How Is Covid-19 Impacting Life in Your City?

[homebucket]

At the Heart of It: Cardiac Inflammation the Next Virus Hurdle for College Leaders
Of all the hurdles impeding a 2020 college football season, there is one roadblock that has gone mostly overshadowed—the heart.

ROSS DELLENGERUPDATED:AUG 9, 2020ORIGINAL:AUG 9, 2020

Dr. Matthew Martinez has studied so many images of a beating heart that he couldn’t possibly count them. Maybe 500,000. Maybe 1 million. As a non-invasive cardiologist, his job revolves around the constant evaluation of pictures of the heart.

He knows what a strong, healthy heart looks like. He knows what a poor, struggling heart looks like. And he knows what a heart looks like after COVID-19’s tentacles have reached the most vital organ in the human body. “This virus,” he says, “seems to have an affinity for causing damage to the heart.”

In a small percentage of infected patients, COVID-19 leaves behind troubling scars in the throbbing muscle within their chests, known as myocarditis. The virus directly invades the heart muscle, weakening and damaging its cells, through blood clots and inflammatory responses to viral infection. Earlier during the pandemic, doctors only associated the condition with severe and, oftentimes, hospitalized COVID victims, usually elderly patients or those with underlying health problems.

Lately, physicians are identifying the condition in young, healthy Americans — including athletes. “The last month or two, even asymptomatic young people are developing myocardial injury,” Martinez says.

https://www.si.com/college/2020/08/0...ditis-concerns

[xzmattzx]

Originally Posted by someone123

Here in Vancouver and BC (which is mostly metro Vancouver cases) we got down to around 5-10 cases per day at the low point and now it's gone up to 80 per day. But cases have shifted to lower risk demographics. The province has 5 million people and so far in August we've had around 5 deaths and hospitalizations. It's possible we've seen more drug overdose deaths than covid deaths here during the pandemic.

We have lots of people pulling their hair out about irresponsible "kids" (i.e. 20 and 30 somethings) partying and ruining it for everyone. We are nowhere near 100% hospital utilization. Nobody really knows the personal details of the party crowd, and the identified cases get isolated, but many people assume social interaction -> covid cases -> deaths (except BLM protests). There's a lot of moralizing, this being Canada.

80% of our deaths were in care homes but the dominant narrative seems to be that the risk is even across the population (push this and people will tell you that deaths in younger people are lower but we just don't know what else might happen to them in the long run).

We're still not doing randomized testing from what I can tell so the numbers are just based on who shows up to be tested and contact tracing. PCR seems somewhat available and antibody or T-cell screening less so.

The dominant attitude seems to be that we should be in semi-lockdown indefinitely. School reopenings are borderline and controversial. Few people seem to talk about the cost of lockdown policies or the endgame, which I guess is assumed to be that a vaccine will allow us to reopen. Policy seems to have gradually shifted from keeping hospital utilization under 100% to getting cases down as low as possible.

It feels like we did pretty well here around March-April, maybe partly by accident (with us being farther from NYC and Europe), but it seems like May-August has been mostly a holding pattern.

Excellent post. So much of this seems true in the United States, and more local for me here in Delaware.

You are right, the goal or narrative has switched from flattening the curve to make sure hospital beds were available, to minimizing cases as much as possible. Everyone knew back in March and April that cases would go up when the economy got started again, but now people are forgetting that.

Like in British Columbia, most new cases in the United States are in younger people, who are supposed to keep the economy afloat while older people continue to shelter in place (whether or not this has been expressly stated). Deaths and hospitalizations have largely remained relatively low, even while positive cases surged. The downside is the possible cardiac residual effects. The upside is the potential antibodies and herd immunity developed.

School openings have been controversial. It has largely been teachers versus parents here. The parents want actual schooling, having not really gotten any schooling since mid-March. The teachers want to protect themselves. There's not been much consideration given to the students themselves. As a youth sports coach, most of the children I interact with are actually getting pretty desperate to go back to school. I can't believe I'm hearing it, because when I was a kid, I would've been happy to have a 6-month summer. But these kids can feel that they are not getting smarter (and therefore not maturing), and there are clear long-term mental health effects coming into play.

Things were going well here from Easter to Memorial Day (end of May) and into June. From mid-June until now it has been a holding pattern where regulations have neither gotten looser or gotten stricter.

I can't remember what I read, because it was a few days ago, but I think Wilmington or Delaware actually has had more overdose deaths than coronavirus deaths. I will have to look for that. Wherever it was, drug overdoses have exceeded coronavirus deaths. I also saw a report indicating that domestic violence has indeed skyrocketed since March.

All of this tells me that we have to avoid the two extremes. We can't stay locked down forever and force people into a year of isolation or constraint. The human brain will eventually reject that and ignore policies in place. At the same time, we cannot pretend that nothing ever happened, and that everything should be back to normal.

Here in Delaware, with a Democratic governor, I think we have done well in finding the best of both worlds. Early on things were tough here. There was a quarantine in place, and all businesses were closed, and everything like that. But I think an element of reasoning was included in restrictions as the economy opened back up. So, while we are being aggressive in trying to keep our positive cases down, much like New York or Massachusetts and unlike Florida or Arizona, there is no arbitrary law about needing to order food when you're in a bar, as if the coronavirus won't spread because you have food on the table, and the quarantine was lifted on June 1 and there has been no talk of reinstating it. It has provided a good balance of determination and vigilance with freedom and normalcy. That makes it easier for people to follow the rules still in place, because they get the sense that things are getting better.

[accord1999]

Other viral infections impact the heart as well, such as:

Many viruses are commonly associated with myocarditis, including the viruses that cause the common cold (adenovirus); COVID-19; hepatitis B and C; parvovirus, which causes a mild rash, usually in children (fifth disease); and herpes simplex virus.

https://www.mayoclinic.org/diseases-...s/syc-20352539

And H1N1:

Conclusions: These observations emphasize the high incidence of cardiac dysfunction in patients with H1N1 influenza infections.

https://pubmed.ncbi.nlm.nih.gov/23566732/

[dave8721]

Florida passed 10k deaths yesterday (British Columbia has had 200 to compare to a previous poster). On a per capita basis still less than 1/4 of NJ though.

[Pedestrian]

Originally Posted by accord1999

Other viral infections impact the heart as well, such as:

That is certainly true, however:

Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management
Bhurint Siripanthong, BA(Cantab),∗ Saman Nazarian, MD, PhD, FHRS,† Daniele Muser, MD,† Rajat Deo, MD, MTR,† Pasquale Santangeli, MD, PhD,† Mohammed Y. Khanji, MBBCh, MRCP, PhD,‡§ Leslie T. Cooper, Jr., MD,# and C. Anwar A. Chahal, MBChB, MRCP, PhD†¶‖∗

ABSTRACT

Human coronavirus-associated myocarditis is known, and a number of coronavirus disease 19 (COVID-19)–related myocarditis cases have been reported. The pathophysiology of COVID-19–related myocarditis is thought to be a combination of direct viral injury and cardiac damage due to the host’s immune response. COVID-19 myocarditis diagnosis should be guided by insights from previous coronavirus and other myocarditis experience. The clinical findings include changes in electrocardiogram and cardiac biomarkers, and impaired cardiac function. When cardiac magnetic resonance imaging is not feasible, cardiac computed tomographic angiography with delayed myocardial imaging may serve to exclude significant coronary artery disease and identify myocardial inflammatory patterns. Because many COVID-19 patients have cardiovascular comorbidities, myocardial infarction should be considered. If the diagnosis remains uncertain, an endomyocardial biopsy may help identify active cardiac infection through viral genome amplification and possibly refine the treatment risks of systemic immunosuppression. Arrhythmias are not uncommon in COVID-19 patients, but the pathophysiology is still speculative. Nevertheless, clinicians should be vigilant to provide prompt monitoring and treatment. The long-term impact of COVID-19 myocarditis, including the majority of mild cases, remains unknown.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199677/

The reason myocarditis is somewhat nonspecific in viral illness is the role played by the host immune response and not just the virus itself. However the thing of most concern with COVID is we don't yet, and can't because the disease is so new, know about the long term sequelae in this illness. Will these patients have a higher rate of heart failure and other complications down the road? Do they need long term monitoring?

[Pedestrian]

Originally Posted by someone123

Where's the data?

COVID-19 in children and adolescents in Europe: a multinational, multicentre cohort study

Florian GötzingerMD, Begoña Santiago-GarcíaPhD et. al.

Background

To date, few data on paediatric COVID-19 have been published, and most reports originate from China. This study aimed to capture key data on children and adolescents with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection across Europe to inform physicians and health-care service planning during the ongoing pandemic.

Methods

This multicentre cohort study involved 82 participating health-care institutions across 25 European countries, using a well established research network—the Paediatric Tuberculosis Network European Trials Group (ptbnet)—that mainly comprises paediatric infectious diseases specialists and paediatric pulmonologists. We included all individuals aged 18 years or younger with confirmed SARS-CoV-2 infection, detected at any anatomical site by RT-PCR, between April 1 and April 24, 2020, during the initial peak of the European COVID-19 pandemic. We explored factors associated with need for intensive care unit (ICU) admission and initiation of drug treatment for COVID-19 using univariable analysis, and applied multivariable logistic regression with backwards stepwise analysis to further explore those factors significantly associated with ICU admission.

Findings

582 individuals with PCR-confirmed SARS-CoV-2 infection were included, with a median age of 5·0 years (IQR 0·5–12·0) and a sex ratio of 1·15 males per female. 145 (25%) had pre-existing medical conditions. 363 (62%) individuals were admitted to hospital. 48 (8%) individuals required ICU admission, 25 (4%) mechanical ventilation (median duration 7 days, IQR 2–11, range 1–34), 19 (3%) inotropic support, and one (<1%) extracorporeal membrane oxygenation. Significant risk factors for requiring ICU admission in multivariable analyses were being younger than 1 month (odds ratio 5·06, 95% CI 1·72–14·87; p=0·0035), male sex (2·12, 1·06–4·21; p=0·033), pre-existing medical conditions (3·27, 1·67–6·42; p=0·0015), and presence of lower respiratory tract infection signs or symptoms at presentation (10·46, 5·16–21·23; p<0·0001). The most frequently used drug with antiviral activity was hydroxychloroquine (40 [7%] patients), followed by remdesivir (17 [3%] patients), lopinavir–ritonavir (six [1%] patients), and oseltamivir (three [1%] patients). Immunomodulatory medication used included corticosteroids (22 [4%] patients), intravenous immunoglobulin (seven [1%] patients), tocilizumab (four [1%] patients), anakinra (three [1%] patients), and siltuximab (one [<1%] patient). Four children died (case-fatality rate 0·69%, 95% CI 0·20–1·82); at study end, the remaining 578 were alive and only 25 (4%) were still symptomatic or requiring respiratory support.

Interpretation

COVID-19 is generally a mild disease in children, including infants. However, a small proportion develop severe disease requiring ICU admission and prolonged ventilation, although fatal outcome is overall rare. The data also reflect the current uncertainties regarding specific treatment options, highlighting that additional data on antiviral and immunomodulatory drugs are urgently needed.

https://www.sciencedirect.com/scienc...52464220301772

[Pedestrian]

Originally Posted by someone123

I think you are right to point out that there's no clear endgame to this policy. Why would we set mitigation policies such that we get 5 in hospital instead of a higher volume, with most people recovering fine and developing immunity?

There is a clear endgame and it should become much clearer over the next several months. 32 vaccines against SARS-CoV-2 are in human trials and 8 are in phase 3 trials (each being given to as many as 30,000 test volunteers):


https://www.nytimes.com/interactive/...e-tracker.html

The leading vaccine candidates in the West come from Oxford/Astrazeneca, Moderna, Johnson & Johnson and Pfizer/BioNTech. Others among the 8 are in Russia and China.

All evidence indicates that one and probably more of these vaccines will be approved by the FDA in the US before the end of 2020 (conspiracy theorists are already suggesting it could happen before the November 3 election). It will likely take another several months to manufacture and administer enough doses to vaccinate most of the willing populations in North America even though the US government has already contracted to purchase hundreds of millions of doses of the leading western candidates:

US cuts $1.95 billion deal with Pfizer for 100 million doses of COVID-19 vaccine

Trump says U.S. has reached deal with Moderna for 100 million doses of coronavirus vaccine

U.S. secures 300 million doses of potential AstraZeneca COVID-19 vaccine

That's 500 million doses. The population of the US is less than 400 million so enough to vaccinate all Americans has been purchased and is already being manufactured, assuming all 3 vaccines work. If only one works, we will have the amount of that one at least. One hopes Canada is doing something similar. But the point here is we are already making vaccine at the fastest rate possible. and should know by Christmas which one(s) work and have them ready to provide at least to those most at risk. In the ensuing months, we should be able to vaccinate the rest of the population, say by late Spring.

That may be why several large companies such as Facebook and Salesforce.com have told their workers who are working at home they plan to continue that until next June or July. By then, everyone who is willing to be should be vaccinated and life should be returning to normal if largely normal (it's my own opinion that the economic recovery will take a while longer).

So the point here is that we need to continue measures to avoid infecting as many people as possible for just 4 or 5 more months. That goes for those at most risk and for others because those others can infect the ones at risk. Just today, a study result was released showing that school aged children and adolescents can carry a viral burden--and spread it--higher even than very sick adults. Taking a fairly conservative estimate of the mortality rate of the disease, if we do not do this we can see the death of 100,000 or several hundreds of thousands who don't need to die because in just a few months they can be vaccinated and survive this disease.

[someone123]

Originally Posted by homebucket

https://jamanetwork.com/journals/jam...rticle/2768915

https://www.nytimes.com/2020/08/17/o...t-disease.html

https://www.statnews.com/2020/07/27/...-heart-damage/

https://www.pennmedicine.org/updates...-heart-disease

Yeah, I'd like my heart to remain functional and not equivalent to someone 60 years older than I.

Did you read these? I don't have time to read them all (a list of links is not a good argument supported by data), but here's a summary of the first one:

- One study was 39 autopsies of people who died from covid and 100 who recovered.
- They noticed heart involvement in many recovered patients but there's no discussion of the true health impact and there's no control or context given. Does this damage persist? Is it different from what happens with other infections that we know people are at risk of and recover from, and that we don't implement lockdowns for?
- The authors call for more study and data, i.e. this is not information that by itself can usefully guide public policy decisions or individual decisions.

Unfortunately we will have to take risks in life and make decisions with incomplete data. We cannot react in a reliable way that improves our standard of living based on fears about poorly understood potential future effects.

[dc_denizen]

NEWS FLASH

In Sweden, where they did and continue not to social distance, where they did not wear masks, where they let the pandemic play out, where schools are open, the same amount of people have died, per capita, as in the US. Cases in Sweden are miniscule, per capita at the same levels as states that were hard-hit early on like NY and CT.

[someone123]

Originally Posted by Pedestrian

All evidence indicates that one and probably more of these vaccines will be approved by the FDA in the US before the end of 2020 (conspiracy theorists are already suggesting it could happen before the November 3 election). It will likely take another several months to manufacture and administer enough doses to vaccinate most of the willing populations in North America even though the US government has already contracted to purchase hundreds of millions of doses of the leading western candidates

Yes, this is true. There might be a vaccine available as early as the fall. Maybe it will take until 2021. I think chances are good that a vaccine will be available around North America around that time period.

Let's suppose the best-case scenario is true and everybody in the United States who wants to be vaccinated can get vaccinated in October before the election and the vaccine works perfectly, instantly reducing covid risk to 0.

People will have spent March-October in partial lockdown, about 8 months. The US life expectancy is about 78.5 years. So the average American will have spent 0.8% of their lifespan during this period. Note that some older people will have spent 20% or 40% of their remaining life expectancy in lockdown; the ones at highest risk of death are giving up the largest percentage of their remaining life in the strictest isolation.

The fatality rate for under 40's is something like 0.2%, with the rate being lower for people without health problems and for those under 20. Actually the difference in mortality is even lower because some people are still getting covid despite the measures happening right now.

Is it rational for households made up of people age 40 and under to lock themselves up for 0.8% of their life to avoid a 0.2% or maybe 0.1% risk of death plus the risks of other health impacts (which are probably not multiple times costlier than the risk of death)?

Can authorities answer this question? No, because it depends on how much people care about the covid measures they take. The price of not going to the theatre or to a restaurant depends on the value to the individual. But I'd say it's far from being a clear win.

[homebucket]

Originally Posted by someone123

Did you read these? I don't have time to read them all (a list of links is not a good argument supported by data), but here's a summary of the first one:

- One study was 39 autopsies of people who died from covid and 100 who recovered.
- They noticed heart involvement in many recovered patients but there's no discussion of the true health impact and there's no control or context given. Does this damage persist? Is it different from what happens with other infections that we know people are at risk of and recover from, and that we don't implement lockdowns for?
- The authors call for more study and data, i.e. this is not information that by itself can usefully guide public policy decisions or individual decisions.

Unfortunately we will have to take risks in life and make decisions with incomplete data. We cannot react in a reliable way that improves our standard of living based on fears about poorly understood potential future effects.

Yes I did. I said there was growing data. You asked for proof, and I provided it. I never said it was complete data. As I said before, the risk of chronic heart disease and the complications that come along with it is enough for me to support continuing of phase 2/3 lockdowns.

[someone123]

Originally Posted by homebucket

Yes I did. I said there was growing data. You asked for proof, and I provided it. I never said it was complete data. As I said before, the risk of chronic heart disease and the complications that come along with it is enough for me to support continuing of phase 2/3 lockdowns.

I guess. I disagree, and I think there is a heavy burden of proof on the pro-lockdown crowd to prove why a continued widespread and involuntary lockdown is worthwhile (it might be or might not be). Lockdown is not our default state, and in fact is a significant infringement on personal liberty.

One of the red flags is you haven't talked about probabilities at all, or attempted to characterize the health impact (e.g. in terms of QALY) of these aftereffects. To make a rational decision you need to quantify the costs and benefits. If your lockdown argument would be the same if the risk were 10x higher or 10x lower it's unlikely to be rational; that would swing the cost-benefit ratio by 10-100x.

[Pedestrian]

Originally Posted by someone123

Is it rational for households made up of people age 40 and under to lock themselves up for 0.8% of their life to avoid a 0.2% or maybe 0.1% risk of death plus the risks of other health impacts (which are probably not multiple times costlier than the risk of death)?

Can authorities answer this question? No, because it depends on how much people care about the covid measures they take. The price of not going to the theatre or to a restaurant depends on the value to the individual. But I'd say it's far from being a clear win.

They are not locking themselves up to avoid 0.1% of death to themselves. In fact, they aren't locking themselves up. They are wearing masks, not going to events with more than 10 people or indoor restaurants and they are doing it to avoid increasing the amount of circulating virus--the R0 if you will--so that the populations vulnerable will have a lower chance of catching the illness and dying . . . for a few more months.

To argue as you seem to be is to argue as long as "I'm alright, Jack", 100,000 extra deaths among other groups is insufficient to keep me from going to the gym or a football game or concert (that's what 10023 regularly argues).

I had a very pleasant OUTDOOR lunch at a restaurant yesterday. I didn't feel I had missed anything when I went to bed last night.

[Pedestrian]

^^By the way, I'm an opera fan. I miss real live opera. But Rome just proved even that is possible (thanks to their ancestors of 2000 years ago):

Rigoletto at the Circus Maximus

https://www.wantedinrome.com/news/fr...s-maximus.html

[someone123]

Originally Posted by Pedestrian

They are not locking themselves up to avoid 0.1% of death to themselves. In fact, they aren't locking themselves up. They are wearing masks, not going to events with more than 10 people or indoor restaurants and they are doing it to avoid increasing the amount of circulating virus--the R0 if you will--so that the populations vulnerable will have a lower chance of catching the illness and dying . . . for a few more months.

Does this really make sense when the more vulnerable may not even live in the same household and when everybody can choose for themselves whether to go out to a restaurant? What if the 25 year olds ate out normally and the 80 year olds got takeout?

It's odd to accept that distancing measures make a big difference but also a young healthy person getting covid implies other more vulnerable people will get it too.

I have a feeling a lot of businesses and cultural institutions are not going to survive covid. The profit margins for concerts and restaurants are probably pretty thin. I would argue that a lot of these activities are what make life worth living, and so going without them significantly worsens quality of life.

[someone123]

You guys are coming up with really weak arguments given that you're supporting the most unusual mandatory change to life in North America that has been seen since WWII.

I don't necessarily have a strong opinion one way or the other about the policies that should be implemented but it's food for thought.

I think for the most part we should try to open up over time and let actual deaths and hospitalizations determine the public health response, while being careful to tease out exactly who is affected. I don't think this process should be governed by fear of the unknown.

[Pedestrian]

Originally Posted by someone123

Does this really make sense when the more vulnerable may not even live in the same household and when everybody can choose for themselves whether to go out to a restaurant? What if the 25 year olds ate out normally and the 80 year olds got takeout?

It's odd to accept that distancing measures make a big difference but also a young healthy person getting covid implies other more vulnerable people will get it too.

I have a feeling a lot of businesses and cultural institutions are not going to survive covid. The profit margins for concerts and restaurants are probably pretty thin. I would argue that a lot of these activities are what make life worth living, and so going without them significantly worsens quality of life.

Yes, it makes sense. First of all, many older people do not live by themselves and are not locked up in nursing homes. But those that do depend on others who are younger. I've been about as strict as is practical to isolate myself, but I've had to have younger tradespeople--plumbers, appliance repair people and delivery people etc--in my home a number of times since March. The concierge in my condo who hands me packages is about 20. The guys who deliver my groceries are about the same. Most of the waiters at outdoor dining spots and/or that hand you takeout are the same age. And not everybody delivers everything (especially not if money matter--I'm lucky in that I'm not short of it but delivery gets expensive). Then there's an upcoming doctor's appointment that can't be "zoomed"--I'll get there and back in an Uber, likely with a youngish driver--maybe the same age as the guy who drew my blood for tests last month.

It simply isn't possible to totally remove the young people from your life. You can only take reasonable precautions. But if you are a 40-something diabetic or maybe a little fat with kids in school, you are entirely subject to what the kids may bring home.

[Pedestrian]

Originally Posted by someone123

You guys are coming up with really weak arguments given that you're supporting the most unusual mandatory change to life in North America that has been seen since WWII.

I don't necessarily have a strong opinion one way or the other about the policies that should be implemented but it's food for thought.

I think for the most part we should try to open up over time and let actual deaths and hospitalizations determine the public health response, while being careful to tease out exactly who is affected. I don't think this process should be governed by fear of the unknown.

The arguments you are being presented with are essentially those that every western government has adopted. You are the outlier by wanting something different and your motives are open to question, the question being , "Do you actually care about anyone else?" Our leaders are trying to do the best things for their entire populations/societies. We can debate the balance between economics and epidemiology, but the starting point will not be "just lock the old people up and let everything else go back to normal". The old people aren't going to let you and thank goodness for that.

[someone123]

Originally Posted by Pedestrian

Yes, it makes sense. First of all, many older people do not live by themselves and are not locked up in nursing homes. But those that do depend on others who are younger. I've been about as strict as is practical to isolate myself, but I've had to have younger tradespeople--plumbers, appliance repair people and delivery people etc--in my home a number of times since March. The concierge in my condo who hands me packages is about 20. The guys who deliver my groceries are about the same.

Why do you need to have significant exposure to these people? If you stay 2 m away from them your odds of getting covid are minimal.

Care homes were a disaster. That's where 80% of Canada's deaths were. But they are supposed to use PPE, limit visits or moving workers between facilities, etc. That shit show is not the fault of 30 year olds who have never even been in a care home.

[Pedestrian]

[QUOTE=someone123;9018403]Why do you need to have significant exposure to these people? If you stay 2 m away from them your odds of getting covid are minimal.

We simply don't know that. The 2m "rule" has always been a compromise based on guesses. Plenty of research now shows that (a) sometimes droplets or aerosols can travel further than that, especially indoors where air movements are gentle and constant, and (2) aerosols containing virus can persist in the air for hours so even if you stay 2m from the plumber while he's there, you are likely to walk through his aerosol cloud after he leaves. Similarly, you can walk through the cloud left by the last person to pick up a package, ride in the elevator or sit in the Uber. If they are all properly masked, it helps a lot. But young people where I live seem to like wearing "gators" and those are now being shown not to work for aerosols and no face covering totally eliminates the risk

https://wwwnc.cdc.gov/eid/article/26/7/20-0885_article

Care homes were a disaster. That's where 80% of Canada's deaths were. But they are supposed to use PPE, limit visits or moving workers between facilities, etc. That shit show is not the fault of 30 year olds who have never even been in a care home.

Where do you think the virus in care homes came from? It was multiple sources. Often, it was already infected individuals transferred into the home. But it was also younger staff people who got infected outside the home and brought virus into the home. Most homes are not allowing visitors because they too would bring in virus. But as with individuals living in their own homes, sometimes repair people are needed. Home residents come and go. Nursing homes are not sealed environments and can't be.