By Vivian Ho, Ph.D.
James A. Baker III Institute Chair in Health Economics
Heidi Russell, M.D., Ph.D.
Department of Pediatrics and Center for Medical Ethics and Health Policy
Baylor College of Medicine
As much of the nation completes its fourth week of isolation at home, sources suggest that we are gaining a better of idea of when we can relax social distancing and what needs to be accomplished before we ease restrictions. We continue our commentary on sources we read this week that shaped our thoughts on how the nation is coping with the pandemic and what actions policymakers can take to address the crisis.
Epidemiology and treatment
Last week the Institute for Health Metrics and Evaluation’s (IHME) model predicted that the U.S. pandemic would peak on April 15, with 2,644 deaths on April 16. Fortunately, the April 10 update predicts that the pandemic peaks on this day, with fewer deaths (1,983) nationwide. The modelers assume that social distancing stays in place until the point when daily deaths fall below 0.3 per million people. Their latest projections suggest that this point will be reached at the end of May. The IHME predicted last week that the pandemic would peak later in Texas, on May 6, with 160 deaths. This week IHME predicts that the pandemic will peak on April 29, with 66 deaths. The state would fall under the IHME’s cutoff of .3 per million deaths on May 27. The modelers caution that significant public health measures must be exercised after social distancing is relaxed, in order to prevent a resurgence of the virus. These steps include mass screening, contact tracing, testing of all individuals entering the country, and quarantine of people who test positive.
Our reading of news stories has us thinking that one is much more likely to contract the coronavirus by inhaling it than by touching a surface that contains the virus. Watch this video and make up your own mind. Watch the entire 5.5-minute video, because you’ll see how droplets a person exhales travel after a sneeze, during a close-up conversation without any sneezing or coughing, and in a crowded enclosed room.
As the lack of sufficient supplies of test kits remains a signature failure of the battle against the coronavirus in the U.S., Californians have adopted an alternative strategy to measure the prevalence of Covid-19 in the community. The Los Angeles Times reported that Los Angeles County officials will begin testing the blood of 1,000 randomly selected residents, including those with no symptoms, to see if they have or had Covid-19. The serological testing looks for antibodies to the virus in the blood. The testing could allow researchers to quantify how many people have had the virus, which will provide more accurate information on the true mortality rate for Covid-19, as well as the benefits of social distancing. The article reports that a similar study recruiting 3,000 individuals began in Santa Clara County last week. However, because these antibody tests are so new, an expert in a New York Times piece commented that “serological tests are plagued with issues.” There are cases where the tests yield too many false negatives (not picking up antibodies when they’re present) and other times yield too many false positives (indicating antibodies when there are none). We consulted with infectious disease experts, and one suspects that the tests which are widely available now in the U.S. can only detect whether you have had any type of coronavirus (including a common cold), but not which one.
Much uncertainty remains regarding best approaches to treating severely ill Covid-19 patients. An AP article reports that some doctors are moving away from ventilators for hospitalized patients after 80% or more of coronavirus patients placed on the machines in New York City have died. Some health professionals are concerned that ventilators may ignite or worsen a harmful immune system reaction in patients.
On a more positive note, a study published this week in Proceedings of the National Academy of Sciences showed that convalescent plasma, which is drawn from the blood of recently recovered Covid-19 patients, was effective in improving the clinical outcomes of 10 severely ill patients in China. More extensive clinical trials of this treatment approach are underway in the U.S.
Many public health experts worry that the federal government is responding to the pandemic in a slow and disorganized manner, with the lack of sufficient test kits being just the tip of the iceberg. An article in Kaiser Health News outlines multiple actions that the federal government could be taking to curb the virus. Most importantly, the Trump administration has undercut the Federal Emergency Management Administration’s power. The article reports that states and hospitals are leveraging White House contacts to bypass FEMA’s approval process — diluting the effectiveness of national efforts to coordinate and distribute supplies where they’re most needed. In addition, the administration has not designated FEMA or any other federal authority to be the sole agency purchasing equipment, forcing states and localities to bid on the same supplies, driving up costs. The article mentions several other actions the federal government could be taking, such as a standardized hospital intake form for Covid-19 patients, with fast relaying of the data to the Centers for Disease Control.
In our March 30 blog, we highlighted the Roadmap to Reopening the Economy report by former FDA commissioners Scott Gottlieb and Mark McClellan and others. This week Drs. Gottlieb and McClellan partnered with other experts to publish detailed recommendations for a national COVID-19 surveillance system that would enable us to safely reopen the economy without fear of a recurring pandemic. The steps they recommend are extensive and costly, but they are comprehensive and worth paying careful attention to. The authors recommend a national capacity of at least 750,000 tests per week to allow for isolation and contact tracing to contain disease spread. Contact tracing is labor intensive. For example, Massachusetts recently announced a new program to hire and train 1,000 people to support contact tracing. The report also recommends sentinel surveillance programs, e.g., in select populations or in settings where people congregate with high risk of transmission. They view sentinel surveillance as a critical tool for identifying asymptomatic or mildly symptomatic spread. To make the best use of testing information, the report lays out guidelines for electronic data sharing of testing results across insurers, health care providers, and public health experts in the private and public sectors.
This week Scott Gottlieb also penned an op-ed in the Wall Street Journal describing two types of coronavirus treatments that policymakers should be doing everything possible to encourage drug manufacturers to move forward with as quickly as possible. One approach involves antiviral drugs that target the virus and block its replication. Antivirals already exist for influenza, HIV and cold sores. The other approach involves antibody drugs, which can be used to fight an infection and to reduce the risk of contracting Covid-19. Antibody drugs function on the same scientific principles as convalescent plasma, but because they are synthesized, they could be manufactured in large quantities using recombinant technology.
We are saddened by both personal stories and those in the news of patients with other diseases who are facing delays in treatment because of the pandemic. The Center for Medicare and Medicaid Services has published guidelines for triaging care in order to conserve critical resources for fighting Covid-19 and to limit exposure of patients and staff to the coronavirus. An article in Kaiser Health News reports that the American Cancer Society is hearing from patients across the country who are having their chemotherapy delayed or surgery canceled. Hospitals and professional organizations are developing their own guidelines for triaging surgery and other treatments based on their medical knowledge and the availability of resources in their local area.
On the medical frontlines
If you are interested in Covid-19 resources that physicians are receiving, the American College of Physicians has published a comprehensive online guide that is being disseminated among health care professionals.
We are watching the local and national reports of workforce changes in the health care industry. In locations with patient volume exceeding health care system capacity, medical providers are under physical and emotional strain, with some falling ill. More providers are needed. New York Health + Hospitals has a disaster volunteer recruitment system, and California has a request for emergency personnel via healthcorps.ca.gov. Practicing requirements are at the state level, and some states are implementing emergency licensing processes to allow providers to get to the front lines faster. For example, Texas is temporarily allowing medical providers – including physician assistants, perfusionists, and respiratory therapists – who have completed all other steps toward their license to undergo a name-based background check instead of a more lengthy fingerprint background check. Other states are allowing retired providers to return to work.
Meanwhile, pay cuts, layoffs and temporary furloughs are occurring across the nation. Hospitals have cancelled elective procedures. Outpatient clinics and dental offices have cancelled non-urgent visits or increased the use of telehealth. Outpatient primary care visits have decreased by 75% according to a report from National Public Radio. This has resulted in less activity and less revenue. As a result, practices find it difficult to pay the salaries of their staff. As of this writing, there does not appear to be a consistent plan or extent of cutbacks across health care systems, except that they are focused on personnel without patient care duties. Cuts at the Boston Medical Center affect approximately 10% of its workforce. Envision Healthcare Corporation has cut salaries of senior leadership by 50%. Health care systems hope that these measures are temporary. But others are attempting to predict the longer-term effects. If the financial changes in our health care system because of Covid-19 continue, HealthLandscape predicts nearly 60,000 family medicine physicians will lose their jobs or practices by the end of June 2020. This is particularly impactful as family practice physicians often deliver medical care to rural and underserviced Americans.
In this massive, unprecedented worker safety crisis, the Occupational Safety and Health Administration (OSHA) is missing in action. The agency could play a major role in protecting workers and slowing the epidemic, but it has been limited to putting out recommendations. As far as we know, the word “OSHA” only began to be mentioned in POTUS/WH Task Force briefings last Friday. The CDC and most states aren’t tracking cases by occupation, but Ohio reports 20% of cases are health care workers. There are more than 2,200 workers at two Detroit hospital systems who are infected. Workers are being fired for raising concerns about inadequate protection and not a peep out of the administration. Employers, even ones who want to protect workers, are not being told what they need to do. There is much OSHA and the Department of Labor could do. This Politico piece describes what OSHA could and should be doing. Labor Secretary Gene Scalia finally appeared at last Friday afternoon’s press briefings with the president telling employers to protect workers and not retaliate against them. OSHA should issue an emergency standard for health care workers and start inspecting and quickly issuing general duty clause citations in situations where workers are egregiously exposed.
Even as we have reached a point where the country is suffering massive loss of life from Covid-19, we are encouraged by the fact that social distancing is proving effective at slowing the spread of disease. Predictive models suggest there is a light at the end of the tunnel, and the country could begin a return to normality in late May or early June. However, that normality will be short-lived unless the country is able to implement a rigorous Covid-19 surveillance system as recommended by Drs. Gottlieb and McClellan. We have seen much in the news about federal efforts to secure more ventilators, but nothing about efforts to aggressively ramp-up availability of coronavirus tests. We hope there is better news on the testing front next week.