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INDIANAPOLIS Indiana United States Sen. Mike Braun is pushing President Joe Biden to release information regarding the origin of the COVID-19 virus.
He co-authored a bill on this topic over a month ago, but his efforts are now gaining traction after recent reports show three researchers from Chinas Wuhan lab were hospitalized in November of 2019.
Braun said he hopes his bill isnt needed. He wants the President to declassify U.S. documents related to the origin of COVID-19 without legislation demanding it. Hes confident there will at least be a conversation about this after Wednesdays discussion with Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases and Dr. Francis Collins, Director of the National Institutes of Health.
This shouldnt be political, said Sen. Braun
He said everyone should want certainty about the source of the COVID-19 virus.
I still believe that the most likely scenario is that this was a natural occurrence, but no one knows that 100 percent for sure, said Dr. Fauci.
Thats why Braun believes there should be an in-depth investigation. He wants it to start with the United States sharing what we know.
Not only did he propose legislation to declassify info related to the origin of the pandemic, he also asked Dr. Anthony Fauci and Dr. Francis Collins to urge the president to release this information to the public.
Im not sure its my place to tell the president of the united states said Fauci as Sen. Braun interrupted.
Youve been very engaging on a wide range of topics and I think he would respect your opinion as much as anyone, added Braun.
Im just not in a position to know what might be in the classified documents, what else might be there that would not be relevant to this, might actually be harmful to national security, explained Dr. Collins.
Braun said he supports redacting whats necessary and then releasing what we can.
And then we can say, hey this is meaningful or there was nothing there but until we look at it, you wont know, said Braun.
I take your point, but I know the president is very interested also in seeing truth come out here, said Collins.
Why wasnt this something that was focused on from the beginning? asked reporter Kayla Sullivan.
Because it arose in a country thats not known for transparency, said Braun. He said he wants the United States to be a leader in transparency.
Something has changed in the dynamic over the last week or two, said Braun. And to me, it would be the ultimate cover up if you didnt pry further, especially with the information you house within your own intelligence agencies.
Braun said those agencies would include the Department of National Intelligence and the Department of Homeland Security.
A laboratory building at the Wuhan Institute of Virology in Wuhan, China, is seen on May 13, 2020. Hector Retamal/AFP via Getty Images hide caption
A laboratory building at the Wuhan Institute of Virology in Wuhan, China, is seen on May 13, 2020.
President Biden said on Wednesday that he has asked the U.S. intelligence community to push to get closer to a "definitive conclusion" on how the pandemic started.
In a statement, Biden said the intelligence community has "coalesced around two likely scenarios" that the coronavirus either came from human contact with an infected animal, or from a laboratory accident in Wuhan, China.
He said most intelligence entities don't believe there's sufficient information to reach a conclusion about the virus' origins, and the three intel entities that lean toward one explanation or another only have "low or moderate confidence" in their conclusions.
"As of today, the U.S. Intelligence Community has 'coalesced around two likely scenarios' but has not reached a definitive conclusion on this question," Biden said in the statement. He added: "I have now asked the Intelligence Community to redouble their efforts to collect and analyze information that could bring us closer to a definitive conclusion, and to report back to me in 90 days."
He said he wants intel officials to identify "areas of further inquiry," including from China, and the United States would continue to push China to provide access to data.
"Back in early 2020, when COVID-19 emerged, I called for the CDC to get access to China to learn about the virus so we could fight it more effectively," he said. "The failure to get our inspectors on the ground in those early months will always hamper any investigation into the origin of COVID-19."
"Lab leak" theory
The first known cases of the novel coronavirus came from Wuhan, where there is a lab, the Wuhan Institute of Virology, that works with bat coronaviruses.
The notion that the virus had "escaped" from the lab that there had been some sort of accident and then someone got sick emerged in the early days of the pandemic, but was largely dismissed as highly unlikely by most scientists.
Some researchers and far-right commentators latched onto the idea, however, and the theory spread, especially in conservative news circles and among Republicans.
Former President Donald Trump, long a purveyor of right-wing conspiracies, also bought into the idea that the coronavirus had come from a lab accident and spent much of the remaining months of his administration criticizing China for allowing it to spread, occasionally employing racist language to describe the virus.
Recent reporting from the Wall Street Journal, which cited a U.S. intelligence report that said three Wuhan Institute researchers became sick enough in November 2019 to seek hospital care, has refocused attention on the lab leak theory.
"Now everybody is agreeing that I was right when I very early on called Wuhan as the source of COVID-19," Trump said in a statement Tuesday.
Most scientists continue to think the virus is more likely to be natural in origin.
"I feel the likelihood is still high that this is a natural occurrence," Dr. Anthony Fauci, Biden's chief medical adviser, told Congress Wednesday, "but since we cannot know 100% whether it is or is not, other possibilities exist and for that reason, I and my colleagues have been saying that we're very much in favor of a further investigation."
In a statement Wednesday, a spokesperson for the Chinese embassy in the U.S. wrote the lab leak theory off as nothing more than a smear campaign.
"Lately, some people have played the old trick of political hype on the origin tracing of COVID-19 in the world. Smear campaign and blame shifting are making a comeback, and the conspiracy theory of 'lab leak' is resurfacing," the person said.
"Since the outbreak of COVID-19 last year, some political forces have been fixated on political manipulation and blame game, while ignoring their people's urgent need to fight the pandemic and the international demand for cooperation on this front, which has caused a tragic loss of many lives."
In March, following an investigation on the ground in China, the World Health Organization released a joint report with Beijing on the origins of the pandemic that concluded that the lab leak hypothesis was "extremely unlikely."
But WHO Director-General Tedros Adhanom Ghebreyesus responded that he didn't believe the team's assessment of the lab leak possibility was extensive enough.
Biden wants to "press" China
Biden in his Wednesday statement said the U.S. would continue to work to ascertain the origins of the pandemic.
He added: "The United States will also keep working with like-minded partners around the world to press China to participate in a full, transparent, evidence-based international investigation and to provide access to all relevant data and evidence."
Adam Schiff, D-Calif., chair of the House Intelligence Committee, said the panel continues to review the United States' findings in relation to the origins of the virus and sharply criticized China for its "obstruction" of the investigation.
"Beijing's continued obstruction of a transparent, comprehensive examination of the relevant facts and data about the source of the coronavirus can only delay the vital work necessary to help the world better prepare itself before the next potential pandemic," Schiff said in a statement. "Nonetheless, I am confident that the [intelligence community] and other elements of our government will continue to pursue all possible leads and provide an updated, evidence-based finding in line with the President's 90-day requirement. It is critical that we allow the [intelligence community], and other scientific and medical experts, to objectively weigh and assess all available facts, and to avoid any premature or politically-motivated conclusions."
NPR's Geoff Brumfiel contributed reporting.
Immunity to the coronavirus lasts at least a year, possibly a lifetime, improving over time especially after vaccination, according to two new studies. The findings may help put to rest lingering fears that protection against the virus will be short-lived.
Together, the studies suggest that most people who have recovered from Covid-19 and who were later immunized will not need boosters. Vaccinated people who were never infected most likely will need the shots, however, as will a minority who were infected but did not produce a robust immune response.
Both reports looked at people who had been exposed to the coronavirus about a year earlier. Cells that retain a memory of the virus persist in the bone marrow and may churn out antibodies whenever needed, according to one of the studies, published on Monday in the journal Nature.
The other study, posted online at BioRxiv, a site for biology research, found that these so-called memory B cells continue to mature and strengthen for at least 12 months after the initial infection.
The papers are consistent with the growing body of literature that suggests that immunity elicited by infection and vaccination for SARS-CoV-2 appears to be long-lived, said Scott Hensley, an immunologist at the University of Pennsylvania who was not involved in the research.
The studies may soothe fears that immunity to the virus is transient, as is the case with coronaviruses that cause common colds. But those viruses change significantly every few years, Dr. Hensley said. The reason we get infected with common coronaviruses repetitively throughout life might have much more to do with variation of these viruses rather than immunity, he said.
In fact, memory B cells produced in response to infection with SARS-CoV-2 and enhanced with vaccination are so potent that they thwart even variants of the virus, negating the need for boosters, according to Michel Nussenzweig, an immunologist at Rockefeller University in New York who led the study on memory maturation.
People who were infected and get vaccinated really have a terrific response, a terrific set of antibodies, because they continue to evolve their antibodies, Dr. Nussenzweig said. I expect that they will last for a long time.
The result may not apply to protection derived from vaccines alone, because immune memory is likely to be organized differently after immunization, compared with that following natural infection.
That means people who have not had Covid-19 and have been immunized may eventually need a booster shot, Dr. Nussenzweig said. Thats the kind of thing that we will know very, very soon, he said.
Upon first encountering a virus, B cells rapidly proliferate and produce antibodies in large amounts. Once the acute infection is resolved, a small number of the cells take up residence in the bone marrow, steadily pumping out modest levels of antibodies.
To look at memory B cells specific to the new coronavirus, researchers led by Ali Ellebedy of Washington University in St. Louis analyzed blood from 77 people at three-month intervals, starting about a month after their infection with the coronavirus. Only six of the 77 had been hospitalized for Covid-19; the rest had mild symptoms.
Antibody levels in these individuals dropped rapidly four months after infection and continued to decline slowly for months afterward results that are in line with those from other studies.
Some scientists have interpreted this decrease as a sign of waning immunity, but it is exactly whats expected, other experts said. If blood contained high quantities of antibodies to every pathogen the body had ever encountered, it would quickly transform into a thick sludge.
Instead, blood levels of antibodies fall sharply following acute infection, while memory B cells remain quiescent in the bone marrow, ready to take action when needed.
Dr. Ellebedys team obtained bone marrow samples from 19 people roughly seven months after they had been infected. Fifteen had detectable memory B cells, but four did not, suggesting that some people might carry very few of the cells or none at all.
It tells me that even if you got infected, it doesnt mean that you have a super immune response, Dr. Ellebedy said. The findings reinforce the idea that people who have recovered from Covid-19 should be vaccinated, he said.
Five of the participants in Dr. Ellebedys study donated bone marrow samples seven or eight months after they were initially infected and again four months later. He and his colleagues found that the number of memory B cells remained stable over that time.
The results are particularly noteworthy because it is difficult to get bone marrow samples, said Jennifer Gommerman, an immunologist at the University of Toronto who was not involved in the work.
A landmark study in 2007 showed that antibodies in theory could survive decades, perhaps even well beyond the average life span, hinting at the long-term presence of memory B cells. But the new study offered a rare proof of their existence, Dr. Gommerman said.
Dr. Nussenzweigs team looked at how memory B cells mature over time. The researchers analyzed blood from 63 people who had recovered from Covid-19 about a year earlier. The vast majority of the participants had mild symptoms, and 26 had also received at least one dose of either the Moderna or the Pfizer-BioNTech vaccine.
So-called neutralizing antibodies, needed to prevent reinfection with the virus, remained unchanged between six and 12 months, while related but less important antibodies slowly disappeared, the team found.
As memory B cells continued to evolve, the antibodies they produced developed the ability to neutralize an even broader group of variants. This ongoing maturation may result from a small piece of the virus that is sequestered by the immune system for target practice, so to speak.
A year after infection, neutralizing activity in the participants who had not been vaccinated was lower against all forms of the virus, with the greatest loss seen against the variant first identified in South Africa.
Vaccination significantly amplified antibody levels, confirming results from other studies; the shots also ramped up the bodys neutralizing ability by about 50-fold.
Senator Rand Paul, Republican of Kentucky, said on Sunday that he would not get a coronavirus vaccine because he had been infected in March of last year and was therefore immune.
But there is no guarantee that such immunity will be powerful enough to protect him for years, particularly given the emergence of variants of the coronavirus that can partially sidestep the bodys defenses.
The results of Dr. Nussenzweigs study suggest that people who have recovered from Covid-19 and who have later been vaccinated will continue to have extremely high levels of protection against emerging variants, even without receiving a vaccine booster down the line.
It kind of looks exactly like what we would hope a good memory B cell response would look like, said Marion Pepper, an immunologist at the University of Washington in Seattle who was not involved in the new research.
The experts all agreed that immunity is likely to play out very differently in people who have never had Covid-19. Fighting a live virus is different from responding to a single viral protein introduced by a vaccine. And in those who had Covid-19, the initial immune response had time to mature over six to 12 months before being challenged by the vaccine.
Those kinetics are different than someone who got immunized and then gets immunized again three weeks later, Dr. Pepper said. Thats not to say that they might not have as broad a response, but it could be very different.
All these promising signs suggest the summer of 2021 could be very different from a year ago.
Half of the adult population is now fully vaccinated, according to data published Wednesday by the US Centers for Disease Control and Prevention. In the past week, the US averaged about 28,000 daily new cases, a 19% drop compared to the previous week, according to the CDC.
However, a new study underscored the importance of vaccinating more people as it detailed how some of those who had Covid-19 can suffer from symptoms months later.
Researchers from Stanford University conducted a review of 45 existing studies that followed 9,751 patients in the months after a Covid-19 infection. They found 73% of the patients had at least one symptom 60 days after diagnosis, symptom onset or hospital admission. That finding was consistent even in studies that followed patients up to six months.
The researchers also found across the studies that 40% of participants experienced fatigue, 36% had shortness of breath and another 25% reported an inability to concentrate, often referred to as brain fog.
"We had no data on individuals who got Covid-19 and simply went about their day, so we don't want to cause a lot of alarm with the value of 73% of people experiencing long-term outcomes," Tahmina Nasserie, a Ph.D. candidate in epidemiology and population health at Stanford University and the lead author of the study, told CNN. "We want people to understand that these are mainly hospitalized so we can only generalize our findings for that particular population."
Race to vaccinate
During a Wednesday subcommittee hearing of the House Committee on Appropriations, CDC officials were asked what keeps them up at night.
"Variants, and the concern that people won't get vaccinated and the fact that we're not serving everybody in the country equally," Director Dr. Rochelle Walensky responded.
Dr. Anne Schuchat, the CDC's principal deputy director, added: "I think we have to remember the rest of the world and that while it's getting better here there are many places at risk -- so until we're all out of this, none of us are out of this."
Health experts have recently turned their focus to persuading young people to get vaccinated.
Young children when they become infected are less likely to have serious disease compared to an elderly person or a person who has an underlying health condition, said Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases.
However, they "are not exempt from getting serious illness," he said during President Joe Biden's YouTube town hall on Covid-19 vaccination. "So you want to protect the youngsters, be they adolescents, be they young children."
Country continues to reopen
For many Americans, the Memorial Day holiday weekend marks the start of the summer season -- and experts are increasingly hopeful given the trend of fewer Covid cases and more vaccinations.
"It means a lot. It means that the summer is looking bright," said Dr. Monica Gandhi, professor of medicine and associate division chief of the division of HIV, infectious diseases and global medicine at the University of California, San Francisco.
And local leaders are gearing up for a possibly near-normal summer.
New Orleans on Friday will begin expanding how people are allowed to gather, including opening gyms at 100% capacity.
Large indoor events will be allowed at 50% capacity without masks and distancing, 100% capacity with masks required, or 100% capacity without masks if people provide proof of vaccination or a negative Covid-19 test within 72 hours.
For large outdoors events, 75% capacity will be allowed without masks and distancing, 100% capacity with masks required, or 100% capacity without masks if people provide proof of vaccination or a negative test within 72 hours.
National Football League Commissioner Roger Goodell said the league expects full stadiums for all 32 teams next season.
"We do think it will be a much more normal experience than it has," Goodell said on a conference call on Wednesday.
New Jersey Gov. Phil Murphy announced on Monday that MetLife Stadium, home of the New York Jets and Giants in East Rutherford, would be permitted to operate at full capacity next season.
In Kentucky, Gov. Andy Beshear announced that in-person visitation at all of Kentucky's Department of Corrections state prisons and Department of Juvenile Justice facilities will resume the week of June 20.
The new in-person visitation guidelines only apply to 14 state prisons and not to county jails. Visitors will have to schedule their visitation in advance, Beshear said.
As of earlier this week, 76% of adult inmates housed in state custody have been vaccinated.
"And so, to those in custody -- good for you! Good for you! I know you've seen the harms of this virus and thank you for responding in such a responsible way," the governor said.
CNN's Ryan Prior, Jamiel Lynch, Rebekah Riess, Gregory Lemos, Jacob Lev and Stephen Collinson contributed to this report.
Today (27 May 2021) marks the launch of a joint project by two Italian and Austrian universities aimed at enhancing health and safety on the workplace, in response to new challenges posed by the COVID-19 global pandemic.
This multi-year initiative supported by the NATO Science for Peace and Security (SPS) Programme involves researchers from the Sapienza University of Rome (Italy) and Graz University of Technology (Austria). Their collaboration caters to the need to develop new detection tools in the context of the ongoing health emergency, but will also contribute to the identification of potential contamination from other toxic bio-agents. Specifically, this project will combine expertise in biophysics, materials science and spectroscopy to propose an innovative monitoring platform based on nanotechnology. The techniques employed by this project are expected to provide a cost-effective, selective and efficient solution to monitor the presence of the coronavirus and other pathogens.
During the launch of the project, H.E. Ambassador Elisabeth Kornfeind, Ambassador of Austria to NATO and to the Kingdom of Belgium, said: The ongoing pandemic has clearly shown that we have to work and cooperate on resilience in a multitude of fields this project clearly fits into this aim. H.E. Ambassador Francesco Maria Tal, Permanent Representative of Italy to NATO, remarked: The complexity of the challenges of the XXI century, such as those resulting from the coronavirus, demonstrates the importance of the link among science, security and safety. The Science for Peace and Security Programme represents a precious resource for the whole Alliance, he added. Since the start of the pandemic, the SPS Programme has been contributing to the Alliances initiatives to build resilience and promote recovery from COVID-19, David van Weel, NATOs Assistant Secretary General for Emerging Security Challenges pointed out.
SPS has been an integral component of NATOs response to COVID-19, and has tapped into its broad network of scientists and research institutions in NATO and partner countries to foster collaborative solutions against the coronavirus. In doing this, it adapted ongoing activities and launched new initiatives to contribute to strengthening diagnosis capacity, enhancing crisis management, and facilitating coordination among first responders.
1. How COVID-19 is affecting the globe
Confirmed cases of COVID-19 have passed 168.4 million globally, according to Johns Hopkins University. The number of confirmed deaths stands at more than 3.49 million. More than 1.74 billion vaccination doses have been administered globally, according to Our World in Data.
France has joined Germany and Austria in imposing a mandatory quarantine period on arrivals from Britain. It comes as the variant first detected in India spreads in the UK.
India has recorded 211,298 new COVID-19 cases, with 3,847 new deaths.
The US Food and Drug Administration has given emergency use authorization to an antibody treatment developed by Vir Biotechnology and GlaxoSmithKline for treating mild-to-moderate COVID-19 in people 12 and over.
Roughly 15% of Brazil's 210 million people have COVID-19 antibodies, researchers said yesterday.
The Philippines will authorize the use of the Pfizer/BioNTech COVID-19 vaccine for children aged 12-15, the head of its Food and Drugs Administration has said.
France's average daily number of new COVID-19 cases has fallen to its lowest level since mid-September.
Many people who've been infected with COVID-19 will make antibodies for the rest of their lives, according to a new study published in Nature.
The vaccine rollout remains uneven.
Image: Our World in Data
2. Victoria, Australia to enter COVID-19 lockdown
The Australian state of Victoria will enter a one-week COVID-19 lockdown, which will require residents to remain at home except for essential business. It comes as authorities race to contain an outbreak.
"We're dealing with a highly infectious strain of the virus, a variant of concern, which is running faster than we have ever recorded," Victoria Acting Premier James Merlino told reporters in Melbourne.
"Unless something drastic happens, this will become increasingly uncontrollable."
The cluster of cases in Melbourne has risen to 26, with the number of virus-exposed sites rising to more than 150.
Several infected people had visited crowded areas in the city, including sports stadiums and a large shopping centre.
As part of work identifying promising technology use cases to combat COVID, The Boston Consulting Group recently used contextual AI to analyze more than 150 million English language media articles from 30 countries published between December 2019 to May 2020.
The result is a compendium of hundreds of technology use cases. It more than triples the number of solutions, providing better visibility into the diverse uses of technology for the COVID-19 response.
To see a full list of 200+ exciting technology use cases during COVID please follow this link.
3. COVID-19 deaths in the Americas might be higher than reported
The Pan American Health Organization (PAHO) has warned that the real number of COVID-19 deaths in the Americas might be higher than official statistics show. Almost half of global deaths from COVID-19 have been reported in the region.
"According to new projections, many more people are dying from COVID complications or from the pandemic's indirect impacts, like disruptions to essential services, that have put their health at risk," PAHO director Carissa Etienne said.
The World Health Organization (WHO) warned last week that COVID-19 deaths were being significantly undercounted across the globe.
For 2020, deaths stood at 1.8 million, but the true 2020 global death toll is now estimated to be closer to 3 million people.
Written by
Joe Myers, Writer, Formative Content
The views expressed in this article are those of the author alone and not the World Economic Forum.
Disclaimer: Early release articles are not considered as final versions. Any changes will be reflected in the online version in the month the article is officially released.
Author affiliations: Malawi Liverpool Wellcome Clinical Research Programme, Blantyre, Malawi (R. Nzawa Soko, R.M. Burke, H.R.A. Feasey, W. Sibande, M. Nliwasa, M.Y.R. Henrion, M. Khundi, A.T. Choko, T.H. Divala, E.L. Corbett, P. MacPherson); London School of Hygiene and Tropical Medicine, London, UK (R. Nzawa Soko, R.M. Burke, H.R.A. Feasey, M. Khundi, T.H. Divala, E.L. Corbett, P. MacPherson); University of Malawi College of Medicine, Blantyre (M. Nliwasa); Liverpool School of Tropical Medicine, Liverpool, UK (M.Y.R. Henrion, P. MacPherson); University of Sheffield, Sheffield, UK (P.J. Dodd, C.C. Ku); District Health Office, Blantyre (G. Kawalazira)
Tuberculosis (TB) is a major killer, causing 1.4 million deaths worldwide annually (1), making it second only to coronavirus disease (COVID-19) as the biggest cause of infectious disease deaths in 2020 (2). In addition to the direct health effects of COVID-19, the secondary effects of the COVID-19 pandemic, including lockdowns, economic turmoil, healthcare worker illness and attrition, overwhelmed health facilities, and fear of healthcare facilities, might affect delivery of health services (3). Concerns have been raised that COVID-19 could adversely affect TB disease diagnosis, treatment, and prevention, reversing recent progress in improving TB case detection and reducing deaths, although protective measures used for COVID-19 also could reduce TB transmission (1,3,4). Initial modeling published in May 2020 suggested that healthcare service disruption worldwide could lead to 6.3 million additional TB cases and 1.4 million additional TB deaths from 2020 through 2025 because of TB underdiagnosis and interruptions in TB treatment (5). Empirical data from settings with high TB burdens are urgently needed to examine the effects of COVID-19 on TB and to determine mitigation strategies (4).
According to the World Health Organization, Malawi is 1 of 30 countries that have high TB and HIV burdens (1). In Blantyre, in the southern region of Malawi, a citywide electronic TB register has been maintained in partnership by the Malawi Liverpool Wellcome Trust, Malawi National Tuberculosis Control Programme, and Blantyre District Health Office (6). We used these data to investigate the effects of COVID-19 on citywide TB case notifications. We hypothesized that the direct and indirect effects of the COVID-19 epidemic in Malawi would reduce TB case notifications and that effects might have been experienced disproportionately at different health system levels and by certain population groups, including persons living with HIV. Our primary objective was to estimate the number of missed TB case notifications. Our secondary objective was to determine whether missed notifications were affected by sex, health facility, or HIV status. Finally, to investigate and explain the underlying causes of under notification of TB, we performed a qualitative study with TB officers, the cadre of healthcare workers who provide most TB services in Malawi.
To estimate population denominators for Blantyre District, we obtained age- and sex-specific background mortality rates and fertility rates from 20082020 World Population Prospect data (7). We used the cohort-component method to combine these data into local estimates from the 2008 and 2018 Malawi national population censuses.
In Blantyre, TB officers working at all primary health centers and the citys main hospital, Queen Elizabeth Central Hospital (QECH), record demographic and clinical characteristics of all TB patients who register for treatment by using an electronic case record form. Data collected includes date and clinic of registration, age, sex, HIV status, residential address, and TB characteristics, such as pulmonary versus extra-pulmonary TB and microbiological classification. Records are reconciled with the Ministry of Health National Tuberculosis Control Programme treatment registers every quarter. Each month, a randomly selected 5% sample of registered TB cases undergo home tracing for data validation purposes.
To investigate the effects of COVID-19 on TB case notification in Blantyre, we conducted an interrupted time series analysis (8). The Malawi government declared a state of emergency due to COVID-19 on the March 23, 2020, and the first COVID-19 cases were diagnosed on April 2, 2020. We assumed that COVID-19 restrictions and the government and public response to the emerging epidemic would cause both an immediate step change in TB case notifications and a slope change leading to different month-by-month trends than those seen before COVID-19 (8). Using a negative binomial distribution to account for overdispersion, we modeled monthly counts of TB cases as a function of month, COVID-19, and month-given-COVID-19, with an offset term to account for underlying population (Appendix). We used TB notification data from June 2016, when the country began a universal test-and-treat program to provide antiretroviral therapy for persons with HIV and started using the Xpert MTB/RIF assay (9), which rapidly diagnoses Mycobacterium tuberculosis, the bacterium that causes TB disease, and rifampin resistance in <2 hours (10).
We estimated trends in TB case notification rates (CNRs) by using estimated Blantyre census population denominators to convert model-fitted monthly numbers of notified cases to annualized equivalent cases per 100,000 population. We used the model to predict TB CNRs from April 2020 on under a counterfactual situation in which COVID-19 had not occurred and background trends from April 2016 and March 2020 continued linearly. We defined numbers of missed TB cases as the difference between the observed numbers of notified cases and numbers expected under the counterfactual noCOVID-19 situation, acknowledging that some of the missed cases might be diagnosed later and thus be delayed rather than entirely missed. We estimated the 95% CI for the total number of missed TB cases through 1,000 parametric bootstrap replications. We took observed cases as-is and predicted cases under the counterfactual scenario from a normal distribution on the link scale with the mean equal to model prediction for given month under the counterfactual and SD equal to model SE for predictions for the given month under the counterfactual scenario.
For the secondary objective, we modeled the differential effect of COVID-19 on TB case notifications by sex, HIV status, and whether TB was diagnosed at the QECH or primary care level (Appendix). Because a small amount of data were missing for HIV status and sex, we performed multiple imputations using chained equations with predictive mean matching by using the mice package in R software (11).
All decisions about the expected effect model (i.e., a step and slope change), the date of change (i.e., April 2020), and the covariates in model 2 (i.e., age, sex, and primary care vs. QECH) were made a priori on the basis of knowledge about likely effects of COVID-19 and covariates known to differentially affect access to TB healthcare (12). To assess the statistical significance of the change in TB notifications concurrent with COVID-19 epidemic in Malawi, we extracted residuals from a regression that did not model changes due to COVID-19. We compared the sum of the residuals for the 9 months during the COVID-19 epidemic in Malawi, AprilDecember 2020, with the distribution of this statistic from 1 million randomly permuted residuals. We also computed this statistic for all 9-month windows, excluding COVID-19 within the data.
TB exhibits seasonality related to climate and weather conditions (13). Therefore, we performed a sensitivity analysis by adding seasonal effects to the interrupted time series model by using a harmonic term with 2 peaks every 12 months.
During October 21December 14, 2020, we conducted in-depth interviews with 12 TB officers from healthcare facilities in Blantyre, 2 from QECH and 10 from primary healthcare centers, to ascertain the main reasons for changes in TB case notifications during the COVID-19 pandemic. A local social scientist with experience of qualitative interviewing conducted interviews in Chichewa, the local language. Data were recorded and simultaneously transcribed and translated to English. We developed a thematic framework from the initial 4 interviews, which we applied across all subsequent interviews. Coding and data analysis were done using NVIVO (QSR International, https://www.qsrinternational.com). Interviews were continued until saturation of themes was reached. We did not interview persons attending clinics to receive healthcare.
Participants provided oral consent for their data to be recorded in the enhanced surveillance dataset. A waiver of requirement for written consent was approved by London School of Hygiene and Tropical Medicine and College of Medicine, University of Malawi, both of which provided ethical approval for the Blantyre enhanced TB surveillance system and qualitative interviews. TB officer participants in the in-depth interviews provided informed written consent.
During June 2016December 2020, a total of 10,274 TB cases were notified in Blantyre. During June 2016March 2020 (i.e., before COVID-19), annualized Blantyre TB CNRs fell by 1% per month, reaching a peak of 405 cases/100,000 persons in November 2016 and declining to 137 cases/100,000 persons in October 2019. A total of 9,199 TB cases were notified in Blantyre during the preCOVID-19 period (June 2016 to December 2020), 3,561 among women and girls and 5,611 in men and boys; 27 cases were missing data on sex. Persons living with HIV represented 5,820 (63.3%) TB notifications and 3,279 (35.6%) HIV-negative persons were among notified TB cases; 100 TB cases had missing data or unknown HIV status. TB notifications were split almost evenly between QECH (4,889 notifications; 53.1%) and primary health facilities (4,310 notifications; 46.9%). Children <14 years of age comprised 920 (10%) notifications. The median age among adults with diagnosed TB was 35 (interquartile range [IQR] 2844) years for women and 37 (IQR 3045) years for men.
Figure 1
Figure 1. Effects of coronavirus disease (COVID-19) pandemic on monthly TB case notification rates in Blantyre, Malawi. Circles represent the observed number of cases each month. Solid blue linerepresents the fitted model...
The declaration of a national COVID-19 disaster led to an abrupt 35.9% (95% CI 22.1%47.3%) decline in TB notifications in April 2020 (Figure 1). However, subsequent TB notifications increased at a rate of 4.40% (95% CI 0.59%8.36%) per month. The effect of the initial decline at the start of the COVID-19 pandemic was that observed Blantyre TB annualized CNRs preCOVID-19, in March 2020, were 240 cases/100,000 persons and rates after the COVID-19 disaster declaration were 152 cases/100,000 persons in April 2020. By comparison, the predicted April CNR in the counterfactual scenario without COVID-19 was 230 cases/100,000 person-years. However, by November 2020, observed Blantyre TB CNRs were 205 cases/100,000 person-years and December 2020 rates were 156 cases/100,000 person-years, compared with a predicted CNR of 213 cases/100,000 person-years in November and 211 cases/100,000 person-years in December in the counterfactual scenario.
During AprilDecember 2020, a total of 1,075 TB cases were notified in Blantyre, equivalent to 196 cases/100,000 person-years (Table 1). Under the counterfactual situation of no COVID-19 epidemic, we would expect 1,408 (95% CI 1,3661,451) TB cases would have been notified, equivalent to annualized case notification rate of 221 cases/100,000 person-years. Therefore, we estimate that the COVID-19 epidemic directly and indirectly led to 333 (95% CI 291376) fewer TB notifications, a 23.7% (95% CI 21.4%26.0%) reduction in TB notifications.
Figure 2
Figure 2. Effects of coronavirus disease (COVID-19) on monthly TB case notifications in Blantyre, Malawi, by HIV status, registration site, and sex. A) TB notifications at primary healthcare centers. B) TB notifications...
As a secondary objective, we modeled which population groups were most affected by disruption to TB services (Figure 2). This model incorporated sex, HIV status, and healthcare facility (QECH vs. primary care clinics) and estimated that 352 (95% CI 319385) TB cases were missed during AprilDecember 2020. Men and boys accounted for a slightly larger number of missed TB diagnoses with 183 (95% CI 158209) missed cases compared with 170 (95% CI 151188) missed cases among women and girls. However, women and girls had a larger proportional decline, 30.7% (95% CI 28.4%33.0%) than did men and boys, 20.9% (95% CI 18.5%23.3%). Notifications at primary healthcare centers also were disproportionately reduced compared with hospital notifications, as were notifications for HIV-negative persons compared with those living with HIV (Table 2). The nonoverlapping confidence intervals for these groups indicated statistically significant differences in effects of COVID-19 by gender, HIV status, and healthcare setting.
The drop in TB notifications during AprilDecember 2020 was greater than that for any other 9-month period observed, and the sum of the residuals during this period was more negative than expected by random chance (p = 0.004). The sum of residuals in other 9-month periods was significantly more negative than anticipated from random resampling (p<0.05), indicating a unique statistically significant drop in cases during AprilDecember 2020. Sensitivity analysis around seasonality of TB did not materially affect the conclusions.
Of the 12 in-depth interviews with healthcare providers, 9 participants were female and 3 were male; ages were 3453 years. Most (10/12) participants had secondary-level education. Themes that emerged from the in-depth interviews related to both an overall reduction in persons attending health facilities and to TB-specific issues.
In addition to reduced attendance at healthcare facilities among the general public from fear of being infected with COVID-19, participants mentioned that several healthcare workers tested positive for COVID-19 during the epidemic (Table 2). The facility-based COVID-19 outbreaks led to temporary closures for disinfection. Facility closures not only affected the number of persons attending the health facilities on the days of closure but also led to greater fear of infection at healthcare facilities and, in 1 instance, rumors that the clinic was closed for a longer period than it was (Table 2). Finally, health facility worker strikes and sit-ins over risk allowance payments and lack of personal protective equipment (PPE) also resulted in temporary closures of facilities (Table 2).
Government COVID-19 prevention measures that required use of facemasks and social distancing also were reported to have contributed to reduced access to health services. Mandatory use of face masks at health facilities was introduced during the epidemic, but TB officers cited the inability to afford a mask and the feeling that masks suffocate them as reasons patients did not want to wear masks (Table 2). Patients who tried to attend facilities without having a mask were sent away (meaning that they were not seen by a healthcare worker) and often did not return (Table 2). Public transportation in Blantyre also had a limit on vehicle capacity, which led to doubled transport costs and limited clinic access (Table 2).
Because TB and COVID-19 both have symptoms of cough and fever, TB officers reported issues around TB testing. First, persons with fever and cough reportedly were afraid of being tested for COVID-19 if they went to healthcare facilities. TB officers said patients were more afraid of COVID-19 than TB because they knew that TB could be cured and that patients with COVID-19 might need to be placed under facility isolation (Table 2). The similarity of symptoms also led to persons who normally would have been tested for TB being turned away from healthcare facilities and told to go home and call the COVID-19 help line (Table 2).
TB officers also spoke of their own fear of contracting COVID-19 from presumptive TB patients. TB officers reported changing how they interacted with symptomatic persons, including interacting less directly and not supervising sputum collection as closely (Table 2). In addition, many TB officers reported that the lack of PPE in health facilities forced them to temporarily stop conducting TB tests or supervising sputum collection at all. For those patients who did submit sputum, results could be delayed because, as a TB officer reported, laboratory staff were taught that sputum has the highest concentration of COVID-19 (Table 2).
In addition to directly causing millions of deaths, the COVID-19 pandemic has directly and indirectly affected delivery of health services globally (14). In our analysis of the effects of the COVID-19 pandemic on TB notifications in Blantyre, Malawi, we found a substantial immediate decline in TB case notifications concurrent with the start of the COVID-19 epidemic in Malawi. Our findings are consistent with initial reports on COVID-19 effects on HIV and TB diagnosis and care from other settings (1522). However, we show that, after an initial decline, TB CNRs increased and reached near prepandemic levels within 9 months. Overall, we estimate that 333 fewer cases of TB were notified, equivalent to 39 cases/100,0000 persons, during AprilDecember 2020 than would have been expected in the absence of the COVID-19 epidemic. For the affected persons, the missed or delayed diagnoses likely will have severe consequences, and for public health programs the consequences might hinder progress toward TB elimination. The reduction in TB case notifications also could be indicative of more general disruption of a range of primary healthcare services.
To put these results into context, Malawi has high HIV and TB burdens. Estimated prevalence of TB in urban Malawi was 988 cases/100,000 persons at the last national survey in 2013 (4). TB in Malawi is declining in response to concerted efforts from the national and district TB and the HIV programs. In June 2016, Malawi introduced a test-and-treat program for HIV, which involved starting antiretroviral therapy for persons who had positive HIV tests regardless of CD4 cell count. Malawi is coming close to achieving United Nations AIDS/HIV 90-90-90 goals (23). However, TB remains one of the leading causes of death and years of life lost in Malawi (24).
We hypothesize that the major reason for the drop in TB notifications during the COVID-19 pandemic is that persons with true TB disease had their TB diagnosis missed or at least delayed. This hypothesis is consistent with data from our qualitative interviews with TB officers, who noted that, in the immediate period after the Malawi COVID-19 epidemic began, access to health facilities was extremely challenging. Alternative explanations are that persons with diagnosed TB started on treatment, but their cases were not notified to the national program, or that the true incidence of TB declined. However, we consider these explanations unlikely. TB treatment cannot be accessed in Malawi outside of TB registration centers, and our electronic TB surveillance system is cross-referenced with paper ledgers that confirm the same trends in notifications. Reduced incidence of other respiratory pathogens, notably influenza, has resulted from the nonpharmaceutical interventions for COVID-19, which possibly also resulted in a decline in TB transmission. However, the prolonged interval between infection and onset of symptoms for TB makes an immediate effect on notifications in <3 months implausible, particularly because Malawi has had less stringent COVID-19 prevention measures than many other countries.
Our qualitative interviews indicate that, in addition to general restrictions on healthcare access during the COVID-19 epidemic, TB testing and notifications particularly were affected because of the similarity in clinical presentation of TB and COVID-19. The TB officers considered that persons with TB symptoms were less likely to attend facilities for fear of a COVID-19 diagnosis and possible consequences, such as isolation. In addition, TB officers believed that at least some persons with possible TB who went to healthcare facilities were turned away and directed to COVID-19specific services where they would be unlikely to be assessed for TB. In countries with high TB burdens, alignment of COVID-19 and TB diagnosis, prevention, and care will likely lead to improved outcomes for both diseases.
Women and girls had disproportionately higher reductions in case notifications than men and boys, as did HIV-negative compared with HIV-positive patients and notifications from primary care clinics compared with the central hospital. We hypothesize that women and girls faced greater barriers to accessing healthcare during COVID-19 than men and boys because of greater requirements of women to stay home to school children; social gender norms, meaning that men were more likely to disregard COVID-19 public health restrictions; and perhaps economic requirements for men leave the house to work, meaning men could more easily continue to access TB services (25).
Primary healthcare centers were more affected than QECH, both in terms of initial step change (drop in TB cases notified at the start of COVID-19) and with slower recovery in the period after the initial phase of COVID-19 epidemic in Malawi. Reasons for the difference in reporting rates could include QECH being prioritized for PPE, thus remaining more functional than healthcare centers; in addition, patients with TB diagnosed at QECH tend to have more severe illness and potentially were unable to delay seeking healthcare.
TB cases among HIV-negative persons declined more than among persons living with HIV, which also could be associated with site of TB diagnosis. QECH has the largest number of HIV-positive persons registered for antiretroviral therapy in the city, and so persons living with HIV may have accessed TB services through the ART clinic. Alternatively, persons living with HIV can have more severe TB symptoms and be less able to defer healthcare seeking.
Limitations to our study include uncertainty around the counterfactual conditions; during June 2016 March 2020, TB case notifications were declining in Blantyre, and for the counterfactual condition, no COVID-19 scenario we modeled TB notifications as continuing to decline at the same rate. Since December 2020, Malawi has had a second wave of COVID-19. Our electronic enhanced surveillance data are entered in real time, but data are monitored and verified on a quarterly basis, so we do not yet have information on the effects of the second wave of COVID-19 in Malawi. Finally, we only interviewed healthcare workers; we did not directly capture perspectives of patients about their difficulties accessing healthcare.
Malawi is fortunate to have well-functioning TB and HIV programs that are more resilient to COVID-19 than programs in other countries. Malawi did not introduce any substantial restrictions on population movement and gathering due to COVID-19, so no legal restrictions hindered travel to TB clinics. Therefore, our data are not necessarily generalizable to other settings in southern Africa or elsewhere.
In conclusion, the effects of missed or delayed TB diagnoses likely will be severe for affected persons and households. However, the initial COVID-19related decline in TB case notification was not sustained, and the Malawi National Tuberculosis Control Programme had a relatively quick recovery after the first wave of COVID-19. We observed a shorter period of disruption than earlier modeling of COVID-19 effects on TB assumed (5). COVID-19 or TB diagnosis, treatment, care, and public health measures should not be considered in isolation. Rather, public health and healthcare officials should seek opportunities to combine resources to tackle both COVID-19 and TB. Through improved infection prevention and control at health facilities, strengthened laboratory infrastructure, and community engagement to address stigma and provide sources of information about both diseases, communities can create a setting of universal health coverage.
Dr. Burke is a medical doctor and research fellow at London School of Hygiene and Tropical Medicine and the Malawi Liverpool Wellcome Trust. She researches HIVassociated TB, public health effects of TB diagnostics and reducing deaths among hospitalized adults with HIV in southern Africa. Ms. Nwanza Soko is studying for her masters of science degree at London School of Hygiene and Tropical Medicine and is a data manager at Malawi Liverpool Wellcome Trust. Her research interest is TB epidemiology in Malawi.
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Suggested citation for this article: Nwaza Soko R, Burke RM, Feasey HRA, Sibande W, Nliwasa M, Henrion MYR, et al. Effects of coronavirus disease pandemic on tuberculosis notifications, Malawi. Emerg Infect Dis. 2021 Jul [date cited]. https://doi.org/10.3201/eid2707.210557
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
FAIRMONT, W.Va. The Three Rivers Festival is back.
The 42ndannual festival has carnival rides, pageants, educational events, among other things,all scheduledthis year.The weekend has some rain in theforecast,butorganizerssaid they will try their best to put on as many events as planned.
I think that people are going to be happy and ready to get out, as long as we continue to be cautious and safe,John Dodds, member of theThree Rivers Festival Board of Directors,said.
Most of thefestivalseventswerecanceledlast year due tocoronavirus,butorganizershave adapted the event this year for social distancing and cleanliness.
Werevery excited to have an unmodified festival this year, of coursesafetyis a precaution, andeveryonessafetyis our greatest concern, so weveconsulted with the health department on virtually all aspects of the festival,from the parade to the music, the events, the carnival, Doddssaid. We still encourage people toparticipateinwhateverlevels that theyseemto be comfortable with. Weve reduced theamountof commercial vendorsat thecarnival area, to get moredistancingspace, so things are not as crowded. But, Im excited to get out in the community, see the community members and get back to a new sense of normal.
Dodds has been helping with the Three Rivers Festival for two years. In his first year, he was a volunteer, but this year he is serving on the boardof directors. Doddssaid that most of the people who help with thefestival are unpaidvolunteers.
The full list of events can be found here.
Dr. Shiv Joshi (third from left) with colleagues at the fever clinic where he is a junior doctor in Sevagram, India. Junior doctors are the equivalent of medical residents in the U.S. health system. Dr. Shiv Joshi hide caption
Dr. Shiv Joshi (third from left) with colleagues at the fever clinic where he is a junior doctor in Sevagram, India. Junior doctors are the equivalent of medical residents in the U.S. health system.
MUMBAI Three years ago, when Shiv Joshi was studying to become a doctor at the Mahatma Gandhi Institute of Medical Sciences in central India, he had to choose a specialty. He'd been reading about the Black Death and the Spanish flu, and he wanted to learn how to track infectious diseases through triage, testing and contact tracing. So he decided to specialize in community medicine.
This was in 2018 a century after the 1918 flu pandemic he was reading about, and two years before the coronavirus would become a full-blown pandemic in India.
"Community medicine is about preventing disease in the first place, and then also reacting to it. One of my first assignments was to investigate an epidemic of dengue fever, where an entire village had it," Joshi, 27, recalls. "But I never thought I would find myself in the middle of an actual global pandemic."
When he did, he and his fellow junior doctors the equivalent of medical residents in the U.S. health system were all reassigned to COVID-19 wards. Instead of shadowing more senior specialists, they often found themselves running emergency rooms and clinics and making life-or-death decisions on their own.
"All of a sudden, a lot of additional tasks and responsibilities got shifted to us," he recalls. "I lost two friends who were also doctors, and I'm routinely seeing people dying. Definitely it has been stressful."
Medical attendant Gurmesh Kumawat prepares to administer supplemental oxygen to a coronavirus patient in the emergency ward at the BDM Government Hospital in mid-May in Kotputli, India. Rebecca Conway/Getty Images hide caption
Medical attendant Gurmesh Kumawat prepares to administer supplemental oxygen to a coronavirus patient in the emergency ward at the BDM Government Hospital in mid-May in Kotputli, India.
As India battles the world's biggest and deadliest COVID-19 outbreak, its junior doctors and in some cases, even medical students have been staffing the front lines for more than a year. They're doing the same work as more senior physicians, while those doctors oversee overflowing intensive care units and battle bureaucracy to try to fix supply chains and get deliveries of medical oxygen.
With medical board exams canceled, many junior doctors have been pressed into emergency medicine and critical care, regardless of what they studied. Working 24-hour shifts, they're often the ones who deliver bad news to grieving families and bear the brunt of anger directed at medical professionals due to shortages of oxygen and drugs.
Many have seen more death, suffering and grief in the past year than they expected in an entire career. Indian hospitals rarely provide counseling to their staff. So experts warn these junior doctors may suffer from post-traumatic stress disorder for years to come.
"What this is going to generate is a generation of doctors who are traumatized," says Devika Khanna, a psychiatrist who runs online support groups from her base in London. "That means you're reducing the capacity of medical provision for the future."
"I felt absolutely helpless"
After graduation, Joshi was assigned to a fever clinic in the same town as his medical school Sevagram, a village of about 8,000 people. It's in an impoverished rural area, where illiteracy runs high and medical care is scant. It's also home to one of Mahatma Gandhi's ashrams.
"When the first COVID-19 case arrived in my hospital, I started realizing this problem was going to be huge," Joshi says.
Joshi, 27, in an undated selfie after a long day of work at the fever clinic in Sevagram, a town in a rural area of central India. Dr. Shiv Joshi hide caption
He recalls one of the first times he was left in charge of the clinic. An ambulance pulled up, and the patient's family members piled out, screaming. The patient was a woman who looked extremely unwell.
"I tried to locate her heartbeat, but she was already cold she was in shock. I had to inform my superiors. I didn't think she had a lot of time," Joshi says.
Do something, the patient's relatives pleaded, staring at him.
"But we did not have beds," he says. "Not a single bed was vacant. I mean, that was the time when I felt absolutely helpless."
He called his supervisor, but the supervisor couldn't come. All the higher-ups were too busy with other patients.
"You feel sometimes so stranded. You cannot just say that the patient is not going to survive, to their relatives, because you cannot take their hope away," he says. "Whatever the science we study, the books we read, they do not prepare us for such situations."
Joshi's patient died a half-hour later. He mustered all his strength to deliver the news to her anguished family. It would be the first of dozens of times over the year that he'd have to do so.
Threats of violence in the ER
Rimy Dey, another junior doctor, has faced similar pressures.
Dr. Rimy Dey (left) treats COVID-19 patients in the emergency room of a private hospital in Gurugram, a suburb of New Delhi. Dr. Rimy Dey hide caption
"The physical and mental stress is immense. In a 24-hour shift before the pandemic, we used to see 40 or 50 patients. Right now, we are seeing up to 200 all COVID patients, all critical," Dey says. "And because of the lack of doctors, they've started assigning COVID duties to even medical students third- or fourth-year students who have not even completed their basic medical education!"
Last month, in the wee hours of the morning, a man in his 20s stormed into Dey's emergency room at the hospital where she works in Gurugram, a suburb of India's capital, New Delhi. "Please do something, doctor! Just save my father!" the man shouted.
At the time, hospitals across the capital region were running out of medical oxygen. Hundreds of patients who might have survived COVID-19 were dying because of problems in India's medical supply chains.
The man's father was in the back of a car or an ambulance Dey can't remember which and was hooked up to an oxygen cylinder. But it was running low.
Her hospital had run out of beds, and there was no room for new patients.
"I had to tell him, 'Sir, this cylinder is going to run out of oxygen. We're having a severe crisis,' " Dey recounts. She gave him contacts so he could try other nearby hospitals.
"And that's when the patient's son started telling us, 'If my father dies, you will be responsible for his death! We are going to break this emergency room down.' "
Patients in their beds stared at Dey from behind their oxygen masks wide-eyed, blinking, terrified.
"I was thinking, I did not become a doctor for this to be scared to death while attending to patients," she says.
Dey, 28, in an undated selfie at work at her hospital in a suburb of India's capital. Dr. Rimy Dey hide caption
With help from the hospital's security guards, she was able to defuse the situation. She squeezed the man's father into her emergency room, stabilized him and eventually convinced his son to take him to another hospital with more space.
She doesn't know what happened after that. She has so many patients, she can't follow up on each one.
Afterward, Dey thought about that case for a long time. It troubled her, because the son was right: She had been responsible for his father's care in a health system that was collapsing.
And it often feels like it's collapsing on her shoulders: "I'm checking a patient, declaring a patient dead and then going back [home] and crying for hours," she says.
Lack of support for young doctors
Dey says she often feels angry at India's government for leaving junior doctors overworked and lacking in support. Even before the pandemic, India invested less in public health just above 1% of its gross domestic product than most other countries. (The U.S. spends nearly 18% of its GDP on health, though most of that is private, not public, investment.)
India's government was blindsided by COVID-19's second wave. In January and February, daily caseloads hit record lows. By early March, the country's health minister declared that India was in the "endgame" of the pandemic. Extra wards were disassembled, and lockdown restrictions eased.
Health workers wearing protective gear place a defunct ventilator machine in the corridor of a hospital in mid-May in Amritsar, India. Narinder Nanu/AFP via Getty Images hide caption
Health workers wearing protective gear place a defunct ventilator machine in the corridor of a hospital in mid-May in Amritsar, India.
But new virus variants were circulating even as Prime Minister Narendra Modi presided over huge political rallies and failed to curb a massive Hindu pilgrimage that drew millions of devotees to the banks of the Ganges River.
In April and May, India broke records for the most coronavirus cases and deaths in the world, straining its already understaffed and underfunded health system.
NPR asked Dey and Joshi if their facilities Dey's urban and private, Joshi's rural and public offer them counseling or mental health support. Both say they are unaware of any such resource. In any case, both say, they have no time to devote to therapy.
"Most of the time, it falls on us junior doctors to support one another," Joshi says.
He and his fellow junior doctors try to allay one another's fears. They've been learning on the job while watching their own families and friends fall ill and worrying about their own health.
He and his colleagues belong to a WhatsApp group where they send each other words of encouragement. But the group is also a place where they share grim news stories about fellow junior doctors who've taken their own lives. It seems there are stories like this every month, Dey says.
More than 500 doctors have died in India's second COVID-19 wave, according to the Indian Medical Association, which does not specify how many of those were suicides.
Experts warn the stress these junior doctors describe may have a lasting impact.
Khanna, the London-based psychiatrist, says post-traumatic stress disorder is often compounded by the sense the junior doctors share that government action could have prevented the worst and India's second COVID-19 wave didn't have to be this bad.
"When there's a natural disaster, then trauma is obviously huge. But the PTSD from a man-made disaster is much greater, because there's that sense that people weren't looked after," Khanna says. "If God or the universe did it to you, it's different to if human beings did it to you. It feels so much more personal."
"I have grown ahead of my years"
After more than a year of treating COVID-19 in the rural fever clinic, Joshi recently tested positive for coronavirus antibodies. It means he probably had the virus at some point and didn't realize it. Knowing he's already survived the virus is a relief, he says. He'd spent a year wondering whether he would be able to get a bed in his own hospital if he fell gravely ill.
"That saddens me the most," he says. "How can you work in a hospital, in a pandemic, at your fullest, knowing that if you get infected, there might be nothing available to you?"
Dey's father and brother, back in her home state of Assam, got sick with COVID-19 this winter, and she wasn't able to travel to see them. They've since recovered. But sometimes it feels like only her fellow junior doctors can really understand what she's going through.
A doctor is seen at a facility for COVID-19 patients in April when a New Delhi banquet hall was converted into an isolation center to handle rising cases of infection. Anindito Mukherjee/Getty Images hide caption
A doctor is seen at a facility for COVID-19 patients in April when a New Delhi banquet hall was converted into an isolation center to handle rising cases of infection.
"We've seen a lot more than we should have at our age. When I see old friends from school, they're actually enjoying the lockdown! They're enjoying being at home," she says with a laugh. "And here I am, seeing a lot of death every day and coming back to my room and crying. I think I have grown ahead of my years."
She says her hair is already turning gray. She's 28. But she has no plans to leave medicine.
NPR producer Sushmita Pathak contributed to this report from Hyderabad, India.
