bookmark_borderMoving Forward

I have been remiss from making new posts, but I did not realize until I logged on today that it has been nearly a month since the last one.

The things I had wanted to post about became overwhelming as everything is so intertwined. I would begin writing about one topic (herd immunity, for example) and then find myself down a rabbit hole of other topics and then I felt stymied. As well, life intervened with a couple of new developments that needed attention.

Now, with areas in the country opening up, politics entering into an arena which should not be political (n.b., I do not kid myself that they haven’t been since the beginning of this crisis), and tensions running high across the country about a perceived dichotomy of choice (open now/hoax vs. lockdown forever/fear), I continue to ask: we have flattened the curve—we are working toward our new normal—what have we accomplished during the lockdown these past 11 (!!) weeks?

There has been progress—we know more about the SARS-CoV-2 virus and how it affects the body, we know more about how it transmits, we know more about how to treat cases, we know more about the potential for immunity, we have antibody tests, and we have many groups working on vaccines (even some under trial). This is pretty impressive progress—because the whole world is working towards a common goal.

But there is still so much more to learn. We are hearing reports about how the disease may affect children (albeit case studies). The CDC is saying the virus doesn’t spread easily from surfaces (but we must still remain cautious; contaminated surfaces are still a concern, just not the primary concern). Medical care for COVID-19 is evolving with the experience of the many doctors in our country who demonstrate that the practice of medicine is nuanced and an art, not neccessarily a methodology. We have treatments that are promising for severe cases; I am hopeful there will be treatments for less-severe cases that do not require hospitalizations (I will update this once I research that). We have evidence that there is an immune response and antibodies from the virus, and though there remains more to be learned about what level of immunity is conferred, this is promising for detecting people who have been infected previously (and were asymptomatic or mildly symptomatic) and a vaccine. Vaccines are under development, with some being tested. However, among approximately 200 antibody tests available on the market, as of this writing, 13 have been approved by the FDA for Emergency Use and even those will not tell us too much at this point (see CDC: EUA Authorized Serology Test Performance which also includes a good background on testing re: sensitivity, specificity, positive predictive value, negative predictive value and WebMD: Do I Need to Get an Antibody Test?). Lastly, as I mentioned before, a vaccine will not be a panacea—simply stated, just because a vaccine is available, it doesn’t mean we can snap our fingers and get adequate coverage—especially should immunity wane after 1-3 years.

An area which needs huge improvement is a commitment to bolstering and maintaining public health infrastructure. Public health is largely ignored and when it is needed—in times like this—it cannot function the way it should.

We have to learn how to live with this virus. We can. And we can do it without fear. But we have to be cautious.

So let’s figure that out.

The experts from all sectors within our country and globally must work together to come up with a plan to move forward into a new normal for at least the next few years. At the same time, we must continue our efforts for public health globally and at home. There will be another pandemic and we have to be ready for it.

bookmark_borderWhen Can We Get Back to Normal?

People are experiencing quarantine fatigue, that’s for sure. But we need to continue holding the line and following social distancing guidelines right now. Different segments of society are calling for lifting restrictions immediately, and yet others are calling to wait for a vaccine. Neither of these is reasonable right now.

First, we don’t want to undo the progress we have made with social distancing and make the mistake of opening too soon (or rather, too soon and without important safeguards in place) like we are seeing in Hokkaido, Japan:

  • “Experts say restrictions were lifted too quickly and too soon because of pressure from local businesses, coupled with a false sense of security in its declining infection rate.”
  • ““Hokkaido shows, for example, that what’s happening in the U.S. with individual governors opening up is very dangerous; of course you can’t close interstate traffic but you need to put controls in place,” says Kazuto Suzuki, Vice Dean of International Politics at Hokkaido University. “That’s what we now know: Even if you control the first wave, you can’t relax.””

Second, we know there are conversations happening on when it’s appropriate to re-open and how. It is not and cannot be a unilateral discussion or decision—there are so many intertwined factors to consider. I, for one, am happy to leave that to the experts. I also do not envy our leadership right now; they are kind of in a damned if you and damned if you don’t situation. Regardless, it would behoove us all to acknowledge that this is a NEW virus never before seen in the world’s population. Even the experts from all sectors of society are scrambling to figure out not only the science of the virus and its medical effects, but also how to manage public health, the economy, and society overall.

The White House recently released the guidelines for Opening Up America Again (download the website as a document here; accessed April 27, 2020). These guidelines are state- or region-based with three phases to opening and a path to “normal.” However, before a state or region can begin Phase One, it must meet data-driven “gating” criteria and have core preparations in place.

Are states or regions ready? The gating criteria are:

  • Downward trajectory of flu-like illnesses reported in a 14-day period –AND– downward trajectory of COVID-like syndromic cases reported in a 14-day period
  • Downward trajectory of documented COVID cases within a 14-day period –AND– downward trajectory of percentage of COVID-positive tests within a 14-day period
  • Hospitals are able to treat all patients without crisis care –AND– have a robust testing program in place for at-risk healthcare workers including emerging antibody testing

Are states or regions ready? Core preparations which should be worked on right now, during this restriction phase, include:

  • Testing and contact tracing
  • Healthcare system capacity
  • Plans to protect workers in high-risk settings, mass transit, protocols for social distancing and mask use, and surveillance and plans for mitigation should new outbreaks occur

When the states/regions have met these criteria, that is when the reopening phases can occur. “In the first phase, people are encouraged to continue practicing social distancing while vulnerable populations remain at home and employees are allowed to continue teleworking. If there’s no indication of a coronavirus rebound, a state can move to phase two, which allows schools to open, nonessential travel to resume and large venues to begin to ease physical distancing. Phase three lifts most remaining restrictions, although it still advises large venues continue “limited” social distancing.” (White House is reviewing expanded guidance on reopening society, Washington Post, April 27, 2020)

The important thing to remember: the stay-at-home/shelter-in-place restrictions were placed to BUY TIME for us to prepare. To reopen, we need to have in place:

  • Testing – who is infected, who has antibodies (at this point in time – antibody testing will give us better answers on how much it has spread in the population; we cannot as of now say they confer immunity)
  • Fortified healthcare system including protection for our healthcare workers
  • Strengthened public health system with surveillance, contact tracing, isolation/quarantine protocols

This draft document from Resolve to Save Lives (downloaded April 19, 2020) is a nice overview of its recommendations on when and how to reopen.

Our way of life will be different at least for a while, likely including continued social distancing measures, wearing masks, and other recommendations (e.g., hand sanitizers at every entrance to buildings, temperature checks). Even following these guidelines, there will be mistakes. There will be second waves. There will be more COVID-19 deaths. This virus is likely not going away. But, better treatments will be discovered. A vaccine, if and when it is available, will not be a panacea, but will be extremely beneficial.

We can learn to live with it, there is hope.

bookmark_borderConversation with Tom Frieden on Coronavirus

On April 13, 2020, Helen Branswell, senior infectious diseases and global health reporter for STAT, hosted a chat with Tom Frieden, current president and CEO of the global public health initiative Resolve to Save Lives. Dr. Frieden is a former director of the CDC and commissioner of the NYC Department of Health.

I highly recommend watching this chat including the Q&A session at the end. It is about a 40 minute investment of your time. Notable takeaways:

  • We need to continue working together around the world and learn best practices from each other
  • The time we have been sheltering in place was buying us time to prepare to continue fighting it so we can BOX IT IN* – widespread testing, isolate the infected, find the exposed, quarantine the exposed
  • Current state of testing for disease – tests are pretty good although difficult to get a good sample, but still need to ramp up testing
  • Current state of antibody testing – most of the tests out there are “junk” – we need reliable tests and also, we don’t know whether everyone gets antibodies nor whether or how long they confer immunity – however, it would give us good epidemiologic information on how much it has spread in the population
  • MASKS – outside of healthcare front line or anyone taking care of the sick, more important for actively sick to use to prevent spread (but they should be staying home anyway)
  • MASKS for general public is a judgment call – but important to ensure that they aren’t being taken from healthcare workers, they don’t give undue increased confidence of protection – still more important to WASH YOUR HANDS AND NOT TOUCH YOUR FACE
  • Don’t ask “when can we reopen” – this is about data, not dates – we have to maximize public health protection while minimizing economic dislocation.
  • This virus is here to stay – we need to learn how to live with it. There will be waves of outbreaks, we need to keep them small and contained clusters so we don’t have to come back to this type of lockdown.

*BOX IT INclick here for the briefing document (downloaded April 19, 2020) for more detailed information.