US regions start reopening despite limited COVID-19 testing capacity
In recent weeks, state and local governments across the United States have begun making plans to reopen their economies after weeks of social distancing and stay-at-home orders to prevent the spread of COVID-19.
Some regions have started the process of reopening, such as Georgia, where businesses like restaurants, gyms, hair and nail salons, barber shops and massage therapy clinics are allowed to resume business as long as certain social distancing precautions are in place.
One of the top recommendations from the Infectious Diseases Society of America and the HIV Medicine Association on how to safely reopen the country is to first ensure that rapid diagnostic tests are available in every community. However, a recent survey conducted by the Primary Care Collaborative and the Larry A. Green Center found that approximately 32% of primary care practices had no testing capacity and 50% lacked adequate personal protective equipment (PPE) that would allow the practices to safely test patients.
“As some governors start to ease restrictions in their states, we see from our survey that many primary care clinicians are concerned about resuming normal life,” Rebecca Etz, PhD, co-director of The Larry A. Green Center and associate professor of family medicine and population health at Virginia Commonwealth University, said in a press release. “They are largely not providing care face-to-face, so it is really not a surprise that primary care clinicians largely do not think we are ready to open the country back up.”
In the medical community, those in favor of reopening include Dan Erickson, DO, and Artin Massihi, MD, physicians and co-owners of Accelerated Urgent Care in Bakersfield, California. During a press briefing, they gave multiple reasons to support reopening the economy based on what they have seen in their centers and cases in California. Other physicians have disputed their statements.
“The press conference by those doctors was full of factual inaccuracies, which is blatantly wrong at its worst and subtly misleading at its best,” Raghavendra Tirupathi, MD, FACP, medical director of Keystone Infectious Diseases/HIV, chair of infection prevention at Summit Health and clinical assistant professor of medicine at Penn State University School of Medicine, told Healio Primary Care. “These doctors are not infectious disease experts, immunologists, public health experts, epidemiologists or researchers.”
Quarantine and immunity
One reason Erickson and Massihi gave for reopening the country was that immunity could be lowered during prolonged stays at home.
“Our immune system is used to touching. We share bacteria, staphylococcal, streptococcal bacteria [and] viruses. We develop an immune response daily to this stuff,” Erickson said. “When you take that away from me, my immune system drops. As I shelter in place, my immune system drops. You keep me there for months, it drops more.”
He added that if social distancing continues, the population will be more vulnerable to infection, and other diseases could spike as a result when these measures are lifted.
Tirupathi, who is also an Editorial Board member of Infectious Disease News, explained that “the whole concept of shelter in place or lockdown is to reinforce social distancing and decrease exposure to vulnerable patients. The concept of acquiring herd immunity by infection will come at a considerable cost of significantly higher number of lives lost.”
“I don’t think that staying indoors is harmful to our immune system,” he said.
COVID-19 vs. influenza
Erickson and Massihi also said the mortality rate for COVID-19 is similar to that of seasonal influenza.
“COVID-19 is definitely more deadly and infectious than flu,” Tirupathi said.
The case fatality rate of influenza is approximately 0.1%, while the fatality rate of COVID-19 is estimated to be about 1%, making the disease “ten times more deadly than flu,” Tirupathi added. The R0 of COVID-19 — the basic reproduction number — is between 2.5 to 3, and “the secondary attack rate is much higher if it’s a household contact for COVID compared to flu.”
Anne Schuchat, MD, principal deputy director of the CDC, said during a Q&A session with JAMA that the virus is similar to influenza in that it spreads through respiratory droplets, it primarily affects vulnerable populations and it is transmissible from person to person.
However, she noted that as the virus is completely new, there is no built up immunity within the population.
“With influenza, even though there is constant mutation... and every year we make up new vaccines, there is residual population immunity year to year that keeps us from having 100% of people getting flu each year,” she said. “And we have a vaccine for flu. Half of Americans get a flu vaccine each year. So, it’s a pretty big difference in terms of a susceptible population experiencing a transmissible virus.”
Erickson and Massihi also claimed that states should reopen because there have been significantly fewer deaths from COVID-19 than models had projected, including those that accounted for social distancing.
“The initial models were woefully inaccurate,” Erickson said. “They predicted millions of cases of death — not of prevalence or incidents, of death — that is not materializing.”
According to Erickson, 12% of tests in California were positive meaning that when applied to the entire population of 39.5 million in the state, there could be approximately 4.7 million cases in the state. He also said that as 1,227 deaths attributed to COVID-19 had occurred in the state, the chance of dying from the disease was 0.03% in California.
“Does that necessitate sheltering in place? Does that necessitate shutting down medical systems? Does that necessitate people being out of work?” he questioned, noting that 96% of patients who contract COVID-19 in the state recover without significant medical issues.
The latest information on the COVID-19 model from the Institute for Health Metrics and Evaluation — which has been used by the White House Coronavirus Task Force — projects there will be more than 72,000 COVID-19 deaths by August if social distancing continues.
Schuchat noted that the weeks and months of social distancing has flattened the curve in some areas, “but I think this is a virus that it is going to take a long time for us to really wrestle down.”
“We do hope for a vaccine,” she continued. “We hope some of the treatments will bear fruit, but the extent to which this is challenging ... it’s hard to overstate.”
Tirupathi said that although many want to leave home and return to work, “lifting social-distancing measures all at once could risk simply delaying the epidemic’s peak and potentially making it more severe as was noticed in the 1918 pandemic with the second wave much deadlier than the first one.”
Therefore, he explained that a staggered approach led by science and data is needed when relaxing social distancing measures, possibly with states with a lower burden of COVID-19 reopening first.
“It’s difficult to predict how long we may need social distancing given we still do not completely understand the transmission dynamics,” Tirupathi continued. “I would agree with the Harvard study prediction of having some form of distancing until 2022.”
Johns Hopkins’ plan for reopening
Researchers at Johns Hopkins Bloomberg School of Public Health proposed a plan for reopening the nation, which is broken down into four phases.
During a recent media briefing, Crystal R. Watson, DrPH, a senior scholar at Johns Hopkins Center for Health Security at Johns Hopkins Bloomberg School of Public Health outlined the plan. The first phase, she said, is slowing the spread of the virus by staying home and implementing social distancing, followed by a second phase of gradually lifting social distancing measures and reopening state by state. The third phase, she explained, is establishing immune protection for the population through either vaccines or an effective therapeutic, and the final phase is preparing for the next pandemic.
There are four requirements before a region can enter the second phase, according to Watson, which include sustaining a reduction in COVID-19 cases for a 14-day period and ensuring community hospitals are no longer under stress and have adequate clinical supplies and PPE.
Before entering the second phase, regions should also have more widespread testing, she explained.
“We need to be able to test anyone with symptoms at a bare minimum, and we also need those tests to return results back very quickly to enable decision-making,” Watson said.
Johns Hopkins’ plan also calls for an increased workforce responsible for contact tracing in a community before it can enter the second phase of the plan.
Watson noted that while contact tracing is not new, scaling up these efforts will help ensure outbreaks of COVID-19 are more rigorously managed.
“It is used to break chains of transmission... to prevent future waves or surges of cases and to enable us to get back to work in a much safer way,” she said. – by Erin Michael
IMHE. COVID-19 projections: Social distancing assumed until infections minimized and containment implemented. https://covid19.healthdata.org/united-states-of-america. Accessed Apr. 30, 2020.
KGET. Doctors provide differing opinion on shelter-in-place order, say county should reopen. https://www.kget.com/health/coronavirus/doctors-provide-differing-opinion-on-shelter-in-place-order/. Accessed Apr. 29, 2020.
PCPCC. Quick COVID-19 primary care survey. https://www.pcpcc.org/sites/default/files/news_files/C19%20Series%206%20National%20Executive%20Summary%20with%20comments.pdf. Accessed Apr. 29, 2020.
Disclosures: Tirupathi reports no relevant financial disclosures. Healio Primary Care was unable to confirm Erickson, Massihi and Watson’s relevant financial disclosures prior to publication.