12 0 N THE NEW YORK TIMES, SUNDAY, AUGUST 9, 2020Tracking an OutbreakThe Americas
fections.
Still, experts said the results
strongly suggest that asymptom-
atic people are unwitting broad-
casters of the virus.
“They don’t look any different
from the symptomatic popula-
tion” in terms of how much virus
they carry, said Marta Gaglia, a vi-
rologist at Tufts University in
Massachusetts who was not in-
volved in the work. “There’s no ac-
tual reason to believe a priori that
they would transmit any differ-
ently.”
Dr. Cowling was more circum-
spect. Because asymptomatic
people do not cough or sneeze, he
said, it is possible that they are
less efficient at expelling the virus
than those who are clearly unwell.
On the other hand, Dr. Gaglia of-
fered, people who feel ill tend to
take to the bed or couch, whereasOf all the coronavirus’s quali-
ties, perhaps the most surprising
has been that seemingly healthy
people can spread it to others.
This trait has made the virus diffi-
cult to contain, and continues to
challenge efforts to identify and
isolate infected people.
Most of the evidence for asymp-
tomatic spread has been based on
observation (a person without
symptoms nevertheless sickened
others) or elimination (people be-
came ill but could not be con-
nected to anyone with symp-
toms).
A new study in South Korea,
published Thursday in JAMA In-
ternal Medicine, offers more de-
finitive proof that people without
symptoms carry just as much vi-
rus in their nose, throat and lungs
as those with symptoms, and for
almost as long.
“It’s important data, that’s for
sure,” said Benjamin Cowling, an
epidemiologist at the University
of Hong Kong who was not in-
volved in the work. “And it does
confirm what we’ve suspected for
a long time — that asymptomatic
cases can transmit infection.”
Discussions about asymptom-
atic spread have been dogged by
confusion about people who are
“pre-symptomatic” — meaning
they eventually become visibly ill
— versus the truly asymptomatic,
who appear healthy throughout
the course of their infection.
The new study is among the
first to clearly distinguish be-
tween these two groups.
“There’s been this big question
pretty much since January, since
data started coming out of China,
about people that were asymp-
tomatic or pre-symptomatic,” said
Jason Kindrachuk, a virologist at
the University of Manitoba who
was not involved in the work.
“What we haven’t really had any
clue of yet is what role people who
are asymptomatic play in trans-
mission of disease.”
The new study measured the vi-
rus’s genetic material in the pa-
tients; the researchers did not fol-
low the chain of transmission or
grow live virus, which might have
more directly confirmed active in-
the infected but unaware may
carry on with their business, sick-
ening others along the way.
The South Korean team ana-
lyzed samples taken between
March 6 and March 26 from 193
symptomatic and 110 asymptom-
atic people isolated at a communi-
ty treatment center in Cheonan.
Of the initially asymptomatic pa-
tients, 89 — roughly 30 percent of
the total — appeared healthy
throughout, while 21 developed
symptoms.
The participants were mostly
young, with a median age of just- (A study last week found that
children, who are mostly mildly
infected, also harbor at least as
much virus as adults do.)
“The real strength of the study
is they have a very large number
of patients and they have very
good follow-up,” Dr. Gaglia said.
“When they talk about asymp-
tomatic patients, they really, re-
ally know that these were true
asymptomatics.”
The study’s estimate that 30
percent of infected people never
develop symptoms is in line with
findings from other studies. In a
television interview on Wednes-
day, Dr. Anthony Fauci, director of
the National Institute of Allergy
and Infectious Diseases, tendered
40 percent as the figure.
“The good news about Covid-
is that about 40 percent of the pop-
ulation have no symptoms when
they get infected,” Dr. Fauci said.
But “even though you are likely
not going to get symptoms, you
are propagating the outbreak,
which means that you’re going to
infect someone, who will infect
someone, who then will have a se-
rious consequence.”The participants in the new
study were all isolated when they
tested positive for the virus and
did not have the opportunity to in-
fect others. Doctors and nurses
tracked their temperatures and
other symptoms, and tested their
sputum — which indicates virus
present in the lungs — as well as
their noses and throats.
“Both groups had similar
amounts of virus pretty much
throughout the entire course of in-
fection,” Dr. Kindrachuk said.
Asymptomatic people became vi-
rus-free a little sooner: around
Day 17, compared with Day 19 or
20 for those with symptoms.
Both estimates are much longer
than the period of isolation re-
quired in most countries, Dr.
Gaglia noted. The Centers for Dis-
ease Control and Prevention re-
cently decreased the recom-mended isolation for infected peo-
ple without symptoms to 10 days
from 14.
Several studies have suggested
that infected people shed — or
pass into the environment — live
coronavirus for only about a week,
even though the tests may pick up
viral fragments in their bodies for
much longer.
Dr. Cowling also noted that the
study was retrospective, meaning
the researchers looked at samples
collected from people who had
tested positive earlier, instead of
following a group of people over
time, identifying everyone who
became infected as well as their
contacts, and assessing their
symptoms and virus levels.
“It would still be valuable to de-
sign a study like that,” he said.
Still, he conceded that comparing
people with symptoms and with-
out was challenging because in-
fected people are found in varying
ways.
Most testing plans focus on peo-
ple who need medical care, and
rarely whole groups regardless of
symptoms — especially in places
like the United States, where tests
are often scarce to begin with.
A lack of testing can also influ-
ence how much asymptomatic
people contribute to the size of an
outbreak.
With enough testing, everyone
found to be infected could be sepa-
rated from others. But if the test-
ing is barely enough to catch the
visibly ill, then asymptomatic peo-
ple — particularly the young and
social — may fan out into society
and keep the virus circulating at
high levels.
Many other viruses can be
spread by people without symp-
toms, usually at negligible levels,
Dr. Kindrachuk said.
It’s still unclear whether the
new coronavirus is unusual in this
respect, able to spread widely
from asymptomatic people, he
added, or whether it just seems so
prolific because of the scale of the
pandemic. Studies addressing
those questions are underway.
“There are all these small nu-
ances about this virus that are
coming to light each day,” Dr. Kin-
drachuk said.RESEARCH
Even Asymptomatic People Carry the Coronavirus in High Amounts
Dongdaemun Design Plaza in Seoul in March. A South Korean team followed 193 symptomatic and 110 asymptomatic patients.LEE JIN-MAN/ASSOCIATED PRESSBy APOORVA MANDAVILLIThey arrive each week.
Words of light encouragement.
Moments to reflect.
On Sundays, thousands of resi-
dents of Portsmouth, N.H., find a
poem nestled inside the city’s
Covid-19 newsletter.
The poems, written by Tammi J.
Truax, the city’s poet laureate,
help offset the gloom of the pan-
demic while giving residents a
chance to pause briefly and reflect
on something other than the virus.
Since the beginning of the pan-
demic, there have been over 6,
cases and at least 419 deaths in
New Hampshire, according to a
New York Times database, with a
recent average of 28 cases per day.
The idea for featuring the po-
ems came from Stephanie Sea-
cord, the public information offi-
cer in Portsmouth, a city of 21,
about 60 miles north of Boston.
Ms. Seacord was compiling in-
formation about the coronavirus
and health updates in a weekly
city newsletter sent to some 5,
email subscribers and circulated
on social media.
“When the pandemic hit, it be-
came quickly clear that people
needed information more than
once a week,” Ms. Seacord re-
called in an interview on Thurs-
day, adding that “things were
changing almost on a daily basis.”
In mid-March, the newsletter
turned into a daily advisory of co-
ronavirus cases and tips, such as
where to find personal protective
equipment.
Around that time, Ms. Seacord
had the idea that including a poem
in the Sunday newsletter would be
“a good calm moment in the mid-
dle of the intensity,” she said.
She reached out to Ms. Truax to
ask for a weekly contribution.
“She has not only risen to the
occasion by providing a poem, she
is also teaching Portsmouth about
poetry, which is part of her role as
poet laureate,” Ms. Seacord said.
In Portsmouth, the poet laure-
ate serves a two-year term. The
program, which was established
in 1997, supports “an outstanding
local poet” and “brings people to
celebrate the written word.” Ms.
Truax is the city’s 12th poet laure-
ate. The Portsmouth program
echoes similar programs in neigh-
boring Maine, which has a vener-
ated poetic tradition and several
cities with laureates of their own.
“Tammi is part of a long and no-
ble tradition of poetry in Maine,
and of the tradition of Maine poets
laureate to bring the joy of poetry
to the wider community by any
means possible,” said Jenny
Doughty, president of the Maine
Poets Society. “Offering a way to
look at the times through the lens
of poetry, to bring a moment of joy
or reflection or even to tap into
their own creativity, is a psycho-
logically and spiritually healing
thing at the best of times, and even
more so during a pandemic.”
Ms. Truax, an elementary
school librarian who lives in Eliot,
Maine, just across the Piscataqua
River from Portsmouth, said that
she thought of poetry “as a heal-
ing power.”
“I think connecting to a poem
because you connect to the feeling
is what makes poetry powerful,”
she said.
“The poems are an unexpected
bright light from City Hall,” Anne
Weidman, a 63-year-old Ports-
mouth resident, said on Friday.
“The poems add a human voice to
the sometimes depressing lists of
food resources, government-as-
sistance links, mask-wearing pro-
tocols and health statistics. They
are a Sunday feature, and it’s a
day that I always make it a point to
click and read the advisory.”
So far, Ms. Truax has contribut-ed 17 poems to the newsletter. The
shortest was a haiku, a traditional
Japanese three-line poem; the
longest was 31 lines of free verse.
The themes vary.
“Each week I have just been
writing about what has been on
my mind,” said Ms. Truax, who is
also the current Maine beat poet
laureate, adding that she writes
the poems on Saturdays.
One poem paid tribute to a new
class of nurses in Nichinan, Japan,
one of Portsmouth’s sister cities.
Ms. Truax and students from
Portsmouth High School had
planned to visit a school and its
companion nursing school in
Nichinan in April; the trip was
canceled because of the pan-
demic.
Inspired by the nurses, Ms.
Truax wrote a poem about them.
It began:As you finished your formal
studies
the world has demonstrated
what an enormous
responsibility
is being pinned upon you
along with a pretty white cap.Another poem, called “Transi-
tions,” was about masks and say-
ing goodbye to a fellow poet.Today I find the mask usefulalong with sunglasses
to hide my tear streaked face,
not wanting to scare the
barista
who has enough to deal with
behind his own mask.For July 4, Ms. Truax created a
“found poem” by extracting lines
from Alexander Hamilton’s es-
says.
“Like so many, I had just seen
‘Hamilton’ for the first time, and it
was what I was thinking about,”
Ms. Truax said.
In the most recent Sunday
newsletter, tucked amid news of
the death rates of Covid-19 in the
United States and New Hamp-
shire, there was an ode to fishing
by Ms. Truax.At about the age of eight
my father gave me a fishing
pole.
A girly one, pretty, like an
accessory.
Bright blue stripes — how I
loved it!Ms. Truax said she hoped that
the poems provide comfort.
“If they help anybody at all get
through this difficult time, I would
be content,” she said.
One unexpected result: inspir-
ing a reporter to open his article
with a haiku.THE BARD OF PORTSMOUTH
Amid the Stats and Protocols, Poems Speak to the Soul
Tammi J. Truax, the poet laureate of Portsmouth, N.H., contributes to the city’s Covid newsletter.CHARLES KRUPA/ASSOCIATED PRESSBy JOHNNY DIAZWhile politicians wrangled over
a pandemic relief package and
schools struggled over whether to
open their doors to students, the
United States and Brazil passed
more milestones on Saturday. The
United States surpassed more
than five million known coro-
navirus infections, and Brazil re-
corded its 100,000th death.
No other country has reported
as many cases. Brazil ranks sec-
ond, with more than three million,
and India is third with two million.
(In cases per capita, the United
States ranks eighth, between
Oman and Peru.)
The data, from a New York
Times database, is based on re-
ports of known cases from federal,
state and local officials. Public
health experts have warned that
the actual number of people in-
fected is far greater.
Cases are trending upward in
seven states, as well as in Puerto
Rico, Guam and the U.S. Virgin Is-
lands, and decreasing in 17, ac-
cording to The Times database. In
the past week, Louisiana, Missis-
sippi and Florida had the most
new cases relative to population.
The United States reported its
millionth case on April 28, more
than three months after the first
reported case. The country
passed two million cases on June
10, three million on July 7 and four
million on July 23.
The United States now tests
roughly 720,000 people a day, ac-
cording to data from the Covid
Tracking Project.
The number of new coronavirus
cases daily peaked on July 16, with
75,697. It has been slowly tapering
off since then, to a seven-day aver-
age of around 54,000 per day.
The seven-day average daily
death toll is hovering around
1,000. That is down from a peak of
more than 2,200 on a single day in
mid-April, when bigger cities like
New York and Seattle were hit the
hardest. (The most deadly single
day was April 15, with 2,752.)
At least 161,000 people have
died since the pandemic began.
But the seven-day average daily
death toll is now significantly
higher than it was in early July,
when it was around 500. Cases
have surged since then — particu-
larly in the Sun Belt states and in
communities where officials
moved quickly to reopen. Many of
the places with the most cases per
capita have been smaller cities
and rural communities in theSouth and the Midwest.
Five months after its first case
of Covid-19, Brazil has passed the
bleak milestone of 100,000 deaths,
the Ministry of Health reported on
Saturday. The country is also re-
porting more than three million
cases.
President Jair Bolsonaro has
repeatedly denied the severity of
Brazil’s crisis even as the death
count has risen more quickly than
the government anticipated.
Mr. Bolsonaro’s refusal to sup-
port social distancing measures
pushed two health ministers out,
leaving the country’s response to
the virus to be led by a general
with no experience in public
health.
The ministry has yet to reach an
agreement with city and state offi-
cials, who have been scrambling
to respond with varying levels ofsuccess, on how to combat the
pandemic.
In early March, officials at
Brazil’s Ministry of Health pre-
dicted the virus would kill at least
100,000 of the country’s citizens.
But they estimated that number
would only be reached in Septem-
ber, said Julio Croda, who then
headed the ministry’s department
overseeing immunization and
transmissible diseases.
“The presidency wouldn’t be-
lieve in these numbers,” he said.
“It’s one month ahead of schedule
because the social distancing
measures fell.”
Since June, Brazil has fre-
quently reported more than 1,
new deaths a day, as the number
of new infections and deaths
plateaued at a high level. Dr.
Croda believes the country will
continue on this trajectory for
some weeks, adding tens of thou-
sands of deaths to its toll in the
coming months.
The numbers, he believes, will
eventually fall — as they have be-
gun to do in severely hit states
such as Amazonas — when a large
number of Brazilians acquire im-
munity to the virus.
But that “has nothing to do with
the government,” Dr. Croda said.
“It is a consequence of tragedy.”GRIM MILESTONESU.S. Caseload Surpasses
5 Million, Leading World
By JACEY FORTIN
and MANUELA ANDREONIAlso this weekend,
Brazil records its
100,000th death.
No day is complete
without
The New York Times.