On Wednesday, July 1, leaders in a recently created collaborative, CovidExitStrategy.org, presented a briefing via telephone, to give members of the press an overview of some of the key issues at this precise moment in the evolution of the COVID-19 pandemic in the United States.
As the website of the collaborative explains, “We are a group of public health and crisis experts. With former experience working at the White House, Department of Health and Human Services, and on the Ebola epidemic in West Africa. We are a non-partisan group, having worked across multiple administrations. We built this site to track each state's progress towards stopping the spread of COVID-19. Our focus is the data available on the ground and how we can surface it in meaningful ways for state and local leaders to act on. This is a collaborative effort between individuals from a few organizations.”
The organizations participating in the collaborative are U.S. Digital Response, Resolve to Save Lives, and the Duke-Margolis Center for Health Policy.
On Wednesday, Ryan Panchadsaram of CovidExitStrategy.org; Cyrus Shahpar of the New York City-based Resolve to Save Lives, an initiative of the global public health organization Vital Strategies; Marta E. Wosinska Ph.D, deputy director for policy at the Durham, North Carolina-based Duke-Margolis Center for Health Policy; and Erin Huppert, state affairs director at the Washington, D.C.-based non-profit policy-focused collaborative United States of Care, shared the microphone in front of members of the press, by phone connection.
“We started this project three months ago to help policy leaders understand what’s going on, and we’ve been aggregating state cases, how health systems are doing, etc.,” Pandchadsaram said at the outset of the press briefing. “Two of our main sources of data are the CDC [the federal Centers for Disease Control and Prevention] and the COVID Tracking Project—which collects information from state government websites.”
And Shahpar said, “I’m excited to discuss CovidExitStrategy. There’s no one single indicator that matters; what matters is a combination of indicators. And states vary in terms of the types and amount of information they share. How many hospitalizations? How many new confirmed cases? Are critical care beds occupied? Are people dying? And can a state reopen safely?”
Indeed, Shahpar said, “In most of the U.S., we can’t reopen safely right now. Looking just at Arizona and New Jersey this morning; the contrast between the two states is eye-opening. Both states have 7-8 million people. Look at today in Arizona with 391 new cases and rising, and NJ with 30 new cases. Look at testing: Arizona with a low level of testing; New Jersey is testing 146 percent, so they’re testing more. Doubling time: Arizona with the lowest doubling time in the country at 16 days, NJ with the highest. Test positivity: one in 4 positivity rate in AZ: 1.5 percent in NJ. Occupied ICU beds and level of disease burden. You can see that Arizona is red and trending upwards.
Dr. Wosinska of the Duke-Margolis Center for Health Policy said that, “While Arizona is perhaps on the extreme, there is a divergence we’ve been seeing since states started to reopen. Even following the WH criteria, almost no states were ready to reopen at the time that they did. Among the core questions that needed to be answered,” she said, “are, are you creating enough infrastructure, what is your health system capacity, what is the level of disease? The states that were pretty badly hit in the Northeast and Mid-Atlantic are continuing to see declines. They’ve presumably been putting systems in place. In contrast, a lot of the states experiencing large outbreaks right now, did not have much experience with this virus. So the health system and testing infrastructures were implicated. But also, how were they reopening? Were those states allowing high-risk openings? And it also depended on the extent to which the various states’ residents participated in physical distancing and wearing masks, and isolating when showing symptoms. So there’s been this interesting divergence; it’s not just been whether you reopened too early, but how you did it.”
Further, Wosinska said, “One of the critical measures here is the positivity rate. There’s been some conversation around yes, if we test more, we’ll see more cases. The thing is that if you double your rate of testing but triple the number of positive results, something is going on. And levels of hospitalization. Those are alarms. Hospitalization is a lag indicator. We haven’t seen a large increase in deaths; that also is a lag indicator. We also have treatment protocols, including the use of Remdesivir. Also, we have a younger population that’s being infected, so some might end up with better outcomes even in hospitalization.”
Because of all the factors involved, Wosinska said, “We’ve been seeing this divergence between and among states. One really striking thing is that it is surprising to see that certain states are still doing a really low level of testing, relatively speaking, such as Colorado and Pennsylvania. We have very little visibility into the extent of contact tracing.
“We recently published a memo on the state of COVID-19 testing,” said Huppert of the United States of Care. “States have reached varying levels of success in testing. If you go to covidexitstrategy.org, about half of the states are reaching the benchmark. So—every state is gearing up its capacity for dynamic and serologic testing. They’re all doing different things, though, in terms of focus. Second, most states lack adequate resources to pursue significant testing and contact tracing; states will need federal support. Third, people’s attitudes are changing, likely as a product of people’s desire for accurate data on the virus; and also because of the desire to reopen the economy.”
Still, Huppert emphasized, “The majority of the public remains pro-mask—about 73 percent right now. Only 20 percent of people in another survey believed we should relax social distancing measures. Meanwhile, 84 percent say that they would self-isolate if tested positive. And 74 percent say they would give officials a list of people they’ve been in contact with, to support contact tracing. 79 percent of voters in another poll believe we could see another wave of infection. There is a growing level of comfort for resuming activity. When you think about where public sentiment is at and you marry that with the data, it’s clear that investments in public health efforts are investments in our economic future as well.”
Asked by a member of the press what strategies state governments and individual people can take in order to keep safe over the coming Fourth of July weekend, Wosinska said that “What’s important to keep in mind is how this virus spreads—when people cough, sneeze or exhale. So to keep a physical distance and be in a well-ventilated area. And so if you can’t be in a well-ventilated area, wear masks. Being in an outdoor setting is important. And also, if anyone is experiencing any symptom—not just fever, but also loss of smell or taste—or if someone has been exposed to someone who is positive, one shouldn’t be participating in those activities.”
Shahpar added, “Keep washing your hands, maintaining distance, being outside and maintaining distance. Wearing a mask cuts your transmission rate by 80 to 85 percent.”
How feasible is rolling out sample (pool) testing across the country? “Pool testing could enable more frequent testing; it’s an idea that’s intriguing,” Shahpar said. “It would work better in areas that have already had high infections, for example, in New York versus Arizona. We need good protocols around testing. It’s been done in other countries, so we know it can be done; it’s a matter of implementation. There have been some challenges with labs in general. It does have a role.”
“And there is a good portion of states that are finally reaching higher levels of testing,” Pandchadsaram said. “And to get to that four million a day target, I do not see a way that we get there through brute-force one-to-one testing; pool testing will be necessary. But we need good strategies. They’re doing it already in China. When we shift to a world of sample testing, we can start to become more efficient in terms of the number of test supplies that are used. Cyrus, do you think it’s useful now, or not yet?”
“I think that if you’re a large employer, for example, and there’s not a lot of disease out there, you could certainly employ pool testing to achieve higher levels of testing,” Shahpar said. “But pool testing isn’t a magic bullet; it doesn’t address the question of who is getting tested. Are residents of nursing homes, frontline healthcare workers, other frontline workers, being tested? If we’re hitting testing targets in terms of the amount of testing, what is the distribution of that testing?”
The impact of statewide mask policies
Asked about the current trends in infection levels among states that have imposed statewide mask mandates, Shahpar responded by saying that, “Basically, states with mandated mask policies have shown reduced infection levels. The scientific opinion is a consensus, that masks are an important tool in our fight against COVID. That’s a shift from earlier thinking, when we didn’t yet have the data.”
Looking at data from the collaborative’s database, Pandchadsaram said, “This data comes from the team at the University of Washington. Eighteen states have a statewide mandated mask policy—four—Utah, Nevada, North Carolina, and Washington—have enacted them in the past couple of weeks. All those states that mandated them before May—eleven states that mandated them before May—three are green, five are yellow, three are red, in terms of their overall trends.”
“Clearly, masks are really important,” Wosinska stated. “When you mandate the use of masks, whether or not it’s effective depends on whether people adhere to the mandate. Some of the states that created mandates early on were hard hit early on. It’s a very different situation when you put in a mandate into a state that hasn’t had a high level of infection. You need to get people on board with it. This is where you might want to engage your religious leaders, for example. When you want people to adhere to physical distancing and mask-wearing, whom will people listen to? It’s really important for public health officials and governors to be teaming up with other people—with the healthcare industry, making sure that doctors reinforce this, and teaming up with religious leaders as well.”
