First Documented Coronavirus Reinfection Reported in Hong Kong – The New York Times

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A 33-year-old man was infected a second time with the coronavirus more than four months after his first bout, the first documented case of so-called reinfection, researchers in Hong Kong reported Monday.

The finding was not unexpected, especially given the millions of people who have been infected worldwide, experts said. And the man had no symptoms the second time, suggesting that even though the prior exposure did not prevent the reinfection, his immune system kept the virus somewhat in check.

“The second infection was completely asymptomatic — his immune response prevented the disease from getting worse,” said Akiko Iwasaki, an immunologist at Yale University who was not involved with the work but reviewed the report at The New York Times’s request. “It’s kind of a textbook example of how immunity should work.”

People who do not have symptoms may still spread the virus to others, however, underscoring the importance of vaccines, Dr. Iwasaki said. In the man’s case, she added, “natural infection created immunity that prevented disease but not reinfection.”

“In order to provide herd immunity, a potent vaccine is needed to induce immunity that prevents both reinfection and disease,” Dr. Iwasaki said.

Doctors have reported several cases of presumed reinfection in the United States and elsewhere, but none of those cases have been confirmed[1] with rigorous testing. Recovered people are known to carry viral fragments for weeks, which can lead to positive test results in the absence of live virus.

But the Hong Kong researchers sequenced the virus from both of the man’s infections and found significant differences, suggesting that the patient had been infected a second time.

Updated

Listen to ‘The Daily’: Where We Stand on the Pandemic

As summer draws to a close, four new developments in the treatment and understanding of the coronavirus have arisen in the United States and abroad.

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transcript

Listen to ‘The Daily’: Where We Stand on the Pandemic

Hosted by Michael Barbaro, produced by Stella Tan, Eric Krupke and Jessica Cheung, and edited by Lisa Chow

As summer draws to a close, four new developments in the treatment and understanding of the coronavirus have arisen in the United States and abroad.

michael barbaro

From The New York Times, I’m Michael Barbaro. This is “The Daily.”

Today: My colleague, Donald G. McNeil Jr. on four new developments in the treatment and understanding of the coronavirus.

It’s Tuesday, August 25.

Donald, we wanted to check back in with you because the summer is drawing to a close and there have been a few major developments in the pandemic that we wanted to better understand by talking to you, our resident expert on the coronavirus. And the first development involves a new treatment in the U.S. So tell us about that.

archived recording (president donald trump)

Thank you very much. It’s good to see you all. Hope you have —

donald g. mcneil jr.

So just in time for the Republican convention, the Food and Drug Administration director, on the podium with his boss, the head of H.H.S., and his boss, the President of the United States —

archived recording (president donald trump)

Today, I’m pleased to make a truly historic announcement in our battle against the China virus that will save countless lives.

donald g. mcneil jr.

— gave emergency use authorization —

archived recording (president donald trump)

— a powerful term, emergency use authorization for a treatment known as convalescent plasma.

donald g. mcneil jr.

— to a therapy called convalescent plasma.

archived recording (president donald trump)

Because the F.D.A. has really stepped up and especially over the last few days in getting this done. The results have been incredible. And I think you’ll see the results even go up very substantially. So we appreciate it and —

michael barbaro

And Donald, what is convalescent plasma?

donald g. mcneil jr.

Convalescent plasma is the serum from blood that’s taken from people who are convalescing, who are recovering from having had Covid. You draw out about a pint of their blood. You spin it down to take off the red blood cells and white blood cells, and then you keep the serum that contains a lot of things, including the antibodies. I probably shouldn’t admit this, but I used to sell plasma when I was in college.

michael barbaro

Wait, I’m sorry, whose plasma did you sell?

donald g. mcneil jr.

Mine.

michael barbaro

Huh.

donald g. mcneil jr.

Yeah, $5 for the first donation a week, $15 for the second. I paid my rent for part of the time in college that way. And I assume, although I never asked back then, that they wanted it for the clotting factors they had for hemophiliacs.

michael barbaro

And just to be clear, who were you selling it to, presumably not like somebody off the street?

donald g. mcneil jr.

No, no, to a blood bank.

michael barbaro

And why would anyone pay for your plasma or anyone else’s plasma for that matter? What is so special about blood plasma?

donald g. mcneil jr.

It contains your antibodies. And antibodies is what they need to kill the virus as it’s going through them.

michael barbaro

Got it. And so this is now being applied to Covid-19?

donald g. mcneil jr.

Yes. People who have had Covid and are immune to it are in very high demand for their plasma, which has antibodies in it, which is what the president and the F.D.A. approved for emergency use authorization this weekend.

archived recording (president donald trump)

And today, I once again urge all Americans who have recovered from the virus to go to coronavirus.gov and sign up and donate plasma today, please.

michael barbaro

And what was the evidence that the Trump administration cited in granting this emergency use authorization for blood plasma?

donald g. mcneil jr.

There is a program to distribute plasma and analyze the results run by the Mayo Clinic. And they are aiming to give the plasma out to 70,000 patients and see how they do. And the result was that people who got plasma did not do better across the board. But if you splice out a subgroup of people who were under 80 years old, hospitalized, but not on ventilators, were given a high dose of plasma, not a low or medium dose, and were given it within three days of diagnosis, those people did better. And better was defined as — they seemed to have a 35 percent lower chance of dying.

michael barbaro

So a narrow slice of that overall group of people who got this blood plasma did 35 percent better. And that was the basis for this emergency authorization?

donald g. mcneil jr.

Yes, but some doctors, some experts are unhappy with the way this is done, because they would want to know a lot more things. Even in the context of this trial, they would like to know what other treatments those patients got just in case they got something like the steroids that we already know save people, or the remdesivir that we already know saves people. And really, what they’d like to see is a real randomized clinical trial done in which half the people got plasma and the other half of the people got placebo, and neither the doctors nor the patients knew who was getting which.

michael barbaro

Right.

donald g. mcneil jr.

Because that’s really the only way in order to prove something really works.

michael barbaro

So why not undertake such a clinical trial now?

donald g. mcneil jr.

The Tony Faucis and Francis Collins would love to. The problem is that people are so excited about the idea of plasma, because it’s been talked up, that they refuse to go into a clinical trial. Because they would get a 50 percent chance of getting the placebo. And once you’re sick, you don’t want that. You want — hey, if you think it saves me, give it to me.

michael barbaro

Oh, that’s interesting. So the government’s decision — the Trump administration’s decision to talk up blood plasma as a potential treatment, even though there’s not a ton of evidence for it, might actually make it harder to do the kind of gold standard clinical trial test that lots of doctors, it sounds like — including Anthony Fauci — would want to know whether or not plasma really is a serious therapy for Covid-19.

donald g. mcneil jr.

Yeah, and that’s exactly what happened with hydroxychloroquine. It was talked up so much that people wanted it. And so it became hard to do the clinical trials, in which they got a 50 percent chance of getting a placebo, because they didn’t want it. They heard the president say it’s a miracle drug, so they insisted on it.

michael barbaro

And of course, in the case of hydroxychloroquine, that too was granted an emergency authorization from the Trump administration as a treatment. But then subsequent testing showed it was not considered effective and it was not considered so safe. And that emergency authorization was eventually rescinded.

donald g. mcneil jr.

It was not considered effective at all, and it was definitely dangerous. And so emergency authorization was rescinded.

michael barbaro

So this potentially could be a similar situation?

donald g. mcneil jr.

Yes, in fact a doctor said that to me yesterday exactly. This feels like hydroxychloroquine all over again. And the president is hoping to be able to announce a miracle. And that’s the tone — the calls for the press conference on Sunday where you know, gigantic therapeutic breakthrough, going to come through this evening. And then everybody was saying, I think he’s going to talk about convalescent plasma, which we’ve known about since the 1890s. And what this really is, is it’s a bureaucratic breakthrough, because hospitals are going to find it easier to use plasma than they did before, because they don’t have to go to the Mayo Clinic for permission to enroll in the trial. But that’s all. And what Tony Fauci and Francis Collins and Clifford Lane and the others at the N.I.H. said just in the last week or so, we don’t think an emergency use authorization should be granted. And the president basically just reversed them.

michael barbaro

Or overruled them?

donald g. mcneil jr.

Yeah.

michael barbaro

OK, so Donald, the second big recent development in the pandemic involves a case of reinfection out of Asia. Tell us about that.

archived recording

Researchers in China say a 33-year-old man living in Hong Kong is the first person confirmed to have been reinfected with the coronavirus.

donald g. mcneil jr.

So the case is about a man who gets infected in Hong Kong early in the year, recovers. Four and a half months later goes to Spain, gets sick again, recovers. And so doctors know that he got infected twice.

michael barbaro

Which is kind of the nightmare situation?

donald g. mcneil jr.

Yeah.

archived recording

Right, well, this is a potentially serious setback tonight in our war against coronavirus. This new case you mentioned out of Hong Kong really does put into question that belief that so many of us have had — that if you’ve got coronavirus once, you couldn’t get it again.

donald g. mcneil jr.

The reason that would worry people is because, well, that would imply that we’re never free of the disease and maybe a vaccine wouldn’t work. Because if you’ve got a vaccine, you’re protected, and then you know, a couple of months later, you got infected again. Then you know the vaccine’s a bust.

michael barbaro

Right, infection is supposed to equal immunity.

donald g. mcneil jr.

Infection is supposed to produce immunity, yes.

Now in this case that was just reported out of Hong Kong, this doesn’t shock immunologists.

michael barbaro

Why not?

donald g. mcneil jr.

Well, because it’s been known that even with some diseases where you think getting it provides lifetime immunity, some people get it again. And what happened in this guy’s case was his first bout of the disease was mild. And his second bout was so mild it was asymptomatic. He didn’t realize he had it. And what may have happened in this case is that he had such a mild infection the first time that he got over it. But he really didn’t produce enough long-lasting immunity in the form of antibodies to prevent him from getting a second infection. So the reaction of doctors is well, this is a curiosity, and it’s kind of the exception that proves the rule. But it’s not something to panic about. This is not common. This is not something we’re seeing all over the place. There’s millions and millions and millions of infections around the world, and we’ve only seen one proven case, so don’t worry that this means the end of the vaccine or the vaccine won’t work or anything like that.

michael barbaro

So this does not fundamentally change our understanding of immunity from a Covid-19 infection?

donald g. mcneil jr.

We’re still in the gray area where we don’t know how long immunity lasts. But we suspect it lasts for a year or more. Although that’s impossible to prove, because this disease is only — it didn’t come into existence before December.

michael barbaro

Got it.

donald g. mcneil jr.

But looking at other diseases like it, that’s what the best immunologists expected to happen.

michael barbaro

Donald, immunity for a year or so would probably imply that whenever a vaccine is ready, it might last just a year. Or is that too big a logical leap?

donald g. mcneil jr.

So the answer is, nobody knows yet.

Because we don’t have the vaccine, and we don’t have a year’s experience with the virus. But we know that some viruses mutate so fast that you need a vaccine every year, typically the flu virus. We know that this virus mutates at about one third the rate of flu. So maybe if it hangs around, we’ll need a new shot every three years, rather than every year as you do with flu. But this is all a big gray area. It’s really hard to say. No expert is going to say, we know what’s going to happen.

michael barbaro

We’ll be right back.

[music]
archived recording 1

Chinese military is actually giving doses of the vaccine developed by a unit of the China National Pharmaceutical Group to soldiers and employees traveling overseas. That still though, is in the phase 3 testing. It’s experimental.

archived recording 2

Russia is claiming victory in the worldwide race for a coronavirus vaccine. The government is clearing a vaccine for use, despite not putting it through a third round of testing on humans. President Vladimir Putin insists the vaccine is safe, and says one of his daughters has been inoculated.

michael barbaro

Donald, our third development relates to the progress that we are making in the battle for a vaccine. And the biggest of these developments seem to be occurring overseas in Russia and in China. And I was hoping you could update us on those.

donald g. mcneil jr.

Yeah, both the Russians and just recently, the Chinese, say they have started distributing their vaccines without having done the phase 3 safety and efficacy trials that we are doing here.

michael barbaro

And those are the ones that are double blind with the placebo, like we talked about before?

donald g. mcneil jr.

Right. And more importantly, they recruit tens of thousands of people. I think for these trials, we’re recruiting 30,000 people per vaccine. So immunologists and vaccine executives here say, this is crazy what the Russians and the Chinese are doing. You don’t release a vaccine before you’ve done the big safety trial, because problems that you did not find earlier could crop up. And the big dangerous problem, the one that everybody is worried about, is that the vaccine makes you more likely to have a bad outcome if you do have the virus — as in more likely to get hospitalized and die. So doctors here think the Russians and the Chinese are very irresponsible to do this. It looks like they may be doing it for competitive reasons. The Russians wanted — they called their vaccine Sputnik. They want to brag that hey, we beat the United States. We beat the world at this, you know, as they did with Sputnik back in 1957 or whatever it was for a satellite in space. So what they’re really doing is using their own population as the guinea pigs for doing the safety and efficacy testing on the vaccine. And one hopes that, you know, they are following those first 30,000 guinea pigs really carefully to see if they pick up any dangerous signals that are there. You want to make sure that the vaccines go to people you think are likely to do well — you know, healthy young people — and then you move it out into the risk groups.

michael barbaro

But, Donald, and maybe I’m being unnecessarily provocative here, but how different is what China and Russia are doing with these vaccines from what the United States and our F.D.A. is doing with hydroxychloroquine and blood plasma? Which is starting to authorize the delivery of it to people before it’s gone through those kind of gold standard, double-blind placebo tests.

donald g. mcneil jr.

It’s similar, and yet it’s different. It’s similar, because we are letting it be generally distributed before it’s been proven that it works and is totally safe. It’s different, because hydroxychloroquine did have a long safety record. Convalescent plasma does have a long safety record. These vaccines that the Chinese and the Russians are using have no safety record other than the tests they’ve done just in the last two or three months, presumably on you know, maybe 1,000 people. Another important difference between what the Russians and Chinese are doing with their vaccines and what we’re doing with treatments here is that treatments are given to people who are already sick and in trouble. Like, you can take wild chances with cancer treatments when you have patients who were on the brink of death and there’s nothing else that will save them.

michael barbaro

Right.

donald g. mcneil jr.

Whereas vaccines are given to healthy people, even sometimes to babies and pregnant women. So you do not want something that is at all unsafe, because you turn someone from healthy into unhealthy. You’ve done more damage than if you just left them alone.

michael barbaro

So our risky emergency authorizations are less risky than what China and Russia are doing with vaccines, because our emergency authorizations are going into sick people, theirs are going into healthy people?

donald g. mcneil jr.

Correct.

michael barbaro

OK, so Donald, finally, the fourth development here in the United States is a somewhat happy one for a change. And that centers around the current infection rate in the United States, which is flat.

donald g. mcneil jr.

Yes, it’s flattening. But I don’t see this as a happy story. What are we flattening at, about 40,000 cases a day? You know, even in our good period back in June when we thought we were doing well, we had 20,000 cases a day. I mean, none of this has been a good-news story. We have an out-of-control epidemic in this country. And the fact that we’ve brought it down by 10,0000 cases is good-ish news relative to how bad it was getting. But I don’t think we should pat ourselves on our national back over getting down to 40,000 new cases a day.

michael barbaro

And what are the implications of us even staying at such an infection rate?

donald g. mcneil jr.

The implications are that a lot of people are going to continue to die. You know, this is like climbing a mountain. And you get up to 14,000 feet, and you stay at 14,000 feet because you’re walking through a meadow. It’s still hard to breathe up at that altitude. It’s not a happy situation. We’re not going back down to zero. We’re going back down to a few hundred cases a day, which some other countries have gone to, that the implication is that we’re going to have more people hospitalized, more people die. We’re going to see our death numbers go up beyond 200,000, definitely on the way to 300,000. Don’t know exactly when it’s going to reach that, but we’re steadily plodding, day after day, up that peak of deaths.

michael barbaro

I don’t want to let that slide by. You’re saying that it feels likely that the United States will hit 300,000 before the pandemic’s over.

donald g. mcneil jr.

Oh before it’s over? Yeah, the question is when before it’s over? I mean, it’s not just me. It’s the models. Some models suggest that it’s is going to be, you know, well before Christmas.

michael barbaro

300,000 American dead before Christmas would be absolutely horrific.

donald g. mcneil jr.

Yeah, it would. And we can avoid that by being smart, using masks, socially distancing. All the usual things. But we have to do it.

michael barbaro

And of course, the fall in the U.S., beyond everything we’re talking about means something else, which is the flu. The flu is now about to kind of merge with the coronavirus. And I know that that has raised some fears. Is that something you worry about?

donald g. mcneil jr.

No.

michael barbaro

Why not?

donald g. mcneil jr.

And I’m kind of an outlier on this. But there are doctors who agree with me. The flu doesn’t sit around, hide in the country during the year. Flu travels. It migrates to the southern hemisphere and hits them in the middle of their winter. And then it comes back in the fall. But flu transmission went to zero in this country in the third week of April during lockdown. It just went boom, right down to zero. And then it did not really go south.

michael barbaro

Because people aren’t really flying south?

donald g. mcneil jr.

Right. It turns out that flu in Australia is down by 99 percent this year. And in the rest of the southern hemisphere, it’s way, way, way, way down too — you know, Chile, Argentina, New Zealand. If it isn’t big there, and there are no flights from there to here, you can’t reseed flu here. And also, practicing social distancing as we are now, cuts down flu transmission in any year. So I don’t expect a big flu season. But I still think everybody should get their flu shot. And I got mine, in case I’m wrong.

michael barbaro

So it sounds like another incentive to abide by all the rules around the coronavirus is that it has very nicely diminished the flu.

donald g. mcneil jr.

And other respiratory diseases — R.S.V., and the cold coronaviruses, and things. Any respiratory disease, they get knocked out. All those diseases have dropped in this country.

michael barbaro

But still, I’m hearing you say in your role as our collective conscience that everyone should still get the flu vaccine just in case, in order to kind of take it off our plate. And here, I should say, Donald, and I’ve always wanted to be you’re A student in this respect. I got the flu vaccine just a few days ago.

donald g. mcneil jr.

Good, excellent. I got mine. I got the senior shot, the four times as powerful one that you can’t get unless you’re 65.

michael barbaro

I don’t think I got that one.

donald g. mcneil jr.

I’ve had people ask me, how do I get one of those? And I’m like, nope, insurance will not pay for it until you’re over 65. But then — and you know, I kind a slightly sorer arm than usual, I think. But you know, that’s actually a good sign. It means the shot is working.

michael barbaro

Well, Donald, thank you very much. We appreciate it.

donald g. mcneil jr.

You’re welcome.

michael barbaro

On Monday night, The Times reported that many scientists have been startled by the way that the F.D.A. has interpreted and communicated data about the effectiveness of blood plasma in treating Covid-19. Several of them, including those who worked on the Mayo Clinic study cited by the Trump administration, said they cannot figure out the origins of the claim that it reduced deaths by 35 percent and are highly doubtful of that figure.

We’ll be right back.

[music]

Here’s what else you need to know today.

archived recording

[GUN SHOTS] [ALARM SOUNDING]

Unrest in the city of Kenosha, Wisconsin turned violent on Monday night as protests over the police shooting of a black man there, Jacob Blake, gave way to fires, destruction and looting. By early Tuesday morning, a strip of stores in Kenosha’s downtown was consumed by flames. Blake was shot repeatedly by a white officer as he tried to get inside his car. The shooting appeared to be unprovoked and was immediately condemned by Wisconsin’s governor. The officers involved in the encounter have been placed on administrative leave as an investigation continues. And —

archived recording 1

Madam Chairman, Louisiana proudly casts its 46 votes for President Donald J. Trump.

archived recording 2

Michigan, the Great Lakes state, is going to cast all 73 votes for President Donald J. Trump.

archived recording 3

In order to keep America first, the state of Arizona casts our 57 votes for President Donald J. Trump. [CHEERING]

michael barbaro

During the opening night of the Republican National Convention in Charlotte, President Trump was nominated for a second term after an in-person roll call by delegates.

archived recording

(CHANTING) Four more years! Four more years!

archived recording (president donald trump)

Yeah, if you want to really drive them crazy, you say, 12 more years.

archived recording

(CHANTING) 12 more years! 12 more years!

michael barbaro

In a short speech accepting the nomination, Trump sought to cast doubt on this fall’s election by attacking mail-in voting and accusing Democrats, without evidence, of seeking to steal the election.

archived recording (nikki haley)

Last time, Joe’s boss was Obama. This time it would be Pelosi, Sanders and the squad. Their vision for America is socialism. And we know that socialism has failed everywhere. They want to tell Americans how to live and what to think.

michael barbaro

Later in the night, a series of speakers, including Trump’s first ambassador to the United Nations, Nikki Haley, claimed that Joe Biden, a moderate, would pursue a left-wing agenda that would undermine American values at home and overseas.

archived recording (nikki haley)

This president has a record of strength and success. The former vice president has a record of weakness and failure. Joe Biden is good for Iran and ISIS, great for communist China, and he’s a godsend to everyone who wants America to apologize, abstain and abandon our values. Donald Trump takes a different approach. He’s tough on China. And he took on ISIS and won. And he tells the world what it needs to hear.

michael barbaro

That’s it for “The Daily.” I’m Michael Barbaro. See you tomorrow.

“I believe this is the first reported case that is confirmed by genome sequencing,” said Dr. Kelvin Kai-Wang To, a clinical microbiologist at the University of Hong Kong.

The study is to be published in the journal Clinical Infectious Diseases. The Times obtained the manuscript from the university.

The man’s first case was diagnosed on March 26, and he had only mild symptoms. In accordance with regulations in Hong Kong, he was hospitalized on March 29 even though his symptoms had subsided, and released on April 14 only after he had tested negative for the virus twice.

He had no detectable antibodies after that first bout with the virus. He was positive again for the coronavirus on a saliva test on Aug. 15 after a trip to Spain via the United Kingdom; the test was administered at the airport. The man had picked up a strain that was circulating in Europe in July and August, the researchers said.

His infections were clearly caused by different versions of the coronavirus, Dr. To said: “Our results prove that his second infection is caused by a new virus that he acquired recently, rather than prolonged viral shedding.”

Common cold coronaviruses are known to cause reinfections in less than a year, but experts had hoped that the new coronavirus might behave more like its cousins SARS and MERS, which seemed to produce protection lasting a few years.

It’s still unclear how common reinfection from the new coronavirus might be, because few researchers have sequenced the virus from each infection.

“We’ve had, what, 23 million cases documented thus far, but the fact that one out of them at this point has been reinfected should not cause undue alarm as of yet,” said Jeffrey Shaman, an epidemiologist at Columbia University in New York.

“However, it remains very, very concerning — and this does nothing to dispel that — that we may be subject to repeat infection with this virus,” he said.

Dr. Iwasaki was more sanguine. She noted that the man had no antibodies after the first infection but produced them after the second exposure. Immunity is expected to build with each exposure to a pathogen exactly in this way, she noted.

“Again, it’s what the textbook says should happen,” she said. “When you have second exposure to the same pathogen, you should elevate the antibody, and that’s what’s happening.”

Most people who are infected with the coronavirus produce detectable antibodies that would be expected to protect against the virus. Even people who had only mild symptoms, including this man, may also have immune “memory” in the form of B and T cells that prevent symptoms on second exposure.

“The majority of patients likely have a cocktail of immune responses that activate on second exposure,” said Brian Wasik, a virologist at Cornell University. “This Hong Kong patient also seems to have been asymptomatic on second infection, perhaps due to some immune response.”

But the researchers said it’s also possible that in some people, a second exposure will prove more severe. “It cannot be generalized yet, because there’s still a possibility that the second infection can be worse,” Dr. To said.

Building immune memory is not unlike boosting memory of a person, said Dr. Michael Mina, an immunologist at the Harvard T.H. Chan School of Public Health.

The initial bout with the new coronavirus is likely to result in “non-sterilizing immunity,” but the virus will elicit a stronger response with each exposure, he said: “It is often these second and third exposures that help to solidify the memory response for the long term.”

Over all, experts said, it’s unclear how often people might become reinfected, and how soon, after a first bout with the virus.

“Those remain open questions, because one person exhibiting a mild reinfection, clearly documented as a distinct strain of the virus, does not provide enough evidence one way or another,” Dr. Shaman said.

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