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Saturday, November 26, 2022

Protests erupt across China in unprecedented challenge to Xi Jinping’s zero-Covid policy

 Protests are erupting across China, including at universities and in Shanghai where hundreds chanted “Step down, Xi Jinping! Step down, Communist Party!”, in an unprecedented show of defiance against the country’s stringent and increasingly costly zero-Covid policy.

A deadly fire at an apartment block in the country’s far western region of Xinjiang that killed 10 people and injured nine on Thursday appears to have fueled the anger, as video emerged that seemed to suggest lockdown measures delayed firefighters from reaching the victims.

Protests broke out in cities and at universities across China on Saturday and early Sunday morning, according to social media videos and witness accounts.

Firefighters spray water on a fire at a residential building in Urumqi in western China's Xinjiang region on Nov. 24, 2022.

In multiple videos seen by CNN, people could be heard shouting demands for China’s leader Xi Jinping and the Communist Party to “step down.”

Some videos show people singing China’s national anthem and The Internationale, a standard of the socialist movement, while holding banners protesting Beijing’s exceptionally stringent pandemic measures.

Videos widely circulated on Chinese social media show hundreds of people in downtown Shanghai on Saturday lighting candles to mourn the dead from the Xinjiang fire.

The crowd later held up blank sheets of white paper – in what is traditionally a symbolic protest against censorship – and chanted, “Need human rights, need freedom.”

Demonstrators stand by protest signs in Shanghai, China, on Saturday, Nov. 26, 2022.

Protests have also broken out in the capital city Beijing. One student at the prestigious Peking University told CNN that when he arrived at the protest scene at around 1 a.m. Sunday local time, there were around 100 students, and security guards were using jackets to cover a protest slogan painted on the wall.

The student said security guards later covered the slogan with black paint.

Students later gathered to sing the The Internationale before being dispersed by teachers and security guards.

In the eastern city of Nanjing, dozens of students from Communication University of China gathered to mourn those who died in the Xinjiang fire.

Is it Covid, flu or RSV?

 Covid, flu and respiratory syncytial virus (RSV) are together driving a national wave of respiratory illnesses.

Around 76% of U.S. hospital inpatient beds are full, according to data from the Department of Health and Human Services. Pediatric beds are at a similar level, though six states have 90% or more of their pediatric beds full, according to an NBC News analysis of HHS data.

Covid, flu and RSV can be difficult to distinguish, since they share many common symptoms. But it's useful to know which virus you have, since that determines the treatments you should receive and how long you should isolate.

Certain hallmarks — either symptoms or how the illness progresses — can help differentiate each virus. Here are five factors to consider.

Some symptoms are unique to particular viruses

A runny nose, cough, congestion or sore throat can arise because of any of the three viruses or a common cold. But a loss of taste and smell is more commonly associated with Covid than with flu or RSV. And wheezing is often a tell-tale sign of a serious RSV infection, usually found in kids or older adults.

The only way to know for certain, though, is to get tested.

“I don’t think anybody would ever go, ‘Hey, listen, I think you have a virus based on your symptoms,’ and feel confident to say what virus that is,” said Dr. Frank Esper, a pediatric infectious disease specialist at Cleveland Clinic.

Are symptoms coming on gradually or all of a sudden?

Flu symptoms tend to develop more suddenly than those of Covid or RSV.

“Flu classically comes on with an abrupt fever first that happens pretty quickly. That’s somewhat contrasted by RSV and Covid, where we think of a slow escalation in symptoms,” said Dr. Scott Roberts, a Yale Medicine infectious disease specialist.

How long has it been since exposure?

The illnesses have different incubation periods — the time between exposure and symptoms. On average, flu symptoms tend to develop two days after exposure to the virus, whereas RSV symptoms tend to take around four to six days to appear, and Covid's typical incubation is three to four days for the omicron variant.

"If I go to a party and I get symptoms the next day, it’s probably flu because that can be as short as 24 hours’ incubation period," Roberts said.

Age makes a big difference in a disease's symptoms and severity

RSV is unlikely to make a healthy adult feel very sick, whereas Covid and flu certainly can.

“In general, if you’re a young healthy adult or you’re not in an extreme of age, and you get pretty severe illness, it’s probably not RSV,” Roberts said.

The groups most vulnerable to severe RSV infections are babies, children with lung diseases, adults ages 65 and up and people with weakened immune systems.

Symptoms can also look different depending on your age and immune status. Many kids are encountering respiratory viruses for the first time this year as they return to regular schooling and socializing, so their bodies may have a harder time clearing the infection, which can lead to more wide-ranging symptoms.

According to Esper, almost a fourth of children have gastrointestinal symptoms (like diarrhea, stomach pain or vomiting) from viral infections. That's less common in adults with seasonal flu or RSV.

People with weakened immune systems, meanwhile, are more likely to develop severe symptoms or pneumonia from any of the three viruses.

Consider which virus is circulating the most in your community

Disease experts anticipate that Covid cases will climb over the holidays as more people travel and gather indoors. Average daily cases reported to the Centers for Disease Control and Prevention have already risen nearly 11% over the last two weeks, according to NBC News’ tally.

But it's difficult to determine local Covid transmission levels, since many people use at-home tests. RSV and flu tests, by contrast, are performed at a doctor’s office or ordered via prescription.

RSV infections seem to have passed their peak nationally. Although the CDC does not keep a national count of RSV cases, the number of positive weekly tests fell from more than 17,000 in the week ending Nov. 5 to around 9,000 in the week ending on Saturday.

By contrast, flu cases are skyrocketing. The national share of influenza tests that came back positive rose from around 8% in the week ending Oct. 30 to nearly 15% in the week ending Nov. 13. Flu hospitalizations are the highest they've been at this time of year in more than a decade. 

Esper said he expects the Cleveland Clinic to be “swimming in flu” two weeks from now.

The picture varies by region, however. In the Northeast, Roberts said, “we saw RSV surge over the last one to two months and it’s actually plateaued — which is great news — and then flu, only the past few weeks we’re seeing an exponential rise."

“The Southeast U.S. — Georgia, Alabama, Mississippi — they saw kind of the opposite. They saw initially a surge in flu, and then now you’re seeing RSV start to catch up,” he added.

Available treatments and vaccines

Unlike Covid and the flu, there are no vaccines or universally prescribed treatments for RSV.

"RSV scares me the most, probably, because you can’t do anything about it and so many young kids haven’t seen it. We’re really seeing record surges in our pediatric hospitals,” Roberts said.

To reduce the length of flu symptoms, though, doctors usually prescribe Tamiflu or one of three other approved treatments. For some people with Covid, doctors can prescribe Paxlovid.

Dr. Ashish Jha, the White House Covid-19 Response Coordinator, emphasized the benefits of getting flu shots and Covid boosters.

“In this moment where we have a lot of flu, still have a decent amount of RSV, still got a good amount of Covid, the single most important thing people need to do is go get vaccinated,” Jha said at a Tuesday briefing. “It keeps you out of the hospital.”

Navigating uncharted terrain of Consolidated Appropriations Act: guide for employer health plans

 The Consolidated Appropriations Act (CAA) of 2021 is long overdue legislation aiming to improve prescription drug price transparency and shed light on the role of pharmacy benefit managers (PBMs). 

During the Payer Issues Roundtable hosted by Becker's Hospital Review, in a session sponsored by Capital Rx, a pharmacy benefit manager and a pharmacy benefit administrator, Phil Vecchiolli, senior vice president and general manager of PBA services at Capital Rx, moderated a discussion with the company's president, Matthew Gibbs, about drawbacks of the legislation and steps organizations can take to prepare for compliance. 

Three key takeaways were:

  1. The CAA provides a framework for how drug procurement should work in the future. It mandates that employer-based health plans and health insurers submit data about drug spending to the government to nudge plan sponsors toward making well-informed, cost-effective purchasing decisions. 

Gibbs noted that while the intentions behind the legislation are good, the requirements for how data will be submitted still need to be clarified. Further, he said that those requirements would put employers in a tight spot because the requirements force employers to disclose drug rebates they may be receiving from so-called aggregator services — which negotiate rebates on behalf of PBMs and the employers they serve.

"Employers are completely upset that the government wants to know their cost of healthcare. Employees' premiums go up every year, and [employees] wouldn't feel very good if they knew a broker was making $5/Rx [at their expense]," Gibbs said. "There are tons of fees being taken off the top by employers' channel partners doing weird things with rebates. It's not pretty."

  1. There can be heavy penalties for non-compliance with the CAA. While no employer is expected to go to jail for not reporting the data, those who choose not to do so will likely be subject to civil monetary penalties. The expectation is that the Department of Labor will look closely at large employers (> 100K covered employees) who spend billions of dollars on drug purchasing.

Gibbs said, "The DOL will ask, 'How much is your broker getting? What are you doing with the $200 million in rebates you get every year? Is it going to go into [capital] investments, or are you giving back to the employees who are actually using the drugs?'" 

"If you think as a fiduciary that this [legislation] will come and go, you're making a big mistake. I think it's going to get more intense," Vecchiolli added.

  1. To prepare for CAA, organizations would be wise to follow this checklist. Employer groups gearing up for compliance with CAA must prepare by addressing the following issues:
    • Plan oversight: identifying and naming all plan fiduciaries in writing, adopting health plan procurement standards, and having a documented process for interviewing and hiring third-party service providers.
    • Advisor relationships: identifying external advisors subject to fee disclosure rules outlined in the CAA, assessing whether the compensation paid to advisors is reasonable, and having advisors create a problem list to guide fiduciary oversight and action.
    • Third-party/PBM relationships: drafting agreements that include restrictions on employer access to health plan data and the employer’s ability to share health plan data with third-party business associates; limiting audit rights for claims processing, claims payment or provider contracts; limiting recovery rights for claims.

How payers compare on Medicare Advantage over-the-counter benefits

 More than four in five Medicare Advantage enrollees receive some kind of over-the-counter benefits, according to an analysis from Kaiser Family Foundation. 

The report, published Nov. 16, compared the types of benefits the largest Medicare Advantage plans provide. Almost every plan offers vision, hearing, dental and fitness benefits, other services vary widely between plans. 

Over-the-counter assistance was the most common benefit offered outside of vision, hearing, dental and fitness. Overall, 84 percent of members are offered some benefits for over-the-counter products in their plans. 

Here's how the largest payers stacked up in KFF's analysis: 

  1. Humana — 97 percent of enrollees have over-the-counter benefits
  2. Cigna — 93 percent of enrollees have over-the-counter benefits 
  3. Kaiser Permanente — 90 percent of enrollees have over-the-counter benefits 
  4. Centene — 88 percent of enrollees have over-the-counter benefits 
  5. CVS Health — 81 percent of enrollees have over-the-counter benefits 
  6. UnitedHealthcare — 80 percent of enrollees have over-the-counter benefits.
  7. Blue Cross Blue Shield — 73 percent of enrollees have over-the-counter benefits 

NYC convictions plummet, downgraded charges surge under Manhattan DA Bragg

 Soft-on-crime Manhattan District Attorney Alvin Bragg has downgraded more than half his felony cases to misdemeanors — while also managing to lose half of the felony cases that do reach court.

Since taking office on Jan. 1, Bragg has downgraded 52% of felony cases to misdemeanors — compared to 39% in all of 2019. Between 2013 and 2020, under District Attorney Cyrus Vance Jr., the percentage of cases the office downgraded had never exceeded 40%, according to data made public by the DA’s office.

How Manhattan DA Bragg's office performed this year
New York Post composite

When serious felony charges are brought, Bragg’s office wins a conviction just 51% of the time — down from 68% in 2019, the last year before the pandemic disrupted the court system.

He has declined to prosecute 35 percent more felony cases this year than in 2019, with 1,119 so far in 2022 compared to 828 three years ago.

The DA’s office requested bail in only 49% of felony cases this year compared to 69% in 2019. State bail reform measures mean almost no non-violent felonies are eligible for bail now although they were in 2019.

Misdemeanor convictions have also spiraled downward — to 29% so far this year, from 68% in 2019.

Bragg, who campaigned last year on a promise of criminal justice reform, proudly displays the numbers on his web site, the only one of the city’s five district attorneys to do so.

“The people in charge right now want to talk about gun violence and getting these shootings down,” said Jennifer Harrison, the founder of Victims Rights NY. “But I wonder how many of the incidents [where] the charges were downgraded or dismissed or dropped involved guns or weapons, and how are we going to eradicate this kind of violence when people like Alvin Bragg are in charge?”

Madeline Brame, the mother of Hason Correa was dragged out of the courtroom after a video of the knife that kiiled her son was shown. Travis Stewart appears in court for a bail heaing for his murder case
Madeline Brame was dragged out of a courtroom after a video was involving her son’s death — a case that occurred under Bragg’s watch.
Steven Hirsch

Harrison added that Bragg “really needs to stop with the public defender mentality and do his job and enforce the law and prosecute crime correctly.”

Bragg issued a controversial “Day One” memo after taking office saying he would no longer seek prison sentences in many crimes, would downgrade felony charges in cases including armed robberies and drug dealing, and drop some misdemeanors.

A short time later, career criminal William Rolon was busted for threatening a store worker with a knife and charged only with a misdemeanor, leading a judge to stunningly tell him he should “feel lucky” because of Bragg’s new policies.

Bragg reversed a couple of the policies in February, including once again allowing commercial robberies committed with knives to be prosecuted as felonies.

So far this year, 1,210 felony cases have resulted in a prison sentence, a 29% drop from 1,699 in 2019. As for misdemeanor cases, the drop was even steeper — 78% — with just 522 resulting in jail compared to 2,413 in 2019.

Anguished Manhattan mom Madeline Brame says she was “traumatized” by the outcome of the case against the four defendants in the 2018 murder of her Army vet son, Hason Correa, 35. Two got plea deals from Bragg’s office, one pleaded guilty to second-degree murder and the fourth was convicted of gang assault at trial earlier this month.

“We’re not getting any justice or closure. The victims are just left hung out to dry. There is no consideration for the victims or their families. None,” said Brame. “There should be no plea deals to lesser charges, downgrading of charges, none of that.”

Bragg was accused of giving a sweetheart plea deal in August to Justin Washington, accused of raping a teen-age relative, only for Washington to be arrested on new sex-crime charges the next month. The DA’s office said he would seek a greater sentence in the rape case.

New York Post cover from Sept. 22, 2022.
New York Post cover from Sept. 22, 2022.

Bragg did come down hard on bodega worker Jose Alba, who killed a crazed customer attacking him in his Harlem store. After a public outcry, Bragg dropped the murder charge against him.

Meanwhile, major crimes are up throughout Manhattan, with a 38% increase through Nov. 20 in Manhattan South and a 17% rise in Manhattan North compared to the same period last year.

“The real question at this point is why do you have a DA’s office? What is the DA’s office there for? The guy is avowedly anti-punishment. He’s avowedly anti-responsibility. These numbers reflect that,” said Eugene O’Donnell, a John Jay College of Criminal Justice professor and a former NYPD officer and prosecutor in Queens and Brooklyn.

Bragg’s office said it was still dealing with the impact of COVID-19 pandemic and working under burdensome discovery reforms adopted by the state in 2019. It also contended that not every felony case was correctly classified at arrest.

“The fact is, we have prosecuted 459 more felonies this year compared to last and we have three times as many gun convictions so far this year compared to all of 2019 … we will continue prosecuting violence drivers and prioritizing safety and fairness in every case,” spokesman Danielle Filson said.

Competition between respiratory viruses may hold off a ‘tripledemic’ this winter

 Triple threat. Tripledemic. A viral perfect storm. These frightening phrases have dominated recent headlines as some health officials, clinicians, and scientists forecast that SARS-CoV-2, influenza, and respiratory syncytial virus (RSV) could surge at the same time in Northern Hemisphere locales that have relaxed masking, social distancing, and other COVID-19 precautions.

But a growing body of epidemiological and laboratory evidence offers some reassurance: SARS-CoV-2 and other respiratory viruses often “interfere” with each other. Although waves of each virus may stress emergency rooms and intensive care units, the small clique of researchers who study these viral collisions say there is little chance the trio will peak together and collectively crash hospital systems the way COVID-19 did at the pandemic’s start.

“Flu and other respiratory viruses and SARS-CoV-2 just don’t get along very well together,” says virologist Richard Webby, an influenza researcher at St. Jude Children’s Research Hospital. “It’s unlikely that they will circulate widely at the same time.”

“One virus tends to bully the others,” adds epidemiologist Ben Cowling at the University of Hong Kong School of Public Health. During the surge of the highly transmissible Omicron variant of SARS-CoV-2 in Hong Kong in March, Cowling found that other respiratory viruses “disappeared … and they came back again in April.”

Untangling such interference hasn’t been easy given the number of respiratory viruses—coronaviruses, rhinoviruses, adenoviruses, RSV, and influenza are just among the best known—and the many infections that escape notice. Recent advances in technology, however, make it easier to detect infections in people and study how multiple viruses behave in the lab, in cell cultures or stem cell–derived tissues known as organoids. Increasingly, researchers are fingering a cause: chemical messengers that infected people produce called, fittingly, interferons.

When a respiratory virus sweeps through a community, interferons can broadly raise the body’s defenses and temporarily erect a populationwide immune barrier against subsequent viruses that target the respiratory system. “Basically, every virus triggers the interferon response to some extent, and every virus is susceptible to it,” says immunologist Ellen Foxman at Yale University, who has been exploring interference between SARS-CoV-2 and other viruses in a laboratory model of the human airway.

Rhinoviruses, which cause common colds, can trip up influenza A (the most prevalent flu virus). RSV can bump rhinoviruses and human metapneumoviruses. Influenza A can thwart its distant cousin influenza B. “There are a lot of major health implications from viral interference,” says Guy Boivin, a virologist at Laval University who co-authored a review on viral interference earlier this year.

Still, interference isn’t a sure thing when multiple viruses are circulating. A household survey of 2117 people in Nicaragua, for example, found both flu and COVID-19 cases peaked at the same time in February, suggesting “limited viral interference,” the researchers concluded in a preprint. “I think of interference as a small push,” says Aubree Gordon, the University of Michigan, Ann Arbor, researcher who led the study with colleagues from Nicaragua’s Ministry of Health. “It depends on population immunity and when that virus last circulated and flu and COVID vaccination rates.”


As early as 1957, two virologists at the National Institute for Medical Research in London reported a convincing mechanism by which one animal virus might bump aside another. Alick Isaacs and Jean Lindemann probed a well-known mystery in virology circles: Membranes from chicken eggs inoculated with inactivated influenza virus cannot then be infected with a live version. Isaacs and Lindemann found that the chicken embryo secreted a chemical, which they dubbed interferon, that accounted for the interference. Unlike other immune responses—antibodies, for example—that target specific pathogens an animal has seen in the past, this nonspecific, rapid response is part of what’s known as the immune system’s innate arm.

A decade passed before interference between different viruses in humans received serious attention. Soviet virologist Marina Voroshilova at the Academy of Medical Sciences wondered why live but weakened versions of poliovirus used in vaccines sometimes didn’t grow in the guts of people who received them, failing to trigger protective immune responses. She found that harmless enteroviruses in the intestinal tract appeared to interfere with the polioviruses. Voroshilova then ran large field trials of vaccines composed of attenuated enteroviruses. They worked against those gut pathogens and also, surprisingly, warded off multiple respiratory viruses. Her team pegged the protection against the respiratory viruses to increased levels of interferons.

Colliding viruses

Testing of people in Scotland who had respiratory problems and sought medical care reveals peaks and troughs of influenza A and rhinovirus prevalence that indicate the two viruses likely interfere with each other.

Influenza ARhinovirusPrevalence (%)010203040 %20052007200920112013

But few studies followed up on the early findings. “If you look at the virology literature, over 95% of studies are based on the study of a single virus,” says Pablo Murcia, a virologist at the University of Glasgow.

Sporadic epidemiologic reports have documented how waves of influenza seemed to crowd out RSV, parainfluenza, and other respiratory viruses. But confounding variables riddled the data. What if, for example, sick children who stayed home from school dodged the other viruses? And confirming which virus had sickened a person required culturing samples, which, until recently, was cumbersome and often inconclusive.

The influenza pandemic in 2009, driven by a novel flu virus dubbed pH1N1 that had recently emerged in pigs, put the study of viral interference on more solid footing. When populations have scant immunity to a novel flu strain, it can circulate widely outside of the winter season, as happened with pH1N1 worldwide. But groups from Sweden and France, who used the highly sensitive polymerase chain reaction (PCR) assays to detect viral genetic sequences, showed that in those countries, spikes of rhinovirus infections in late summer delayed the peaks of influenza until late fall, the normal start of flu season.

More recently, in one of the largest, longest, and most comprehensive studies of respiratory virus infections in humans, Murcia and colleagues used a PCR assay that can identify members of 11 viral families to probe nasal and throat samples from more than 36,000 individuals who sought care from the National Health Service in Glasgow over 9 years. Among other examples of viral interference, their data clearly showed rhinovirus and influenza A peaked at different times (see graph, above), demonstrating a “negative interaction” between the two viruses, the group concluded in the 26 December 2019 issue of the Proceedings of the National Academy of Sciences.

The next year, Foxman and colleagues reported finding interference after PCR testing for 10 different viruses in 13,000 respiratory samples from adults who sought care at the Yale New Haven hospital system. Between 2016 and 2019, about 7% of people tested positive for rhinovirus or influenza A virus, but of these 1911 samples, only 12 had both viruses, significantly fewer than expected, they reported in The Lancet Microbe. “It was great to see Ellen Foxman’s paper,” Murcia says. “She essentially showed similar results to ours, and they are completely independent studies.”

In the same report, Foxman pinned down the causal role of interferons. Like normal airways, the organoids her team makes from bronchial epithelial cells mount immune responses, including secreting interferons. Infecting organoids with rhinovirus nearly halted the growth of influenza A viruses added later. The rhinovirus infections led to the expression of a flood of interferon-related genes, the study showed. And when her team treated the organoids with drugs that blocked their cells from mounting an interferon response, the influenza viruses thrived.


Now, viral interference researchers are closely watching the newest respiratory virus to circle the globe. “What interactions could SARS-CoV-2 have with other viruses?” Murcia asks. “To this day, there are no robust epidemiological data.” For one thing, the widespread social distancing and mask wearing in many countries meant there was little chance to see interference in action. “There was almost no circulation of other respiratory viruses during the first 3 years of the pandemic,” Boivin says. Also, SARS-CoV-2 has many defenses against interferons, including preventing their production, which might affect its interactions with other viruses.

Still, Foxman has published evidence that, in her organoid model, rhinovirus can interfere with SARS-CoV-2. And Boivin’s team has reported that influenza A and SARS-CoV-2 each can block the other in cell studies.

Learning how SARS-CoV-2 and other viruses interfere with each other outside the lab will take prospective studies that closely monitor the same populations for several seasons. Cowling now has several, relatively small studies underway in Hong Kong, where people are repeatedly giving blood and respiratory samples, regardless of whether they have disease symptoms. It’s slow going, he says. “At the moment we don’t have many respiratory infections in Hong Kong,” Cowling adds, noting that masking is still common.

Cowling, Murcia, and Foxman all say a dearth of funding has limited their abilities to do large population studies. Still, they and others remain optimistic that we will soon have the best data yet about the tussle between SARS-CoV-2 and other respiratory viruses. “This will be the first real winter where we have a normal mixing pattern of people, and we hopefully will start to see some signals,” Murcia says. With multiple viruses running into each other for the first time in 3 years, he hopes to learn that interference remains alive and well, and able to blunt this winter’s triple threat.