DENTAL TRIBUNE The World’s Dental Newspaper · South Asia Edition Published in India www.dental-tribune.in 10/20 Infrared thermometers Infrared thermometers used for temperature check are very safe. Ignore illogical WhatsApp videos. ” Page 03 Vitamin D Making a case for Vitamin D during COVID 19 – Subhasree Ray (Clinical & Public Health Nutritionist) “Feluda”- CRISPR “Feluda”- CRISPR based high accuracy, low cost Covid-19 test gets DCGI approval for commercial use Israeli lockdown Let dentists keep working—lessons from the second Israeli lockdown ” Page 04 ” Page 06 ” Page 07 Little risk from dental aerosol procedures: 10 minutes gap is enough between two procedures by Rajeev Chitguppi, Dental Tribune South Asia We summarize all the latest pieces of evidence on dental aerosol procedures. We also trace the evidence back to 2003 SARS times when the aerosols were studied first. Despite weak evidence, dental aerosol- generating procedures have been termed risky. Dentists all over the world are concerned about the risks and the safety of dental aerosol procedures. We present the summary of all recent publications on this topic. Let‘s start with a recent publication titled Evaluating dental aerosol and splatter in an open plan clinic environment: implications for the COVID-19 pandemic (OSF Preprints, 10 Sept 2020) of Since there has been very little evidence to support the practice environmental cleaning in open-plan or closed clinical environments between two patients, this identified the splatter and aerosol distribution resulting from dental aerosol- generating procedures (AGPs) in the open-plan clinic environment. A secondary aim of this study was to explore the detailed time course of aerosol settling after an AGP. Here we the conclusions and our present author interpretations of the same.  The cross-infection risk from conducting Aerosol Generating Procedures in an open plan clinic environment appears to be small, mainly when bays are 5 m apart in a setting with 3.45 ACH (Air Changes/ Hour). Interpretation/ Implications: Open plan clinics (open bay set 10 minutes gap could be enough between two aerosol producing dental procedures up) is a type of clinic that has multiple dental chairs installed in the room. Plenty of clinics have such arrangements. This finding shows that dental clinics with single operatories and separate operatories are the safest. If your clinic has multiple chairs and the distance between them is much greater than 5 meters, the chance of cross-contamination appears to be small with an ACH setting of 3.45 more than 5 meters. If your clinic has less than 5 meters of distance between two chairs, use only one chair at a time.  With 1.5 m high lateral bay partition with open fronts, at least 99.99% of splatter following an AGP is contained within the bay. As you move farther, the distant contamination from aerosol was at very low levels. The farther you go from the dental chair that produces aerosol/ splatter, the lesser the splatter and aerosol contamination. Most contamination is limited to the first 1.5 m from the procedure as shown by previous studies. So if a 1.5 m high bay partition with a patient positioned 73 cm above the floor (operator heights 1.67 m – 1.87 m), it might be adequate to prevent distant splatter contamination. Previous reports had recommended 2 m high partitions.  There is a significant dilution effect from the water spray of dental instruments. Interpretation/ Implications: Minimal splatter was detected outside of the AGP producing bay. Interpretation/ Implications: Dental-generated is predominantly due to water or air aerosol spray, which would substantially dilute any potential viral presence, whereas in medical aerosol procedures, water irrigation is not used and manipulation of the airway occurs.  Dental suction has a substantial positive effect. Interpretation/ Implications: Again, the distance matters. The effect of suction is more potent on more distant contamination. rates  Comparison of different suction flow indicates that even low volume suction (40 L/min air, with a wide- bore aspirating tip) confers a substantial benefit. Interpretation/ Implications: Use of a high- volume (high vac HVE) suction would be even better.  Time-course experiments show that the majority of dental aerosol settles in the first 10 minutes post-procedure. Interpretation/ Implications: This means environmental cleaning may be appropriate within this period. Understand ‘fallow time’: how much time one has to allow for the droplets to fall & settle before re-entering and disinfecting the surgical room. The earlier numbers given for this fallow time have been as large as 60 minutes or even 2 hours 27 minutes. This area always lacked evidence. This study seems to have shown that the fallow time is far shorter - about 10 minutes. Reference: Holliday, Richard, et al. “Evaluating Dental Aerosol and Splatter in an Open Plan Clinic
2 News Implications Environment: for the COVID-19 Pandemic.” OSF Preprints, 7 Sept. 2020. Web. Dental Aerosol Generating Procedures: Evidence is weak (Grade 4) - BMJ Editorial (20 Aug 2020) to The term “Aerosol- Generating Procedures” became popular after the 2003 SARS epidemic, when small retrospective studies found an association between transmission healthcare workers and the use of procedures such as endotracheal intubation & non-invasive ventilation. This weak (grade D) evidence has been misused to infer a causal link between procedural aerosols and infection even though aerosols were not measured during these SARS epidemic studies. Reference: Airborne transmission of covid-19. BMJ 2020;370:m3206 and generating Aerosol procedures risk of transmission of acute respiratory infections to healthcare workers: a systematic review (2003)  Despite the comprehensive nature of the limitations of the included studies serve to emphasize the lack of search, the high-quality studies which have examined the risk of transmission of microbes responsible for acute respiratory infections to HCWs caring for patients undergoing aerosol-generating procedures.  The findings of this study serve to highlight the lack of precision in the definition of aerosol-generating procedures.  The results of this report should not be generalized to all acute respiratory infections because the evidence available is strictly limited to SARS.  A significant research gap exists in the epidemiology of the risk of transmission of acute respiratory infections from patients undergoing aerosol- generating procedures to HCWs, and clinical studies should be carefully planned to address specific questions around the risks of transmission in these settings. Reference: Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. doi:10.1371/journal.pone.0035797 Dental procedure aerosols and COVID-19: The Lancet Infectious Diseases (10 Aug 2020) This communication (letter to the editor) highlighted two main issues: A. Do aerosols—specifically, aerosols—contain dental potentially infectious virus?  Testing to date has focused on Polymerase Chain Reaction (PCR), and even when positive, viral culture is required to confirm the potential for infection, as shown in investigations of other body sites.  of aerosols Estimates risk from surface contamination must be based on the recovery of viable virions, not only on PCR testing. and potential viral load could be further reduced if a dental rubber dam is in place isolating the dentition. Reference: Dental procedure aerosols and Covid-19. Lancet Infectious Diseases. 10 Aug 2020. DOI: https://doi.org/10.1016/ S1473-3099(20)30636-8 Latest recommendations by the Centres of Disease Control & Prevention (CDC) on aerosol- generating procedures used in dental clinics In the CDC guidelines, aerosol procedures are NOT contraindicated. latest report (updated on 28 Aug 2020) recommends the following things if aerosol-generating procedures are necessary for dental care: The B. Should we compare dental A. To minimize droplet aerosols with medical aerosols? spatter and aerosols,  A dental-generated aerosol is due to water or air spray, which would substantially dilute any potential viral presence, whereas in anaesthesia and upper-airway procedures, water irrigation is not used and manipulation of the airway occurs.  Dental management includes routine use of high- volume evacuation, which reduces aerosol at source, and  use four-handed dentistry  high evacuation suction  dental dams B. CDC also states that Preprocedural Mouth Rinses (PPMRs) with an antimicrobial product (chlorhexidine gluconate, essential oils, povidone-iodine or chloride) may reduce the level of oral microorganisms in aerosols and cetylpyridinium 10/20 spatter generated during dental procedures. substantial C. In areas with moderate to community transmission, during patient encounters with patients not suspected of SARS-CoV-2 infection, CDC recommends that dental healthcare personnel (DHCP):  Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters, including those where splashes and sprays are not anticipated.  Use an N95 respirator or a respirator that offers an equivalent or higher level of protection during aerosol- generating procedures. Reference: CDC Guidance for dental settings, 28th Aug 2020 Ad PRINT EVENTS EDUCATION DIGITAL SERVICES Dental Tribune International The World's Dental Marketplace www.dental-tribune.com
3 News 10/20 Infrared thermometers used for temperature check are very safe. Ignore illogical WhatsApp videos. by Rajeev Chitguppi, Dental Tribune South Asia Many patients are refusing to co-operate and not allowing the doctors to record temperatures using infrared thermometers - all thanks to a fake Facebook post and an illogical Whatsapp video. The aim of this article is to bring the facts to you and assure you that infrared guns are absolutely safe. A Facebook post that went viral from July 25, 2020, and until now shared by 2000 people claims that an unnamed Australian nurse has warned everyone about the purported dangers of using infrared thermometer guns to check temperatures. Some points mentioned in the post: Infrared temp gauging on the pineal glands!  for I aim I‘m really worried ... One of my new tasks is taking and recording each person‘s temperature. the center of their forehead with my thermometer shaped gun, I pull the trigger, wait for the beep and record the temperature. I always apologize to the person before proceeding!  Are we being desensitized to be targeted at the head and also causing potential health issues by aiming an infrared ray to the pineal gland?”  So I started taking the temperature on the wrist, which turned out to be more accurate given that the forehead is cooler than the wrist and the results It‘s time to educate the public against the fake Facebook post & the Whatsapp video that claim that infrared thermometers are not safe. (Photo: Pexels.com) differ by more than one degree in some cases.  As a medical professional, I refuse to directly target the pineal gland which is located directly in the center of the forehead, with an infrared ray. Our pineal glands must be protected as it is crucial for our health both now and in the future.  Ask yourself: Is it ever wise to aim an infrared laser light at the pineal gland? There is a viral Whatsapp video too, which claims the same things. Let‘s analyse these absurd social media posts. Please read the reasons, why not to believe in these fake claims: We hereby provide you with the scientific explanations offered by neuroscience experts on this matter on the AFP website. Girardeau, researcher a Gabrielle neuroscience at France’s Inserm institute, told AFP on July 22, 2020: People tested are in no way subjected to infrared radiation exposure during temperature measurement. The thermometer captures the infrared radiation emitted by the human body, on a sensor. Maude Claude Beaudoin- Gobert, Bernard Lyon 1 University’s doctor in neurosciences, in his statement to AFP on July 23, 2020, explains the reasons behind this fear of pineal gland damage: In reptiles and birds, the pineal gland is just under the skull and contains photosensitive cells that are sensitive to visible and infrared spectrum sunlight, which for mammals. the case is not According to Gabrielle Girardeau, even if infrared rays were to be directed towards the pineal gland, it is positioned too deeply in the brain for the rays to reach it. Light has a very low capacity to penetrate the barrier formed by the skull. AFP Fact check debunked this on their website (Published 25 July; Updated 2 September): https://factuel.afp.com/ It is very important to share the facts with the general public who refuse to get their temperature checked by tested by infrared thermometers based on these baseless social media posts and WhatsApp videos. Co-author of the article: Ashwini Bhangale, Intern, MGVM‘s KBH Dental College & Hospital, Nashik. A viral WhatsApp video that claims infrared thermometer guns damage the pineal gland.
4 News 10/20 Making a case for Vitamin D during COVID 19 – Subhasree Ray (Clinical & Public Health Nutritionist) than reporting, obesity is associated with alterations in the vitamin D endocrine system. Lower levels of serum 25-hydroxyvitamin D (25-OHD) in morbidly obese individuals may be related to deposition of adipose cells. obese Therefore, morbidly individuals are expected to need higher doses of vitamin D supplementation the general population. However, it is still unknown whether adiposity (or percentage body fat) into consideration while assessing vitamin D requirements in the general population. Another theory certain enzymes are needed to convert vitamin D into its active form, and levels of these enzymes may differ between obese and non- obese individuals. should be stated taken that A 2012 study (Drincic A et al.) reported adjusting Vitamin D levels in obese individuals reduced the difference in Vitamin D levels among obese and non- obese individuals. This indicates vitamin D needs to depend on body size, & obese need more than normal-weight people. loss, These serum Interestingly, losing weight can also affect vitamin D levels. RCT (Rock C et al, 2012) reported weight presumably associated with a reduction in body fat, is associated with increased 25(OH)D concentration in overweight or obese women (n=383). studies conclude that intricate relationship between vitamin D status and body weight or body fat percentage and getting enough vitamin D may help in preventing body weight gain or accumulation of fat cells. In turn, losing weight can increase vitamin D levels and help maximizing its other benefits. there an is • Insulin Resistance and Diabetes: Inadequate vitamin D status and inflammation can contribute to pancreatic β-cell dysfunction and the formation of insulin resistance. Comprehensive Fig 1: The influence of 1,25(OH)2D on the different cell types of these immune system segments (Shymanskyi I et al, 2019) A growing body of evidence now links COVID-19 outcomes with vitamin D status. (Photo: Monfocus/ Pixabay) by Dental Tribune South Asia A body growing of evidence now links COVID- 19 outcomes with vitamin D status. Subhasree Ray, a clinical and public health nutritionist, literature and analyses makes evidence-based recommendations. the her in COVID It’s been six months since the World Health Organization has declared COVID 19 pandemic. COVID 19 is defining the global health crisis of our time and one of the major threats posed to the world since world war two. Worldwide, scientists are racing for a safe vaccine or medicine. Amid these hustles, nutrition, one of the most crucial aspects recovery and prevention is overlooked. Specific micronutrients (Vitamins and Minerals) are potential and play a vital role in boosting immunity as well as keep the pathogens at bay. Vitamin D, among these micronutrients, found be of utmost importance during COVID 19 as researchers’ uncovered of Vitamin D deficiency in people to death. who Observational on mortality and severity in COVID 19 patients also revealed that the pandemic is affecting people who are either overweight, obese, living with diabetes, antioxidant succumbed prevalence studies hypertension, malnourished, and immune suppressants. Vitamin D deficiency is associated with all these conditions, directly or indirectly. Global Literature: Vitamin D Deficiency and COVID 19 Mortality: A most recent study (Merzon E et al, 2020) published in FEBS Journal shows, out of 7807 COVID 19 patients, 782 (10.1%) were COVID-19 positive, and 7,025 (89.9%) were COVID-19 negative. The mean plasma vitamin D level was significantly lower among those who tested positive than negative for COVID-19. The authors also stated people who are aged over 50 years, male and from low socio-economic status were having a positive the risk of association with infection and COVID-19 the likelihood of hospitalization. explains Hans K. Biesalki (June 2020) in an article titled “Vitamin D Deficiency and Comorbidities in COVID 19 patients – A Fatal Relationship” the vitamin’s crucial role in the immune system that raises the question whether an inadequate Vitamin D supply has an influence on the progression and severity of COVID 19 disease. Physicians, Dr Issac Pugach and Dr Sofya Pugach at the Complete Med Care clinic in Dallas, Texas, have conducted a the showing study that prevalence of severe vitamin D deficiency is strongly correlated with COVID 19 mortality rate in European countries. The study found, EU countries, with the prevalence of severe Vitamin D deficiency, reported more COVID 19 deaths/million than countries who had lower prevalence. Importance of Vitamin D in Human Physiology: • Role of Vitamin D in Immune Regulation and Inflammatory Responses cells) and Vitamin D receptor (VDR) is expressed on immune cells (B cells, T cells and antigen- presenting these immunologic cells are all are capable of synthesizing the active vitamin D metabolite, vitamin D has the capability of acting in an autocrine manner in a local immunologic milieu. Vitamin D can modulate innate and adaptive immune responses. Deficiency in vitamin D is associated with increased autoimmunity as well as increased susceptibility to infection. Global data, stating deficiency of vitamin D in COVID 19 positive patients and those who succumbed to death supports the theory that vitamin D is one of the most important factors in regulating the basic immunological functions in the body. • Obesity Studies et al, 2003; Parikh S et al, 2004) (Arunabh S
6 News 10/20 “Feluda”- CRISPR based high accuracy, low cost Covid-19 test gets DCGI approval for commercial use by Rajeev Chitguppi, Dental Tribune South Asia test CRISPR (Clustered Interspaced Short Regularly Palindromic Repeats) - FELUDA, received regulatory approvals on 19 September 2020 from the Drug Controller General of India (DCGI) for commercial launch, as per guidelines, meeting ICMR high-quality benchmarks with 96% sensitivity and 98% specificity for detecting the novel coronavirus. Two senior scientists Dr Debojyoti Chakraborty and Dr Souvik Maiti from the Council of Scientific and Industrial Research- Institute of Genomics and Integrative Biology (CSIR- IGIB) have developed a quick paper strip Covid-19 testing kit - “Feluda.” Using the CRISPR gene- editing Feluda technology, identifies and targets the genetic material of Sars-CoV2, the causative virus of Covid-19. This is the only Covid-19 testing kit that has been developed using Feluda is an indigenously developed test that uses the cutting-edge CRISPR technology to detect the genomic sequence of SARS-CoV-2. (Photo: Mufid Majnun/ Unsplash) CRISPR-based India. technology in The name “Feluda” coined for the testing kit is based on a fictional detective character Feluda (alias Prodosh C Mitter) created legendary moviemaker late Satyajit Ray, who wrote 35 Feluda stories and made two films. But here, Feluda the by stands for „FnCas9 Editor Linked Uniform Detection Assay“. This test uses an indigenously developed, cutting-edge CRISPR technology for detection of the genomic sequence of SARS- CoV-2 virus. CRISPR is a genome- editing technology to diagnosing diseases. Moreover, CRISPR is a futuristic technology that can also be configured for detection of multiple other pathogens in the future. Feluda detects active Covid- 19 infection by using a CRISPR CAS 9 based readout on a paper strip - world‘s first kit to do so for SARS-CoV-2. This marks a significant achievement for the Indian community, scientific moving from R & D to a high- accuracy, scalable and reliable test in less than 100 days. The effort is the result of a fruitful collaboration between the scientific community and industry. The Tata Group has worked closely with CSIR-IGIB and ICMR to create a high- quality test that will help the nation ramp up Covid-19 testing quickly and economically, with a ‘Made in India’ product that is safe, reliable, affordable, and accessible. The first-of-its-kind test kit that costs less than Rs 1000 can give results in one hour. Feluda doesn’t require real- time PCR machine. It can be performed at the point of care settings where a simple PCR machine is present. The Tata CRISPR test achieves accuracy levels of traditional RT-PCR tests, with quicker turnaround time, less expensive equipment, and better ease of use. Ad Relax your patients and make them feel more comfortable during dental procedures Matrx Nitrous Oxide and Oxygen Conscious Sedation Systems There are many good reasons to use nitrous oxide sedation in your dental practice: • Safe - N2O/O2 has been used globally for over 100 years • Relieves patient anxiety and discomfort • Patients remain awake, yet more relaxed, making it an excellent patient management tool • Improves patient experience, resulting in return visits Matrx is made in the USA 210 Udyog Mandir 1 7-C Bhagoji Keer Road Mahim West, Mumbai 400016 India Phone: +91 22 61 46 47 48 Email: firstname.lastname@example.org www.lifecare.in
7 News 10/20 Let dentists keep working—lessons from the second Israeli lockdown by Jeremy Booth, Dental Tribune International TEL AVIV, Israel: Dental clinics in Israel are operating as usual this week, despite a government-imposed lockdown that has been implemented to curb the spread of SARS-CoV-2. Dental Tribune International (DTI) spoke with an Israeli dentist, who commented that the strict health protocols that are in place within dentistry justify the continued provision of elective care in Israel has started the Jewish calendar year its second general lockdown, making it the first wealthy country to return to a period of strict government- mandated business closures and restrictions on movement. to slow Implemented the spread of SARS-CoV-2, the new lockdown began on 18 September and is set to continue for a period of three weeks, ending on 9 October. Widely unpopular, it confines people to within a 1 km radius of their homes and shuts schools, day care centres, and many private businesses, such as restaurants, hairdressers and gyms. Like the country’s first forced dental practices to close for a period of five to six weeks from mid-April—it coincides with a Jewish holiday period and aims to prevent the rate of infections soaring as a consequence of family gatherings and religious ceremonies. This time, however, dental clinics remain open, lockdown—which in invested had additional infection control measures, such as air filtration devices. Israel’s lockdown: How is it affecting dental patients? Schifter had just returned home from his clinic when DTI spoke with him on 21 September— three days into the lockdown period—and he commented that patient numbers were as high as they had been several weeks before. “Patients are displaying a degree of confidence and trust in us. They trust us that we are taking the maximum possible measures to protect them, and ourselves, and as a result of this, they are coming and having their dental work done as usual— routine work, not only emergency care.” importance of “We are very aware of the infection protection. We were actually doing this on a daily basis before the coronavirus outbreak” – Dr Alon periodontist, Tel Aviv Schifter, But Schifter said that the lockdown was having an effect on dental treatment, particularly for patients. “It is because some of our patients are elderly—especially if you are a periodontist like me and you treat periodontal disease, which often occurs in the elderly. Then there are the maintenance and hygienic treatments, which are very important, but also result in the largest generation of aerosol.” He added that some patients have been reluctant to attend their appointments A second lockdown in Israel has put many things on hold, but not dental care. (Image: StockStudio Aerials/Shutterstock) together with doctors’ offices and other health service providers. Dr Alon Schifter, who practises as a periodontist in the Tel Aviv area, told DTI that this second lockdown is more flexible. Some private businesses are allowed to remain open, and medical and dental treatments can continue to be carried out according to the rigorous restrictions and health measures that have already been implemented in the country to combat the spread of the virus. include dental “The second lockdown does not clinics,” Schifter confirmed. “We are open, we are working, and we are very cautious and careful.” performing He explained that the strict health measures in place at dental clinics in Israel meant that there was no need to restrict dentists to emergency procedures only. “According to government statistics, there have been almost no new infections in dental clinics in Israel. Owing to the good infection control protection, due to the measures that are taken, there have been no new infections reported in either staff or patients in dental clinics.” He continued: “Based on the responsibility of the dental practitioners—whether this themselves, is or the administrators who are working in the clinics—we are very aware of the importance of infection protection. We were actually doing this on a daily basis before the coronavirus outbreak.” the dentists the hygienists and Schifter echoed the sentiment of dental associations around the world, who have emphasised that dentists are instructed in infection prevention during their studies. “We were taught that every patient is a potential carrier of hepatitis or any other infectious disease,” he explained. “You have to take measures to protect yourself, your staff and your patients.” He added that, since the onset of the pandemic, Israeli dentists had been even more careful to maintain their high standards and that many and have preferred to postpone treatments for a period of three to four weeks after the lockdown is due to end. Minister of Health Yuli Edelstein said in mid-September that a second lockdown in Israel was inevitable, owing to what he said had been a lack of aggressive and effective enforcement of the government’s health measures. “The coronavirus is neither a matter of politics nor of populism. This is a matter of life and death. I suggest that anyone who claims that it is possible to do otherwise will go on a tour of the hospitals, of the coronavirus wards, and see the situation for themselves,” Edelstein told the Knesset, the Israeli parliament, on 13 September. Israel reported more than 4,000 new daily cases of COVID- 19 over three consecutive days in mid-September, and hospital facilities were reportedly nearly stretched to capacity in some areas. On 17 September—the day prior to the start of the lockdown— active cases of COVID-19 in Israel had passed 46,000 and 1,165 people had died from the virus, according to local newspaper Haaretz. By the same date, there were 10,433 active cases and 246 associated deaths recorded in the West Bank, and 1,688 active cases and 15 associated deaths in Gaza, Haaretz reported. The total number of Israel infections recorded by 24 September was 206,332, according to the Johns Hopkins University tracker. in COVID-19 herd immunity: Current status by Rajeev Chitguppi, Dental Tribune South Asia states Herd immunity is a key concept for epidemic control, which that only a proportion of a population needs to be immune to an infectious agent for it to stop generating large outbreaks. We can achieve herd immunity through two strategies: by overcoming natural infection or through vaccination. is This the summary of the article “COVID-19 herd immunity: Where are we?” published in Nature Reviews Immunology on 9th Sept 2020. Authors article Arnaud Fontanet & Simon this of Cauchemez state that there is little evidence to suggest that the spread of SARS-CoV-2 might stop naturally before at least 50% of the population has become immune. So, what would take to achieve 50% population immunity? it of 1. One the main problems is we currently do not know how long the naturally acquired immunity to SARS- CoV-2 lasts. The duration of immunity is particularly of concern among those who had mild forms of Covid-19. If we take seasonal coronaviruses as the benchmark, they usually have short-lived immunity. immunity 2. We should also check whether it might take several rounds of re-infection before robust is attained against SARS-COV-2. With flu pandemics, herd immunity is usually attained after two to three epidemic waves. 3. The cost of reaching herd immunity through natural infection would be very high, especially among individuals who are at a higher risk of developing severe complications. That’s why an effective vaccine presents the safest way to reach herd immunity. As of August 2020, six anti- SARS-CoV-2 have reached phase III trials. We can assume that some will become vaccines available by early 2021, although their safety and efficacy remain to be established. We wait for further evidence. Ref: Fontanet, A., Cauchemez, S. COVID-19 herd immunity: where are we?. Nat Rev Immunol 20, 583–584 (2020). https://doi. org/10.1038/s41577-020-00451-5 Latest review states that there is little evidence to suggest that the spread of SARS-CoV-2 might stop naturally before at least 50% of the population has become immune. (Photo: Cavernia/ Wikimedia Commons)
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