Services around the world have been disrupted due to the coronavirus crisis

The top stories you're waking up to Listen to your Morning Bulletin on Google Assistant and Amazon Alexa smart speakers from 7am every weekday

The top stories you're waking up to Listen to your Morning Bulletin on Google Assistant and Amazon Alexa smart speakers from 7am every weekday

The top stories you're waking up to Listen to your Morning Bulletin on Google Assistant and Amazon Alexa smart speakers from 7am every weekday

The top stories you're waking up to Listen to your Morning Bulletin on Google Assistant and Amazon Alexa smart speakers from 7am every weekday

FULL STORY: Patients kept awake during cancer surgery to protect them from coronavirus

Draft proposals for how to return to work safely have been leaked and they paint a very different picture of the workplace post lockdown.​

Italy has already taken its first steps towards easing lockdown restrictions and now the country has revealed how restaurants could look once they re-open.

The top stories you're waking up to Listen to your Morning Bulletin on Google Assistant and Amazon Alexa smart speakers from 7am every weekday

Tomorrow night a rare "Super Flower Moon" will light up the UK's night skies.

The top stories you're waking up to Listen to your Morning Bulletin on Google Assistant and Amazon Alexa smart speakers from 7am every weekday

Boris Johnson is due to reveal details of the Government's "road map" for easing the UK's coronavirus lockdown, some of which may begin as early as next week.

Warmer weather during summer months usually spells bad news for hay fever sufferers

Coronavirus: The symptoms

The Royal Air Force Aerobatic Team, or the Red Arrows, is the aerobatics display team of the Royal Air Force.

We're used to thinking of DNA as a rigid blueprint. Karissa Sanbonmatsu researches how our environment affects the way DNA expresses itself—especially when it comes to sex and gender.

On Monday, officials in Los Angeles County released preliminary results of a study that suggest roughly 4.1% of the county's adult population has already had the coronavirus, which translates to between 221,000 and 442,000 people, factoring in adjustments for statistical margin of error.That's a much higher number than confirmed case counts indicate. (As of early Tuesday, the county had 13,816 cases.)"We haven't known the true extent of COVID-19 infections in our community because we have only tested people with symptoms and the availability of tests has been limited," Neeraj Sood, a professor of public policy at the University of Southern California and lead investigator on the study, said in a statement.Dr. Barbara Ferrer, LA County's public health director, said in a statement that the early results pointed to the possibility that many people may have been unknowingly infected.The study relies on rapid antibody tests, which have faced concerns about accuracy.And as The Mercury News reported, a Stanford study that also showed higher rates of infection in Santa Clara County drew criticism, although that was largely from statisticians over the study's methodology.Still, experts have emphasized that more studies will help develop a clearer picture of the virus's true prevalence.In any case, officials say it's crucial to continue to adhere to public health orders for many reasons, including that if more people are infected but asymptomatic, they could unknowingly spread the virus.______A change to the USNS Mercy's assignmentOn Monday, my New York Times colleague John Ismay and I spoke with leaders aboard the Navy hospital ship Mercy. Here's our dispatch about how their assignment has changed:In the weeks since the Mercy arrived at the Port of Los Angeles from San Diego, the hospital ship's mission has been clear: Serve as a crucial relief valve for patients who have not been infected with the coronavirus as hospitals fill up with patients sick with COVID-19.In recent days, the work has shifted, but that underlying goal has remained the same, the commanding officer of the ship's medical facility told us."FEMA, after having made an assessment of the situation and the local needs, has changed our assignment," said Capt. John Rotruck, the medical treatment team's commanding officer.The Mercy has sent 40 medical staff members -- two family practice doctors, 16 nurses and 20 corpsmen, including two respiratory technicians -- to help care for patients who do not have COVID-19 at a state-run skilled nursing facility in Orange County."We're essentially augmenting their staff," Rotruck said, as the anticipated surge in COVID-19 hospitalizations has, for now, been held at bay.The capacity onboard will decrease to 250 beds from 1,000, in large part as a result of that staffing shift -- although officials emphasized that leaves more than enough space at the rate the Mercy has been taking in patients.At the same time, leaders aboard the Mercy said that most of the military crew is moving off the ship to stay at nearby hotels to make it possible for crew members to keep their distance from one another as they work, eat and sleep.Sailors will be bused from their hotels to work their shifts aboard the ship.The move, which will decrease the number of crew members staying aboard the ship to roughly 140 from more than 800, came as the number of crew members who may have been exposed inched upward.By Monday, Rotruck said that nine crew members had tested positive for the coronavirus and that about 130 people were in quarantine because they had come into what federal officials define as close contact with at least one of those nine. All of those in quarantine tested negative.All nine who have COVID-19 were outpatients as of Monday -- meaning their cases were not severe enough to warrant being hospitalized -- and their conditions are being closely monitored.Rotruck said that moving crew members off the Mercy was unusual but not unprecedented.During a previous mission, for instance, some medical staff members flew to Vietnam to provide medical care to patients on the Mercy, although they did not sleep on the ship.However, Rotruck added, "We have not done it to this scale," with the vast majority of the ship's crew members living ashore.A spokesman said Friday that the crew aboard the Navy hospital ship Comfort, which is docked in New York City, recently moved most of its crew to hotels ashore as well.Rotruck said that the Mercy was ready to care for coronavirus-negative seniors living in nursing homes, as the governor has previously announced, but none had been transferred yet.Such nursing home patients may be moved to the Mercy for care through the typical intake process, if, for example, a facility needed to free up space to care for COVID-19 patients.As of Monday evening, the ship had taken in 65 patients total since it docked in San Pedro, and its crew had performed 22 surgeries. There were 13 patients still being treated onboard, meaning that 52 had been discharged.This article originally appeared in The New York Times.(C) 2020 The New York Times Company

For Jeff Anderson, 61, working from home during the coronavirus pandemic has been a respite from office politics and the chatter around the copy machine.But as the push to reopen the country's economy intensifies, so do feelings of dread at the idea of returning to the office, said Anderson, a self-described introvert and anthropology professor at Hobart and William Smith Colleges in Geneva, New York."Just walking from the parking lot to my office I feel like I could be sick," he said. "It's that bad."In wanting to work alone, Anderson is not alone. People other than introverts view a return to the office with sadness and anxiety, and not just because they still risk getting infected. A Gallup poll found a majority of U.S. adults working from home would prefer to continue doing so "as much as possible" after the pandemic.These fans of online work worry that they -- and the country itself -- will lose important benefits discovered during this unprecedented experiment in mass remote work. People who have never liked schmoozing with colleagues have found new heights of productivity away from meetings and office chitchat. People worried about climate change are eager to reduce their carbon footprints by avoiding commutes by car. And while many parents are desperate for schools and day care centers to reopen, some working parents are appreciating more time with their children.Before the pandemic, Christine Reilley had to wake up at 4:30 a.m. to catch an early bus to Manhattan where she works as senior director of strategy and innovation for the American Society of Mechanical Engineers."I'm better rested. I can devote more time to my work," she said. "Just saving the time and money of commuting, I really like this personally."Impossible for Some and 'Overrated' for OthersIt did not take long for naysayers to declare that working from home was "overrated."And yes, it is an option mostly for white-collar office workers. Telecommuting is rarely possible for people in manufacturing or service jobs, and for the health workers, emergency responders, grocery store clerks and delivery people who have been deemed essential personnel. And the more than 30 million Americans who have lost their jobs since March may be impatient about complaints from people still drawing paychecks.Nor can the other downsides be denied. Trying to meet on Zoom from a kitchen table with bored children and annoyed spouses complaining in the background is hardly good for productivity. Women say that video calls make it harder for them to get in a word during meetings dominated by men. This crisis has also increased the burdens on working mothers.Telecommuting was already a growing trend that left out many low-wage workers and was viewed warily by employers who worried that people were slacking off at home. Researchers warned that problem solving and creativity suffer when workers are isolated from one another. Isolated work can lead to loneliness and boredom. Remote workers have also reported they have had to work even longer hours.OK, So What Are the Benefits?For remote work to be successful, employers need to provide the right equipment and other support, said Laurel Farrer, chief executive of Distribute Consulting, a business consulting firm. And the employees must be able to get work done without supervision. If set up properly, experts and advocates say, remote work has many benefits:-- Less time on the road. Commuting by car has been linked to increased stress, more pollution and respiratory problems. The average American who drives to work spends 54 hours per year stuck in traffic, according to an analysis by the Texas A&M Transportation Institute.-- Greater productivity. One well-known study from 2014 led by Stanford professor Nicholas Bloom examined remote workers at a Chinese travel agency and found that they were 13% more efficient than their office-based peers.-- A cleaner environment (maybe). According to estimates from Global Workplace Analytics, a research and consulting firm, if everyone in the United States worked remotely half the time, it could reduce greenhouse gas emissions from vehicle travel by more than 51 million metric tons a year. Graphics showing the reduction in air pollution and pictures of clearer skies over cities like Los Angeles have been among the silver linings of the pandemic. Of course, when people return to work, the roads may fill up again, especially if people fear getting the virus on public transit. And even if more people start working remotely, they might use their cars more for errands closer to home, said Bill Eisele, a senior research engineer at the Texas A&M Transportation Institute. Office commuters make up only about 18% of all traffic, he said.-- Money saved. Global Workplace Analytics estimated that people could save, on average, $2,000 to $6,500 every year by not spending on things like gasoline and day care. Companies could spend less on real estate. The U.S. Patent and Trademark Office estimated it saved more than $38 million in 2015 by not using as much office space, according to a Harvard Business School working paper from November.-- More job satisfaction. A 2005 study found that job satisfaction increased with each additional hour people spent working remotely. But it stopped increasing beyond 15 hours worked remotely.-- Less sickness. Even as companies consider reconfiguring workplaces with plexiglass barriers on desks and special air filters, letting employees work from home can help keep them safe from communicable diseases (and not just COVID-19).-- More time for fitness. You may be able to squeeze in more workouts. "Having a little more time, if you're using it wisely, can be very beneficial," said Marilyn Skarbek, an assistant professor of exercise science at North Central College in Naperville, Illinois. "There are a lot of other things you can do around the house to keep you moving: laundry, cleaning -- all of that keeps you active. My house is definitely cleaner than normal." But there is a risk you could be more sedentary, she warned.Kate Lister, president of Global Workplace Analytics, predicted that workers will be looking for the "happy medium," splitting time between remote work and showing up at the office. The hope is that the pandemic will have shown managers that workers can be trusted to do their jobs without constant supervision."Any kind of flexibility is something that people are really, really ripe for, just some control over where and when they work," she said.Happy Tales From the Home OfficeMany people who had never considered this kind of working life have now had a taste of it, and they love it.Jacquie Benetua-Rolens, communications and engagement coordinator at Santa Cruz Community Health Centers in Santa Cruz, California, has a 2-year-old son who has become a daily part of Zoom meetings with colleagues, waving at them in his pajamas."There is this softened, unfiltered, more honest version of ourselves that I'm enjoying getting to know," Benetua-Rolens said. "There is room to be forgiving and understanding with each other and ourselves. And it's because we've all had to juggle."Benetua-Rolens said she often thinks of her small cubicle back at the office, which she decorated with plants and pictures of her two children."I used to love it," she said. "But I don't miss it at all. I don't want to go back to that even though my house is filthy."Jessica Keup, a 37-year-old single mother and a computer programmer in Ann Arbor, Michigan, moved to her parents' home in rural Tennessee with her 3-year-old son in mid-March, after her company told employees to work from home.Since then, she has been coding from the deck while her son plays with the goats, chickens and peacocks that roost on the vast property.Keup said the solitude has made her more focused and more productive. Her work is not interrupted by chatty colleagues who want to say hi or need help fixing a computer glitch."The people who are in the office who are extroverts stand out and talk a lot and can take the oxygen out of the room," she said.At least one poll from early in the pandemic suggests a strong preference for remote work. Gallup found that almost 60% of Americans working from home would prefer to work remotely "as much as possible" after restrictions are lifted, with 40% saying they preferred to return to the workplace. The online survey of 2,276 randomly selected adults was conducted from March 14 through April 2. It had a margin of sampling error of plus or minus 4 percentage points.At the very least, some workers would like to see employers put lessons of the pandemic into practice, including more compassionate management in general.Rico Sisney, who works for Greenpeace USA, said he would like to continue seeing the kinds of emails his organization has been sending lately encouraging employees to take walks and small breaks."Organizations can continue that even when there is not a pandemic," Sisney said. "Highlight mental health."Christine de Denus, a chemistry professor at Hobart and William Smith Colleges, said she has relished the quiet of working from her porch. She thinks workplaces should adapt to all styles of working."Go to the people and say, 'How can I help you thrive?'" de Denus said. "Just because I'm quiet in a meeting doesn't mean I don't have ideas."When the time comes to return to the office, Keup said she plans to ask if she can work two to four weeks a year from Tennessee."It's beautiful. It's resting and restorative," she said. "And I'll miss that."This article originally appeared in The New York Times.(C) 2020 The New York Times Company

BBC News looks at what we know and don't know about the Earth's changing climate.

After a string of studies that highlight the possible link between air pollution and Covid-19 deaths, Ian Sample hears from Prof Anna Hansell about the complicated relationship between pollution, health and infection with Sars-CoV-2

No, you should not CC the CEO on every email you send.

Mission is remembered as perhaps Nasa's finest, and most desparate, hour

While staying at home during the pandemic, people are now trying gardening to find out if they have a green thumb. But gardening is not an easy hobby and requires some research.

Marc Lipsitch, a professor of epidemiology at the Harvard School of Public Health, answers questions about access to testing for COVID-19, false-negative results and the challenges of mass testing.

The team behind The Artist will have spent the first day of the rest of their lives conforming to the grandest, and most lucrative, of Hollywood traditions.

'I am a fan of ETFs, well certainly they have grown a whole lot'

Singer Miley Cyrus is comfortable in her space but understands that the COVID-19 pandemic has been rough for a lot of people, financially and otherwise

If I was ever going to ‘come out’, I should have done it when I was younger

If anyone ever offers me a cigarette, I always reply: “No thanks, I don’t smoke.” But I’m lying.

I started smoking at 16. I thought it made me look grown-up, but I was shy so I’d do it on my own. I would go into the woods near my home, or occasionally “bravely” have one in the house if nobody was else in.

The actor on walking the red carpet while having an allergic reaction, her controversial Calvin Klein campaign and dressing like Michael Jackson

I’m not known for wearing outfits that are as completely covered up as this. Often, you are uncomfortable on the red carpet, worried that something is going to pop out, unzip or break. There was something about this look that felt like protection and armour to me. I wore it to the 2018 CFDA fashion awards and I loved how extreme it felt: chic and strong, slightly androgynous but with a femininity to it. It came together nicely with no stress – until I was in the car, when I realised I was having some kind of allergic reaction to my makeup! One of my eyes swelled up right before I was stepping out on to the red carpet. I panicked and put on my reading glasses to camouflage the fact that one eye was almost completely shut!

As a teenager, my relationship with apparel was fraught because I never cultivated my own style. My mom and I bought everything from thrift shops – I would wear the same jeans all year and then cut them into shorts – but every time I would go on a set I would be decked out in designer clothes. There was a disconnect: clothes were just something belonging to other people that I would embody, and then shed.

From Matilda the Hun to the first fleet, test your knowledge with the Weekend quiz

1 Which South American was the world’s first female president?
2 What was the destination of the First Fleet?
3 Who lived at 308 Negra Arroyo Lane, Albuquerque?
4 Which epic poem is based on the Battle of Roncevaux?
5 What animal is a sarcastic fringehead?
6 What German car was last made in Mexico in 2019?
7 Pollex is the medical name for what part of the body?
8 Thomas Neuwirth won Eurovision under what stage persona?
What links:
9 Norwich; Newlyn; St Ives; Camden Town; Bloomsbury?
10 Platypus and four species of echidna?
11 Renren; QQ; Sina Weibo; WeChat?
12 Sydenstricker; Stearns; Staples; Surajprasad?
13 Colonel Ninotchka; Mt Fiji; Zelda the Brain; Matilda the Hun?
14 Harmost; satrap; voivode; bey; subahdar?
15 Ridley Scott; James Cameron; David Fincher; Jean-Pierre Jeunet?

We can expect psychological difficulties to follow as we come out of lockdown. But we have an opportunity to remake our relationship with our bodies, and the social body we belong to. By Susie Orbach

When lockdown started, I was confused by bodies on television. Why weren’t they socially distancing? Didn’t they know not to be so close? The injunction to be separate was unfamiliar and irregular, and for me, self-isolating alone, following this government directive was peculiar. It made watching dramas and programmes produced under normal filming conditions feel jarring.

Seven weeks in, the disjuncture has passed. I, like all of us, am accommodating to multiple corporeal realities: bodies alone, bodies distant, bodies in the park to be avoided, bodies of disobedient youths hanging out in groups, bodies in lines outside shops, bodies and voices flattened on screens and above all, bodies of dead health workers and carers. Black bodies, brown bodies. Working-class bodies. Bodies not normally praised, now being celebrated.

A trio of Senate Democrats wants to give $2,000 per month to individuals through the end of the health emergency. One Senate Republican suggests covering payroll for companies that rehire workers.

Any big weekend plans? Don't worry, we've got you covered. Every weekend, E! is giving you the top binge picks, including new and old TV series, movies and specials. And this...

I've traveled a lot over the years, saving up all the dollars and vacation days I can manage to embark on solo adventures around the globe. Whether I've ended up road-tripping...

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Coronavirus: The symptoms

The Speaker is presiding over his first virtual PMQs. Susannah Butter meets him (on FaceTime)

The pair announced the exciting news this morning

It seems like people who get infected with SARS-CoV-2 retain immunity, but we can’t be sure how long that immunity will last. We still lack the testing capabilities to be certain.eamesBot / Shutterstock

This story was updated post-publication to include information from a study published on the preprint server medRxiv on April 17, 2020.

With more than half a million cases of COVID-19 in the United States1 and the number of deaths increasing daily, it remains unclear when and how we might return to some semblance of pre-pandemic life. This leaves many grappling with an important question: Do you become immune after SARS-CoV-2 infection? And, if so, how long might that immunity last?

In 2019, the virus SARS-CoV-2 jumped to a human host for the first time, causing the disease COVID-19. When you become infected with a new virus, your body does not possess the antibodies necessary to mount a targeted immune response. Antibodies, proteins belonging to the immunoglobulin family, consist of four chains of amino acids that form a characteristic Y-shaped structure. Antibodies are manufactured by the immune system to bind to antigens (viral proteins) to neutralize viral infectivity.

When you inhale an aerosolized droplet containing SARS-CoV-2, the virus encounters the cells of the mucous membrane lining the respiratory tract. If effective contact is made, the virus binds to a particular receptor on these cells called ACE-2. After binding ACE-2, a host enzyme is co-opted to cleave the virus’ surface protein, called the spike protein, allowing the virus to enter the cell.

It appears that individuals with COVID-19 do create neutralizing antibodies—the basis of immunity.

Within the first few hours of infection, the body’s first line of defense—the innate immune response—is activated. The innate immune response is non-specific. When a “foreign” molecule is detected, innate immune cells signal to other cells to alter their response or prepare to combat infection.

In the following days, the adaptive immune response is activated, which is more specific. The adaptive immune response will peak one to two weeks post-infection and consists of antibodies and specialized immune cells. It is called the “adaptive” immune response because of its ability to tailor the response to a specific pathogen. Antibodies can neutralize viral infectivity by preventing virus from binding to receptors, blocking cell entry, or causing virus particles to aggregate.2 Once an infection has resolved, some of these antibodies remain in the body as immunological memory to be recruited for protection in the case of reinfection. To be immune to a virus is to possess this immunological memory.

Many vaccines work by activating the adaptive immune response. Inactivated virus, viral protein, or some other construct specific to a particular virus are introduced into the body as vaccines to initiate an immune response. Ideally, the body creates antibodies against the viral construct so that it can mount a succinct response when infected by the virus. However, in order to work effectively, a vaccine must provoke an immune response that is sufficiently robust. If the body only produces low concentrations of neutralizing antibodies, adequate immunological memory may not be sustained.

While there is still much that we have to learn about SARS-CoV-2, it appears that individuals with COVID-19 do create neutralizing antibodies—the basis of immunity. However, we don’t know for certain how long that immunity might offer protection. On the question of COVID-19 re-infection, Matt Frieman, a coronavirus researcher at the University of Maryland School of Medicine, commented in a recent interview with NPR: “We don’t know very much … I think there’s a very likely scenario where the virus comes through this year, and everyone gets some level of immunity to it, and if it comes back again, we will be protected from it—either completely or if you do get reinfected later, a year from now, then you have much less disease. That’s the hope, but there is no way to know that.”3

Immunity to a virus is measured by serological testing—patient blood is collected and analyzed for the presence of antibodies against a particular virus. Serological data is most informative when collected long-term, so the data we have been able to obtain on SARS-CoV-2 is limited. However, data on other coronaviruses that we’ve had the opportunity to study in more depth can inform our estimations on how this outbreak may evolve.

First, we can look to the coronaviruses that are known to cause the common cold. Following infection with one of these coronaviruses, disease is often mild; therefore, the concentration of antibodies detected in the blood is low. This is because mild disease often indicates a less robust immune response. Interestingly, it is not the virus itself that causes us to feel sick, but, rather, our body’s response to it. Typically, the sicker we feel, the stronger the immune response; therefore, after a cold, we are often only protected for a year or two against the same virus.4 While SARS-CoV-2 wouldn’t necessarily act like these common coronaviruses, the body’s response to these coronaviruses serves as a point of reference upon which to make predictions in the absence of virus-specific data.

We can also look to coronaviruses that are known to cause severe disease, such as SARS-CoV, which caused the 2002-2003 outbreak of SARS in China. One study discovered that antibodies against SARS-CoV remained in the blood of healthcare workers for 12 years after infection.5 While it is not certain that SARS-CoV-2 will provoke a response similar to that of SARS-CoV, this study provides us with information that can inform our estimates on immunity following COVID-19 and provide hope that immunity will provide long-term protection.

If immunity to SARS-CoV-2 diminishes as it does for common cold coronaviruses, it is likely that wintertime outbreaks will recur.

Scientists have also been working to analyze antibodies in samples from individuals infected with SARS-CoV-2. A research group in Finland recently published a study detailing the serological data collected from a COVID-19 patient over the course of their illness.6 Antibodies specific to SARS-CoV-2 were present within two weeks from the onset of symptoms. Similarly, another recent report analyzing patients with confirmed COVID-19 indicated that it took approximately 11-14 days for neutralizing antibodies to be detected in blood.7 Both of these studies, while preliminary, suggest that the basis for immunity is present in patients infected with SARS-CoV-2.

Another report looked at the possibility for recurrence of COVID-19 following re-infection with SARS-CoV-2.8 In this study, rhesus macaques were infected with SARS-CoV and allowed to recover after developing mild illness. Once blood samples were collected and confirmed to test positive for neutralizing antibodies, half of the infected macaques were re-challenged with the same dose of SARS-CoV-2. The re-infected macaques showed no significant viral replication or recurrence of COVID-19. While macaques “model” human immunity, not predict it, these data further support the possibility that antibodies manufactured in response to SARS-CoV-2 are protective against short-term re-infection.

We can also analyze a virus’ structure, and the information gained from sequencing the viral genome, when trying to predict its behavior. All viruses continually undergo mutation in the process of rapid replication. They lack the necessary machinery to repair changes incurred to the genetic sequence (we as humans also incur mutations to our genetic sequence daily, but we have more sophisticated genetic repair mechanisms in place). The occurrence of significant genetic changes to the viral genome that result in viable genetic changes to a virus is termed antigenic variation. We see a lot of antigenic variation in influenza viruses (thus the need to create new vaccines each year); but the coronaviruses seem to be relatively stable antigenically.4 This is because most coronaviruses have an enzyme that allows them to correct genetic errors sustained during replication. The more stable a virus remains over time, the more likely that antibodies manufactured in response to infection or vaccination will remain effective at neutralizing viral infectivity.

All this considered, it appears that immunity is retained following SARS-CoV-2 infection. So too, that immunity might persist long enough to warrant the implementation of vaccination. However, we still have much to learn about this virus, and whether there may be some cross-immunity between SARS-CoV-2 and other coronaviruses. The widespread variation in patient immune responses adds an additional layer of complexity. We still don’t have a good understanding of why people have different responses to viral infection—some of this variation is owed to genetic variation, but how and why some people have more robust immune responses and more severe disease is still unknown.4 In some cases, individuals show a high immune response because the concentration of virus is high. In other cases, individuals show a high immune response because they differ in some aspect of immune regulation or efficiency. However, as levels of immunity increase generally across a population, the population approaches what is called “herd immunity”—when the percentage of a population immune to a particular virus is sufficiently high that viral load drops below the threshold required to sustain the infection in that population.9

How the pandemic will evolve in the coming months is uncertain. Outcomes depend on a myriad of factors—the duration of immunity, the dynamics of transmission and how we mitigate those dynamics through social distancing, the development of therapeutics and or vaccines, and the ability of healthcare systems to handle COVID-19 caseloads. If immunity to SARS-CoV-2 diminishes as it does for common cold coronaviruses, it is likely that wintertime outbreaks will recur in coming years.10 Whether immunity to other coronaviruses might offer some cross protective immunity to SARS-CoV-2 will also play a role, albeit to a lesser extent. Widespread serological testing to assess the duration of immunity to SARS-CoV-2 is imperative, but many countries still lack this capability.

A recent study looking at serological data from 3,300 symptomatic and asymptomatic individuals in California estimates that there may be as many as 48,000-81,000 people who have been infected with SARS-Cov-2 in Santa Clara County, which is 50- to 85-fold more cases than we previously thought.11 This small-scale survey emphasizes the importance of serological testing in determining the true extent of infection.

The continuation of rigid social distance also hangs in a balance—one-time social distancing measures may drive the SARS-CoV-2 epidemic peak into the fall and winter months, especially if there is increased wintertime transmissibility.10 New therapeutics, vaccines, or measures such as contact tracing and quarantine—once caseloads have been reduced and testing capacity increased—might reduce the need for rigid social distancing. However, if such measures are not put in place, mathematical models predict that surveillance and recurrent social distancing may be required through 2022.10 Only time will tell.

Helen Stillwell is a research associate in immunobiology at Yale University.

References

1. The COVID Tracking Project https://covidtracking.com/data/us-daily (2020).

2. Virology Blog: About Viruses and Viral Disease. Virus neutralization by antibodies. virology.ws (2009).

3. GreenfieldBoyce, N. Do you get immunity after recovering from a case of coronavirus? NPR (2020).

4. Racaniello, V., Langel, S., Leifer, C., & Barker, B. Immune 29: Immunology of COVID-19. Immune Podcast. microbe.tv (2020).

5. Guo, X., et al. Long-Term persistence of IgG antibodies in SARS-CoV infected healthcare workers. bioRxiv (2020). Retrieved from doi: 10.1101/20202/02/12/20021386

6. Haveri, A., et al. Serological and molecular findings during SARS-CoV-2 infection: the first case study in Finland, January to February 2020. Euro Surveillance 25, (2020).

7. Zhao, J., et al. Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019. Clinical Infectious Diseases (2020). Retrieved from doi: 10.1093/cid/ciaa344

8. Bao, L., et al. Reinfection could not occur in SARS-CoV-2 infected rhesus macaques. bioRxiv (2020). Retrieved from doi: 10.1101/20202.03.13.990226

9. Virology Blog: About Viruses and Viral Disease. Herd immunity. virology.ws (2008).

10. Kissler, S.M. Tedijanto, C., Goldstein, E., Grad, Y.H., & Lipsitch, M. Projecting the transmission dynamics of SARS-CoV-2 through the post-pandemic period. Science eabb5793 (2020).

11. Bendavid, E., et al. COVID-19 antibody seroprevalence in Santa Clara County, California. medRxiv (2020). Retrieved from doi: 10.1101/2020.04.14.20062463

In the COVID-19 pandemic, numerous models are being used to predict the future. But as helpful as they are, they cannot make sense of themselves. They rely on epidemiologists and other modelers to interpret them. Trouble is, making predictions in a pandemic is also a philosophical exercise. We need to think about hypothetical worlds, causation, evidence, and the relationship between models and reality.1,2

The value of philosophy in this crisis is that although the pandemic is unique, many of the challenges of prediction, evidence, and modeling are general problems. Philosophers like myself are trained to see the most general contours of problems—the view from the clouds. They can help interpret scientific results and claims and offer clarity in times of uncertainty, bringing their insights down to Earth. When it comes to predicting in an outbreak, building a model is only half the battle. The other half is making sense of what it shows, what it leaves out, and what else we need to know to predict the future of COVID-19.

Prediction is about forecasting the future, or, when comparing scenarios, projecting several hypothetical futures. Because epidemiology informs public health directives, predicting is central to the field. Epidemiologists compare hypothetical worlds to help governments decide whether to implement lockdowns and social distancing measures—and when to lift them. To make this comparison, they use models to predict the evolution of the outbreak under various simulated scenarios. However, some of these simulated worlds may turn out to misrepresent the real world, and then our prediction might be off.

In his book Philosophy of Epidemiology, Alex Broadbent, a philosopher at the University of Johannesburg, argues that good epidemiological prediction requires asking, “What could possibly go wrong?” He elaborated in an interview with Nautilus, “To predict well is to be able to explain why what you predict will happen rather than the most likely hypothetical alternatives. You consider the way the world would have to be for your prediction to be true, then consider worlds in which the prediction is false.” By ruling out hypothetical worlds in which they are wrong, epidemiologists can increase their confidence that they are right. For instance, by using antibody tests to estimate previous infections in the population, public health authorities could rule out the hypothetical possibility (modeled by a team at Oxford) that the coronavirus has circulated much more widely than we think.3

One reason the dynamics of an outbreak are often more complicated than a traditional model can predict is that they result from human behavior and not just biology.

Broadbent is concerned that governments across Africa are not thinking carefully enough about what could possibly go wrong, having for the most part implemented coronavirus policies in line with the rest of the world. He believes a one-size-fits-all approach to the pandemic could prove fatal.4 The same interventions that might have worked elsewhere could have very different effects in the African context. For instance, the economic impacts of social distancing policies on all-cause mortality might be worse because so many people on the continent suffer increased food insecurity and malnutrition in an economic downturn.5 Epidemic models only represent the spread of the infection. They leave out important elements of the social world.

Another limitation of epidemic models is that they model the effect of behaviors on the spread of infection, but not the effect of a public health policy on behaviors. The latter requires understanding how a policy works. Nancy Cartwright, a philosopher at Durham University and the University of California, San Diego, suggests that “the road from ‘It works somewhere’ to ‘It will work for us’ is often long and tortuous.”6 The kinds of causal principles that make policies effective, she says, “are both local and fragile.” Principles can break in transit from one place to the other. Take the principle, “Stay-at-home policies reduce the number of social interactions.” This might be true in Wuhan, China, but might not be true in a South African township in which the policies are infeasible or in which homes are crowded. Simple extrapolation from one context to another is risky. A pandemic is global, but prediction should be local.

Predictions require assumptions that in turn require evidence. Cartwright and Jeremy Hardie, an economist and research associate at the Center for Philosophy of Natural and Social Science at the London School of Economics, represent evidence-based policy predictions using a pyramid, where each assumption is a building block.7 If evidence for any assumption is missing, the pyramid might topple. I have represented evidence-based medicine predictions using a chain of inferences, where each link in the chain is made of an alloy containing assumptions.8 If any assumption comes apart, the chain might break.

An assumption can involve, for example, the various factors supporting an intervention. Cartwright writes that “policy variables are rarely sufficient to produce a contribution [to some outcome]; they need an appropriate support team if they are to act at all.” A policy is only one slice of a complete causal pie.9 Take age, an important support factor in causal principles of social distancing. If social distancing prevents deaths primarily by preventing infections among older individuals, wherever there are fewer older individuals there may be fewer deaths to prevent—and social distancing will be less effective. This matters because South Africa and other African countries have younger populations than do Italy or China.10

The lesson that assumptions need evidence can sound obvious, but it is especially important to bear in mind when modeling. Most epidemic modeling makes assumptions about the reproductive number, the size of the susceptible population, and the infection-fatality ratio, among other parameters. The evidence for these assumptions comes from data that, in a pandemic, is often rough, especially in early days. It has been argued that nonrepresentative diagnostic testing early in the COVID-19 pandemic led to unreliable estimates of important inputs in our epidemic modeling.11

Epidemic models also don’t model all the influences of the pathogen and of our policy interventions on health and survival. For example, what matters most when comparing deaths among hypothetical worlds is how different the death toll is overall, not just the difference in deaths due to the direct physiological effects of a virus. The new coronavirus can overwhelm health systems and consume health resources needed to save non-COVID-19 patients if left unchecked. On the other hand, our policies have independent effects on financial welfare and access to regular healthcare that might in turn influence survival.

A surprising difficulty with predicting in a pandemic is that the same pathogen can behave differently in different settings. Infection fatality ratios and outbreak dynamics are not intrinsic properties of a pathogen; these things emerge from the three-way interaction among pathogen, population, and place. Understanding more about each point in this triangle can help in predicting the local trajectory of an outbreak.

In April, an influential data-driven model, developed by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, which uses a curve-fitting approach, came under criticism for its volatile projections and questionable assumption that the trajectory of COVID-19 deaths in American states can be extrapolated from curves in other countries.12,13 In a curve-fitting approach, the infection curve representing a local outbreak is extrapolated from data collected locally along with data regarding the trajectory of the outbreak elsewhere. The curve is drawn to fit the data. However, the true trajectory of the local outbreak, including the number of infections and deaths, depends upon characteristics of the local population as well as policies and behaviors adopted locally, not just upon the virus.

Predictions require assumptions that in turn require evidence.

Many of the other epidemic models in the coronavirus pandemic are SIR-type models, a more traditional modelling approach for infectious-disease epidemiology. SIR-type models represent the dynamics of an outbreak, the transition of individuals in the population from a state of being susceptible to infection (S) to one of being infectious to others (I) and, finally, recovered from infection (R). These models simulate the real world. In contrast to the data-driven approach, SIR models are more theory-driven. The theory that underwrites them includes the mathematical theory of outbreaks developed in the 1920s and 1930s, and the qualitative germ theory pioneered in the 1800s. Epidemiologic theories impart SIR-type models with the know-how to make good predictions in different contexts.

For instance, they represent the transmission of the virus as a factor of patterns of social contact as well as viral transmissibility, which depend on local behaviors and local infection control measures, respectively. The drawback of these more theoretical models is that without good data to support their assumptions they might misrepresent reality and make unreliable projections for the future.

One reason why the dynamics of an outbreak are often more complicated than a traditional model can predict, or an infectious-disease epidemiology theory can explain, is that the dynamics of an outbreak result from human behavior and not just human biology. Yet more sophisticated disease-behavior models can represent the behavioral dynamics of an outbreak by modeling the spread of opinions or the choices individuals make.14,15 Individual behaviors are influenced by the trajectory of the epidemic, which is in turn influenced by individual behaviors.

“There are important feedback loops that are readily represented by disease-behavior models,” Bert Baumgartner, a philosopher who has helped develop some of these models, explains. “As a very simple example, people may start to socially distance as disease spreads, then as disease consequently declines people may stop social distancing, which leads to the disease increasing again.” These looping effects of disease-behavior models are yet another challenge to predicting.

It is a highly complex and daunting challenge we face. That’s nothing unusual for doctors and public health experts, who are used to grappling with uncertainty. I remember what that uncertainty felt like when I was training in medicine. It can be discomforting, especially when confronted with a deadly disease. However, uncertainty need not be paralyzing. By spotting the gaps in our models and understanding, we can often narrow those gaps or at least navigate around them. Doing so requires clarifying and questioning our ideas and assumptions. In other words, we must think like a philosopher.

Jonathan Fuller is an assistant professor in the Department of History and Philosophy of Science at the University of Pittsburgh. He draws on his dual training in philosophy and in medicine to answer fundamental questions about the nature of contemporary disease, evidence, and reasoning in healthcare, and theory and methods in epidemiology and medical science.

References

1. Walker, P., et al. The global impact of COVID-19 and strategies for mitigation and suppression. Imperial College London (2020).

2. Flaxman, S., et al. Estimating the number of infections and the impact of non-pharmaceutical interventions on COVID-19 in 11 European countries. Imperial College London (2020).

3. Lourenco, J., et al. Fundamental principles of epidemic spread highlight the immediate need for large-scale serological surveys to assess the stage of the SARS-CoV-2 epidemic. medRxiv:10.1101/2020.03.24.20042291 (2020).

4. Broadbent, A., & Smart, B. Why a one-size-fits-all approach to COVID-19 could have lethal consequences. TheConversation.com (2020).

5. United Nations. Global recession increases malnutrition for the most vulnerable people in developing countries. United Nations Standing Committee on Nutrition (2009).

6. Cartwright, N. Will this policy work for you? Predicting effectiveness better: How philosophy helps. Philosophy of Science 79, 973-989 (2012).

7. Cartwright, N. & Hardie, J. Evidence-Based Policy: A Practical Guide to Doing it Better Oxford University Press, New York, New York (2012).

8. Fuller, J., & Flores, L. The Risk GP Model: The standard model of prediction in medicine. Studies in History and Philosophy of Biological and Biomedical Sciences 54, 49-61 (2015).

9. Rothman, K., & Greenland, S. Causation and causal inference in epidemiology. American Journal Public Health 95, S144-S50 (2005).

10. Dowd, J. et al. Demographic science aids in understanding the spread and fatality rates of COVID-19. Proceedings of the National Academy of Sciences 117, 9696-9698 (2020).

11. Ioannidis, J. Coronavirus disease 2019: The harms of exaggerated information and non‐evidence‐based measures. European Journal of Clinical Investigation 50, e13222 (2020).

12. COVID-19 Projections. Healthdata.org. https://covid19.healthdata.org/united-states-of-america.

13. Jewell, N., et al. Caution warranted: Using the Institute for Health metrics and evaluation model for predicting the course of the COVID-19 pandemic. Annals of Internal Medicine (2020).

14. Nardin, L., et al. Planning horizon affects prophylactic decision-making and epidemic dynamics. PeerJ 4:e2678 (2016).

15. Tyson, R., et al. The timing and nature of behavioural responses affect the course of an epidemic. Bulletin of Mathematical Biology 82, 14 (2020).

Lead image: yucelyilmaz / Shutterstock

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