Infectious Diseases Specialists Share their Perspectives on States’ Reopenings

What are some of the practical considerations for the public as communities begin to reopen in advance of the upcoming holiday weekend? That was the subject of a telephonic press briefing held on Tuesday, May 19, by the Arlington, Va.-based Infectious Diseases Society of America (IDSA). IDSA represents infectious diseases specialists, epidemiologists, and others whose work focuses on infectious diseases.

Christopher Busky, IDSA’s CEO, moderated a discussion on Tuesday, with two experts. Preeti Malani, M.D., M.S., and Leonard Mermel, D.O., ScM, are both fellows in the Infectious Diseases Society of America. Dr. Malani is chief health officer at the University of Michigan and a professor of medicine in the Division of Infectious Diseases at the University of Michigan (Ann Arbor). Dr. Mermel is a professor of medicine at the Warren Alpert Medical School of Brown University, an adjunct clinical professor in the University of Rhode Island College of Pharmacy, and medical director of the Department of Epidemiology & Infection Control, at the 719-bed Rhode Island Hospital in Providence.

Christopher Busky introduced the physicians, and each made an opening statement, before welcoming questions from the telephonically assembled press. “There have been about 1.5 million confirmed cases since January and 90,000 deaths” so far from COVID-19, Dr. Malani said. “As everyone knows, the response to COVID-19 has brought rapid and profound change to every aspect of our lives. In the past couple of months, a lot of attention has been focused on keeping our health systems intact. But as the statistics have improved, things are (changing). My state, Michigan. Ramping down was pretty easy; we basically flipped a switch. Reopening is going to be much more complicated. At University of Michigan, we’re going to begin with our research labs in the next few days. And in MI, many manufacturing plans will be reopening; and that’s my state’s economic lifeblood. You can think of high, medium, and low risk. Access control, how people enter; do people get temperatures taken? Cleaning, sanitation. Contact tracing.”

“The most fundamental thing we can do to prevent workplace spread and transmission is to make sure that employees do not come to work sick, and if they do get sick, to take care of them, and keep them quarantined,” Dr. Mermel said. “A lot of this is unknown; the playbook just doesn’t exist. And each industry’s going to figure this out for itself. And in some cases, you really can’t socially distance. But maybe you can do a better job of screening workers and customers, using PPE, employing better social distancing protocols. But you won’t be able to test everyone every day. And if you drive up to a nursery to buy gardening elements, maybe it’s too crowded, and you come back later? All of these situations will require that everyone take responsibility—employers, employees, customers. There’s no way that you can eliminate risk; but you can reduce risk,” applying some very basic public health principles to this situation, he added.

“I spend most of my time trying to figure out how to reduce risk in healthcare settings,” Mermel continued, “but I had a phone conversation with my older sister who is a school superintendent in California. And to this point, she and her husband have been pretty much homebound in their home in Los Angeles. And I realized I can use some of my knowledge to help people reintegrate into society. It is OK to go outside for health. One element is the possibility of using a full face shield instead of a mask when outdoors. Obviously, either with a mask or a face shield, keeping the six-foot distance is important. Some are asking, can I see a friend? We all produce bioaerosols when we talk, and produce more when we cough or sneeze. When you get together with friends, ideally staying six feet apart, and you’re all covering your faces, you can ideally reengage socially.”

Meanwhile, Mermel said, “What about going to a store: how safely can we do grocery shopping? To begin with, wear a mask or face shield. Gloves are important, but you also should carry hand sanitizer when you’ve touched your purse, wallet, credit card, etc. I myself haven’t touched a doorknob for months. I carry paper towels with me and use those as barriers when coming into contact with a high-touch surface. So that’s ideal. If you don’t have a barrier, you need to be in the habit of using hand hygiene after touching high-touch surfaces. Do you need to mask while driving alone in your car alone? I don’t think so. Riding your bicycle alone? I don’t think that needs to be done. I cycle a fair amount, cycled last weekend with a colleague, and safely rode my bike. In terms of masking, there are various types of materials to use. A New York Times article I read recently recommended a double layer of quilter’s cotton or flannel, or a double layer of batik. I think masks that can be used that are homemade that can get close to the standard of surgical masks.”

In response to the first question from the press, which was to ask the physicians what they think about the fact that few states have met the criteria created by the Centers for Disease Control and Prevention (CDC) for reopening, including two weeks of slowing rates of infection, yet nearly all are reopening at least partially, Malani said, “Yes, some criteria from the CDC include seeing decreases in confirmed cases over 14 days and having sufficient testing in place. We’re almost like the EU, in that every state is doing something different. It’s encouraging that we’re not seeing massive outbreaks. I think that some of the most vulnerable settings have done some form of mitigation, including nursing homes, and jails. But this is a little bit early. And if you’re not testing and tracking, you might not see yet.”

“Dr. Mermel, what are you seeing in Rhode Island?” IDSA’s Busky asked.

“We’re opening up in a phased approach, we’re just starting to reintroduce elective surgeries,” Mermel responded. “And they’re going to start opening up some beaches here in a very controlled way. The bathrooms are closed, they’re going to enforce social distancing. We’ve had a high level of testing. It’s definitely a concern if states don’t have the testing capacity after opening up.”

Another member of the press asked the physicians whether they had heard of any businesses that might be requiring their employees to be COVID-19 tested as a condition of reentry into the physical workspace? Would such a system be useful for infection control? The journalist asked.

“I’m not aware of businesses requiring it, even in healthcare,” Malani said. “But the bigger issue is, what does it mean? You might be tested in one moment; also, there is some question about the different tests. But in any case, it doesn’t obviate the need for social distancing and the use of masks or face shields.”

“I think that testing could give employers and employees a false sense of security,” Mermel said. “Someone could test negative and a couple of days later could come down with symptoms; and that negative test could give a false sense of security. So a good infection control regime is important and requiring masking and hand hygiene. Easy access to hand hygiene. So the employer needs to limit the number of people going into a confined space, needs to enforce social distancing and hand hygiene and masking. If businesses want to test, it’s fine. And there are a lot of nuances to testing; it doesn’t circumvent the good infection control practices needed.”

Another member of the press asked, how do we manage sending our children back to daycare?

“There is actually CDC guidance about childcare,” Mermel said. “They recommend setting up a kind of a pod system, so it’s a small group of children, and those children stay with the same teacher or small group of adults, and those children aren’t interacting with children in other pods, such that contact tracing wouldn’t involve so many people. And parents dropping them off are going through a screening procedure before the children enter the system. With older children, they could be masked. For me, in terms of congregate settings, those are the most complex to mitigate risk. With influenza and other respiratory illnesses, a lot of transmission occurs with children. We’ve found that the 0-5 age group is one with high rates of transmission among children. We don’t know with COVID-19 whether it will follow that pattern; children tend to be far less sick. So we don’t know whether there will be transmission rom children to others. There are articles on both sides. But childcare is going to be quite challenging.”

Another journalist asked whether the doctors had any suggestions around guidelines for safety in the Airbnb/hosted home visit setting.

“My son actually has an Airbnb space in Los Angeles, and we’ve had quite a few chats about how to manage that,” Mermel said. “First of all, preparing it before someone comes in, that it’s scrupulously and assiduously cleaned with a disinfectant. The virus can survive on surfaces for various periods of time, s that’s important. I think t’s important to screen people, asking some general questions you’d ask when someone came to work, for example; and to have people contact the owner should they come down with any symptoms. Again, after use, scrupulously cleaning again. So this might be more difficult than for a hotel chain. Maybe it would be better for Airbnb to develop some requirements around cleaning, frequency of cleaning, drying time, that would create a standard similar to hotels.”

What about sporting events: is college football, for example, “off the table” for the foreseeable future? one journalist asked.

“That’s a question near and dear to my heart and also one I’m connected to through a Big Ten task force,” Malani said. “College sports are complicated. As we think about returning to school in the fall, the biggest thing is that college campuses are places of gathering. So I’m thinking of a return to training. The return to competition, I’m thinking of as a second step. I think you might not need to take that risk; nothing is off the table, but there are going to be some real barriers to safety, particularly when you combine issues of travel, and teams traveling. And there are false negative tests, as Dr. Mermel noted. So And you can’t physically distance.”

What about beaches and public pools reopening? What do we know about the science of the transmission of the virus in water?

“I’ve been asked that question by some colleagues who are avid swimmers,” Mermel said. “Part of it is a dilutional effect. Chlorine in municipal pools will limit growth in infectious agents; I’m not sure of the level needed. I’m not so concerned about swimming. Part of the problem in a beach setting is the crowds: maintaining social distancing is the issue. I’m not so much concerned that there would be transmission in the water or pool.”

What should people look for when they go to a restaurant, for example? Signs that the right precautions are being taken?

“First of all, proper screening,” Mermel said. “And restaurants should keep a log of all their diners, so that if we have to do contact tracing, it’s possible to do so. And if each of the serves wears a mask or possibly a face shield. Cleaning the high-touch surfaces on a frequent, regular basis, is going to be important. One of the concerns there is that since the patrons are going to be unmasked, there’s a potential risk that they could transmit to someone else, so limiting the number of people at a table, a distance of at least six feet between tables, screening when they come into the restaurant, and a full face shield or face shield and mask.”

And the final question from the press was this: do the physicians anticipate a second or even third wave of infection later this year, and if so, how big might it be? “I would anticipate that there will be at least a second wave,” Malani said. “My hope is that any second or third wave will be a small one that can be managed, and we will take care of people in a way that we can manage.”

“We know from 1918 and looking at cities that moved too quickly, that they had second or third waves,” Mermel said. “We have to be particularly careful about our highest-risk individuals, and that includes homeless individuals; and reduce large congregate settings. And public health infrastructure has been decimated. And the number of people we’ll need to do contact tracing will be quite expansive. So we’re going to need quite a robust contact-tracing infrastructure. I agree completely with Dr. Malani: we need to shore up our public health infrastructure to do good contact tracing.”