Life during COVID

Life during COVID

Source:

Healio Interviews


Disclosures: Chin-Hong, Clancy, Frieden, Krammer, Osterholm, Pai, Sharma, Thompson, Tirupathi, Volberding and Wooten report no relevant financial disclosures.

March 18, 2022
16 min read
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‘This is gonna be bad’: An oral history of the early days of COVID-19

Source:

Healio Interviews


Disclosures: Chin-Hong, Clancy, Frieden, Krammer, Osterholm, Pai, Sharma, Thompson, Tirupathi, Volberding and Wooten report no relevant financial disclosures.

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What started as an outbreak of viral pneumonia that infected dozens of people in a city in central China has grown into a pandemic that has killed nearly one million people in the United States alone.

In a new series of stories called “Life during COVID,” Healio will speak with experts to discuss how the COVID-19 pandemic has reshaped American medicine and society, the lessons it has taught us and whether we are prepared for the next “pathogen X.”

LifeDuringCOVID

For the first installment of the series, we asked infectious disease physicians and other experts about their memories of those first few months, from the initial reports of an unexplained outbreak in Wuhan to the first stay-at-home order issued in the United States by the state of California on March 19, 2020.

What follows is an oral history of their experiences — first as observers of a widening outbreak overseas, then as clinicians, many of them on the front lines, at the start of the first U.S. wave.

The participants, in alphabetical order, are:

Peter Chin-Hong

Peter Chin-Hong, MD, Infectious Disease News Editorial Board Member, and professor of medicine and director of the transplant infectious disease program at the University of California, San Francisco

Conelius (Neil) J. Clancy

Cornelius (Neil) J. Clancy, MD, associate professor of medicine and director of the extensively drug-resistant pathogen lab and mycology program at the University of Pittsburgh

Tom Frieden

Tom Frieden, MD, MPH, former CDC director and president and CEO of Resolve to Save Lives

 

Florian Krammer

Florian Krammer, PhD, professor of vaccinology at the Icahn School of Medicine at Mount Sinai in New York

 

Michael T. Osterholm

Michael T. Osterholm, PhD, MPH, director of the Center for Infectious Disease Research and Policy at the University of Minnesota

 

Gitanjali Pai

Gitanjali Pai, MD, AAHIVS, FIDSA, Infectious Disease News Editorial Board Member, infectious disease physician at Memorial Hospital and Physicians Clinic in Stilwell, Oklahoma, and chief medical officer for the Oklahoma State Department of Health

Amit M. Sharma

Amit M. Sharma, MD, MPH, clinical assistant professor at Geisinger Commonwealth School of Medicine and infectious diseases physician at Geisinger Community Medical Center in Scranton, Pennsylvania

Melanie Thompson

Melanie Thompson, MD, Infectious Disease News Editorial Board Member, and principal investigator at the AIDS Research Consortium of Atlanta

 

Raghavendra Tirupathi

Raghavendra Tirupathi, MD, FACP, Infectious Disease News Editorial Board Member, medical director for Keystone Infectious Diseases/HIV, medical director of infection prevention for WellSpan Chambersburg & WellSpan Waynesboro Hospitals, and clinical assistant professor of medicine at Penn State University School of Medicine in Chambersburg, Pennsylvania

Paul A. Volberding

Paul A. Volberding, MD, Infectious Disease News Chief Medical Editor, and professor emeritus of medicine at the University of California, San Francisco

 

Darcy Wooten

Darcy Wooten, MD, MS, Infectious Disease News Editorial Board Member, and associate professor of medicine and program director of the ID fellowship training program at the University of California, San Diego School of Medicine

[Editor’s note: Some comments have been edited for length and clarity.]

Part I: Emergence

On Dec. 30, 2019, ProMED-mail published a report of a cluster of “unexplained pneumonia” in Wuhan, China. “[T]he type of social media activity that is now surrounding this event is very reminiscent of the original rumors that accompanied the SARS-CoV outbreak,” the post read.

Sharma: My recollection of those earliest reports was of a new pneumonia from Wuhan, China, and the mention of the seafood market.

Krammer: I was very concerned. I heard about it on Dec. 31, 2019. I talked about it at a New Year’s Eve party.

Osterholm: I had a contact on the ground in Wuhan. Those first 2 days in January, I was talking to them, and they were explaining how quickly this was moving and what was happening.

Wooten: As an ID physician, I tend to always focus on the worst-case scenario. When I heard the first reports about the illnesses occurring China, I thought, “Oh no, this is gonna be bad.”

Tirupathi: I was worried about the possibility of an outbreak or even an epidemic, with cases in China and beyond — akin to avian flu — but never thought it would have this scale, magnitude and impact.

Clancy: There was certainly a sense within the ID community that we were overdue. That said, the full scale of what we were facing didn’t become apparent to me until mid- to late January, as cases emerged from elsewhere. To that point, I thought there was at least some chance the wider world might dodge a bullet, as we did with SARS or MERS.

Osterholm: Having extensive experience with both SARS and MERS, I was reassured that we can control this, because in both of those instances, the infectiousness really didn’t develop until day 4 or 5 of the illness. That’s how we were able to shut those down. By Jan. 10, it was very clear that that was not the case. This was not acting like MERS or SARS.

Krammer: I think I realized it was going to be bad in mid-January — human-to-human transmission, rising numbers, first deaths. I was shocked how unresponsive the WHO was and how unresponsive the CDC was. That combination left me with a very bad feeling.

[Editor’s note: WHO directed Healio to a timeline of its response, which can be found here.]

Chin-Hong: The prevailing thinking was, well, maybe the West has better health care capacity, and we will be able to stop it.

Thompson: When Wuhan locked down, I was impressed that this was a serious situation. I remember thinking, “Is this the one?” It was only weeks later that the first U.S. case was identified in Washington State.

Part II: ‘A sense of déjà vu’

On Jan. 21, 2020, health officials confirmed the first U.S. case of the novel coronavirus in a Seattle-area man who had recently returned from a trip to China. Three days later, officials identified a second U.S. case in a Chicago woman who had visited Wuhan and returned to Chicago before the start of precautionary screenings at U.S. airports. On Jan. 30, around the same time officials reported the first case of human-to-human transmission in the U.S., WHO declared the novel coronavirus a Public Health Emergency of International Concern. At the time, there were more than 7,700 reported cases in China and 98 cases in 18 countries outside China. On Feb. 11, the disease caused by SARS-CoV-2 got a name: COVID-19.

Pai: When the first case of this new illness was detected in the U.S., the level of fear exceeded that generated by Ebola and SARS, with its unmistakable link with globalization through air travel — a sense of déjà vu.

Thompson: The ensuing weeks are almost a blur.

Wooten: There was tremendous fear because so much was unknown. These seemed very similar to the emotions from the early days of the AIDS epidemic. Everyone was hungry for information, data, and more details about the virus — how it was transmitted, how it could be prevented, and how to treat it.

Chin-Hong: I had no idea that it would reach all over the world. I thought it would reach some places but would be stamped out in a few months, at least in that region. Globalization and air travel — that happened during SARS as well. But I hoped that it would still be relatively localized.

Osterholm: On Feb. 24, I published an op ed in The New York Times titled, “Is the coronavirus outbreak a pandemic yet?” The subhead was, “It’s now clear that the coronavirus epidemic was never going to be contained. What’s next?” I wrote that the world had to wake up, that this was going to be a pandemic. For me, it wasn't as much of a surprise. I had been thinking a lot about this.

Volberding: I have a long history of working in Italy and with Italian infectious disease and HIV investigators. And so, one of the things that really caught my attention right away was the outbreak in northern Italy. These are my friends, so it made it absolutely not abstract, but very real.

Sharma: I think the literature coming from Italy was a fair measure of what was to come ahead. Until then, both South Korea and China had laid out aggressive containment measures, and testing was rampant. When we started to get data on mortality and the long incubation period, and the involvement of the pulmonary parenchyma, then we all knew that we were probably in it for the long run.

Chin-Hong: There were two phases of me realizing COVID would be bad. The first was when it came to Italy. The second was when the Grand Princess cruise ship came to port. That was really the metaphor for COVID coming to our shores because here was this big cruise ship full of people and they were docked right in the port of San Francisco. I think those two things really made it very obvious that we were dealing with something very global and very different.

Volberding: It was definitely not business as usual at work.

Krammer: We worked crazy hours, 7 days a week. When the wave hit New York, our studies were already up and running. It was crazy busy at Mount Sinai, and we were also shipping reagents and materials to more than 250 labs globally. I didn't sleep much.

Wooten: Even though the scientific advances around COVID-19 were developed faster than for almost any other disease we have encountered, it still wasn't fast enough.

Pai: The medical fraternity had not gauged the forthcoming impact of its high reproduction number and its ability to spread like wildfire.

Volberding: I'm very involved in CROI, which was scheduled for February in Boston. Early on, there was an email discussion: Should we cancel CROI? Had CROI happened, I have no doubt that it would have played a major role as a spreader event, so the decision to go virtual was hugely important. And I'm not sure that the meeting or the organization would have survived had the decision made to the people to do it in person. It was, in retrospect, a really important decision.

Part III: Pandemic

On March 11, with more than 118,000 reported cases in 114 countries and after more than 4,200 deaths, WHO declared a pandemic — the first ever caused by a coronavirus. “We have rung the alarm bell loud and clear,” WHO Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, said.

Pai: In the beginning, we had very few COVID-19 patients. There was more of an “information panic” than a real handle on the severity of the illness. Based on the experience of our Northeast and West Coast colleagues, we tried to preemptively establish testing strategies by putting up testing tents, setting safety protocols — including quarantine guidance — as well as creating new isolation wards, and brainstorming about ventilation, especially negative pressure rooms.

Thompson: In our outpatient setting, we didn’t see the sickest patients but were acutely aware that COVID could be behind every exam room door.

Chin-Hong: We didn't know how it was spread, really. I mean, we knew from infectious disease that it would be respiratory droplets, but I had no idea at that point in retrospect that it could be aerosol. Eventually we went to universal masking, and we navigated the world with trepidation, fear, uncertainty, anxiety, and anticipation at the same time.

Sharma: We had our first wave in mid-March. Initially, elderly nursing home patients were predominant, and then we had household contacts. It was hard work.

Pai: At times, I felt helpless. We had no effective treatments, or for that matter, no proven treatments at all.

Thompson: The early days were spent rapidly transitioning to the new reality — writing protocols for infection control, patient triage, and SARS-CoV-2 testing, all the while trying to manage the fears of patients and staff.

Chin-Hong: In the early days, it was very somber. Knowledge was being acquired very rapidly and locally. We had to teach ourselves, because our biggest usual teacher, the CDC, wasn’t really sending out a lot of dispatches, and what they were sending out was very muted. We summarized information as best as we could, and we started going on social media to share guidelines. At the time, diagnostics were very, very scarce, so we had to rely on clinical criteria. Also, we're trying to get drugs for people when they're severely ill, and this required a lot of, you know, getting approval from the FDA, and then getting compassionate use authorization from Gilead. That took days, and the steps were very opaque to everyone. So, we also put that on social media. That was the knowledge base, in terms of clinical care.

Pai: Every provider evolved their own version of optimal treatment — repurposing existing drugs and so on — since the limited clinical trials of new medications had not yielded conclusive results, at least in the initial days.

Tirupathi: It was the Wild West during the first few weeks, with everyone doing their own thing in treating these patients. I saw all sorts of prescriptions, including hydroxychloroquine, ivermectin, Kaletra, zinc.

Wooten: It was depressing. Caring for patients who are very sick and for whom there are not necessarily optimized treatments is always difficult. I felt so bad for patients because they could not be with their loved ones and were very physically and emotionally isolated during their illness. I was incredibly fortunate that my health system had enough PPE and I felt protected wearing PPE and caring for patients with COVID.

Thompson: PPE was scarce, and we rationed and reused the few KN95/M95 masks available for staff. We also scrounged for surgical masks, both for staff and patients. We ran into shortages of disinfectant and of course, we were constantly wiping down everything, including computer keyboards multiple times a day. The lack of clarity about fomite transmission meant that we went above and beyond in the earliest days.

Pai: The consuming thought was striking a balance between professional duties and the possible risk of infection to near and dear ones. All health care workers were worried about contracting the infection and carrying it home with them.

Chin-Hong: I remember the first patient early on that I could take care of. I was afraid for myself but at the same time we were worried about surfaces and things like that, so when I went home, I would leave my hospital clothes at the door and be certain to take a shower before seeing everyone. I would leave my shoes in the car. I know a lot of colleagues who either stayed in a separate place or in a different part of the house, [for] the entire beginning phase.

Wooten: I remember stripping down outside after coming home from work and taking a shower before hugging and playing with my daughter. Looking back, it's clear that these measures were not necessary. Everything I was doing was driven out of fear of transmitting COVID to my family.

Pai: We started having COVID patients much later than in other areas of the country. Initially, we were hoping against hope that it may not make it to the interior regions of the country, like ours, especially those away from urban population centers. It turned out to be wishful thinking, and it was just a matter of time until we were swamped. Being a small rural hospital, most of the sicker patients ended up being shipped out.

Sharma: Every time I felt that the work was getting too much, I would look at Dr. Fauci, who was probably working harder. The entire experience had shades of emotions — initially, slight anxiety, followed by a sense of pride that we can help the patients and finally, pure happiness when the patients would be discharged home.

Clancy: We got our first cases in Pittsburgh and western PA relatively late, so we had a few extra weeks of preparation. It was, of course, insane at work, even before patients began to arrive. I remember St. Patrick’s Day being a watershed moment. Tom Hanks had hit the news, the NBA announced it was suspending operations, and Pittsburgh decided to let the bars stay open over the St. Patrick’s weekend, which is a bacchanal here. This was, of course, a terrible decision, and then things really shut down locally immediately thereafter.

Part IV: Stay at home

Issued by Gov. Gavin Newsom on March 19, 2020, California’s stay-at-home order did not impact essential workers — including health care workers — and allowed people to visit certain businesses, including supermarkets. Other states issued similar orders.

Chin-Hong: It was sudden. We didn’t have a lot of warning. People are rushing to get to the grocery store — toilet paper and wipes and a lot of groceries in general, because people panicked and didn't know how long it would last. We thought it would be at least a few days, if not a couple of weeks, but then you still have to be prepared.

Thompson: The first days of lockdown were surreal. At home, we closed our doors to the outside world as much as possible, although we always did our own grocery shopping.

Krammer: It was scary. I went to the lab every day. Streets were empty in New York City. The large space we have downstairs, the Guggenheim Pavilion, was converted into bed space. Then we got a field hospital outside in Central Park. Very depressing and scary.

Wooten: I felt mostly fortunate that I never actually had to stay at home to work. I needed to be in clinic and on the ground, and even though this put me at risk for COVID exposure, it did maintain a sense of normalcy and routine that was helpful for my mental health. I remember being in a state of constant anxiety and panic during the first several months of the pandemic.

Chin-Hong: It was just like a nuclear holocaust. Nobody was moving around in the streets. Everybody was quiet. People were staying at home, and people were very isolated.

Volberding: I have a lot of vivid memories of that time. I went to a local small grocery store to buy some stuff. This was before there was any real panic, but already, it was kind of obvious that the toilet paper was gone. There's no toilet paper in the store. And it's like, weird. But I didn't think much more of it than that. And then the next day, I went to a different small grocery store in the neighborhood, and it was panic. There were no potatoes, no garlic, no shallots, no pasta, no tomato sauce. In the middle of that, a woman I'd never seen before came up to me and handed me a package of eggless noodles, something that I was not looking for and had never bought. She said, “I hear they're the last ones.” It was like, “What? What is going on?” That is a very striking memory of that very, very early a moment when everything changed.

Pai: Disinfectants and wipes were suddenly so hard to get hold of. I still remember wiping down mail and packages and using gloves while doing so.

Volberding: Surface spread didn't seem likely to me, so I never got into wiping down groceries, but I did wear gloves in the grocery store. I remember Tony Fauci was quoted as saying that he let his mail sit for 24 hours before he opened it. He might do that now for other reasons.

Thompson: Initially we wiped down handles of grocery carts, nonperishable groceries, and even takeout containers.

Chin-Hong: I never wiped down groceries, but I definitely did a lot of things like wash my hands and rotate masks, which is generally a good idea but still was more religion rather than optional in those early days because we didn't have enough masks. You had a group of five to seven masks, and you just rotated them so that the last one would be the most intact in terms of minimizing surface transmission. Those are the kinds of things that I definitely don't do anymore.

Krammer: Something that seems silly now — I went running in an N95. That made no sense.

Wooten: I remember walking my dog or going for a run with a mask.

Volberding: People didn't shake hands, people didn’t hug. I’m from Minnesota. We're pretty reserved. But I've been in California long enough that, you know, hugging is a normal way of greeting people. And I never could imagine doing that once this started. It was a number of months later before I remember first shaking hands with somebody.

Thompson: The best thing we did was to establish “Sunday supper” by Zoom with a group of friends.

Pai: Then came the pandemic of misinformation! We were constantly battling — and continue to battle — misinformation on repurposed drugs like hydroxychloroquine. Misinformation turned out to be a bigger beast, which has continued till this day.

Frieden: The CDC was in a battle against marginalization and politicization. The most important action that could have been taken would have been to be open and honest with the public by telling them what the agency knew and didn’t know about COVID, as well as what it was doing to learn more. Expressing empathy while promoting practical actions people could take to protect themselves and their communities in a clear, concise manner is vital in public health crises. In fact, Dr. Nancy Messonnier did exactly that — and the CDC was virtually not heard from again in that way for more than a year. Much of the agency’s power and credibility was hindered by the administration at the time, including a focus on low-priority actions which distracted the agency from more important work. Two years on, it’s important that the CDC is strengthened and has the full support of the U.S. government to assess the processes, structures, and funding issues for the agency to succeed at this mission.

Part V: ‘A historic change’

Globally, there have been approximately 464 million reported cases of COVID-19 over the last 27 months, including more than 6 million deaths, according to tracking by Our World in Data and John Hopkins. Around 11 billion doses of COVID-19 vaccine have been administered globally, including almost 700 million in the U.S., but two important waves in the last 8 months — caused by delta and omicron variants of SARS-CoV-2 — have raised questions about how much longer the pandemic will last.

Krammer: Most respiratory virus pandemics in history took 1 1/2 to 2 years.

Thompson: I never had a timeline in my head for when the pandemic would subside, always wary to expect the unexpected. I had cancelled international travel in 2020 and had some hope that I could reschedule in 2021 but was never optimistic about this and for good reason.

Pai: Before the delta wave, we thought we were on the other side of this. The surge in numbers periodically ebbed and got flatter — only to deceive. I believe we are inching gradually toward the other side this time.

Sharma: I initially hoped that the vaccine would help reduce the transmission, and the pandemic may die down in 2 years. But, unfortunately, the presence of variants and the global inequity of vaccine distribution could ensure another couple of years of the pandemic.

Pai: As we continue to maintain our vigilance, we are more optimistic this time around because of the availability of highly effective vaccines and effective treatments, and our understanding of the virus, which has significantly improved since the beginning of the pandemic. We are getting better and better at managing patients, and we continue to try to address vaccine hesitancy and misinformation — which remains the biggest challenge before us currently.

Chin-Hong: A colleague, Brian Schwartz, told me, “You better not get used to talking to media because you'll be in withdrawal by the summer of 2020,” because it will have gone away. He was being cheeky, of course. We definitely thought it would be a hard time, but that it would fizzle out around the world, and everybody would get back to normal. Now, 2 years in, in retrospect, it’s such a humbling and shocking experience every time we get another surge.

Tirupathi: The pandemic brought our specialty into the limelight, with everyone from hospitals to the county government to local businesses to school districts relying on our advice to keep their day-to-day operations going. We were the go-to resource for all things COVID.

Clancy: I hope this doesn't get taken the wrong way, but if on some level an event like this didn't fill you with purpose as an ID clinician, then you chose the wrong line of work. I chose ID as a career because it changes the course of human events and history.

Osterholm: Medicine and public health absolutely have been changed. Just look at what's happened. We've lost 500,000 health care workers in this country in the last 2 years. We're likely to lose more — post-traumatic stress has been remarkable. The same is true with public health. This is truly a historical change in how we looked at and will in the future look at these professions.

Frieden: COVID taught us how severely underprepared and underfunded our public health systems are for health threats. Memories are short, and we are seeing early signs that policymakers just want to move on. We cannot let the cycle of panic and then neglect take hold and allow us to forget COVID’s devastating human and economic losses. We need sustained investments to strengthen public health systems that detect, respond to, and contain infectious disease outbreaks before they grow into epidemics. Unless Congress can ensure a long-term sufficient, sustainable funding mechanism to support these investments, we will find ourselves unprepared for the next pandemic. At the most fundamental level, COVID should teach us that we are all connected, and that ill health anywhere is a threat to health everywhere.

References:

CDC. COVID Data tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-home. Accessed March 17, 2022.

Johns Hopkins University Center for Systems Science and Engineering. https://gisanddata.maps.arcgis.com/apps/dashboards/bda7594740fd40299423467b48e9ecf6. Accessed March 17, 2022.

Our World in Data. https://ourworldindata.org/coronavirus. Accessed March 17, 2022.