Issue: April 2020
Source/Disclosures
Disclosures: Adalja, Chin-Hong, Clancy, Creech, Marrazzo, Tirupathi and Volberding report no relevant financial disclosures.
April 23, 2020
11 min read
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‘We should have been prepared’: COVID-19 devastates vulnerable US

Issue: April 2020
Source/Disclosures
Disclosures: Adalja, Chin-Hong, Clancy, Creech, Marrazzo, Tirupathi and Volberding report no relevant financial disclosures.
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A little more than 3 years before the United States announced its first confirmed case of what would come to be called COVID-19, Anthony S. Fauci, MD, told a gathering of students and global health experts at Georgetown University that there was “no doubt” the Trump administration would face a surprise infectious disease outbreak. Fauci’s experience as director of the National Institute of Allergy and Infectious Diseases for more than 30 years told him that it was inevitable. Just since 2000, there had been outbreaks of West Nile virus, severe acute respiratory syndrome (SARS) and Zika virus, the 2009 H1N1 influenza pandemic and the years-long West African Ebola epidemic.

“We will definitely get surprised in the next few years,” Fauci said during a forum on pandemic preparedness held Jan. 10, 2017 — 10 days before Donald J. Trump was inaugurated.

Infectious Diseases in Children spoke with infectious disease and public health experts about the U.S. response to the COVID-19 pandemic and why the country was caught off guard.

Experts have long warned that it was not a matter of if, but when, the next pandemic would strike. In May 2018, the Johns Hopkins Center for Health Security published a report on the pandemic potential of certain microbes, naming RNA viruses as the biggest threat. SARS-CoV-2, the novel coronavirus that causes COVID-19, is an RNA virus. The authors of the report called for improved global surveillance of respiratory-borne RNA viruses and an increased emphasis on developing therapies and vaccines against them. The Trump administration itself conducted a series of exercises over the course of several months last year that simulated a pandemic caused by another RNA respiratory virus, influenza, in which more than half a million Americans died. According to a report in The New York Times, the results showed that the country was “underfunded, underprepared and uncoordinated” to face a deadly virus with no treatment.

President Donald J. Trump and National Institute of Allergy and Infectious Diseases Director Anthony S. Fauci, MD, often gave conflicting messages about COVID-19, health experts said.
President Donald J. Trump and National Institute of Allergy and Infectious Diseases Director Anthony S. Fauci, MD, often gave conflicting messages about COVID-19, health experts said.
Source: Courtesy of White House/Photo by Joyce N. Boghosian

On Jan. 29 this year, after returning from a visit to China with other WHO officials, Michael J. Ryan, MD, MPH, head of the agency’s emergencies program, described the “extraordinary challenge” that China was facing in responding to the novel coronavirus and warned that “the whole world needs to be on alert now.”

Despite these and numerous other warnings, the U.S. government was not ready for a dangerous pandemic and was slow to act when COVID-19 emerged as a clear threat, according to experts who spoke with Infectious Diseases in Children. Testing capacity described by experts as inadequate meant officials were unsure of the scope of the U.S. outbreak for some time, delaying an appropriate response. National messaging came mostly from the White House — not the CDC — and was often awash with misinformation not rooted in the science of outbreaks or infectious diseases, experts recalled.

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Hospitals and health care workers were left unprepared, lacking surge capacity to provide available beds for sick patients and personal protective equipment like masks and gloves to safeguard physicians and nurses. Once testing finally ramped up, there was a shortage of nasal swabs, experts said.

Infectious Diseases in Children Editorial Board Member C. Buddy Creech, MD, MPH, associate professor of pediatrics and director of the Vanderbilt Vaccine Research Program at the Vanderbilt University School of Medicine, said the response has been complicated by the challenge of learning quickly about a disease that was unknown until just months ago.

C. Buddy Creech, MD, MPH
C. Buddy Creech

Thus far, the disease has been uncommon in children. When it does occur, it is typically milder compared with adult cases, Creech noted.

“There’s a need for a lot of agility and a lot of modifying things on the fly,” he said. “The analogy of building the plane while you’re flying it is perfect here.”

Cornelius (Neil) J. Clancy, MD
Cornelius (Neil) J. Clancy

Health care delivery in the U.S. is short term and largely reactive, said 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. The U.S. does not spend enough money on prevention, leaving it to “respond to a crisis and then move on, forget,” Clancy said.

“This was not a surprise,” Clancy said. “We should have been prepared.”

‘Flying blind’

Early in the outbreak, all U.S. testing for SARS-CoV-2 was conducted at the CDC, which had developed a test within a week after scientists in China shared the genome sequence of the virus on Jan. 10. The agency submitted an Emergency Use Authorization package to the FDA on Feb. 3 — 2 weeks after the first U.S. case was reported on Jan. 21 — with the hope of accelerating FDA-permitted use of the diagnostic panel. But a wider rollout of testing was delayed when a problem related to the manufacturing of one of the reagents kept laboratories from being able to verify the test performance, the CDC said.

Despite the availability of other tests, including one developed by WHO, testing in the U.S. was not common for weeks as the virus spread.

The lack of testing capacity “left us largely flying blind, not knowing where cases were and hampering response efforts,” said Amesh A. Adalja, MD, senior scholar at the Johns Hopkins Center for Health Security.

Not only that, but it forced states to use “draconian measures” to keep people quarantined, according to Infectious Diseases in Children Editorial Board Member Paul A. Volberding, MD, professor of medicine and director of the AIDS Research Institute at the University of California, San Francisco (UCSF). Without a clear idea of how many people were infected and where, governors closed schools and nonessential businesses and issued stay-at-home orders.

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Paul A. Volberding, MD
Paul A. Volberding

“The fact that our government insisted on going its own way, even though other tests were developed almost immediately, was really the huge failing of our response,” Volberding said.

Clancy called the failed testing rollout “inexplicable” and said he fears the CDC and U.S. more generally have “taken a massive blow to their credibility and long-standing position as the international leader in public health.” The nadir, Clancy said, was a March 6 press event at the CDC in Atlanta during which Trump, flanked by HHS Secretary Alex M. Azar II and CDC Director Robert R. Redfield, MD, exclaimed that “anybody that needs a test can have a test,” despite there being no evidence that the country was in a position to test very many people at that point or in the near future.

“I can’t imagine a lower day in CDC history,” Clancy said. “As a nation, we currently have very little credibility internationally at this point in COVID-19 matters.”

In early March, Vice President Mike Pence, picked by Trump to lead the U.S. response, said that the U.S. would soon be capable of testing 1 million people. On March 26, the day the U.S. surpassed Italy and China for the most reported cases, Pence announced that 552,000 tests had been conducted in the U.S.

Jeanne M. Marrazzo, MD, MPH, professor and director of the division of infectious diseases at the University of Alabama at Birmingham School of Medicine, called the early testing issues a “debacle” and said it was “the most embarrassing thing the CDC has ever been involved with.”

Experts and officials have drawn comparisons between the testing capacity of the U.S. and that of other countries like South Korea, which has experienced a less intense outbreak. Blame for the lack of testing in the U.S. has been directed at both the White House and the CDC.

Jeanne M. Marrazzo, MD, MPH
Jeanne M. Marrazzo

“The problems with testing deployment must at least partly be the CDC’s fault,” Volberding said. “To be unable to mobilize testing and unable to maintain a consistent message about what we know and what we don’t know speaks to a failure at some level.”

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What is unclear is how the situation unfolded, said Marrazzo. Was it the result of internal errors, "or meddling from above?" Marrazzo asked.

“Did Redfield fail to exert control and leadership because he was shackled by the administration? Was he simply not up to the task?” Marrazzo asked. “Even if he wasn’t, you have amazing veterans like Dan Jernigan, Anne Schuchat, Nancy Messonnier and Jay Butler who are the consummate pros in this type of situation, and they have been hugely sidelined. So, one wonders: Who was in charge? If competent people were in charge, were they able to communicate their recommendations up, and were they ignored? Did Redfield do enough to argue on their behalf? That worries me.”

Harmful messaging

By mid-March, the CDC stopped its regular press briefings, which usually were led by Messonnier, the director of the agency’s National Center for Immunization and Respiratory Diseases. Redfield was not seen as often at pandemic-related briefings, and Schuchat, the agency’s principle deputy director, was rarely involved in public events. Experts accustomed to seeing the CDC take the lead during health emergencies wondered why the agency’s profile was so low as the U.S. outbreak mushroomed.

“I’m perplexed, and saddened, that the agency seems to be sitting on the sidelines for this pandemic and is not building on the accumulated skills and experience from its past,” Pierre Rollin, MD, retired deputy chief of the CDC’s Viral Special Pathogens Branch, wrote in an opinion article on the news website Stat.

A CDC spokesperson told Infectious Diseases in Children that, as of March 20, 111 of the agency’s Epidemic Intelligence Service officers were involved in the response, many of them embedded in state health departments.

Fast Facts

“I feel very badly for the CDC rank-and-file, who are dedicated public servants and highly competent professionals, and the ones responsible for the agency’s past reputation,” Clancy said. “They have been badly let down by their director and our political leadership.”

The White House began hosting daily briefings. It was typical of these briefings for Trump to make predictions about the end of the U.S. outbreak or tout unproven treatments like hydroxychloroquine, an antimalarial drug often prescribed to treat lupus and one of four treatments included in an international trial launched by WHO to find potential therapies for the disease. Clancy said that hospitals and clinics in Pittsburgh were “inundated” with requests for the drug, and that pharmacies received numerous outpatient requests for it, after Trump used the White House briefing room and his Twitter account to trumpet its promise. (The FDA authorized the emergency use of two antimalarial medications, including hydroxychloroquine, to treat some hospitalized patients with COVID-19.)

 

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According to Volberding, the message coming from the president seemed to be “don’t worry, this is not a big deal.”

“It was repeated over and over, along with a lot of self-congratulation,” Volberding said. “I understand the temptation to say, ‘Don’t worry, we’re facing a frightening situation.’ But the message shouldn’t sound as though you know there’s no need to worry.”

The lack of communication about the urgency of the situation and how dangerous the virus was, especially after what occurred in China, left the U.S. more vulnerable, Marrazzo said.

“It was harmful not giving CDC and NIH clear authority to be the scientifically credible voices to communicate what was happening in real time,” she said.

Fauci, as part of the president’s coronavirus task force, was present at most briefings and was a prominent source of scientific information about the outbreak. But Trump and Fauci often gave conflicting messages, and the messages were muddled, Clancy said. Worse, Trump’s early understatement or denial of the true threat posed by COVID-19 made it difficult to convince some people to take it seriously and change their behaviors, he said.

“While events unfolded overseas, our leadership first dawdled and then minimized the situation,” Clancy said. “You had various parties contradicting one another, and the president in turn saying and tweeting whatever popped in his head. Every principle of the CDC’s rules for communication in time of public health crisis were violated: be fast, be accurate, be consistent.”

‘We have to hope and pray’

Some, including Fauci and Trump, have credited an early federal order to restrict travel from China with delaying the eventual widespread emergence of COVID-19 in the U.S. Clancy agreed.

“As many others have pointed out, however, we squandered that lead time by failing to prepare for COVID-19 and denying or minimizing the threat,” he said.

The federal government eventually authorized trillions in pandemic-related funding, but some of the most helpful responses came at the local level, Clancy said. Hospitals, labs, universities, medical schools, public health departments, businesses and sporting and cultural leaders “took bold action when they realized they would not get meaningful federal guidance,” he said.

In hospitals, physicians are worried not just about their patients but also their friends and families.

“I fear that we are going to see many patients and possibly some colleagues die,” Marrazzo said.

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Raghavendra Tirupathi, MD, medical director for Keystone Infectious Diseases/HIV and chair of infection prevention at Summit Health, said a lack of investment in pandemic preparedness was “bearing its effect” in this regard.

“The thought of rationing care and equipment when there is a surge is very unsettling for all of us and will be one of the nightmarish decisions we hope we never have to make,” he said. “These are extraordinary times.”

Peter Chin-Hong, MD, professor of medicine and director of the transplant infectious disease program at UCSF, recounted treating a patient with COVID-19 and worrying that he would carry the virus home on his shoes, spreading it around the house. He said some colleagues started keeping a clean pair of shoes in the car.

“In ID, you can be in two camps: You can be afraid of everything because you know too much, or you can be afraid of nothing because, what’s the point? There’s too much to worry about,” Chin-Hong said. “I’m in the not-afraid-of-anything camp, but it is very different with this infection. There’s the fear of making other people sick.”

Experts have warned for years that few hospitals in the U.S. have surge capacity, an issue that was brought to the surface during the severe 2017-2018 influenza season, in which the number of hospitalizations exceeded the number of staffed hospital beds.

“I don’t know that [the health care system] will do well in the in the end or not,” Volberding said. “We all have to hope and pray that it does.” – by Gerard Gallagher, Julia Ernst, MS, Ken Downey Jr. and Eamon Dreisbach

Editor’s note: Developments in the COVID-19 pandemic are quickly evolving. Information in this story was up to date at the time of publication. To access the latest updates for practicing clinicians, visit our COVID-19 Resource Center at www.Healio.com/coronavirus.

Click here to read the POINTCOUNTER, “What is the US’s single greatest weakness in regard to pandemic preparedness?

Disclosures: Adalja, Chin-Hong, Clancy, Creech, Marrazzo, Tirupathi and Volberding report no relevant financial disclosures.