Shutdowns prevented 60 million coronavirus infections in the U.S., study finds

https://www.washingtonpost.com/health/2020/06/08/shutdowns-prevented-60-million-coronavirus-infections-us-study-finds/?fbclid=IwAR3J402h_abt63p-JDNEEBrNwrZ_nRjQza8OKxtV9xmtt4n5Oky-droY_-c&utm_campaign=wp_main&utm_medium=social&utm_source=facebook

Shutdowns prevented 60 million coronavirus infections in the U.S. ...

Shutdown orders prevented about 60 million novel coronavirus infections in the United States and 285 million in China, according to a research study published Monday that examined how stay-at-home orders and other restrictions limited the spread of the contagion.

A separate study from epidemiologists at Imperial College London estimated the shutdowns saved about 3.1 million lives in 11 European countries, including 500,000 in the United Kingdom, and dropped infection rates by an average of 82 percent, sufficient to drive the contagion well below epidemic levels.

The two reports, published simultaneously Monday in the journal Nature, used completely different methods to reach similar conclusions. They suggest that the aggressive and unprecedented shutdowns, which caused massive economic disruptions and job losses, were effective at halting the exponential spread of the novel coronavirus.

“Without these policies employed, we would have lived through a very different April and May,” said Solomon Hsiang, director of the Global Policy Laboratory at the University of California at Berkeley, and the leader of the research team that surveyed how six countries — China, the United States, France, Italy, Iran and South Korea — responded to the pandemic.

He called the global response to covid-19, the disease caused by the virus, “an extraordinary moment in human history when the world had to come together,” and said the shutdowns and other mitigation measures resulted in “saving more lives in a shorter period of time than ever before.”

The two reports on the effectiveness of the shutdowns come with a clear warning that the pandemic, even if in retreat in some of the places hardest hit, is far from over. The overwhelming majority of people remain susceptible to the virus. Only about 3 percent to 4 percent of people in the countries being studied have been infected to date, said Samir Bhatt, senior author of the Imperial College London study.

“This is just the beginning of the epidemic: we’re very far from herd immunity,” Bhatt said Monday in an email. “The risk of a second wave happening if all interventions and precautions are abandoned is very real.”

In a teleconference with reporters later, Bhatt said economic activity could return to some degree so long as some interventions to limit viral spread remain in place: “We’re not saying the country needs to stay locked down forever.”

The Berkeley study used an “econometric” model to estimate how 1,717 interventions, such as stay-at-home orders, business closings and travel bans, altered the spread of the virus. The researchers looked at infection rates before and after the interventions were imposed. Some of these interventions were local, and some regional or national. The researchers concluded that the six countries collectively managed to avert 62 million test-confirmed infections.

Because most people who are infected never get tested, the actual number of infections that were averted is much higher — about 530 million in the six countries, the Berkeley researchers estimated.

Timing is crucial, the Berkeley study found. Small delays in implementing shutdowns can lead to “dramatically different health outcomes.” The report, while reviewing what worked and what made little difference, is clearly aimed at the many countries still early in their battle against the coronavirus.

“Societies around the world are weighing whether the health benefits of anti-contagion policies are worth their social and economic costs,” the Berkeley team wrote. The economic costs of shutdowns are highly visible — closed stores, huge job losses, empty streets, food lines. The health benefits of the shutdowns, however, are invisible, because they involve “infections that never occurred and deaths that did not happen,” Hsiang said.

That spurred the researchers to come up with their estimates of infections prevented. The Berkeley team did not produce an estimate of lives saved.

One striking finding: School closures did not show a significant effect, although the authors cautioned that their research on this was not conclusive and the effectiveness of school closures requires further study. Banning large gatherings had more of an effect in Iran and Italy than in the other countries.

In discussing their findings Monday with reporters in the teleconference, leaders of the two research teams said challenges exist in crafting their models and thus there are uncertainties in the final estimates.

Bhatt, for example, said the model used by his team is highly sensitive to assumptions about the infection fatality rate, estimates for which have varied among researchers and from one country to another. He said his team was heartened to see that its estimates for the number of people infected so far is generally consistent with antibody surveys that attempt to calculate the attack rate of the virus.

Ian Bolliger, one of the Berkeley researchers, acknowledged the difficulty in obtaining reliable numbers for coronavirus infections given the haphazard pattern of testing for the virus. Both research teams said the peer review process had made their findings more robust.

 

 

 

 

An optimistic view from health system workforce leaders

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

Aldous Huxley and Brave New World: The Dark Side of Pleasure

Continuing our series of Gist member convenings to discuss the “Brave New World” that awaits in the post-pandemic era, we brought together a group of senior human resources and nursing executives this week for a Zoom roundtable.

Several themes emerged from the discussion. First, there was general consensus that the COVID crisis exposed a workforce that had become over-specialized and inflexible. Said one chief nursing officer, “Our workforce is much more brittle than we thought.” A key lesson learned is the need for increased cross-training—especially for nurses, and especially in critical care. Systems should work now to increase the supply of nurses comfortable in an ICU environment to enable hospitals to flex staff across settings and roles to deal with future waves of the virus.

Not surprisingly, layoffs were top-of-mind for many. Executives were of one mind on the need to safeguard clinical staff as much as possible, and many systems are now considering deep cuts to management and administrative ranks: “It’s easier to stand in front of your clinical staff and be able to say you’ve stripped millions from administration before turning to clinical cuts.”

There was broad consensus for the potential for artificial intelligence and robotic process automation to enable greater reliability and productivity at lower cost in areas such as billing, coding, and even some clinical functions—and that the pandemic will accelerate plans to implement these solutions.

On a more optimistic note, one executive shared that “relationships between clinicians and administrators have never been stronger. The pandemic has forced us to have difficult and constructive conversations we would have never had the courage to have before.”

Another noted the pandemic has spotlighted new leadership talent who might otherwise have been overlooked, and plans are now in place to formally recognize and retain newly crisis-tested talent for the work of restructuring the system.

On the whole, the discussion was far more upbeat that we had expected—as difficult as the crisis has been for many teams, the opportunity to rethink old ways of doing business seems to have created renewed enthusiasm even in the face of daunting financial and operational challenges ahead.

 

How the CDC “missed its moment”

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

CDC releases new guidance for colleges on reducing coronavirus spread

If, like us, you’ve been wondering exactly why the CDC always seems to be a step behind in responding to the pandemic, a new, in-depth New York Times piece helps elucidate the myriad challenges—structural, cultural and political—that led to the agency’s flawed response.

Given the CDC’s history, it should have been the world’s “undisputed leader” in the pandemic response. But its early reticence to absorb lessons from other countries, combined with flawed testing, slowed down responses across the nation. While much has been made of political machinations within the Trump administration, a deep-rooted bureaucratic and exacting culture left the CDC ill-suited to respond to a crisis of this scale, requiring improvisation and rapid adaptation.

Career scientists and epidemiologists clashed with CDC leader Dr. Robert Redfield, who was eclipsed by Drs. Tony Fauci and Deborah Birx in public communication. But even if it were firing on all cylinders, the CDC is only one of the many parts of government at the table for what should have been a coordinated, all-government response.

Whether led by the CDC or another entity, the pandemic response has highlighted the need for a massive overhaul of the nation’s public health system, so that future challenges—both COVID-related and beyond—are met with a rapid and coordinated response.

 

 

 

 

The patients stayed away—will they come back?

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

Emergency Department Patient Resources

new analysis from the CDC this week confirmed what we have been hearing anecdotally from health systems for several weeks—as the coronavirus lockdown took hold, there was a precipitous drop in visits to hospital emergency departments. According to the study, visits were down by 42 percent in the month of April compared to the previous year, and despite a rebound in May, were still 26 percent lower than a year ago. Visits in the Northeast dropped the most, as did those among women, and children under 14.

Although visits for minor ailments and symptoms declined the most, even more disconcerting was the drop in visits for chest pain, echoing the concern we’ve heard in many parts of the country that many patients may have suffered minor heart attacks without being treated, or may have waited to be seen until significant damage had been done.

As non-emergent visits have begun to return to many facilities, we continue to hear that emergency department and urgent care volume remains relatively low.

Survey data indicate that patients are fearful of becoming infected with coronavirus if they visit healthcare facilities—especially, it seems, ones where they’ll be forced to wait.

While many providers are investing in messaging campaigns to assure patients it’s safe to return, this nightmarish first-person account by one healthcare insider provides a useful cautionary tale.

Visiting a surgeon for a pre-op consult, she found the experience of visiting a COVID-era hospital downright dystopian. Simply touting safety precautions by itself won’t make patients more comfortable—they’ll need to see and feel that measures are in place to make time spent in a care setting as efficient and reassuring as possible. Otherwise, like the insider in question, they’ll take their business elsewhere. There’s work to be done.

 

Hospitals Emptied Out by Pandemic Push for Patients to Return

https://www.bloomberg.com/news/articles/2020-06-04/dear-patient-we-want-you-back-for-that-knee-replacement

Empty Emergency Rooms Worry Doctors as Heart Attack, Stroke ...

After months of lock down, hospitals are eager to get patients back for routine care and elective procedures.

An executive at a Palm Beach hospital stands between a box of surgical masks and a Purell dispenser.

“We understand you haven’t been inside our hospitals for some time,” she says to the camera. The executive is delivering her line for a promotional video intended to get people back to hospitals after almost three months of avoiding the place at all costs. 

Moments later, the film crew records her chatting with a vascular surgeon in an idled operating room, who soothingly reassures that  a hospital is the cleanest place to be outside your home. “The hospital is safer than the grocery store,” the doctor says.

The video published on YouTube in mid-May is part of a marketing campaign by Tenet Healthcare, which operates 65 hospitals and about 250 ambulatory surgery centers. It’s one attempt to solve a problem the entire health-care industry faces: Most patients vanished when Covid-19 swept the country.

Billions in Losses

Much of routine health care came to a halt in March as hospitals cleared space for an expected wave of Covid-19 patients and authorities ordered a halt to surgeries and other procedures that could be postponed. The decline in volume has clobbered hospital finances, with the industry estimating it is losing $50 billion a month.

Emergency visits dropped by 42% in four weeks in April compared to the same period last year, the Centers for Disease Control reported June 3. The number of U.S. patients getting hospital care dropped by more than half in late March and early April compared to 2019, according to data from Strata Decision Technology, which provides software to hospitals.

Some of that rebounded modestly in May as distancing rules eased, but hospital volume is nowhere near pre-Covid levels. With the pandemic ongoing and many states still confirming hundreds of new cases daily, patients are hesitating to rush back to hospitals.

“The main thing that really is a gating factor at this point is patient comfort,” Tenet President and Chief Operating Officer Saumya Sutaria said at a recent virtual conference with investors. Tenet declined interview requests.

Free Masks

To counter the public’s fears, hospitals publicize what they’re doing to keep patients safe. They’re handing out masks at the door and spacing out chairs in waiting rooms. They’re steering Covid-19 patients to dedicated sites and testing staff regularly.

Hospitals need to show patients that their facilities are safe. At Catholic hospital chain Trinity Health, that includes moving patients through “Covid-free” zones with separate doors, elevators and waiting areas.

“We can put all of the outreach and marketing in place, but it’s only as effective as the people who execute those strategies,” said Julie Spencer Washington, Trinity’s chief marketing and communications officer.

The question for the entire industry is how quickly patients come back. The answer will depend on a constellation of related variables, including how reluctant people are to resume care, and the course of the pandemic. Future surges could force hospitals to shut down regular care again — and spook patients further.

Hospitals and doctors are going to have to do as much as they can as fast as they can until they can’t anymore,” said Lisa Bielamowicz, co-founder of consultancy Gist Healthcare.

Many patients, on the other hand, are in no rush. “They’re waiting and watching rather than pulling the trigger and going to see the doctor like they would have in the past,” Bielamowicz said.

The calculation for the health-care industry is different than for many other service businesses resuming operations. A hospital procedure or even a check-up is more intimate than a meal out.

For procedures that require in-patient rehab stints for recovery, the havoc Covid-19 has brought to nursing homes adds another layer of concern. “Those places seem like deathtraps now, so it’s much harder to bring back those patients because you need to find an alternative way for them to rehab,” Bielamowicz said.

And the biggest consumers of health care are the elderly and the chronically ill, the very people Covid-19 most threatens. “From personal discussions with my patients, the older and more co-morbidities that any individual has, the more nervous they are about returning,” said Shauna Gulley, chief clinical officer at Centura Health, which has hospitals in Colorado and Kansas.

Patients with serious ongoing needs like cancer treatment or emergencies like heart attacks and strokes have continued to get care. And many medical problems resolve on their own. The decline in those visits – for a migraine headache, for example – reduces providers’ revenue but may not harm patients in the long-term.

While people often go to the emergency room for needs better treated in other settings, now the concern is the opposite: That true medical emergencies will be neglected.

Ascension, the nation’s largest Catholic hospital chain, has purchased billboards that say “Don’t delay ER care.” On hospital websites and social media posts, Tenet facilities reminded patients that “Emergencies Can’t wait. We’re Open & Safe.”

Deferred Care

Doctors fear that some patients will defer needed care too long, allowing progressive conditions to deteriorate. Clinicians at Maimonides Medical Center in Brooklyn, New York, have seen patients arrive sicker because they didn’t come earlier, said Ken Gibbs, the hospital’s CEO.

“There are unmet needs, I think that’s clear,” he said. “And I think the data on that will emerge, but it will take time.”

Maimonides treated 471 Covid patients at the peak on April 9, Gibbs said, and still had about 100 in late May. The hospital has applied for a waiver from New York State to resume elective surgeries, which are still on hold in New York City.

Some hospitals are preparing for a lasting dent in their revenue. For years, health economists have pointed to waste in the health-care system, with the estimated cost of unnecessary treatments in the hundreds of billions of dollars. Covid-19 may demonstrate that patients are willing to forego some of that care or opt for more conservative treatment.

People who had delayed back surgeries, for example, may now decide that doing physical therapy at home is good enough, said Marvin O’Quinn, president and chief operating officer at CommonSpirit Health, a large Catholic hospital system.

“We’ve all talked about too much intervention in health care in the past,” he said. “I think we’ll see a new normal in terms of what patients want to do and what doctors want to do, and we will have to adjust to that.”

 

 

 

 

Identifying “triple-threat” counties at higher risk of COVID outbreaks

https://mailchi.mp/9f24c0f1da9a/the-weekly-gist-june-5-2020?e=d1e747d2d8

“Superspreader facilities”—nursing homes, correctional facilities, and meatpacking plants—have become major COVID hotspots across the US. Many counties are dealing with a large outbreak in one type of tightly-packed facility or another.

Case in point: the outbreak at Cook County Jail in Chicago, which now accounts for a whopping 15.7 percent of all COVID cases in the state of Illinois. Some places, like Colorado’s Weld County, are managing outbreaks across all three types of superspreader facilities.

The graphic above highlights the nearly 260 counties that we’ve termed “triple-threat counties”: those which have all three types of superspreader facilities. The counties are mapped using our Gist Healthcare COVID-19 Risk Factor Index, which identifies particularly vulnerable populations using chronic disease, demographic, and acute care access variables.

The top 10 “triple-threat counties” by risk index score are all in more rural areas of the country with limited acute care access and more vulnerable populations—places where a COVID outbreak is likely to be particularly devastating. Seven of the 10 have a high percentage of African-American or Hispanic/Latino residents, groups with a an outsized burden of COVID-19 illness and death. These risk factors are intersectional; for example, food processing plants employ twice as many Hispanic workers as the national average, and a disproportionate share of long-term care workers are black.

[Click here for more information and interactive data from our analysis of the risk impact of these superspreader facilities.]

 

 

 

 

66% of counties with most COVID-19 cases lack infectious disease physician

https://www.beckershospitalreview.com/infection-control/66-of-counties-with-most-covid-19-cases-lack-infectious-disease-physician.html?utm_medium=email

About 208 million Americans are living in counties with no or very few infectious disease physicians, and many of these areas have been hit hardest by COVID-19, according to a study published in Annals of Internal Medicine.

Researchers determined the density of infectious disease physicians in every U.S. county using 2017 Medicare Provider Utilization and Payment Data. They also used aggregated data from the CDC and local public health agencies to plot the rate of confirmed COVID-19 cases in each county as of May 12.

Four study findings:

1. Of the 3,142 total counties in the U.S., 79.5 percent did not have a single infectious disease physician.

2. Among 785 counties with the highest burden of COVID-19 cases, 66 percent did not have an infectious disease physician working in the county.

3. About 9.9 percent of counties had an infectious disease physician density below the national average of 1.76 physicians per 100,000 population.

4. Only 10.5 percent of counties had an infectious disease physician density above the national average.

“The deficits in our [infectious disease] physician workforce today have left us poorly prepared for the unprecedented demand ahead,” study authors said, highlighting telemedicine as a key strategy for expanding access to this speciality.

To view the full study, click here.

 

 

 

 

A Third of Unemployment Benefits Haven’t Been Paid Out: Report

https://www.thefiscaltimes.com/2020/06/02/Third-Unemployment-Benefits-Haven-t-Been-Paid-Out-Report

A Third of Unemployment Benefits Haven't Been Paid Out: Report

The U.S. Treasury paid out $146 billion in jobless benefits in the three months ending in May as tens of millions of Americans lost their jobs due to the coronavirus pandemic. Although the number is massive – larger than all of the unemployment benefits provided during the depths of the Great Recession in 2009 – it’s smaller than it should have been, according to a new analysis by Bloomberg News. Crunching the numbers on weekly unemployment filings and average claim size, Bloomberg found that total jobless benefits should have come to roughly $214 billion during that time.

“The estimated gap of some $67 billion shows how emergency efforts to boost payments, and deliver them via creaking state-level systems, are lagging the needs of a jobs crisis that’s seen more than 40 million people file for unemployment as the economy shut down,” Bloomberg’s Shawn Donnan and Catarina Saraiva wrote Tuesday.

A tough calculation: Although it’s hard to put a precise number on the shortfall – the Labor Department pushed back against the method used by Bloomberg to develop its estimate – there is general agreement that there are many people who still haven’t received the unemployment assistance they are entitled to. “There’s a lot more money that should have gone out that has not gone out,” said Jay Shambaugh, an economist at the Brookings Institution who has been studying the issue.

And Bloomberg says its analysis likely provides a conservative estimate of the shortfall. Some states are still working through backlogs of unemployment claims – Texas alone is waiting to verify nearly 650,000 cases – and more than 7 million people are still owed retroactive benefits under the Pandemic Unemployment Assistance program for independent contractors.

Why it matters: In addition to the unnecessary suffering the delays are causing, the shortfall is reducing the positive economic effect that unemployment benefits are intended to provide. “On paper the U.S. strategy is very generous,” Ernie Tedeschi, a former U.S. Treasury economist now at Evercore ISI, told Bloomberg. “But that generosity on paper is meaningless if it doesn’t translate into actual money in people’s pockets when they need it.”

Diane Swonk, chief economist at the accounting firm Grant Thornton, said she is worried that lawmakers are experiencing “fiscal fatigue” as the crisis wears on, risking a falloff in aid that could prolong the recession. “We’re really talking about an economy that is going to be operating at a fraction of its capacity for a long period of time,” she told Bloomberg.

 

 

 

 

The Value of Home Health Care

https://morningconsult.com/opinions/the-value-of-home-health-care/?utm_source=ActiveCampaign&utm_medium=email&utm_content=Does+the+US+Spend+Too+Much+on+Police%3F&utm_campaign=TFT+Newsletter+06042020

5 Truths About Home Health Care

For the first time in our modern history, staying at home has become a “new” normal. And with more than 1.5 million Americans now infected with COVID-19, never before in our lifetime has accessing care in a person’s home been so important.

Smartly, our federal and state policymakers quickly expanded reimbursement for telehealth and removed barriers that have now allowed more providers to care for patients virtually via video and phone, eliminating the risk of COVID-19 exposure during provider visits. But not all care can be provided through telehealth – and we would be shortsighted to not also address the growing need for home-based care.

Long before the COVID-19 emergency, health care policy experts have increasingly recognized the value of home-based health care. A recent AARP survey found that three in four adults 50 years and older would prefer to age in their homes and communities. And a growing body of evidence suggests it is less expensive to deliver care in the home. Indeed, for years we’ve seen hospitalized patients more quickly returning to their homes and communities to heal and recover safely, reducing costs for themselves and the health care system.

Home-based care addresses some of the negative health effects of social isolation and loneliness, which drive poorer health outcomes that annually cost billions of excess health care dollars. According to one study, those experiencing loneliness and social isolation had a more than 60 percent higher risk of developing dementia and a fourfold increase in hospital readmission rates within a year of discharge.

Despite its demonstrated value, our country has yet to fully integrate the support needed for home-based care. Instead, we have a collage of different reimbursement frameworks across state, federal, and private payers.

Traditionally, Medicare has paid only for home caregivers in very limited circumstances. But we’re now seeing small and promising changes. The Medicare Advantage program, for example, now allows plans to offer non-medical care services in the home as supplemental benefits. These benefits can include day care services, in-home support services including meals and support for caregivers.

We have also seen a surge of technologies to enable home-based care. From those receiving home infusion therapies, to home dialysis, to remote patient monitoring, the private sector has stepped up to meet the needs of those wanting to or needing to receive care at home.

Now is the time to expand on these promising changes with a more comprehensive approach to paying for home-based care delivery. With more thoughtful integration of caregiving services and improved care coordination across care settings, including the home, such models can drive down health care costs for patients and the system overall.

Whether caring for those impacted by our current public health crisis, or those who are medically homebound, or those who simply choose to age in place, policymakers should think beyond essential medical services and consider the non-medical drivers of health that are often as essential to good health outcomes. For example, many individuals needing to stay at home are ill-equipped to carry out their own basic needs. Daily tasks — such as getting in and out of a chair or bed, moving about the house, shopping and preparing meals, taking medications properly, bathing and dressing, and cleaning and laundry — can be a struggle for the elderly and those with serious health conditions.

Fortunately, we have millions of home health nurses and caregivers working on the front lines to care for vulnerable adults who should safely remain in their homes during this pandemic and beyond.

These workers are the foot soldiers who perform tasks such as shopping, meal preparation and assisting with mobility and personal care. Well-trained caregivers and nurses, sensitive to the time and place where patients actually live, can more readily identify and address issues that can exacerbate a person’s chronic, complex illness that may not otherwise be visible in a single visit to a traditional health care setting.

As we face record unemployment, federal, state and local policymakers should consider how best to utilize this untapped resource both now and in the future. With the appropriate testing, training, and reimbursement, individuals can have a choice in where they age and receive care.

While keeping people safe and healthy in their homes has always been appealing, now it is imperative. For our most vulnerable individuals — the elderly and those with chronic health conditions – home-based care can save their lives.

 

 

 

CDC director: US needs up to 100,000 contact tracers by September to fight coronavirus

https://thehill.com/policy/healthcare/501157-cdc-director-us-needs-30-to-100-thousand-contact-tracers-by-september-to?utm_source=ActiveCampaign&utm_medium=email&utm_content=Does+the+US+Spend+Too+Much+on+Police%3F&utm_campaign=TFT+Newsletter+06042020

CDC director: US needs up to 100,000 contact tracers by September to fight coronavirus

Centers for Disease Control and Prevention (CDC) Director Robert Redfield told Congress on Thursday that the country needs between 30,000 and 100,000 people working on contact tracing in order to help contain the next wave of the coronavirus.

The estimate shows the daunting challenge of hiring an army of people to interview those infected with coronavirus to identify who they have been in contact with so that those people can quarantine and help prevent the spread of the virus.

“I’ve estimated between 30 and 100,000” contact tracers are needed,” Redfield told the House Appropriations Committee during a hearing Thursday. He acknowledged the figure is “sizable,” though it is actually less than the 300,000 people former CDC director Tom Frieden has estimated the U.S. will need.

He said it is crucial to get the contact tracing system in place by September to try to keep the virus in check ahead of an expected surge in the fall and winter. That could help prevent the type of blunt stay-at-home orders that the U.S. had to implement this spring after missing the window to contain the virus earlier this year.

“We really have to get this built and we have to get it built between now and September,” Redfield said.

Redfield said his agency has met with all 50 states to discuss hiring contact tracers and is pleased that some states have already started to do so. New York City, for example, has hired 1,700 contact tracers. 

He said the CDC Foundation is working to hire personnel to augment state efforts and the CDC has distributed funding to states provided by Congress for the purpose. He added he hopes AmeriCorps is a source of additional staff.

“It is fundamental that we have a fully operational contact tracing workforce that every single case, every single cluster, can do comprehensive contact tracing within 24 to 36 hours, 48 hours at the latest, get it completed, get it isolated, so that we can stay in containment mode as we get into the fall and winter of 2020,” he said.