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10 California counties see restrictions eased, risks remain

LOS ANGELES (AP) — Ten California counties were cleared to ease coronavirus restrictions Tuesday, including some in the Central Valley that saw major case spikes over the summer, but the state’s top health official warned that upcoming Halloween celebrations pose a risk for renewed spread.

Dr. Mark Ghaly, the state health secretary, said no counties moved backwards in California’s color-coded, four-tiered system for reopening, but Riverside was on the verge of reverting to the most restrictive purple tier. The county of about 2.5 million residents has asked for a review of its data and will stay in the red tier until the state makes a decision on its status later this week.

“Moving back a tier is important,” Ghaly said. “We don’t want to do it without a significant degree of conversation and understanding.”

Riverside County Public Health Officer Dr. Cameron Kaiser said the county hopes to persuade the state that it can maintain its current status while still slowing the spread of the virus. A slip back to the purple tier would adversely affect small businesses like restaurants and gyms, which could be forced to shut down indoor operations again, the county said in a statement.

Two San Francisco Bay Area counties, Alameda and Santa Clara, will advance to the less-restrictive orange tier, which allows for increased capacity at restaurants, movie theaters and houses of worship — all with modifications to require face coverings.


The lifting of some restrictions in counties that have shown improvement comes as California sees a continued drop in COVID-19 cases. The seven-day positivity rate was down to 2.7%, Ghaly said. The number of hospitalizations is about 2,225 — a significant drop from a peak of around 7,000 over the summer, he said.

Ghaly said overall trends are moving in the right direction, thanks in part to Californians’ increased willingness to wear masks and avoid large gatherings.

“The more that that becomes widespread around the community, we’re going to see these numbers stabilize and come down,” Ghaly said.

But he added “we’re not out of the woods, and we’re seeing a number of increases across the country, and across the world in terms of cases, hospitalizations, and deaths.”

Officials are urging families to skip trick-or-treating this Halloween and instead have costume contests and pumpkin carvings online.

“The whole act of going door-to-door in groups ringing doorbells, digging into buckets of delicious candy, create a risk of spreading spreading COVID-19,” Ghaly said. But he stressed that it was a recommendation, not a rule, and trick-or-treaters will not see any enforcement.

California on Friday night also eased restrictions to allow up to three households to socialize outdoors, an expansion of rules aimed at people tempted to have even larger gatherings around Halloween, Thanksgiving and end-of-year holidays.

Meanwhile Tuesday, Fresno County stayed in the red tier and four other counties in the central part of the state — Kern, Colusa, Sutter and Stanislaus — advanced from purple to red. Those improvements were particularly gratifying after those counties experienced

Why anti-maskers ignore risks even after Trump’s COVID-19 diagnosis

  • President Donald Trump, who has long mocked others for wearing masks, was diagnosed with coronavirus. 
  • Following his diagnosis, family members and White House staff that previously flouted mask wearing recommendations since appear to have reconsidered, and are now wearing masks in public. 
  • That may not be enough to persuade some staunch anti-maskers to change their minds, since evidence of the risks is “irrelevant” to their ideological concerns, according to psychologists.
  • But for those who oppose masks as part of a partisan identity, seeing influential people like the Trump family wearing masks may be enough reason to follow suit, as group norms are a powerful motivator.
  • Visit Insider’s homepage for more stories.

Wearing a mask is recommended by health officials and experts around the world as one of the most effective ways to stop the spread of the novel coronavirus. 

Yet in the US, it’s become a contentious issue, in part due to inflammatory statements from politicians like President Donald Trump, who has mocked people for wearing masks. 

But since President Trump was diagnosed with COVID-19, the people around him, including daughter Ivanka and son-in-law Jared Kushner, have been spotted wearing masks in public, after previous high-profile instances of declining to do so. 

Their change of heart may not be enough to convince staunch anti-maskers to do the same, psychologists say.

That’s because masks have become a powerful symbol of ideology and identity, according to Jacob Teeny, an assistant professor of marketing at Northwestern University who has written about the psychology behind opposition to masks. This can lead to top-down processing, wherein people interpret data to fit their pre-existing ideas of how things work. 

“The ambiguity of Trump’s handling of this situation will allow people to shift it to seem however they want,” Teeny told Insider.

Anti-maskers may be unlikely to change if they’re more concerned with ideology than risks or harm

Seeing that there might be negative consequences to an action is a big source of behavioral change, Teeny explained. That means one motivation for wearing a mask may be observing that non-mask-wearers become ill.

In theory, that could be the case with Trump, and his diagnosis might serve as a warning of the serious risk facing those who eschew mask-wearing recommendations. 

But more than seven months into the pandemic, there’s a wealth of evidence that wearing a mask can protect against the deadly viral infection. Even the risk of serious illness or death hasn’t stopped people from opposing masks, according to Andrew Luttrell, professor of social psychology at Ball State University and co-writer of a Psychology Today column with Teeny. 

“The one thing that’s strange about it is that this isn’t the first time we’ve seen a consequence,” Luttrell said.”The folks that have been anti-mask have acknowledged and rejected those consequences, which makes me wonder if this new piece of evidence would change their minds.” 

That may be because anti-maskers aren’t interested in debating the science of masks or viral risk at all, he said. Their arguments are instead

How Two Compliance Officers Tackled Risks Arising From the Coronavirus Pandemic

To tackle health-care needs during the coronavirus pandemic, companies have had to strike a balance between haste and prudence—an act that often requires the attention of compliance teams grappling with amplified risks and fewer resources.

“There’s a volume and a speed at which we’ve needed to respond to ensure that we [are] meeting the same standards and the same requirements that we would always, understanding the risk profile probably changes somewhat, knowing that you’re addressing a global health crisis,” Ashley Watson, Johnson & Johnson’s chief compliance officer, said Thursday at the WSJ Risk & Compliance Forum.

The New Brunswick, N.J., health-products company has been working with governments and other companies to try to find solutions to address the pandemic, such as developing a Covid-19 vaccine.

The effort has required the company to take on new suppliers and partners quickly while still conducting the necessary due diligence to ensure that they meet the company’s compliance expectations. “Just your ability to connect with them is tougher in a virtual environment,” Ms. Watson said.

More than half of the compliance professionals that responded to a recent Wall Street Journal survey said they experienced increases in new third-party risks as a result of Covid-19. Many of the respondents also said their relationships with third-parties have become harder during the pandemic.

Companies outside the health-care sector have had the added burden of learning the expectations of new regulators and hastily vetting unfamiliar suppliers to make pandemic-related products outside their typical processes.

Ashley Watson, Johnson & Johnson’s chief compliance officer.



Photo:

Johnson & Johnson

VF Corp.

, the Denver-based maker of Dickies work clothes and Vans sneakers, shifted production to make millions of medical gowns and hundreds of thousands of face masks. The effort required a new grasp of rules governing the manufacturing of protective equipment, understanding of how those rules change by jurisdiction, and investigating whether potential new suppliers will follow them, according to Kellye Gordon, the company’s vice president of ethics and compliance and legal operations.

Potential suppliers, perhaps out of a need to win a lucrative contract or maybe even survive, might be willing to skimp on compliance, increasing third-party risks, she said. “And so in terms of our ability to vet those suppliers, that actually became even more important with regards to quality assurance,” Ms. Gordon said during a Forum panel.

There are also supply chain, export and even antitrust considerations Ms. Gordon’s team has had to manage when collaborating with certain partners on new production lines. “You’ve got to think about sharing competitive information and making sure that you are removing all the risks related to pricing and confidentiality,” she said. The company has sought to mitigate those risks through additional training.

Kellye Gordon, vice president of ethics and compliance and legal operations at VF Corp.



Photo:

VF Corp.

Companies have also had to manage risks not just with selling pandemic-focused products,

The Risks Of Dental Anxiousness And Dental Phobia

Bettering your dental health and at the same time enhancing your facial appearance are the 2 aims of beauty dentistry. Germany, with the oldest universal healthcare program has three.5 doctors per every 1000 citizens, as well as even Sweden whose docs do not take pleasure in a excessive degree of compensation. Gum disease (pyorrhea) and tooth decay are the two most typical problem areas requiring dental remedy.

This Hub presents questions and solutions that might be of interest to anybody considering pursuing both a second or a first profession within the professional area of dentistry. At present dentistry has advanced tremendously and even for those people who have misplaced their teeth, many reasonably priced treatment options can be found to stay healthy and regain their lovely smile.

That is my downside with healthcare. People still believed that their movement across the mouth was the reason for toothache, and used all sorts of remedies to kill them off. Issues get significantly problematic when a tooth begins rubbing in opposition to the roof of the mouth causing pain and lesions.

People will certainly love going to the dentist if all dental clinics are nearly as good as this. Low cost dental plans provide a set charge schedule for dental procedures achieved by dentists within a community of dentists. Direct rear position :- The operator is located straight behind the affected person and appears down over the affected person’s has restricted is primarily used for working on the lingual surfaces of mandibular anterior enamel.

To keep your enamel wholesome, it’s important that you simply go to your dentist every six months known as as ‘recall’ visits. I’ve had issues with enamel points being misdiagnosed and have learnt the laborious means that generally it would not harm to get a second opinion earlier than agreeing with a Dentist’s persistence.…

Does Cancer Chemotherapy Increase My Covid Risks?

Q. I have cancer and am being treated with chemotherapy. Am I at increased risk of getting sick and dying from Covid-19?

A. People with cancer, and particularly those with leukemia, seem to have a higher death rate from Covid-19 than the general population, though cancer chemotherapy does not appear to further increase the risk of dying from Covid. Studies, however, have been limited and results are sometimes difficult to interpret.

Many types of chemotherapy work by disrupting the cancer cell’s machinery that allows it to divide and grow so rapidly. Unfortunately, chemotherapy can also disrupt healthy cells that grow rapidly in the body, including the bone marrow cells that make our immune system. Consequently, people receiving chemotherapy are at risk of becoming immunocompromised. The immune system, our body’s primary line of defense against microbes, can also be corrupted directly by blood and bone marrow cancers such as leukemia, which can prevent the immune system from maturing, rendering it incompetent to fight infections.

It’s a logical assumption that people with compromised immune systems would be more susceptible to catching the novel coronavirus and getting sick from it. In one recent study, patients with cancers of the blood and bone marrow had higher coronavirus viral loads, which was associated with higher mortality. But there have been a paucity of population-based studies of coronavirus infection rates in people with cancer, so we don’t know for sure.

A few studies have explored the severity of Covid-19 infections in people with cancer. One study from Britain of more than 1,000 cancer patients seen over a seven-week period during the pandemic found a twofold higher death rate for patients with leukemia, but not for those with other cancers, compared to a similar group of cancer patients from three years earlier, before Covid.

In another study of more than 900 patients with ongoing or previous cancers and Covid-19 infections from the United States, Canada and Spain, 13 percent died and 26 percent either died or had illness severe enough to require intensive care. These rates are much higher than for the general population; among those with Covid-19, the estimated case-fatality rate is about 3 percent in the United States. Cancer patients receiving chemotherapy did not appear to have higher death rates or more severe disease than other cancer patients, though in patients with cancers of the blood or bone marrow, such as leukemia and lymphoma, 14 percent died and 35 percent developed severe illness.

Another international study of almost 200 patients with chronic leukemia found even higher death rates from Covid-19, 33 percent, though again, rates were no greater for those receiving chemotherapy. Interestingly, patients receiving palliative cancer care, which focuses on improving quality of life and providing symptom relief rather than active cancer treatment, were more likely to die outside of an intensive care unit, likely because they declined aggressive therapy given their cancer prognosis.

In an ongoing Covid-19 registry through the American Society of Hematology, the death rate among almost 600 patients with blood

Dexamethasone side effects and risks, the steroid Trump was treated with

Trump’s doctors at Walter Reed National Military Medical Center in Bethesda, Md., cited the positive research when they disclosed that they prescribed the steroid after Trump’s oxygen levels concerningly dropped to 93 percent. Healthy blood oxygen levels range from 95 to 100 percent.

For covid-19 patients on ventilators or receiving oxygen, taking dexamethasone increased their chance of survival, according to the research published in July. But patients receiving dexamethasone who didn’t require ventilation or oxygen fared no better than patients on the normal course of treatment.

In fact, giving dexamethasone to coronavirus patients who are not at risk of severe illness could further endanger their health, according to research published in the August issue of the Journal of Hospital Medicine.

In its guidelines, the National Institutes of Health recommends against using dexamethasone for covid-19 patients who do not require supplemental oxygen.

Dexamethasone is not often prescribed toward the start of a patient’s infection, experts say, because it can suppress the immune system’s ability to ward off the virus. But Trump’s doctors opted to administer the steroid less than two days after Trump publicly disclosed that he had tested positive.

“We decided that in this case the potential benefits early on in the course probably outweighed the risks,” Conley said Sunday.

Dexamethasone can also have concerning side effects, ranging from blood clots, blurred vision, and headaches to “psychic derangements,” such as insomnia, mood swings and “frank psychotic manifestations,” according to the drug label.

Doctors know what to expect with dexamethasone because the drug itself is not new. The steroid, which is used to treat asthma, Crohn’s disease, IBS and some cancers, is 60 years old and ubiquitous.

“It’s cheap as borscht, as my grandparents would say,” Isaac Bogoch, an infectious-disease specialist at Toronto General Hospital, previously told The Washington Post. “It’s widely available. Every single physician on the planet that practices hospital-based medicine is comfortable using this drug.”

Another well-known, therapeutic effect of the drug is a sensation of euphoria. But the relief a patient may feel should not be confused with physical improvement, said Paul B. Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan Kettering Cancer Center.

Before departing Walter Reed on Monday, Trump boasted on Twitter that he felt better than he did two decades ago.

“Feeling really good! Don’t be afraid of Covid. Don’t let it dominate your life,” he wrote after his brief hospitalization for the disease that has killed more than 210,000 Americans.

Patients who are prescribed a steroid like dexamethasone can over-exaggerate how well they feel, Bach told The Post. But he advises patients who take the steroid not to be deceived by the reprieve and overexert themselves.

“Having taken this myself, for a herniated disc, I felt like a million bucks,” Bach said, “but actually I was barely able to move.”

Trump was prescribed the drug in concert with other medicine — supplemental oxygen, a monoclonal antibody cocktail and a five-day course of the intravenous antiviral remdesivir.

It’s

Trump and the risks of ‘VIP syndrome’

With unlimited access to resources and the nation’s finest physicians by his side, President Donald Trump may reasonably expect to be treated with a higher level of care and attention than the average American infected with COVID-19.



a man wearing a suit and tie: Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.


© Susan Walsh/AP
Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.

Experts say that may not be a good thing.

On Friday, after the White House revealed that the president had been given an unapproved but promising antibody cocktail, medical professionals warned that his special treatment, known colloquially in medical circles as “VIP syndrome,” may have adverse effects.

“When a patient is high profile, there’s a temptation to break away from the standard medical care that you would give to any other patient — and sometimes to the disadvantage to the patient, the VIP,” said Dr. Mark Siegel, a Yale academic and physician.



a man wearing a suit and tie: Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.


© Susan Walsh/AP
Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.

Dr. Sean Conley, the president’s personal physician, said at a Saturday press briefing that Trump is “receiving all the standard of care and beyond.”

“We are maximizing all aspects of his care, attacking this virus with a multi-pronged approach,” he said. “I didn’t want to hold anything back. If there was any possibility that it would add value to his care and expedite his return, I wanted to take it.”

MORE: Tracing Trump’s movements: A timeline of the days leading up to his COVID diagnosis

Shortly before Marine One swept the president off to Walter Reed National Military Medical Center in Bethesda, Maryland, on Friday, the White House announced that the president had been administered a dose of an unproven antibody therapy developed by drugmaker Regeneron.

Regeneron’s treatment has not been authorized by the Food and Drug Administration. The company said in a statement that the president was granted approval to use it as part of a “compassionate use” clause, which clears the way for legal access to an experimental drug outside of a clinical trial.

Experts said there’s evidence the antibody cocktail may improve the president’s condition, but it carries the risk of producing unexpected side effects.



a man wearing a suit and tie talking on a cell phone: President Donald Trump walks to Marine One prior to departure from the South Lawn of the White House, Oct. 2, 2020, as he heads to Walter Reed Military Medical Center, after testing positive for COVID-19.


© Saul Loeb/AFP via Getty Images
President Donald Trump walks to Marine One prior to departure from the South Lawn of the White House, Oct. 2, 2020, as he heads to Walter Reed Military Medical Center, after testing positive for COVID-19.



a man standing next to a plane: A U.S. Secret Service agent wears a face covering as Marine One, with President Donald Trump onboard, leaves the White House for Walter Reed National Military Medical Center from the South Lawn of the White House, Oct.2, 2020.


© Drew Angerer/Getty Images
A U.S. Secret Service agent wears a face covering as Marine One, with President Donald Trump onboard, leaves the White House for Walter Reed National Military Medical Center from the South Lawn of the White House, Oct.2, 2020.

Gallery: I’m a Doctor and Here’s What’s Trump Does Next (ETNT Health)

Regeneron CEO George Yancopoulos told

An unusual patient, an unusual treatment: Trump and the risks of ‘VIP syndrome’

With unlimited access to resources and the nation’s finest physicians by his side, President Donald Trump may reasonably expect to be treated with a higher level of care and attention than the average American infected with COVID-19.

Experts say that may not be a good thing.

On Friday, after the White House revealed that the president had been given an unapproved but promising antibody cocktail, medical professionals warned that his special treatment, known colloquially in medical circles as “VIP syndrome,” may have adverse effects.

“When a patient is high profile, there’s a temptation to break away from the standard medical care that you would give to any other patient — and sometimes to the disadvantage to the patient, the VIP,” said Dr. Mark Siegel, a Yale academic and physician.

PHOTO: Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.

Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.

Dr. Sean Conley, physician to President Donald Trump, briefs reporters at Walter Reed National Military Medical Center in Bethesda, Md., Oct. 3, 2020. Trump was admitted to the hospital after contracting the coronavirus.

Dr. Sean Conley, the president’s personal physician, said at a Saturday press briefing that Trump is “receiving all the standard of care and beyond.”

“We are maximizing all aspects of his care, attacking this virus with a multi-pronged approach,” he said. “I didn’t want to hold anything back. If there was any possibility that it would add value to his care and expedite his return, I wanted to take it.”

Shortly before Marine One swept the president off to Walter Reed National Military Medical Center in Bethesda, Maryland, on Friday, the White House announced that the president had been administered a dose of an unproven antibody therapy developed by drugmaker Regeneron.

Regeneron’s treatment has not been authorized by the Food and Drug Administration. The company said in a statement that the president was granted approval to use it as part of a “compassionate use” clause, which clears the way for legal access to an experimental drug outside of a clinical trial.

Experts said there’s evidence the antibody cocktail may improve the president’s condition, but it carries the risk of producing unexpected side effects.

Trump Age And Weight Add To Covid Risks: Experts

As a 74-year-old obese man, Donald Trump has several known risk factors after contracting Covid-19, but experts say it is difficult to predict how the American president will be affected by a disease that leaves some without symptoms but is deadly to others.

Trump has become the highest profile patient of the new coronavirus, which has scorched across the planet killing more than a million people, including 200,000 Americans.

The US president is currently “well” according to his official doctor and able to continue performing his duties from quarantine.

Experts said that while he does have several of the risk factors associated with severe forms of Covid-19 — being male, older and overweight — it is hard to say how the disease will affect him.

“The risk of serious disease and death depends on many factors — some unmeasurable, so there is always uncertainty — and it is not so simple as to make inferences from one or two alone,” said Naveed Sattar, professor of metabolic medicine at the University of Glasgow.

Trump has seldom appeared in public wearing a face mask Trump has seldom appeared in public wearing a face mask Photo: AFP / Brendan Smialowski

He said that the risks may be “offset” by other factors, including if Trump has no chronic conditions and is reasonably active, noting the US leader’s love of golf.

At his most recent medical check-up, published in June, Trump weighed-in at 244 pounds (110.67 kg). For his height of six feet and three inches (1.91 meters), this means he exceeded the official threshold of obesity for a second year in a row.

According to the US Centers for Disease Control and Prevention, a person in this category is three times as likely to need hospital care than someone with a lower weight.

Another high risk factor is age.

The CDC reports that eight of 10 Covid-19 related deaths in the US are of people over 65.

“In general, your risk of getting severely ill from COVID-19 increases as you get older,” it says on its website.

There are concerns about others Trump came into contact with in recent days -- including his 77-year-old electoral challenger Joe Biden.  There are concerns about others Trump came into contact with in recent days — including his 77-year-old electoral challenger Joe Biden.  Photo: AFP / Jim WATSON

Michael Head, senior research fellow in global health at the University of Southampton, said Trump would be classified as “vulnerable”.

“Many people in their 70s will also have further co-morbidities that increase the risks of a more severe illness,” he added.

Currently, however, the US leader appears to have few if any symptoms.

Britain's Prime Minister Boris Johnson was hospitalised after contracting coronavirus in April Britain’s Prime Minister Boris Johnson was hospitalised after contracting coronavirus in April Photo: POOL / Matthew Horwood

His official physician, Sean Conley, also described the presidential couple as “both well at this time”.

“We are feeling good & I have postponed all upcoming engagements,” said First Lady Melania Trump in a tweet.

Coronavirus infection can begin on a slow burn, often taking several days before symptoms appear.

“Most studies suggest that those with symptomatic COVID-19 infections could remain outside hospital during the first 5-7 days of the illness

Trump Has the Coronavirus. What Risks Does He Face?

President Trump’s announcement on Friday that he had tested positive for the coronavirus has raised many questions about what the infection could mean for the health of America’s top leader.

In a statement, the president’s physician said Mr. Trump, who is 74, was “well” but did not say whether he was experiencing symptoms. He said the president would stay isolated in the White House for now.

Here is what we know about how the virus could affect people with his general profile.

Older men are up to twice as likely to die from Covid-19, the disease caused by the coronavirus, as women of the same age are, according to an analysis by the Chinese Center for Disease Control and Prevention. Another study, published in Nature in August, found that this was because men produce a weaker immune response than do women.

The potential for needing hospitalization rises after the age of 50, said Raina MacIntyre, who heads the biosecurity program at the Kirby Institute of the University of New South Wales in Sydney, Australia.

Obesity poses another risk factor for dying — particularly among men, according to an analysis of thousands of patients treated at a Southern California health system.

“If you don’t know anything about Donald Trump, just knowing that he’s a male, over 70, and appears to be overweight, right away, you can say he’s in the high-risk group,” said Michael Baker, a professor with the department of global health at the University of Otago in Wellington who is an adviser to the New Zealand government.

Even though the risk of severe illness from Covid-19 increases with age, most people who contract it get well quickly with minimal symptoms.

“The good news is that even people who have a number of risk factors, on average, do well,” Professor Baker said. “Only a minority have illness and severe consequences.”

“A lot of people his age who get Covid are actually fine,” said Benjamin Cowling, head of the division of epidemiology and biostatistics at the University of Hong Kong.

The outcome could be complicated if Mr. Trump has certain underlying health conditions, which researchers widely agree pose a risk of serious illness.

Mr. Trump, White House officials and his doctor have maintained in recent months that the president was in good health. But Mr. Trump loves cheeseburgers and does not exercise much, aside from playing golf. In June, Mr. Trump’s doctor said the president weighed 244 pounds, which makes him slightly obese.

“If he doesn’t have diabetes, high blood pressure or any long-term illness, then the outcome probably won’t be severe,” said David Hui, the director of the Stanley Ho Center for Emerging Infectious Diseases at the Chinese University of Hong Kong.

Experts agree that the next week will be critical in determining the course of Mr.