The United States is Both Stalling and Failing in Our Effort to Combat Covid

(Blog initially published on Tom Frieden’s LinkedIn account https://www.linkedin.com/pulse/united-states-both-stalling-failing-our-effort-combat-tom-frieden/)

September 5, 2020. Continued spread of Covid in the US will continue to undermine health, jobs, economy, and education. A concerted, strategic approach would help, a lot. Parts of the Federal government are making a fundamental error: Failure to recognize we’re all connected, all in this together. Spread in any place or group is a risk everywhere, and if we work together, mask up, increase distance, improve testing, tracing, and support for patients and contacts, we can get more of our economy, more of our jobs, and more in-person education back.

Some are speaking about this outbreak as if it’s in the past tense. But more than 4 out of 5 Americans aren’t yet infected - it could get a lot worse, and it will if we don't improve our approach.

According to CDC’s CovidView, test positivity inched up from 5.4 to 5.5% in the past week, driven by an increase in positivity among 19-49-year-olds (and this is before many colleges try to open). Test positivity is at low levels in the northeast and some other states, but very few places are finding where most spread is occurring - most sources of infection, and even fewer -- maybe none -- are quarantining most contacts effectively. Because of that, virtually everywhere, the risk of explosive outbreaks remains. Rates of infection and of test positivity are high or increasing rates in most of the US. These rates are too high for economic and social recovery.

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There are two data sources of note. County-specific test positivity, which should be open source but at least is available here (image below -- I wish they had zip code lookup).

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And we’re delighted to work on the Covid Symptom Data Challenge. This could become an important early warning system for Covid. The competition is open until September 29. 

Deaths and hospitalizations continue to decrease overall. But 500-1,000 deaths/day is horrific. These deaths also reflect approximately a quarter of a million infections per day a month ago (so we’ve only been detecting about 1 in 5 infections). 

There were 215,000 more US deaths March-July than baseline. Of these, 71% were diagnosed as Covid by their doctor. The remainder were either undiagnosed Covid or deaths from Covid-disrupted care. Covid-disrupted care is an even greater risk in Africa and elsewhere, where measles, malaria, and other causes of death can rapidly and drastically increase death rates. Good tracker by The Economist.

Imagine how many fewer deaths the US could have had if the Federal government had focused right. One example: masks vs. hydroxychloroquine. Masks work. Places around the world that used masks consistently had half to two thirds less spread. 100,000+ deaths could quite possibly, simply, and cheaply have been prevented.

Good news on steroids. Confirmation that they help with severe Covid. The sicker you are, the more they help, with up to a 35% reduction in risk of death in the sickest patients. Yes, really, 35%. Nice review of all key data by WHO. Yes, really, WHO. Press conference, anyone?

I’m guardedly optimistic that we’ll have evidence of a safe and effective vaccine in the next few months. But we need to look at all the data. Efficacy is more likely to be proven early than safety. So when one CEO spoke recently of having early data because there are lots of events, that’s a big concern, because the events he’s talking about are Covid infections in trial participants who got placebo. We need transparency about what safety signals are being looked at. There are at least two important concerns about safety:

  1. Inflammatory reactions. MIS-C in children - the Kawasaki-like syndrome - is the result of immune over-reaction. Will this happen with a small proportion of people vaccinated? How will we know? What sample size is needed to evaluate for this?

  2. Antibody-dependent enhancement. This means that infection with the virus that causes Covid after vaccination could, for some people, result in more serious illness. This occurred in one animal model, for one vaccine against SARS. How is this being evaluated for? What is the sample size needed?

Oh, and for the mRNA vaccines, what adverse events do we even look for? We've never used this type of vaccine in people before.

Lots has been done right with Operation Warp Speed (multiple vaccine types, manufacturing and trials in parallel), but let’s hope they don’t warp the science. There’s no way to stop epidemics without trust. Politicizing data and decisions is essential for trust, and very, very dangerous.

The pandemic ain’t over until it’s over, and it’s nowhere near over. Even with a safe, effective, available, and trusted vaccine, it would be months or years before the risk of deadly outbreaks is down to manageable levels.  We need continuous improvement in testing, isolation, tracing, and quarantine. The 3W’s make a big difference: Wear a mask, Watch distance, Wash hands. Improving ventilation and spending more time outdoors also help. Smarter limitations on activity can balance jobs and health. We’ll need to make preparations for vaccination, hoping that safe and effective vaccines become available. These including improving the cold chain and engaging communities. It's past time to begin conversations with communities, sharing what we know and don’t know and listening to concerns and perceptions.

Cases in the United States remain at a high level, increasing in much of the country, and we continue to fail to implement an effective, coordinated response.