Monday, March 16, 2020
"As the Covid-19 pandemic continues to spread rapidly, every step of the response needs to prioritize actions most likely to achieve three overarching goals: prevent infections, prevent death in infected people, and reduce societal harms.
But the United States’ response is being undermined by seven potentially deadly errors.
1) Testing is not a panacea
There is understandable frustration and outrage that testing has been slow and often inaccessible in the US. But lack of testing has led some to miss the point of what tests can — and cannot — do.
A surge in people being tested could actually spread disease, because people can become infected by someone else waiting to be tested. Getting tested today is no guarantee you won’t get infected tomorrow — and may give you a false sense of security. Furthermore, emerging data suggests that testing of throat swabs may miss as many as two-thirds of infections.
From my point of view as an infectious disease control physician, it’s dismaying to see both the promises of and demands for widespread testing that, if met, will do little good and possibly some harm. That said, in some contexts testing is absolutely, crucially important:
In areas with few or no cases, to inform containment and isolation strategies and facilitate contact tracing. Seattle would likely have had a much smaller outbreak if testing there had been widely available sooner.
In areas with community transmission, to inform treatment and protection of vulnerable groups, especially when there are outbreaks in hospitals, nursing homes, homeless shelters, and prisons.
In health care facilities treating severely ill patients, to identify those with Covid-19 in order to improve infection control, know when it is safe to discharge patients, and identify participants in clinical trials. For these reasons, every patient in the United States with severe pneumonia should be tested for SARS-Cov-2 infection.
For epidemiologic investigations, to determine how widespread infection is, facilitate surveillance and inform situational analysis, projections, and investigations, including into how the virus is spreading and how infectious asymptomatic people are. The Centers for Disease Control and Prevention’s initiative of testing for the virus in all patients with influenza-like illness at outpatient health care providers is essential to help understand where the virus is spreading, to whom, and what the trend will be in the coming weeks and months.
In areas where the virus is spreading, there is little benefit, and some potential harm, to testing individuals with mild or no symptoms. In the process of getting tested, these people will take up the time, protective equipment, and lab materials of health facilities. If they’re not infected when they travel to and get care, they may get infected in the process.
This is less of a concern for parking-lot, drive-through testing in the private sector, but whether people with symptoms are positive or not, they must isolate themselves, especially from medically vulnerable people: the test could be falsely negative, or could become positive the next day. Furthermore, in a community-wide outbreak, there’s no way public health workers will be able to identify and track contacts of all people who test positive.
The larger problem is not the limited value of testing of mildly ill patients. It’s the distraction from what’s most important. Just as the CDC was distracted from its core activities by cruise ships and dealing with repatriating travelers to the United States, the urge to test is distracting much of the US response from the actions that can save the most lives. Which brings me to the single most concerning error:
2) We’re not getting and disseminating answers to key epidemiologic questions.
This is the most important thing we’re not doing right now. There is so much we need to know in order to make better decisions about what to do. We need to know who is most likely to die from Covid-19. We know that older people and those with underlying health conditions are at greater risk. But we don’t know at what age risk actually increases. We don’t know which medical conditions may be riskier than others. Over 60? Over 80? Which underlying conditions? Controlled diabetes? Hypertension? On certain medications?
If we know this, we can give better advice: who to tell to become “semi-hermits,” and who to test even if they are only mildly ill. And we don’t know the answers to other key questions that determine policy decisions. Can children, who don’t seem to get severely ill with Covid-19, spread the disease? How is Covid-19 spreading in hospitals and other care facilities, and how does this affect health care worker safety and infection control procedures?
Although the virus can persist on surfaces, is it common for people to get infected from contact with contaminated surfaces, and how does this change the need for environmental cleaning — or reduce it? Answers to these questions are essential to guiding rational, effective action. If the studies are being done, they need to be accelerated and published. If not, they need to start, today.
3) We’re not preparing adequately for a surge in cases that could overwhelm our health care system
If there are too many cases at one time to allow effective care, patients who could be saved will die and infection will spread to patients and health care workers, as occurred in Wuhan, China and in northern Italy. There’s a need for more protective equipment for health care workers, and we’ll need to explore use of newer technologies including reusable respirators.
Even though we have increased the number of ventilators in the Strategic National Stockpile severalfold, in a worst-case scenario, we wouldn’t have the hundreds of thousands we’d need. Every hospital needs to come up with a plan now to double or triple its intensive care capacity.
We should be starting to distribute supplies from the stockpile to get the kinks out of the system. And we should be planning for the awful possibility that we may need to construct MASH-type intensive care units. This is why we are now urging social distancing measures that seem extreme: by reducing disease spread, we can “flatten the curve” so that the cases we will inevitably see are spread out over time and don’t overwhelm the health care system.
4) We’re not assessing the costs and health benefits of specific social distancing interventions
It makes perfect sense to wash hands, cover coughs, stay home if ill, and stop shaking hands — and it’s all free. And we will have to telework, cancel meetings and sporting events, and consider ways to decrease potential contact on subways and buses.
But closing all schools may not make sense right now. Unless there is documented widespread community transmission — something we’re not yet seeing in most of the country — there is no need to close schools. An interim intervention is to allow schools to remain open but require them to enable online options for teachers and students who are medically vulnerable. We must consider the huge societal costs of closing schools against what may be little or no health benefit — particularly if kids continue to go out and are increasingly cared for by grandparents and others who are vulnerable.
What if parents are needed at health care facilities, or utility plants, or to provide other essential services? Where will those who depend on meals provided at school get food? In influenza, closing schools for months may reduce spread by up to 40 percent. But we don’t know that there will be any decrease in spread of Covid-19 from closing schools.
5) We’re not effectively communicating risk
Many young people are terrified, while many older people seem to be taking a business-as-usual approach. This is not the end of the world, it’s not the zombie apocalypse, we’re not all going to die.
Most people who get Covid-19 have mild, moderate, or no symptoms, and approximately 99 percent recover. Yes, this is the most disruptive health threat since the influenza pandemic of 1918. And, sadly, many people are still going to get sick and some will die. We need to focus our attention on preventing our most vulnerable people from infection and providing safe, excellent care to those who become severely ill.
6) Public health professionals at CDC and elsewhere need to speak with the public every single day
There have recently been attacks on CDC and inaccuracies about what it has done. CDC did have an initial problem with public health laboratory tests.
But it remains a wonderful organization with 20,000 staff dedicated to protecting and improving health. It has some of the best health experts anywhere in the world, and is the single best source for information on the pandemic. The public will be best served if we hear directly from CDC’s top experts every day. This is especially important because we are learning more about the virus every day, and need definitive information.
Whatever your view of the current administration, some of its actions have saved lives. The ban on travel from China undoubtedly reduced the number of Americans who became infected with Covid-19. The new ban on travel from the EU could have some benefit — but only if we understand that this delays disease spread and does not prevent it, and is justified only if we use the time it buys to follow the first six steps above.
Presidential attacks on CDC and misrepresentations of past actions can undermine the ability of society to respond effectively — public health should be non-partisan space. President George W. Bush advanced pandemic influenza planning. President Obama oversaw effective responses to H1N1 influenza and Ebola, and created the Global Health Security Initiative to begin building the systems to address exactly this type of health event.
Partisanship has no place when lives are at stake. Covid-19 might even help all of us realize that we are all connected, and although we need to increase social distance, we also need to increase solidarity to help each other get through what has quickly become a national and global crisis.
Dr. Tom Frieden is the former director of the US Centers for Disease Control and Prevention and former commissioner of the New York City Health Department. He is currently president and CEO of Resolve to Save Lives, a global nonprofit initiative funded by Bloomberg Philanthropies, the Chan Zuckerberg Initiative, and the Bill and Melinda Gates Foundation and part of the global nonprofit Vital Strategies. Resolve to Save Lives works with countries to prevent 100 million deaths and to make the world safer from epidemics. Frieden is also Senior Fellow for Global Health at the Council on Foreign Relations. @DrTomFrieden."
Coronavirus US: 7 potentially deadly errors in the response - Vox