Two passengers on an international commercial flight may have contracted COVID-19 on the airplane, researchers from Germany found.
A flight of 102 people from Tel Aviv to Frankfurt apparently included seven infected individuals (“index cases”). Two others believed not to be infected when they boarded were later diagnosed with the infection, reported Sandra Ciesek, MD, of Goethe University Frankfurt am Main, and colleagues.
Both sat within two rows of index cases, Ciesek’s group wrote in a JAMA Network Open research letter. The authors noted, however, that they couldn’t prove the two passengers contracted their infections on the plane.
One factor that may increase the chance of mid-air transmission: passengers were not wearing masks.
Ciesek and colleagues reviewed the 4-hour, 40-minute flight from Tel Aviv to Frankfurt on March 9. Among the passengers was a tourist group. Beginning 7 days earlier, the group had contact with a hotel manager who was later diagnosed with COVID-19, but no member of the group was diagnosed with the virus prior to the flight.
That changed when the plane landed in Germany, however. Of the 24 members in the tourist group, seven tested positive for SARS-CoV-2 via a throat swab on arrival. Four passengers were symptomatic during the flight, two were pre-symptomatic, and one was asymptomatic.
They also were able to interview 71 of 78 other passengers 4 to 5 weeks later. Passengers within two rows of the index case and those who reported symptoms were offered an antibody test. Borderline or positive IgG tests were confirmed with a plaque reduction neutralization test (PRNT).
Serum samples from 13 of these passengers were obtained about 6 to 9 weeks following the flight. Of these, one passenger tested positive for SARS-CoV-2 4 days after the flight, but could not recall any symptoms, and SARS-CoV-2 IgG was detected 7 weeks after the flight, with a positive PRNT result.
Seven other passengers said they were symptomatic within 14 days after the flight. One passenger reported “headache, muscle ache and hoarseness” beginning 5 days after the flight. Nine weeks later, researchers got a serum sample and SARS-CoV-2 IgG was detected, though the PRNT result was borderline.
However, the six other symptomatic and five other asymptomatic passengers who provided serum samples 9 weeks after the flight tested negative except for one, who had a borderline result on the IgG, but a negative result on PRNT.
SARS-CoV-2 transmission could not be excluded for one passenger who had previous contact with a COVID-19 patient, and the 46 asymptomatic passengers who were not tested.
Ciesek and colleagues cited prior research noting both SARS and influenza transmission may occur among passengers seated beyond the “two-row perimeter.”
They noted the airflow in the cabin “from the ceiling to the floor and from the front to the rear” may be tied to a reduced rate of transmission, but with a caveat: “Our findings do not rule out airborne transmission of SARS-CoV-2 in an airplane cabin,” they wrote.
Disclosures
The authors disclosed no relevant relationships with industry.
Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, had surgery Thursday morning to remove a polyp on his vocal cord, CNN reported.
“He had general anesthesia and texted me after to let me know he was doing ok,” CNN‘s Sanjay Gupta, MD, tweeted. “Doctors have advised him to curtail his talking for a while to allow his vocal cords to recover.”
Gupta said vocal cord polyps typically form due to overuse. Singers, for instance, are more likely to develop them, he said.
As the nation’s top infectious disease expert and a member of the White House coronavirus task force, Fauci’s busy briefing schedule and frequent media appearances during the COVID-19 pandemic have required frequent speaking engagements.
He has faced questions about his gravelly voice in the past months. In April, NBC‘s Savannah Guthrie asked, “Are you OK? Your voice does not sound great.” He replied that he was “physically fine. All I do all day long is brief people. … I just need to keep my mouth shut for a little while.”
Around that time he also told the Economic Club of Washington, D.C.: “When you get your voice damaged a little, your trachea — I probably have a polyp there — that the only way you’re going to make it get better is to keep your mouth shut.”
Gupta said on CNN that Fauci has been wanting to address the polyp for the past few months and determined that now was the best time to get it done.
“The advice is going to be, ‘Don’t talk for a while,'” Gupta said. “That’s how you recover from this surgery.”
Pfizer and BioNTech surprised many industry watchers on July 27 when they announced they would conduct a large-scale study of a vaccine for Covid-19. The surprise? The vaccine that would be tested in a 30,000-patient trial wasn’t the one for which the companies had presented data on July 1.
The reason, the companies said, was that a second vaccine seemed to generate a similar immune response, but fewer side effects. On Thursday, they posted the results from all 332 people who received either vaccine, referred to as vaccines B1 or B2 — and indeed, B2 recipients experienced markedly fewer adverse events tied to the vaccine.
The study tested doses of each vaccine ranging from 10 micrograms to 100 micrograms. The 30-microgram dose of B2 is being taken forward in clinical trials.
With the original vaccine, called BNT162b1, or B1 for short, patients between the ages of 18 and 55 had adverse events thought to be related to the vaccine 50% of the time at the 30-microgram dose. Those between the ages of 65 and 85 had related adverse events 16.7% of the time.
For the second vaccine, BNT162b2, or B2, patients between 18 and 55 had adverse events thought to be related to the vaccine 16.7% of the time, and no adverse effects thought to be related to the vaccine were reported in those between the ages of 65 and 85.
Both vaccines use mRNA — the genetic messenger the body uses to make the DNA code into proteins — packaged inside a fatty capsule, called a lipid nanoparticle, that allows it to get into cells. The mRNA instructs cells to make a protein, which then triggers the immune system into action. For the B1 vaccine, the mRNA coded for the part of a protein on the SARS-CoV-2 virus that binds to a receptor on human cells in order to gain entry to them. The B2 vaccine makes the entirety of this protein, known as the spike protein.
Using the full spike protein may allow the immune system to figure out more ways to detect and attack the virus. Chemical modifications to the mRNA may also explain some of the difference. Although the same dosage, by weight, was given to patients with each vaccine, the B2 vaccine would include fewer particles, because the full-length mRNA is heavier.
The side effects tracked were mostly those one would expect from a vaccine injection, including soreness at the injection site, fever, chills, headache, and muscle or joint pain. No older adult who received B2 reported redness or swelling at the injection site.
The average level of antibodies to the virus in older adults was only 41% that seen in younger participants. However, it was still higher than the level of antibodies seen in recovered patients, the authors said.
All patients in the study of B2 were white and non-Hispanic, with more older women than older men participating. The younger patients were a median of 37 years old, while the older ones were a median of 69.
Pfizer has said that some data from its large study of the B2 vaccine could come as early as October.
But if Joe Biden is elected in November, he has made clear that his first moments in office would mark a dramatic shift in the nation’s approach to Covid-19.
Biden’s first post-election phone call, he has said, would be to Anthony Fauci, requesting that the renowned infectious disease researcher continue his government service. For months, he and his staff have pressed for specific answers about how many coronavirus tests the U.S. could conduct by January, when he’d be sworn in as the 46th president. (Biden’s optimistic target: 100 million per month.) And he has pledged to institute daily pandemic briefings for the American public — conducted by scientists and public health experts, not by politicians.
The platform is as much a rebuke of President Trump as it is a pandemic-response roadmap. Throughout the past six months, Trump has repeatedly undermined Fauci, suggested that the government should “slow down” coronavirus testing, and has taken center stage at careening, misinformation-heavy press briefings.
In interviews with STAT, numerous campaign surrogates, scientific advisers to Biden’s campaign, and an array of former U.S. health policy officials have made clear that Biden’s inauguration, and the weeks leading up to it, would set off a mad dash to reverse the country’s pandemic misfortunes. They described in detail a de facto Covid-19 war room, and identified the key aides who brief the former vice president.
The Biden advisers acknowledge that after 170,000 American deaths, Covid-19 will not be easily tamed, no matter who is in the Oval Office. Partisan defiance of public health guidance is likely to persist under any president, and Biden’s administration might still face resistance from individual governors.
Nonetheless, the Biden camp says it is hatching plans for a slate of executive orders and federal guidance that could land as soon as Inauguration Day. In the hours after he’s inaugurated, his advisers said, the Senate could move to quickly confirm top health care officials — and the federal government could launch aggressive new messaging campaigns on vaccines, mask use, and social distancing.
In making the case for how he would govern, Biden’s campaign has been more concrete in how he would approach the country’s coronavirus response than perhaps any other issue. He has pledged to dramatically ramp up testing efforts, restore a biodefense official to the National Security Council, and improve Covid-19 surveillance by revamping insurance claims data.
The planning is informed by a cast of physicians who include a top Obama administration pandemic-response expert, a former Food and Drug Administration commissioner, a former surgeon general, and a Yale researcher focused on health disparities.
“You need to put in place, one Day 1, a team of people who have been planning and thinking deeply about this, and who know what they’re doing,” said Nicole Lurie, the assistant health secretary for preparedness and response from 2009 to 2015 and a current adviser to Biden. “A really great thing about working with this campaign, from my perspective, is that it’s really been the A-team.”
On March 13, Biden’s campaign faced an urgent decision about its own operations: Across the country, health officials had reported thousands of new Covid-19 cases. The escalating pandemic was racing across the U.S., but Biden was only midway through a bruising primary campaign.
The question on the table: Should Biden shut down his campaign headquarters in Philadelphia?
In a conference call, his aides brought together a group of doctors that included David Kessler, the former FDA commissioner, to seek advice.
“We recommended on that day, my first phone call, to shut down campaign headquarters,’’ Kessler told STAT. “And to the campaign’s credit, they did that within two hours.” Biden’s campaign, he noted, made that call before there was clear guidance from the local or federal governments.
The newly work-by-Zoom campaign went beyond following Kessler’s counsel on shutting down its headquarters. Before long, Biden’s policy team brought on Kessler and Vivek Murthy, the former surgeon general, to provide daily pandemic briefings to the former vice president and his top advisers.
Biden quickly labeled the pair “The Docs,” and turned to Kessler and Murthy as his top lieutenants on the pandemic, urging staff to workshop language in speeches and public statements by the physicians for their approval.
Murthy and Kessler have served as Biden’s eyes and ears on issues ranging from mask use to vaccine development to diagnostic testing. They assembled 80- to 90-page memos, briefing Biden at such length that Kessler occasionally fretted to high-level aides that he and Murthy were taking up too much of the candidate’s time.
Stef Feldman, Biden’s policy director, and Jake Sullivan, a senior adviser, frequently sat in, peppering Murthy and Kessler with their own questions. Biden, Kessler recalled, often drilled down and demanded specific estimates of how many tests the U.S. could administer by January.
Other conversations have drilled down on the supply of masks, protective gear for medical workers, and Covid-19 kits, Lurie said.
“He has been really clear that he’s going to appoint a supply-chain commander,” she said. “Clearly, the supply-chain issues are pretty significant, whether it’s about masks and PPE — none of us think right now that if there’s a really bad surge this fall and winter, that we have enough masks to protect health care workers — or whether it’s about the supply chain for diagnostics.”
While they’ve long been conducted without much public attention, the briefings in recent weeks have figured prominently into Biden’s campaign: The day he unveiled Sen. Kamala Harris of California as his running mate, he brought her to his informal Covid-19 war room. There, she sat in on a videoconference with Kessler, Murthy, Lurie, and Marcella Nunez-Smith, a physician and Yale researcher.
“We’re going to get what I get four times a week: A briefing on the state of coronavirus here and around the world, and what we should and shouldn’t be doing,” Biden told Harris, according to pool reports. “It usually takes somewhere between an hour and an hour and a half.”
Biden and his staff have pressed Kessler and Murthy, in particular, on issues as specific as equipment to transport vaccines that must be stored at below-freezing temperatures, advisers aid.
The campaign has also followed news regarding potential coronavirus treatments like dexamethasone, a steroid shown to reduce Covid-19 death rates, and remdesivir, the Gilead Sciences antiviral that has shown some impact on death rates and the duration of Covid-19 patients’ hospital stays.
“He’ll sometimes hear an expert on TV or read an expert study, and he’ll bring that question to us of what he’s heard or read,” Kessler said. “But we brought to him the clinical trials on remdesivir when that data was available. We brought to him the clinical trial data on dexamethasone. So we’re presenting him the data — obviously, he is attuned to this independently, but he’ll bring anything he hears to us, and we’ll all discuss it.”
When President Trump began to aggressively tout hydroxychloroquine, another antimalarial drug, as a Covid-19 cure-all, Biden, of course, wanted to know more.
“On hydroxychloroquine, very early on there were questions — and I simply said, Mr. Vice President, I need more time to see the data,” Kessler said. “Until I can see clinical trial data, I can’t give you a judgment on what works or doesn’t work. And he was fine with that.”
Biden’s allies are already laying out plans for a brutal transition — acknowledging that, if Biden wins, they don’t expect much bipartisan goodwill between outgoing Trump administration staffers and their incoming Biden administration counterparts.
“My guess is there won’t be a lot of reliance on the Trump team to brief the incoming Biden team,” said Kathleen Sebelius, the Obama administration health secretary who oversaw the implementation of the Affordable Care Act. “There will be information gathered from the Obama era, as much as possible, to then brief the incoming Biden team. Because I don’t know that the Trump folks paid much attention at all to the briefing books, and I’m not sure that most departments bear any resemblance to the way they were left.”
The Trump administration has been criticized for its scattered and inefficient approach to procuring masks and tests, and for abruptly undercutting the Centers for Disease Control and Prevention from collecting basic data about Covid-19 hospitalizations and infections.
“We know that there have been major problems with data and transparency,” Lurie said. “Whether it’s about some aspect of epidemiology, or whether it’s the supply chain, you’ve got to pretty rapidly get your arms around a set of facts that you can really count on — that has to be done really during the transition, and before.”
The administration would also install new leadership atop key health care agencies, like the Department of Health and Human Services, the CDC, and the FDA.
Much of Biden’s health policy team, nonetheless, would need to be confirmed by the Senate, and therefore would likely not be in place for weeks or months after his inauguration, forcing a newly sworn-in president to rely on career staff and acting officials to steer the pandemic response.
There’s already a playbook for such a scenario, however: In interviews, numerous Democratic operatives noted that Biden already has experience taking over a country in crisis and charting a new course even in the absence of a full cabinet.
In 2009, Biden was sworn in alongside President Obama amid the worst economic crisis since the Great Depression.
Within a month, Congress had passed a sweeping stimulus package that many in his inner circle view as a template for significant Covid-19 dealmaking in the opening weeks of his presidency.
Still, some confirmations could come quickly — Sebelius noted that some cabinet officials were sworn in within days of Obama’s inauguration. (The Senate confirmed Hillary Clinton, the secretary of state, on the second day of his presidency.)
“That’s how I would expect Joe Biden to act,” Sebelius said. “He will tee people up, he will ask the committees to meet, he will actually be able to swear a number of secretaries in on Day 1.”
But outside experts have warned that Biden shouldn’t expect to orchestrate a major course-correction instantly, or at all. And some of Biden’s plans are perhaps too optimistic, such as his hope of conducting 100 million tests per month by January (the country has conducted just 73 million, to date), or of establishing a new insurance code for Covid-19 treatment, to be used for federal pandemic surveillance (such claims data is typically gathered long after patients receive care).
“I don’t think anyone is suggesting that we can reverse” the past six months, said Sheila Burke, the former chief of staff to Sen. Bob Dole, the longtime Republican majority leader. “But rather we can improve upon the situation going forward — whether it’s the availability of testing, whether it’s the availability of PPE, or whether it is establishing an expectation standards with respect to the use of masks.”
Even in the face of the Trump administration’s haphazard response, however, leading Republicans in Congress have argued Biden isn’t up to the job of managing a pandemic.
“If Joe Biden was president, we’d still be debating whether planes from China should be coming to America instead of discussing the six vaccines we have about ready to go through BARDA or the more than 600 therapeutics we have about to come online,” said Kevin McCarthy, the top House Republican, in a recent Fox News interview. (Biden did not oppose Trump’s ban on direct flights from China when it was issued, and the U.S. government has not yet approved a vaccine for Covid-19, though it has issued a number of emergency authorizations for therapeutics.)
In a speech last week, Trump leveled his latest attack on Biden’s coronavirus approach, accusing him of “ignoring the scientific evidence and putting left-wing politics before facts and evidence.” Trump’s campaign has also repeatedly rebroadcast a remark from Ron Klain, the former Biden chief of staff and Obama administration Ebola czar, recalling that the administration “did every possible thing wrong” in responding to H1N1.
Biden, throughout his campaign, has punched back.
“I don’t think he’s competent enough to know what to do. He just waved the white flag.”
Joe Biden, in remarks about President Trump’s response to the Covid-19 pandemic
“You know, I used to think it was because of his personality, but I just don’t think he can intellectually handle it,” he told reporters on Wednesday. “I don’t think he’s competent enough to know what to do. He just waved the white flag.”
At the Democratic National Convention this week, Biden’s supporters have doubled down: Former president Bill Clinton described Trump’s pandemic response as “only chaos.” Kristin Urquiza, a Democratic voter, blamed Trump’s disdain for stay-at-home orders and Arizona’s hasty reopening for her father’s death.
In making their case, Biden’s backers argue that he would take charge of the public health crisis with the benefit of his decades-deep web of connections in Washington’s health care intelligentsia.
As vice president, he frequently crossed paths with Fauci, the director of the National Institute of Allergy and Infectious Disease, particularly during the H1N1 flu pandemic of 2009 and the Ebola scare several years later. Fauci, Biden has pledged, would have “full access to the Oval Office.”
Despite Trump’s criticism of Biden for his role in the Obama administration’s response to H1N1, which sickened 60 million Americans but killed only 12,469 — roughly 7% of Covid-19’s U.S. death toll to date — Biden’s campaign has cast his pandemic-response experience as a strength.
His chief of staff during the early Obama years, Klain, has remained outspoken on Covid-19 issues throughout the pandemic.
Another key campaign adviser, Chris Jennings, is a health policy veteran who worked in the Obama administration alongside Lurie, the government’s top pandemic-preparedness official, and Murthy, a surgeon general known for his focus on addiction, gun violence, and the phenomenon of loneliness as a public health crisis.
And as FDA commissioner, Kessler, now a top adviser, worked closely with Fauci during the HIV/AIDS crisis of the 1980s and 1990s.
Another occasional campaign adviser, Greg Simon, is a longtime Biden confidant dating back to the vice president’s “Cancer Moonshot” in 2016, following the death of his son, former Delaware attorney general Beau Biden, from brain cancer. Following Trump’s election, Biden hired Simon to run the Biden Cancer Initiative, the cancer-research nonprofit that folded once Biden declared his candidacy last year.
“He’s grounded” in health care issues, Kessler said. “He knows the players. He has enormous admiration for Dr. Fauci.”
Should Biden become president, advisers said he would immediately emphasize the stark differences between Trump’s regime and his own. The most important element of Biden’s plan, they say, is simply that it exists.
“I expect will be very clear, unambiguous communication, coming from the very top, about what needs to be done,” Lurie said.
