U.S. Still in First Wave of COVID-19, Fauci Says

https://www.webmd.com/lung/news/20200925/us-still-in-first-wave-of-covid-19-fauci-says

US still in first Covid-19 wave and should be prepared for 'challenge' of  fall and winter, Fauci says

Anthony Fauci, MD, says talk about a second wave of the coronavirus is premature because the United States is still dealing with the first one.

The idea of a second wave is based on the 1918 flu pandemic, when many cases were seen in the spring, he says. The spring cases “literally disappeared” and were followed by a spike in flu cases in the fall, he told CNN’s Sanjay Gupta, MD, on Thursday in an online conversation organized by Emory University.

“Rather than say, ‘A second wave,’ why don’t we say, ‘Are we prepared for the challenge of the fall and the winter?’” said Fauci, director of the National Institute of Allergy and Infectious Diseases and a member of the White House coronavirus task force.

Flu shots are an important measure to help the U.S. get through the winter, he said.

He and other health care professionals have observed that the Southern Hemisphere has had a very light flu season, probably because measures to curb the coronavirus, such as social distancing and mask-wearing, have limited the spread of the flu.

“If we listen to the public health measures, not only would we diminish the effect of COVID-19, we might get away with a very, very light flu season if we combine that with getting the flu vaccine,” Fauci said.

In a separate interview, he said the arrival of the coronavirus vaccine will not stop the need for tried-and-true measures such as mask-wearing, hand-washing, and social distancing.

In a Facebook Live conversation with New Jersey Gov. Phil Murphy, Fauci said the coronavirus vaccine will not be 100% effective and won’t be taken by the entire population. That means the virus could still spread.

“So when a vaccine comes, we look at it as an important tool to supplement the public health measures that we do,” he said. “It will allow us to more quickly and with less stringency get back to some degree of normal. But it is not going to eliminate the need to be prudent and careful with our public health measures.”

Fauci said that vaccinating 75% to 80% of the population “would be a really good accomplishment.” He expects 700 million doses to be produced by the end of this year or early 2021.

 

 

 

 

Moody’s: Hospital financial outlook worse as COVID-19 relief funds start to dwindle

https://www.fiercehealthcare.com/hospitals/moody-s-hospital-financial-outlook-worse-as-covid-19-relief-funds-start-to-dwindle?mkt_tok=eyJpIjoiWTJZek56Z3lNV1E0TW1NMyIsInQiOiJKdUtkZE5DVGphdkNFanpjMHlSMzR4dEE4M29tZ24zek5lM3k3amtUYSt3VTBoMmtMUnpIblRuS2lYUWozZk11UE5cL25sQ1RzbFpzdExcL3JvalBod3Z6U3BZK3FBNjZ1Rk1LQ2pvT3A5Witkc0FmVkJocnVRM0dPbFJHZTlnRGJUIn0%3D&mrkid=959610

For-profit hospitals are expected to see a financial decline over the next 12 to 18 months as federal relief funds that shored up revenue losses due to COVID-19 start to wane, a recent analysis from Moody’s said.

The analysis, released Monday, finds that cost management is going to be challenging for hospital systems as more surgical procedures are expected to migrate away from the hospital and people lose higher-paying commercial plans and go to lower-paying government programs such as Medicaid.

“The number of surgical procedures done outside of the hospital setting will continue to increase, which will weaken hospital earnings, particularly for companies that lack sizeable outpatient service lines (including ambulatory surgery centers),” the analysis said.

A $175 billion provider relief fund passed by Congress as part of the CARES Act helped keep hospital systems afloat in March and April as volumes plummeted due to the cancellation of elective procedures and reticence among patients to go to the hospitals.

Some for-profit systems such as HCA and Tenet pointed to relief funding to help generate profits in the second quarter of the year. The benefits are likely to dwindle as Congress has stalled over talks on replenishing the fund.

“Hospitals will continue to recognize grant aid as earnings in Q3 2020, but this tailwind will significantly moderate after that,” Moody’s said.

Cost cutting challenges

Compounding problems for hospitals is how to handle major costs.

Some hospital systems cut some costs such as staff thanks to furloughs and other measures.

“Some hospitals have said that for every lost dollar of revenue, they were able to cut about 50 cents in costs,” the analysis said. “However, we believe that these levels of cost cuts are not sustainable.”

Hospitals can’t cut costs indefinitely, but the costs for handling the pandemic (more money for personal protective equipment and safety measures) are going to continue for some time, Moody’s added.

“As a result, hospitals will operate less efficiently in the wake of the pandemic, although their early experiences in treating COVID-19 patients will enable them to provide care more efficiently than in the early days of the pandemic,” the analysis found. “This will help hospitals free up bed capacity more rapidly and avoid the need for widespread shutdowns of elective surgeries.”

But will that capacity be put to use?

The number of surgical procedures done outside of the hospital is likely to increase and will further weaken earnings, Moody’s said.

“Outpatient procedures typically result in lower costs for both consumers and payers and will likely be preferred by more patients who are reluctant to check-in to a hospital due to COVID-19,” the analysis said.

The payer mix will also shift, and not in hospitals’ favor. Mounting job losses due to the pandemic will force more patients with commercial plans toward programs such as Medicaid.

“This will hinder hospitals’ earnings growth over the next 12-18 months,” Moody’s said. “Employer-provided health insurance pays significantly higher reimbursement rates than government-based programs.”

Bright spots

There are some bright spots for hospitals, including that not all of the $175 billion has been dispersed yet. The CARES Act continues to provide hospitals with a 20% add-on payment for treating Medicare patients that have COVID-19, and it suspends a 2% payment cut for Medicare payments that was installed as part of sequestration.

The Centers for Medicare & Medicaid Services also proposed increasing outpatient payment rates for the 2021 fiscal year by 2.6% and in-patient rates by 2.9%. The fiscal year is set to start next month.

Patient volumes could also return to normal in 2021. Moody’s expects that patient volumes will return to about 90% of pre-pandemic levels on average in the fourth quarter of the year.

“The remaining 10% is likely to come back more slowly in 2021, but faster if a vaccine becomes widely available,” the analysis found.

 

 

 

 

Bill Gates: U.S. Needs To ‘Own Up To The Fact That We Didn’t Do A Good Job’

https://www.forbes.com/sites/mattperez/2020/09/20/bill-gates-us-needs-to-own-up-to-the-fact-that-we-didnt-do-a-good-job/?utm_source=newsletter&utm_medium=email&utm_campaign=coronavirus&cdlcid=5d2c97df953109375e4d8b68#54d6544f3fb8

TOPLINE

The United States needs to “own up to the fact that we didn’t do a good job” up until this point of the Covid-19 pandemic, billionaire and philanthropist Bill Gates said during a Fox News Sunday interview, adding that the slow turnaround for testing results remains “outrageous.”

KEY FACTS

“Unfortunately we did a very poor job and you can just see that in the numbers,” Gates said.

Despite having around 4% of the world’s population, the U.S. has around 22% of all cases with 6,782,083 and about 21% of all reported deaths with 199,411.

The inability to create a testing structure as seen in countries like South Korea “led to us having not just a bad spring, we’ve had a pretty tough summer and sadly because of the seasonality, until we get these new tools, the fall is looking to shape up as pretty tough as well,” Gates said.

“Part of the reluctance I think to fix the testing system now is that nobody wants to admit that it’s still outrageous,” Gates said, adding, “The U.S. has more of these machines, more capacity than other countries by a huge amount, and so partly the reimbursement system is creating perverse incentive.”

After remaining fairly stagnant through the end of summer into September, the U.S. performed a record 1,061,106 Covid-19 tests on Saturday, according to Johns Hopkins University, but labs are still dealing with supply shortages and delays in results.

“We’ll have time to look at those mistakes, which in February and March were really super unfortunate, but we can’t pretend like we get a good grade even today,” Gates said.

CRUCIAL QUOTE

“Even today, people don’t get their results in 24 hours, which it’s outrageous that we still have that,” Gates said.

BIG NUMBER

4.7%. That’s the average positivity percentage in the past week, according to Johns Hopkins.

TANGENT

President Trump has excused the world-leading cases of the coronavirus as a result of the number of tests performed in the country, even saying that he instructed officials to slow testing down. The Centers for Disease Control and Prevention sparked outrage in August when it published new guidelines on testing, recommending people exposed to the virus but not showing symptoms should not get tested. Reports indicate that the guidance was dictated by the Health and Human Services and Trump administration as opposed to CDC scientists. The guidelines were changed again on Friday.

 

 

 

 

The N95 shortage America can’t seem to fix

https://www.washingtonpost.com/graphics/2020/local/news/n-95-shortage-covid/?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most

Nurses and doctors depend on respirator masks to protect them from covid-19. So why are we still running low on an item that once cost around $1?

The patient exhaled. She lifted her tongue for a thermometer. She raised her finger for a blood sugar test, and that’s when she started coughing. One cough can send 3,000 droplets into the air, one droplet can contain millions of coronavirus particles, and now some of those particles were heading for the face of emergency department nurse Kelly Williams.

The nurse inhaled. Strapped over her mouth and nose was an N95 respirator, the disposable filtering mask that has become the world’s most reliable and coveted defense against the virus.

N95s were designed to be thrown away after every patient. By this July afternoon, Williams had been wearing the same one for more than two months.

To get to her, the N95 had traveled from a British factory to a Baltimore warehouse, in a supply chain as tangled and layered as the web of microscopic fibers inside the mask’s filter.

It was purchased by Johns Hopkins Hospital, the famed medical institution that has tracked cases of the novel coronavirus around the world since the pandemic’s start. When its map of dots marking clusters of infections began to show pools of red across the United States, Hopkins was quietly unpacking a stock of personal protective equipment it had been building for over a year — a literal lifesaver when the onslaught of covid-19 cases led to a massive shortage of N95s.

Six months later, that shortage persists, leaving health-care workers exposed, patients at risk and public health experts flummoxed over a seemingly simple question: Why is the world’s richest country still struggling to meet the demand for an item that once cost around $1 a piece?

At Hopkins, nurses are asked to keep wearing their N95s until the masks are broken or visibly dirty. Williams, a 30-year-old from Georgia with a marathoner’s endurance and a nurse’s practicality, went into health care after working for three years in the corporate offices of retailers Abercrombie & Fitch and Under Armour. She understood supply chains. She believed that the makers of N95s, anticipating the pandemic’s eventual end, would invest only so much in expanding production. She believed it was her duty, on top of risking her life for her patients, to make her disposable respirator mask last through as many 12-hour shifts as she could.

When the country was short of ventilators, the companies that made them shared their trade secrets with other manufacturers. Through the powers of the Defense Production Act, President Trump ordered General Motors to make ventilators. Other companies followed, many supported by the government, until the terrifying problem of not enough ventilators wasn’t a problem at all.

But for N95s and other respirators, Trump has used this authority far less, allowing major manufacturers to scale up as they see fit and potential new manufacturers to go untapped and underfunded. The organizations that represent millions of nurses, doctors, hospitals and clinics are pleading for more federal intervention, while the administration maintains that the government has already done enough and that the PPE industry has stepped up on its own.

As the weather cools and the death toll climbs, America’s health-care workers fear that when winter comes, they still won’t have enough respirators. And the longer the shortage lasts, the longer N95s will remain largely out of reach for millions of others who could be protected by them — teachers and day-care workers, factory employees and flight attendants, restaurant servers and grocery store clerks.

While the pandemic that has killed almost 200,000 Americans drags on, Williams will keep trying to conserve her respirator, wearing it as she rushes in and out of virus-filled rooms, touches virus-shedding patients, and now, comforts a covid-positive woman who is having a coughing fit.

“How can I help you feel a little more comfortable?” Williams asked her patient, who was in her 80s. The woman was about to be admitted to the hospital. Her oxygen level was too low, so they had to run tubes of air into her nostrils. If her situation didn’t improve, a ventilator could come next.

This was the routine in the part of the emergency department Williams called “Covidland.” She’d just risked exposure to care for this woman, but she would never get to find out what happened to her.

She could only take a deep breath through her N95, roll her patients upstairs and hope that she would never become one of them.

‘The gauntlet’

Before the N95 was on her face, it was in a plastic wrapper, in a box, on a shelf inside an East Baltimore warehouse four miles from the hospital. The 165,000-square-foot building had concrete floors, rolling doors, overhead lighting — unremarkable, except to a man named Burton Fuller.

Fuller, a 38-year-old father of three, had once planned on becoming a doctor. Instead, he went into hospital supply chains. It was the kind of job that didn’t earn many follow-up questions at dinner parties. But six months after Fuller was hired at Hopkins, the pandemic made him the person that everyone relied on and no one envied. It was up to him to keep 40,000 employees in six hospitals safe.

Even before covid-19, masks were key to that equation. There are surgical masks, which protect a patient from a nurse’s germs, and respirator masks, which protect a nurse from the patient. Humans have recognized the need for protective masks since at least A.D. 77, when Pliny the Elder wrote about wearing animal bladders as face coverings to make breathing easier in lead-filled mines.

The evolution of early masks brought leather beaks stuffed with straw and herbs to ward off the bubonic plague, and long beards that firefighters would wet and clamp between their teeth. Once the far more effective gas mask became standard for coal miners breathing in silica and soldiers facing chemical weapons, engineers at the Minnesota Mining and Manufacturing Company, better known as 3M, started trying to make a protective respirator that wasn’t so bulky. They realized in the 1960s that the technology used to make pre-made gift bows could also make a mask that was a lightweight, molded cup. And so began the single-use respirator as it exists today.

Inside that cup, and more recently, inside the flat-fold versions, is the key component: fibers 1/50th the width of a human hair, blown together in an intricate web that creates an obstacle course for dangerous particles. An electrostatic charge works like a magnet to trap the floating menaces and attach them to the fibers. If an N95 is fitted properly — a metal nose piece folded snugly, no beard in the way — less than 5 percent of even the most difficult-to-catch particles will make it into the lungs.

At Hopkins, Fuller’s job was to get manufacturers to deliver N95s and other equipment directly to the warehouse, rather than through a distributor. In 2019, the shelves started to fill up, and on one of them was the N95 that would make its way to nurse Kelly Williams. The respirator had been made by 3M at a plant in Aycliffe, a town of 7,000 in northern England.

But this Hopkins stockpile was rare in the world of hospitals, where costs were cut by using medical supply companies to provide equipment when it was needed, rather than letting PPE pile up.

Hospital administrators knew that in cases of natural disaster, chemical warfare or what global health officials used to call “Disease X,” the federal government had its own warehouses in secret locations, filled with PPE.

Except that in 2009, while Fuller was in his first job out of college, the H1N1 flu epidemic depleted 85 million N95s from the national stockpile — and the supply was never replenished. In 2013, 2014, 2016 and 2017, public health officials published alarming reports warning of a “massive gap” in what remained. Even more concerning, they said, the vast majority of N95s and the materials needed to manufacture them were now being made in Asia.

The Department of Health and Human Services did fund the invention of a “one-of-a-kind, high-speed machine” that could make 1.5 million N95s per day. But when the design was completed in 2018, the Trump administration did not purchase it.

This year, as the virus spread from Wuhan to Washington state, HHS turned down a January offer from a manufacturer who could make millions of N95s. The agency didn’t start ordering N95s from multiple companies until March 21. Paul Mango, deputy chief of staff for policy at HHS, would later call that timeline “friggin’ light speed … the fastest this has ever been done.”

By then, the United States had 8,000 reported coronavirus cases and 85 deaths, and health-care workers were panicking over PPE shortages.

Fuller’s orders began being canceled. As the Hopkins emergency department was being readied for covid-19 patients, and Williams was being told she would need to start wearing an N95, the hospital’s administration decided not to reveal how many N95s were in the warehouse.

“Only a half a dozen people know,” Fuller said. “Behavioral economics say that if we communicate a number someone perceives as high, they will use the supply more gratuitously. If we communicate a number they perceive as low, they may hoard to ensure there is enough.”

As the boxes of N95s were loaded into trucks headed for Hopkins hospitals, Fuller and a dozen staff members entered what he would come to call “the gauntlet.” Every hospital and health department in the country was competing for N95s and other PPE, a mess of bidding wars, price gouging and worthless knockoff masks. Fuller uncovered one scam when a company CEO, claiming to be based in Indianapolis, didn’t recognize the name of the city’s most famous steakhouse.

“For every mask shipment we have been able to bring in,” Fuller said, “there are 10 or 15 transactions we have had to terminate.”

He worked so much that his wife, home with their children, received flowers from Hopkins executives. He joked about the other crucial stockpile in his life, his wine collection.

Fuller was desperate to make the stockpiled N95s last as long as possible. He wanted every employee wearing one to also wear a face shield, but those, too, were impossible to find.

So at the end of March, the warehouse filled with folding tables spaced six feet apart. Volunteers were given foam strips, elastic straps and sheets of plastic to make homemade shields. At one of the most prestigious medical institutions in the country, they were trying to fix the problem for themselves, with scissors, staplers and hot glue guns.

‘Bracing yourself’

A face shield was clipped to Williams’s belt in the middle of May, when for only the fourth time during the pandemic, she unwrapped a new N95.

After nine weeks in and out of Covidland, she had come to trust in her disposable respirator. It hurt her nose, gave her acne and made breathing hard. But the power of its protection was starting to give her back the feeling of safety she’d lost in March when she and the dozens of colleagues who worked alongside her each shift watched the areas where they’d cared for gunshot victims and heart attack patients turn into isolation rooms. They were tested to make sure the N95s fit their faces and taught to use other respirators that looked like gas masks or blew clean air into a hood.

And then, they were slammed. The first covid patient to go on a ventilator at Hopkins was a 40-year-old who worked out every day. The ambulance bay became a testing center. Williams’s co-workers were crying in the break room. Her patients couldn’t breathe, and then tubes were going down their throats, and then it felt like she couldn’t breathe, like everything she knew about nursing would never be enough.

“Our lives changed overnight,” she said. “You’re bracing yourself for people to die.”

She started silently saying a prayer she knew, every morning, every few hours, then sometimes 20 times a day in Covidland.

God, grant me the serenity to accept the things I cannot change, it began. She said it before her patient started violently shaking and flailing, seizing in his bed. She couldn’t run out the door to ask for help, because to leave the room without potentially taking the virus out, she had to sanitize her gloves, trash them, take her gown off, trash it, exit into an antechamber, take off her first layer of gloves, sanitize her hands and wipe down her face shield. So she ran to the window and banged on it, then ran back to her patient, trying to hold him down, her face inches from his.

Courage, to change the things I can, the prayer continued. Williams said it in the car that she drove to work and wouldn’t let any member of her family touch. Its speakers blared Lizzo-filled playlists she used to pump herself up for what she told her friends was an “awesome learning experience.” She had been a nurse for only two years. Her job in merchandising at Under Armour had brought her to Baltimore, where she met her husband, Sean, and his two children. They were the ones to make her realize that she wanted a job where she could actually see the impact of all those hours she worked. Now, every day might be the day she took the virus home to them.

Grant me the serenity to accept the things I cannot change, courage, to change the things I can, and wisdom to know the difference. Another day in Covidland, and Williams was wearing her new N95, pumping her palms into an unconscious man’s chest, not thinking of all the particles flying out of his airways. Another, and her face shield popped off and clattered to the floor. Another, and a young Latina mother told Williams she couldn’t self-quarantine because she could not afford to stay home from work.

Another, and Williams was watching the chest of a middle-aged man rise and fall by the force of a ventilator. Outside the walls of the hospital on this day in July, America seemed to have moved on from the conversation about the shortage of N95s. Instead, people were fighting over simple cloth masks.

Maybe this patient had worn one. Maybe he’d said he didn’t believe in them. Either way, it was her job to take care of him. Williams suctioned virus-filled fluid from his airways, and breathed in again.

‘Not profitable’

The radio advertisements could be heard across South Dakota, playing inside cars passing billboards plastered with the same message: 3M is hiring in Aberdeen. In a state that hosted 460,000 people at an August motorcycle rally and requires no one to wear a mask sits the largest respirator plant in the United States.

Its N95 manufacturing lines have been running 24 hours a day, 7 days a week since Jan. 21, the same day public health officials announced the arrival of the coronavirus in Washington state.

Plant manager Andy Rehder hired 200 new employees this year and was still looking for more this summer so he could staff another N95 line being built. Rehder, whose wife wears an N95 as a hospital social worker, had a Bloomberg Magazine article from March displayed in his office. The headline asked, “How do you make more masks yesterday?”

The question still hangs over the plant, and the entire country, nearly six months after that article was published.

Ask the Trump administration, and the N95 shortage is nearly solved. Rear Adm. John Polowczyk, whom Trump put in charge of securing PPE, said that by December, 160 million N95s will be made in the United States per month. By his calculations, that will be enough to handle a “peak surge” from hospitals, clinics, independent physicians, nursing homes, dentists and first responders. The Strategic National Stockpile has 60 million N95s on hand, and states are rebuilding their stockpiles.

“I’ve got production up to what we think is the limits of what we need,” Polowczyk said. “I believe now that hospital systems are making management decisions that might lead to an appearance that we still don’t have masks, which is the farthest from the truth.”

But ask the people inside hospitals, and the shortage is far from over. An August survey of 21,500 nurses showed 68 percent of them are required to reuse respirators, many for more than the five times recommended by the CDC, and some even more than Kelly Williams. One Texas nurse reported she’s still wearing the same five N95s she was given in March.

Many health-care facilities that ordered KN95s, Chinese-made masks meant to have a similar filtering efficiency, gave up on them after realizing that the looser fit left workers in danger. The N95 shortage is more acute for primary care physicians, home health aides and hospice workers. But even for many hospital systems, the situation remains “fragile and challenging,” the American Hospital Association said this month.

“Maddening, frustrating, mind-blowing, aggravating, that’s the polite language for it,” said American Medical Association President Susan Bailey, who still hears from doctors who do not have respirators. “There has been such an outpouring for support for ‘health-care heroes.’ Everybody knows now how important it is for our front-line health-care workers to be able to work in a safe environment. … And yet, that desire doesn’t seem to be turning into a reality.”

The AMA, AHA, American Nurses Association and the AFL-CIO all point to the same solution: broader use of the Defense Production Act, which gives the president power over funding for the production and distribution of critical supplies during crises.

In August, Trump stood before a group of socially distanced reporters, praising himself for using the DPA “more comprehensively than any president in history.”

“There was a time,” he said, “when the media would say, ‘Why aren’t you using it? Why aren’t you using it?’ Well, we have used it a lot, where necessary. Only where necessary.”

That’s not what it looks like to the man who used to run Trump’s DPA program within the Federal Emergency Management Agency. Larry Hall, who retired last year, said the authority has been executed in an “ad hoc, haphazard fashion.”

Along with ordering 3M to import 166.5 million masks from China, the administration has used the DPA to invest $296.9 million in bolstering the N95 and filter-making supply chains. The Department of Defense, which oversees that funding, spends more per year on instruments, uniforms and travel for military bands.

“By not having a national strategy,” Hall said, “we have fewer masks.”

Ask the PPE industry and the refrain is that without long-term guarantees that the government will keep buying respirators, N95 manufacturers are wary of investing too much, and other companies that could start making respirators or the filters for them are hesitant to do so.

Peter Tsai, the scientist who invented a method to charge the fibers inside the respirator filter, knows why: “It is not profitable to make respirators in the United States,” he said. It can take six months just to create one manufacturing line that makes the N95′s filter.

But there is a workaround, Tsai said. Companies that already make similar filters — for vehicle emissions, air pollution and water systems — can modify their equipment to make N95 filters.

While Tsai, 68, has been fielding hundreds of calls from hospitals and researchers trying to sanitize N95s with heat and ultraviolet light, he has been working with Oak Ridge National Laboratory in Tennessee to woo the 15 to 20 American companies that have the potential to produce respirator filters more quickly.

The government has funded just three of these companies through the DPA.

Others have gradually joined in on their own. But then those filters have to be made into respirators, and those respirators have to be approved by NIOSH, the National Institute for Occupational Safety and Health.

The entire process has moved at a glacial pace in comparison with the flurry of activity that rid the country of its ventilator shortage. Ventec, a company known for its efficient, toaster-size ventilators, handed its plans over to General Motors so that the auto company, under the DPA, could mass produce a product that was known to work. Other ventilator companies followed, handing over their trade secrets to Ford, Foxconn and other major manufacturers.

But when GM started making N95s, engineers with expertise in car interiors and air bags were charged with figuring out the process from scratch, the company said. Although they received advice from major mask makers, there were no groundbreaking corporate partnerships this time. The first N95s GM made were rejected by NIOSH. The second design didn’t correctly fit most people.

Other potential manufacturers went through the same challenges as GM, failing tests and making flat-fold N95s that experts worry do not offer a tight enough seal.

“If there was some kind of intellectual sharing, they wouldn’t be doing that,” said Christopher Coffey, who was the associate director for science in the NIOSH approvals program before retiring in January.

The DPA does have a provision that would allow manufacturers to work together without being subject to antitrust laws. But it has yet to be used for N95s.

Instead, established U.S. makers of N95s, whose products have been successfully protecting miners, construction workers and health-care professionals for decades, have continued to protect their processes as intellectual property.

Though 3M helped Ford make the far more expensive powered respirators, which blow clean air into a hood, the company has not entered into any major partnerships with outside manufacturers to make N95s. Asked why, 3M declined to explain, instead pointing to its other pandemic partnerships.

Ford gained its own approval to manufacture disposable respirators but has made just 16,000 of them while focusing instead on face shields and surgical masks. Other major U.S. manufacturers of N95s, including Honeywell and Moldex, have kept their manufacturing in-house, too.

“Folks aren’t likely to share that information outside of their own company,” said Jeff Peterson, who now oversees NIOSH approvals. NIOSH employees may know how 3M makes its respirators and the filters inside them. But by contract, they can’t tell other manufacturers how to do the same.

Meanwhile, 3M continues to dominate the American N95 market. While other parts of its business, such as office supplies and industrial adhesives, have struggled during the pandemic, 3M has invested $100 million to expand domestic production of respirators from 22 million to 50 million per month. Once the new production line is up and running in South Dakota in October, that number is expected to reach 95 million per month in the United States.

It still won’t be enough.

“Even though we are making more respirators than ever before and have dramatically increased production,” 3M spokeswoman Jennifer Ehrlich said, “the demand is more than we, and the entire industry, can supply for the foreseeable future.”

‘I just don’t get it’

Her N95 was already on, but Williams’s hands were slipping as she tried to force on a pair of gloves. She could hear the alarms going off. One of her patients was crashing, and she had to get into the room.

She should be able to just go, her runner’s legs carrying her to the bedside. But in Covidland, there were two closed doors standing in her way. She had started wearing her N95 all day so she could be ready for this moment. She pulled on her gown and another set of gloves and her face shield, reached for the door — and realized the patient inside was her 13-year-old stepson Kellen.

She jolted awake. She was in her bed. Her husband was asleep beside her. She slid out from her sheets and went downstairs to check on her stepchildren. Kellen and 19-year-old Alle were sleeping, too.

The nurse inhaled. She could still hear the alarms.

This is what it meant now, to be a health-care worker: across the country, nurses and doctors were reporting increased sleeplessness, anxiety, depression and post-traumatic stress.

Williams reminded herself that she’d always had an N95, and the heavier, more protective respirators she sometimes wore instead.

But she knew, too, that covid-19 had taken the lives of more than 1,000 health-care workers, including a New Jersey primary care doctor who, determined to keep his practice open, doubled up on surgical masks when his N95 orders didn’t come. And a California nurse who rushed into a covid patient’s room to perform chest compressions. She saved his life, then doused her hair in hand sanitizer. She hadn’t been given an N95 at the beginning of her shift.

And then there was the news that shook every health-care worker Williams knew: Less than two miles from Hopkins, the head of the ICU at Mercy Hospital died after contracting the virus in July.

Joseph Costa was one of the people who’d guided the hospital through its PPE shortage early in the pandemic. His husband, David Hart, remembered him coming home and saying, “This is my mask for the week.” Neighbors pushed N95s through their mailbox slot.

“This is the United States of America, and we can’t seem to get factories built to deliver this stuff? I just don’t get it,” Hart said.

He will never know exactly how his husband, who insisted on caring for covid patients alongside his staff, became infected. Costa died in the ICU, the gloved hands of his colleagues on him as he went. Minutes later, they returned to caring for other patients.

At Mercy, at Hopkins, at every hospital that had found a way to get N95s, health-care workers wore their PPE to try to save the lives of people who contracted the virus because they had none.

Williams and her colleagues didn’t need to see the statistics to know that the pandemic was disproportionately affecting Black and Brown people, especially those deemed essential workers. They saw it in their patients and heard it from their families and friends.

Williams worked side by side with Shanika Young, a nurse whose brother seemed to have every known covid-19 symptom before he started to recover.

Afraid of infecting anyone in her community, Young went weeks without seeing her parents and newborn niece. She adopted a hound-mix puppy to have a friend when she couldn’t see her own. In the weeks that followed the killing of George Floyd, she agonized over her decision to stay away from the protests. She knew there wouldn’t be N95s there.

On a sweltering August morning, she left her dog in her apartment and packed her respirator in her car. She, too, re-wore her mask, but usually for four or five 12-hours shifts.

Now Young was taking it across Baltimore, not toward the hospital, but to a predominantly Hispanic neighborhood with one of the worst infection rates in the city.

During the pandemic, Baltimore has seen outbreaks in its homeless shelters, its trash-collecting facility and its jail. Now every place Young drove by fell on one side or the other of a new dividing line in America: those who have PPE and those who don’t. Bodegas, restaurants, nail salons and funeral homes. Downtown, a nonprofit’s dental clinic remained shuttered. She passed a mental health counseling center where sessions were still conducted only by video, and a physical therapist who wore KN95s to see clients. She parked near a school that, without N95s, had no way of ensuring its teachers were protected. It serves primarily Latino children, all of whom would be forced to learn online.

In the parking lot of the church, a booth that used to sell $1 snow cones had been transformed into a coronavirus testing center run by a team of Hopkins doctors and nurses.

On her day off, Young volunteered to work with them, spending hours sweating in her scrubs, sending swabs deep into nose after nose. She wore a surgical mask on top of her N95.

“I don’t think there’s any science that says this is actually safer,” she said. “But it’s just a mental thing.”

The line of people sweating on the asphalt was so long, Young couldn’t see the people at the end: a man in painter’s clothes, a mother pushing a stroller and a woman who, like Young, was wearing scrubs. Stitched onto the chest was the name of a retirement home.

‘Hazard’

The coughing patient was starting to fall asleep when Williams left her in the covid unit. Her shift had been over for more than 30 minutes. She checked in to make sure there was no one else who needed her help and headed for the locker room. She washed her hands twice. She used alcohol wipes to sanitize her phone, glasses, ID badges and pens.

She took off her N95, and she inhaled.

For the first time in two months, she decided that this respirator was done. Its straps were starting to feel too stretched. The shape of it looked just a little too warped.

Instead of hanging the N95 from a hook in her locker to air dry, she stuffed it in a bag marked “hazard.”

A new mask, still in its plastic packaging, was waiting for her next shift. She would wear it as long as possible, especially after learning that the Hopkins stockpile had run out of the British-made mask she wore and couldn’t get any more. She needed to change to a different type of N95, one that felt unfamiliar once again. She told herself that she was grateful just to have it. She told herself that it would protect her just the same.

 

 

 

 

 

Cartoon – Something that would greatly Prevent Covid 19

U.S. sets record for new coronavirus cases, surpassing 53,000 - The  Washington Post

What it’s like to be a nurse after 6 months of COVID-19 response

https://www.healthcaredive.com/trendline/labor/28/?utm_source=HD&utm_medium=Library&utm_campaign=Vituity&utm_term=Healthcare%20Dive#story-2

Those on the front lines of the fight against the novel coronavirus worry about keeping themselves, their families and their patients safe.

This story is part of a series examining the state of healthcare six months into the public health emergency declared for COVID-19.

There’s no end in sight for the country as it grapples with another surge of COVID-19 cases.

That’s especially true for nurses seeking the reprieve of their hospitals returning to normal operations sometime this year. Many in the South and West are now treating ICUs full of COVID-19 patients they hoped would never arrive in their states, largely spared from spring’s first wave.

And like many other essential workers, those in healthcare are falling ill and dying from COVID-19. The total number of nurses stricken by the virus is still unclear, though the Centers for Disease Control and Prevention has reported 106,180 cases and 552 deaths among healthcare workers. That’s almost certainly an undercount.

National Nurses United, the country’s largest nurses union, told Healthcare Dive it has counted 165 nurse deaths from COVID-19 and an additional 1,060 healthcare worker deaths.

Safety concerns have ignited union activity among healthcare workers during the pandemic, and also given them an opportunity to punctuate labor issues that aren’t new, like nurse-patient ratios, adequate pay and racial equality.

At the same time, the hospitals they work for are facing some of their worst years yet financially, after months of delayed elective procedures and depleted volumes that analysts predict will continue through the year. Many have instituted furloughs and layoffs or other workforce reduction measures.

Healthcare Dive had in-depth conversations with three nurses to get a clearer picture of how they’re faring amid the once-in-a-century pandemic. Here’s what they said.

 

Elizabeth Lalasz, registered nurse, John H. Stroger Hospital in Chicago

Elizabeth Lalasz has worked at John H. Stroger Hospital in Chicago for the past 10 years. Her hospital is a safety net facility, catering to those who are “Black, Latinx, the homeless, inmates,” Lalasz told Healthcare Dive. “People who don’t actually receive the kind of healthcare they should in this country.”

Data from the CDC show racial and ethnic minority groups are at increased risk of getting COVID-19 or experiencing severe illness, regardless of age, due to long-standing systemic health and social inequities.

CDC data reveal that Black people are five times more likely to contract the virus than white people.

This spring Lalasz treated inmates from the Cook County Jail, an epicenter in the city and also the country. “That population gradually decreased, and then we just had COVID patients, many of them Latinx families,” she said.

Permission granted by Elizabeth Lalasz

Once Chicago’s curve began to flatten and the hospital could take non-COVID patients, those coming in for treatment were desperately sick. They’d been delaying care for non-COVID conditions, worried a trip to the hospital could risk infection.

A Kaiser Family Foundation poll conducted in May found that 48% of Americans said they or a family member had skipped or delayed medical care because of the pandemic. And 11% said the person’s condition worsened as a result of the delayed care.

When patients do come into Lalasz’s hospital, many have “chest pain, then they also have diabetes, asthma, hypertension and obesity, it just adds up,” she said.

“So now we’re also treating people who’ve been delaying care. But after the recent southern state surges, the hospital census started going down again,” she said.

Amy Arlund, registered nurse, Kaiser Permanente Medical Center in Fresno, California:

Amy Arlund works the night shift at Kaiser Fresno as an ICU nurse, which she’s done for the past two decades.

She’s also on the hospital’s infection control committee, where for years she’s fought to control the spread of clostridium difficile colitis, or C. diff., in her facility. The highly infectious disease can live on surfaces outside the body for months or sometimes years.

The measures Arlund developed to control C. diff served as her litmus test, as “the top, most stringent protocols we could adhere to,” when coronavirus patients arrived at her hospital, she told Healthcare Dive.

But when COVID-19 cases surged in northern states this spring, “it’s like all those really strict isolation protocols that prior to COVID showing up would be disciplinable offenses were gone,” Arlund said.

Widespread personal protective equipment shortages at the start of the pandemic led the CDC and the Occupational Safety and Health Administration to change their longstanding guidance on when to use N95 respirator masks, which have long been the industry standard when dealing with novel infectious diseases.

The CDC also issued guidance for N95 respirator reuse, an entirely new concept to nurses like Arlund who say those changes go against everything they learned in school.

“I think the biggest change is we always relied on science, and we have always relied heavily on infection control protocols to guide our practice,” Arlund said. “Now infection control is out of control, we can no longer rely on the information and resources we always have.”

Permission granted by Amy Arlund

The CDC says experts are still learning how the coronavirus spreads, though person-to-person transmission is most common, while the World Health Organization recently acknowledged that it wouldn’t rule out airborne transmission of the virus.

In Arlund’s ICU, she’s taken care of dozens of COVID positive patients and patients ruled out for coronavirus, she said. After a first wave in the beginning of April, cases dropped, but are now rising again.

Other changing guidance weighing heavily on nurses is how to effectively treat coronavirus patients.

“Are we doing remdesivir this week or are we going back to the hydroxychloroquine, or giving them convalescent plasma?”Arlund said. “Next week I’m going to be giving them some kind of lavender enema, who knows.”

 

Erik Andrews, registered nurse, Riverside Community Hospital in Riverside, California:

Erik Andrews, a rapid response nurse at Riverside Community Hospital in California, has treated coronavirus patients since the pandemic started earlier this year. He likens ventilating them to diffusing a bomb.

“These types of procedures generate a lot of aerosols, you have to do everything in perfectly stepwise fashion, otherwise you’re going to endanger yourself and endanger your colleagues,” Andrews, who’s been at Riverside for the past 13 years, told Healthcare Dive.

He and about 600 other nurses at the hospital went on strike for 10 days this summer after a staffing agreement between the hospital and its owner, HCA Healthcare, and SEIU Local 121RN, the union representing RCH nurses, ended without a renewal.

The nurses said it would lead to too few nurses treating too many patients during a pandemic. Insufficient PPE and recycling of single-use PPE were also putting nurses and patients at risk, the union said, and another reason for the strike.

But rapidly changing guidance around PPE use and generally inconsistent information from public officials are now making the nurses at his hospital feel apathetic.

“Unfortunately I feel like in the past few weeks it’s gotten to the point where you have to remind people about putting on their respirator instead of face mask, so people haven’t gotten lax, but definitely kind of become desensitized compared to when we first started,” Andrews said.

Permission granted by Erik Andrews

With two children at home, Andrews slept in a trailer in his driveway for 12 weeks when he first started treating coronavirus patients. The trailer is still there, just in case, but after testing negative twice he felt he couldn’t spend any more time away from his family.

He still worries though, especially about his coworkers’ families. Some coworkers he’s known for over a decade, including one staff member who died from COVID-19 related complications.

“It’s people you know and you know that their families worry about them every day,” he said. “So to know that they’ve had to deal with that loss is pretty horrifying, and to know that could happen to my family too.”

 

 

 

 

Pandemic spurs national union activity among hospital workers

https://www.healthcaredive.com/trendline/labor/28/?utm_source=HD&utm_medium=Library&utm_campaign=Vituity&utm_term=Healthcare%20Dive#story-1

When COVID-19 cases swelled in New York and other northern states this spring, Erik Andrews, a rapid response nurse at Riverside Community Hospital in southern California, thought his hospital should have enough time to prepare for the worst.

Instead, he said his hospital faced staffing cuts and a lack of adequate personal protective equipment that led around 600 of its nurses to strike for 10 days starting in late June, just before negotiating a new contract with the hospital and its owner, Nashville-based HCA Healthcare.

“To feel like you were just put out there on the front lines with as minimal support necessary was incredibly disheartening,” Andrews said. Two employees at RCH have died from COVID-19, according to SEIU Local 121RN, the union representing them.

A spokesperson for HCA told Healthcare Dive the “strike has very little to do with the best interest of their members and everything to do with contract negotiations.”

Across the country, the pandemic is exacerbating labor tensions with nurses and other healthcare workers, leading to a string of disputes around what health systems are doing to keep front-line staff safe. The workers’ main concerns are adequate staffing and PPE. Ongoing or upcoming contract negotiations could boost their leverage.

But many of the systems that employ these workers are themselves stressed in a number of ways, above all financially, after months of delayed elective procedures and depleted volumes. Many have instituted furloughs and layoffs or other workforce reduction measures.

Striking a balance between doing union action at hospitals and continuing care for patients could be an ongoing challenge, Patricia Campos-Medina, co-director of New York State AFL-CIO/Cornell Union Leadership Institute.

“The nurses association has been very active since the beginning of the crisis, demanding PPE and doing internal activities in their hospitals demanding proper procedures,” Campos-Medina said. “They are front-line workers, so they have to be thoughtful in how they continue to provide care but also protect themselves and their patients.”

At Prime Healthcare’s Encino Hospital Medical Center, just outside Los Angeles, medical staff voted to unionize July 5, a week after the hospital laid off about half of its staff, including its entire clinical lab team, according to SEIU Local 121RN, which now represents those workers.

One of the first things the newly formed union will fight is “the unjust layoffs of their colleagues,” it said in a statement.

A Prime Healthcare spokesperson told Healthcare Dive 25 positions were cut. “These Encino positions were not part of front-line care and involved departments such as HR, food services, and lab services,” the system said.

Hospital service workers elsewhere who already have bargaining rights are also bringing attention to what they deem as staffing and safety issues.

In Chicago, workers at Loretto Hospital voted to authorize a strike Thursday. Those workers include patient care technicians, emergency room technicians, mental health staff and dietary and housekeeping staff, according to SEIU Healthcare Illinois, the union that represents them. They’ve been bargaining with hospital management for a new contract since December and plan to go on strike July 20.

Loretto Hospital is a safety-net facility, catering primarily to “Black and Brown West Side communities plagued with disproportionate numbers of COVID illnesses and deaths in recent months,” the union said.

The “Strike For Black Lives” is in response to “management’s failure to bargain in good faith on critical issues impacting the safety and well-being of both workers and patients — including poverty level wages and short staffing,” according to the union.

A Loretto spokesperson told Healthcare Dive the system is hopeful that continuing negotiations will bring an agreement, though it’s “planning as if a strike is eminent and considering the best options to continue to provide healthcare services to our community.”

Meanwhile in Joliet, Illinois, more than 700 nurses at Amita St. Joseph Medical Center went on strike July 4.

The Illinois Nurses Association which represents Amita nurses, cited ongoing concerns about staff and patient safety during the pandemic, namely adequate PPE, nurse-to-patient ratios and sick pay, they want addressed in the next contract. They are currently bargaining for a new one, and said negotiations stalled. The duration of the strike is still unclear.

However, a hospital spokesperson told Healthcare Dive, “Negotiations have been ongoing with proposals and counter proposals exchanged.”

The hospital’s most recent proposal “was not accepted, but negotiations will continue,” the system said.

INA is also upset with Amita’s recruitment of out-of-state nurses to replace striking ones during the COVID-19 pandemic.

It sent a letter to the Illinois Department of Financial and Professional Regulation, asserting the hospital used “emergency permits that are intended only for responding to the pandemic for purposes of aiding the hospital in a labor dispute.”

 

 

 

 

America Doesn’t Have a Coherent Strategy for Asymptomatic Testing. It Needs One.

https://www.propublica.org/article/america-doesnt-have-a-coherent-strategy-for-asymptomatic-testing-it-needs-one?utm_source=sailthru&utm_medium=email&utm_campaign=dailynewsletter&utm_content=feature

While it battles a virus that can spread quickly via silent carriers, the United States has yet to execute a strategy for testing asymptomatic people. This is a problem — and ProPublica health reporter Caroline Chen explains why.

Dr. Sara Cody, health officer of Santa Clara County, California, was tired of seeing the same thing over and over again. Her contact tracers were telling people exposed to COVID-19 that they needed to get tested, but when some went to testing sites, health care providers turned them away because they didn’t have any symptoms.

This posed a problem for Cody’s work. Knowing if a contact was infected would help her department keep an accurate count of her county’s coronavirus infection rate; also, if a contact tested positive, it’d spur a new round of contact tracing from her staff, to help stop any further transmission from that asymptomatic carrier.

Cody decided to issue a countywide health officer order in June requiring certain health care facilities to provide testing for all close contacts, and also all front-line workers, such as mass transit drivers and retail workers, whether or not they had symptoms.

Then last week, the U.S. Centers for Disease Control and Prevention quietly changed guidelines on its website to say that people without symptoms did not necessarily need to be tested, even if they had been in contact with someone who had COVID-19. Cody was confused. ”Was it because there isn’t enough testing capacity?” she initially wondered. But there was no such explanation from the agency.

The CDC was met with a degree of pushback that was notable in its intensity; several states flat-out said they would not follow the guidelines, including California, where Gov. Gavin Newsom said, “I don’t agree with the new CDC guidance. Period. Full stop.”

The controversy surrounding the CDC guideline change is all just a symptom of a deeper issue that has plagued America’s coronavirus response: Even though we have spent more than half a year battling a virus whose insidious hallmark is its ability to spread through those with no symptoms, the country has not yet articulated a coherent strategy to test these silent carriers.

“The fact that we’re this far into the pandemic and we’re still talking about how to do asymptomatic testing and going back and forth on this is a major part of the reason why we’re struggling to open schools and colleges, and why people are still dying in prisons,” said Dr. Ashish Jha, dean of the Brown University School of Public Health.

The lack of consistent asymptomatic testing guidelines means that from state to state, county to county, a hodgepodge of strategies are being used with varying standards, testing methods and levels of access. Decisions are being made sometimes by people who have been thrust into the role of public-health officer with no training — school principals and college deans, leaders of companies and daycares and churches, who are just trying to do right by the people they are responsible for.

It’s unfair to ask them to have to come up with their own testing strategies, or to have to navigate the maze of their local health authority’s often shifting recommendations. There may be pros and cons to various strategies experts have proposed, with variables to consider like testing technologies, supply chains and federal funding, but perhaps the more urgent need at this point is picking a plan and actually seeing it through.

To understand why, we need to start with a clearer understanding of the pivotal role asymptomatic testing plays in containing this virus, particularly in the absence of a vaccine.

Why Asymptomatic Testing Is Important

Let’s start with the most basic question: Why do we bother testing in the first place? There are, broadly speaking, two reasons to use a test. The first is as a clinical diagnostic; the other is as a public health tool. Both are important, but for different reasons.

Doctors use a clinical diagnostic like a strep test to tell whether a patient is sick with a disease that can be treated with particular medicines. “The purpose of the test is based around doing one thing when it’s negative and doing another thing when it’s positive,” said Dr. Patrick O’Carroll, head of health systems strengthening at the Task Force for Global Health, who previously worked at the CDC for 18 years.

From this perspective, it seems pointless for an asymptomatic person who might have COVID-19 to take a test, because there’s not going to be any difference in how they will be treated — there are no symptoms to medicate. You might have even heard your doctor say, “Don’t bother taking a test if you only have mild symptoms, because I’m not going to tell you do anything different besides drinking fluids, taking Tylenol and resting.”

But from a public health standpoint, testing asymptomatic people can yield actionable information. COVID-19 is unlike many other diseases, in which a patient’s peak contagiousness coincides with the height of their symptoms. With COVID-19, about 40% of patients do not show any symptoms or have such mild ones that it would never have occurred to them that they had been infected. In a recent study of 192 young people with suspected COVID-19 in Boston, only half who tested positive had a fever.

Furthermore, studies have shown that among patients who do develop symptoms, viral load, which correlates with a patient’s contagiousness, is highest right before or at the time when symptoms start appearing. Put together, these features have explained why the coronavirus has been able to spread so perniciously across the globe. It’s one sneaky virus.

If an asymptomatic person tests positive, public health officials can ask them to isolate from others and begin the process of contact tracing in order to break chains of transmission. In the bigger picture, it also helps them keep tabs on where the virus is spreading in their city. (This is what’s known as “surveillance” in public health parlance: They’re not spying on you. They’re tracking the virus.)

“Since the beginning, testing has been the foundation of our response, because it tells us who is positive, where they are, in which demographic, and what the patterns are,” said Dr. Umair Shah, executive director for Harris County Public Health in Texas.

Understanding population prevalence also helps guide public health actions. For example, said O’Carroll, “if testing shows that only 2% of the population is positive, I’m going to call all of those people, interview them, put all of the contacts in quarantine and really try to stamp it out. But if I find that 30% are positive, then I really don’t have the resources to interview and chase down thousands and thousands of people — that’s when spread is too high for contact tracing to be useful.”

When testing is restricted to symptomatic patients, health officials will only have limited signals about the extent of the virus’s spread, leaving them to operate partially blind.

Standards Vary From State to State

There are two categories of asymptomatic people to consider: The first includes those who had close contact with someone who has already tested positive for the virus. The second includes people who don’t have any reason to believe they have been exposed. The first group is a higher testing priority, because there’s a far greater chance that they have been infected and can be spreading the virus.

In an ideal world, if testing were abundant and cheap and results were fast, we would test everyone daily and catch all of the asymptomatic carriers. But when there aren’t enough tests to go around, public health officials need to triage.

In the earliest stages of the pandemic, when there were hardly any tests available across the country, public health officials had to limit tests to the most urgent need — people with severe symptoms in hospitals. As tests became more available, they started to widen the criteria, first to people with symptoms, then to asymptomatic people with known exposure. Finally, in some areas of the country, anyone who wanted a test could get one, whether or not they had symptoms.

But to this day, the decisions have been made piecemeal. I reached out to health departments around the country, and found that testing criteria still vary depending on where you live.

In Delaware, close contacts are asked to get tested once, at the end of their 14-day quarantine period. The state lets anyone get tested, whether or not they were exposed or have symptoms. Maryland recommends that people who suspect they’ve been exposed to the virus get a test, whether they are symptomatic or not. Arkansas says it works to facilitate testing for all close contacts of positive cases, and also tries to provide testing for anyone in the state who wants a test, asymptomatic or not.

But Oregon and Wisconsin don’t recommend testing for asymptomatic people who have not had close contact with a confirmed case. (Oregon makes an exception for people in a high-risk category, such as agricultural workers.)

Some states have more nuance to their recommendations. New Jersey said testing is available to all, but noted that if you are asymptomatic, testing is recommended if you are a front-line worker, if you were in a large crowd with difficulty social distancing, if you are a member of a vulnerable population or if you recently traveled somewhere with a high COVID-19 infection rate.

Effective Contact Tracing Can’t Happen Without Efficient Testing

Within each state, however, guidelines aren’t always followed consistently by test providers. Cody, the health officer in California, isn’t the only one whose contact tracers are unable to get asymptomatic people tested.

Rebecca Fischer, an assistant professor at Texas A&M University School of Public Health, said she’s seen the same thing happen in Brazos County. “We call them and say, ‘How did the test go? And they’ll say, ‘They sent me away because I don’t have symptoms.’ and we’ll say, ‘You need to go back and say the health department sent you,’ and often they get turned away again.” Sometimes, Fischer said, the health department would have to give the person a letter to verify that they needed a test.

“We get on the local news station and plead with test providers to help us facilitate widespread testing,” Fischer said.

It’s unclear why providers are turning down asymptomatic patients. It may be, in part, due to the perceived purpose of the test. Dr. Michael Hochman, a primary care doctor and director of the Gehr Family Center for Health Systems Science and Innovation at the University of Southern California, said he thinks the value of testing contacts without symptoms is “modest” and would rather make them stay home for 14 days instead of come into a clinic for a test, “which is bringing them together with other people, the opposite of what you want.”

He worries that a false negative could give patients a misguided sense of security and prompt contacts to leave quarantine before they’re supposed to. Hochman says he sometimes has patients calling who say they have potential exposure and want a test, but when he explains to them that regardless of the result, they still will need to quarantine, the patients often then decide they won’t bother with a test.

Cody countered that many people don’t always adhere to the 14-day guidelines. “We’re not doing legal orders, so there’s not going to be perfect compliance,” she said. Given the opportunity to test and find out that an asymptomatic contact is positive is always preferable, she said, because people are more likely to take precautions and isolate properly, particularly around family members.

Without a Clear National Strategy, Confusion Abounds

Into this already chaotic environment came the CDC’s guidance change on Aug. 24.

Normally, when the agency updates its guidances, it gives a heads-up to state and local health departments, so they can decide how to adjust their own recommendations or how to communicate to the public, said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents large metropolitan health departments.

“Usually at minimum, there’s a big tent call … and normally at the top of the call, they say, we’re going to update this.”

But this time, it didn’t happen. “It was buried in an email,” she said. “If you hadn’t clicked on it, you wouldn’t have known.”

Previously, the CDC recommended testing for all close contacts of people with known COVID-19 infection, specifically noting that “because of the potential for asymptomatic and pre-symptomatic transmission, it is important that contacts … be quickly identified and tested.” The new guidance, however, said, “If you have been in close contact … you do not necessarily need a test unless you are a vulnerable individual or your health care provider or state or local public health officials recommend you take one.”

The new guidance for asymptomatic people who had no known exposure conveyed a number of different messages, depending on which part of the website you read. On one hand, it said, “If you do not have COVID-19 symptoms and have not been in close contact with an infected person: You do not need a test.”

But farther down the page, the site also said, “If there is significant spread of the virus in your community, state or local public health officials may request to test more asymptomatic ‘healthy people.’”

In the absence of explanation or context, confusion ensued.

Calling the new guidelines “vexing and hard to interpret,” Dr. Jeff Duchin, health officer for public health for Seattle & King County said in a statement that “testing asymptomatic close contacts of COVID-19 cases is important to identify cases and interrupt transmission and we intend to continue to do that pending additional information that would lead us to reconsider.”

When I asked the CDC to explain the change in guidance, it didn’t respond, instead pointing me toward the Department of Health and Human Services.

HHS sent me a statement from Adm. Brett Giroir, the federal testing czar, saying that the updated guidance “places an emphasis on testing individuals with symptomatic illness, those with a significant exposure or for vulnerable populations, including residents and staff in nursing homes or long term care facilities, critical infrastructure workers, healthcare workers and first responders, and those individuals (who may be asymptomatic) when prioritized by public health officials.”

The revised guidance did not appear to be generated internally by the CDC. Giroir later told reporters that the recommendations were approved by members of the White House coronavirus task force, saying, “We all worked together to make sure that there was absolute consensus that reflected the best possible evidence.” Dr. Anthony Fauci, however, said he was undergoing surgery and was not part of the discussion.

A few days later, CDC director Dr. Robert Redfield verbally softened the changes, saying that testing “may be considered” for asymptomatic contacts, though the guidelines online were not changed.

“Ultimately, it may not actually be a huge change,” said Juliano, but in practice it means that the federal government “is really pushing the decision down to states and local.”

“It means when public health says you should get tested, someone could say, ‘well, the CDC says it’s not necessary.’ It leads to public confusion, and you’re really putting state and local in a line of fire that’s not necessary.”

Use the Right Test for the Right Situation

Now that we’ve talked about the reasons it’s important to do asymptomatic testing, it’s time to think about resources. In recent months, many experts have been advocating that different types of tests be used for different purposes, in order to optimize available supplies and avoid testing delays.

The idea goes like this: We should save the most sensitive tests — known as PCR tests — for diagnostic purposes, when we need to be absolutely sure that a patient has COVID-19, because we’re going to be treating them or asking them to isolate, based on the results. So these tests should be used for people with COVID-19 symptoms and people who were known to be exposed to the virus.

But for public health purposes, when it comes to keeping tabs on how broadly the virus is spreading, we could instead be using slightly less sensitive — though not poor quality — rapid tests, known as antigen tests, which typically can provide results in minutes to hours. Such tests should be used for screening people en masse in settings like nursing homes, essential workplaces, and communities that have limited testing resources, proposes a team at Duke University’s Margolis Center for Health Policy. Any positives that turn up could then be confirmed with a PCR test.

The goal is to avoid the long testing turnaround times that the country was plagued with this summer. PCR tests, while highly accurate, usually require at least a day or two to return results even under optimal conditions, and require more specialized equipment, labs and staff. This summer, when the majority of tests were being shoved into the PCR queue, turnaround times stretched out, with some people waiting more than two weeks for test results.

This is not just an annoyance for individuals. It’s a massive public health problem, because a test that takes more than two days to come back is pretty much useless.

“Patients don’t know what to do in those two weeks, and guess what, we can’t do our contact tracing, so we can’t fight the pandemic — all of that gums up the system.” said Shah, of Harris County. Such long turnaround times are “shameful. It makes no sense.”

Dr. Mark McClellan, one of the authors of the Duke paper, said the government must set aside funding to pay for antigen tests in at-risk populations, including low-income, minority and immigrant communities, and public schools and colleges.

The University of Illinois is requiring all faculty, staff and students to participate in screening testing twice a week, using a rapid saliva-based test. Not every college has the resources to perform these routine tests, but advocates for this kind of testing point to the university to show that it isn’t a fantasy.

“It is feasible,” said Carl Bergstrom, a computational biologist at the University of Washington. “It’s just a matter of will.”

McClellan and his co-authors estimate that about 14 million people are in high-risk settings that need regular screening testing, requiring an average of two tests per week. “There needs to be a lot more financial support to get that capacity up, something like Operation Warp Speed, with the government going in jointly with manufacturers,” he said.

What We Need to Do: Pick a Plan, and See It Through

For now, though, the federal government doesn’t appear to embrace this vision. Testing czar Giroir told reporters in a call on Aug. 13, “I’m really tired of hearing, by people who are not involved in the system, that we need millions of tests every day. … You don’t need this degree of testing. You need strategic testing combined with smart policies.”

Giroir explained that the administration’s focus was testing symptomatic patients as well as vulnerable populations, such as nursing home residents, coupled with policies including mask wearing, social distancing and hand washing. “That plan is being implemented and that plan is working,” he told reporters.

Some public health experts say that approach won’t be enough to curb the pandemic.

“Masks are a very powerful tool for virus control, and they’re not completely off the table, but a lot of our population has not been able to adhere to them because it’s become politicized,” said Dr. Michael Mina, assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health.

And while social distancing is important, said Jha, he doesn’t think that alone will work in places where people are regularly congregating, like schools. “It’s not the real world,” he said. “Do we really think kids will never get close to each other?”

Mina argues for an audacious plan that calls for far more testing than the U.S. has been capable of to date. His testing strategy, particularly when it comes to how it approaches asymptomatics, seems directly at odds with Giroir’s.

Mina envisions tests so cheap ($1 apiece) and so widely available (over the counter) that every American can test themselves at least twice a week. The tests we’d use are paper strips that require only a saliva sample. They would certainly be less sensitive than PCR tests, but sensitive enough to catch people when their viral load is highest, which is exactly when they are most infectious.

The technology for a cheap, rapid antigen test certainly exists: Abbott Laboratories’ $5 test, authorized by the U.S. Food and Drug Administration last week, goes a long way to prove this point. But Abbott’s test is intended to be used on symptomatic patients, and needs to be performed by a doctor. Mina wants people to be able to test themselves.

Mina’s vision has gained broad support in recent weeks by numerous public health experts, but would need buy-in from the federal government, particularly the FDA, to become reality.

Many other plans have been proposed, but at this point, more time has been spent talking about what we should be doing and debating the various options, rather than mustering the necessary regulatory, financial and political power to get any one of the plans fully executed.

“Choosing not to test those who are asymptomatic is like saying we won’t fight the fire until it reaches the second floor,” said Brian Castrucci, chief executive officer of health philanthropy the de Beaumont Foundation.

The pandemic has been raging across America for more than half a year. It’s past time we had a coherent national plan to put out the fire.

 

 

San Francisco’s lonely war against Covid-19

https://www.vox.com/future-perfect/2020/7/30/21331369/london-breed-coronavirus-covid-san-francisco-california-trump

On June 25, San Francisco Mayor London Breed was excited the city’s zoo would finally reopen after closing down for months in response to Covid-19. She visited the facilities, posting photos on social media with a mask on and giraffes in the background.

“I know people are eager to get back to some sense of normalcy, especially families and children,” she tweeted. And it looked like her city was taking a step toward it.

The day after the visit, Breed had to announce the sad news: San Francisco’s reopening plan — for the zoo and various other facilities, including hair salons and indoor museums — would have to be put on hold.

“COVID-19 cases are rising throughout CA. We’re now seeing a rise in cases in SF too. Our numbers are still low but rising rapidly,” she tweeted. “As a result, we’re temporarily delaying the re-openings that were scheduled for Monday.”

While state and local leaders nationwide were pushing ahead with reopening, Breed pulled back. “I listened to our public health experts,” she told me. “It’s hard. The last thing I want to do is go out there and say one thing and then have to say something else. But I think it’s important that people understand things can change. This is a fluid situation.”

The decision — taken weeks before California Gov. Gavin Newsom’s move to shut down risky indoor venues statewide in July — was emblematic of San Francisco’s cautious approach throughout the coronavirus crisis. The city joined a regional stay-at-home order in March, before the rest of the state and New York, which became a Covid-19 epicenter, imposed their own orders. It was also slower to reopen: When California started to close down indoor venues again, the order largely didn’t affect San Francisco — because the city never reopened bars and indoor dining, among other high-risk venues, in the first place.

By and large, the approach — aided by regional cooperation, with leadership from Santa Clara County Health Officer Sara Cody, and widespread social distancing and mask-wearing by the public — has kept cases of Covid-19 manageable. In the spring, California and the Bay Area saw some of the first coronavirus cases, but quick action since then has let San Francisco and the surrounding region avoid turning into a major hot spot.

The increase in cases this summer has exceeded the April peak and fallen particularly hard on marginalized groups, especially Latin communities. But that, too, seems to be turning around: New cases started to fall by July 20 — almost a week before the state as a whole began to plateau. San Francisco has maintained less than 60 percent the Covid-19 cases per capita as California, and less than 30 percent the deaths per capita. Its caseload and death toll are lower than other large cities, including Washington, DC, and Columbus, Ohio, and far lower than current hot spots like Arizona and Florida.

“It’s doing as well as it can, given what’s going on around it,” Peter Chin-Hong, an infectious disease expert at the University of California San Francisco, told me.

Experts and local officials say the summer increase in cases doesn’t take away from what San Francisco has done. What it shows, instead, is the limits of what a local government can do — and the risk of relying on a county-by-county, state-by-state approach to a truly national crisis.

“We have to accept that we are all interrelated in a pandemic,” Kirsten Bibbins-Domingo, an epidemiologist at UCSF, told me. “We have to help each other out.”

The city’s leaders agree, pointing to some of the problems that have addled their response to the pandemic as the federal government did little — from a lack of personal protective equipment for health care workers to continued shortfalls in tests for Covid-19.

“We are not isolated; we are interconnected,” Grant Colfax, director of the San Francisco Department of Public Health, told me. “The virus exploits that very interconnectedness of our society. Without a consistent, robust, and sustained federal response that is driven by science … eventually things cannot be sustained.

This is why, experts argue, federal leadership is so key: The federal government is the one entity that could address these problems on a large scale. But President Donald Trump has ceded his role to the states and private actors — what his administration called the “state authority handoff” and the New York Times described as “perhaps one of the greatest failures of presidential leadership in generations.”

That’s left cities and states to fend for themselves. San Francisco has made the best of it, with the kind of model that experts argued could have prevented the current coronavirus resurgence if it had been followed nationally.

“There’s a value to being cautious,” Bibbins-Domingo said. “Any type of reopening is going to come with some increase in cases. That’s what we are learning in the pandemic. That’s what the infectious disease experts told us was going to happen. Places that thought they could just reopen without caution have really paid the price for it.”

San Francisco’s leaders were ahead on Covid-19

Breed started to really worry about the coronavirus in February, when she saw a glimpse of the future.

Stories of overwhelmed hospitals in Wuhan, China, showed that Covid-19 could cripple health care systems. But Breed believed, she said, that San Francisco’s larger, more advanced health care system could handle the blow. Then her advisers and experts told her differently — that a situation like Wuhan’s really could happen in San Francisco if she didn’t act.

“The shock I got,” Breed said. “We have all these hospitals, all these places where we have some of the most incredible doctors and research institutions. So in my mind, I’ve always thought this is where you want to be if something happens. To be told that here’s what our capacity is, here’s what happens if we do nothing, and what we need to prepare for, it really did blow my mind.”

At that point, she concluded, “We need to shut the city down to make sure this doesn’t happen.”

The virus has been the biggest challenge yet for Breed, who first became mayor in 2017 when her predecessor died, before she was elected to the role in 2018, having previously served on the Board of Supervisors.

But Breed, with the guidance of the Bay Area’s public health officials, has consistently kept the city ahead on Covid-19. The day before Trump claimed, falsely, that coronavirus cases would go from 15 to nearly zero in the US, Breed on February 25 declared a local state of emergency over the virus. Three days before California imposed a stay-at-home order and nearly a week before New York state did, San Francisco County, with Breed’s full backing, on March 16 joined the five other Bay Area counties in issuing the country’s first regional stay-at-home order.

Breed was ahead of not just much of the nation, but her progressive peers as well. On March 2, she warned on Twitter that the public should “prepare for possible disruption from an outbreak,” advising people to stock up on essential medications, make a child care plan in case a caregiver gets sick, and plan for school closures. The same day, New York City Mayor Bill de Blasio, a fellow Democrat, tweeted that he was “encouraging New Yorkers to go on with your lives + get out on the town despite Coronavirus.”

New York City would go on to suffer one of the worst coronavirus outbreaks in the world, with its total death rate standing, as of July 29, at 272 per 100,000 people — more than 45 times as high as San Francisco’s rate of 6 per 100,000. (De Blasio’s office didn’t respond to a request for comment.)

San Francisco’s death toll is also fairly low compared to that of some other areas in California — a fraction of Los Angeles County’s 45 per 100,000 and Imperial County’s 103. San Mateo County, a Bay Area county that reopened more aggressively, has more than double the death rate, at 15 per 100,000. San Francisco looks even better compared to cities and counties beyond California — with less than a tenth the deaths per capita as Washington, DC, and about a sixth as many as Franklin County, Ohio, where Columbus is, and Fulton County, Georgia, where most of Atlanta is.

At the time of the initial stay-at-home order, Chin-Hong said, people wondered if Breed was overreacting. “Of course, in hindsight, she was very prescient. She knew what was coming.”

There’s good reason to believe that San Francisco’s early action, particularly its lockdown, helped. The research indicates that stay-at-home orders and similar measures worked, with one preliminary Health Affairs study concluding:

Adoption of government-imposed social distancing measures reduced the daily growth rate by 5.4 percentage points after 1–5 days, 6.8 after 6–10 days, 8.2 after 11–15 days, and 9.1 after 16–20 days. Holding the amount of voluntary social distancing constant, these results imply 10 times greater spread by April 27 without SIPOs (10 million cases) and more than 35 times greater spread without any of the four measures (35 million).

That’s not to say San Francisco performed flawlessly.

Even the experts who praised Breed simultaneously raised alarms about how the virus had disproportionately affected minority populations — with about half of confirmed Covid-19 cases affecting Latin people, even though they comprise about 15 percent of the local population. The city’s large homeless population is also a major point of concern, with a big outbreak at the largest local homeless shelter. These are the kinds of blind spots with Covid-19 that have shown up across the country — as minority groups, in particular, are more likely to work in the kind of job deemed “essential” — and San Francisco isn’t immune to them.

“Myself, just taking care of patients, I know that some of those patients are going back to work sick if they don’t have to be hospitalized,” Yvonne Maldonado, an infectious disease expert at Stanford, told me. “They can’t afford not to work.”

Local officials point out they have taken aggressive action to shield marginalized populations — creating support programs for them, fielding contact tracing calls in Spanish, and setting up more than 2,500 hotel rooms for the vulnerable, including homeless people. And the disproportionate case count for Latin people is from a baseline of cases that’s lower than other parts of the state and country with similar disparities. Out of 57 Covid-19 deaths in the city, only one was a homeless person.

Breed acknowledged the challenge, describing the city’s response to Covid-19 as a work in progress as she and other officials struggle with the uncertainty that surrounds a virus that’s still relatively new to humans.

“That’s hard,” Breed said. “We have to make the hard decisions. What we hope people will understand is why. We keep trying to call attention to what’s happening or could happen to any of us. It’s a constant struggle.”

That’s especially compounded by the massive sacrifices that people have to make as they’re forced to stay at home, potentially giving up income, child care, and social connections.

Breed is aware this is no easy task. On a personal level, she said, “I’m tired of being in the house. I’ll tell you that much.” She acknowledged that the shutdown has left many people struggling, “because their livelihoods are at stake, their ability to take care of themselves is at stake.”

But the alternative, she suggested, is much worse. It’s not just more Covid-19 cases, hospitalizations, and deaths — but harm to the economy if a major outbreak forces cities and states to shut down all over again. As a preliminary study of the 1918 flu pandemic found, the cities that came out economically stronger back then took more aggressive action that hindered economies in the short term but better kept infections and deaths down overall.

Experts echoed a similar sentiment. “Dead people don’t shop. They don’t spend money. They don’t invest in things,” Jade Pagkas-Bather, an infectious disease expert and doctor at the University of Chicago, told me. “When you fail to invest in the health of your population, then there are longitudinal downstream effects.”

Breed had a key ally in San Francisco: The public

Chin-Hong, who lives and works in the Bay Area, recalled a recent experience he had at the grocery store. With the place at full capacity, people were waiting outside the store in a line. One person joined the line without a mask on. People began to eye him disapprovingly. He grew visibly nervous, at one point pulling his shirt over his mouth. After a while, a store staff member came out and gave him a mask, which he quickly put on.

The story is emblematic of one of Breed’s key advantages as she has pushed forward with aggressive actions against the coronavirus: San Francisco’s public is by and large on board, with a lot of solidarity built around social distancing and masking.

“The politician is only as good as her constituents,” Chin-Hong said. “It’s a key factor in all of this.”

In some ways, the public was even ahead of Breed. In the weeks before Bay Area counties issued a stay-at-home order, major tech companies in the region, like Google and Microsoft, told employees to work from home. That partly reflects tech employees’ ability to work from home with fewer disruptions, but also a greater sense of vigilance for an industry with close ties to the countries in East Asia that saw Covid-19 cases earlier.

It wasn’t just the tech sector. Restaurant data from OpenTable shows San Francisco was starting to avoid dining out by the first week of March, while most other cities in the US saw at best small decreases, if any changes: On March 1, dining out via OpenTable was down 18 percent in San Francisco, compared to down 3 percent in Los Angeles, down 2 percent in New York City, up 2 percent in Houston, and up 21 percent in Philadelphia. From that point forward, San Francisco’s numbers steadily dropped, while much of the US fluctuated before the depth of the outbreak became clearer nationwide.

San Francisco has also been better than much of the country about mask-wearing.New York Times analysis found there’s a roughly 60 to 90 percent chance, depending on the part of the city, that everyone is masked in five random encounters in San Francisco. In other parts of the US, including cities, the percent chance can drop to as low as 20, 10, or the single digits.

Even in California, it wasn’t guaranteed things would go like this. Orange County’s chief health officer resigned in June due to public resistance against a mask-wearing order. Sheriffs in Orange, Riverside, Fresno, and Sacramento counties said they wouldn’t enforce Gov. Newsom’s June order requiring masks in public and high-risk areas. With Trump and other Republicans suggesting that social distancing and masking requirements were part of a broader overreaction to the pandemic and an attempt at government overreach, and people genuinely suffering due to the economic downturn, San Francisco could have taken a very different direction.

We don’t know for certain why San Francisco’s public is more aggressive about precautions against Covid-19. One advantage San Franciscans have is many of them, particularly those in the tech sector and other office jobs, can work from home much more easily than, say, “essential” agricultural employees. The city also has close ties to East Asia, including China, potentially offering personal connections — and an early warning — to the first coronavirus outbreaks and the value of masking. San Francisco is also very progressive and Democratic, which helps as physical distancing, masking, and related measures have become politically polarized. Perhaps Breed’s more aggressive communication paid off.

Whatever the cause, there’s good reason to believe the public embrace of precautions helped the city. A review of the research published in The Lancet found that “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”

Again, it’s not perfect. Breed told me of a recent trip to a local store that was clearly far above the city’s reduced standards of capacity, with some of the staff and customers not wearing masks. “I was like, ‘What the heck is this? This is ridiculous,’” she said. “I called [the San Francisco Department of] Public Health, and they put a stop to it.”

More recently, Breed had to get tested for coronavirus after she went to an event attended by someone who reportedly knew they were positive. She used the moment to lightly admonish those who didn’t follow the recommended precautions: “I know people want to be out in public right now, but this disease is killing people. It’s simply reckless for those who have tested positive [to] go out and risk the lives of others,” she tweeted. “I cannot stress this enough: if you test positive, it’s on you to stay home and not expose others.” (Breed tested negative.)

But San Francisco’s public is seemingly better than much of the country at following the recommended precautions. Beyond Breed’s actions, that’s a potent explanation for why San Francisco has done relatively well — and why other parts of the state and country haven’t.

Local governments can only do so much about a pandemic

As successful as San Francisco has been relative to other parts of California and the US, it hasn’t escaped the recent rise in Covid-19 cases untouched. As of July 22 (the most recent reliable local data available), the city hit a seven-day average of 98 new cases a day — down from a peak of 120 several days prior but up from the previous peak of 48 in mid-April.

More than reflecting San Francisco’s own failures, experts said the upward swing in cases reflects the limits of what a local government can do when a virus spreads nationally and globally. When a virus can cross borders, there’s only so much San Francisco can do if its residents can drive an hour or two to a county where bars and indoor dining are open for service, or to meet with family members in an area that’s hit much harder by Covid-19.

“When you have different rules for different counties, it’s very confusing,” Maldonado said. “People lose the message.”

There are similar limitations to what even California can do. It can impose its own lockdown, but it has less control over cases from Arizona, Nevada, Mexico, or other parts of the globe. While the state has taken steps to build up its testing capacity — surpassing the benchmark of 150 tests per 100,000, which is the equivalent of 500,000 tests nationwide — it can only go so far if there are constraints around the country for testing.

The testing problem is especially acute now: With new outbreaks across the US, demand for tests climbed as supply constraints reappeared. That’s led to waiting periods of up to weeks for getting results back — making tests practically useless for confirming, tracing, and containing infections before they have time to spread.

But there are limits to what San Francisco or California can do if the bottlenecks for testing are originating in other parts of the country or world — whether they’re due to epidemics in Arizona and Florida, or because factories in the Northeast and South can’t produce enough swabs to collect samples or reagents to run tests.

“We need a national plan,” Cyrus Shahpar, a director at the global health advocacy group Resolve to Save Lives, told me. “In terms of the structures to improve the supply chain or procure more stuff for the whole country, that’s a federal level of support. You need that to be in place.”

The Trump administration, however, has explicitly left most of these issues for states to solve. The White House’s testing plan declared that the federal government is merely a “supplier of last resort,” leaving it to local and state governments and private actors to fix choke points along the testing supply chain. The New York Times explained this was part of a broader “state authority handoff” plan that would “shift responsibility for leading the fight against the pandemic from the White House to the states.”

To the extent the federal government has provided support, Trump has actively undermined it. When the federal government released a phased plan for state reopenings, Trump called on states to reopen faster — to supposedly “LIBERATE” them from economic calamity. After the Centers for Disease Control and Prevention recommended people in public wear masks, Trump said it was a personal choice, refused for months to wear a mask in public, and even suggested that people wear masks to spite him (although a recent tweet seemed to support masking). (The White House didn’t return a request for comment.)

In my interviews, local officials, health care workers, and experts repeatedly complained about the problems caused by federal inaction. Breed lamented that San Francisco, and California, couldn’t rely on federal support to get personal protective equipment for health care workers, particularly in the early stages of the pandemic. A San Francisco Department of Public Health spokesperson told me that testing took time to scale up while the federal government did little to address supply constraints, commenting that the mixed messaging and inaction from the federal government “are hampering local efforts to be as effective as we would like to be.”

Over time, even the once-proactive California let its guard down. As Gov. Newsom faced pressure from local governments and businesses to reopen the state quickly, he allowed counties to reopen at a quicker pace if they met certain metrics. That led to new outbreaks, particularly in Central and Southern California — each of which presented a risk of bleeding over to the Bay Area. As Bibbins-Domingo said, county-by-county variations “have not been helpful” for suppressing the virus in San Francisco or statewide.

California Health and Human Services Secretary Mark Ghaly said that, like everyone else, the state was still learning how to properly combat the pandemic. But he argued it does make sense to tailor local responses to Covid-19 to what’s happening locally — and that’s what the state tried to do as it let some counties move quicker than others, while keeping some oversight by enforcing certain criteria before counties moved ahead.

The state is still “figuring out … the balance between hundreds of different things,” Ghaly told me. That includes, he added, “how you support counties making local decisions while maintaining some level of cohesiveness at a regional and statewide level so we don’t erode gains.”

Still, the fractured nature of federalism doesn’t help for fighting a virus that ignores local, state, and national borders.

A recent study in Science backed that up. Running simulations for Europe, researchers concluded that better-coordinated action within the European Union can help suppress Covid-19 better than different countries acting in different ways. Drawing on that finding, the authors concluded:

The implications of our study extend well beyond Europe and COVID-19, broadly demonstrating the importance of communities coordinating easing of various [non-pharmaceutical interventions] for any potential pandemic. In the United States, [non-pharmaceutical interventions] have been generally implemented at the state-level, and because states will be strongly interconnected, our results emphasize national coordination of pandemic preparedness efforts moving forward.

That the US has by and large stuck to a state-by-state and county-by-county approach to public health — an approach that predates the coronavirus pandemic — can help explain, then, why the country has continued to fail to control Covid-19 in the same way countries with strong national plans and, in some cases, international cooperation haven’t. To this day, America reports among the highest rates of coronavirus cases and deaths in the world.

In that context, with outbreaks raging around San Francisco and California, there’s only so much any single local or state government could do. “When you look at success stories of countries on Covid, you had a strong central voice,” Chin-Hong said.

So while San Francisco has done a lot right, it will take the rest of the country adopting a similar approach for the city, the broader Bay Area, or anywhere else in the US to really be safe from the coronavirus.

 

 

 

 

Administration’s new pandemic adviser pushes controversial ‘herd immunity’ strategy, worrying public health officials

https://www.washingtonpost.com/politics/trump-coronavirus-scott-atlas-herd-immunity/2020/08/30/925e68fe-e93b-11ea-970a-64c73a1c2392_story.html?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most

 

 

One of President Trump’s top medical advisers is urging the White House to embrace a controversial “herd immunity” strategy to combat the pandemic, which would entail allowing the coronavirus to spread through most of the population to quickly build resistance to the virus, while taking steps to protect those in nursing homes and other vulnerable populations, according to five people familiar with the discussions.

The administration has already begun to implement some policies along these lines, according to current and former officials as well as experts, particularly with regard to testing.

The approach’s chief proponent is Scott Atlas, a neuroradiologist from Stanford’s conservative Hoover Institution, who joined the White House earlier this month as a pandemic adviser. He has advocated that the United States adopt the model Sweden has used to respond to the virus outbreak, according to these officials, which relies on lifting restrictions so the healthy can build up immunity to the disease rather than limiting social and business interactions to prevent the virus from spreading.

Sweden’s handling of the pandemic has been heavily criticized by public health officials and infectious-disease experts as reckless — the country has among the highest infection and death rates in the world. It also hasn’t escaped the deep economic problems resulting from the pandemic.

But Sweden’s approach has gained support among some conservatives who argue that social distancing restrictions are crushing the economy and infringing on people’s liberties.

That this approach is even being discussed inside the White House is drawing concern from experts inside and outside the government who note that a herd immunity strategy could lead to the country suffering hundreds of thousands, if not millions, of lost lives.

“The administration faces some pretty serious hurdles in making this argument. One is a lot of people will die, even if you can protect people in nursing homes,” said Paul Romer, a professor at New York University who won the Nobel Prize in economics in 2018. “Once it’s out in the community, we’ve seen over and over again, it ends up spreading everywhere.”

Atlas, who does not have a background in infectious diseases or epidemiology, has expanded his influence inside the White House by advocating policies that appeal to Trump’s desire to move past the pandemic and get the economy going, distressing health officials on the White House coronavirus task force and throughout the administration who worry that their advice is being followed less and less.

Atlas declined several interview requests in recent days. After the publication of this story, he released a statement through the White House: “There is no policy of the President or this administration of achieving herd immunity. There never has been any such policy recommended to the President or to anyone else from me.”

White House communications director Alyssa Farah said there is no change in the White House’s approach toward combatting the pandemic.

“President Trump is fully focused on defeating the virus through therapeutics and ultimately a vaccine. There is no discussion about changing our strategy,” she said in a statement. “We have initiated an unprecedented effort under Operation Warp Speed to safely bring a vaccine to market in record time — ending this virus through medicine is our top focus.”

White House officials said Trump has asked questions about herd immunity but has not formally embraced the strategy. The president, however, has made public comments that advocate a similar approach.

“We are aggressively sheltering those at highest risk, especially the elderly, while allowing lower-risk Americans to safely return to work and to school, and we want to see so many of those great states be open,” he said during his address to the Republican National Convention Thursday night. “We want them to be open. They have to be open. They have to get back to work.”

Atlas has fashioned himself as the “anti-Dr. Fauci,” one senior administration official said, referring to Anthony S. Fauci, the nation’s top infectious-disease official, who has repeatedly been at odds with the president over his public comments about the threat posed by the virus. He has clashed with Fauci as well as Deborah Birx, the White House coronavirus response coordinator, over the administration’s pandemic response.

Atlas has argued both internally and in public that an increased case count will move the nation more quickly to herd immunity and won’t lead to more deaths if the vulnerable are protected. But infectious-disease experts strongly dispute that, noting that more than 25,000 people younger than 65 have died of the virus in the United States. In addition, the United States has a higher number of vulnerable people of all ages because of high rates of heart and lung disease and obesity, and millions of vulnerable people live outside nursing homes — many in the same households with children, whom Atlas believes should return to school.

“When younger, healthier people get the disease, they don’t have a problem with the disease. I’m not sure why that’s so difficult for everyone to acknowledge,” Atlas said in an interview with Fox News’s Brian Kilmeade in July. “These people getting the infection is not really a problem and in fact, as we said months ago, when you isolate everyone, including all the healthy people, you’re prolonging the problem because you’re preventing population immunity. Low-risk groups getting the infection is not a problem.”

Atlas has said that lockdowns and social distancing restrictions during the pandemic have had a health cost as well, noting the problems associated with unemployment and people forgoing health care because they are afraid to visit a doctor.

“From personal communications with neurosurgery colleagues, about half of their patients have not appeared for treatment of disease which, left untreated, risks brain hemorrhage, paralysis or death,” he wrote in The Hill newspaper in May

The White House has left many of the day-to-day decisions regarding the pandemic to governors and local officials, many of whom have disregarded Trump’s advice, making it unclear how many states would embrace the Swedish model, or elements of it, if Trump begins to aggressively push for it to be adopted.

But two senior administration officials and one former official, as well as medical experts, noted that the administration is already taking steps to move the country in this direction.

The Department of Health and Human Services, for instance, invoked the Defense Production Act earlier this month to expedite the shipment of tests to nursing homes — but the administration has not significantly ramped up spending on testing elsewhere, despite persistent shortages. Trump and top White House aides, including Atlas, have also repeatedly pushed to reopen schools and lift lockdown orders, despite outbreaks in several schools that attempted to resume in-person classes.

The Centers for Disease Control and Prevention also updated its testing guidance last week to say that those who are asymptomatic do not necessarily have to be tested. That prompted an outcry from medical groups, infectious-disease experts and local health officials, who said the change meant that asymptomatic people who had contact with an infected person would not be tested. The CDC estimates that about 40 percent of people infected with covid-19, the disease caused by the coronavirus, are asymptomatic, and experts said much of the summer surge in infections was due to asymptomatic spread among young, healthy people.

Trump has previously floated “going herd” before being convinced by Fauci and others that it was not a good idea, according to one official.

The discussions come as at least 5.9 million infections have been reported and at least 179,000 have died from the virus this year and as public opinion polls show that Trump’s biggest liability with voters in his contest against Democratic nominee Joe Biden is his handling of the pandemic. The United States leads the world in coronavirus cases and deaths, with far more casualties and infections than any other developed nation.

The nations that have most successfully managed the coronavirus outbreak imposed stringent lockdown measures that a vast majority of the country abided by, quickly ramped up testing and contact tracing, and imposed mask mandates.

Atlas meets with Trump almost every day, far more than any other health official, and inside the White House is viewed as aligned with the president and White House Chief of Staff Mark Meadows on how to handle the outbreak, according to three senior administration officials.

In meetings, Atlas has argued that metropolitan areas such as New York, Chicago and New Orleans have already reached herd immunity, according to two senior administration officials. But Birx and Fauci have disputed that, arguing that even cities that peaked to potential herd immunity levels experience similar levels of infection if they reopen too quickly, the officials said.

Trump asked Birx in a meeting last month whether New York and New Jersey had reached herd immunity, according to a senior administration official. Birx told the president there was not enough data to support that conclusion.

Atlas has supporters who argue that his presence in the White House is a good thing and that he brings a new perspective.

“Epidemiology is not the only discipline that matters for public policy here. That is a fundamentally wrong way to think about this whole situation,” said Avik Roy, president of the Foundation for Research on Equal Opportunity, a think tank that researches market-based solutions to help low-income Americans. “You have to think about what are the costs of lockdowns, what are the trade-offs, and those are fundamentally subjective judgments policymakers have to make.”

It remains unclear how large a percentage of the population must become infected to achieve “herd immunity,” which is when enough people become immune to a disease that it slows its spread, even among those who have not been infected. That can occur either through mass vaccination efforts, or when enough people in the population become infected with coronavirus and develop antibodies that protect them against future infection.

Estimates have ranged from 20 percent to 70 percent for how much of a population would need to be infected. Soumya Swaminathan, the World Health Organization’s chief scientist, said given the transmissibility of the novel coronavirus, it is likely that about 65 to 70 percent of the population would need to become infected for there to be herd immunity.

With a population of 328 million in the United States, it may require 2.13 million deaths to reach a 65 percent threshold of herd immunity, assuming the virus has a 1 percent fatality rate, according to an analysis by The Washington Post.

It also remains unclear whether people who recover from covid-19 have long-term immunity to the virus or can become reinfected, and scientists are still learning who is vulnerable to the disease. From a practical standpoint, it is also nearly impossible to sufficiently isolate people at most risk of dying due to the virus from the younger, healthier population, according to public health experts.

Atlas has argued that the country should only be testing people with symptoms, despite the fact that asymptomatic carriers spread the virus. He has also repeatedly pushed to reopen schools and advocated for college sports to resume. Atlas has said, without evidence, that children do not spread the virus and do not have any real risk from covid-19, arguing that more children die of influenza — an argument he has made in television and radio interviews.

Atlas’s appointment comes after Trump earlier this summer encouraged his White House advisers to find a new doctor who would argue an alternative point of view from Birx and Fauci, whom the president has grown increasingly annoyed with for public comments that he believes contradict his own assertions that the threat of the virus is receding. Advisers sought a doctor with Ivy League or top university credentials who could make the case on television that the virus is a receding threat.

Atlas caught Trump’s attention with a spate of Fox News appearances in recent months, and the president has found a more simpatico figure in the Stanford doctor for his push to reopen the country so he can focus on his reelection. Atlas now often sits in the briefing room with Trump during his coronavirus news conferences, even as other doctors do not. He has given the president somewhat of a medical imprimatur for his statements and regularly helps draft the administration’s coronavirus talking points from his West Wing office as well as the slides that Trump often relies on for his argument of a diminishing threat.

Atlas has also said he is unsure “scientifically” whether masks make sense, despite broad consensus among scientists that they are effective. He has selectively presented research and findings that support his argument for herd immunity and his other ideas, two senior administration officials said.

Fauci and Birx have both said the virus is a threat in every part of the country. They have also put forward policy recommendations that the president views as too draconian, including mask mandates and partial lockdowns in areas experiencing surges of the virus.

Birx has been at odds with Atlas on several occasions, with one disagreement growing so heated at a coronavirus meeting earlier this month that other administration officials grew uncomfortable, according to a senior administration official.

One of the main points of tension between the two is over school reopenings. Atlas has pushed to reopen schools and Birx is more cautious.

“This is really unfortunate to have this fellow Scott Atlas, who was basically recruited to crowd out Tony Fauci and the voice of reason,” said Eric Topol, a cardiologist and head of the Scripps Research Translational Institute in San Diego. “Not only do we not embrace the science, but we repudiate the science by our president, and that has extended by bringing in another unreliable misinformation vector.”