Federal Program to Supply Coronavirus Tests to Nursing Homes Led to Unexpected Costs and ‘Testing Hell’ – The New York Times


Credit…Julia Rendleman for The New York Times

After months of enduring a dearth of protective medical gear and staggering death tolls from the coronavirus pandemic, nursing home operators and employees across the United States experienced something close to elation as rapid-result test machines paid for by the federal government began arriving last month at 14,000 residential facilities that serve the elderly.

The hand-held testing devices, which spit out results in as little as 15 minutes, were intended to quickly diagnose and isolate patients, and alter the deadly calculus of a contagion that has taken the lives of 77,000 nursing home residents and workers, more than 40 percent of the nation’s fatalities from Covid-19.

But the initial sense of relief has been overtaken by frustration as nursing homes have discovered that they must pay for test kits on their own, and that the machines are markedly less accurate than lab-based diagnostics.

Because the devices come with a modest starter-set of test supplies that only last a few weeks, facilities, many of them buffeted by financial losses from the pandemic, must pay roughly $32 for each additional test. In communities with high rates of infection, a typical nursing home can churn through hundreds of tests a week.

Many nursing home operators also say they have been overwhelmed by new federal reporting rules, fines and financial incentives that are associated with the program. Facilities can be fined up to $10,000 for failing to meet daily reporting rules that sometimes conflict with those from state or local health agencies, raising questions about the free machines, which cost about $300.

“My initial happiness over the machines has quickly turned to disillusionment,” said Ben Unkle, the chief executive of Westminster-Canterbury on Chesapeake Bay, which operates a skilled nursing center in coastal Virginia. “At the moment we’re in testing hell.”

Shortages in testing supplies have forced Mr. Unkle to rely on an outside lab that charges $100 a test, an expense that he estimates will add $875,000 to the $1 million in pandemic-related losses that the nonprofit provider expects this year. Rather than the 15-minute turnaround, the lab results take up to four days to arrive, complicating efforts at infection control.

“As far as I’m concerned, this is an unfunded mandate that is not giving us the data we need fast enough to improve either care or protection,” Mr. Unkle said.

Credit…Juan Arredondo for The New York Times

New York City officials announced on Tuesday a significant uptick in the citywide daily rate of positive coronavirus tests, which was in part attributable to a rise in cases in nine ZIP codes in Brooklyn and Queens — some in predominantly Orthodox Jewish communities that have largely ignored public health guidance, like wearing masks.

In a news conference, Mr. de Blasio announced a daily rate of 3.25 percent, the highest it had been since June. It was a relatively low number compared with other parts of the country, but “cause for real concern,” the mayor said. On Monday, he reported that the daily rate was 1.93 percent; for weeks it had generally held between 1 and 2 percent on most days.

The uptick in the city comes at a particularly crucial moment, as the city tries to fully reopen public schools this week for in-person learning to hundreds of thousands of students and to resume indoor dining.

The mayor has said that he will automatically shut down classrooms — which are all slated to be open by Thursday — if the test positivity rate exceeds 3 percent over a seven-day rolling average. On Tuesday, Mr. de Blasio said the seven-day average was 1.38 percent and that he would not seek to change those guidelines to target specific areas that had seen an uptick. The city had not seen an increase in cases in schools in the nine ZIP codes in question.

According to the city’s health officials, if schools are forced to close, it could take weeks for them to reopen. The president of the city’s teachers’ union said that if the rates do not drop this week, the city should move to close as many as 80 public schools in ZIP codes where the virus is surging. Random student testing is set to begin Thursday, which could also drive down the rate.

“The goal is to be under 3 percent in a way that is consistent,” Mr. de Blasio said, cautioning that the city was not yet near that point. Public health experts have said cases in schools are inevitable and not necessarily cause for alarm if they are detected quickly.

Over the past two weeks, the cases in the nine ZIP codes account for 25.6 percent of the city’s cases, despite the fact that the population in those areas make up only 7.4 percent of the city’s population, according to information provided by the city’s Health Department.

As part of new enforcement measures in those areas, the city will move to fine anybody who refuses to wear a mask, said Mr. de Blasio, a Democrat. Members of the city’s test and trace program, the Sheriff’s Office and the New York Police Department, among others, will help with enforcement, he said.

If city officials didn’t see improvement in numbers by the end of the day, the city was weighing possible additional options, Mr. de Blasio said, including business closures in certain areas, and a wide-scale closure of institutions like yeshivas and child care, and limits on gatherings.

Community leaders have faulted the city for a lack of engagement with the Orthodox, and particularly Hasidic, communities, which have a longstanding distrust of secular authorities and a particular dislike for Mr. de Blasio. City officials said on Tuesday that they had made extensive outreach efforts recently in the affected communities, which included distributing masks to synagogues, speaking to area leaders and passing out literature about the dangers of the virus.

Indoor dining would begin on Wednesday, the mayor said, but added that officials would watch and see if the move resulted in a further increase in cases.

“If anything looks problematic, we’ll talk to the state and decide together if any adjustments need to be made,” he said.

Shortly afterward, Gov. Andrew M. Cuomo, a Democrat, said that city officials would have to get approval from the state in order to enact any major restrictions. He also said that clusters identified by the state in Brooklyn, as well as Rockland and Orange counties in the Hudson Valley region, required movement to “stamp out the embers right away.”

“A cluster problem is caused by a lack of compliance,” Mr. Cuomo said on Tuesday. “Why was there a lack of compliance? Because the local government failed to do its compliance job.”

He called on local governments to take stronger action to enforce social-distancing rules. But in response to a question about the status of indoor dining, he said “I don’t believe we’re at the point of rolling back anything.”

The governor did warn that without local officials and communities taking more steps, the clusters could quickly turn into a wider outbreak. “A cluster today can be community spread tomorrow,” he said.

Mr. Cuomo has previously said that reaching a 2 percent positivity rate would make him “nervous,” and that surpassing a 3 percent rate would cause “the alarm bells to go off.”

All the clusters, he said on Tuesday, had “an overlap with large Orthodox Jewish communities” and that he would meet with religious leaders to discuss better compliance to mask-wearing and public health guidelines.

Mr. Cuomo also said Tuesday that travelers from Colorado are now required to quarantine for 14 days upon arrival, joining a long list of other states and territories. Arizona and Virginia were removed in the weekly update.

Travelers to Connecticut and New Jersey are also now subject to a 14-day quarantine if they are coming from those same places, though compliance is voluntary in New Jersey and there is a testing alternative in Connecticut.

United States › On Sept. 29 14-day
change
Trend
New cases 43,355 +13%
New deaths 918 –17%

Where cases are highest per capita

Credit…Christinne Muschi/Reuters

The sense that regular life was gradually returning to Quebec was upended this week when the province, faced with a resurgence of coronavirus cases, became the first in Canada to reintroduce tough shutdown measures — including closing restaurants, cinemas and theaters, and forbidding household visits to friends or family, with some exceptions. Schools will remain open.

“The situation has become critical,” Quebec’s premier, François Legault, said on Monday evening, lamenting that people had relaxed their vigilance and prioritized fun. “If we don’t want our hospitals to be submerged, if we want to limit the number of deaths, we must take strong action.”

The new restrictions will be imposed for 28 days and apply to three regions in Quebec, including Montreal.

Canadians have until recently taken some quiet satisfaction in the country’s sensible albeit patchwork approach to containing the virus. Political leaders have deferred to physicians, scientists and public health experts. But epidemiologists said inadequate contact tracing, an unwillingness to shut down schools and businesses, and people letting their guard down had exacerbated the surge. For example, the karaoke bar, Bar Kirouac, in Quebec City, was linked to 72 cases of Covid-19, according to Quebec health officials.

Alarm has also shaken neighboring Ontario, the most populous province, where some cities are again posting record case numbers, and some new, modest restrictions have been imposed, including shutting down strip bars and banning alcohol sales after 11 p.m.

On Tuesday, Ottawa, the national capital, reported 105 cases — its highest number of new cases in one day since the beginning of the pandemic. It now has the highest number of active cases since late April.

Quebec, Canada’s epicenter throughout the pandemic, reported 750 new cases on Monday, helping to bring the total number in the province to 73,450. In total, 5,833 people have died in Quebec; the entire country has seen 9,289 deaths.

Video

transcript

bars

0:00/0:54

0:00

transcript

Trump and Biden on a Coronavirus Vaccine

President Trump claimed that a vaccine for the coronavirus would be available to the public “soon,” while Joseph R. Biden Jr. expressed concern over the safety of any rapidly approved vaccine.

“He puts pressure and disagrees with his own scientists.” “But you’re saying, Senator Harris is saying you can’t trust the scientists.” “No, no, no, no — you can trust the scientists. She didn’t say that. You can trust —” “She said the public health experts, quote, will be muzzled, will be suppressed.” “Yes — well, that’s what he’s going to try to do, but there’s millions of scientists, there’s thousands of scientists out there, like here at this great hospital, that don’t work for him. Their job doesn’t depend on him. That’s not — they’re the people, and by the way —” “I spoke to the scientists that are in charge —” “— and by the way —” ”— they will have the vaccine very soon.” “Do you believe for a moment what he’s telling you, in light of all the lies he’s told you about the whole issue relating to Covid? He still hasn’t even acknowledged that he knew this was happening, knew how dangerous it was going to be back in February, and he didn’t even tell you.”

President Trump claimed that a vaccine for the coronavirus would be available to the public “soon,” while Joseph R. Biden Jr. expressed concern over the safety of any rapidly approved vaccine.CreditCredit…Mark Makela for The New York Times

Joseph R. Biden Jr. was given an opportunity in the first presidential debate Tuesday night to lay out how President Trump has botched the country’s response to the coronavirus crisis, the key topic for the Democratic nominee and the subject where the president is most vulnerable.

“He said, ‘It is what it is,’” Mr. Biden said, referring to the president’s reaction to the grim milestone earlier this year that 100,000 people in the United States had been killed by the virus (the death toll is now over 200,000). “It is what it is, because you are who you are,” Mr. Biden said.

“We should be providing all the protective gear possible,” Mr. Biden said. “The money the House has passed in order to be able to go out and get people the help they need to keep their businesses open.”

He added, “You should get out of your bunker and get out of the sand trap and your golf course and go in your Oval Office and bring together the Democrats and Republicans and fund what needs to be done now to save lives.”

Mr. Biden said voters should not trust the president on his promises of a vaccine within weeks. “He puts pressure and disagrees with his own scientists,” Mr. Biden said. He challenged voters that it was hard to believe him “in light of all the lies he’s told you about the whole issue relating to Covid.”

Mr. Trump defended his administration’s response, claiming that many Democratic governors had said he did a phenomenal job. Some Democratic governors over the spring walked a careful line because they did not want to risk alienating Mr. Trump and jeopardizing their ability to received desperately needed federal resources. But many Democratic governors criticized him. Gov. J.B. Pritzker of Illinois, a Democrat, for instance, said the federal government had “not lived up to its expectations” when it came to making coronavirus tests available.

“We got the gowns, we got the masks, we made the ventilators,” Mr. Trump said, claiming Mr. Biden would have failed to do so.

Mr. Trump said that his comment suggesting that ingesting disinfectant could help combat the virus was “said sarcastically, you know that.”

No issue has threatened Mr. Trump’s re-election more than a health crisis he has been unable to talk his way out of — one that has hurt him with older adults who are anxious for their lives, and complicated his attempts to appeal to more Black voters, who have been disproportionately affected by the virus.

When asked about his statements regarding the availability of a vaccine before the election — which directly contradict his own health experts who say it will most likely not be publicly available before next summer — Mr. Trump said they were wrong: “I’ve spoken to the companies and we can have it a lot sooner.”

“We’re for a vaccine, but I don’t trust him at all and nor do you, I know you don’t,” Mr. Biden said. “We trust the scientists.”

The president, frustrated that the economic gains he had claimed credit for and had expected to help him win re-election were wiped away, has deliberately tried to play down the seriousness of the virus, hoping it would simply disappear. In January, Mr. Trump dismissed it as “one person coming in from China,” even though he knew it was far more deadly than the common flu he compared it to in public. He has also claimed falsely that the United States had “among the lowest case fatality rates of any major country anywhere in the world,” even though it ranks in the top third.

Even as coronavirus cases spike across parts of the country, Mr. Trump has insisted that states could reopen, children should go to school, people should be allowed to worship at church and that he should be able to hold campaign rallies. He has helped make the wearing of face masks, which his own experts say are the most important measure to stop the spread and keep Americans safe, the latest front of the culture war, rather than a measure embraced by all.

Despite his best efforts to talk up his administration’s response to the virus crisis — and his efforts to change the subject, completely — Mr. Trump has not been able to convince voters that his response was adequate, according to polls. A recent ABC News poll showed that 58 percent of voters disapproved of the president’s performance on the pandemic.

Credit…Agence France-Presse — Getty Images

President Trump and Joseph R. Biden Jr. both invoked China during Tuesday’s presidential debate as they argued over who bore responsibility for the coronavirus outbreak in the United States.

Mr. Trump deflected blame, referring to the virus as the “China plague” and casting doubt on whether the official Covid-19 death tolls in China, Russia and India were accurate.

“It’s China’s fault,” he said of the crisis. “It should have never happened.”

Mr. Trump also said that without the travel measures that he had imposed on China over the winter, millions of Americans would have died.

However, the measures did not ban all travel from China. Nearly 40,000 people traveled to the United States from China from the end of January to April, after Mr. Trump’s restrictions were imposed. And during the first half of January, when Chinese officials were underplaying the severity of the outbreak, no travelers from China were screened in the United States for potential exposure to the virus.

On Tuesday, Mr. Biden said that in the early days of the outbreak, Mr. Trump could have asked China’s leader, Xi Jinping, to give permission for American experts to travel to Wuhan, the world’s first Covid-19 hot spot, to determine how dangerous the virus was.

“He did not even ask Xi to do that,” Mr. Biden said. “He told us what a great job Xi was doing. He said we owe him a debt of gratitude for being so transparent with us.”

Mr. Biden was referring to a tweet from late January in which the president thanked Mr. Xi, saying China had been “working very hard to contain the coronavirus” and that the U.S. “greatly appreciates their efforts and transparency.”

In Beijing on Wednesday, Wang Wenbin, a spokesman for China’s foreign ministry, was asked about the debate at a regular news conference. He told reporters that the government “resolutely opposes” efforts to involve China in the U.S. election, and that accusations leveled against the country during the debate were “groundless and untenable.”

Hu Xijin, the editor of Global Times, a staunchly nationalistic and Communist Party-run tabloid, also said on Twitter that Mr. Trump and Mr. Biden “obviously did not show an exemplary role to American people on how to engage in debates.”

“Such a chaos at the top of U.S. politics reflects division, anxiety of U.S. society and the accelerating loss of advantages of the U.S. political system,” added Mr. Hu, a combative public supporter of Mr. Xi’s government.

Others weighed in on Chinese social media platforms, saying that the debate had left them puzzled and amused.

One user said that Mr. Trump’s frequent interruptions of Mr. Biden lent a “comedic feel” to what should have been a serious discussion, while another compared the debate to a quarrel at a vegetable market.

Coral Yang contributed research.

A 19-year-old student at Appalachian State University — a basketball player “in tremendous shape,” according to his family — died Monday night, apparently of neurological complications related to Covid-19, his family and the university said.

Chad Dorrill, a sophomore at the school in Boone, N.C., had been living off campus and taking classes online when he became ill with flu-like symptoms, Appalachian State’s chancellor, Sheri Everts, wrote Tuesday in a statement to students.

Mr. Dorrill tested positive for the coronavirus on Sept. 7 and quarantined for 10 days with his family in Wallburg, N.C., before returning to Boone, according to an uncle, David Dorrill. He said after his nephew returned to college, he almost immediately began experiencing dramatic neurological problems.

“When he tried to get out of bed,” Mr. Dorrill said, “his legs were not working, and my brother had to carry him to the car and take him to the emergency room. The doctor said it was a one-in-a-million case — that they’d never seen something progress the way it did. It was a Covid complication that rather than attacking his respiratory system attacked his brain.”

Although colleges and universities have become hot spots in the pandemic, young, healthy people generally have been at lower risk for developing severe forms of Covid-19. Only a handful of deaths among American college students has been linked to the virus, including a football player at California University of Pennsylvania.

A New York Times database tracking the virus on college campuses has recorded at least 130,000 confirmed cases since the start of the pandemic, mostly this fall, but only about 70 confirmed deaths, mostly in the spring among college employees.

David Dorrill said an autopsy was being conducted. Dr. Colin McDonald, chair of neurology at Forsythe Medical Center in Winston Salem, N. C., where Chad’s parents removed him from life support at 8 p.m. on Monday, said that the hospital and staff who cared for him were “devastated” by his passing.

“We are doing everything we can to figure out why this happened,” Dr. McDonald said.

A new scientific report confirms that cats and dogs can be infected by the novel coronavirus, and that neither animal is likely to get sick. Cats, however, do develop a strong, protective immune response.

There is still no evidence to suggest that pets have passed the virus to humans, although cats do shed the virus and infect other cats.

Infected dogs in the study didn’t produce the virus in their upper respiratory tracts and didn’t shed it at all, although some other studies have found different results. Neither the cats nor the dogs in the study showed any illness.

Scientists say that while millions of humans have been infected with the virus worldwide and 1 million have died, there are only a handful of reports of pets that have become infected naturally.

So why haven’t cats infected humans if they shed the virus? It might be because the number of humans who have contracted the virus is so large, and they are the ones giving it to cats, said Angela M. Bosco-Lauth, one of the authors of the study. Another possible reason is that infection in everyday life is very different from infection in the lab, where scientists inserted pipettes in the nasal cavities of cats and dogs to give them the virus.

Or, Dr. Bosco-Lauth said, cat infection with the virus could be relatively common without humans noticing, because of a lack of symptoms.

Researchers advise keeping cats indoors, particularly if a human in a household has become infected, because they could spread it to other cats.

Credit…Elisabeth Ubbe for The New York Times

Almost alone in the Western world, Sweden refused to impose a coronavirus lockdown last spring, as the country’s leading health officials argued that limited restrictions were sufficient and would better protect against economic collapse.

It was an approach that transformed the country into an unlikely ideological lightning rod. Many scientists blamed it for a spike in deaths, even as many libertarians critical of lockdowns portrayed Sweden as a model.

For their part, the Swedes admit to making some mistakes, particularly in nursing homes, where the death toll was staggering. Now, though, the question is whether the country’s current low caseload — compared with sharp increases elsewhere — shows that it has found a sustainable balance, or whether the recent numbers are just a temporary aberration.

With a population of 10.1 million, Sweden averaged just over 200 new cases a day for several weeks, though in recent days that number has jumped to about 380, and critics say the country should test more. The per capita rate is far lower than nearby Denmark or the Netherlands (if higher than the negligible rates in Norway and Finland). Sweden is also doing far better, for the moment, than Spain, with 10,000 cases a day, and France, with 12,000.

In response to the recent outbreaks, many European countries are imposing new restrictions, but avoiding total lockdowns. In essence, some experts say, they are quietly adopting the Swedish approach.

“Today, all of the European countries are more or less following the Swedish model, combined with the testing, tracing and quarantine procedures the Germans have introduced, but none will admit it,” said Antoine Flahault, director of the Institute of Global Health, in Geneva. “Instead, they made a caricature out of the Swedish strategy. Almost everyone has called it inhumane and a failure.”

Credit…Hilary Swift for The New York Times

In the six months since Covid-19 brought the United States to a standstill, the opioid epidemic has taken a sharp turn for the worse. More than 40 states have recorded increases in opioid-related deaths since the pandemic began, according to the American Medical Association.

In Arkansas, the use of Narcan, an overdose-reversing drug, has tripled. Jacksonville, Fla., has seen a 40 percent increase in overdose-related calls. In March alone, York County in Pennsylvania recorded three times more overdose deaths than normal.

And in Vermont, opioid addiction has been a scourge for more than two decades, and as the painkillers that many young Vermonters became addicted to in the early 2000s grew harder to get starting about a decade ago, heroin moved in. Then came fentanyl, which is far more potent and has driven up deaths in almost every corner of the country.

Last year, after aggressive efforts to expand access to treatment, Vermont saw its first decrease in opioid-related deaths since 2014; that year, the governor devoted his entire State of the State Message to what he called “a full-blown heroin crisis” gripping Vermont.

But Vermont saw 82 opioid overdoses through July of this year, up from 60 during the same period last year.

Hardest hit is Windham County, which borders New Hampshire and Massachusetts. In the first three months of this year, emergency workers in Brattleboro, the county seat, responded to 10 overdose calls, none of them fatal. But by August they had responded to a total of 53 overdoses, including seven that were fatal.

SPORTS ROUNDUP

Credit…Stephen Maturen/Getty Images
  • After an auspicious beginning to the N.F.L. regular season played during a pandemic, the league got news of its first coronavirus outbreak after Week 3’s games. The Tennessee Titans suspended all in-person activities Tuesday after three players and five members of the team’s personnel tested positive, the first such outbreak to hit a team since training camps began in late July. The Minnesota Vikings, who hosted the Titans on Sunday, also shut down in-person activities. “Both clubs are working closely with the N.F.L. and the N.F.L.P.A., including our infectious disease experts, to evaluate close contacts, perform additional testing and monitor developments,” the league said in a joint statement with the players’ union. “All decisions will be made with health and safety as our primary consideration. We will continue to share updates as more information becomes available.”

  • After weeks of indecision and discussion, FIFA is planning to order soccer clubs to release players who have been called up for World Cup qualification games next week, a move that is very likely to lead to a furious backlash from teams, leagues and player unions fearful of the risks of international travel during the pandemic. The FIFA demand will come after weeks of unsuccessful talks to find a compromise that addresses concerns about committing players to intercontinental travel amid a global rise in cases, and will apply most notably to South American national teams eager to recall their overseas-based players for the first round of qualifying matches for the 2022 World Cup.

Credit…James Estrin/The New York Times

Fatimah Ali spent the first days of April organizing a Zoom memorial service for Sandra Santos-Vizcaino, the first New York City public-school teacher to die of the coronavirus and a beloved third-grade teacher at Brooklyn’s Public School 9.

This week, Ms. Ali, the school’s principal, hopes she can bring a similar sense of calm to another exceptionally difficult moment: the reopening of school on Tuesday. Finding ways to make the building feel welcoming and safe for students who have been away for six months is as complex a challenge as Ms. Ali has faced in her career.

And she must do this in a city where people are still reeling from the events of the spring, when many hundreds of New Yorkers were dying each day, and where many parents remain nervous about returning to schools.

That’s why the trauma that has come with school reopening in New York City “is doubly as real for us,” Ms. Ali said. Nearly half of families across the city have opted their children out of in-person classes altogether through at least the end of November, a statistic that reflects both the pervasive fear felt by many city parents and skepticism of the city’s reopening plan.

Just a few weeks after the death of Ms. Santos-Vizcaino, Ms. Ali logged on to a Google Hangouts session and watched as the faces of third-grade students, some of whom were taught by Ms. Santos-Vizcaino, popped up on the screen.

“Today the purpose is to learn from you, and to share the tools we all can use to help us feel happy,” Ms. Ali told the children on a cloudy morning in early May. She held up her own journal, and encouraged the students to write down what they were experiencing. “I feel scared” was the first prompt.

Credit…Robert Franklin/South Bend Tribune, via Associated Press

The president of the University of Notre Dame, the Rev. John I. Jenkins, has issued a public apology after coming under criticism for not wearing a mask or adhering to social distancing guidelines during the Supreme Court nomination ceremony over the weekend at the White House for Judge Amy Coney Barrett.

“I failed to lead by example,” Father Jenkins, who is also a philosopher trained in theology and a member of Notre Dame’s philosophy department, said in a letter on Monday to the Notre Dame community. “I especially regret my mistake in light of the sacrifices made on a daily basis by many, particularly our students, in adjusting their lives to observe our health protocols.”

The move by Father Jenkins points to the challenges some public figures face as they promote virus-mitigation efforts. He has repeatedly urged students and staff to hew to social-distancing guidelines but was seen in videos and photographs shaking hands with others and not wearing a mask at the Rose Garden event on Saturday for Judge Barrett, who is a professor at Notre Dame.

In his written apology, Father Jenkins said he was given a rapid coronavirus test upon arriving at the White House. He said he and others were told after receiving negative results that it would be safe to remove their masks. Still, he said following that guidance was a mistake.

In August, Notre Dame became one of the first major universities to resume in-person classes, but had to shift to virtual learning for two weeks this month in response to a spike in coronavirus cases. While Notre Dame has switched again to in-person classes, Father Jenkins said he had decided to quarantine “in an abundance of caution” after returning to the campus from the White House.

In other news around the United States:

  • In the six months since Covid-19 brought the United States to a standstill, the opioid epidemic has taken a sharp turn for the worse. Last year, after aggressive efforts to expand access to treatment, Vermont saw its first decrease in opioid-related deaths since 2014; that year, the governor devoted his entire State of the State Message to what he called “a full-blown heroin crisis” gripping Vermont. But the state saw 82 opioid overdoses through July of this year, up from 60 during the same period last year.

  • In New York City, a principal prepared for the first day of school at Brooklyn’s Public School 9, where Sandra Santos-Vizcaino — the first New York City public-school teacher to die of the coronavirus — was once a beloved third-grade teacher. Nearly half of families across the city have opted their children out of in-person classes altogether through at least the end of November, a statistic that reflects both the pervasive fear felt by many city parents and skepticism of the city’s reopening plan.

  • After months of keeping tens of thousands of theme park workers on furlough with full health-care benefits in hopes that a light at the end of the pandemic tunnel would appear, Disney announced it would eliminate 28,000 theme park jobs in the United States, or about 25 percent of its domestic resort work force. The job cuts will come from Disney’s theme parks in California and Florida.

Credit…Octavio Jones/Getty Images

The day after Florida surpassed 700,000 coronavirus cases, Dr. Anthony S. Fauci, the nation’s top infectious disease expert, called the recent move by the governor to lift state restrictions on bars and restaurants “very concerning.”

“Now’s the time, actually, to double down at bit,” Dr. Fauci said Monday on ABC’s “Good Morning America.” “And I don’t mean close. When I say that, people get concerned that we’re talking about shutting down. We’re not talking about shutting anything down. We’re talking about common-sense type of public health measures.”

He also expressed reservations about the lack of mask usage, saying Florida and other states were “asking for trouble” by allowing people to congregate without masks. Gov. Ron DeSantis of Florida, a Republican and Trump ally, refused on Friday to mandate mask usage in the state, insisting that such a decision should be left up to local governments.

At a news conference on Tuesday, Mayor Carlos Gimenez of Miami-Dade County discussed a weekly call he had earlier in the day with Dr. Fauci and Dr. Deborah L. Birx. Mr. Gimenez said that on the call, Dr. Birx, too, appeared to be “deeply concerned” with the governor’s decision.

He added that Dr. Birx noted that the virus positivity rate in Miami-Dade remains higher than it was in May. As of Tuesday, the average 14-day positivity rate in the county was 4.44 percent.

“She was heartened by the steps that we took, but she was somewhat concerned about the loosening of the rules,” he said.

In the last week, the state has been experiencing a relatively low number of new cases a day, on average — about one-fifth the seven-day average number of new cases a day it reported at its peak on July 17.

As of Monday, Florida was meeting 36 percent of a testing target developed by Harvard Global Health Institute researchers that measures the minimum amount of testing necessary to mitigate the disease. The state had a positivity rate of 11 percent for the total number of tests processed over the two-week period ending Monday, according to data analyzed by The New York Times. Positive rates should be at or below 5 percent for at least 14 days before a state or country can safely reopen, according to the World Health Organization.

On Friday, Mr. DeSantis removed state restrictions for restaurants and many other businesses. He has also pushed the state’s largest school district, in Miami-Dade County, to open classrooms to in-person learning, despite concerns from parents and teachers.

Over the weekend, Tallahassee police broke up a large party near Florida State University’s campus where about 700 cars were parked and blocking travel lanes, and more than 1,000 people gathered outside. The university has been trying to contain the spread of the virus on campus, where 1,448 students and 31 employees have tested positive since Aug. 2, including 51 people last week. Over a seven-day period ending Monday, Leon County, which includes Tallahassee, has reported 501 new cases, according to a Times database.

While other universities have suspended and expelled students for attending parties against campus policies, Mr. DeSantis last week called those measures “dramatically draconian” and called for creating a “bill of rights” for college students. The return of students to campus — and the parties that come with them — have been blamed for some of the recent outbreaks across the country.

On “Good Morning America,” Dr. Fauci was asked whether he agreed with W.H.O. projections that global deaths, which surpassed one million this week, might double before vaccines could bring the virus under control.

“I’ve got to be careful,” he replied, noting that such predictions, imprecise by nature, might inappropriately ring alarms. “But you’ve got to take it very seriously,” he said of a possible doubling in worldwide deaths. “The numbers globally are very serious.”

Global roundup

Credit…Sebastian Scheiner/Associated Press

Israel’s second national lockdown is likely to last at least a month and perhaps much longer, Prime Minister Benjamin Netanyahu said on Tuesday, as the country’s soaring infection rate of around 8,000 confirmed new cases a day remained among the highest in the world.

“In my opinion, it won’t be less than a month, and it could take much more time,” Mr. Netanyahu said during a Facebook Live video session.

The lockdown came into effect in mid-September, on the eve of the Jewish New Year holiday, and was tightened on Friday after Mr. Netanyahu warned that without immediate measures, Israel would “reach the edge of the abyss.” Israelis must remain within 1,000 meters of their homes unless they are going to authorized places of work or seeking essential supplies or services, and outdoor gatherings are limited to 20 people.

But synagogues were allowed to hold indoor prayers for limited numbers of worshipers during Yom Kippur, the holiest day in the Jewish calendar, which fell on Sunday night and Monday, and large gatherings of ultra-Orthodox worshipers were captured on video in several locations.

The number of seriously ill virus patients has surpassed 800, a number that government and health officials had long cited as the maximum that Israel’s hospitals could cope with in their current capacity.

Israel reported 234 virus deaths over the last week, which works out to 2.6 per 100,000 people, exceeding the per capita death rate for that period in the United States.

In other developments around the world:

  • South Korea said on Wednesday that it will impose a fine of up to $85 on anyone caught without a mask in public, starting on Oct. 13. As people in the country began on Wednesday to celebrate Chuseok, a major holiday that runs through the weekend, health officials reported 113 new cases, the highest daily tally in five days. Tens of millions of South Koreans are traveling for Chuseok and officials fear that holiday gatherings could create new vectors of infection.

  • The authorities in Germany announced a number of new rules to try to halt rising cases while keeping the economy, schools and day care centers open. Group gatherings will be capped at 50 in bars and rented spaces, with a recommendation that private parties be capped at 25. Bars, restaurants, hairdressers and others will be fined a minimum of about $58 if patrons don’t leave required contact data.

  • Kenya on Monday extended its nationwide curfew for two months, though it will start two hours later, at 11 p.m. In an address to the nation, President Uhuru Kenyatta also said bars and nightclubs could reopen starting Tuesday. There will be no change to schools, which have been closed since March.

  • The drug company Regeneron announced on Tuesday that a Covid-19 treatment in an ongoing study hastened recovery time and reduced the amount of virus in the nasal cavities of a small number of volunteers. Its drug is a combination of two monoclonal antibodies, powerful proteins that can attach to and destroy the virus. The new results are from 275 volunteers who were treated after being diagnosed with Covid-19, half of whom received one infusion of the drug while the rest got a placebo. Volunteers who were not making their own antibodies at the start of the trial benefited the most, Regeneron reported; their symptoms resolved in an average of 6 to 8 days, compared with 13 days in those who received a placebo. Dr. George Yancopoulos, the company’s president and chief scientific officer, said in a news release that Regeneron had “begun discussing our findings with regulatory authorities.”

  • Twelve crew members on a cruise ship intercepted by the authorities in Greece tested negative for the virus on Tuesday, after initially testing positive. The ship, carrying more than 1,500 people and bound for the Greek island of Corfu, was docked in Piraeus, Greece’s main port.

Katina Brenn, the school superintendent in Colby, Kan., knows what is supposed to be done when students are exposed to the virus: Quarantine them at home for 14 days.

But what if it’s a quarter of the school?

Colby is a small town in western Kansas, with fewer than 300 students in its close-knit high school. When a girl on the volleyball team tested positive recently, the whole team was sent home to quarantine. Then a football player was exposed, raising concerns about the rest of the squad. Soon, the school was facing having to quarantine as many as 75 students.

The town pushed back. “The parents were upset,” Ms. Brenn said. “They want their kids to get an education.”

She said she heard from parents who were worried that the way things were going, their children would have to be quarantined again and again when someone they knew was potentially exposed — and in Colby, everybody knows everybody.

The pandemic, once mainly an urban problem, has surged across the Great Plains and Upper Midwest in recent weeks, reaching previously unscathed small towns and rural areas. North Dakota, South Dakota and Wisconsin now lead the nation in new cases per capita, and the figures for states like Kansas are as bad as they have ever been.

No one has yet died of Covid-19 in Thomas County, which includes Colby, but there have been 163 coronavirus cases so far among the population of 7,700, and one-third of those cases are new and considered currently active. And the hub of the community is Colby High.

Ms. Brenn said having the schools open for in-person learning was vital, so parents could go to work and keep the town running.

At a recent county meeting, officials agreed to roll back restrictions and allow students who were not directly exposed to a known case and who had no symptoms to return to school.

“Parents really want their children to be at school,” Ms. Brenn said, adding that the school system had taken precautions like hula hoops laid out on gym floors to enforce spacing between students during physical education classes. “We’re really trying to keep our kids safe,” she said. “We think that their schools are their safe place.”

Credit…Federico Parra/Agence France-Presse — Getty Images

An independent association of health workers in Venezuela reported this week that at least 200 doctors, nurses and health care technicians across the country have died after contracting the coronavirus.

The count by Médicos Unidos Venezuela involves a rare effort to provide greater visibility into how the virus is evolving in Venezuela. Officially, Venezuela’s government says the virus has killed only 12 health workers.

In what critics contend is also a gross undercount, Venezuela officially had 73,528 cases and only 614 deaths as of Monday, far lower than any other large country in Latin America either on a per capita or absolute basis. Neighboring Colombia has reported 818,203 cases and 25,641 deaths.

Public health experts say the Venezuelan government’s repressive measures in response to the pandemic are hampering efforts to accurately assess its impact. Security forces have detained at least 12 doctors and nurses in Venezuela for speaking publicly about the virus, according to medical unions.

Venezuela’s health ministry did not immediately respond to a request for comment.

Dr. Jaime Lorenzo, the director of Médicos Unidos, said the exodus of thousands of health workers from Venezuela in recent years had also constrained efforts to mitigate the spread of the virus in the country.

“The personnel we have left are getting sick as they deal with fatigue and a lack of protective equipment,” Dr. Lorenzo said.

Health care workers have been hit hard by the virus around the world. In a survey of countries in the Western Hemisphere, including the United States, the Pan American Health Organization found that the virus had killed more than 2,500 health workers, the group said this month.

A leading humanitarian relief organization issued a sharply critical report Tuesday on what it described as fundamental shortcomings in the global response to the pandemic, punctuated by “absence of global leadership, insufficient funding, and lack of coordination between countries.”

The report by the International Rescue Committee, a group formed during World War II that responds to the most urgent humanitarian crises, said it had calculated that an unprecedented $8 trillion had been committed by governments to domestic economic stimulus packages to counter the pandemic’s effects — but only $48 billion for areas of the world least capable of combating the scourge. The group said the lack of a coordinated approach to the pandemic had led to “dire consequences for millions of the most vulnerable people around the world.”

Within the first few months of lockdown measures this year, the group said, 15 million more known cases of gender-based violence were reported. An additional 70 to 100 million people could be pushed into extreme poverty, it said, and 10 of the world’s most fragile countries could face famine this year or in the first quarter of 2021.

“The international community has both a moral obligation and strategic imperative to support the most vulnerable,” said David Miliband, the president and chief executive of the International Rescue Committee.

Its report, coming as global virus deaths surpassed 1 million, was issued on the final day of the United Nations General Assembly session, held virtually this year because of the pandemic. The 193-member organization’s inability to manage the crisis, which Secretary General António Guterres has called the biggest challenge in U.N. history, has been a recurring theme.

Mr. Guterres’s frustration was evident in his opening remarks on Tuesday to one of the last online sessions of the General Assembly.

“Unless we take action now, we face a global recession that could wipe out decades of development,” Mr. Guterres said.

As obesity continues to climb in the United States, its role in Covid-19 is a thorny scientific question. Recent studies have shown that people with extra weight are more susceptible than others to severe bouts of disease. And experiments in animals and human cells have demonstrated how excess fat can disrupt the immune system.

But the relationship between obesity and Covid-19 is complex, and many mysteries remain. Excess weight tends to go hand in hand with other medical conditions, like high blood pressure and diabetes, which may by themselves make it harder to fight Covid-19.

Obesity also disproportionately affects people who identify as Black or Latino — groups at much higher risk than others of contracting and dying from Covid-19, in large part because of exposure at their workplaces, limited access to medical care and other inequities tied to systemic racism. And people with extra weight must grapple with persistent stigma about their appearance and health, even from doctors, further imperiling their prognoses.

“A new pandemic is now laying itself on top of an ongoing epidemic,” said Dr. Christy Richardson, an endocrinologist at SSM Health in Missouri. Regarding obesity’s effects on infectious disease, she said, “We are still learning, but it’s not difficult to understand how the body can become overwhelmed.”

Like many other conditions that can exacerbate Covid-19, excess weight does not have a quick fix, especially in areas where access to healthy food and opportunities for exercise are vastly uneven among communities.

“If we don’t address these social underpinnings, I think we’ll continue to see a recurrence of what is happening now,” said Dr. Jennifer Woo Baidal, a pediatric weight management specialist at Columbia University.

Credit…Adrees Latif/Reuters

A wariness of spam calls and phishing scams has stymied coronavirus contact-tracing efforts around the country to the extent that elected leaders are pleading with their constituents to pick up their phones.

“Hello? Yes, it’s you we’re looking for,” Mayor Muriel Bowser of Washington, D.C., told residents. “Contact tracing is a critical tool in getting our city back on its feet. Answer the call.”

Gov. Mike DeWine of Ohio urged those in his state to “answer the call!”

Both of their pleas, sent in tweets, told residents that contact tracers would not ask them about information like Social Security numbers or bank accounts. But most people don’t wait long enough to hear the voice on the other end.

They have good reason to be wary: Americans received 58.5 billion automated calls, often referred to as robocalls, in 2019, according to YouMail, which provides software that blocks such calls.

The nation’s capital received the most robocalls per person last year, according to YouMail: The average person in Washington was barraged with 599 calls in 2019.

Carolyn Cannuscio, an associate professor of family medicine at the University of Pennsylvania, said that while contact tracing could still be effective without a 100 percent response rate, “the process depends upon active engagement of the public.”

Volunteers at the university have been tracing contacts since April, Dr. Cannuscio said, in conjunction with the Philadelphia Health Department. Calls from the team show as “Penn Medicine,” she said, and around 75 percent of people called answer.

“That’s far better than what many municipalities are reporting,” she said.

Credit…Sharon Chischilly for The New York Times

Long before the coronavirus, the Indian Health Service, the U.S. government program that provides health care to the 2.2 million members of tribal communities, was plagued by shortages of funding and supplies.

Now the pandemic has exposed those weaknesses as never before, contributing to the disproportionally high infection and death rates among Native Americans and fueling new anger about what critics say has been decades of neglect from Congress and successive administrations in Washington.

Hospitals waited months for protective equipment, some of which ended up being expired, and had far too few beds and ventilators to handle the flood of Covid-19 patients. The agency failed to tailor health guidance to the reality of life on poverty-wracked reservations.

The virus has killed more than 500 people in the Navajo Nation in the southwestern United States, giving it a death rate higher than New York, Florida and Texas. It has infected more than 10 percent of the small Choctaw tribe of Mississippi.

A New York Times analysis found that the coronavirus positivity rate for Indian Health Service patients in Navajo Nation and the Phoenix area was nearly 20 percent from the start of the pandemic through July, compared with 7 percent nationally during the same period. It is now down to about 14 percent in both areas, nearly three times higher than the current nationwide rate.

Credit…Ramon Van Flymen/EPA, via Shutterstock

The Netherlands tightened its coronavirus restrictions on Monday while warning that its most severe wave of cases yet was likely to get worse.

People in the country’s three largest cities — Amsterdam, Rotterdam and The Hague — are now advised to wear masks in stores, a step the government had not yet recommended. Bars and restaurants will be closed at 10 p.m., with no new customers allowed after 9 p.m.

No more than four people will be allowed in a group indoors, with a total capacity of 30 people, and just three visitors can be hosted inside a home. A limit of 40 people was set for outside gatherings, with exceptions for events like funerals and religious gatherings.

The new restrictions are effective as of Tuesday night and will be in place for at least three weeks.

The Netherlands, with a population of 17.4 million, never instituted a full lockdown, instead targeting more high-risk businesses for shutdowns. Its daily cases had topped out at 1,335 on April 10 before falling into double-digits in June and July.

But figures began rising in late July, and September has seen a dramatic, steady increase. Officials recorded nearly 3,000 cases on Sunday and Monday, and warned that the figure was expected to reach 5,000 in the coming weeks.

“We’re doing our best, but the virus is doing better,” Hugo de Jonge, the country’s health minister, said at a news conference on Monday.

Credit…Anna Moneymaker for The New York Times

Negotiators resumed talks on Monday over a coronavirus relief package in a final bid to revive stalled negotiations as House Democrats unveiled a $2.2 trillion coronavirus relief bill that would provide aid to American families, businesses, schools, restaurants and airline workers.

The release of the legislation came minutes before Speaker Nancy Pelosi of California and Steven Mnuchin, the Treasury secretary, spoke on the phone Monday evening, as the pair seeks to end the impasse over another round of aid. Ms. Pelosi and Mr. Mnuchin spoke for about 50 minutes Tuesday morning, said Drew Hammill, a spokesman for Ms. Pelosi, and discussed the new legislation House Democrats had introduced. The pair agreed to speak again on Wednesday.

The moves appeared to be the most concrete action toward another stimulus bill since negotiations stalled nearly two months ago. But the sides remain far apart on an overall price tag, and with just over a month before Election Day, lawmakers and aides in both chambers warned that the time frame for striking a deal was slim.

Absent an agreement with the administration, the House could vote this week to approve the legislation, responding to growing pressure for Congress to provide additional relief and quelling the concerns of moderate lawmakers unwilling to leave Washington for a final stretch of campaigning without voting on another round of aid. But at roughly $1 trillion more than what Mr. Mnuchin has signaled the White House is willing to consider, the package is likely just a starting point, all but guaranteed to be rejected by the Republican majority in the Senate should the House pass it in its current form.

Democrats maintained a provision that would revive a lapsed $600 enhanced federal unemployment benefit and another one that would send a second round of $1,200 stimulus checks to Americans. And some measures were either added or expanded: $225 billion for schools and $57 billion for child care, an extension of an expiring program intended to prevent the layoffs of airline workers through March 31 and the creation of a $120 billion program to bolster ailing restaurants.

Credit…Fabio Bucciarelli for The New York Times

In the 10 months since a mysterious pneumonia began striking residents of Wuhan, China, Covid-19 has killed more than one million people worldwide as of Monday — an agonizing toll compiled from official counts, yet one that far understates how many have really died.

The coronavirus may already have overtaken tuberculosis and hepatitis as the world’s deadliest infectious disease. And unlike all the other contenders, it is still growing fast.

Like nothing seen in more than a century, the virus has infiltrated every populated patch of the globe, sowing terror and poverty, infecting millions of people in some nations and paralyzing entire economies.

But as attention focuses on the devastation caused by halting a large part of the world’s commercial, educational and social life, it is all too easy to lose sight of the most direct human cost.

More than a million people — parents, children, siblings, friends, neighbors, colleagues, teachers, classmates — all gone, suddenly, prematurely. More than 200,000 in the United States, which has the largest total number of coronavirus deaths in the world, followed by Brazil, with over 140,000.

Dr. Michael Ryan, the head of the World Health Organization’s emergencies program, said on Monday that the actual numbers were probably higher.

“When you count anything, you never count it perfectly,” he said at a news conference in Geneva. “But I can assure you that the current numbers are likely an underestimate of the true toll of Covid.”

Those who survive Covid-19, the disease caused by the virus, are laid low for weeks or even months before recovering, and many have lingering ill effects of varying severity and duration.

Yet much of the suffering could have been avoided.

“This is a very serious global event, and a lot of people were going to get sick and many of them were going to die, but it did not need to be nearly this bad,” said Tom Inglesby, the director of the Johns Hopkins Center for Health Security.

At the height of the first wave, places like China, Germany, South Korea and New Zealand showed that it was possible to slow the pandemic enough to limit infections and deaths while still reopening businesses and schools.

But that requires a combination of elements that may be beyond the reach of poorer countries — and that even ones like the United States have not been able to muster: wide-scale testing, contact tracing, quarantining, social distancing, mask wearing, providing protective gear, developing a clear and consistent strategy, and being willing to shut things down in a hurry when trouble arises.

Time and again, experts say, governments reacted too slowly, waiting until their own countries or regions were under siege, either dismissing the threat or seeing it as China’s problem, or Italy’s, or New York’s.

Thomas R. Frieden, a former head of the U.S. Centers for Disease Control and Prevention, said that a major failing had been in governments’ communication with the public, nowhere more so than in the United States.

“You have standard principles of risk communication: Be first, be right, be credible, be empathetic,” he said. “If you tried to violate those principles more than the Trump administration has, I don’t think you could.”

The world now knows how to bend the curve of the pandemic — not to eliminate risk, but to keep it to a manageable level — and there have been surprises along the way.

Masks turned out to be more helpful than Western experts initially predicted. Social distancing on an unheard-of scale has been more feasible and effective than anticipated. The difference in danger between an outdoor gathering and an indoor one is greater than expected.

And, crucially, people are most contagious when they first show symptoms or even earlier, not days or weeks later, when they are sickest — a reversal of the usual pattern with infectious diseases. That makes preventive measures like wearing masks and swift responses like isolating and testing people for possible exposure much more important. If you wait until the problem is evident, you’ve waited too long.

Credit…Pete Kiehart for The New York Times

While families across the United States this summer were on edge about the coming school year, top White House officials were pressuring the Centers for Disease Control and Prevention to play down the risk of sending children back to school, according to documents and interviews with current and former government officials.

The effort included an attempt to find alternate data showing that the coronavirus pandemic was weakening and posed little danger to children — a strikingly political intervention in one of the most sensitive public health debates of the pandemic.

A member of Vice President Mike Pence’s staff said she was repeatedly asked by Marc Short, the vice president’s chief of staff, to get the C.D.C. to produce more reports and charts showing a decline in coronavirus cases among young people.

Mr. Short dispatched junior members of the vice president’s staff to circumvent the C.D.C. in search of data he thought may better support the White House’s position, said Olivia Troye, the aide, who has since resigned.

In another instance, Dr. Deborah L. Birx, the White House’s coronavirus response coordinator, pushed the C.D.C. to incorporate a document from a mental health agency inside the Department of Health and Human Services that warned school closures would have a long-term effect on the mental health of children and that asymptomatic children were unlikely to spread the virus.

Scientists at the C.D.C. pointed out numerous errors in the document and raised concerns that it appeared to minimize the risk of the coronavirus to school-age children, according to an edited version of the document obtained by The New York Times.

The gist of the mental health agency’s position — stressing the potential risks of children not attending school — became the introductory text of the final C.D.C. policy, leaving some officials there dismayed.

United States › On Sept. 29 14-day
change
Trend
New cases 43,355 +13%
New deaths 918 –17%

Where cases are highest per capita

Credit…Mark Abramson for The New York Times

After months of promising signs in its fight against the coronavirus, New York State on Monday reported a spike in its rate of new cases, including a rise in New York City and in its northern suburbs.

The rate of positive test results in the city reached 1.93 percent, Mayor Bill de Blasio said on Monday, an increase from the 1.5 percent rate reported by the city a week before, as officials continued to warn about dangerous behavior in several communities.

The increase in the city, the onetime center of the pandemic, and some suburbs contributed to the statewide rate of approximately 1.58 percent — a jump from results reported on Sunday and in prior weeks.

Gov. Andrew M. Cuomo, a third-term Democrat, said on Monday that the increase was primarily because of clusters in Brooklyn, as well as in Rockland and Orange Counties, in the Hudson Valley, saying there was “significant action” in those areas.

Officials are particularly concerned about eight neighborhoods in Brooklyn and Queens, some with large Orthodox Jewish communities, that have accounted for about one-fourth of New York City’s new cases in the past two weeks, despite representing about 7 percent of the city’s population.

On Monday, Mr. Cuomo said that he would make 200 rapid testing machines available to schools and local governments in areas where rates were rising, saying “the key with these clusters is to jump on them quickly.”

All told, the state on Monday reported 834 new cases, out of nearly 53,000 tests, the governor said, adding that the spike in the positivity rate was largely confined to 20 ZIP codes, where the rate went as high as 30 percent, in contrast with the rest of the state, where the rate remained around 1 percent.