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Even as Americans fight (and even kill) over the country’s response to the Covid-19 pandemic, there is no disagreement on one point: With 1.9 million cases and the death toll closing in on 110,000 as of June 5, for both economic and humanitarian reasons we absolutely cannot have a repeat of the tragedy that has unfolded since March. But with the current drop-off in cases, hospital admissions, and deaths likely to be followed sooner or later by local, regional, and possibly national resurgences, the implication is clear: If — or, more likely, when — those occur, we have to do better.
“I’m still getting over my shock at how badly this was handled,” said epidemiologist Stephen Morse of Columbia University, who helped create an international network to detect and monitor disease outbreaks. “After all the work and all the exercises everyone did, it’s heartbreaking to see how badly the ball was dropped.”
STAT therefore asked 11 experts in infectious disease, epidemiology, and pandemic preparedness how to avoid the mistakes, poor decisions, and incompetence of this spring. We asked them not to invoke magic; advice like “develop a vaccine” is obvious but not very helpful. We also asked them to look forward more than backward; we don’t want to relitigate things like the monthslong shortages of Covid-19 diagnostic tests, President Trump’s cheerleading for unproven (and potentially harmful) treatments, or the demonstrably false assurances by the White House that anyone who wanted a diagnostic test could get one. The experts did take some peeks into the rear-view mirror, since understanding past mistakes can help us avoid repeating them. But for the most part they focused on how to do better next time.
Prioritize early warnings: By now, the limitations of swab tests, which analyze nasal and throat samples for the coronavirus’s genes, are infamous: They miss something like 30% of infected people, and even more of those who are infected but not showing symptoms. And by the time people start showing up for testing, community transmission may be accelerating and hard to control. Last month, public health researchers reported that although watching for people with symptoms of Covid-19 “did not show an increase in visits for COVID-19–like illness before February 28,” retrospective genetic analyses reveal that the virus “began circulating in the United States between January 18 and February 9.” Sustained community transmission began before detection of the first cases.
So although “test, trace, isolate” — testing symptomatic people and then finding their contacts to test and isolate if they’re positive, too — still has value, we need something faster than starting with diagnosed cases. One idea: wastewater surveillance that tests for the presence of the coronavirus’s genes can determine that cases exist in a given community at least a week before people start becoming sick.
Hundreds of U.S. utilities are now running such tests as part of studies, and the current decline in cases will give public health systems time to get effective wastewater surveillance programs in place. After all, Finland is testing water in 28 sites every week, the Netherlands in 37, and Germany in 20 per day, said microbiologist Gertjan Medema of KWR, a water research institute in the Netherlands. Wastewater surveillance can provide “an early warning tool to see if cases are rising again,” he said.
Pay attention to small numbers: Once cases begin rising exponentially, finding them and their contacts becomes nearly impossible. “If you wait for big numbers, it will be too late,” said Paul Biddinger, an emergency preparedness expert and physician at Harvard T.H. Chan School of Public Health.
The challenge here is distinguishing between small numbers that will increase exponentially and those that won’t: two cases that become six that become 18 that become thousands, versus two cases that become six that become 18 — and then peter out.
“If you see a clear, sustained trend in case numbers from week to week,” Biddinger said, that’s likely a harbinger of exponential growth.
Determining which small numbers spell trouble is more possible if we plan now, said Amesh Adalja of Johns Hopkins University Center for Health Security, an expert on emerging infectious disease and pandemic preparedness. “With a respiratory virus that’s often asymptomatic, you know that whatever number of cases you think you have is not the number you really have; it’s only the tip of the iceberg,” he said.
Officials therefore have to take even a few cases dead seriously. But that doesn’t mean locking down a city immediately. Once cases are identified — again, wastewater surveillance can tell that something’s afoot, and fanatically testing and tracing can then identify at least some of them — tracers should be able to tell if they became infected at a large event or a 10-person picnic. The former can explode exponentially, the latter not so much, Adalja said.
Act fast: If an exponential increase is in the cards, dithering around as New York and other places did in March will only make history repeat. Imposing business restrictions and other social distancing measures two weeks sooner than most U.S. states did could have averted tens of thousands of deaths, Columbia University scientists calculated.
But act fast strategically: Shutdowns came too late in some places, notably New York City. But elsewhere, communities that hadn’t experienced Covid-19 in any real way suffered economic and social disruption anyway. Getting them to agree to another round of shutdowns could be a real challenge.
“Imposing a lockdown on places that didn’t have Covid was inevitably going to cause a lot of economic harm with very little public health benefit. And that was going to lead to resentment,” said Thomas Frieden, president and CEO of Resolve to Save Lives, a global nonprofit initiative of Vital Strategies that works with countries to make the world safer from epidemics.
More targeted action going forward might be the answer.
“I do not think it will be nationwide or even statewide again,” said Caitlin Rivers, an assistant professor of epidemiology at the Johns Hopkins Center for Health Security. “I think that decision will be very local. But I could also see a middle ground where certain activities, high-risk activities are shut down even if they reopen in the interim.” Mass gatherings and restaurant dining, she said, might need to be suspended again if cases climb.
Do a way better job in minority and high-poverty communities: Drive-in testing centers? Really? The testing debacle was exacerbated when officials to set up the first testing centers in largely white and affluent communities, many requiring a car to access. Yet frontline workers whose jobs made social distancing impossible (transit workers, grocery cashiers) and who were therefore at high risk of infection were more likely to be members of minority groups or to not have access to a car. They also are more likely to live in low-income households where it was impossible for an infected person to isolate from others.
As early as February, readers asked STAT reporters if Black people were immune to the new coronavirus, an example of misinformation that health officials were disastrously slow to address, reflecting the almost nonexistent outreach to minority communities. Another assumption of universal privilege: Officials ordered people to wear masks in public but, rather than providing them, left people to fend for themselves.
As the country takes steps to mitigate any second wave, it is in danger of compounding these missteps: contact-tracing apps require working cell phones, which low-income people are less likely than others to have, especially since so many have lost jobs.
Don’t hide the truth or pretend to have more knowledge than you have: Early on, the Centers for Disease Control and Prevention told Americans they didn’t need to wear face masks. There was no evidence that anything but medical-grade ones blocked the virus, they said, and snapping up even disposable masks (as people did anyway) would worsen the shortage of protective equipment for health care workers.
There were two problems with that. First, the experts didn’t consider that masks might — and, it turns out, do — block the transmission of virus from infected people via coughing, sneezing, and even speaking. Calling face masks ineffective went beyond what was known. Second, the “don’t get face masks” advice was largely driven by supply concerns (homemade masks and bandanas would not have taken masks away from health care workers), but experts didn’t readily acknowledge that.
Both failures damaged their credibility. Once experts acknowledged the importance of preventing virus transmission, the pandemic was out of control, and Americans questioned both whether experts knew what they were talking about and whether they could be trusted to tell the truth. Adding insult to injury, many employers — even hospitals — prohibited employees from wearing masks because doing so “would upset customers/patients.”
Do social distancing smarter: We’re reluctant to tell scientists to make discoveries; it’s not like we have a recipe for that. But we’ll say it anyway: Use the lull in cases to identify which social distancing measures were and will be most effective, and which can be eased or dropped entirely.
“If there is a second wave, we shouldn’t have to shut down the health care system as we did this time,” postponing surgeries, preventive care, and much more, Biddinger said. That should hold true for the rest of society. A mathematical model of Covid-19 transmission suggests that hand hygiene and near-universal wearing of face masks can achieve the 60% reduction in contacts needed to defeat the pandemic, said Gerardo Chowell of Georgia State University, even if people return to their workplaces, restaurants, and stores.
Japan, for instance, shut schools but not workplaces and businesses, yet has kept a lid on the outbreak — very possibly because of widespread use of masks, hand hygiene, and other voluntary social distancing (bowing, not hand-shaking, for instance). We need to learn from other countries.
Take mild cases seriously: “The number one thing we need to do differently next time is to find the mild cases and trace their contacts,” Adalja said.
That was not done during the pandemic’s early days. People with mild symptoms who did not meet strict (and, it turns out, wrongheaded) travel and symptom criteria were denied testing but, in many cases, told to isolate themselves to be safe. “People don’t isolate themselves if you tell them they probably have Covid-19,” Adalja said. “An actual test result carries much more weight.”
As a result, “chains of transmission that started with mild cases bubbled over and overwhelmed hospitals,” he said. “To be able to live with this virus” (he expects it to become endemic in the population, never disappearing), “we need to get the chains of transmission down, and to do that we need to test people with mild symptoms. We can’t be complacent about even a single case,” which means tracing and testing the contacts of mild cases.
Beef up the Strategic National Stockpile: Stocked with pharmaceuticals and other medical supplies, the stockpile was allowed to lapse in recent years: “There was nothing on the ground” when we needed it for the Covid-19 pandemic, said Columbia’s Morse. (The supplies are housed in warehouses in secret locations around the country.) By early April, barely a month into the U.S. outbreak, some 90% of the masks, gloves, gowns, and other protective equipment were gone, forcing states and cities into the disastrous everyone-for-themself effort to obtain it. The time to build it up is during the current lull in cases.
While we’re at it, figure out a system for fulfilling requests based on need and urgency, and decide now who the stockpile is for. Prior to this administration, the understanding was that the U.S. maintained it to fill state needs, wherever those were. But when criticism started raining down about the inadequacy of supplies — including millions of out-of-date N95 masks — the president’s son-in-law and aide Jared Kushner said it was for the federal government, not the states, and the wording on the website was changed to reflect his claim.
Don’t expect patients to figure out isolation on their own: Countless infected people who didn’t need hospitalization were told to recover at home and stay away from others. Much like “get in your car and drive to a testing site,” this policy was woefully blind to the circumstances of resource-poor individuals.
“Next time, we have to provide infected individuals with strategies to effectively isolate at home to reduce the risk of spreading the virus within their households,” said Chowell. Although much of the transmission has occurred in public settings, “we cannot ignore the role of household-based transmission particularly among the most vulnerable, who are more likely to share small living spaces with many other people.” If the outbreak returns in force (and even now), provide isolating households with PPE and other support.
Biddinger goes further: Other communities should do what some hard-hit Boston-area communities have, providing temporary housing and other support to patients until they’re no longer contagious. “When people who are infected don’t have a way to self-isolate, we should be sure our strategy includes the necessary support so they don’t infect others, including in their households,” he said. “We didn’t appreciate that early in this outbreak.”
Get serious about staying on top of the virus: When experts began pushing the tried-and-true public health strategy of case identification and contact tracing, public health departments around the country shuddered. They didn’t have the person-power to do the kinds of labor-intensive interventions China, South Korea, Singapore, and Hong Kong were employing. But the impressive results those methodical approaches achieved chart the route to where Americans want to go, said Rivers.
“I’m hearing a lot of reflections from community members. ‘When will I be able to see my elderly family members?’ And ‘When will I be able to go to a concert?’ And the answer to all the questions without case-based interventions is probably: not yet,” she said. (Case-based interventions means widespread testing, tracking the contacts of cases, isolating cases, and quarantining their contacts.)
“Other places that have made this transition, they have more flexibility. They’re able to incorporate these activities back into their life. And if we want that, we need to really summon the will to really put that in place,” Rivers said.
Not everyone is convinced there’s a one-size fits all approach, however. Japan, which recently lifted its Covid-19 state of emergency, focused on finding clusters of cases rather than tracing the contacts of all Covid-19 patients, calculating that since many patients don’t infect anyone else, finding the people — or the circumstances — that gave rise to multiple infections is more effective.
Stay humble, be flexible: Everyone hoped “non-pharmaceutical interventions” — things like school closures, mask wearing, physical distancing, and canceling mass gatherings — would slow spread of the SARS-CoV-2 virus. But even the experts are taken aback at how effective these measures have been to curb transmission.
“New York City was having over 500 deaths a day and now it is less than 50 deaths a day. It’s still far too many. But it’s a dramatic demonstration that it works,” Frieden said.
But no one really knows how much any of these interventions individually contributed to the effect, and how much the layering of multiple measures — or factors we haven’t accounted for — impacted the outcomes seen.
“We are not driving this tiger, we are riding it. And we are making assumptions that what we do will control it,” warned Michael Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy.
Reject false dichotomies like “open or close,” Frieden said. The economy and society were never fully closed, and won’t be fully open until there is a vaccine. Rather, it may be like a light on a dimmer switch — brighter at some times and in some places than at other times or in other places.
Resist magical thinking: A strange sense of denial, even among experts, slowed preparations for what was already a pandemic. As countries have driven down their outbreaks through measures unlike anything attempted in modern times, some experts are worried magical thinking is again taking root.
“If we see that the cases go down, substantially drop in the next four to six weeks, I fear desperately that we’ll declare a victory. That would be our worst mistake,” Osterholm said.
Flu pandemics spread in waves. But we’ve never watched a coronavirus pandemic unfold. Will summer weather really slow spread or will the easing of restrictions bring an immediate resurgence of cases? Will there be another — a worse? — wave in the fall? Do we face years of waves, until the world can be vaccinated?
In the absence of answers, governments, public health leaders, the medical community, and the public need to plan for worst-case scenarios so we’re ready if they come to pass. If they don’t, we should feel grateful, not like we’ve been duped.
Devi Sridhar doesn’t see that approach in action, however. Sridhar, chair of global public health at Edinburgh University Medical School in Scotland, fears people think the worst is over and we can revert to life before Covid-19. She’s afraid the gains made through the painful lockdowns will be lost — and will be hard to retake. “That period of time when people were willing to comply is gone,” Sridhar said. “People are done with lockdown.”
Communicate better: After the whipsawing early in the pandemic — China will get it under control, it’s going to go away like magic, please go home and stay home — there’s tons of room for improvement.
Since March, nearly all of the U.S. government’s efforts to communicate with Americans has come via the White House, not the CDC, which routinely — before this administration, at any rate — takes the lead on infectious disease crises. The overlaying of politics on public health hasn’t served the American public well.
“I think the communications have been deliberately bad,” said Marc Lipsitch, a professor of epidemiology at Harvard’s T.H. Chan School of Public Health. “The plan all along in this country has been to minimize it and try to prop up the stock market and try to pretend it’s less bad than it is.”
The public needs clearer information, even when that information is merely an acknowledgement that some facts about the virus remain unknown and the course of the pandemic isn’t currently predictable. And it should be steeped in science and fact, not politics.
All of this can make a difference next time. After all, Biddinger said, “the virus is still out there.” But much of what happens next “is under our control.”