What we've been missing, below the surface, about #COVID19. The focus has been on confirmed cases, hospitalizations and deaths. But there's so much more we've been learning. United States data here

2. Let's start with the excess deaths, attributed to non-covid19 diagnoses. Here's a sampling to show excess causes of death in March-May in many places was likely inaccurately categorized. The estimates of actual covid-19 deaths suggests an additional >40,000 fatalities

3. Now the missed cases from lack of testing availability, mild/moderate symptoms that did not lead to testing, false negatives tests, and those never having discernible symptoms. Asymptomatics comprise at least 30% those infected
https://www.acpjournals.org/doi/10.7326/M20-3012 @AnnalsofIM

4. There are now 3 series of lung CT scans in people who were asymptomatic. More than half of these patients show distinct GGO abnormalities consistent w/ #COVID19
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30364-9/fulltext
https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30482-5/fulltext
https://www.medrxiv.org/content/10.1101/2020.05.09.20096370v1.full.pdf

5. This represents silence at 2 levels: lack of symptoms and lack of awareness of internal damage. It's especially concerning since other organs may be affected (like heart or kidneys) but have not been studied. Nor has the natural history of such subclinical covid-19 impact

6. Infection ≠ Infectious.
This big question about aymptomatics is how frequently they can infect others. All the studies to date show similar viral loads as people with symptoms.
Yesterday a new @CDCgov report provided some light from Japan's clusters
https://wwwnc.cdc.gov/eid/article/26/9/20-2272_article

7. 9 of 22 clusters originated from people without symptoms
"Probable primary covid-19 case-patients appear to transmit the virus and generate cluster even in the absence of apparent symptoms"'
This occurred throughout all ages.
1= Asymptomatic in Figure

8. More on infectiousness from asymptomatics from Italy:
"Contact tracing of the newly infected cases .. revealed that most new infections in the second survey were infected in the community ... from asymptomatic infections living in the same household." https://www.medrxiv.org/content/10.1101/2020.04.17.20053157v1?utm_source=Le+courrier+du+coronavirus&utm_campaign=cf1817b4ab-EMAIL_CAMPAIGN_2020_04_21_06_17&utm_medium=email&utm_term=0_86263c6a35-cf1817b4ab-116191806

9. The magnitude of transmissibility from people without symptoms remains unknown and is hopefully low, but all the more reason to #masksforall and other mitigation measures. One last below the surface group are the chronic #COVID19 hits

10. There are several very good pieces to describe this group, with multi-organ chronicity potential, especially in younger people, but it's important we learn much more about them and how to better prevent/treat
https://www.theatlantic.com/health/archive/2020/06/covid-19-coronavirus-longterm-symptoms-months/612679/
https://www.vox.com/2020/5/8/21251899/coronavirus-long-term-effects-symptoms