WHO Says Masks Necessary Due to Delta Variant

Variant is Causing COVID Surges in Countries With High Vaccination Rates

Delta Plus is a New Variant with Uncertain Impact

What the Delta Variant Could Mean for Covid-19 in the United States

Is the Delta Plus Variant More Infectious, Deadly or Vaccine-Resistant?

Delta Plus Variant in Eleven Countries

U.S. Mask Production Declines Precipitously

Royal Caribbean Cruise Ship Sets Sail With Hospital Quality Ventilation

___________________________________________________________________________

WHO Says Masks Necessary Due to Delta Variant

World Health Organization (WHO) officials stressed Friday the need for fully vaccinated people to “continue to be appropriately cautious” and keep up with social distancing measures like mask wearing as the highly infectious Delta variant of the coronavirus becomes increasingly dominant in the U.S. and spurs new Covid-19 surges around the world—including in highly vaccinated countries.

The Delta variant, which was first identified in India and is more infectious than previous coronavirus strains, is now responsible for approximately 10% of coronavirus infections in the U.S. as of June 5 and has caused new Covid-19 outbreaks in such countries as the United Kingdom, Australia and Israel.

The variant’s spread means people should follow public health measures like mask wearing, frequent sanitizing and social distancing “with much more care,” Dr. Michael Ryan, executive director of the WHO’s World Emergencies Programme, said at a press briefing Friday, saying the Delta strain should make the world “more cautious, more diligent, and more dedicated to” following those protocols.

WHO senior advisor Dr. Bruce Aylward said fully vaccinated people should “play it safe,” noting people can “end up as part of a transmission chain” even if they’ve received both shots.

Dr. Maria Van Kerkhove, the WHO technical lead on Covid-19, said while vaccines are “incredibly effective at preventing severe disease and death” including against the Delta variant, the strain is a “dangerous variant” and large events taking place as the variant spreads “will have consequences.”

Using masks consistently” and following other social distancing measures like avoiding crowds, hand washing and being in well-ventilated spaces is “extremely important, even if you’re vaccinated,” Dr. Mariangela Simao, WHO assistant director-general for access to medicines and health products, said, warning, “Vaccine alone won’t stop the community transmission.”

“The first message that we want to be careful about is saying once you’re vaccinated, you can go ahead and do whatever. Yes, you can reduce some measures...but there’s still the need for caution,” Aylward said Friday. “We’re still in a world with a lot of people who are not protected.”

Covid-19 vaccines are considered to be largely protective against the Delta variant, with recent studies finding the Pfizer vaccine is approximately 90% effective against the new strain. Only receiving one dose of the vaccine provides far less protection against the variant, however—one Pfizer dose is only approximately 36% effective against symptomatic disease, Public Health England reported—and breakthrough infections are possible but rare.

The rise of new and more dangerous variants has provoked fears the virus will continue to mutate and could evolve to evade vaccines, particularly as much of the world remains unvaccinated. While right now measures like vaccines, social distancing and mask wearing have been proven to work against Covid-19, Van Kerkhove said Friday, “there may be a time when this virus evolves, and these countermeasures don’t.”

The Centers for Disease Control and Prevention has not yet responded to a request for comment on the WHO officials’ warning Friday and whether the agency will reconsider guidance saying fully vaccinated Americans do not have to wear masks in light of the Delta variant’s spread. The Delta strain is right now estimated to double in prevalence approximately every two weeks in the U.S., and it is expected to ultimately become the country’s dominant strain.

Dr. Anthony Fauci has warned the variant poses the “greatest threat” to the U.S.’s effort to eradicate Covid-19, and officials have particularly warned about surges in areas where the vaccination rate remains low, such as Southern states like Mississippi and Alabama.

 

Variant is Causing COVID Surges in Countries With High Vaccination Rates

Many of the countries that have faced the largest Covid-19 surges in recent months are also those with among the highest vaccination rates in the world—such as Uruguay, Bahrain, the Maldives and the Seychelles—a trend that’s been partially attributed to countries relaxing their restrictions too quickly. The latest highly vaccinated country to face a new surge is Israel, which is reimposing their indoor mask mandate amid a new rise in cases linked to the Delta variant. Approximately half of the country’s new infections appear to be in people who are fully vaccinated with the Pfizer/BioNTech vaccine.

Infectious disease experts are weighing the need for booster shots of the Pfizer/BioNTech (PFE.N), or Moderna (MRNA.O) mRNA-based vaccines for Americans who received Johnson & Johnson's (JNJ.N) one-dose vaccine due to the increasing prevalence of the more contagious Delta coronavirus variant.

A few say they have already done so themselves, even without published data on whether combining two different vaccines is safe and effective or backing from U.S. health regulators. Canada and some European countries are already allowing people to get two different COVID-19 shots.

The debate centers on concerns over how protective the J&J shot is against the Delta variant first detected in India and now circulating widely in many countries. Delta, which has also been associated with more severe disease, could quickly become the dominant version of the virus in the United States, Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky has warned.

There is no substantial data showing how protective the J&J vaccine is against the new variant. However, UK studies show that two doses of either the Pfizer/BioNTech or AstraZeneca (AZN.L) vaccines are significantly more protective against the variant,

A double dose of COVID-19 vaccines is almost as effective against the fast-spreading variant of the coronavirus first identified in India as it is against Britain’s dominant strain, English health officials said.

A study by Public Health England found the Pfizer-BioNTech vaccine was 88% effective against symptomatic disease from the B.1.617.2 variant two weeks after the second dose.

That compared with 93% effectiveness against the B.1.1.7 "Kent" strain which is Britain's dominant COVID variant.

Two doses of the AstraZeneca vaccine were 60% effective against symptomatic disease from the Indian variant compared with 66% effectiveness against the Kent variant, PHE said.

 

Delta Plus is a New Variant with Uncertain Impact

A new and slightly changed version of the Delta coronavirus variant is spreading in a number of countries including the United Kingdom, United States and India, health officials say.

This strain, which has generated a significant amount of global media attention, is called B.1.617.2.1 or AY.1 -- Delta Plus for short and is a version of the Delta variant first detected in India in February.

It was first reported by Public Health England, a government health agency, on June 11. But the UK's first few cases had been sequenced on April 26 -- suggesting the variant may have been present and spreading by the spring.

The Indian government said it has submitted the variant to the Global Data System and sent samples for genomic testing.

About 200 cases have been spotted in 11 countries. Only one death has been reported so far, in India.

Health experts are investigating whether Delta Plus may be more transmissible than other strains like the Alpha or Delta variants -- but it's too early to say for sure what its effects may be.

 

All variants carry clusters of mutations. Delta Plus has an extra mutation called K417N, which distinguishes it from the regular Delta variant. This mutation affects the spike protein, the part of the virus that attaches to the cells it infects.

The K417N mutation isn't entirely new -- it has "arisen independently in several viral lineages," said Francois Balloux, director of the University College London (UCL) Genetics Institute.

The mutation was seen in a strain found in Qatar in March 2020, and is also found in the Beta variant, which was first detected in South Africa last fall, he told the Science Media Centre on Wednesday.

 

 

What the Delta Variant Could Mean for Covid-19 in the United States

"The mutation may contribute to immune escape, though its impact on transmissibility is not clear-cut," said Francois Balloux, director of the University College London (UCL) Genetics Institute.

All viruses mutate constantly. Some of those changes make viruses better at infecting cells, or better at replicating, while others have little effect or are even harmful to the virus.

To date, there have been about 160 strains of the coronavirus sequenced globally, said Balloux.

There are also "other Delta plus variants with other mutations," said the Indian government on Wednesday, adding that AY.1 was just the most well-known.

Maria Van Kerkhove, the World Health Organization's technical lead on Covid-19, added that the team was "looking at these specific mutations and what these mean in terms of transmission, in terms of severity, and really importantly what these means in terms of our medical countermeasures."

Meanwhile, the regular Delta variant, also known as the B.1.617.2 strain, has spread rapidly. It has been reported in dozens of countries and is 40% to 60% more transmissible than the Alpha variant first identified in England, said the European Centre for Disease Prevention and Control (ECDC).

"I know that globally there is currently a lot of concern about the Delta variant, and the WHO is concerned about it too," said Tedros Adhanom Ghebreyesus, director general of the World Health Organization, on Friday. "Delta is the most transmissible of the variants identified so far."

 

Is the Delta Plus Variant More Infectious, Deadly or Vaccine-Resistant?

According to the Indian government's Covid-19 genome sequencing body, the Delta Plus variant exhibits several worrying traits such as increased transmissibility, stronger binding to receptors of lung cells, and a potential reduction in antibody response.

It's not yet clear what effect the mutation may have on vaccine efficacy -- but Julian Tang, professor of respiratory sciences at the University of Leicester, warned it could potentially give the variant "significant vaccine escape properties."

Most of the coronavirus vaccines are designed to train the body to recognize the spike protein, or parts of it -- the place where Delta Plus' extra mutation is. 

However, there isn't enough evidence to determine anything conclusively yet and other experts have expressed caution. On Wednesday, the Indian government said the mutation's role in "immune escape, disease severity or increased transmissibility etc. is under continued surveillance."

"This virus has also been isolated and cultured," said Balram Bhargava, Director General of the Indian Council of Medical Research, on Friday. "We should have the results in seven to ten days on whether the vaccines are working against Delta Plus."

For now, experts are largely cautioning the public and governments to remain watchful but calm.

Besides the Beta variant, none of the other strains carrying the K417N mutation "have been particularly successful so far," said Balloux. "It has been found in several countries but has remained at extremely low frequency ... There is no evidence the strain is currently expanding in any country."

Van Kerkhove from WHO said the organization was tracking Delta Plus to determine its transmissibility and severity.

 

Delta Plus Variant in Eleven Countries

So far, Delta Plus has been reported in 11 countries -- but the number of cases per country only reflects samples that have been sequenced, and more data is needed to determine the actual rate of spread.

"As far as I am aware, the speed of spread of a variant cannot be measured by the early spread frequency," said T. Jacob John, head of clinical virology at India's Christian Medical College. "There is no information that Delta Plus is infecting people who were infected in the first wave, immunized people or those infected in the second wave. The spread has to be watched to know more."

The US has sequenced and confirmed the highest number of cases so far, with 83 cases as of June 16, according to Public Health England.

India follows with 48 cases, the government said on Friday. One patient, an 80-year-old female with pre-existing conditions, has died, said Rajesh Tope, health minister of Maharashtra state, on Friday.

The cases began in three states -- which were all placed on alert -- but have since spread to a total of eight states. The central government is urging states with cases to "enhance their public health response" by stepping up testing, tracing, and priority vaccination.

India is still recovering from its devastating second wave, which has infected millions and killed hundreds of thousands in the past few months. It's not clear whether Delta Plus will deliver another blow -- John said it was unlikely, as the country's vaccination rate picks up -- but the trauma of the second wave has authorities on high alert.

"Once bitten, twice shy," John said. "Those who did not predict the second wave do not want to be caught a second time, so they are alerting everyone of a possible third wave."

The UK has reported 41 cases as of June 16. Enhanced contact tracing, testing, and isolation has been deployed in areas where Delta Plus has been reported, Downing Street confirmed on Thursday.

The first few cases sequenced in the UK were contacts of individuals who had traveled from or transited through Nepal and Turkey, according to Public Health England.

The rest of the cases are spread out between Canada, India, Japan, Nepal, Poland, Portugal, Russia, Switzerland, and Turkey.

U.S. Mask Production Declines Precipitously

A year after several American businesses sprang up to manufacture much-needed masks and N95 respirators within U.S. borders, many of those businesses are now on the brink of financial collapse, shutting down production and laying off workers.

The nationwide vaccination campaign, combined with an influx of cheaper, Chinese-made masks and N95 respirators, has dramatically cut into the companies' sales and undermined their prices.

And while some call it a normal consequence of a free market, a few business owners say they feel abandoned by the same government that relied on them to help save American lives during the COVID-19 pandemic.

"This is not only a matter of national security but of national pride," a group of them wrote last month in a letter to President Biden asking for government help.

Last year, dozens of companies like Armbrust American answered the nation's call for more domestic production of personal protective equipment (PPE).

Using its own resources and without government assistance, Armbrust purchased a facility near Austin, Texas, bought machinery, hired over a hundred workers, applied for a complicated and lengthy certification and started manufacturing.

We started at the height of the pandemic really, in April, and very, very quickly, in about six months, we were able to scale up to producing about a million masks per day. And today we produce both surgical and N95-style masks," said Lloyd Armbrust, the founder and CEO.

Business was doing well, until the mass vaccination effort dramatically reduced demand for masks. Now, Armbrust predicts he can keep going for another four months at most, before completely shuttering the plant. "We are down to a skeleton crew on the alternate shifts and just barely a full crew on the main shift," he said.

At the beginning of this year, Armbrust and 27 other small-business mask manufacturers formed the American Mask Manufacturer's Association (AMMA).

"Let me put this in perspective: We have 28 members who are going to go out of business in the next 60 to 90 days, and when they go out of business, it's not like we turn off the lights and mothball these machines. We send them to the dump. That capacity that we created goes away," Armbrust said. Already five of the AMMA members have stopped production, he said.

These recent entrants into the mask-manufacturing industry are not the only companies cutting back on production, laying off workers and fighting for a share of a market long dominated by foreign-made products.

Before the pandemic began, about 10 American companies were actively making N95 respirators, according to Anne Miller, executive director of the nonprofit ProjectN95, a national clearinghouse for PPE founded in 2020. Larger companies such as Honeywell and 3M also manufactured N95s in factories abroad. All told, fewer than 10% of the N95 respirators used in the U.S. were manufactured domestically, according to industry experts.

In early 2020, China, the world's largest manufacturer of masks, was also fighting the pandemic and nationalized its manufacturing. The U.S. market, which depended mostly on masks from China, was essentially cut out.

"China, realizing that they have a crisis on their hands, restricted the export of all masks to the United States," said Robert Handfield, a professor of supply chain management at North Carolina State University. So, while those companies were still producing, he says, they were forbidden by the Chinese government from shipping the masks to the United States.

To add to the problem, even U.S. companies such as Honeywell and 3M, which manufactured predominantly abroad, faced restrictions. "3M was unable to get shipments from its own factories in China back to the United States because the exports were being prevented by the Chinese government from leaving the country," Handfield said. The inability to get masks from abroad led to shortages domestically that put the U.S. in a precarious position.

The dependency on China and other foreign countries was nothing new, recalled Mike Bowen, executive vice president of Prestige Ameritech, one of the oldest domestic manufacturers of masks in the United States.

In 2009, during the H1N1 pandemic, Prestige Ameritech stepped up production to meet the growing domestic need.

Before the pandemic, larger companies such as Honeywell and 3M manufactured N95 respirators in factories abroad. All told, fewer than 10% of the N95 respirators used in the U.S. were manufactured domestically, according to industry experts.

"Last time we were stupid," Bowen said. "We believed everyone when they said they would stay with us. ... We're buying a factory, we're building more machines, we're hiring people, but you got to stay with us. And everybody said they would, but they didn't."

As soon as the health scare was over, the market dried up. The aftermath was harsh — laid-off workers, financial losses — but he survived.

This time, Bowen tried to be more careful.

"It's like people want to have their cake and eat it too. They want to have the cheapest prices — they want China prices — but then they want American manufacturers to bail them out when they can't get their Chinese products. That doesn't work," Bowen said. For comparison, one N95 respirator costs about 25 cents to manufacture in China. Producing the same product in the U.S. can cost more than double.

When the COVID-19 pandemic began, Bowen's company was slammed with new orders. His facility uses primarily domestically sourced raw materials, so he stepped up again. He ramped up production to meet the growing demand, adding more machines and increasing his labor force more than threefold.

Now, much cheaper masks from abroad have reentered the market yet again, as China has lifted export embargoes, competing directly against masks made in America. Bowen has six machines sitting idle in his factory.

"They want to have the cheapest prices — they want China prices — but then they want American manufacturers to bail them out when they can't get their Chinese products. That doesn't work," Mike Bowen, executive vice president of Prestige Ameritech, told NPR.

Susanne Gerson is the executive vice president of the Louis M. Gerson Co. in Middleboro, Mass. Much like Bowen, Gerson has been in the business for years. "We've been in business for approximately 60 years, and we've been making N95 respirators since about 1985. So we're a very experienced respiratory manufacturer," she said.

When the pandemic started, Gerson said she started receiving calls personally from doctors in Massachusetts.

"I actually had people crying when I would talk to them on the phone that they didn't know what to do — women doctors who were pregnant and they weren't being provided any protection," she said.

The company made a decision to reconfigure its business from making masks for industrial workers to making masks for health care workers, doubling the workforce on the floor and modifying the facility.

"I think people outside of manufacturing don't understand what it takes to produce a product where we're the most critical part of this whole process and yet we're the most ignored," she said.

"We have not had to lay off people, but if things don't clear up in the pipeline and we don't get some of this confusion addressed, we don't know what's going to happen," she added.

Gerson, like Bowen and others, is calling on the Biden administration to stop the influx of Chinese products.

"We ramped up our capacity to such a level based on what we thought were commitments from new customers and people saying, 'No, we're going to need product,' and being told this by the government and by everyone. And then it's just like, poof, they're not sure," she said.

Gerson is also calling for more clarity around the emergency use authorization that allowed for the reuse of masks, a response to severe shortages that no longer exist.

"We are required to put that on our packaging by the FDA when we make a respirator — that it's a single-use product. And yet my understanding is they are still being used ... oftentimes I think what the hospital is doing is they're putting the other mask over the N95 as a way of trying to keep it clean. But it wasn't designed like that," she said.

Larger manufacturers have faced consequences from the shifting market as well.

Honeywell recently announced that it is shutting down production of N95 respirators at two facilities, in Smithfield, R.I., and Phoenix, laying off more than 1,000 workers. But the company says it has made permanent changes to its structure that would allow for a faster ramp-up next time there is a need. "While we have closed some of our manual operations efforts at two facilities, we are maintaining the automated lines to continue to fulfill orders and can ramp back up as needed," said Honeywell company spokesperson Eric Krantz.

The foreign-dependence vulnerability is something both the White House and members of Congress are well aware of.

Rep. Anna Eshoo has represented California's 18th Congressional District, near San Jose, for nearly three decades. She also chairs the Energy and Commerce Committee's Subcommittee on Health.

"Shame on us that we found ourselves in the position that we were in, especially at the height of the pandemic and the risk that our health care workers had to take and did take," said Eshoo, a Democrat who has often spoken against foreign dependence on commodities, such as PPE and pharmaceuticals, and lack of domestic manufacturing.

"This is a warped picture of America," she said. "We can do so much better."

The White House says it is working on a strategy for a more resilient pandemic supply chain. And recent legislation signed by the president included $10 billion for investments in additional manufacturing capacity, extended contracts for PPE and more.

Armbrust, like other members of the AMMA, said he knew he took a risk.

"I made a stupid decision, because I'm an entrepreneur and I cared about our country and bringing this strategic manufacturing back," he said. "A bunch of people made bad decisions personally to do something that was right at the time, and that to me is the American spirit."

 

Royal Caribbean Cruise Ship Sets Sail With Hospital Quality Ventilation

Cruise ships are now back in business but the  safety validation which claims hospital quality ventilation is not reassuring.  Hospital ventilation quality varies considerably from facility to facility and from area to area.

The Celebrity Edge. cruise ship, owned by the Royal Caribbean Group, became the first to sail from a U.S. port since the US Centers for Disease Control and Prevention brought the industry to a halt more than 15 months ago 

For this start-up period, we're sailing with a reduced capacity to give us all a chance to get used to the protocols and to really allow for natural social distancing," said Susan Lomax, head of global public relations at Celebrity Cruises. She said the cruise line does not plan to exceed 50% capacity on any of its trips this summer. Because of the reduced capacity, cabin occupancy will be spaced out and people will be put into cabins with windows that face outward. Crew members will get their own cabins.

Lomax said filtration experts from the University of Nebraska were asked to evaluate the ventilation/HVAC system and pronounced it "better than what hospitals have."

 

Linsey Marr, an environmental engineer and professor at Virginia Tech, agrees the Edge's ventilation system is more than adequate. "The combination of high air change rates and high-quality filters ... will greatly reduce the amount of virus that can build up in the air. Thus, it is unlikely that people will be exposed to elevated levels of virus in cabins and public indoor spaces," she told CNN. "If this is the case, then the biggest risk comes from being in close proximity, within the exhaled respiratory plume of an infected individual."

Yuguo Li, from the department of mechanical engineering at The University of Hong Kong, sides with Marr.

"Taking all evidence so far, I highly believe that SARS-CoV-2 is predominantly transmitted by the short-range inhalation route in inadequately ventilated spaces. We have studied about 20 outbreaks of SARS-CoV-2, and performed ventilation measurement for 10 of them, all supporting this hypothesis," Li wrote in an email. His study on the Diamond Princess was published online in April in the journal Building and Environment and his editorial appeared in the journal Indoor Air in mid-May.

"For the Diamond Princess outbreak, we showed that their cabin ventilation might be sufficient, and suspect that infections occurred in the public areas. There are two major factors in these public areas: First, in gyms and dancing floors, people perform high [energy] activities with more droplet release and higher inhalation flow, hence infection risks are high ... Second, if occupancy is not controlled in these public spaces, the ventilation per person can be even lower. In some spaces such as restaurants, people cannot wear masks," he explained.

On the Edge, other procedural changes include staggered arrival and departure times to prevent large crowds, and a muster drill -- the mandatory safety exercise done at the start of every trip -- done virtually instead of in person, again to avoid large crowds. And food lovers need not fear: the all-you-can-eat buffets will still be a staple of the dining experience, but instead of self-serve, crew members will lend a hand.

In the unfortunate event of an outbreak, the Edge has the capacity to manage 33 patients, and there are four ICU beds. The entire medical area is on a separate ventilation system.

Contact tracing plans that make use of the ship's CCTV have been drawn up, there are protocols for isolation and quarantining, and disinfection procedures following positive cases.

Importantly, Royal Caribbean has agreements with a number of countries to act as disembarkation ports, should there be a need to get people off the ship.

"There's no longer any 'Oh my gosh, we're sailing for days and no one will take us,' " said Lomax. "There's no reason to wait till the end of the cruise; we have the ability to go to those disembarkation ports if and as needed."

But everyone, from those in the cruise industry to health experts, says the real game changers are vaccines, which offer up to 95% protection against symptomatic Covid-19. Even if there are breakthrough infections, vaccines reduce the amount of virus in the body, making people less infectious to others.

"It's really the vaccines that have enabled us to return to cruising with a low enough level of risk of transmission," said Marr.

On the Edge, 100% of the crew and at least 95% of passengers are vaccinated, which considerably lowers the risk of people getting infected and sparking an outbreak.

However effective vaccines are, it's unclear whether, when and where they can be mandated on future cruises. The CDC currently advises unvaccinated people against going on a cruise -- but that's just guidance. Additionally, Florida is one of several states that has banned businesses from requiring customers to provide proof of vaccination, although upcoming cruises leaving from ports in Washington state and Alaska are expected to have vaccination requirements.

And to top it off, a federal district judge in Tampa recently concluded the CDC's restrictions on the cruise industry are likely unconstitutional and the agency is overstepping its legal authority. So, starting July 18, the agency will no longer be able to enforce its sailing rules, including requirements that either 95% of passengers be vaccinated or that the ship successfully conduct a simulated voyage. The judge gave the CDC until July 2 to propose more modest guidelines.

A judge ruled that Florida would be harmed by the CDC stopping most cruise ships from sailing

In navigating these murky, fluctuating rules, Lomax said that the Edge capped at 5% the number of cabins for people who choose not to disclose their vaccination status. They are counted as unvaccinated. People presumed to be unvaccinated will have to wear masks in public areas and will also have to undergo additional Covid-19 testing -- both to board and midway through the cruise -- at their own expense. Everybody has to be tested before disembarking in the United States.

"With 95% of passengers vaccinated, that's far more than we have in any country. And we know that the higher vaccination rates have really brought down cases. So I think it's probably reasonable for healthy vaccinated people to go on a cruise," said Marr. "The risk of an outbreak on a cruise ship, together with the measures that they're taking requiring unvaccinated people to wear masks, the overall risk of an outbreak should be quite low. And I'd be surprised if we saw something like the Diamond Princess again."

But, despite all the precautions, the experience is still not guaranteed to be 100% coronavirus-free, if the Celebrity Millennium is any example. That ship, carrying the first North American paying passengers, set sail in early June out of St. Maarten, and made several ports of call. The crew were all fully vaccinated as were more than 95% of passengers. Nonetheless, two passengers tested positive for coronavirus at the end of the trip.

"In term of vaccination, the protection is not 100%. Sufficient vaccination protects us from developing a chain of infection, i.e. sustained infection in a large population but ... that means sporadic outbreaks can still occur particularly with the new variants of concern," Li noted.