By Vivian Ho, Ph.D.
James A. Baker III Institute Chair in Health Economics
Kirstin R.W. Matthews, Ph.D.
Fellow in Science and Technology Policy
Heidi Russell, M.D., Ph.D.
Department of Pediatrics and Center for Medical Ethics and Health Policy
Baylor College of Medicine
Now that most of us have finished our fifth week in isolation, we are encouraged that the nation may have passed its peak date for the number of new cases, but the number of new deaths appears to continue rising. We update you on efforts to identify treatments for the coronavirus, as well as policymakers’ discussions on when to reopen the economy, what that might look like, and where government funding should be directed.
Epidemiology and Treatment
Health experts warn us not to expect a single peak day in terms of new cases, deaths or otherwise. Daily reports of new cases and deaths can fluctuate depending upon the availability of tests and delays in reporting. The New York Times’ juxtaposes a bar graph of the number of new cases by day with a line calculating the seven-day average of these numbers, indicating that the number of new cases has fallen to just under 30,000 per day. However, the seven-day average of new deaths continues to rise to roughly 2,000 per day. Late Friday afternoon, the Institute for Health Metrics Evaluation posted an update for Texas, stating that the state is one day away from its projected peak in daily deaths. More encouragingly, the website states, “After June 1, 2020, relaxing social distancing may be possible with containment strategies that include testing, contact tracing, isolation and limiting gathering size.”
On Friday, Worldometers estimated that 58,000 people in the U.S. have recovered from the coronavirus. Mark Lipsitch, an epidemiologist at Harvard University, provides a compelling case that most individuals who contracted the virus will have an immune response, some better than others. He suggests that the immune response will offer some protection over the medium term — at least a year — and then its effectiveness might decline. This view that contracting the virus yields only temporary immunity is shared by other experts. Thus, treatments and a vaccine for Covid-19 are absolutely crucial in ultimately conquering this pandemic.
To date, researchers and drug companies have launched over 100 human experiments to identify treatments for the coronavirus. However, an article in the Washington Post reports that health experts are concerned that the lack of coordination across investigations could lead to an array of small-scale trials that might yield conflicting answers. For example, there are more than two dozen separate U.S. trials listed for the anti-malarial drug hydroxychloroquine, all with different designs. Some use the drug as a preventive, others as a treatment; some in combination with other drugs, and some with no comparison group. Information on multiple treatment approaches is often better, but coordination across these studies could have yielded larger sample sizes and cleaner study designs so that results could be used to prioritize treatments. Francis Collins, director of the National Institutes of Health, has been working behind the scenes to launch an unprecedented public-private partnership to achieve better coordination.
While estimates range for one to three years for a viable vaccine for Covid-19/SAR-CoV-2, many different research groups are working on novel approaches. In the scientific journal Immunity, researchers review the COVID-19/SARS-CoV-2 vaccine development and its challenges In addition, the World Health Organization (WHO) cataloged a long list of potential candidates, and an article from The Scientist describes frontrunners that hoped to be tested this year, providing details on each vaccine’s approach to target the virus as well as preliminary evidence.
Meanwhile, fake news regarding causes of and treatment for coronavirus are circulating through social media. The WHO has posted a series mythbuster infographics to dispel rumors, such as one that 5G mobile networks spread Covid-19. Other concerns related to unproven treatments center around the use of stem cells after the president’s lawyer, Rudy Giuliani, promoted a company’s protocol of infusing mesenchymal stem cells to modulate immune responses caused by COVID-19. As a result, the FDA approved the treatment for clinical trials, but many researchers in the field question the pre-clinical data showing any effectiveness.
Public health experts continue to emphasize that passing the peak number of cases or deaths does not mean that the pandemic is over, and that we will need to maintain social distancing in one form or the other for months to come. More than a dozen states have extended stay-home orders past the White House deadline of April 30. In the meantime, governors on the East and West Coasts were reported last Monday to have formed pacts to decide when they would reopen their economies. Governors of Midwest states followed suit soon afterward. These pacts will draw on facts and science to create plans to reopen each state in a way that limits new outbreaks of coronavirus. Among the steps are contact tracing, treatment and social distancing measures.
For example, last week we highlighted the recommendation for a National Covid-19 Surveillance System that included capacity to conduct 750,000 coronavirus tests per week. Unfortunately, most parts of the country report test supply shortages that remain “crippling.” Experts emphasize the need for contact tracers, to identify those who could have contracted the virus by coming into contact with someone who has tested positive for the virus. Policymakers are acting on that recommendation, with the CDC planning to hire hundreds of contacts tracers and it is in discussions to divert 25,000 Census Bureau workers to do contact tracing in the coming weeks and months. However, a former CDC director has stated that 300,000 contact tracers may be needed to control spread of the coronavirus. Experts suggest that employers can do their part to reduce the spread of coronavirus by offering screening at their place of business. Employers can help workers to safely self-isolate at home and work with local health authorities to improve contact tracing.
As TIME magazine stated, “Public health experts have savaged President Donald Trump’s decision to cut U.S. funding to the World Health Organization (WHO).” Critics include U.N. Secretary General António Guterres and the editor-in-chief of the Lancet medical journal, who called the decision “a crime against humanity.” However, The Wall Street Journal reported that the administration is withholding funds because the WHO failed to adequately investigate early information about the virus’ ability to spread between humans and for not criticizing China for its lack of transparency over the virus. This view is echoed in an article in The Atlantic, which points to structural problems at the WHO that make the organization vulnerable to misinformation and political influence, in this case by China. Nevertheless, the U.S. pays for about 22% of the WHO’s budget. Cutting funding for international public health initiatives in the midst of a crisis could have dire consequences for Americans in the future.
A furor has also erupted regarding the initial distributions from the $100 billion in funding for health care providers included in the $2 trillion CARES Act passed by Congress. The Department of Health and Human Services (HHS) is distributing the first $30 billion in emergency grants to hospitals and doctors according to their historical share of revenue from the Medicare program for seniors — not according to their coronavirus burden. States only lightly hit by the coronavirus, such as Minnesota, are getting more than $300,000 per Covid-19 case, while New York is receiving $12,000 per case. The HHS decision raises the prospects that hospitals in hard-hit areas will be weighing their financial health more heavily than patient well-being for each additional Covid-19 case that comes through their doors.
On the Medical Frontlines
Evidence of strain on the health care workforce continues to mount. The Centers for Disease Control published a report estimating at least 9,282 U.S. health care workers have been sickened by Covid-19, and at least 27 have died. This is likely an underestimate because of how local or state authorities report cases. The CDC concluded that approximately half of these providers were exposed in their workplace. The worse outcomes were in the over-65 workforce, although death and critical illness occurred at all ages. The first installment of a bi-weekly survey of medical staff across the country was performed by MedPage Today. The responses suggest that regional variation in the share of the physician and nurse workforce that is temporarily out, critically ill, or dead because of Covid-19 lies between 1% and 20%. The proportions are much higher in concentrated areas like New York. For an in-depth account of health care workers who have died from Covid-19, we applaud the stories found in Lost on the Frontline.
Health care workers are particularly at risk when performing nasal swabbing to test for the coronavirus, which requires the provider to stand directly in front of the person being tested. The swabbing generates is a natural reflex to cough or sneeze, which sends droplets into the air. To that end, the first Covid-19 test of saliva was approved by the FDA this week. This new test will allow patients to spit into a vial and hand it back to the health care worker. The test is not yet available in most health care organizations, and questions remain about its accuracy. But as these hurdles are overcome, this safer, simpler testing would also circumvent the shortage of nasal swabs that is hindering test availability across the country.
In the coming we week, we hope that new cases of the coronavirus continue to decline, and that the number of new deaths also starts to fall. We are most concerned about the continuing short supply of coronavirus tests. We hope that federal, state, and local governments aggressively pursue efforts to hire and train contact tracers throughout the country. Debate has begun on what role smartphone apps by Apple and Google could play in contact tracing, and we will follow that discussion closely. We also look forward to reviewing state governors’ developing plans to reopen their economies.