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From Our Archives
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Author:
Roger Bernier, PhD, MPH
The Institute for Health Metrics and Evaluation (IMHE) released an updated estimate for the cumulative number of deaths in the US projected to occur by August 4, 2020. That number is 143,357, a number which has increased over time as the modelling has improved and the realities of the disease have become more apparent. First Projections Initially, the Seattle based group had projected approximately 82,000 deaths, a number much lower that the projected number from modellers at the Imperial College in London. Those numbers were widely reported to have influenced both the US and UK decisions to adopt drastic social distancing measures. They indicated that 2.2 million deaths in the US and 510,000 deaths in the UK could occur without any social distancing measures at all. Since that scenario was judged unlikely, the Imperial group subsequently revised their estimates downward to 1.1-1.2 million deaths in the US and 250,000 in the UK taking social distancing into account. Potential Revisions The IMHE estimate now has almost doubled since the first estimates were released in March. And it is possible the estimates will have to be revised upwards again depending on what happens to the testing, tracing, and isolation strategy that has been recommended across the board by public health professionals. Few areas have created the full infrastructure they will need. According to the IHME, “it is worth noting that the full effects of recent actions to ease social distancing policies, especially if robust containment measures have yet to be fully scaled up, may not be fully known for a few weeks due to the time periods between viral exposure, possible infection, and full disease progression.” In short, the final cumulative number of deaths could grow even larger. “Ensemble Model” In what is called a COVID-19 forecast hub, Nicolas Reich and colleagues at the University of Massachusetts have curated 36 models from 20 teams of highly respected infectious disease forecasters. “Forecasting COVID-19 is acompletely different ballgame because we can’t rely on 20 years of public health surveillance data like we have for flu,” Reich says. The hub has implemented what it calls an “ensemble” forecast which they claim offers a more accurate picture of the future than any single model can project. They estimate that even though the US weekly count of deaths will continue its current downward trend from approximately 10,000 deaths per week now to 7,000 per week by early June, the cumulative number of deaths is projected to exceed 110,000 by June 13. Country Comparisons To put these statistics in perspective, it is useful to compare the number of deaths in the US with other countries. We selected the top ten countries with the largest number of confirmed cases from the WorldoMeter website. The US accounts for approximately 30% of all cases worldwide. The nine other countries account for 39% of cases so that altogether the top ten countries which account for only 5% of the 213 countries being tracked account for just over two thirds of all cases. While the US is first in the absolute number of cases, its reported case rate per million population (5,058) is lower than that of Spain (6,040). In terms of deaths per million population, which may be a more reliable measure of impact since it is not influenced by level of testing, the US at 299 ranks fifth in the top ten countries with the most reported cases. The rate in Germany at 100 is lower than other comparable European countries.■
At first, concerns about the absence of the CDC Director and other agency leaders at White House public briefings about the COVID-19 pandemic were shared quietly “within the family” between epidemiologists and other public health professionals. Then, in mid-April, former CDC Director Tom Frieden published an op-ed in the New York Times, stating “Just when American most needs its guidance on the pandemic, the country’s top public health experts do not appear to be guiding, and are certainly not communicating our response.” Premier Public Health Agency Also, Ashish Jha, director of the Harvard Global Health Institute, writing this month in STAT News said “during this pandemic when timely, nationwide information is the lifeblood of our response, the CDC has largely disappeared.” He called CDC “the premier public health agency in the world”, and asserted “Americans are suffering and dying because CDC’s voice is absent.” Depolitization Rich Besser, former acting director CDC and now at the Robert Wood Johnson Foundation said it a recent video chat that Americans are not hearing from CDC about best practices in this pandemic. He called for depoliticizing the information provided to the public and agreed that it was “detrimental” to American public health not to be receiving these regular briefings. Press Briefings The last CDC press briefing on the pandemic was on March 19 and efforts to restart them have been rebuffed by the White House, according to media reports. Two former CDC employees, Bruce Weniger and Chin-Yih Ou published an essay on Medium saying the lack of CDC direct communication is “denying a worried public straight talk from what has been the world’s premier public-health agency.” Lancet Editorial Also, a recent editorial in the Lancet titled “Reviving The US CDC” states the Trump administration's further erosion of the CDC will harm global cooperation in science and public health, as it is trying to do by defunding WHO. A strong CDC is needed to respond to public health threats, both domestic and international, and to help prevent the next inevitable pandemic. Why Low Profile One possible explanation for CDC’s absence was the ubiquitous media presence of the NIH’s Anthony Fauci whose knowledge and experience with infectious diseases are widely respected. With a non-partisan reputation and a clear focus on the science, having Fauci in a prominent role communicating with the public was reassuring to many laypersons as well as scientists. Yet Fauci’s knowledge and experience has come from leading a research institution, and NIH does not have CDC’s relationships with state and local health departments, a tradition of holding regular briefings during evolving outbreaks, and a large cadre of disease detectives with a respected reputation for responding effectively to outbreaks in all parts of the world. Points of Tension However, as time goes on, it becomes clearer that there are multiple points of tension between CDC and the White which might better explain CDC being prevented from playing its rightful role in fighting the pandemic. Some of these reasons have been described in multiple media accounts, including the following: 1. It seems clear that the leadership in Washington is not interested in developing a coordinated national plan for addressing the different pandemic challenges. This is so despite multiple pleas to do so from leading epidemiologists such as Minnesota’s Michael Osterholm and others. Putting CDC in charge would signify a federal level commitment and obligation. 2. The White House is questioning the validity of the death counts being reported by the Mortality Statistics Branch in CDC’s National Center for Health Statistics. Claims are being made that deaths are being overcounted when expert opinion is that the US is actually underestimating the deaths from COVID-19. In an interview with the Daily Beast, the chief of that activity at CDC said “The system can always get better. But if we’ve learned anything it’s that we’re seeing some of these individuals who have died of the virus slip through the cracks…It’s not that we’re overcounting.” 3. Another tension is the limited guidance on reopening different sectors of American society which has been published by the CDC. After early versions of the guidance with specific recommendations were leaked to the press, a revised and much less specific version was published on the CDC website, according to the Washington Post. Now a more detailed guidance document is available, but this document, is nothing like what we are accustomed to seeing from CDC, according to Weniger . Interviewed on the Rachel Maddow show, he said the new guidance is complicated, inconsistent, and full exceptions to exceptions. In his opinion, CDC personnel must be embarrassed to see it. 4. Criticisms of Robert Redfield, the CDC Director, are also beginning to surface such as those in the Washington Post recently. Redfield is accused of being an ineffective communicator and a weak leader not in control of his agency and not on a par with others in the struggles within the White House environment. 5. There is an ideological struggle according to the former CDC employees between those who believe government has a constitutional role to play in promoting the general welfare and those who place more faith on the private sector. In this category appears to be the recent award of a contract to a Pittsburgh company to collect data from hospitals which is already being reported to the CDC Healthcare Reporting Network. Richard Jackson, professor emeritus at UCLA and a former CDC Center Director told the Post, “it is unprecedented that you’d set up a competing system separate from CDC." Painful moment According to Jha, “this must be a painful time for the many extraordinary career scientists who continue to work at the agency. But it's a painful moment for the American people too and with deadly consequences. Real CDC leadership—clear, science based guidance, effective coordination of states, and public transparency of data---is absolutely essential for confronting and getting clear of this crisis.” He concludes, “The CDC was once the world’s greatest public health agency. We need that CDC back, and we need it now.” Scientists Under Duress An indication of just how painful a time it is for many at CDC, NIH, and other agencies is the recent decision to terminate an NIH grant to the ECO-Health Alliance, a private research organization doing work on coronaviruses. According to our sources at NIH, these researchers are doing the best research on coronaviruses. Yet because of misinformation about the relationship with the research facility in Wuhan and because of unproven theories about the true origins of the virus, the NIH grant was terminated without due process. The grant cancellation was recently the subject of a special expose report on 60 Minutes. When the best researchers in the world have their work cancelled for political rather than scientific reasons, then you can understand the difficult environment that our government scientists are working in, said the NIH source. In a recent op-ed in the NY Times, Seema Yasmin, a former CDC Epidemic Intelligence Service (EIS) Officer concluded by saying, "Given the complex relationship between American public health law, regulations and epidemiology, a complete divorce of politics from public health might not be feasible anytime soon. But week after week, as Covid-19 has killed almost asmany Americans a day as the Sept. 11 attacks, our best response against the pandemic demands unleashing the top disease detectives in the world and fully applying their advice. E.I.S. officers were trained to fight this battle, and no one should stand in their way.” ■
Many countries hard hit with COVID-19 outbreaks have applied harsh social distancing measures to flatten or decrease their epidemic curves. Thousands of lives may have been saved if initial predictions from epidemiologic models were accurate at the time. However, the economic and social consequences have been severe, and some publics are anxious to resume a normal life. In the US, some states are reopening their economies sooner than what public health authorities are recommending. All Eyes On Sweden Countries which undertook harsh, mandatory social distancing measures are keen to discover if the significantly less harsh approaches taken in Sweden can offer any guidance about the best way forward from here. Many are looking for the right balance between retaining strict measures to save lives and allowing people to return to more normal lives. Swedish Strategy What more specifically has been the Swedish strategy and is it a success story? Does it provide lessons? The following article was written after reviewing multiple articles and interviews by Swedish and other officials. The main features of the control measures in Sweden were to encourage social distancing without requiring it. The allowable crowd size was limited, however, restaurants and businesses were allowed to stay open and children below secondary school age were allowed to stay in school. People were encouraged to work from home, and sick persons were advised to stay home from work with pay. Travel was discouraged. Goals The economic and social disruption appear to have been significantly less in Sweden than in the US and somewhat less than other European countries. This strategy is often referred to as a “herd immunity” strategy, but in fact is more a byproduct of the Swedish approach than its primary purpose, according to Anders Tegnell, the country’s lead epidemiologist. Sustainablility The Swedes understood from the outset that any control measures had to be sustainable, that is, feasible and acceptable over the longer term since no vaccine was considered likely to appear for months or even years. The main goal was to avoid overwhelming the health system, however, this is precisely the risk entailed by their voluntary, soft containment strategy. Without adequate constraints on social interactions, cases could climb dramatically and overwhelm the health care system. Even in the best case scenario, one could expect that Sweden would have to accept a certain number of preventable deaths in the short term that would be avoided in other countries adopting harsher measures. This has not been stated publicly in multiple media accounts reviewed by the Epi Monitor. Success? Has the strategy succeeded? The answer is that it is too soon to tell. There are some features of the Swedish situation which suggests that their gamble has paid off for now in that they have avoided social and economic disruption on a large scale. However, the deaths per 100,000 in Sweden are much higher than in neighboring Scandinavian countries. As stated above, some of these excess deaths should have been anticipated as the result of a softer containment strategy. By themselves, they do not point to a failure of the Swedish strategy, at least not yet, but they may reflect a more fatalistic or realistic streak in the Swedish mindset. Nursing Home Deaths At least 50% of the deaths in Sweden have been in nursing home residents, according to Tegnell, and there was an admitted failure to prevent introduction and proper management of cases in these facilities. A stricter lockdown strategy might have prevented more COVID-19 infections and reduced the chances ofintroductions into a high risk population. Still if the nursing home deaths are excluded, Sweden’s death rate is still several fold higher than neighboring Scandinvavian countries. (See table on at the end). Epidemic Curve At present, the epidemic curve or weekly case count is decreasing according to Tegnell from 90 to 70 or less per week. The first reported antibody study on approximately 1000 persons from the Stockholm area found that only 7.3% have antibody, much lower than the 25% Tegnell has estimated might have been produced by their less strict strategy. The health system in Sweden has not been overwhelmed and the Intensive Care Units have not exceeded 80% of their capacity. Tegnell suggests that Sweden could expect to have a smaller second wave of COVID-19 in the fall and winter if the virus remains endemic or returns later in the year. But now this prediction seems ill-founded if antibody levels in the population remain in single digits. Sweden As Model? The big unanswered question is whether the lower death rates in other Scandinavian countries which took drastic measures will eventually rise to catch up with the death rate in Sweden which took a less strict approach. For now, their rates are lower. In theory, other countries with harsh measures may have only postponed some deaths that will come later if population level immunity is truly significantly lower after the first wave of cases. Feasibility Is Sweden’s volunteer strategy coupled with guidance from health officials workable in other countries? The question about the rightness or wrongness of the Swedish strategy may be moot if other countries could not make the Swedish strategy work. Context Matters As Tegnell has acknowledged, context is crucial. He states clearly that the Swedish approach would not have been a good idea in countries that were hard hit to begin with or became aware of cases only relatively late after importation. What about the best strategy going forward when case counts have declined significantly. The voluntary approach may only be feasible in a country where the level of trust in government and health officials is high. Evidence for this is that “fake news” and misinformation have had little influence on the Swedish population, according to Tegnell. Thus, the Swedes may have had the luxury of taking a longer view because they did not miss as many early cases and did not have the pressure to do something drastic to prevent an anticipated wave of new cases. It was their intention from the outset to implement what they thought would be sustainable measures acceptable in a trusting population that values personal responsibility and is likely to heed public health guidance. Collaboration Key For Unity Also, the Swedes have a history of working together in different segments of the health system, so that achieving a unified strategy was possible even though local jurisdictions make final decisions. Tegnell did not agree that having a decentralized system such as in the US was antithetical to achieving a unified national strategy since that outcome is what Sweden has created beforehand on other topics and it replicated that unity in the present pandemic situation. ■
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