Tag Archives: pandemic

The CDC’s Cloth Face Cover Recommendations

How to Wear Face Cover


As we discussed yesterday in Masking Our COVID-19 Concerns, there has been a growing call for Americans to wear some sort mask in public during the pandemic, if for no other reason than to prevent asymptomatic carriers from spreading the virus.  

After much debate, late yesterday the CDC issued `Face Cover’ recommendations for the general public, along with some easy tutorials (below) on how to make these items at home. 

Although a homemade face cover probably provides very limited protection to the wearer, it can reduce the transmission of the virus to others and it can remind us not to touch our face. They are not a substitute, however, for social distancing (staying 6 feet apart), handwashing, or staying home as much as possible.

While a imperfect solution, as part of a layered, NPI approach, they can help reduce community transmission of the virus. If nothing else, by wearing one, you are showing respect for the health and welfare of others, and are setting a good example at the same time.

Use of Cloth Face Coverings to Help Slow the Spread of COVID-19

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Face coverings should—

  • fit snugly but comfortably against the side of the face
  • be secured with ties or ear loops
  • include multiple layers of fabric
  • allow for breathing without restriction
  • be able to be laundered and machine dried without damage or change to shape

CDC on Homemade Face Covers

CDC recommends wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission.

CDC also advises the use of simple cloth face coverings to slow the spread of the virus and help people who may have the virus and do not know it from transmitting it to others. Cloth face coverings fashioned from household items or made at home from common materials at low cost can be used as an additional, voluntary public health measure.

Cloth face coverings should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.

The cloth face coverings recommended are not surgical masks or N-95 respirators. Those are critical supplies that must continue to be reserved for healthcare workers and other medical first responders, as recommended by current CDC guidance.


Should cloth face coverings be washed or otherwise cleaned regularly? How regularly?

Yes. They should be routinely washed depending on the frequency of use. 

How does one safely sterilize/clean a cloth face cover?

A washing machine should suffice in properly washing a face covering. 

How does one safely remove a used face cover?

Individuals should be careful not to touch their eyes, nose, and mouth when removing their face covering and wash hands immediately after removing.


Italy Continues to Flatten The Curve



While the numbers being reported out of Italy are sobering, over the past week we’ve see a significant reduction in daily case counts, dropping from more than 6,500 ten days ago to just over 4000 a day for the past two days. 

Three weeks after entering into a nationwide lockdown, this is clear evidence that their social distance strategy is working. 

Deaths, however, are always a lagging indicator, and over the past two days Italy has averaged more than 800 fatalities per day, raising their official death toll to 12,428. As high as that is, there are media reports suggesting that the actual toll could be considerably higher, as many non-hospital  deaths may not have been tested.

Even so, the preliminary CFR (Case Fatality Rate) in Lombardy is an astronomical 16.67%, and for Italy as a whole, 11.7%.  Both numbers clearly several times higher than anything we’ve seen reported anyplace else in the world. 

While it is probable that many mild and moderate cases have not been counted – and adding those in would substantially lower the CFR – there are also numerous reports of overwhelmed hospitals, and a lack of staffed ICU beds, which has likely also contributed to Italy’s case fatality rate. 

The after-action report from hard hit countries – including Italy – after this pandemic wave has passed, should tell us a great deal more about how, and why differing numbers of pandemic deaths occurred. 

And while Italy’s numbers look huge today, they could easily be surpassed by other nations in the days and weeks ahead. 

The situation in Italy: March 31, 2020, 6.00 p.m.

DECEASED                           12428
HEALED                                15729

Press conference at 6 pm on March 31st

105,792 total cases, currently positive people are 77,635, 12,428 dead and 15,729 recovered.

Among the 77,635 positives:

  • 45,420 are in home isolation
  • 28,192 hospitalized with symptoms
  • 4,023 in intensive care

Read the tables
Italy situation as of March 31stBreakdown by provinces as of March 31st


Cold Calculations: The Realities Of Ventilator Triage

Credit Wikipedia

# 15,129

It is a bit sobering to realize that if I were living in some parts of Northern Italy right now, and had severe COVID-19 respiratory disease, I might not qualify for an ICU bed or a ventilator given my age (66), and moderate comorbidities.

Of course, I’m lucky enough to live in Florida, and probably need not worry about that  for another month, maybe longer. 

Welcome to ventilator triage, a world where medical needs exceed immediately available resources, and very tough decisions have to be made.  As a former paramedic, I understand the realities facing us – because in the past – I’ve had to make similar decisions, albeit not very often, and on a much smaller scale.

We aren’t talking about withholding last ditch, heroic treatments from terminal patients, or from those so badly injured where such measures are deemed futile.  That happens all the time, in hospitals, ambulances, and hospices across the country. 

With triage, you are confronted with more potentially-salvageable severely ill or injured patients than you can possibly care for, and you must prioritize who gets treated, and who doesn’t.  Normally, we think of this occurring in a mass casualty incident, like on a battlefield, at a train wreck, plane crash, or a building collapse, or in a multi-car pile up on the Interstate.

In some hospitals in Italy right now, they have far more critically ill COVID-19 patients than they have ICU beds, ventilators, and trained personnel to care for them.  And according to multiple media reports, they are having to decide which patients to treat, and which to allow to die.

The same scenario is likely playing out in Iran, undoubtedly occurred in Wuhan City, China at the height of their epidemic, and will very likely start happening with greater frequency around the world as COVID-19 spreads. 

The reason behind the `flatten the curve‘ strategy being adopted by governments around the world is to try to avoid the `Italy scenario‘, by limiting the number of severely ill cases needing ICU treatment at any given time.

In normal times, ICU beds and ventilators are assigned on first-come-first serve basis.  If you are put on a vent, you stay on the vent until you improve, or a decision is made by the patient’s doctors and family that improvement is no longer likely. 

During a pandemic, or other surge event, decisions are far less clear-cut.  Deciding who gets a vent, and for how long, becomes an ethical minefield.  We’ve talked about this nightmare scenario many times over the past 14 years, but most recently in Ventilator Shortages And Pandemic Triage.

Different countries will use different criteria for deciding how to prioritize patients, and while many nations are still debating the issue, the UK has apparently adopted a two-pronged approach. 

The first involves determining a patient’s Clinical Frailty Scale (CFS) or score.


NICE (The National Institute for Health and Care Excellence) has published guidelines using the above Frailty score, to help clinicians prioritize COVID-19 patients for critical care treatment.


Admission to critical care

See the critical care admission algorithm. 

2.1  Discuss the risks, benefits and possible likely outcomes of the different treatment options with patients, families and carers using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible. See information to support decision making.

2.2 Involve critical care teams in discussions about admission to critical care for a patient where: 

  • the CFS score suggests the person is less frail (for example the score is less than 5), they are likely to benefit from critical care organ support and they want critical care treatment or
  • the CFS score suggests the person is more frail (for example the score is 5 or more), there is uncertainty regarding the likely benefit of critical care organ support, and critical care advice is needed to help the decision about treatment. 

Take into account the impact of underlying pathologies, comorbidities and severity of acute illness on the likelihood of critical care treatment achieving the desired outcome. 

2.3 Support non-critical care healthcare professionals to discuss treatment plans with patients who would not benefit from critical care treatment or who do not wish to be admitted to critical care.

2.4 Sensitively discuss a possible ‘do not attempt cardiopulmonary resuscitation’ decision with all adults with capacity and a CFS score suggestive of increased frailty (for example of 5 or more). Include in the discussion:

  • the possible benefits of any critical care treatment options
  • the possible risks of critical care treatment options
  • the possible likely outcomes.

Involve a member of the critical care team if the patient or team needs advice about critical care to make decisions about treatment.

2.5 Ensure healthcare professionals have access to resources to support discussions about treatment plans (see for example decision-making for escalation of treatment and referring for critical care support, and an example decision support form).

2.6 Ensure that when treatment outside critical care is the agreed course of action, patients receive optimal care within the ward.

If all of this seems somewhat cold and calculated. It is. 

But it beats assigning ICU beds based on non-medical criteria, like how much money someone has, or how `connected‘ they are (not that I don’t expect that will happen).

Personally, if I were in charge, I would put all active 1st responders and HCWs at the top of the list. Then triage the rest.  But that’s just me. 

In the months ahead we may see 3 , 4,  5 . . .  or even more critically ill patients for every available ventilator.  And while I’ve seen some interesting schemes for maximizing ventilators (such as 4 patients on 1 vent), some people simply aren’t going to get the lifesaving treatment they need.

Of course the more staffed and equipped ICU beds we can bring online in the weeks and months ahead, the fewer heartbreaking decisions will have to be made.  The longer we can delay the rise of COVID-19 cases, the more lives we can save. 

In many parts of the world, however, ICU beds are almost non-existent, and prospects for adding more are slim at best.  COVID-19 will undoubtedly hit these ill equipped regions the hardest.

While I’m in no hurry to shuffle off this mortal coil, I have to admit that if I’m denied an ICU bed because of an agreed upon, and reasonably fair triage scheme, I’ll take some solace in knowing someone with a better shot of survival was given a chance.

And I can live with that. 

Johns Hopkins: Public Health On Call Podcasts



If you, like me, are craving `adult conversation’ regarding COVID-19 and are finding very little of that available from cable-TV outlets, and on the internet, there are other options.  One that I found this morning  a series of podcasts created by the Johns Hopkins Bloomberg School of Public Health.

There are currently 17 audio files, each running between 10 and 20 minutes in length, and they cover everything from the science behind the virus, to the economic, and ethical impacts of the pandemic. 

I’ve only listened to the two most recent podcasts, but found them refreshingly devoid of drama and hyperbole.   You can access them at the link below.

Public Health On Call

Experts from the Johns Hopkins Bloomberg School of Public Health offer science and evidence-based insights on the public health news of the day. The current focus is the novel coronavirus spreading around the world.

Email the show at PublicHealthQuestion@jhu.edu, or follow us on Twitter at @PublicHealthPod.


Italy Surpasses 41,000 COVID-19 Cases – 3405 Deaths



The explosion of confirmed COVID-19 cases in Italy continues today with a record-setting 24 hour total of 5322 new cases reported, along with an additional 427 deaths. Italy’s confirmed numbers have more than doubled over the past 4 days.

The apparent case fatality rate (CFR) in the hard-hit Lombardy region continues to hover around 11%, while it is closer to half that (5.8%) across the remainder of Italy.  Both are much higher numbers than we’ve seen reported elsewhere. 

An older demographic may be contributing to the higher number of deaths, and a significant number of mild or moderate cases may not be included in the case count, which would skew the CFR higher.  But we continue to see reports of overcrowded ICUs, and a hospital system on the verge of collapse, which is likely contributing to the high death toll as well.

The situation in Italy: March 19, 2020, 6.00 p.m.


Press conference at 6 pm on March 19th

41035 total cases, currently positive people are 33190, 3405 died and 4440 recovered.
Among the 33190 positives:

  • 14935 are found in home isolation
  • 15757 hospitalized with symptoms
  • 2498 in intensive care

Read the tables:
Italy situation as of March 19thBreakdown by provinces on March 19

Florida DOH: 2 New COVID-19 Cases – 2 Deaths

Fl COVID-19 Stats 10pm March 6th


Florida, with 20 million residents and tens of millions of visitors each year, has been testing for COVID-19 for barely a week, and only 5 days ago confirmed their 1st  2 Presumptive Positive COVID-19 Cases

Testing, however, remains quite limited (100 negative results, 6 positive), and so we really have no idea how prevalent the virus might be in our population.  This deficit in testing is not unique to Florida, or to the United States. 

Overnight, however, we’ve learned of two new COVID-19 cases, and two deaths.  This from Florida’s Department of Health.

Department of Health Announces Important Updates Regarding Covid-19 in Florida – Two Confirmed Deaths Regarding Covid-19
March 06, 2020

Communications Office
NewsMedia@flhealth.gov(850) 245-4111

Tallahassee, Fla. — The Florida Department of Health has announced updates regarding the 2019 coronavirus disease (COVID-19) in Florida. Two individuals have died and two new presumptive positive cases have been identified in Broward County.

Deceased Individuals

A previously announced COVID-19 patient in Santa Rosa County has died, following an international trip.

A new individual in their seventies that tested presumptive positive for COVID-19 in Lee County has died, following an international trip.

New Presumptive Positive Cases

A 75-year old male in Broward County has been identified as a presumptive positive. This person is isolated and will continue to remain isolated until cleared by public health officials.

A 65-year old male in Broward County has been identified as a presumptive positive. This person is isolated and will continue to remain isolated until cleared by public health officials.

The Florida Department of Health is working closely with the patients, potential close contacts of each case and health care providers to isolate and monitor persons who may have been exposed to COVID-19 and implement testing of anyone who may develop COVID-19 symptoms, including fever, cough or shortness of breath.

(Continue . . . )

While the number of confirmed cases in Florida remains reassuringly small – at least when compared to Washington State (n=79) and New York (n=44) – the limited testing to date leaves a lot of room for undetected cases, and deaths.

This is flu season, we have a large elderly population, and many people are hospitalized with ILIs (Influenza-Like-Illnesses).  Having worked as a paramedic here, I can attest to the fact that hundreds of (mostly) elderly people die of `natural causes’ each day – and the cause of death is almost never confirmed.

This is why it is so hard to tell how many people die from the flu each year.  Influenza almost never appears on a death certificate as a primary cause of death.

If the patient is elderly, and there are no `unusual circumstances‘ surrounding the death, the patient’s doctor generally signs the death certificate, attributing COD to heart attack, stroke, COPD, or other chronic condition.

As we’ve discussed often, heart attacks and strokes are linked to recent flu infections (see Eur. Resp.J.: Influenza & Pneumonia Infections Increase Risk Of Heart Attack and Stroke) and most of those deaths are attributed to cardiovascular – not viral – causes.   

Two weeks ago, Italy and Iran were both posting reassuringly low, double digit COVID-19 case counts. Today, those two countries have identified close to 10,000 cases, a great many of which were already infected when their surveillance was still reporting only a handful of cases. 
Even when we have point-of-care diagnostics and excellent lab testing and surveillance – as we do for influenza – the CDC can only estimate the number of cases each year, how many of those are hospitalized, and how many deaths.  
So far, this winter, the CDC estimates between 350,000 and 625,000 flu hospitalization and between 20,000 and 52,000 flu deaths. No one is actually counting, and so we end up with a pretty wide range.

Without extensive testing, we have no way of knowing how many of these flu deaths might have been due to COVID-19.  Probably not a huge number yet, but nobody really knows. 

Ten years after the 2009 H1N1 pandemic, researchers are still arguing its impact. Early estimates (see Lancet: Estimating Global 2009 Pandemic Mortality) – released during the pandemic by WHO – now appear to have captured as little as 5% to 7% of the true number of deaths.

We will likely see the same thing happen with COVID-19.  The number of cases, and deaths, reported in real time during the next few months will only reflect a fraction of the true burden.

At best, in a few years, we’ll have a crude estimate. Not a count, but a benchmark, to compare COVID-19 to 1918, 1957, 1968 and 2009. 

For now, perhaps the best way to get a crude estimate of the severity of COVID-19 is by the impact it has on hospitals and healthcare delivery, the economic losses attributed to the epidemic, and the severity and duration of societal disruptions.

Governments, and the media, love to report numbers. The public expects them, as they provide a sense of certainty, and of things being under control.

But with infectious diseases – particularly during an epidemic – they should never be assumed to reflect the true burden of an outbreak.

Why NPIs Will Be Our 1st Line Of Defense Against COVID-19



The movie `Contagion’, released 9 years ago, portrayed a fictional SARS-like virus (dubbed MEV-1) emerging from bats in China and spreading quickly around the globe as scientists at the CDC frantically worked to develop a vaccine. Unlike most summer blockbusters, this film endeavored to portray the science as accurately as possible (see my review here).

One area where the movie took considerable dramatic license was in portraying the development (and deployment) of a vaccine for this never-before-seen virus as happening over a matter of months, rather than years.

Just 4 months ago, a naturally occuring novel coronavirus sparking an epidemic was the fictional scenario used by Johns Hopkins Center For Health Security (JHCHS) – in concert with the World Economic Forum and the Bill & Melinda Gates Foundation – in a half-day table top pandemic exercise (#Event201) hosted in New York City.

JHCHS Pandemic Table Top Exercise (EVENT 201) Videos Now Available Online

The JHCHS #Event201 (Fictional) CAPS Pandemic Scenario 

Johns Hopkins Pandemic Table Top Exercise (EVENT 201)

In the JHCHS scenario, there was no possibility of a vaccine being available in the first year, and while there was a fictional antiviral drug that could help the sick, it wouldn’t do much to slow the pandemic.

Now, with life imitating art, we’ve got a very real novel coronavirus – albeit of uncertain severity – spreading across China and slowly spilling out around the world. A vaccine is considered a long shot in anything less than 12 to 18 months, and right now, we don’t have a known pharmacological intervention.

Despite all of this, we are not defenseless. 

Last November, I wrote a multi-blog series (links below) on the WHO’s revised 91-page Guidance document on the use of Non-Pharmaceutical Interventions during a severe influenza epidemic or pandemic.

WHO Guidance: Non-pharmaceutical Public Health Measures for Mitigating the Risk and Impact of Epidemic and Pandemic Influenza

The WHO NPI Guidance : Personal Protection

The WHO NPI Guidance : Social Distancing

The WHO NPI Guidance : Environmental Measures

The WHO Pandemic Influenza NPI Guidance : Travel Measures

While many countries have triggered these NPIs a lot sooner (and far more rigorously) than envisioned in this WHO document, when properly and consistently used, they can greatly reduce the spread and impact of a pandemic virus. 
The CDC’s Nonpharmaceutical Interventions (NPIs) webpage defines NPIs as:

Nonpharmaceutical interventions (NPIs) are actions, apart from getting vaccinated and taking medicine, that people and communities can take to help slow the spread of illnesses like influenza (flu). NPIs are also known as community mitigation strategies.

Measures like social distancing, hand hygiene, staying home when sick, avoiding crowds, wearing a mask if you are sick, even the closure of schools or other public venues are all potential NPIs.

While some may scoff at their effectiveness, we have a real-world example during the worst flu pandemic in recorded history – the 1918 Spanish flu.

The chart above, taken from the PNAS journal article entitled Public Health Interventions and Pandemic Intensity During the 1918 Influenza Pandemic, illustrates what happened in two American cities during the 1918 pandemic. 
  • The sharp, but much shorter pandemic wave depicted by the solid line occurred in Philadelphia, where relatively few steps were taken by the public health department to slow the spread of the disease . They even went ahead with a massive Liberty Loan parade on September 28th of that year, apparently heartened by the low number of flu cases reported in Pennsylvania to that point.
  • The dotted line represents St. Louis, which closed schools early and where the Health Department prohibited public gatherings in places like theaters, churches, and restaurants. As you can see, the percentage of cases reported on a daily basis were far fewer in St. Louis, but their pandemic wave lasted nearly twice as long as in Philadelphia.

During the 3 weeks following Philadelphia’s parade at least 6,081 deaths from influenza and 2,651 deaths from pneumonia were registered in Pennsylvania, most occurring in Philadelphia (CDC source).At its worst, the percentage of excess  people afflicted in the city of Philadelphia was 5 times greater than what St. Louis experienced.

The burden on hospitals, mortuaries, and practically all segments of the economy was certainly far greater. 

In 2017’s  Community Pandemic Mitigation’s Primary Goal : Flattening The Curvewe look at the HHS/CDC’s 2017 revised Community Mitigation Guidelines to Prevent Pandemic Influenza, which urges communities to be more like St. Louis in a pandemic. 

Specific goals for implementing NPIs early in a pandemic include slowing acceleration of the number of cases in a community, reducing the peak number of cases during the pandemic and related health care demands on hospitals and infrastructure, and decreasing overall cases and health effects ( Figure 1).

NPIs don’t come without a cost, both economic and societal, but they can greatly limit the impact of a severe epidemic or pandemic, and save lives.

But in order to be successful, they must be rigorously observed. 

If you haven’t done so already, now would be a good time to familiarize yourself with the CDC’s plans to deal with a severe epidemic.  You’ll find some earlier blogs on the revised 2017 guidance at:

CDC/HHS Community Pandemic Mitigation Plan – 2017

PSAF Is The New Pandemic Severity Index

Additionally, the CDC has prepared pandemic guidance for a number of other venues:

While it is too soon to know which of these measures will be needed here for the novel coronavirus, much of what you can do now to prepare for a pandemic will hold you in good stead for any prolonged emergency or disaster.

Flight of the aerosol

Understanding what we mean when we discuss airborne virus infection risk.

An article collaboratively written by (alphabetically)..

Dr. Katherine Arden
A former postdoctoral researcher with interests in the detection, culture, characterization and epidemiology of respiratory viruses.
Dr Graham Johnson
A post-doctoral scientist with extensive experience investigating respiratory bioaerosol production and transport during breathing, speech and coughing and determining the physical characteristics of these aerosols.
Dr. Luke Knibbs
A Lecturer in Environmental Health at the University of Queensland. He is interested in airborne pathogen transmission and holds an NHMRC Early Career Fellowship in this area.
A. Prof Ian Mackay
A virologist with interest in everything viral but especially virus discovery, diagnostics, respiratory, gastrointestinal and central nervous system viruses of humans.

PLEASE NOTE. There is an important follow-up to this post, “Ebola, pigs, primates and people“, that continues this story. I recommend you read it next. There are other posts on VDU as well that deal with Ebola virus disease and different fluids (semen and blood/sweat) that may contain and spread the virus. Please do search them out.

ALSO NOTE: When this post was originally written, a variant Ebola virus belonging to Zaire ebolavirus (EBOV) was active in four West African countries.


Much was being said and written about Ebola virus disease (EVD), and much of that revolved around our movie-influenced idea of an easily spread, airborne horror virus. Many people worry about their risks of catching EBOV, particularly since it hopped on a plane to Nigeria. However, all evidence suggests that this variant is not airborne. The most frequent routes to acquire an EBOV infection involve direct contact with the blood, vomit, sweat or stool of a person with advanced EVD. But what is direct contact? What is an “airborne” route? For that matter what is an aerosol and what role do aerosols play in spreading EVD? How is an aerosol different from a droplet spray? Can droplets carry EBOV through the air?

Direct contact includes physical touch but also contact with infectious droplets; the contact is directly from one human to the next, rather than indirectly via an intermediate object or a lingering cloud of infectious particles. You cannot catch EVD by an airborne route, but you may from droplet sprays. Wait, what?? This is where a simple definition becomes really important.

Airborne, aerosols, droplets, nuclei and confusion

Whether propelled by sneezing, coughing, talking, splashing, flushing or some other process, aerosols (an over-arching term) include a range of particle sizes. Those droplets larger than 5-10 millionths of a meter (a micron [µm]; about 1/10 the width of a human hair), fall to the ground within seconds or impact on another surface, without evaporating (see Figure). The smaller droplets that remain suspended in the air evaporate very quickly (< 1/10 sec in dry air), leaving behind particles consisting of proteins, salts and other things left after the water is removed, including suspended viruses and bacteria. These leftovers, which may be more like a gel, depending on the humidity, are called droplet nuclei. They can remain airborne for hours and, if unimpeded, travel wherever the wind blows them. Coughs, sneezes and toilet flushes generate both droplets and droplet nuclei. Droplets smaller than 5-10µm almost always dry fast enough to form droplet nuclei without falling to the ground, and it is usual for scientists to refer to these as being in the airborne size range. It is only the droplet nuclei that are capable of riding the air currents through a hospital, shopping centre or office building.

The droplet nuclei and the air that surrounds them are correctly referred to as an aerosol, but so are lots of other things and this is where confusion grows. The term aerosol is used to refer to any collection of particles suspended in air, and particle sizes vary enormously. Spray paint from a can is produced in droplets a few hundred microns in diameter so as to quickly coat the intended surface rather than undesirably linger in the air. A can of fly spray, on the other hand, produces smaller droplets, because that aerosol should stay suspended for long enough to make contact with insects. ‘Aerosol’ is a confusing term, and its varied usage does not help when discussing the risk of EBOV infection.

The simplest definition for public understanding of infection risk is to use “airborne” to refer only to the droplet nuclei component.(4) 

Figure 1. A representation of how different viruses may be propelled on
their journey to cause disease in humans. Recommended droplet precautions for dealing with cases of EVD include the use of gloves, impermeable gowns, protective goggles or face shield and a face mask.(5,6)

For EBOV at least, airborne droplet nuclei are apparently not infectious to primates under natural or near-natural circumstances (see here for more detail about non-human primates and aerosols used under highly unnatural laboratory conditions). 

Why that is so is not known, but perhaps it is because this virus does not survive being dried down, or that primates don’t produce enough virus in what is coughed out to make infectious droplet nuclei. To be clear, there may be some EBOV in these droplet nuclei – but it has never been shown to cause disease, even when that route has been looked for in the same household as a case of EVD.

How the science helps and also hinders understanding.

The scientific literature has a number of very specific examples where droplet nuclei have been used to infect non-human primates with ebolaviruses in order to study the effectiveness of vaccines or antivirals.(1,7,8) These infections are under idealised laboratory conditions, often with what we think are unrealistically high levels of virus. Although airborne infection can be made to occur in a lab, there is no evidence for airborne droplet nuclei spreading EBOV from person-to-person or between non-human primates whether inside or outside the lab.

Protection and clarification.

Included in guidelines issued by the WHO (7) and CDC (5) is the need for droplet precautions (Figure). This is very important for healthcare workers, family and other caregivers who stay close and are frequently exposed for lengthy periods of time with severely ill, highly virulent cases of EVD. These cases may actively propel infectious droplets containing vomit and blood across the short distances separating them from caregivers. But this is a form of direct transmission and is not airborne transmission.

Messaging the masses.

Leaving aside other issues around acquiring a rare disease like Ebola when outside of the current outbreak region, the case definitions and risk assessments have raised confusion. There are questions around how otherwise apparently well-protected healthcare workers in West Africa are acquiring an EBOV. For a virus described as spreading only through direct contact, recommendations for the use of masks, implying airborne spread to many, fuel such questions.  In fact, face protection is recommended to prevent infectious droplets landing on vulnerable membranes (mouth and eyes).

It’s important to pass a message that is correct but also to ensure distrust does not result from a public reading apparently contradictory literature. Such distrust and real concern have been rampant among a hyperactive #ebola social media. Simple, clear phrases like “ebolaviruses cannot be caught from around a corner” (h/t @Epidemino), may help uncomplicate the communication lines. And it works on Twitter.


  1. 9-Sept-2014

*Imported Post

This post from 15AUG2014 was posted over on my old blog platform virologydownunder.blogspot.com.au. It has now been moved to here and lightly updated. 


  1. http://www.ncbi.nlm.nih.gov/pubmed/21651988
  2. WHO page
  3. http://www.who.int/csr/resources/publications/WHO_CDS_EPR_2007_6c.pdf?ua=1
  4. http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html
  5. http://www.who.int/csr/resources/who-ipc-guidance-ebolafinal-09082014.pdf?ua=1
  6. http://www.ncbi.nlm.nih.gov/pubmed/24462697
  7. http://www.ncbi.nlm.nih.gov/pubmed/20181765

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China’s Escalating Coronavirus Response – Mandated Cremation



The `official’ numbers we get from China are highly suspect, and based on numerous anecdotal reports of people being turned away from hospitals, likely only represent a fraction of the cases on the Mainland.

Presumably, the `sickest of the sick‘ are the ones being hospitalized, and `milder‘ cases are sent home to be cared for by their families, but that may not be entirely true.  Some patients may be too sick to travel to a hospital, or unable to handle the queue. 

While the numbers are worrisome, the CFR (Case Fatality Rate) remains reassuringly low – at least when compared to MERS-CoV or Avian Flu.  But again, there are (unconfirmed) reports of many `pneumonia deaths’ not being counted.

Against this backdrop we are seeing a truly remarkable, albeit draconian, response by the Chinese government, including the quarantining of major cities and tens of millions of people, the rapid construction of`hospitals’, the closure of schools, factories, and most public venues; an apparent willingness to sacrifice the economic engine of their nation in order to combat this outbreak.

While laudable, perhaps even `heroic’ , these actions appear to be a disproportionate response to the threat, at least based on the official numbers we’ve seen. 

Adding to the mystery (and the concern), we’ve a new edict from China’s National Health Commission – issued yesterday – which raises even more questions; a document picked up by the Newshounds at FluTrackers that now orders the disposal of all confirmed or suspected coronavirus bodies by cremation.

Exactly why Chinese authorities would feel the need to mandate cremation for all coronavirus victims isn’t clear, but based on the documentation, they are obviously worried about infection control. 

First, a (translated) brief announcement which curiously buries the word `cremation’ near the bottom, followed by a link to (and translated text from) newly issued guidelines.

Interpretation of the Documents of Guidelines for Handling the Remains of Patients with Pneumonia Infected with New Coronavirus (for Trial Implementation)

Published: 2020-02-01 Source: Medical Administration

In order to do a good job in the disposal of the remains of patients with death from pneumonia infected with new coronavirus, and prevent the risk of disease spreading, the National Health and Health Commission, the Ministry of Civil Affairs and the Ministry of Public Security jointly issued the Guidelines for the Disposal of the Remains of Patients with Pneumonia Infected with New Coronavirus (for Trial Implementation). 

The document highlighted the problem orientation, and put forward the overall requirements, division of responsibilities, and the procedure and relevant provisions for the disposal of remains. The specific duties of the medical institutions, funeral homes, disease control institutions, health and health administrative departments, civil affairs departments and public security organs are specified, and detailed provisions are made on the whole process of reporting the death of patients, sanitation and epidemic prevention treatment, handling procedures, transfer of bodies, personnel protection, cremation of bodies, etc. Through this document, all departments and institutions shall be urged to perform their duties, work smoothly, and improve the standardization of the disposal of mortal remains. 

Related Links: Notice on Issuing the Guidelines for the Disposal of Remains of Patients with Pneumonia Infected with New Coronavirus (for Trial Implementation)

Notice on the issuance of guidelines (trial) for the disposal of the remains of pneumonia patients with the new coronary virus infection

Published: 2020-02-01

Source: State Health Administration Medical Letter (2020) No. 89

Provinces, autonomous regions, municipalities directly under the Central Government and Xinjiang Production and Construction Corps Health Committee, Civil Affairs Office (Bureau), Public Security Bureau (Bureau):

Now the “new coronary virus infection of pneumonia patients’ remains disposal guidelines (trial)” issued to you, please combine with the actual, conscientiously implement. 

Office of the National Health and Health Commission, General Office of the Ministry of Civil Affairs General Office of the Ministry of Public Security
February 1, 2020   (Information Disclosure Form: Active Disclosure)

Remains of pneumonia patients with new coronary viral infection

Disposal Guidelines (Trial)

In order to do a good job in the disposal of the remains of pneumonia patients with new coronary viral infections (hereinafter referred to as patients with new coronary pneumonia) and to prevent the risk of disease transmission, this work guide is formulated in accordance with the relevant requirements of the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases and the Regulations on the Disposal of the Remains of Victims of Major Emergencies (Minfa (2017) No. 38).

  First, the overall requirements

In accordance with the principle sanitization of people-oriented, standardized according to law, timely and sound, near cremation, suspected from the principle, the implementation of unified leadership, graded responsibility, mutual coordination, territorial management, scientific norms of disposal of the remains of patients with new coronary pneumonia, strengthen health protection, prevent the risk of disease transmission, to protect human health and social safety.

  Second, the division of responsibilities

Medical institutions are responsible for issuing medical certificates of death in a timely manner, notifying funeral homes to pick up and transport remains, and doing a good job in the disinfection of the remains and other health and epidemic prevention work.

The funeral home is responsible for the timely receipt of the remains, the establishment of temporary funeral services dedicated channels and special crematoriums, in accordance with the operating procedures to do a good job of cremation of the remains, and issue dissonance certificates.

The disease prevention and control institutions are responsible for supervising and guiding health and epidemic prevention work, do a good job in the training of relevant personnel in the protection of knowledge and skills, and disinfect funeral vehicles, cremation equipment and related places.

The administrative department of health and health shall be responsible for formulating technical documents related to health and epidemic prevention, such as the disinfection of human remains, and guiding medical institutions to do a good job in the standardized disposal of the remains of patients with new coronary pneumonia in their institutions.

The civil affairs department is responsible for a comprehensive understanding of the funeral services in the region and the situation of available resources, timely coordination, guidance and other service institutions to do a good job in the disposal of the remains of patients with new coronary pneumonia.

The public security organs shall give priority to the vehicles transporting the remains and give priority to the traffic facilities, and shall investigate and punish the illegal and criminal acts in the process of transporting the remains in accordance with the law.

Third, the disposal process of the remains

(i) Death report. After the death of a patient with new coronary pneumonia, the medical institution shall report to the administrative department of health and health at the corresponding level, the administrative department of health and health shall inform the civil affairs department at the corresponding level, and the civil affairs department shall inform the relevant funeral home to make preparations for the transportation and cremation of the remains.

(2) Health and epidemic prevention treatment. For the remains of patients with new coronary pneumonia who have died, the remains shall be disinfected and sealed and strictly sealed by medical personnel of the medical institutions in accordance with the provisions of the Technical Guide for the Prevention and Control of New Coronary Virus Infections in Medical Institutions (First Edition).

(iii) The handover of formalities. Medical institutions shall, after completing the treatment of the body’s health and epidemic prevention, issuing a death certificate, and contacting relatives for cremation, contact the funeral home to pick up the remains as soon as possible, and indicate in the body transfer form that the health and epidemic prevention treatment and immediate cremation opinions have been carried out. If the relatives of the patients with the new coronary pneumonia refuse to show up or refuse to transfer the remains, the medical institutions and funeral homes shall persuade them to be invalid, and if the medical institution signed the body, the remains shall be directly cremated by the funeral home, and the public security organs of the district shall cooperate with the relevant work.

(4) Transfer of remains. The transport of the remains shall not be carried out by units and individuals other than funeral homes. The funeral home arranges full-time personnel and special body transport vehicles to the designated place of medical institutions, and transports the remains to the designated special body transport vehicle shipping to the funeral home according to the designated route.

(5) Personnel protection. The disease prevention and control institution shall guide medical personnel and personnel transporting and disposing of human remains, etc., and carry out health protection in accordance with the requirements of disease contact protection.

(6) Cremation of the remains. After the body is transported to the funeral home, the funeral home shall set up a temporary special channel, and the full-time staff of the funeral home shall send the body directly into the special crematorium for cremation. The remains shall not be stored or visited, and it is strictly forbidden to open the sealed body bag throughout the whole process.

(7) The transfer of ashes. After the cremation, the funeral home service staff picked up the ashes, and issued a cremation certificate, together with relatives to take away. If the family refuses to take it, it shall be treated according to the unclaimed remains.

(8) Environmental disinfection. The disease prevention and control institutions strictly disinfect the transport vehicles, equipment tools, cremation workshops, and remaining areas of the remains, and treat the funeral waste harmlessly.

(9) Information management. Medical institutions and funeral homes shall promptly register and deposit the disposal of the remains of patients with new coronary pneumonia into business files, and the handling shall promptly report to the same level of disease prevention and control institutions and civil affairs departments.

Fourth, the relevant provisions

(1) The remains of patients with new coronary pneumonia who have died in the province (region or city) shall be cremated in the near vicinity, shall not be buried or otherwise preserved, and shall not be transported. The remains of patients with new coronary pneumonia who have died outside the province (region seunging) shall not enter the province and shall be cremated on the spot in accordance with the principle of proximity.

(2) After the death of a patient with new coronary pneumonia, a farewell ceremony for the body and the use of the remains for other forms of funeral activities shall not be held.

(3) The remains of patients with new crown pneumonia of ethnic minorities shall be cremated on the spot in accordance with the provisions of the Law on the Prevention and Control of Infectious Diseases. After cremation, the ashes may be placed in accordance with ethnic customs.

(4) If foreigners and people from Hong Kong, Macao and Taiwan in China die in china due to pneumonia from the new coronavirus infection, the remains must be cremated locally in accordance with the provisions of the Law on the Prevention and Control of Infectious Diseases. The cremated ashes may be transported out of the country as the family members of the deceased wish.

(5) The remains of patients suspected of new coronary pneumonia (including those who use preventive and control measures such as isolation observation) shall be treated in accordance with the principle of “suspected from having” to prevent the spread of the epidemic.

(6) The relevant expenses such as the transportation and cremation of the remains shall be settled in accordance with the relevant provisions.

Annex: 1. Protection standards for the transport of human remains of pneumonia patients with new coronary viral infection and methods for transporting vehicles

2. Transfer order for the remains of patients killed by pneumonia with the new coronary virus infection

3. Registration form of cremation of the remains of patients who died of pneumonia with the new coronary virus infection

Annex 1

Remains of pneumonia patients killed by new coronary virus infection
Protection standards for transport personnel and methods for disinfection of transport vehicles

Protection of the body transporter

Refer to the Pneumonia Prevention and Control Program (Third Edition) of New Coronary Virus Infection (3rd Edition) and Annex 5 The Personal Protection Guide for Specific Groups (First Edition) body disposal personnel self-protection standards, or in accordance with the protection requirements of medical personnel in the isolation room of pneumonia patients/suspected patients entering the new coronary virus infection.

It is recommended to wear work clothes, disposable work caps, disposable gloves and long-sleeved thick rubber gloves, disposable protective clothing, medical protective masks, goggles or protective face screens, work shoes or rubber boots. Transport personnel to do a good job of hand hygiene, can use hand sanitizer and flowing water to wash their hands or use quick-drying hand disinfectant.

Second, on the disinfection of vehicles transporting the remains

When transporting vehicles without visible contaminants, spray 1000mg/L of chlorine-containing disinfectant or 500mg/L of chlorine dioxide disinfectant onto the surface of the vehicle for 30 minutes. When transporting vehicles with visible pollutants, should first use disposable absorbent materials to get 5000mg /L to 10000mg/L of chlorine-containing disinfectant (or can achieve a high level of disinfection of disinfection wipes/ dry wipes) to completely remove the pollutants, and then in accordance with the vehicle without visible pollutants treatment. Pay attention to the protection of precision instruments during spraying disinfectant.

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