guangdong after the COVID-19 outbreak. The crude relative change in the median of the search index ranged from 2 099% in Tibet and 2 034% in Hainan to 3 872% in Beijing and 4 284% in Liaoning (Table 1). 89, 936 cases of SARS-COV-2 occurred nationwide (ranging from 1 case in Tibet to 68, 021 cases in Hubei) from December 31, 2020 to March 15, 2021. The number of confirmed cases outside Tibet and Hubei ranged from 18 (0.1%) in Qinghai to 2, 245 (10.6%) in Guangdong province. In conjunction with these search patterns, 13%, 76% and 11% of confirmed Covid-19 cases were reported in January 2020, February 2020 and from March 2020 to March 2021 respectively.
As shown in Table 2, there was a 10% (relative risk (RR)=1.10, 95% CI 1.071.13, p<0.0001), 11% (RR=1.11, 95% CI 1.081.14, p<0.0001) and 13% (RR=1.13, 95% CI 1.101.16, p<0.0001) annual increase in the search index before the pandemic among regions with low, middle and high HDI respectively. The difference in pre-Covid-19 trends of the search index among the three HDI groups was not statistically significant (middle vs. low, ratio of RR=1.01, p=0.6188; high vs. low, ratio of RR=1.03, p=0.2239) (Table 2, Fig.1).
Baidu search index by province and number of new confirmed cases over time. (A) Observed daily search index (log transformed) by province and HDI category over time. Aggregated search index by HDI category over time is shown in Fig. S1. (B) Daily new confirmed COVID-19 in China (cases in Hubei provinces are excluded).
During the initial wave, the search index increased by 41%, 62% and 58% on December 31, 2019 among regions with low (RR=1.41, 95% CI 1.341.49, p<0.0001), middle (RR=1.62, 95% CI 1.541.70, p<0.0001) and high (RR=1.58, 95% CI 1.481.68, p<0.0001) HDI, respectively. The immediate increase in middle and high HDI regions was statistically significantly higher than the increase in low HDI regions (middle vs. low, ratio of RR=1.15, p=0.0002; high vs. low, ratio of RR=1.12, p=0.0091).
Similarly, there was a 107-fold, 125-fold and 125-fold increase in search index between January 18 and January 25 2020, the period shortly after the official announcement of human-to-human transmission (HHT), among regions with low (RR=106.8, 95% CI 100.1114.0, p<0.0001), middle (RR=124.6, 95% CI 117.6131.9, p<0.0001) and high (RR=125.3, 95% CI 116.5134.8, p<0.0001) HDI, respectively. The immediate increase in this short period among middle and high HDI regions were statistically significantly higher than the increase in low HDI regions (middle vs. low, ratio of RR=1.16, p=0.0004; high vs. low, ratio of RR=1.17, p=0.0012). From the peak of the search index on January 25 to June 10 2020, a 10%, 11% and 11% decrease per week was observed in the search index among regions with low (RR=0.90, 95% CI 0.890.90, p<0.0001), middle (RR=0.89, 95% CI 0.880.89, p<0.0001) and high (RR=0.89, 95% CI 0.890.90, p<0.0001) HDI, respectively (Table 2).
The outbreak in Beijing was associated with a 91%, 34% and 112% increase in the search index among regions with low (RR=1.91, 95% CI 1.792.03, p<0.0001), middle (RR=1.34, 95% CI 1.261.42, p<0.0001) and high (RR=2.12, 95% CI 1.982.27, p<0.0001) HDI, respectively, in the first week (June 1117 2020) of the outbreak. Additionally, the Beijing outbreak was associated with an increase in the monthly change rate of the search index. From June 17 to October 11 2020, a 4% decrease, 2% increase and 6% decrease per month in the search index was observed among regions with low (RR=0.96, 95% CI 0.950.96, p<0.0001), middle (RR=1.02, 95% CI 1.011.02, p<0.0001) and high (RR=0.94, 95% CI 0.930.94, p<0.0001) HDI, respectively (Table 2).
The Qingdao outbreak was associated with a comparable 31%, 34% and 41% immediate increase in the search index among regions with low (RR=1.31, 95% CI 1.231.40, p<0.0001), middle (RR=1.34, 95% CI 1.261.42, p<0.0001) and high (RR=1.41, 95% CI 1.311.52, p<0.0001) HDI, respectively. In the winter wave after the Qingdao outbreak, search index increased by 1%, 2% and 2% per week among regions with low (RR=1.01, 95% CI 1.001.01, p=0.0647), middle (RR=1.02, 95% CI 1.011.02, p<0.0001) and high (RR=1.02, 95% CI 1.011.03, p=0.0002) HDI, respectively.
The Shijiazhuang outbreak in January 2021 was associated with a 100%, 167% and 145% immediate increase in search index among regions with low (RR=2.00, 95% CI 1.852.16, p<0.0001), middle (RR=2.67, 95% CI 2.502.86, p<0.0001) and high (RR=2.45, 95% CI 2.242.67, p<0.0001) HDI. In regions with low HDI (middle vs. low, ratio of RR=1.34, p<0.0001; high vs. low, the ratio of RR=1.22, p=0.0007). However, the 20% and 22% weekly decrease in search index after the Shijiazhuang outbreak among regions with middle (RR=0.80, 95% CI 0.790.80, p<0.0001) and high (RR=0.78, 95% CI 0.770.79, p<0.0001) HDI, respectively, was statistically significantly greater (p<0.0001) than the 17% monthly decrease in the region with low HDI (RR=0.83, 95% CI 0.820.84, p<0.0001). Figure2 illustrated the heterogeneity in the immediate relative change in the search index following each pre-specified exposure across the country.
Immediate relative change in search index at different exposure period (A) December 31 2019, the estimated start of the first Covid-19 wave. (B) 18 January 18 2020 (official announcement of human-to-human transmission) to Jan 25 January 2020 (shortly after the lockdown and the estimated peak of daily search index in the initial Covid-19 wave). (C) Outbreak in Beijing starting on June 11 2020. (D) Outbreak in Shijiazhuang starting on January 3 2021. Specific point estimate for relative change and the corresponding 95% CIs are provided in the supplemental materials.
The results from models where HDI or its component was coded as a continuous variable were consistent with findings from our main analysis. As shown in Table S1, the pre-pandemic trends in two provinces differing in HDI, GNPPP (Gross national product per person), education year or life expectancy by one standard deviation were similar (p>0.1). The immediate relative increase in the search index in a province with one standard higher HDI was statistically higher (initial wave: ratio of RR=1.09, p<0.0001; HHT announcement: ratio of RR=1.04 p=0.0395; Beijing outbreak: ratio of RR=1.06, p=0.0090; Qingdao outbreak: ratio of RR=1.04, p=0.0324; Shijiazhuang outbreak: ratio of RR=1.11, p<0.0001). In contrast, the gradual decrease in the search index in a province with one standarddeviation higher HDI after each exposure was either similar or greater. For each exposure, the difference associated with GNPPP, education year or life expectancy in the directions and magnitudes of both immediate and gradual effect across provinces was similar to the difference associated with HDI.
