April 14 2020
Most asked question is what next in this pandemic?
The discussion in the media about the pandemic has changed as NYC reaches the top of their epidemic curve. Such big numbers! There is apparently a sense of relief and suddenly the talk is impatient about “opening” and releasing restrictions for physical distancing. However, before we get too self-congratulatory, let us pause, the US is made of many separate epidemics and the peak in New York was on schedule but for the rest of the country the timing is different.
Regrettably the advice from the White House is at odds with everything coming from medical and public health experts. The experts are expressing concern that decisions will be made without careful consideration of the trade-offs and risks. Fortunately, one can go to local sources to find excellent and measured descriptions of what it takes to plan the next steps. My personal favorite is Governor Andrew Cuomo of NY and Janet Mills of Maine with the Maine CDC director Nirev Shah.
To speak of the future it is important to remember that this virus in new. We can speculate about the post-infection immunity based on what we have seen and use examples from previous epidemics or other coronavirus strains but, these are just speculation.
But, what I do know is this…it is a chorus that every expert is saying…. Track, test, trace, isolate. There are no shortcuts. Rinse and repeat. If we do these activities systematically then we will be able to reopen our social and economic lives in a step-wise careful process that will be nerve-wracking as outbreaks inevitably re-kindle however, it will give us the information we need to proceed. The big change will come with a vaccine (12-18 months at best) or when there is a proven treatment.
To make these steps happen and to begin to relax physical distancing we need laboratory tests and an army of people capable of interviewing every case (case investigation) and to establish their exposures and contacts. Then contact tracers will reach out to all these contacts and ask (require) that they go into quarantine for 14 days. To get a sense of this ask yourself how many people did you have contact with in the past 14 days – within 6 feet for longer than 15 minutes? Since the Stay at Home order the number of contacts per case are much smaller and this makes the work involved with contact tracing more manageable. A close contact is defined by the state health department in collaboration with the US CDC. (Provided in another post)
While in quarantine or isolation people would be called daily by contact tracers to establish if they are experiencing symptoms, if they have need for food or medicine, and if they need to be tested or referred. All of this information about cases (suspect or confirmed), contacts, and quarantine must be linked. If someone cannot be reached then a call is made to the CDC (contact tracing or epidemiology team) to follow up and make sure they are alright and that they are protecting their neighbors by respecting quarantine. These follow-up calls are the simplest place to use volunteers if cases or contacts agree.
When I traveled home from Liberia to the US I got a call every day from the Maine CDC asking me about symptoms, fever, and how I was doing. This call signaled to me that what I was doing was important.
Today the US CDC and FEMA released a draft plan for “reopening” parts of the country:
“The plan lays out three phases: Preparing the nation to reopen with a national communication campaign and community readiness assessment until May 1. Then, the effort through May 15 would involve ramping up manufacturing of testing kits and personal protective equipment and increasing emergency funding. Then staged reopenings would begin, depending on local conditions. The plan does not give dates for reopenings but specified “not before May 1.”
……” The plan also carries this warning: “Models indicate 30-day shelter in place followed by 180 day lifting of all mitigation results in large rebound curve — some level of mitigation will be needed until vaccines or broad community immunity is achieved for recovering communities.”
“The document says reopening communities in this phased approach “will entail a significant risk of resurgence of the virus.” Any reopening must meet four conditions:
- Incidence of infection is “genuinely low.”
- A “well functioning” monitoring system capable of “promptly detecting any increase in incidence” of infection.
- A public health system that is “reacting robustly” to all cases of covid-19 and has surge capacity to react to an increase in cases.
- A health system that has enough inpatient beds and staffing to rapidly scale up and deal with a surge in cases.
The plan describes the conditions under which it is reasonable to lift some community mitigation measures, the phased steps to reduce those measures and indicators to monitor the impact of transmission on public health and health system capacities.”
To pull this off going forward means we need to reverse decades of lack of funding in public health infrastructure and create an army of Americans (and Mainers in our case) to help with case investigation, contract tracing and to support those in quarantine/isolation. In the situation where tests are as limited as they are now, then we will need to use a “suspect” case definition for some cases and some contacts. (See previous blog link here). The inherent uncertainty is dissatisfying but it allows transparent decision-making and errs on the side of caution.
Managing case investigation during the Ebola outbreak in Liberia meant creating an army of smart street-wise people with a broad array of backgrounds. We looked for people that were persistent, good interviewers, and could manage on their feet.
In many articles that are coming out we are given dazzling visions about the promise of phone apps for contact tracing and follow-up. They use South Korea and other parts of Asia as examples. My experience with phone app tracking has been unimpressive. It is harder than the developers promise to start up and it needs to fit the context– especially where there are multiple platforms, where the public fears loss of privacy, and there is not a public health system infrastructure to actually manage it. There is far more training and support needed and the equipment is fussy. I believe that the use of technology and phones will be a great tool but they are inadequate without a system and people.
How do we mange the pandemic and transition to the next phase? The next phase — after this part where we are hunkered down hoping the storm doesn’t kill us – happens when we feel that we have a handle on community transmission and can track the epidemic. Track, test, trace, isolate. It is “over” when there are no cases of community transmission within at least 1 or 2 incubation periods.
The economy is a disaster but lets us not lose our resolve and sacrifice people unnecessarily. What our response tells us is that people matter.
Here are three very good sources for thinking about our next steps:
The new CDC and FEMA draft plan:
2. How Liberia knocked out Ebola and our reliance on Governors in the US.
“….a collection of governors, former government officials, disease specialists and nonprofits are pursuing a strategy that relies on the three pillars of disease control: Ramp up testing to identify people who are infected. Find everyone they interact with by deploying contact tracing on a scale America has never attempted before. And focus restrictions more narrowly on the infected and their contacts so the rest of society doesn’t have to stay in permanent lockdown.”
In America, testing — while still woefully behind — is ramping up. And households across the country have learned over the past month how to quarantine. But when it comes to the second pillar of the plan — the labor-intensive work of contact tracing — local health departments lack the necessary staff, money and training. There are ways to build this and that is the job we need to be doing right now in April 2020.
3. Advice from experts in Seattle about what comes next. There is a bit more excitement in this article about electronic tracking than I might express but for a problem this big we need many strategies.
A great resource:
Ian Lipkin MD, Professor of epidemiology at the Mailman school of Public Health at Columbia University who gave a fantastic talk at the University of New England this evening. It was sponsored by the Center for Global Humanities and it was recorded. He is a true expert in these pandemics and a very clear speaker. It is worth the 60 minutes for the talk and if you are really feeling it there is another 30 minutes of Q&A. Show it to all your friends that have also become pandemic geeks.
Finally, good news! The viral RNA found in stool samples appears to not be infectious. It is just viral bits making their way out of the body (Nature April 2020). As the body destroys and deals with the virus there are bits of RNA that are around to tweak and tease virologists and to confuse the tests looking for them. The studies into SARS-2 in various bodily fluids are fascinating and MIGHT lead to a better understanding of ways to test and how the virus behaves. Meanwhile, not to fret, it seems transmission via feces is not likely.
Wash your hands, don’t touch your face, be kind and stay home