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From Our Archives
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Author:
Roger Bernier, PhD, MPH
Despite the success of ongoing mitigation or social distancing measures in dampening the spread of COVID-19, the strategy’s high social and economic costs have brought forth a flurry of new proposals for how best to control or even eliminate the disease from this point forward. How We Got Here After the first appearance of the COVID-19 cases in the US, the initial control strategy was to test ill persons to identify and treat cases, trace exposed contacts, and quarantine persons when indicated. This containment strategy failed to stop the chains of transmission stemming from the earliest imported cases. This occurred for a variety of reasons, including the fact that not all infected persons were symptomatic, and testing with rapid results was not widely available. As community transmission took hold, the fear that hospitals and other providers would be overwhelmed and that deaths would rise even higher encouraged or even necessitated the use of severe social distancing measures to slow the rate of spread even at the cost of severe economic impact. This mitigation strategy has been widely referred to as flattening the epidemiologic curve. It sought to buy time for hospitals, health care workers, first responders and other service providers by slowing the demand for services and thereby preventing deaths that would have occurred in a completely overwhelmed health system. Not all countries bought into these containment or mitigation strategies as the best approaches. Different Approaches Sweden took a much less restrictive approach with the idea of allowing the population to acquire disease and create a level of population immunity that might become high enough to provide herd immunity against future outbreaks. The United Kingdom also gave consideration to this approach early on until epidemiologic models predicted that this strategy without social distancing measures could produce half a million deaths. The same models predicted over 2 million deaths in the US without aggressive social distancing measures and reportedly influenced the U.S. decision to undertake widespread mitigation. These model estimates of expected deaths have subsequently been lowered to reflect the new realities created by implementation of strict measures in the UK and the US. Crushing The Curve New Zealand took a more extreme strategy to not merely flatten the curve but to crush the curve. The goal here was to implement such strict measures that the imported virus could actually be eliminated and future importations blocked or new chains of transmission contained through testing, contact tracing, and quarantine. Current Situation Now that mitigation efforts have proven effective in slowing spread in several of the viral hotspots where SARS-CoV-first appeared, some of the negative impacts on the economy and the quality of life in the US have become clearer. It is apparent that the restrictions imposed by the social distancing strategy must be eased at some future point and discussions have intensified about what the best way forward might be and what the optimum balance is of public health and economic and social measures. Making these choices will be fraught with uncertainties about the new virus such as whether it will exhibit seasonality or whether it will occur in additional future waves of infection. Lives Saved Do Far A recent Wall Street Journal investigation reports that mitigation efforts in the US have saved more than 100,000 lives by mid-April and will have saved 500,000 lives by the end of the month. Putting the statistical value of a life at $10 million, the benefits of mitigation equalled an estimated $1 trillion by mid-month and $5 trillion by end of April. A second estimate in the report is that social distancing is saving 1.7 million lives worth $8 trillion for three months of social distancing. The cost to the economy is estimated at $3 trillion through 2022 and the article calls this trade-off worth it in an accounting sense. These estimates are derived in part from the work of Alessandro Vespignani and his team of modellers at Northeastern University. He told the WSJ, “The decisions that will be made in the next few weeks must include economists and epidemiologists and public health people to find the trade-off between those two viewpoints.” Articles in this issue of the Epidemiology Monitor provide details about some of the new proposals being circulated. ■
The Association of State and Territorial Health Officers, Johns Hopkins and Duke University are not alone in calling for a change in strategy to combat the coronavirus outbreak. In a stunning editorial in the New England Journal of Medicine published on April 1, 2020 entitled “Ten Weeks To Crush the Curve”, Harvey Fineberg, former head of the Institute of Medicine and former Dean of the Harvard School of Public Health, invokes President Trump to say if we are at war with coronavirus, then “It’s a war we should fight to win.”
Fineberg calls for “a forceful, focused
campaign to eradicate COVID-19 in the United States. The aim is not to
flatten the curve; the goal is to crush the curve.” This goal is based
on the reported success in Wuhan China and echoes New Zealand’s
approach which is also reportedly succeeding in eliminating COVID-19
from the country. Fineberg’s plan has 6 key components to carry out
over just 10 weeks. Fineberg wants a commander appointed by the President with full power to target responses to specific places and times because different regions of the country are at different phases of the epidemic in the US. 2. Make millions of diagnostic tests available. In this regard, Fineberg’s strategy is similar to that of the state health officers reported elsewhere in this issue. He suggests multiple ways of achieving this such as mobilizing the nation’s research laboratories and organizing dedicated clinical test sites. We can’t track if we can’t test is the idea. 3. Supply health workers with personal protective equipment and equip hospitals to care for a surge in severely ill patients. Says Fineberg: “We wouldn’t send soldiers into battle without ballistic vests; health workers on the front lines of this war deserve no less.” He suggests that regional distribution centers could deploy materials to the hospitals in greatest need. 4. Differentiate the population into five groups and treat accordingly. These five groups are:
I. infected persons
who test positive Once identified, there are different means of treating each of these categories of persons, according to Fineberg. 5. Inspire and mobilize the public. Fineberg believes there is a role for everyone and that most are willing to do their part. 6. Learn while doing through real-time, fundamental research. Fineberg concludes his editorial with an exhortation and a bold prediction. “Rather than stumble through a series of starts and stops and half-measures on both the health and economic fronts, we should forge a strategy to defeat the coronavirus and open the way to economic revival. If we act immediately, we can make the anniversary of D-Day on June 6, 2020, the day America declares victory over the coronavirus.” Realistic? Several objections to Fineberg’s proposal can be raised, perhaps the major one being how realistic it is to make millions of tests available in a very short period of time, and whether or not it is possible to effectively categorize the entire population into the five groups described. Interviewed on television by MSNBC’s Brian Williams, Fineberg expanded on his plan by emphasizing that social distancing will only be good enough to reduce the spread of coronavirus and not stop it. For getting ahead of the curve and eliminating COVID-19, aggressive testing, categorizing people into the five groups he described, and acting on that information will be key, he said. Fineberg told Williams that the person to be appointed as commander of the effort needs to have the full confidence of the President, to understand government, the health scene, and federal/state relations, to be decisive and respected. Potential candidates he named included former Department of Health and Human Services Secretary Secretary Mike Leavitt and former Defense Department head Ash Carter. Fineberg added that the country needs to prevent the miscommunications, misunderstandings, and lack of coherence in the attack on coronavirus. “We need the A team,” he said To read the editorial and plan, visit: https://bit.ly/2VjW6WP ■
Johns Hopkins University epidemiologist Justin Lessler was interviewed in the NewYorker to help highlight what we have learned about coronavirus in recent weeks and what still remains uncertain. Here are the key items of information. What we have learned ♦ Countries need to combat the virus or health systems will get overwhelmed as happened in Italy and Spain ♦ Social distancing stay-at-home orders seems to be working in different places, including the US ♦ A path forward for the US could be one focused on testing as learned from South Korea What we still don’t know ♦ What percent of the population has been infected ♦ The mortality rate per infection ♦ How much immune protection is obtained from an infection ♦ How long does immune protection last ♦ How effective will be the level of community or herd immunity ♦ How fast does the virus spread…what is the reproductive number (R naught) ♦ How well do asymptomatic persons transmit infection ♦ Will there be a marked seasonality
No other event in our lifetimes has called upon the knowledge, experience, and expertise of epidemiologists as frequently as the COVID-19 pandemic. Everywhere we turn, epidemiologists are forecasting estimated cases and deaths, being interviewed on television, writing editorials and op-ed articles, and answering questions for a wide variety of audiences. Never have epidemiologists been in such demand, even though we have more uncertainties than facts about the transmission dynamics and other epidemiologic features and parameters of COVID-19 at this point in time. During these times, some epidemiologists have become darlings of the media and some considered heroes in providing reliable, objective, and trustworthy information to an anxious public in various countries. Some have generated many new followers on Twitter. In monitoring the pandemic for our readers, we have collected a sample of contributions made by epidemiologists around the world. It constitutes an unofficial Who’s Who in Epidemiology today. Value of Mitigation Applied Early Britta Jewell, research fellow in the department of infectious disease epidemiology at Imperial College London and Nicholas Jewell, chair of biostatistics and epidemiology at the London School of Hygiene and Tropical Medicine and a professor at the University of California Berkeley, provide a graphic display of the impact social distancing can have, even if applied as little as one or two weeks earlier. According to their calculations based on a model developed by the Institute for Health Metrics and Evaluation, an estimated 90% of the cumulative deaths in the US between now and August 2020 might have been prevented by putting social distancing policies into effect on March 2, two weeks earlier than March 16, when there were only 11 deaths in the entire country. They also utilize the natural experiment of a delay of one week in Tennessee compared to Kentucky in implementing lockdown measures to illustrate clearly the impact of mitigation tactics applied earlier than later in an outbreak. https://nyti.ms/2VDEyDZ
Thomas Frieden, former CDC Director published New York Times op-ed on April 12, 2020 writing “The CDC has the knowledge and expertise to limit the spread of the coronavirus, but it needs the authority and voice that‘s been withheld from it the past three months. It is not too late to limit the devastation of our nation’s health and economy. But the administration must support and follow the guidance of the CDC—and it must do so now.” https://nyti.ms/2RNUP7X
Counting On Herd Immunity Roman Prymula, a respected epidemiology expert in the Czech Republic has made headlines locally for making a surprising U-turn in favor of allowing the population to return to normal gradually to enable a controlled spread of COVID-19 and a gradual building of herd immunity while continuing to protect the vulnerable groups. He based his change of mind, as reported in the Czech media, because he believes China has provided incorrect data and the death rate in Italy is lower than initially calculated (not 15 percent but 2-3 percent). https://bit.ly/2Kggm5c
Straight Talk and Hard Truths Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota writing in the New York Times opinion page stating “It’s too late to avoid disaster, but there are still things we can do. Our leaders need to speak some hard truths and then develop a strategy to prevent the worst.” https://nyti.ms/3eAm93i
Media Criticisms Gregg Gonsalves, assistant professor of epidemiology at Yale, was the subject of an article at Fox News.com for criticizing New York Times reporters for the headline of a story they wrote suggesting there was an unsettled debate about the importance of testing for coronavirus. In an exchange of tweets after the story ran, Gonsalves said “Your collective reporting on the political aspects of this have been off-the-mark. Everything is a Punch & Judy show, and the real story of the absolute and continuing failure of the response to #coronavirus gets obscured in your reporting as “who’s winning the day” in DC.
Need Infection Rate Information Michael Mina, assistant professor of epidemiology at the Harvard School of Public Health and its Center for Communicable Disease Dynamics made a number of observations about the pandemic during a conference call with the media, according to the Harvard Gazette. Part of his advice was to get folks out of nursing homes because he believes the virus is much more transmissible than we have been able to document, and control in those circumstances is “an extraordinary feat.” He added “We have to get to an order of magnitude understanding of how many people have actually been infected. We really don’t know if we’ve been 10 times off or 100 times in terms of the cases. Personally, I lean more toward the 50-100 times off, and that we’ve actually had much wider spread of this virus than testing…numbers are giving us at the moment.”
Government Fumbles Larry Brilliant, an epidemiologist who worked internationally on smallpox eradication, co-founded Seva Foundation to treat eye disease in poor countries, led Google’s philanthropic efforts at one point, and helped create the movie Contagion to show what a serious pandemic could do to society was interviewed on April 1 for a podcast by The Economist. When asked if the governments are taking the pandemic seriously enough, he replied “I would say that governments have been incredibly slow in responding, almost without exception. I think that your government in the UK [...] began on a misguided mission to allow or think that they could allow everybody or a large number of people to become infected, in an effort to reach the epidemiologist’s Holy Grail of “herd immunity”. I think my government [in America] fumbled, almost unforgivably, in the way they mangled the distribution of test kits; in the way that our leadership pretended that the outbreak could be brought down from five to zero and it would not be a problem after a while. And it continued to underplay how important it was, as “a hoax,” until finally confronted with the stark reality.” https://econ.st/2Kif4GK Brilliant was also interviewed for the podcast Soul of the Nation on a moral response to COVID-19. https://bit.ly/3bjXwpP
High Profile in China Zhong Nanshan, is being called China’s leading epidemiologist sometimes referred to as the nation’s “SARS hero” by Chinese media, according to The Diplomat, a publication covering the Asia Pacific region. In 2003, while SARS left China’s health authorities and government officials struggling to rebuild public trust, Zhong was hailed for his integrity. This was largely due to his public admission that the virus was not as under control as state media portrayed. The Diplomat reports that “Despite his advanced age (born in 1936) Zhong has been appointed to lead the National Health Commission’s investigation into the novel coronavirus. By extension, he has become the de facto spokesperson for any information related to the illness. Beyond his work tracking and studying COVID-19, he has given multiple interviews to Chinese and English language media. He is an obvious choice for the position, as the Communist Party tries to highlight its efforts to manage the crisis in a transparent, decisive manner…” https://bit.ly/3eAnebm
Epi Predictions Marc Lipsitch, Harvard professor of epidemiology and director of the School’s Center of Communicable Disease Dynamics has been in the news for the COVID-19 projections his academic group have provided that intermittent social distancing may be needed until 2022. In an informative interview in USA Today, Lispsitch said we’re in a dilemma—if we relax the restrictions we can expect a resurgence, and if we keep the restrictions in place it will be economically disastrous. What to do? He thinks we can try to bring down cases in each locality to a point where they can be controlled individually. But the epidemic will likely appear in more than one wave and people are confused about that thinking if you stop it once you’re done. Asked directly, so how long will people have to hunker down? Lipsitch said “It’s not a scientific choice only. It’s ultimately a political choice, and science is one input.” Asked, so how do you see things playing out, Lipsitch gave his longest reply— “If I had to make a prediction about how the interaction between social and scientific and public health factors will play out, I think there's going to be fatigue at some point. Some places are going to let up either after they've controlled the first peak or before they've controlled the first peak. Cases will reemerge, and because people are so tired of social distancing, it will take until the intensive care units are overwhelmed in that place to get people to crack down again, and then there will be some cycles of that. There are ways to try to avoid that, but they all involve this very long and destructive process of social distancing. It's easy to say as the public health person, this is what we need to do for public health. But I'm acutely aware that there are also other considerations, and I don't see a really good answer.”
Burden Unimaginable
After
offering to come out of retirement to help with COVID-19 control
efforts, Bill Hall's offer was immediately taken up by his
former health department. He told local media
“I am a roving epidemiologist. What
that means is that I’m available to travel to whichever district in
the Eastern Region of the state that is in the greatest need of epi
manpower. According to the paper Hall spends his days interviewing
COVID-19 patients and their contacts; trying to locate contacts who
might have been exposed to the virus; and doing patient followups,
case reviews, case monitoring, and data entry, among other tasks.
Additionally, he provides guidance to health care facilities and
physicians about testing criteria.
Controversy In Sweden Anders Tegnell, Sweden’s chief epidemiologist and reportedly the architect of his country’s “social distancing light” or “soft” approach (allowing population immunity to develop more naturally) has been fending off critics. Sweden sought to shelter the elderly and vulnerable but has left stores and offices open and waiting to see what happens. According to the European Centers for Disease Control and Prevention, Sweden has reported over 1200 deaths through April 16 compared to only 72 in Finland with half the population which is often used as a comparison because it took more stringent measures in the Helsinki area. Other Scandinavian countries have also reported significantly fewer deaths with rates per 100,000 much lower. Joacim Rocklov, a professor of epidemiology at Umea University is quoted in the Wall Street Journal saying “this is a big risky experiment with the entire population that could have a catastrophic outcome…It is risky to leave it to people to decide what to do without any restrictions…” A recent op-ed in one of the important newspapers by 22 physicians urged the government to lockdown the country as is being done elsewhere. Tegnell has rejected these arguments and has debated critics, according to a recent account in Canada’s National Post. It concludes by saying about Tegnell, “One wishes good luck to the temporary helmsman of the Swedish ship of state as he argues that icebergs are not really his department.” https://on.wsj.com/2RKqmru ■
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