What to do in a pandemic

Like everyone else, I am still waiting for the coronavirus pandemic to show signs of slowing down. But it does not. So what do we do now? You don’t have to be an epidemiologist (or even a physician) to figure it out.

Let’s start off with what we know. We know that the coronavirus is an RNA virus. Viruses are classified as RNA or DNA based on the genetic material they use to replicate. RNA viruses are generally simpler than DNA viruses, with fewer surface proteins that can mutate. For that reason, it may be easier to develop a vaccine against the coronavirus, just like we have for the influenza viruses, that are also RNA viruses. Even so, it takes time to do the clinical studies to demonstrate the effectiveness and safety of a new vaccine.

Hospitalization and death rates indicate that the coronavirus is about 5 times more deadly than the influenza viruses (although some influenza viruses are worse than others). We also know that the elderly and people with pre-existing conditions like heart disease, lung disease and diabetes, are more likely to have complications due to coronavirus infection. We also now know that coronavirus may survive on smaller aerosolized droplets than most influenza viruses, meaning that coronavirus may float in the air for long distances. In addition to that, most viruses are also transmitted by contact with contaminated surfaces, like door knobs. So the coronavirus could spread that way too.

We know that one of the late complications of coronavirus infection can be a hyperactive immune response that causes inflammation of the lungs, heart and other organs many weeks after the initial infection. This complication has been seen in adults and children. Except for the pre-existing conditions, it is not clear who is at risk for developing this complication. Everyone is potentially at risk for serious illness at any age.

The incubation period for coronavirus infection is 2-14 days. Some people have very mild infection and may be considered asymptomatic. People with mild symptoms can still be infectious. So you could be infectious before you really know you have symptoms, and you may be infectious if you have no symptoms at all. It may also be difficult to determine when you are no longer infectious unless you have had multiple negative antigen tests.

Some other things we have less clarity about. For example, how well do masks work to prevent transmission of coronavirus? As a physician who understands isolation and quarantine protocols, the way we use masks does not provide me with a lot of reassurance. Under a strict isolation protocol, we would not rely on just a mask for protection, and we would never use the same mask in contact with more than one other person. But we do know that masks can reduce the projection of aerosolized particles from an infected person, and so it should reduce the likelihood of transmission. Masks probably provide less protection from breathing in aerosolized virus particles. Since we don’t have any other good options, masks are recommended. But if you have a known coronavirus infection, you should absolutely isolate yourself and not rely on wearing a mask to protect others.

What about testing? There are two main categories of coronavirus tests – one to see if you have the virus (usually a viral antigen test), and another to see if you have recovered from the infection (usually an antibody test). There are several different types of antigen tests. In general, the more rapid the test result (for example a 15 minute test), the less sensitive the test is (in other words the more likely it could be a false negative test). More sensitive tests take a day or so to run. So if you really need to know (you are having symptoms), you should probably get the more sensitive test and be ready to wait for the results.

There is a lot of back and forth right now about having more people tested, and ensuring low rates of positive tests. My opinion is that with the level of community transmission that we currently have (31 states with rates of new infections >100/100,000 population) it is a waste of time and money to test asymptomatic individuals. The purpose of that testing would be to do contact tracing. There are far too many infections occurring for meaningful contact tracing to be performed. Hospitals report that more than half of patients seen with coronavirus infection are unable to determine where they may have been infected. Testing of asymptomatic contacts only makes sense if you can follow thru with all contact tracing.

When will a vaccine be available? My experience with epidemiology and clinical research (I am not an epidemiologist) would tell me that vaccine researchers would have a hard time getting their study results to the FDA by the end of this year, and then it would take about 3 months for the FDA to review the data and approve a vaccine that demonstrates efficacy and safety. It is possible for the FDA to approve a vaccine for emergency use with limited data, but this would be under research protocols and would limit the number of patients who could receive the vaccine (certainly not millions). So I agree with the CDC and FDA who suggest that wide vaccine availability will be mid-year 2021 or later. By the way, my assessment so far this year is that the FDA is doing an outstanding job of continuing their important work reviewing and approving applications for new medicines under very difficult circumstances.

What do we do in the meantime? As of October 8, 2020, 31 states are classified as red-zones, the highest level of risk, based on infection rates in the population. These infection rates are associated with increased hospitalizations and deaths, as would be predicted. In the early days of the pandemic, red zone classification would mean total shutdown of social interaction. Now it is not clear what it means. Some are recommending shutting down locally to avoid large scale economic disruption. Unfortunately, this makes no sense unless you have a way of restricting travel between local communities.

Now more than ever we need a coordinated, national response to the coronavirus pandemic. This has to begin with interstate and international travel restrictions. Just this week (the week of Oct. 20) it was reported that TSA airport screenings were at their highest level since the pandemic began. Yes, airlines may be reducing the risk of infection while you are flying, but that is not the point. The point is that an infected person could get on an airplane and could take the infection with them everywhere they go. Remember that is how we got the coronavirus in the US in the first place. We need to discourage all interstate and international travel, and halt interstate and international mass transit.

If we get travel under control, we can focus other restrictions on the red zone states. But in those states, we need to go back to stay at home mandates, closing restaurants, bars and other non-essential large scale inter-person venues. That includes most sports venues, colleges and schools. We have seen that you can social distance people to some extent in the stands during college football, but the problem is not in the stadium, it is everywhere else – hotels, restaurants, bars, and yes, even tailgating. If professional sports say they can operate in their bubbles outside of red zone states, I would listen to their argument, but I would have to be persuaded. Restrictions need to be at the state level. It is really not possible to enforce travel restrictions between local communities. Some people have to leave their local communities for essential activities like grocery shopping.

People argue that children need to be back in school for in-person learning, even in red zone states. Kids are resilient. They will get thru this pandemic a lot better than adults, and they will pick up quickly where they left off. Virtual learning should be provided where it is possible. But there is the issue of access to virtual learning – some kids have it and some don’t. That will lead to inequities in learning during the shut-down. It would be better to be prepared for this at the restart, and provide tutoring at that time for children who did not have access to virtual learning during the pandemic.

The biggest issue in all of this is how will people get by financially during a shut down. The federal government has to take the lead and provide financial support for businesses that must shut down. Hospitality, lodging and transportation companies will need direct assistance. Unemployment support should be extended, but general distribution of stimulus checks is unnecessary. Many people are able to work virtually and have no loss of income, and no dire need for assistance with child care. State and local governments can find innovative ways to support local businesses in diverse communities, so the main federal support should probably be in the form of grants to the states. An example would be to have restaurants provide free meals one day a week as a condition for receiving aid for 4-5 other days.

Once we get infection rates under control, the economy should reopen to the extent that testing and strict contact tracing can be accomplished. There should be designated sites for testing that are linked to contact tracing for this purpose. What does this mean in terms of the size of interpersonal gatherings? There are guidelines for no more than 10 or 25 persons interacting. While significant community transmission is occurring you should not attend any gathering of people where you cannot provide full contact information for every person there.

Finally, when a safe and effective vaccine is available, it should be made available widely and at no cost. With the lackluster results from most antiviral therapy at this point, a vaccine is still the best solution to this pandemic. In the meantime, be kind, wear a mask, wash your hands and stay home if you can.