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Which states had the best pandemic response?

For this story, reporters interviewed a wide range of health researchers, public officials and academic experts to ask them which states were standouts in their management of the pandemic. What we heard repeatedly were lessons culled from a handful of states that others could follow.

We’ve distilled their insights into three categories that represent the greatest challenges states are facing: fighting the virus, managing the economic fallout and reopening schools.


Leading the way in the rural Northeast

Few states have a record as unblemished as Vermont.

The odds could have been stacked against the state. The virus arrived in Vermont during the first wave sweeping the country. It shares borders with some of the hardest-hit states and has the third-oldest population in the country.

But Vermont swiftly flattened its initial wave and has since gone weeks at a time without any new confirmed infections. Fewer than 60 people have died, giving the state the second-fewest deaths per capita behind Alaska, which has seen surging caseloads in recent weeks. If the country as a whole had the same per capita death rate as Vermont, the nationwide death toll would be 30,000 instead of more than 215,000.

“This should be the model for the country, how you’ve done it,” Anthony Fauci, the nation’s top infectious disease expert, said during a briefing with state leaders in September. “Notwithstanding that this is a small state, it should be the model of how you get to such a low test positivity that you can actually start opening up the economy in a safe and prudent way.”

While health experts say the state has likely benefited from its rural geography, other sparsely populated areas of the country that let their guard down were overwhelmed by the virus this spring and summer. That sense of complacency never took hold in Vermont, where a moderate Republican governor and a Democratic-led Legislature helped defuse partisan tensions that hampered the response elsewhere.

“Any state that’s going to succeed against Covid has got to have the compliance of the population, because every single thing you do is telling people to alter their personal behavior,” Mark Levine, Vermont’s health commissioner, said in an interview.

What works:

— Vermont reopened slowly. The lockdown it put in place in late March is still gradually being lifted, restaurants and bars are still limited to 50 percent indoor capacity and even outdoor gatherings are still subject to a 150-person limit.

— Local governments have authority to set their own stricter rules. Burlington, the state’s most populous city, reduced its outdoor gathering limit to 25 in late August when college students began returning to nearby campuses.

— The state is also strict about visitors, requiring a two-week quarantine for people arriving from places with higher infection rates. And it invested early in testing and contact tracing and implemented a state-wide mask mandate early on.

“They took action early, they let science lead, and they were consistent

Virginia governor critical of Trump’s coronavirus response in first appearance since testing positive

About 65 staff members who had close contact with the Northams were told to ­self-isolate for two weeks. Northam said none tested positive, which he called “a testament” to the value of wearing masks.

He noted that masks protected several staff members who could not physically distance from him before he tested positive, including a press secretary, photographer and security detail who traveled in an SUV and airplane with Northam.

He contrasted that with the largely mask-free Rose Garden ceremony last month that Anthony S. Fauci, the nation’s top infectious-disease expert, has called a superspreader event. Trump, first lady Melania Trump and several others subsequently tested positive for the virus.

“No masks, no social distancing — and look at the number of people that tested positive,” Northam said Tuesday, referring to the White House event. “We talk about science, it doesn’t get any clearer than that . . . I would remind every Virginian: Masks are scientifically proven to reduce the spread of this disease, plain and simple.”

Northam, a former Army doctor and pediatrician, said his and his wife’s symptoms were mild. He warned Virginians not to let down their guard, particularly as cooler fall temperatures and shrinking daylight hours make outdoor socializing less appealing.

The governor said he is unlikely to ease pandemic-related restrictions in the near term. He acknowledged pressure to return to in-person education at public schools but urged continued caution.

“Numbers are going up in a number of states across this country, so we’re not out of the woods,” he said. “We’re nowhere close to being out of the woods.”

The greater Washington region on Tuesday reported 1,763 additional coronavirus cases and 20 deaths. Virginia added 1,235 cases and 11 deaths, Maryland added 482 cases and nine deaths, and the District added 46 cases and no deaths.

Virginia’s daily caseload was above its rolling seven-day average, lifting that number to 1,089 — the state’s highest daily average since Aug. 13.

The seven-day average in Northern Virginia rose Tuesday to 264 cases, a four-month high in the region.

Daily caseloads Tuesday in Maryland and the District were below their rolling seven-day averages. It’s the third consecutive day that both jurisdictions reported new infections at or below their recent average amid an uptick that began earlier this month.

The recent caseload rise across the region has coincided with the outbreak at the White House, although local health officials have said it’s unclear whether there’s a connection.

Dana Hedgpeth contributed to this report.

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Military-Style Response at One Retirement Community Stymies COVID-19

Along with much of the country, Knollwood Life Plan Community in the District of Columbia went into lockdown in mid-March to try to protect residents and staff from the COVID-19 pandemic.

The retirement community includes sections for independent living, assisted living and skilled nursing. The leadership team stopped allowing visitors to the facility, which is typically home to 280 people – all of whom are retired military service members, former high-level federal government officials and family members. Residents range from those living independently to those needing a high level of care. They are served by 250 staffers, who all began wearing personal protective equipment, including masks, disposable gloves and full gowns, when the pandemic began.

The first weeks of lockdown seemed fine.

Everything changed six days before Easter, on April 6. That day, the District of Columbia Medical Examiner’s office called to notify community officials that a Knollwood hospice resident who had recently died, a woman in her 90s, had tested positive for COVID-19.

The deadly new virus had penetrated Knollwood.

Leaders quickly launched a military-style response to ramp up testing of residents and staff. “It was chaotic,” says Col. Paul Bricker, a retired Army helicopter pilot and Knollwood’s chief operating officer who commanded the effort. “It reminded me very much of being in Afghanistan in a firebase under attack. I almost started wearing camouflage to work.”

Bricker’s wartime aviation experience – he served in Afghanistan and Iraq – informed his efforts.

“When you fly into fog, you’re flying blind,” he says. “Testing provides a light through the (fog) to better understand what you’re dealing with.” As a helicopter pilot, Bricker could rely on his instruments when visibility was poor. Similarly, he knew that mounting a testing effort could illuminate who was infected by the virus, which would help Knollwood stop its spread by quarantining infected residents and staffers for two weeks – until they were no longer contagious, in accordance with guidance from the Centers for Disease Control and Prevention.

In early April, officials decided to launch an offensive against the virus start by testing everyone in the skilled nursing neighborhood, residents and staff.

Skilled nursing is the smallest of three neighborhoods at Knollwood, and is home to residents who are most vulnerable and require full-time care. This neighborhood includes a skilled memory care section, for people with conditions like Alzheimer’s disease. The majority of Knollwood residents live in independent living, and a smaller number in assisted living.

After the Medical Examiner’s notification, Bricker and his colleagues made a series of phone calls and obtained 150 COVID-19 tests. Then Bricker and his team met with CDC officials to discuss the plan to ramp up testing.

Soon after, with the help of CDC doctors who came to the community, Knollwood began testing residents and staff members. Testing began in the skilled nursing section, where the resident who had died with COVID-19 had lived. It’s also where Knollwood’s most vulnerable residents are; their average age

New England Journal of Medicine blasts Trump officials’ response to virus, calls for new leaders

The New England Journal of Medicine on Wednesday, in an unprecedented editorial, denounced the Trump administration’s handling of the coronavirus pandemic and called for voting out “current political leaders” who are “dangerously incompetent.”

The harshly worded editorial is the first time the prestigious medical journal, which usually stays out of politics, has weighed in on an election.  

The editorial does not mention President TrumpDonald John TrumpTrump and Biden’s plans would both add to the debt, analysis finds Trump says he will back specific relief measures hours after halting talks Trump lashes out at FDA over vaccine guidelines MORE by name, but it refers to “the administration” and calls for voting out “our current political leaders.”

“When it comes to the response to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent,” the editorial states. “We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.”

The journal takes the Trump administration to task on a wide range of issues that it argues the U.S. has failed on, from inadequate testing to shortages of protective equipment for health workers. 

“We have failed at almost every step,” the editorial states. “We had ample warning, but when the disease first arrived, we were incapable of testing effectively and couldn’t provide even the most basic personal protective equipment to health care workers and the general public. And we continue to be way behind the curve in testing.”

The editorial also criticizes states for reopening businesses before the virus had been controlled and for a lack of mask-wearing, which it blames on leaders not modeling the behavior. Trump has rarely worn a mask during appearances for months and has mocked their use. 

“Our rules on social distancing have in many places been lackadaisical at best, with loosening of restrictions long before adequate disease control had been achieved,” it states. “And in much of the country, people simply don’t wear masks, largely because our leaders have stated outright that masks are political tools rather than effective infection control measures.”

The U.S. leads the world in cases and deaths from the virus, it notes. 

“The magnitude of this failure is astonishing,” the editors write. “According to the Johns Hopkins Center for Systems Science and Engineering, the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China.” 

It adds that countries like South Korea and Singapore were able to suppress the virus through robust testing and contact tracing, in contrast to the U.S.  

The journal also points to political pressure Trump has placed on health agencies ranging from the Centers for Disease Control and Prevention to the Food and Drug Administration, warning of the undermining of scientific expertise. 

“Our current leaders have undercut trust in science and in government, causing damage that will certainly outlast them,” it states.

Charting a Covid-19 Immune Response

Amid a flurry of press conferences delivering upbeat news, President Trump’s doctors have administered an array of experimental therapies that are typically reserved for the most severe cases of Covid-19. Outside observers were left to puzzle through conflicting messages to determine the seriousness of his condition and how it might inform his treatment plan.

Though Mr. Trump may leave Walter Reed National Military Medical Center tonight to continue his recovery in the White House, the future of his health status is unclear. Physicians have warned that the president remains at a precarious point in his disease course. The coronavirus can be a tricky adversary — and for many people whose cases of Covid-19 are severe, the greatest threat to survival might not be the pathogen itself, but the deadly forces that the body marshals to fight it.

To quash the virus, the immune system unleashes an arsenal of powerful weapons. Sometimes these turn inward and destroy healthy tissues. Combatting this friendly fire has become as crucial a part of the Covid-19 treatment strategy as subduing the virus itself.

Mild and Severe Cases

From the moment the coronavirus enters the body, the immune system mounts a defense, launching a battalion of cells and molecules against the invader.

Most people who are infected with the coronavirus recover, sometimes without ever experiencing symptoms, and do not progress to severe Covid-19. In some cases, the virus may even be brought under control before it has the chance to become established in the body.

Should the virus gain a foothold, it will swiftly infiltrate cells and repeatedly copy itself until levels of the virus, or the viral load, build up. The viral load may even peak before symptoms appear, if they appear at all.

Still, symptoms like fever, cough, congestion and fatigue — all of which have been reported in Mr. Trump — signal that an immune response is underway in the body and may be driving the viral load down. Once the immune system has finished the job, symptoms may abate without medical intervention.

In severe cases, however, the clash between the virus and the immune system rages much longer. Other parts of the body, including those not directly affected by the virus, become collateral damage, prompting serious and potentially life-threatening symptoms.

[For more details on the progression of a typical Covid-19 case, see Charting a Coronavirus Infection.]

Triggering the Immune System

A typical immune response launches its defense in two phases. First, a cadre of fast-acting fighters rushes to the site of infection and attempts to corral the invader. This so-called innate response buys the rest of the immune system time to mount a second, more tailored attack, called the adaptive response, which kicks in about a week later, around the time the first wave begins to wane.

In people with severe disease, however, the immune system appears to botch the timing. The first wave mobilizes too late and must play a frantic game of catch-up that persists even after reinforcements

Insider Q&A: Healthcare Ready director on disaster response

When natural disasters strike, quickly getting the right aid to people is difficult at best. Doing so amid the worst pandemic in a century increases that challenge dramatically.

For thousands of Americans displaced this year by hurricanes, floods and wildfires — plus those trying to avoid COVID-19 — getting their drugs and medical supplies has been critical.

Healthcare Ready, a tiny disaster preparedness and response group, serves as a crucial hub for coordinating donations and shipments of medicines, protective gear and other supplies to those in need.

The Associated Press recently talked with its executive director, Nicolette Louissaint.

Q: What led to your group’s formation in 2005?

A: After Hurricane Katrina, there was a lot of frustration. Pharmaceutical companies knew they could do more to help but didn’t know how to get their medicines into shelters, because they didn’t have relationships with law enforcement, public health agencies or the Red Cross. They decided, let’s do this as a coalition.

Q: How do you prepare for disasters?

A: We make sure we’re refreshing our contacts every year, touching every state’s emergency management and health organizations. We work with national groups with a local presence in many communities, like churches and the NAACP. We do preparedness projects to identify populations that would have the greatest medical needs after a disaster.

Q: How has your work evolved since Hurricanes Harvey, Irma and Maria hit in 2017?

A: The landscape has only gotten more and more difficult. It’s the intensity of the events and the frequency. Being poised to jump in and provide support for multiple intensive events is the hardest challenge, and that’s what COVID has been testing for us.

Q: During the pandemic, medicines largely remained available. What’s been your focus?

A: We continue to work closely with the manufacturers and distributors of personal protective equipment, to have a single clearinghouse for our emergency management agency partners. We worked with the National Governors Association to vet and create a list of credible suppliers of those products. We worked with Project Hope and the Business Roundtable to identify products needed and then distribute their donations to community groups, nursing homes and clinics.

We do a lot of info sharing. We set up our “RX Open” map so people could see where pharmacies were open before leaving home amid stay-at-home orders.

Q: Are you helping with the wildfires?

A: We’re working with pharma and the Red Cross, making sure everyone isn’t sending the same thing. We’re working with pharmacies to be sure they have the medicines they need. We have some partners prepared to provide donations for individuals who’ve lost their homes.

Q: How is Healthcare Ready funded?

A: We receive contributions from the associations for drug manufacturers, distributors, chain pharmacies and other companies, plus other grants and donations.

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Andrew Cuomo on coronavirus response: ‘I put my head on the pillow at night saying I saved lives’

New York Gov. Andrew Cuomo on Wednesday appeared to boast of his handling of the coronavirus pandemic, declaring during a conference call: “I put my head on the pillow at night saying I saved lives, that’s how I sleep at night.”

The Democratic received some pushback online, with many pointing to his March 25th mandate to send coronavirus patients to nursing homes from hospitals – a decision some say factored in to nearly 6,000 deaths.

In this Sept. 29, 2020 photo provided by the Office of New York Governor Andrew M. Cuomo, Gov. Cuomo delivers a COVID-19 update during a briefing in New York City. 

In this Sept. 29, 2020 photo provided by the Office of New York Governor Andrew M. Cuomo, Gov. Cuomo delivers a COVID-19 update during a briefing in New York City. 
(Office of Governor Andrew M. Cuomo via AP)

The mandate required nursing homes to take in patients so long as they were medically stable. The nursing homes were further prohibited from testing incoming residents for the virus before they arrived.

More than 6,300 COVID-positive patients were admitted to nursing homes between March 25 and May, according to a report from the New York state health department. The high number of admitted patients has been widely blamed for the state’s official care home death toll of more than 6,600.

An analysis from the state health department determined that there was no causal link because “the timing of admissions versus fatalities shows that it could not be the driver of nursing home infections of fatalities.”

Still, Cuomo’s mandate stoked the ire of a lot of nursing homes. Rob Astorino, a Republican candidate in the 40th district State Senate race told 77WABC’s Lidia Curanaj that the nursing home owners he spoke to “were upset by Cuomo’s directive.”


“They were overwhelmed with sick patients, understaffed, and lacking in the proper PPE as well as equipment to treat and protect others from catching the virus.”

Pressed on the matter Wednesday during the conference call, Cuomo rejected the premise that the number of nursing home fatalities was linked to his March 25th mandate.

“The premise of your question is just factually wrong, the virus preys on senior citizens,” Cuomo said.


As of Thursday, the virus has claimed some 33,159 deaths out of 76,754 cases recorded in New York since the pandemic began, according to the latest figures from Johns Hopkins University.

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High TMB Predicts Response to Pembrolizumab

Tissue tumor mutation burden (tTMB) has been under study for some time as a biomarker that could predict which patients are most likely to respond to immunotherapy.

In June, it was approved by the US Food and Drug Administration as a biomarker for pembrolizumab (Keytruda) use in patients with advanced cancers who have progressed on prior therapy.

Now the data supporting that approval have been published in Lancet Oncology.

They come from analysis of outcomes from 790 patients who participated in the phase 2 KEYNOTE-158 study of treatment with pembrolizumab in 10 tumor-type-specific groups.

The results show better responses in patients who had a high tissue TMB (≥10 mutations per megabase), which was found in 102 (13%) of the 790 participants.

The majority of these patients (87%) did not have high tTBM.

Of the 102 patients with high tTMB, 29% achieved an objective response to pembrolizumab compared with 6% in the non-tTMB-high group. In addition, the median duration of response was not reached in the tTMB-high group vs 33.1 months in the non-tTMB-high group.

An expert not involved with the study was enthusiastic about the results.

“This gives clinicians treating patients with any metastatic solid tumor the possibility of offering immunotherapy with pembrolizumab to those whose tumors have a TMB greater than 10 mutations per megabase,” said Matthew R. Zibelman, MD, assistant professor, Department of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania.

“The real win here is not for clinicians but for the patients who may get access to this drug with an opportunity for a meaningful response, ” he said.

TMB is essentially a measurement of the number of somatic mutations within a tumor and defined as the total number of somatic mutations per coding area of a tumor genome, he explained.

“Currently, its use as a predictive marker to choose treatment remains investigational in most clinical settings,” Zibelman told Medscape Medical News. “This testing is becoming standard in most commercially available next-generation sequencing platforms offered, and has been looked at as a potential biomarker in several tumors, including non-small cell lung cancer and melanoma,” he added.

Zibelman suggested that the results should now be implemented into clinical practice. “Testing should be offered to all patients with metastatic solid tumors, particularly those without prior approvals for immunotherapy agents specific to their indication,” he said.

“Clear Advantage”

“The higher the TMB, the greater the number of neoantigens expressed by the tumor, enhancing the probability of cancer cells being recognized by the immune system. This simple but captivating rationale likely underlies the clear advantage from pembrolizumab treatment found for patients with tTMB-high tumors, in terms of objective response and duration of response,” writes Melissa Bersanelli, MD, Medical Oncology Unit, University Hospital of Parma, Italy, in an accompanying editorial.

The authors showed the usefulness of tTMB status even in tumors that are well known to be poorly immunogenic, such as small cell lung cancer, she noted.

However, in this setting of rare tumors where there are few viable options and limited

Moderna says coronavirus vaccine boosts immune system response in older adults

Biotech company Moderna announced on Tuesday that its coronavirus vaccine candidate elicited immune responses in older adults from a Phase 1 study in levels comparable to those seen in younger adults. The findings were published Tuesday in the New England Journal of Medicine.

The vaccine candidate, dubbed mRNA-1273, “induced consistently high levels” of neutralizing antibody levels in 40 healthy participants across two age cohorts – 56-70 and 71 and over – per the company announcement.


Biotech company Moderna announced on Tuesday that its coronavirus vaccine candidate elicited immune responses in older adults from a Phase 1 study in levels comparable to those seen in younger adults. (iStock)

Biotech company Moderna announced on Tuesday that its coronavirus vaccine candidate elicited immune responses in older adults from a Phase 1 study in levels comparable to those seen in younger adults. (iStock)

“These interim Phase 1 data suggests that mRNA-1273, our vaccine candidate for the prevention of COVID-19, can generate neutralizing antibodies in older and elderly adults at levels comparable to those in younger adults,” Dr. Tal Zaks, chief medical officer of Moderna, said in the announcement. “Given the increased morbidity and mortality of COVID-19 in older and elderly adults, these data give us optimism in demonstrating mRNA-1273’s protection in this population, which is being evaluated in the Phase 3 COVE study.”


The data stemmed from a second interim analysis which assessed a two-dose vaccination administered 28 days apart in two dose levels, 25 micrograms (µg) and 100 micrograms, reporting findings one month after the second dose.

“This analysis found that both the 25 µg and 100 µg dose levels were generally well-tolerated in both age cohorts,” per the announcement.

The 100 microgram dose elicited higher antibody levels, “supporting the selection of the 100 µg dose for further study in the Phase 3 trial.” Moderna previously announced plans to use the 100 microgram dose in its late-stage trial, which will enroll up to 30,000 volunteers in the U.S. As of Sept. 25, there were 27,232 participants enrolled, 30% of which were from diverse communities.


Company officials said the majority of adverse events were mild to moderate, like headache, fatigue and chills, among others.

After the second vaccination, one patient in the 56-70 cohort with the 25 microgram dose experienced a fever, and a second patient in the older cohort and higher dose had fatigue, but officials said “clinical laboratory values of Grade 2 or higher revealed no pattern of concern” and that the patients would be followed through 13 months for a longer assessment.

The findings were said to be confirmed through three live virus assays, and “robust neutralizing activity was observed in all participants 14 days after the second vaccination.”

The U.S. government already struck a deal with Moderna for 100 million doses of the vaccine, with an option to buy an additional 400 million doses.


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One in Seven Dire COVID Cases May Result from a Faulty Immune Response

Perhaps the most unnerving aspect of COVID-19 is its startling range of severity: from completely asymptomatic to deadly. Starting early in the pandemic, researchers identified factors that put people at risk of a serious case of the disease, such as advanced age, having certain chronic diseases and being male. But these demographic trends do not get at the biological mechanisms that actually cause a life-threatening infection. Nor do they explain why some young, fit, healthy people become mortally ill from the SARS-CoV-2 virus.

Two related papers published in Science onSeptember 24 begin to address these mysteries. They may also partially account for men’s greater vulnerability to the virus and point the way to possible treatments and protective measures. Both studies highlight the critical role of a class of immune system proteins called interferons, so named because they interfere with the replication of viruses.

The new papers were produced by the COVID Human Genetic Effort, a huge international consortium of researchers hunting for genetic mutations that either make individuals unusually susceptible to SARS-CoV-2 or confer exceptional resistance. The consortium is co-led by Jean-Laurent Casanova of the Rockefeller University and Helen Su of the National Institute of Allergy and Infectious Diseases, who are co-senior authors of both of the studies.

In their first paper, the researchers compared DNA from 659 gravely ill COVID-19 patients from around the world with DNA from a control group of 534 infected people who were only mildly affected by the novel coronavirus or did not have symptoms. The scientists specifically looked for mutations that would impair the production of type I interferons—a set of proteins made by every cell in the body that comprise a first-line defense against viruses. Previous work by Casanova and others showed that such mutations left people extremely vulnerable to influenza and other viruses. As it turned out, some of the same mutations associated with life-threatening flu were also present in 3.5 percent of patients with life-threatening COVID-19. No one in the new study’s control group had these mutations.

The second paper focuses on another mechanism that disables interferon responses in patients with severe COVID-19. In this set of studies, researchers examined blood samples from 987 such individuals and discovered that 13.7 percent contained antibodies—dubbed “auto-antibodies”—to the patients’ own type I interferons. In 10.2 percent of the subjects, the auto-antibodies completely blocked the action of these critical virus fighters.

Lab experiments showed that when human cells were exposed to plasma (the liquid part of blood) taken from patients with these self-attacking antibodies, the cells could not defend themselves against SARS-CoV-2. The antibodies were found in 12.5 percent of the severely ill men but only 2.6 percent of similarly ill women—making them a possible factor in the higher COVID-19 mortality rate among men. They were also more common in patients older than 65.

Antibodies to the body’s own cytokines, cell-signaling proteins of the immune system that include interferons, have been known to exacerbate other types of infections. The effect is the same as having