Director’s Corner

Status Update #4

By Irwin Redlener
5/4/2020

NEW RATIONALE FOR SARS-C0V-2 TESTING?

HOW AND WHEN TO SAFELY REOPEN AMERICA’S BUSINESSES:

OUR MOST CRITICAL QUESTION IN MAY 2020

The U.S. is on the verge of a mass reopening of businesses in at least 31 states.

This mad rush is fraught with the danger of new, uncontrollable surges of COVID-19. If the reopening is not done properly, there could well be tens of thousands of potentially avoidable pandemic deaths throughout the nation.

That’s because we are not even close to having sufficiently widespread, rapid and reliable tests available to check for SARS-CoV-2 virus – or immunity to COVID-19.  As of early May, less than 2% of the American public has been tested for the virus. As described in our recent report, Work In the Time of Pandemic, the absence of ubiquitous testing prior to reopening businesses puts every American community at unacceptable risk.

As most of us understand, the need to test for the virus that’s responsible for the COVID-19 pandemic has been an essential objective from at least mid-January. That’s when it was becoming clear that we were well on our way to a major global problem with a novel virus that had arisen in China and was spreading rapidly with highly lethal consequences for humans.

In the U.S. we remain in an inexplicably, sputtering process of perfecting two general kinds of tests: the first (PCR or antigen tests) is to identify the actual presence of the virus in a person at the time of the test; and the second (serology)  is to help establish if a person has developed antibodies and, presumably, immunity as a result of a previous infection.

Strikingly, the FDA has been working with nearly 400 diagnostic test developers and many serology test developers as well. All are seeking – some have obtained – Emergency Use Authorizations (EAU) to allow such tests to be used for clinical or research purposes prior to fully establishing reliability. A vast number of these tests are felt to have high levels of false positive or false negatives. Either of those results are misleading and/ or dangerous.

At some future point, multiple commissions and organizations will do analyses and post-mortems on what went wrong with the nation’s ability to competently develop a large-scale, effective testing program.

That said, here’s why we have long needed a massive testing capacity:

Pre-April 27:

  1. We needed (still do) to know the prevalence of COVID-19 in order to understand where and how extensive the outbreak was. Good data early on would have allowed disease modelers to be much more accurate and more helpful to policy makers in terms of decision-making and response planning.
  2. We needed – and need- to make early and accurate clinical diagnosis on patients presenting to our health care symptoms, as well as to trace the contacts of those exposed to positively tested persons.

Post-April 27

  1. We need testing to be able to reopen businesses safely, virtually impossible to do without sufficient testing and contact tracing capacity.
    • April 27 is the date that Governor Brian Kemp of Georgia decided to “reopen” the state’s businesses over and above the strong objections of many of Georgia’s most powerful mayors, including Keisha Lance Bottoms of Atlanta and Hardie Davis of Augusta. These leaders and many others made a powerful case that (a) cases of COVID-19 were still rising, (b) that some of the most vulnerable citizens were suffering the biggest impact in terms of disease prevalence and fatalities and that (c) without widespread available and frequent testing neither employees nor customers could be assured that business of all types could function safely.
    • Not only was Governor Kemp’s irrational – and politically motivated – decision extremely ill-advised, his order forbade any mayor or local jurisdiction from defying his direction.

Now what?

  1. We must implore any governor, including Governor Kemp, to rescind or reconsider any decision to prematurely reopen the state’s businesses.
  2. All citizens should reject the idea of opening businesses in the absence of the ability to test employees and at least screen all customers or patrons.
  3. Even if testing was sufficiently available, Americans must sustain public health measures such as use of masks and gloves as appropriate, physical separation methods and avoiding crowds. This is clearly a major burden for all of us, but we must continue whatever needs to be done to manage the worst biologic threat to the world since the great Spanish Pandemic of 1918.

[Read Dr. Redlener’s letter urging our Nation’s leaders to carefully consider how and when to re-open the economy. This letter was sent to the Senators, Representatives, Governors across the US.]

Status Update #3

By Irwin Redlener
4/9/2020

“A 102-Year-Old Lesson for Fighting COVID-19: How Soon We Forget”

In 1918, when the so-called Spanish Flu was raging (it was only first reported by Spanish journalists, although it likely began elsewhere), an incredibly powerful lesson was learned through a natural experiment that involved two major American cities. Remember that this deadly virus killed at least 50 million people world-wide and nearly 700,000 Americans. Although these were days long before modern medicine and vaccines, ICUs, and mechanical ventilators, it’s worth revisiting some of those lessons.

In Philadelphia, the city’s response mirrored much of the Trump Administration’s early leisurely tone: authorities downplayed the significance of the threat after the first case was reported on September 17, 1918, and large events weren’t canceled. Notably, the city’s liberty parade – which drew 200,000 Philadelphians to crowded city streets – took place eleven days later on Sept. 28th. By the time social distancing measures and school and restaurant closures were implemented (by October 3rd), it was too late. The virus had spread, overwhelming the city’s public health capacity, law enforcement, and causing the death total to surge to over 17,500 in just six months.

But just several hundred miles away in St. Louis, an entirely different story was playing out. With the first cases of influenza reported on October 5th, the city was shut down by October 7th. Schools, playgrounds, and churches were shuttered, while public gatherings of over 20 people were prohibited. The intervention worked: per capita influenza deaths in St. Louis (347 deaths/100,000 people) were less than half than those of Philadelphia (719/100,000).

Juxtaposing the response of the two cities highlights how quick public health responses can save countless lives. Visualizing the cases of Philadelphia and St. Louis also highlights exactly the notion of ‘flattening the curve.’ While neither city was able to prevent the spread of influenza, St. Louis prevented a spike in the death rate of the virus by mitigation efforts that prevented overwhelming the city’s healthcare system.

Of course, the Spanish flu of 1918 was entirely different from today’s novel coronavirus. But much of the policy prescriptions remain true: social distancing and quarantines can, and do, have a significant effect, if implemented and adopted rapidly, and maintained for the duration of the outbreak.

Source: Richard J. Hatchett, Carter E. Mecher, and Marc Lipsitch, “Public health interventions and epidemic intensity during the 1918 influenza pandemic.” Princeton University, 2007. https://www.pnas.org/content/104/18/7582


Status Update #2

By Irwin Redlener
3/16/2020

Nation should prepare for more draconian strategies to combat COVID-19 Redlener says: more aggressive policies are called for but are unconscionably, inexplicability late “We will be Italy”, as U.S. hospitals face unmanageable crisis Trump’s “happy talk” and incompetence have endangered America.

Dr. Redlener comments on the current state of U.S. efforts to manage raging outbreak of the pandemic across the U.S.

  • Expect cases and rapidly rising fatalities in all 50 states imminently.
  • Expect one-half to two-thirds of Americans to become infected with novel coronavirus
    • Pandemic could last from months to a year or more; may or may not become seasonal
    • Vast majority of people will have very minimal to moderate flu-like symptoms
    • Some 3% – 10% of infected people may need hospitalization
    • Fatalities could range from 400,000 to more than 1.5 million in U.S. alone
  • America’s hospitals facing a tsunami of sick patients that will overwhelm most hospitals in emergency care, in-patient capacity, as well as intensive care units.
    • Inadequate supplies of protective masks, other personal protective equipment, nasal swabs are already problems.
    • Early signs of severe stress on hospitals have been a reality for at least a week.
    • The Nation’s health care workers including, but not limited to, doctors and nurses, house keepers, dieticians, and administrative staff are at excessive risk of contracting coronavirus infection with serious complications.
    • Loss of workforce, from health care providers to support staff, due to illness and not showing up or staying at work is inevitable.
    • Total ICU beds in U.S. is approximately 95,000 – but we’ll likely need 200,000.
    • Total mechanical ventilators currently in U.S. hospitals is approximate 62,000 andapproximately 30,000-35,000 in federal stockpiles. We could need 2x that number, plus technicians, which are already in short supply.
    • Insufficient available personal protective equipment (PPE), including face masks of all kinds.
  • Widely available specific treatment for or prevention of COVID-19 remains 12 -18 months away
    • Re-purposing drugs used for other conditions is possible.
    • Potentially, use of antibodies from people who have recovered from COVID-19 may offer promise.
    • Re-infection of people who have recovered is possible, not proven.
    • Children still seem resistant to serious manifestations. Why? No real answer, probably has to do nature of immune response in children.
  • FOR JOURNALISTS
    • NOTE: Journalists need to push for fulsome reporting of true gap between real need and available assets.
    • What exactly is available in Strategic National Stockpile, and what will Departments of Defense of Health and Defense specifically be able to provide?
  • Exponential growth of infection not close to peaking, provoking increasingly draconian containment and mitigation measures. U.S. inching toward unprecedented “national shutdown”, could be announced in days. Possible new policies:
    • All schools, colleges and training programs shut down.
    • Public gatherings now recommended at 50 could drop to 10-20.
    • New regulations to protect highest risk individuals, including elderly and people with certain pre-existing medical conditions.
    • Strict closings of non-essential businesses, restaurants, bars, theater, sporting events of all kinds, and religious observances.
    • New international and domestic travel restrictions.
    • Potential curfews in some areas.
  • Expect major changes in 2020 national presidential election procedures
  • Trump’s failures continue to pile up:
    • Egregious, inexplicable to get rapid start on mass COVID-19 testing; it should have begun in December 2019. (Tests were available from WHO and international sources from the outset.)
    • Continuing problems in developing and distributing efficient, reliable, rapid tests.
    • Mixed messages and unending, self-congratulatory, often grossly untrue statements from the president and vice president regularly conflicting with public health experts has dangerously delayed development of clear aggressive standards among nation’s governors and mayors and undermined public confidence in political leaders.
    • Trump’s team seem oblivious to scale and scope of health care crisis in relationship to what we have and what we’ll need.

Status Update #1

By Irwin Redlener
2/19/2020

Coronavirus has killed more than 2,000 people. All but six of them were in mainland China. The virus, officially called COVID-19, has infected more than 75,000 people. There are more than a thousand cases outside China.

Singapore’s Ministry of Health today reported three new cases of the COVID-19, bringing the nationwide total to 84 confirmed cases. The arrival this week of 14 infected American evacuees from a cruise ship in Japan brought the total number of cases in the United States to at least 29 people.

What You Should Know

  1. At the moment, there is no evidence of rapidly growing cases of COVID-19 in the U.S. -or any country other than China
  2. But if you have traveled in the past 60 days (overly cautious!) to China or have been in contact with someone with proven or suspected COVID-19, your health care provider and local public health officials should be informed.
  3. No special precautions for COVID-19 are necessary, other than what experts recommend as good practices to limit spread of any virus, such as regular, thorough hand washing and “cough and sneeze hygiene”.
  4. If you have severe “cold symptoms” with a fever, check in with your health provider; you could have the regular flu! (and stay home, if you can…)
  5. Get the seasonal flu vaccine every year

Challenges Ahead For Public Health And Government Officials

  1. Still not sure of actual duration of incubation period. Most experts say 14 days – but it could be longer.
  2. Still trying to prove that people infected with COVID-19 can transmit the virus before symptoms appear
  3. Vaccine to prevent COVID-19 remains in development; many months remain before being ready for widespread distribution
  4. So far, there is no specific medication to treat people who are infected with COVID- 19
  5. Public health scientists are working on more sophisticated and more effective ways to identify, track, test and isolate contacts of people infected with COVID-19