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From Our Archives
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Author:
Roger Bernier, PhD, MPH
The deadly failure of the US to achieve control of the current coronavirus pandemic has frustrated and angered many experts as well as everyday Americans. It has sent some infectious disease and policy experts back to the drawing boards to formulate alternative approaches or reinvigorate old ones that have the best chance of success at this relatively late phase in the pandemic in the United States. Lessons Learned A comprehensive review of the experiences of many US states as well as that of several other countries by the Center for American Progress entitled “A New Strategy to Control the Coronavirus” has identified several lessons learned. Based on these analyses and the success achieved by New York and other Northeast states in maintaining low incidence levels, the Center has proposed the following strategy to prevent future waves of cases in the coming year. 1. Close indoor dining and bars. Experience has shown that these locations are foci of transmission and they should be kept closed or reclosed if reopened, particularly in hotspots. Support with good unemployment insurance should be provided for workers as well as financial support to cover the fixed costs of businesses forced to close. 2. Monitor other potentially high-risk venues Other potentially important sources of transmission such as gyms and places of worship could be closed or other measures used to lower risk such as requiring capacity limits, moving outdoors, or requiring masks. Nail and hair salons have not been linked to outbreaks but are inherently risky and should be monitored closely for breaches in compliance with face coverings. Public education about avoiding any indoor gatherings such as parties especially without masks is needed. 3. Mandate masks This recommendation calls on governors and mayors to implement state and local mask mandates. Financial assistance to businesses should require mask mandates before the aid is provided. 4. Adopt cluster-based contact tracing. The goal of cluster -based tracing is to study the patterns in chains of transmission to identify sources that can produce a large number of cases. These types of sources are super-spreading events and the focus should be on identifying and preventing them rather than tracing all chains of transmission. Bars are an example of such sources but contact tracing may identify others. According to the Center, the model for this approach is Japan which finds patterns in cluster-based contact tracing and uses the information to identify sources that could become major outbreaks. Think Differently About Test Sensitivity Another new strategic approach is being advocated by Michael Mina, professor of epidemiology at the Harvard School of Public Health. He was interviewed recently on the podcast This Week in Virology where he made the case for a different way of thinking about testing. Heretofore, the focus has been on having highly sensitive tests that are able to accurately determine if an individual is infected with SARS-CoV-2. This for the most part has meant relying on polymerase chain reaction or PCR tests to diagnose individuals. However, the PCR test is very sensitive and can even detect virus fragments that may not be capable of spreading and causing transmission to other persons. These tests are relatively expensive and are not easy and straightforward to carry out. Also there has been a long delay in reporting the test results which have made some contact tracing work ineffective because it is too late to halt transmission. New Approach A different approach argues Mina is to lower the bar for how sensitive tests need to be and to focus instead on other kinds of tests that are cheap, easy to carry out, and provide results in minutes rather than days. The type of test Mina is calling for utilizes a thin paper strip that only requires a saliva sample and can deliver results in 15 minutes or less. This type of test will be less sensitive but may be considered sensitive enough to detect infectious persons. In this way of thinking, false negatives are of no concern because they are unlikely to be contagious and the test is good enough to be considered sensitive in picking up persons who are likely to transmit. Thus, if made widely available at low cost, these “contagiousness tests” could become ubiquitous and could serve to quickly determine if someone should be admitted to school or work or into any other environment where the risk of transmission exists. Positive persons would be kept away from others. And the test could be repeated daily if necessary to keep close monitoring of each situation. Test, Test, Test Mina’s idea was also explained recently in a feature article in the Atlantic. It described Mina’s idea this way. “Test negative, and you many enter the public space. Test positive, and you are sent home. In other words: Mina wants to test nearly everyone, nearly every day.” Real Lockdown Another idea has been put forward by Michael Osterholm at the Center for Infectious Disease Research and Prevention (CIDRAP) and Neel Kashkari, president of the Federal Reserve in Minneapolis. In an op-ed piece in the New York Times, Osterholm and Kashkari call for a second more rigid lockdown throughout the US. They believe the earlier lockdown was not carried out well enough and that the only way to get the virus under control now is to get serious about keeping everyone at home for six weeks. The goal of the new lockdown would be to get reported cases to a level as low as 1 case per 100,000 because at that level public health control measures have a possibility of being effective. As rates stand now, the volume of cases is too large for effective testing and contact tracing, according to the authors. New York Example Failing such a rigorous intervention, Osterholm believes that another coronavirus “forest fire” will spread out of control in the US in future months. In one of the regular podcasts from CIDRAP, Osterholm said the US could look to the situation in New York State to envisage how the new lockdown could drive the seven day average numbers of cases and deaths lower. New York had approximately 9800 cases and 921 deaths as of April 10. By June the cases had fallen to 662 and deaths to 39. By August 10, cases were at 651 and 8 deaths and the averages have been flat since June. According to Osterholm, New York has done what the rest of the country can and should now do. Since we have to get through at least 6-8 months without a vaccine, according to Osterholm, the number of cases is going to get much worse. We should take our medicine now and get ready to manage the smaller caseload that will emerge after a rigorous lockdown, he said. It is a pay now or pay me later situation he believes. He is hopeful their proposed strategy can earn discussion and support. NY Times Editorial Board In perhaps a less surprising new strategy, the New York Times Editorial Board has proposed making better use of the tools the US has to achieve a higher level of control that has eluded it. In its view, the US has never really had a true lockdown compared to other countries. It estimated that the US only closed down or “shuttered” half of the country rather than the 90% that was attained in other areas. Consequently the US never achieved the dampening effect that other countries were capable of producing. The Board proposed a new strategy consisting of the following key steps: 1. Clear and consistent messaging. Because of the confusion that has been sown, it is now important to coordinate messaging at every level, especially from the top---masks are essential, and social distancing is a civic responsibility. 2. Better Use of Data Obtaining and sharing more information about how the pandemic is unfolding in various populations and places and how it is being managed could allow public health officials to provide better forecasts of what is coming so that people could adjust their plans accordingly. 3. Smarter shutdowns. Alert levels could be created to warn people about what behaviors are permissible and which are not at different risk levels or at different levels of transmission in the community. Shutdowns would not need to be equally aggressive in all communities. Such color coded alert systems have been developed in Harris County Texas as an example. 4. Testing, Tracing, Isolation, and Quarantine The US has failed at all of these. The Times calls for more effective and rapid diagnostics and the federal government should compel companies to make the needed tests available. Once testing is taking place at a high enough volume, then the other public health measures can be made effective to control the outbreak. ■
As uncontrolled community transmission of COVID-19 persists in the United States, epidemiologists and public health officials are involved in difficult situations. Media accounts of firings, resignations, harassment, and threats are proliferating. While there may be more than one reason for these conflicts, failure to use evidence as the primary basis for decision making is emerging as a common theme in several situations. So is the highly polarized social and political environment in the US. Federal Level Preview The challenges that are playing out at the state and local level are a reflection of similar challenges that have already produced headlines about similar conflicts at the federal level involving all of the major health agencies including the Centers for Disease Control and Prevention, the Food and Drug Administration, and the National Institutes of Health. Sometimes valid political and often serious economic considerations are bumping up against scientific facts or expertise. List of Turnovers A list maintained by Kaiser Health News (KHN) and the Associated Press reportedly contains almost 50 state and local officials who have resigned, retired, or been fired since April.
In an
article in The Hill, NIH Director Francis
Collins
stated: "To see this kind of really
widespread resignations from critical roles
at a time of great importance for our country ought to be a source for
everyone to be
concerned... In a recent report, KHN quoted former CDC Director Tom Frieden “The overall tone toward public health in the U.S. is so hostile that it has kind of emboldened people to make these attacks.” Bad Feelings In the same report, KHN quoted former West Virginia public health commissioner Dr. Cathy Slemp, who was forced to resign by Republican Gov. Jim Justice in June. The past few months have been “frustrating and tiring and disheartening” for public health officials, said Slemp. “You care about community, and you’re committed to the work you do and societal role that you’re given. You feel a duty to serve, and yet it’s really hard in the current environment,” Slemp added. Examples of these conflicts and challenges involving epidemiologists are described below. Indiana Episode The Indianapolis Star reports that Eileen White, the only epidemiologist working for the local city Fishers Health Department resigned earlier this month alleging too much interference by the city’s mayor, especially pushing hard to open classrooms too soon. In an account by the Indy Star, White says “This is a level of interference I had never seen before in a public health agency…I have never seen a health department set up as a business before… I have a feeling of failure that all of us in public health have right now…I had so much hope for what I could do. But we are continuing to see more pushback and politics in public health.” White previously worked for the Minnesota Health Department for three years. The mayor’s office and White’s supervisor pushed back hard in a written statement to the newspaper.
Hawaii Episode In Hawaii, the state epidemiologist Sarah Park has been sidelined for not having in place the required number of contact tracers needed to handle an upsurge of cases in the state. It apparently had a plan for controlling the virus that was not adequately implemented, according to the publication Civil Beat. Park reportedly had refused to accept outside help offered months before the upsurge because she believed the Department could bring on contact tracers quickly if needed. Only about 100 contact tracers are actively working when hundreds were called for three months previously. While continuing at the Department to focus on other aspects of the pandemic, Park will no longer oversee the contact tracing activities which have been transferred to a Department deputy director and the chief of the disease investigations branch. Park Testimony In her defense, Park gave testimony recently in front of a Senate Special Committee on COVID-19. According to the Civil Beat article, “Park downplayed the importance of contact tracing, saying that some states no longer even do it. Park ultimately blamed the public for the surge in cases. She cited beach and house parties and other gatherings that people should have known not to engage in as causes for the surge in cases that quickly overwhelmed the system. She was quoted saying “What we could not have predicted, quite frankly, is how badly our community would behave.” South Carolina Episode In another situation in South Carolina, state epidemiologist Linda Bell has expressed regret in internal emails at not being more forceful and speaking out in press briefings with the governor who has been reluctant to require mandates for mask use and other measures. According to the account published in The State, Bell said in emails to agency public relations specialists that Gov. Henry McMaster’s staff has been “somewhat manipulative” in meetings prior to news conferences about the coronavirus. Bell also said her not speaking out more from “a policy perspective is one of the reasons that South Carolina is now among the states with the worst outlook.” After these emails became public, a group of organizations in the state issued an open letter of support for Bell. In another development, South Carolina lawmakers have called for top health officials to speak out more frankly and forcefully about the pandemic. Most people should be disturbed by the emails, SC House Minority Leader Todd Rutherford told The State. He added, “We need to take steps to separate the governor from DHEC (state’s Department of Health and Environmental Control) and the governor from our chief epidemiologist so that we can get data that is unvarnished by someone’s political ideology.” ■
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