Coronavirus (Covid-19)

While commentators have made theoretical arguments for and against SARS-CoV-2 challenge studies, a consortium of academics, industry collaborators, and the British government has proceeded to address the technical and ethical considerations to enable such studies.

In this study involving 2380 vaccinated persons in a Rhode Island prison complex, there were 27 breakthrough cases of Covid-19, all of which were asymptomatic. Vaccination appeared to be safe and effective at preventing SARS-CoV-2 transmission in a prison.

In this report from Scotland, vaccination of health care workers for SARS-CoV-2 was associated with a decrease in household transmission.

Throughout the course of the past year, patients with Covid-19 — people of all ages — have continued to fill the hospital beds. The city outside may be eerily quiet, the seasons changing as smoothly and beautifully as ever, but the virus is wicked and keeps taking.

Among samples obtained from persons who had received the mRNA-1273 or BNT162b2 vaccines, neutralizing antibody titers against the B.1.617.1 variant were 6.8 times lower than those against the WA1/2020 variant, and titers against the B.1.617.2 variant were 2.9 times lower than those against WA1/2020.

In this article, the authors discuss the challenges of SARS-CoV-2 infection in patients with a weakened immune system, including the potential implications regarding viral evolution and transmission.

Among 288,368 South African health care workers who received the Ad26.COV2.S vaccine, no cases of vaccine-induced immune thrombotic thrombocytopenia have been observed, and the small number of thromboembolic events that have been noted occurred in persons with risk factors for thromboses other than vaccination.

Plans to protect participants and the public from Covid-19 during the Olympics aren’t built on rigorous risk assessment. They fail to consider the ways in which exposure occurs, the factors that contribute to exposure, and which participants may be at highest risk.

The response to the BNT162b2 vaccine was evaluated in 100 health care workers, 38 of whom had recovered from Covid-19. Neutralizing antibody levels were higher 10 days after a single dose in persons who had been previously infected than 10 days after the second dose in those who had not been previously infected.

Some 10 to 30% of Americans who’ve been infected with SARS-CoV-2 are still having debilitating symptoms months later, a trend that suggests that “long Covid” is our next public health disaster in the making. What form will this disaster take, and what can we do about it?

A total of 33 participants who received both doses of the Moderna mRNA-1273 vaccine against SARS-CoV-2 had blood drawn over a period of 6 months after vaccination. SARS-CoV-2 neutralizing activity was maintained in all the patients through the entire period of follow-up. A half-life of 202 days was determined for the live-virus neutralization activity.

Funding designated for increasing understanding of SARS-CoV-2 variants could be used in ways that would help guide the current pandemic response and yield public health benefits for years to come.

In this case series, investigators report a very rare but life-threatening sequela of ChAdOx1 nCoV-19 vaccination. Beginning 5 to 16 days after a first injection, some patients had symptoms consistent with thrombocytopenia, disseminated intravascular coagulation, and thromboses, including cerebral venous sinus thrombosis with catastrophic outcome. An anti–PF4 antibody capable of platelet activation appears to be the cause. Intravenous immune globulin may be therapeutic.

Some state governments and businesses in the United States are starting to pay people to get vaccinated against Covid-19. But even if incentives can produce a short-term bump in vaccination, multiple strategies will be necessary to increase population immunity.

The authors examined incident SARS-CoV-2 infection after mRNA vaccination among residents of 280 nursing homes. A total of 18,242 residents received at least one dose, and 13,048 received both. Infection incidence decreased from 4.5% after the first dose to 0.3% after the second dose. Most infections were asymptomatic, and the incidence of both symptomatic and asymptomatic infections decreased.

Automation using geolocation tracking allowed South Korea to trace contacts of people infected with SARS-CoV-2 reaching back to 14 days before symptom onset or diagnosis. By the end of 2020, there were at least 65 advanced digital contact-tracing systems worldwide.

Between December 22, 2020, and March 4, 2021, the BNT162b2 or mRNA-1273 vaccine was offered to two thirds of prisoners in California, and 66.5% of those offered a vaccine accepted at least one dose. Acceptance was highest among Hispanic residents (72.6%) and White residents (72.1%) and was lowest among Black residents (54.9%).

Millions of people have been exposed to deceptive material about Covid-19. An approach to counteracting deceptions and misconceptions could parallel epidemiologic models by focusing on three elements: real-time surveillance, accurate diagnosis, and rapid response.

After more than 36,500 health care workers at the University of California received at least one dose of vaccine, 71% of 379 workers with positive SARS-CoV-2 tests had positive results within 2 weeks after the first dose. Of 37 workers with positive results after the second dose, 7 had positive results 15 or more days after the dose.

As of March 31, 2021, more than 265,000 people in Qatar had received both doses of the BNT162b2 vaccine. Viral sequencing indicated that 50.0% of infections from February 23 to March 18 were caused by B.1.351 and 44.5% by B.1.1.7. Vaccine effectiveness was 89.5% against the B.1.1.7 variant and 75.0% against the B.1.351 variant. Effectiveness against severe, critical, or fatal disease was 97.4%.

To date, relatively few Americans have received Covid vaccinations where they usually receive care: their regular doctor’s office. Going forward, the sidelining of primary care clinicians and health systems that people trust could hinder progress and undermine equity.

Policymakers could incorporate open-science principles into research policies and programs to optimize the return on federal investment in clinical research on Covid-19, which could have benefits beyond the pandemic.

According to a recent survey, many Americans remain confused about the timing of protection from Covid vaccines and the necessity of a second dose. A large proportion of vaccinees are also uninformed about the need to continue taking prophylactic measures.

This report describes a very rare but life-threatening sequela of vaccination with ChAdOx1 nCoV-19. Within 10 days after a first injection, five health care workers presented with thrombocytopenia and thromboses, including cerebral venous sinus thrombosis with catastrophic outcome. The apparent cause is an anti-PF4 antibody capable of platelet activation; intravenous immune globulin may be therapeutic.

To help meet the global need for Covid vaccination, the United States could create a program that integrates global health needs into ongoing funding priorities, augments funding for vaccine production and delivery, and assists in building critical health infrastructure.

About 27% of Americans say they definitely or probably won’t get a Covid vaccine, even if it’s free and deemed safe by scientists. The behavioral obstacles to widespread vaccination are thus as important to understand as the scientific and logistic hurdles.

Covid-19 appears to have led to a substantial uptick in strike actions by health care workers, protesting inadequate pandemic responses and protections. Such strikes raise questions about what health care workers owe society and what society owes them.

Delayed cutaneous reactions developed in 12 patients days after initial injection-related symptoms resolved. The reactions, some as severe as grade 3, resolved in a few days with local therapy, and all 12 patients received the second vaccination; 6 had no recurrence of the local reaction, 3 had similar reactions to the initial injection reaction, and 3 had milder reactions.

As Covid vaccines are rolled out, it’s time to shift the focus from a sole emphasis on changing hearts and minds among members of BIPOC communities to ensuring that institutions are trustworthy, transparent, and engaged with communities.

In the mid-1990s and early 2000s, highly active antiretroviral treatment was accessible in high-income countries but had limited availability in African countries. What can the Covid-19 vaccination effort in Africa learn from the experience with ART?

Rejecting both a sweeping public Covid-vaccination-passport scheme and a ban on private certification is an easy call. In navigating the large, complex space in between, policymakers should consider the nature of privileged activities and the identity of the regulator.

On top of the social, emotional, and psychological effects of the Covid pandemic, many Asian American patients are feeling the stress of increased anti-Asian sentiment. Physicians can take practical steps to tailor their practices to meet this moment.

The speed, depth, and breadth of the response to Covid-19 by the biomedical research community has been unprecedented. But the pandemic is dismantling the pipeline of investigators who are essential to the future of biomedical science.

The emergence of the SARS-CoV-2 variants B.1.1.7 (VOC-202012/01), 501Y.V2 (B.1.351) and P.1 (B.1.1.28.1) has aroused many concerns, including worsening Covid-19 and escape from vaccine-induced immunity.

With the rollout of mRNA SARS-CoV-2 vaccines under emergency use authorization, dramatic decreases in the incidence of SARS-CoV-2 infections were seen among health care workers at the large University of Texas Southwestern Medical Center.

Reported results of immunization with SARS-CoV-2 vaccine have focused on two doses given to seronegative persons. In a small study involving health care workers, antibody responses were examined after a single dose of vaccine. Consistent increases in antibodies to spike protein subunits S1 and S2 and the receptor-binding domain were noted.

Among more than 3000 hospitalized patients with Covid-19, recipients of high-titer convalescent plasma had a lower mortality at 30 days than recipients of low-titer plasma. The effect of high-titer plasma was greatest in the subgroup of patients who were not receiving mechanical ventilation.

One in four families with school-age children are food insecure. While policy attention is focused on shoring up the nutrition safety net to support pandemic recovery, it’s critical to consider whether children’s nutritional needs are being met throughout the week.

The United States has developed a robust system for vaccine-injury compensation to alleviate the burdens of adverse medical consequences of vaccines. But this system will be unavailable to people who receive Covid-19 vaccines during the declared public health emergency.

In vaccinating low-risk employees early, leaders of some U.S. health care organizations violated their duty to promote public health and contributed to the narrative that powerful people in health care are willing to serve their own interests ahead of society’s.

A systematic program to vaccinate health care workers at Hadassah Medical Center demonstrated a high level of effective prevention of Covid-19 beginning in the second week after the first of two doses of the BNT162b2 vaccine.

In a platform trial involving patients hospitalized with Covid-19, among 314 patients who were also being treated with remdesivir, those who received the monoclonal antibody LY-CoV555 did not have better pulmonary function at day 5 than those who received placebo. The trial was stopped for futility.

Covid-19 vaccination poses challenges that complicate the traditional reliance on primary care delivery. Mass-vaccination sites offer a logical solution, and early adopters have yielded several lessons that are critical to achieving population-wide vaccination.

This interactive feature about administration of the second dose of Covid-19 vaccine either according to the standard schedule or delayed offers a case vignette accompanied by two essays, each of which recommends a different approach.

With the rollout of Covid vaccines, public debate regarding health in jails and prisons has increasingly shifted from decarceration toward vaccination of incarcerated people. But several factors suggest that vaccination alone won’t be enough to stop carceral outbreaks.

The interleukin-6 receptor blockers tocilizumab and sarilumab were tested against standard care in a randomized trial involving patients newly admitted to the intensive care unit and requiring respiratory or blood-pressure support. The median number of organ support–free days was 10 with tocilizumab, 11 with sarilumab, and 0 with standard care.

In this randomized trial involving 438 hospitalized patients with severe Covid-19 pneumonia, the use of the monoclonal antibody tocilizumab did not result in significantly better clinical status or lower mortality than placebo at 28 days.

New therapies effective against SARS-CoV-2 are desirable. Could nanobodies represent an arrow in the quiver of therapeutic strategies to treat Covid-19?

An analysis of multiple polls suggests that much of the U.S. public is currently undecided about whether to take a Covid-19 vaccine. These findings can inform outreach efforts to encourage vaccine uptake — efforts in which physicians can play an important role.

As experience with SARS-CoV-2 vaccination accumulates, meaningful differences among vaccines may emerge, making the question of whether individual vaccinees should be able to choose which vaccine they receive increasingly salient.

Ludvigsson et al. reported on open schools and child and teacher morbidity in Sweden during the Covid-19 pandemic. The authors of two letters further the discussion and Ludvigsson et al. respond.

The growth of telemedicine is seen by some physicians, academics, and policymakers as a silver lining of the Covid-19 pandemic. Congress is considering bills that would facilitate the use of telemedicine, and licensure reform could be an important step.

In the United States, where public–private health care integration is highly variable, patients have turned to their health care providers for information about Covid vaccination, and health care systems are having to master four types of new and unfamiliar work.

In the past few months, as I’ve learned to catch and care for babies, select elegant antibiotics, and titrate methadone, I’ve also learned that bearing witness to my patients’ isolation and its repercussions is now part of my job, too.

Hospitalized adults with severe Covid-19 pneumonia were randomly assigned in a 2:1 ratio to receive convalescent plasma or placebo. At 30 days, no significant difference in clinical status was noted between the two groups. Overall mortality was 11.43% with placebo and 10.96% with convalescent plasma, a difference that was not significant.

Consumer research and behavioral economics suggest 12 key strategies for effective vaccine promotion. We should combine relevant strategies for various persuasive tasks and prioritize tactics according to each population’s degree of vaccine hesitancy.

In 21 consecutive patients with confirmed Covid-19, the median times from symptom onset to negative viral culture and negative real-time RT-PCR were 7 days and 34 days, respectively. The longest interval from symptom onset and from resolution of fever to positive culture was 12 days and 3 days, respectively.

Early in the pandemic, the FDA recognized that ensuring access to antibody tests could advance understanding of Covid-19 and help inform the national response. But it faced several challenges related to evaluating test performance and authorizing products.

As we consider vaccinating children against Covid-19, measles and measles vaccination campaigns may offer relevant insights about parents’ decisions; trust, access, and equity; education campaigns and vaccination mandates; and effects of disinformation.

Two injections of mRNA-1273, a lipid nanoparticle–encapsulated mRNA-based vaccine produced in collaboration with the NIAID that encodes the SARS-CoV-2 spike protein, conferred protection against Covid-19 illness in 94% of vaccinated patients. Adverse effects of the vaccine were mild, transient local reactions, and the incidence of systemic effects such as fever, headache, and fatigue was low.

In a trial involving asymptomatic contacts of patients with PCR–confirmed Covid-19 in Spain, the authors compared the use of hydroxychloroquine with usual care. Postexposure therapy with hydroxychloroquine did not prevent SARS-CoV-2 infection or symptomatic Covid-19 in healthy persons.

Top government officials were among the first people vaccinated against Covid-19 in the United States. But prioritization frameworks do not grant government leaders special status, and giving them priority raises important questions of fairness and transparency.

When we hyperfocus on a few historical racist atrocities, we ascribe current Black health experiences to past racism, rooting our present in immovable past events and undermining efforts to combat mistrust. Everyday racism, by contrast, can be tackled in the present.

In a phase 2 trial, outpatients with Covid-19 who received a single infusion of a 2800-mg dose of the neutralizing antibody LY-CoV555 had a greater reduction from baseline in viral load than those who received placebo. Hospitalization was less frequent among antibody-treated patients (1.6% vs. 6.3%).

In Roman Catholic Diocese of Brooklyn v. Cuomo, the Supreme Court temporarily enjoined New York’s limits on in-person religious worship. The decision could have important implications for public health law during the Covid-19 pandemic and into the future.

We can address important Covid-19 control needs with continued follow-up of placebo recipients in phase 3 vaccine trials, use of placebo controls in large, simple safety trials, and clinical data from randomized trials evaluating new vaccines.

Persons with substance use disorders — particularly those in living conditions that increase Covid risk — should be prioritized to receive SARS-CoV-2 vaccines, and vaccine-rollout plans should account for specific barriers to uptake in this population.

Covid-19 has devastated refugees and asylum seekers in U.S. federal detention centers, and the Trump administration has devised a workaround for vaccine distribution that jeopardizes the prospect of immunizing detainees, further endangering this vulnerable population.

In this interim phase 1–2a trial of an adenovirus-based vaccine (Ad26.COV2.S), participants were divided into two age groups and received one or two injections of either a low-dose or high-dose vaccine or placebo. The vaccine elicited a local injection response in most patients and high titers of neutralizing antibodies in all vaccinated groups. In addition, T-cell responses were noted.

In a randomized trial, the risk of mechanical ventilation or death among patients hospitalized with Covid-19 pneumonia (56.0% Hispanic or Latino, 14.9% Black, and 12.7% American Indian or Alaska Native) was 12.0% in the tocilizumab group and 19.3% in the placebo group. Tocilizumab did not increase survival.

Thirty-four adults received two 100-μg injections of the mRNA-1273 SARS-CoV-2 vaccine, and serum anti–spike protein and neutralizing antibody titers were measured at day 119 — 90 days after the second injection. By three different assays, binding and neutralizing antibody titers declined slightly but remained elevated and higher than titers in convalescent plasma.

In Baltimore, Covid-19 spread rapidly in the immigrant Latinx community. Transmission was fueled by poverty and economic necessity, and precarious housing arrangements and fear and mistrust of medical institutions exacerbated the situation.

Changes in medical understanding or practice usually occur slowly, allowing physicians to carefully update their knowledge and retain their claim on expertise. But Covid-19 has blown a hole in that version of medicine.

A vaccine containing an RNA molecule encoding the SARS-CoV-2 spike protein was tested in a trial in which two injections were given 3 weeks apart. After the second injection, Covid-19 developed in 162 patients receiving placebo, with a median follow-up of 2 months, and in 8 patients receiving the vaccine. Side effects were mainly mild-to-moderate injection-site pain and swelling.

Early in the spread of SARS-CoV-2, the virus mutated, and the mutant form is now the most prevalent genotype worldwide. The vaccines currently being tested in clinical trials are based on the “ancestral” form of the virus. Will they be effective against the mutant form? Recent studies provide some clues.

Under enormous pressure to help patients with Covid-19, clinicians rely on the transparency of the scientific process and on the careful judgment of regulators who base their decisions on the best available science. But recent EUAs granted for unproven therapies have raised the troubling concern that political pressure has influenced the FDA’s decision making.

On October 22, 2020, on the basis of the results of three phase 3 clinical trials, the FDA approved remdesivir for use in adults and pediatric patients (12 years of age or older and weighing at least 40 kg) for the treatment of Covid-19 requiring hospitalization.

Our approach to early Covid cases was as thoughtful as it could have been, but we didn’t know enough, and many patients died. Over time, perhaps we’ll uncover the toll Covid-19 has taken on clinicians, in terms of anxiety, depression, and post-traumatic stress disorder.

Limited progress has been made in addressing some drivers of clinician well-being, including progress in improving workflow and strengthening communication with organizational leaders. Efforts often fail, however, when it comes to supporting emotional well-being.

The prolonged contagious period after viral infection in immunocompromised patients may affect how long precautions will be necessary to reduce further transmission. Replication-competent SARS-CoV-2 was detected for up to 61 days in patients who were immunocompromised by treatment for cancer.

As we weather this pandemic, we are starting to consider what recovery will look like. How can we mitigate the trauma of Covid-19 and its treatment for our patients? And how can we find meaning amid our patients’ needs and our own uncertainties?

How are you holding up? This has become my pandemic refrain, the way I begin my virtual visits. These days, the world is especially heavy. As a primary care doctor seeing patients with a range of lived experiences, I cannot know, until I ask, the burdens they carry.

The mRNA-1273 vaccine, which elicited antibodies and T cells specific for the Covid-19 virus in adults 55 years of age or younger, elicited similarly high levels of neutralizing-antibody and CD4 T-cell responses in a small group of older adults, including those 71 years of age or older.

Two doses 3 weeks apart of a lipid nanoparticle, nucleoside-modified RNA vaccine encoding a trimerized SARS-CoV-2 receptor–binding domain elicited high levels of antigen-binding and virus-neutralizing antibodies in adults 18 to 55 years and 65 to 85 years of age. Reactogenicity was moderate and transient. Large trials are ongoing.

U.S. Marine Corps recruits quarantined at home for 2 weeks; after this period, 0.9% were found to be infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). During a second, supervised 2-week quarantine on a college campus, 1.9% had become newly infected, and most were asymptomatic.

In March of 2020, a sailor on the U.S.S. Theodore Roosevelt was identified as having SARS-CoV-2 infection. Over the next several weeks, 1271 crew members (27% of the crew) tested positive, the majority of whom (77%) had no symptoms at the time of laboratory diagnosis. Twenty-three crew members were hospitalized, and 1 died.

The daily Covid hospitalization rate in the United Kingdom is back where it was at the start of the lockdown on March 23. The exhausted National Health Service workforce will be asked to step up again, and the NHS will again be repurposed as a Covid service.

In the Connecticut correctional system, 13% of the male population tested positive for SARS-CoV-2 infection from March through June 2020. Infection risks were dormitory housing as compared with cells housing one or two persons, Hispanic or Latino ethnic group as compared with White race, and older age.

A recombinant SARS-CoV-2 spike protein nanoparticle vaccine delivered in the deltoid muscle on days 0 and 21 was found to be immunogenic at both 5 μg and 25 μg doses. When given with a saponin-based adjuvant, both doses were equally immunogenic, with little or no reactogenicity, and elicited neutralizing antibody titers higher than those in convalescent serum.

I had learned that communicating with patients and families is a critical part of patient care. So, facing the communication challenges brought by Covid-19, as our unit worked on technological solutions to enable widespread video calling, we learned to improvise.

The efficacy of tocilizumab was tested in a randomized, controlled trial involving patients with Covid-19 who had fever, pulmonary infiltrates, or a need for supplemental oxygen. The treatment had no significant effect on disease progression, independence from supplemental oxygen, or death.

Stay-at-home orders imposed during Covid-19 have left many victims of intimate partner violence trapped with their abusers and unable to safely connect with services. Certain steps could promote more equitable access to services as a second wave of infections looms.

After a cluster of cases was linked to a hospital in a coastal city in China, nearly 11 million residents were tested for Covid-19 in less than a week. A total of 12 cases were identified, and the outbreak was controlled without a lockdown.

Pharmaceutical companies won’t distribute Covid-19 vaccines to lower-income countries without liability protection. To efficiently handle claims, the COVAX Facility could establish a procedure for compensating people who have a severe adverse event after immunization.

People inquiring about Covid-19 vaccines often want to know when the public can be confident that available vaccines are safe and effective, when a vaccine will be available to people like them, and when uptake will be high enough to enable a return to prepandemic life.

As Covid-19 cases accelerate or plateau around the world, we urgently need a point-of-care test that is inexpensive enough to use frequently, even if it lacks high analytic sensitivity. Such a testing regimen would allow us to detect infections in time to act.

Whether public health agencies should recommend that women avoid becoming pregnant during public health crises like Covid-19 because of potential risks to themselves and their newborns has been controversial. Such discussions involve important ethical considerations.

If Black communities are to participate in Covid-19 trials, clinicians, investigators, and pharmaceutical companies must provide convincing evidence — sufficient to overcome the extensive historical evidence to the contrary — that they are, in fact, trustworthy.

Patients with confirmed or suspected Covid-19 were randomly assigned to receive hydroxychloroquine with azithromycin, hydroxychloroquine alone, or usual care. The primary outcome was clinical status at 15 days, assessed on a seven-level ordinal scale. There were no significant differences between groups in the primary outcome.

Among 4716 hospitalized adult patients with Covid-19 in the United Kingdom, those who were treated with hydroxychloroquine did not have a lower incidence of death at 28 days than those who received usual care.

This Graphic Perspective explores the triumphs and tribulations of caring for patients remotely in the Covid-19 era. Suddenly forced to use technology that may not be ready for prime time, a primary care physician and her patients discover its risks and benefits.

Two inoculations with a new SARS-CoV-2 mRNA-based vaccine that encodes a protein in the coronavirus spike elicited high titers of virus-neutralizing antibody in healthy adult volunteers. Virus-specific T-cell responses were also elicited. Interim findings indicated that a dose of 100 μg per injection maximized immune response and minimized the reactogenicity of the vaccine.

Amid ongoing efforts to reduce the risk of Covid-19 infection in correctional facilities, researchers are considering whether incarcerated people should be included in efficacy trials of vaccine candidates after there is some evidence that such vaccines are safe.

In addition to its goal of delivering safe and effective vaccines quickly, Operation Warp Speed aims to combat Covid-19 by improving the use of existing therapies and providing additional treatment options to ameliorate the pandemic as we await full immunization.

A randomized trial comparing a 5-day course of intravenous remdesivir with a 10-day course in patients with Covid-19 pneumonia and hypoxemia who were not yet receiving mechanical ventilation showed no significant differences in outcome related to the duration of treatment.

A median 2-month follow-up after completion of an investigational Covid-19 vaccine regimen is necessary to provide safety and effectiveness data that support distribution of the vaccine under an emergency use authorization.

In the 1800s, the U.K. created a vast workforce of sanitary inspectors, part of an infectious disease surveillance system of notification, isolation, disinfection, and case finding. Its efforts suggest that Covid-19 contact tracers will require more than just persuasion.

Our response to the Covid-19 pandemic should build on lessons from the HIV and Ebola epidemics, including the importance of basing interventions on sound science and of involving affected communities in planning and implementation of research and care.

Investing in community health workers and community-based organizations can help address the social determinants of poor health that disproportionately affect low-income, minority populations and that are magnified during times of crisis.

The morning you die, I don’t want to be there — like most mornings now, when I rise against my will and crawl dejectedly into scrubs. I don’t want to be a plague doctor or a hero on TV. I look for hope and find none, but I’m not allowed to admit to total free fall.

Responses to the Covid-19 pandemic by stakeholders throughout the health care ecosystem are contributing to rapid innovation, including the development of new equipment and drugs. Less attention has been devoted to addressing important gaps in the health care workforce.

The resolution of dueling perspectives from President Trump and industry leaders on Covid-19 vaccine progress will grow out of conflicting currents of clinical trial design, immunology, statistics, regulatory policy, economics, public health, and politics.

New entities and investments have aided the pursuit of Covid-19 vaccines. Moving forward, relying on time-tested mechanisms for evaluating and regulating vaccines and for developing recommendations for their use would promote transparency and scientific integrity.

In the face of President Trump’s hospitalization for Covid-19, what can we learn — about trust, humility, integrity, transparency, optimism, and public health education — from the events surrounding President Eisenhower’s 1955 heart attack?

This interactive feature about a man hospitalized with Covid-19 whose condition is worsening offers a case vignette accompanied by two essays, each of which recommends a different approach to anticoagulation for the prevention of VTE in a patient with severe Covid-19.

The results reported in the letter by Ibarrondo et al. (Sept. 10) regarding the rapid decay of anti–SARS-CoV-2 antibodies in patients who had recovered from Covid-19 are in contrast to the findings of some other research groups, which is discussed in these letters.

Two injections of an mRNA-based vaccine encoding the SARS-CoV-2 spike protein elicited high levels of neutralizing antibody and Th1 CD4 T-cell responses in rhesus macaques. Two days after challenge of vaccinated animals with intranasal and intratracheal virus, viral replication was undetectable in bronchoalveolar-lavage fluid and nasal secretions.

The Covid-19 pandemic has exposed and exacerbated weaknesses in the U.S. health care system. Many patients are losing their health insurance when they lose their jobs. Declining revenues are threatening the financial viability of some hospitals and medical practices. The authors propose policy solutions to address these challenges.

Why has the United States handled this pandemic so badly? The Editors note that although we came into this crisis with enormous advantages, our current political leaders have demonstrated that they are dangerously incompetent.

Despite formidable barriers to designing, implementing, and completing clinical trials in the midst of a pandemic, there are ways to ensure that the selected trials are structured to maximize the chance that the key research questions will be definitively answered.

Although a SARS-CoV-2 vaccine remains months to years away, now is the time to develop a policy strategy to ensure vaccine uptake — including consideration of key criteria for determining when a vaccination mandate is appropriate.

Seeing patients in person is the lifeblood that keeps many physicians going. Being forced by the Covid-19 pandemic to overcome her hesitation about virtual care, a PCP discovers new ways of connecting with and caring for patients and families.

Key changes within hospitals’ cost structures have led them to an economic precipice. Hospitals were vulnerable to economic downturns before the first Covid-19 cases were detected and, barring a correction, will remain so long after the epidemic runs its course.

Although the 10th outbreak of Ebola virus disease in the Democratic Republic of Congo was declared over in late June 2020, additional cases attributable to persistently infected survivors may occur. Therefore, surveillance and rapid-response capacity should be maintained.

The situation on the U.S.–Mexico border is a public health crisis of our country’s own manufacturing, the result of a zealous effort to shirk our responsibility to people fleeing persecution, whom we have instead chosen to put directly in harm’s way.

Many jurisdictions have responded to the unevenness of the unfolding Covid-19 pandemic by battening down their borders. But within the United States, attempts to restrict interstate travel present distinctive legal issues.

A 66-year-old man with hypertension, diabetes, hyperlipidemia, obesity, chronic kidney disease, and end-stage liver disease, for which he had undergone liver transplantation, presented with fever, cough, dyspnea, and hypoxemia during the Covid-19 pandemic. Chest radiography revealed patchy confluent airspace opacities in the mid-to-lower lungs. Management decisions were made.

The Covid-19 pandemic clearly illustrates the intersection of structural racism, social risk factors, and health. But with a concerted effort that encompasses multiple sectors, we can change the entrenched factors that lead to disparities in health.

In April 2020, Congress appropriated $1.5 billion to the NIH to increase national testing capacity for SARS-CoV-2. The NIH established the Rapid Acceleration of Diagnostics program to support the development and deployment of accurate, rapid tests. Among the goals of RADx is to increase capacity to enable testing of approximately 2% of the U.S. population (6 million persons) per day by December 2020.

A recent study of immunity in mice showed that the innate immune system can be primed to respond to later bacterial infection through a process called epigenetic scarring, wherein the protein–DNA complex that makes up chromosomes is altered.

The Covid-19 pandemic presents an urgent imperative to rethink residency graduation requirements and an opportunity to implement the competency-based approach for which many educators have been calling.

Though the factors underlying racial and ethnic disparities in Covid-19 in the United States are multifaceted and complex, long-standing disparities in nutrition and obesity play a crucial role in the health inequities unfolding during the pandemic.

Understanding the challenges posed by the conjunction of the rapidly emerging Covid-19 pandemic and the insidiously evolving climate crisis is essential if we are to devise effective and equitable strategies to protect and improve health in the United States.

Eighteen brains of patients who died 0 to 32 days after the onset of symptoms of SARS-CoV-2 infection showed hypoxic–ischemic changes but no encephalitis, meningitis, strokes, or changes in olfactory bulbs or tracts. Low viral counts were detected by quantitative RT-PCR in a few brain sections, and no virus was evident on immunohistochemical analysis.

In a laboratory setting, SARS-CoV-2 was inoculated into human bronchial epithelial cells. These cells were then examined 96 hours after infection with the use of scanning electron microscopy.

Pressure placed on the CDC raises concern that in responding to the most critical public health emergency of our lifetimes, guidelines regarding the safety of U.S. schoolchildren could be based not on the best scientific data available, but on political considerations.

Covid-19 has exposed the cracks in the U.S. system of providing and funding long-term care, and there are no easy fixes. We need comprehensive policies that take the care of aging Americans seriously and fund it accordingly and in a wider range of settings.

Controlled human infection models have been proposed as a strategy for accelerating SARS-CoV-2 vaccine development. But scientific and technical factors make CHIMs unlikely to accelerate the establishment of vaccine efficacy.

Despite its fearsome appearance, the plague doctor’s costume — the “personal protective equipment” of the Middle Ages — had a noble purpose. It was intended to enable physicians to safely care for patients during the Black Death.

The outbreak on the cruise ship Diamond Princess led to the identification of 96 persons who were infected with SARS-CoV-2 but were asymptomatic. This report describes their course during isolation, with close observation and serial tests for the virus.

To provide the necessary data for generalizing efficacy and safety outcomes across racial groups, Covid-19 clinical trials must prioritize inclusion of patient populations that reflect the demographics of the ongoing pandemic, especially in the United States.

In New Zealand, rapid, science-based risk assessment linked to early, decisive government action was critical to containing Covid-19. The country is now in the postelimination stage, which comes with its own uncertainties.

A 60-year-old woman presented with altered mental status and weakness on the left side during the Covid-19 pandemic. Diffusion-weighted MRI of the head revealed a punctate focus of restricted diffusion within the posterior limb of the right internal capsule, with no corresponding abnormality on fluid-attenuated inversion recovery images. Treatment decisions were made.

Diabetes is associated with an increased risk of severe Covid-19. New-onset diabetes and metabolic complications of preexisting diabetes, including diabetic ketoacidosis and hyperosmolarity, for which very high doses of insulin are warranted, have been observed in patients with Covid-19. This letter discusses these issues.

Soon after Hahnemann Hospital closed, another Philadelphia institution, Mercy Philadelphia Hospital, announced that it, too, will close. But for all the disruption they cause, hospital closures represent opportunities to develop new and robust ways to support patients.

Community health centers have been critical to the U.S. response to Covid and key to treating other medical problems as well, but they are financially vulnerable. Congress should rescue CHCs and lay the foundation for a health system that works for everyone.

We had planned. Our plans had evolved, but we had still planned: for targeted pills, for early goals-of-care discussions, for radiation, for hospice, for dying at home, comfortably, with family. Yet our plans were being thrown out the window by a virus.

Widespread layoffs amid the Covid-19 pandemic threaten to cut off millions of people from their employer-sponsored health insurance plans at a time when insurance is especially important. The ACA will protect many of these people and their families from losing coverage.

On July 7, 2020, the President announced that the United States will withdraw from the WHO. Barry Bloom and Paul Farmer join Eric Rubin in pointing out the particular importance of the WHO during a pandemic, comparing the withdrawal of support to firing a firefighter in the midst of a fire.

Data from the Kaiser Permanente Northern California health care system were used to compare rates of hospitalization for acute MI from March 4 through April 14, 2020 (the Covid-19 period) with rates from the same period in 2019 and rates from an earlier period in 2020. Rates of hospitalization for acute MI decreased by up to 48% during the Covid-19 period.

A 47-year-old woman presented early during the Covid-19 pandemic with cough and shortness of breath. Radiography revealed a rounded mass in the right lower lobe. Computed tomography confirmed the presence of the mass and showed ground-glass attenuation and a reversed halo sign. An oncology consultation was requested, and a diagnosis was made.

World War II’s massive casualties were mitigated by lives saved as a result of medical care. Many of the advances made would persist long after the war concluded — a silver lining that perhaps will have parallels in our current struggle with Covid-19.

There is a high unmet need for better estimates of communities’ burden of Covid-19 to guide decisions about reopening societies. Fortunately, some mobile symptom-surveillance tools can be used for predictive modeling to address this critical priority.

A fundamental aim of residency is to impart to trainees a clinical gestalt. But Covid-19 has shaken our gut instincts and thus our ability to answer family members’ simple question: Is my loved one getting better? Too often, the truthful answer would be, “I don’t know.”

In this double-blind, randomized trial, 821 asymptomatic persons with a high-risk or moderate-risk exposure to SARS-CoV-2 were assigned to receive hydroxychloroquine or placebo within 4 days after the exposure. No benefit in preventing illness compatible with Covid-19 was found.

In Rhode Island, a former hotel was converted into an isolation facility. When gaps in medical care became apparent, clinicians established a system for evaluating people referred to the hotel and assessing their medical needs.

Many aspects of the Covid-19 pandemic and the public health response to it will undoubtedly contribute to widespread emotional distress and increased risk for psychiatric illness. Health care providers have an important role in addressing these emotional outcomes.

Just as the country rallied to care for September 11 first responders who suffered long-term health effects, we must take responsibility for the well-being of clinician first responders to Covid-19 — now and in the long run. Five high-priority actions can help to protect health care workers.

As a cardiology fellow and a surgery resident are redeployed to address the Covid-19 pandemic, one person close to them is bearing an unacknowledged burden of the crisis: their 3-year-old son. To protect him, his parents decide to send him hundreds of miles away.

The same viral fear that has now widely metastasized throughout public life has engulfed our hospital hallways. It’s a fear that dominates my every conversation and punctuates my every professional interaction. I’m scared for my personal safety.

Despite our inability to guarantee the accuracy of an immunity-certification process, failing to take action to identify people who could safely return to the workplace is itself an action that carries profound costs and health consequences.

In this autopsy series, the authors found that SARS-CoV-2 has an organotropism beyond the respiratory tract, including the kidneys, heart, liver, and brain. They speculate that organotropism influences the course of Covid-19 disease and, possibly, aggravates preexisting conditions.

SARS-CoV-2 was detected in three cats after they were cohoused with cats that had been experimentally inoculated with the virus. Cats may be a silent intermediate host of SARS-CoV-2.

The disproportionate effect of the Covid-19 pandemic on African Americans, Latinx Americans, and Native Americans is not unforeseen. Inequities in health, health care access, and quality of care are ingrained in our health care system, and they must be addressed now.

From February 21 through April 1, 2019, a total of 229 cases of out-of-hospital cardiac arrest were reported in four provinces of Lombardy, Italy. During the same period in 2020 (the first 40 days of the Covid-19 epidemic), 362 cases were reported — a 58% increase. Of the additional 133 cases in 2020, a total of 103 involved suspected or diagnosed Covid-19.

Disability rights advocates have filed complaints regarding crisis standards of care put forth by several U.S. states. Policymakers and hospitals can take key steps to honor commitments to antidiscrimination principles while appropriately stewarding scarce resources.

Crisis triage protocols should seek to optimize health outcomes, but doing so requires explicit protection of core values, such as the equal moral worth of all people, including those with disabilities. Some thoughtful policies are capable of meeting both goals.

A strategy to protect at-risk workers requires a framework for counseling patients about the risks posed by continuing to work, policy changes to ensure financial protections for people kept out of work, and a data-driven plan for safe reentry into the workforce.

To prevent officials from trampling civil liberties during emergencies, some checks on their power are essential, but in striking down the state’s renewed stay-at-home order, the Wisconsin Supreme Court misapprehended how such checks ought to function.

A multisystem inflammatory syndrome in children is associated with Covid-19. This report from New York State presents a descriptive analysis that summarizes the clinical presentation, complications, and outcomes of 99 pediatric patients meeting the New York State Department of Health definition of this syndrome.

A 76-year-old woman was admitted to the hospital with confusion and hypoxemia. Multiple residents at her assisted-living facility had received a diagnosis of Covid-19. Testing of a nasopharyngeal swab was positive for SARS-CoV-2. On the fourth hospital day, respiratory distress developed; 36 hours later, the patient died. An autopsy was performed.

Tragically, the United States, unable to match other countries’ pandemic response, has tallied the most Covid-19 cases and deaths in the world. Why has the U.S. response been so ineffectual? A key answer is testing, which has been slow to start and difficult to ramp up.

Certain influenza strains and SARS-CoV-2 gain access to cells by means of the ACE2 receptor. In this database study in the United Kingdom, investigators observed a null-to-protective effect on influenza susceptibility among those taking ACE inhibitors or angiotensin-receptor blockers, possibly owing to mechanisms relevant to infection with coronaviruses, including SARS-CoV-2.

The authors reviewed an imaging database used to determine whether patients with acute stroke were eligible to undergo endovascular thrombectomy. They found a 39% decrease in daily use of this imaging from a 29-day prepandemic period in February 2020 to a 14-day early-pandemic period from late March through early April.

Mechanistic epidemiologic models are designed to help us systematically examine the implications of various assumptions about a highly nonlinear process that is hard to predict using only intuition. Used appropriately, they can help guide us through this pandemic.

As a palliative care leader plans for a Covid surge, she sees that planning for the worst isn’t as simple as she imagined when she asked patients to do it. In many ways, the pandemic is forcing clinicians to gain insight into the experience of seriously ill patients.

Recent state-based crisis standards of care that provide a color-blind process for determining whether a patient with Covid-19 respiratory failure lives or dies are alarming, since color-blind policies result in discrimination against communities of color.

There is so much talk of “endings” and “after this” and even of “returning” to some way that we used to be. None of those imagined times and places feel real to me. Only this timeless space feels real. This is the pause before a new beginning.

A 62-year-old woman was evaluated for a mass that had been identified in the left breast during the Covid-19 pandemic. Mammography revealed a mass with spiculated margins. Ultrasonography showed a solid mass, measuring 3.1 cm by 1.5 cm by 1.2 cm, and normal left axillary lymph nodes. A core-needle biopsy was performed, and management decisions were made.

In this study, 20% of patients with Covid-19 had a prolonged activated partial-thromboplastin time. In 90% of these cases, the cause was lupus anticoagulant, with no associated bleeding. Patients with Covid-19 are susceptible to thromboses. The presence of a prolonged aPTT should, in general, not be considered a contraindication to anticoagulation.

In documenting Covid-19 racial disparities, we must contextualize such data with adequate analysis. Disparity figures without explanatory context can perpetuate harmful myths and misunderstandings that actually undermine the goal of eliminating health inequities.

Despite intensive preparations by African countries that are no strangers to epidemics, we should have no illusions that Africa can confront the Covid-19 threat alone. Coordinated global support is essential in the face of the pandemic, and the time to act is now.

Faced with the Covid-19 pandemic, clinicians feel compelled to do something for their patients. But we need to retain a healthy skepticism and remember the principle of clinical equipoise, particularly when considering interventions that could cause harm.

Autopsy examination of lungs from seven patients who died from Covid-19 showed intussusceptive angiogenesis in greater profusion than was found in lungs from patients who died from influenza or in uninfected lungs that were rejected for transplantation.

This letter describes a cohort of 100 children younger than 18 years of age with RT-PCR–confirmed Covid-19 who were assessed in 17 pediatric emergency departments in Italy. The descriptive results are compared with previously published results involving children in China and the United States.

A 66-year-old homeless man was evaluated for cough and rhinorrhea during the Covid-19 pandemic. He had tested positive for SARS-CoV-2 through a universal testing program at a homeless shelter, and he was admitted to a medical respite facility. Systemwide management strategies have been implemented.

There is emerging consensus that a graduated approach to Covid-19–related restrictive measures will be needed. Decisions to continue, modify, or lift restrictions — particularly bans on movement and gathering — could be tailored using individualized risk assessment.

Reports on the severity of the Navajo Nation outbreak don’t mention the community’s diversity of talent and experience, its resourcefulness. Infections from the outside have always found their way here. It’s just infrastructure that hasn’t.

For some clinicians, the pandemic offers an opportunity to take on the hero’s role as never before. But those who can’t must confront not only shame and guilt, but also the loss of their primordial story. Who are you, if you can’t be the hero you imagined yourself to be?

Unlike ventilator allocation, provision of CPR to patients cannot be practically adjudicated by a hospital-level triage team. How does the surge of patients with Covid-19 complicate standard CPR practices, and how can we best design crisis standards for inpatient CPR?

Lacking international support, clinicians in Haiti have implemented practical solutions to coordinate laboratory testing for Covid-19, provide education and training, and overcome public mistrust and stigma.

The authors describe patients in New York City with known immune-mediated inflammatory disease in whom Covid-19 developed while they were receiving biologics, other immunomodulatory therapies, or both. The incidence of hospitalization among these patients was consistent with that among patients with Covid-19 in the general population in New York City.

During the Covid-19 outbreak in northern Italy, the daily rate of admissions for acute coronary syndrome at 15 hospitals was significantly lower than the rate during two control intervals (13.3 admissions vs. 18.0 and 18.9 admissions for the two control periods).

The outsized impact of Covid-19 on elders has laid bare medicine’s outdated, frequently ineffective or injurious approach to the care of patients who are the planet’s fastest-growing age group and the generations most often requiring health care.

The Covid-19 pandemic offers an opportunity for doctors to recognize more readily facts that can otherwise take years to learn: that we’re no different from our patients and that interacting with them as human beings can be gratifying for them and freeing for us.

A retrospective cohort study analyzed data from a Louisiana health system whose population is 31% black non-Hispanic. A total of 76.9% of the patients who were hospitalized with Covid-19 and 70.6% of those who died from the disease were black. Black race was not associated with higher in-hospital mortality after adjustment for patients’ baseline characteristics.

Five patients who had Guillain–Barré syndrome 5 to 10 days after the onset of Covid-19 are described. Three had severe weakness and an axonal pattern on electrophysiological studies, and two had normal protein levels in the cerebrospinal fluid. The virus was not found in CSF.

In this letter, Mehra and colleagues request retraction of their article, “Cardiovascular Disease, Drug Therapy, and Mortality in Covid-19,” because they were unable to validate the primary data sources underlying the article.

The burnout problem won’t be solved without addressing the issues of autonomy, competence, and relatedness. During the Covid-19 pandemic, a sense of altruism and urgency has catalyzed restoration of these pillars of intrinsic motivation. Can these changes be sustained?

The patchwork way we govern and pay for health care in the United States is unraveling in this time of crisis, leaving millions of people vulnerable and requiring swift, coordinated political action to ensure access to affordable care.

Among 1376 patients with Covid-19 admitted to a New York City hospital, 59% were treated with hydroxychloroquine. Patients selected for treatment were more severely ill. After adjustment for patients’ baseline characteristics, there was no significant association between hydroxychloroquine use and intubation or death (hazard ratio, 1.04; 95% CI, 0.82 to 1.32).

There is concern that patients taking renin–angiotensin–aldosterone system inhibitors have an increased risk of Covid-19, because angiotensin-converting enzyme 2 is a receptor for the virus. This study showed no increase in likelihood of a positive Covid-19 test or severe Covid-19 in patients taking any of five common classes of antihypertensive drugs.

This population-based case–control study from northern Italy shows that the use of ACE inhibitors and ARBs was more frequent among patients with Covid-19 because of a higher prevalence of cardiovascular disease. However, there was no evidence that ACE inhibitors and ARBs affected the risk of Covid-19.

There are several strategies to elicit immunity with an RNA vaccine; they all involve coaxing the host cell to replicate and translate an exogenous RNA encoding the vaccine antigen. A recent study describes a new, versatile approach.

A 74-year-old man with lymphoma was admitted to the hospital during the Covid-19 pandemic because of rapidly progressive respiratory failure. Several years earlier, when he had been critically ill, he had expressed a desire for “do not resuscitate” status. More recently, he had indicated that he would try all therapies that may be helpful. A consultation was requested.

Eighteen patients with Covid-19 presented with ST-segment elevation on ECG or had it develop during hospitalization. Eight patients received a diagnosis of acute myocardial infarction, and 10 had noncoronary myocardial injury. Thirteen patients died in the hospital.

Among 118 pregnant women with Covid-19 in Wuhan, China, the vast majority had a mild course of disease.

A cohort of 36 consecutive kidney-transplant recipients had less fever, lower CD3, CD4, and CD8 cell counts, more rapid clinical deterioration, and a higher mortality than the general population of patients with Covid-19.

Students and trainees are experiencing intense anxiety, uncertainty, and anticipatory loss during the Covid-19 pandemic. Many are facing new ethical dilemmas and practical challenges. Such feelings compete internally with a desire and commitment to serve the sick.

A cohort of patients with severe Covid-19 received treatment with remdesivir under a compassionate-use protocol. Improvement in oxygen-support status was observed in 68% of patients, and overall mortality was 13% over a median follow-up of 18 days.

Despite timely implementation of testing for SARS-CoV-2 virus, a contact-tracing scheme, and social-distancing measures, infection has spread in Iceland. However, there was no detected increase in the proportion of infected persons between March 13 and April 4, 2020.

In this series of 393 consecutive patients admitted with Covid-19 to two New York City hospitals from March 3 to March 27, a third of patients received invasive mechanical ventilation, 10% of patients died, and 24% were still hospitalized as of April 10.

South Africa’s early interventions have delayed the peak of Covid-19 cases. The author describes the eight stages of the national response and ongoing challenges.

As the pandemic focuses medical attention on treating affected patients and protecting others from infection, how do we best care for people with non-Covid disease? Some physicians predict that “the toll on non-Covid patients will be much greater than Covid deaths.”

In the face of the Covid-19 pandemic, expanding Medicaid would rapidly bring needed resources into the health care system and infuse federal dollars into state economies. It requires no new infrastructure or federal oversight, and it can save lives.

The search for a treatment for Covid-19 is testing our country’s ability to quickly develop, test, and deploy medications, and several aspects of the U.S. response highlight how the processes for evaluating and approving drugs can go awry during a public health crisis.

As the deaths from Covid-19 have mounted, many patients with cancer struggle to process the case fatality rate in the context of all the other statistics their oncologists cite. Chemotherapy, hardly desirable at the best of times, may never have been less appealing.

When the wife of a severely ill patient with Covid-19 is told she can’t visit him, her anger quickly gives way to pleading — “What if I only spent 5 minutes and left?” How can we harness creative solutions during this pandemic so that people don’t have to die alone?

Those of us who have found our role diminished as our elective cases have been canceled are being redeployed to the areas of the hospital with the greatest need. I want to help fight the battle against this invisible enemy, but I wonder: How do I not catch this disease?

Molecular-dynamics simulations together with virtual high-throughput screening provide a means of quick evaluation of existing drugs for antiviral activity. The authors explain how these methods serve in the quest for drugs to treat Covid-19.

In a consecutive series of 64 patients with Covid-19 and ARDS, 58 of whom underwent neurologic examination, severe agitation and corticospinal signs were common. In 2 of 13 patients, MRI of the brain showed small acute strokes, and in 1 patient, imaging showed a subacute stroke.

This report describes the deaths from Covid-19 of 23 health care workers, including physicians, surgeons, a nurse, and an electrocardiography technician. Only 2 of the health care workers were physicians in respiratory medicine who had been specifically assigned to treat patients with Covid-19. Eleven had come out of retirement to serve as clinicians.

Dressed in the protective gear, you feel like a soldier about to jump from a plane, hoping your parachute will open. As the hours go by, made longer by thirst, hunger, and the need to relieve yourself, you can’t wait to take it off and breathe. We all just want to breathe.

In January, reported events in China seem remote to a U.S. physician. In February, the new coronavirus spreads to other countries, seemingly selected at random. The physician’s life goes on as usual. Then suddenly, on March 13, everything changes — and all she can do is wait.

It seems clear that health care delivery organizations, educators, and government leaders all have to be willing to cut through bureaucratic barriers and adapt regulations to rapidly expand our health care workforce and sustain it for the duration of the pandemic.

In the face of the Covid-19 pandemic, Americans are waking up to the limitations of their analogue health care system. It seems clear that we need an immediate digital revolution, pursued on several fronts, to address this crisis.