Testing, Treatments, Monitoring and Contract Tracing

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Dear Patients,

Cathy Tong and I compiled our ideas about how our country can move towards normalcy. These ideas are based on our experience with coronavirus so far and our judgment as family health practitioners. We do not claim to be experts on coronavirus or pandemics, but we have formulated what we consider a reasonable guide to the next three months.

America is reaching the peak of this pandemic, and people are asking when we will be able to return to normal. Millions have lost their jobs, rent and mortgages need to be paid, and medical visits necessary to prevent cancer and control other serious illnesses are delayed. Opinions of our lockdown vary widely between the administration, governors, business leaders, public health experts, and among American citizens. One could also expect a difference of opinion between those whose income remains stable while working at home and those at risk of losing wages, health insurance, and the businesses to which they hope to return in the future. America is paying a high price during this pandemic, and a deep recession could be in our future if we can’t reopen the economy sometime soon.

And yet, reopening the economy, lifting the social restrictions we have in place, and risking a second wave of COVID-19 is a very scary prospect. Fortunately, remaining in lockdown until our safety is guaranteed or opening up and rolling the dice are not the only choices we have. You have changed everything – how you shop for food, staying in your home, visiting family and friends on FaceTime, wearing gloves and masks – and you should get used to the idea of doing so for months longer. We may hear soon about a gradual return to normalcy, but it will be a very different normal.

The models predict that the pandemic bell curve will return to baseline in late May or early June, but we will still have cases of coronavirus and COVID-19 related deaths. All countries in the world that completed the up-and-down cycle continue to have cases. The virus will remain at a low level in our communities, and there will be micro or larger outbreaks. So how can we return to work and school if this is the case?

Testing:

We are currently testing mostly sick patients for the virus and by the time you are reading this more than three million tests will have been performed. In the next phase, between now and June or July, we need to test many more people to find out how many have active disease and how many have antibodies, meaning they had the disease and are now immune (at least for some time). We won’t be able to test everyone in the country, so one option is to concentrate on selected zip codes and test as many people as possible with blanket testing. Knowing the status of a representative community in a region may be the most efficient way to evaluate the risk in that region. (There is an effort underway to evaluate whether we can predict the prevalence of the virus in a community by testing wastewater for the presence of the virus.) We could potentially use this information in several ways. People with immunity might be able to return to work. Healthy people who are not infected and living in areas with few active cases may also be able to return to work. Seniors and those with pre-existing conditions would need to wait for an all-clear signal from health officials before they are released from restrictions.

The difficult question will be how we can test millions more people and who will do the testing. We believe this will require a public/private partnership to mobilize enough people and to create the facilities necessary to get this done. Ironically, there are many furloughed healthcare workers as many doctor’s offices have cut staff and their operations. This could be a source for the large force of testing
personnel needed for this important task. Larger businesses with plans to open likely will need to institute testing at their facilities in order to prevent outbreaks and send people home who are sick or who test positive. They should consider checking temperatures; enforcing rules requiring masks, gloves, and handwashing; and change their operations to maintain social distancing. This may
seem like an impossible task, but it is doable in our opinion. The CDC should set guidelines and state departments of health should implement and supervise the operations. If the results of testing show a high level of risk, then we won’t be able to move forward. The level of risk that is acceptable will be hotly debated, of course, and the decision to open the economy will be a difficult one. It may
require baby steps.

Treatments:

I previously wrote about clinical trials and many of those trials will be reporting preliminary results soon. If we find ways to significantly reduce the mortality of our sickest patients or find treatment regimens to keep those infected from needing hospital treatment, we may feel differently about relaxing restrictions. I understand that a clinical trial of hydroxychloroquine in healthcare workers is starting in South Dakota to see if it is effective in preventing serious disease. If it proves successful and safe, perhaps we could use the drug more widely to reduce hospitalizations and deaths. So much of our care for COVID patients has changed in the last month, and we can reasonably expect to make even more progress over the next few months. I am hopeful that we will find good treatment options long before the development of a vaccine, which is moving forward rapidly.

Monitoring and contact tracing:

If we let people go back to work and school, we must have a reliable way to find new cases, isolate each one, and evaluate their contacts. Public health agencies became overwhelmed quickly in the pandemic, and many areas can’t perform this function. Many countries have used technology to find and follow cases with good success. At the very least, we will need to train thousands more people to perform contact tracing in order to suppress micro-outbreaks before they start a second wave of the pandemic. Again, we believe a public/private partnership will be required, as our public health agencies are clearly understaffed and exhausted.

Putting it all together:

So let’s say we ramp up testing, find good treatments, and develop excellent monitoring and contact tracing – is that enough to open the economy? Can we get reasonably close to this best-case scenario over the next two months? No one knows the answer, but getting as close as possible is imperative. We do know that risking more deaths than necessary from COVID must be avoided. We also know that there are risks to remaining in lockdown. The cost of rising suicides, depression, drug and alcohol addiction, violent crime, spousal and child abuse, and delayed detection of cancer or serious illness is far from trivial.

Protests against the lockdown are escalating and reflect both frustration about the drastic change in our lives and fear of losing everything. We can’t ignore these protests during our deliberations about resolving the COVID pandemic because they represent valid concerns, but they may push our politicians to move too quickly. We need to remain deliberate, consider the data, and make the right
decisions. COVID-19 has emerged as the Super Bowl of political footballs and will remain so between now and the November election. We urge you to understand that the pandemic should not a political issue. Many people and administrations over the last several decades are culpable in our lack of preparedness for this pandemic. We need to stop the finger-pointing. It’s time to roll up our sleeves, get focused, remain practical, and get the job done.

Cathy and I feel confident that public health experts and the Coronavirus Task Force doctors will step above the political fray and steer our President towards reasonable decisions about opening the economy when the time is right.

Eugene Shmorhun, MD

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