Infectious Diseases Experts Discuss the Current Moment in the COVID-19 Pandemic
On Thursday, October 29, leading infectious disease experts addressed some of the latest developments in the COVID-19 pandemic, and its implications for the healthcare system and for the American public, during a press briefing sponsored by the Arlington, Virginia-based Infectious Diseases Society of America (IDSA). The IDSA describes himself on its website as “a community of over 12,000 physicians, scientists and public health experts who specialize in infectious diseases. Our mission is to improve the health of individuals, communities, and society by promoting excellence in patient care, education, research, public health, and prevention relating to infectious diseases.”
On Thursday morning, Chris Busky, the IDSA’s CEO, introduced the two speakers at the press briefing: Amesh Adalja, M.D., a senior scholar at the Johns Hopkins University Center for Health Security, in Baltimore; and Ali Mokdad, Ph.D., a professor of health metrics sciences at the Seattle-based Institute for Health Metrics and Evaluation (IHME), and the chief strategy officer for population health at the University of Washington.
Dr. Mokdad spoke first, stating that “Our new projections for the US have increased from our last projection from 385,000 to 399,000 February 1. If everyone can wear a mask, we can save at least 75,000 lives. Globally, our projection is for 2,495,769 deaths by February 1.”
Further, Mokdad said, “Europe is seeing a surge. What we have noticed is that countries in Europe have been much faster in imposing mandates based on what they’re seeing. In the US, we are seeing a rise in nearly all states. We cannot afford to see hospitals and ICUs overwhelmed. Per masks, we need a message that is scientific—and clear). Holidays are upon us and we need to protect our loved ones from transmission.”
What’s more, he said, “On the vaccine front, there will be little or no effect in this calendar year; perhaps in the first quarter of next year. For sure, it will help us here in the months of next summer. For now, we should focus on what we know: people should wear a mask, socially distance, and wash their hands. In order to reach a level of 60 percent herd immunity, that would require 1.2 million deaths here in the U.S.; 800,000 in the U.S., to reach a level of 40 percent. In my opinion, herd immunity is criminal, as that would require the deaths of many frontline workers.”
“To me, hospital capacity is the most paramount thing to look at” among all the data points one could look at, Dr. Adalja said. “That’s where we run into crisis. Trying to understand what proportion of a hospital’s census is COVID, gives you an idea of how disruptive COVID is. A hospital has to be doing cardiothoracic surgery, has to be starting chemotherapy for cancer patients, and so on, so that will show the burden of COVID. We know across the country that there’s been a shrinking of hospital bed availability. That’s one of the most important statistics to look at.”
Further, “Another key data point is understanding percent positivity,” Adalja said. “How hard do you have to look to find a coronavirus case? If your positivity rate is 20 percent, it’s easy to do so. And it’s becoming relatively easier to find a coronavirus case” nationwide, he said. “So that tells you if the testing is flat, that something is going on. It’s kind of like your barometer of what’s going on. It’s misunderstood and is often ignored by some policymakers. If your percent positivity is going up, it’s clearly telling you that your infection rate is going up.”
Meanwhile, Adalja said, “When people do contact tracing—they’re notified of a case and are trying to trace—if there’s a new case unrelated to those already infected, that tells you that there are undetected chains of transmission emerging in the community. We saw this for example in Ebola in the Democratic Republic of the Congo, and that led to what was called a shadow epidemic. And in the U.S., many people don’t pick up the phone when the health department calls, or throw letters out into the trash, thinking they’re junk mail,” which adds to the problem of accomplishing real contact tracing. “Data revision upward or downward is something for the general mainstream media press in the local newspaper to understand. We’ll see revisions of data upwards and downwards; that happens when we’re dealing with a new infectious disease. It won’t be perfect data. And it’s important to remember that models are ‘if/then’ propositions. We have the ability to change the trajectory of models. They will change based on what we do, such as wearing face coverings. Models are sometimes seen as predicting what will definitively happen, when they can be modified over time.”
Asked how the course of the pandemic might change, if a national response were marshaled, Adalja said that “It would make a world of difference if we could achieve a national response.” If a national response can be mustered, he said, “You won’t get a hodgepodge of approaches, and will have a much more robust [overall] response. And testing will be a key component, because if we can’t answer the question of who is infectious and who isn’t, we can’t solve this. And we need the testing to be as seamless as possible. The other part of this has to do with the fact that the guidance is totally different in different states,” he added.. “There are totally different guidelines for behaviors and activity in different states. And a lot of things are being done on the fly. That’s where the CDC [federal Centers for Disease Control and Prevention] and national level coordination will make a real difference. Many state, county, and local health departments have been underfunded for a long time.”
“It’s very clear, the difference between countries that have achieved a national response versus those that haven’t,” Mokdad said. “It’s so confusing right now. In public health, you need to achieve a consistent response to change behaviors; we did that with seat belts. And for example in Florida, you have differences between what they’re doing in Miami versus in other areas of the state.” A national mask mandate, he said, would be very effective in shifting the trajectory of the pandemic.
Asked what the current landscape for COVID-19 patient care looks like now compared to in March, Mokdad said that, “Unfortunately, we’ll be peaking rapidly in many states, leading to exponential growth. We are in a better position in terms of treatment, but in terms of cases rising, we’re seeing exactly what we were seeing before.”
“We are in a very similar situation to where we were in March, but we have made tremendous progress in understanding the disease,” Adalja said. “We have new tools now, dexamethasone, Remdesivir. And early on, we were reflexively putting people on mechanical ventilators because we were afraid of having to intubate people on an emergency basis. So what we’ve seen in the hospitals is improvement in understanding of the disease. And at least in the hospital setting, I can get a test back very quickly. So I do think we’re in a better position in terms of the knowledge and tools we have; and monoclonal antibodies are showing promise. But in terms of fatigue, we’re probably in a worse position.”
Asked whether certain regions in the United States are particularly concerning right now with regard to hospital capacity; and what a vaccine can or cannot do, once approved, Adalja said that “I’m only in one geographic area; I do follow media reporting on hospitals in trouble. Now, Wisconsin, the Dakotas, El Paso, and Utah” have become outbreak hotspots; and “we’re going to see these roving hotspots. I don’t know whether we’ll see places like New York City having that problem again,” he said. “Per the vaccine, do I think this will go away with the vaccine? No. This is the seventh coronavirus we’ve discovered. And these first-generation vaccines will not provide what we call sterilizing immunity, as happened with measles, where you’re going to have immunity for life. They’ll basically lower the level of intense disease and hospitalization,” he emphasized. “We’ll still have some burden of infection in the population. I don’t think these first-generation vaccines will magically make this go away; we’ll still have to engage in mitigation. It won’t be like going back to December 2019.”
Asked about individual-clinician fatigue in caring for COVID-19 patients, as well as longer-term stress on the patient care delivery system, “Adalja said that, “As a clinician, it’s almost been like Groundhog Day, dealing with the same problems and issues every day.” He added that he personally only puts in clinical hours on weekends. “Also, thankfully, I practice in Pittsburgh, where it hasn’t been so bad. But I’ve been on calls with colleagues in New York City, where they are becoming fatigued. And I think we will see clinician burnout. In the early days of the HIV/AIDS pandemic, there was great concern over burnout.”
Speaking more broadly, he said that “Healthcare systems are being overburdened and stressed now. And hospitals tried prior to this to fill every bed and not expand capacity, and now [the pandemic is] stressing healthcare systems. They’re having to decide whether to hold onto patients, for the reimbursement, or not. And there are cascading effects. And it’s not just the people who get the diseases, but the entire healthcare system that has to absorb the impact. It’s going to take some time to get the entire healthcare system back to some kind of normal. Plans weren’t followed from the beginning, so it will take some time to get back to stability.”
Are we testing children enough in the healthcare system? “In the early part of the pandemic, we were not testing children at all, based on early data and on need,” Adalja said. “We are now testing children better, but not as much as with adults. There is a little bit of bias built into the way that clinicians think about children, because they’re not as fully represented in the numbers of hospitalized patients or in the death figures. So we try to spare children the unpleasantness of testing, and we often urge parents to isolate them for 10 days. And we could do just nasal swabs rather than nasopharyngeal swabs; or we could do saliva tests. So the more data we have on children, the better it’s going to be for all of us to understand this disease.”
Asked whether the U.S. in the middle of its first, second, or third wave, “Mokdad said, “We’re still in the first wave in the United States. We had a first rise in March-April, another in July-August, and now we’re seeing a third surge. Meanwhile, when the vaccine first is made available, we’ll face a situation where there won’t be enough vaccine available; meanwhile, 40 percent of Americans say they won’t even take the vaccine.”
And, asked whether Sweden should be seen as providing some kind of model, with the decision of its senior public health officials not to lock the country down, as was done this spring by all the other Nordic countries, Adalja said, “I tell people that Sweden is like tea leaves; you can see whatever you want in it. So if you’re going to not test and isolate, you’ll see a lot of illness and deaths. But in Sweden, people did self-isolate; and mass gatherings were not allowed. They also rationed: if you were over 80 or severely obese, you couldn’t be admitted to an ICU bed. Taiwan is more of a model,” he said. “You have to aggressively find cases, isolate, and find cases. Also, Sweden had a very high hit on its nursing home population. So Sweden’s way was not the way. You need to focus on the basics of testing, tracing, and isolating.”
“Sweden was not a good model,” Mokdad said. “But people in Sweden have done a much better job of self-isolating, compared to in the U.S., where we travel a lot, have larger circles of friends, and gather in larger groups. South Korea was a better model: they shut down at the right time, tested, traced, and isolated.”
