Scientific work on the novel coronavirus and the disease it causes (COVID-19) is exploding in all directions with new discoveries. The number of scientific papers on these topics already surpasses 23,000. So too, the social, economic, and political developments at all levels are evolving at a rapid clip. We are living through a period of unparalleled upheaval - in our homes, our schools, our workplaces, and our communities. Keen observers note that we are all in the “same storm, but in different boats”. But one thing is crystal clear, our fates are joined together. Even if some are on a speed boat, zooming away to safety, and others are on an ill-constructed, rudderless raft, we still inescapably share this world and the consequences of each other’s actions.
On May 8 Governor Cooper announced Phase 1 of reopening. Now we may leave home for commercial activity, gather outdoors with friends, and visit state parks and trails. Also, retail may operate at 50% capacity with cleaning and physical distancing. I was happy that my family was able to take our annual Mother’s Day picture among Occoneechee Mountain’s blooming mountain laurels, but we will not shop any time soon.
Many public health experts share a deep unease at the easing of any official restrictions because workplaces and private citizens have not yet fully adopted the measures that we need to stop spread. State cell phone data show that we have not reduced mobility sufficiently. Surveys of mask-wearing estimate that about 50 percent of us use masks. We know that our progress against the coronavirus will stall if we modify restrictions prematurely. We still lack testing capacity, access to personal protective gear, accurate monitoring of the distribution of infection, and health department capacity.
Our collective efforts have had some impact. The stay-at-home and our physical distancing have helped to flatten the curve. The speed of the epidemic curve, measured by new cases or by daily deaths, has definitely slowed in our state. In March, the number of reported new cases doubled with each passing day. Now the number of cases doubles every 20 days. This progress helped avert disaster at our health care facilities. However, though the rate of increase has slowed, the number of new cases reported daily still climbs upward. We’ve seen peaks above 500 cases per day handfuls of times the past two weeks. We have slowed, but not stopped virus transmission.
Reported deaths now edge toward a total of 700 statewide. The picture for deaths in our state shows that progress has already stalled. We’ve had two weeks with spikes of reported deaths greater than 20 per day with a peak of 29 deaths on April 13. The predictions of the mathematical models I reported in my last column failed to indicate this stalling. The model predicted one spike followed by a rapid decline. On average, instead of a steep decline like the models predicted, we have between 15-20 deaths per day. Different “recipes” for modeling use different “ingredients” and techniques. This model, from the University of Washington, has been strongly criticised for its simplicity and instability by more traditional epidemic modeling groups. These experts contend that we’ve a 76 percent chance that our death rate has already peaked. They predict a slower decline through June, and the total deaths may reach as high as 1350 by early August. In our case, the original model was a blunt tool, unable to capture the characteristics of our state. In the last months, outbreaks tore through North Carolina nursing homes, rehab centers, prisons and jails, and meat and chicken processing plants, generating about 80 percent of the NC deaths early on, whereas nationwide, outbreaks in these types of facilities led to about half of all reported coronavirus deaths. Now they contribute 58 percent of all NC’s coronavirus deaths. In Orange County, the first 13 deaths out of a total of 18 to date victimized elders in three such facilities. Models only give us a glimpse of possible futures, a range of possibilities, and are not a template. Our future is still highly dependent on our actions.
The stay-at-home phase put the breaks on epidemic spread and bought us time to protect our hospitals from catastrophic overload. As we move to the next phase, loosening the stay-at-home and mounting public health efforts to proactively “box in the virus”, we must still keep our foot on the breaks through individual actions - physical distancing, wearing masks, handwashing, and other hygiene practices. Together we are going to box in the virus using tried and true public health strategies. This is going to be a challenge but we can get through this. The four corners of the box are to test widely, to isolate infected people to prevent spread, to find all who came in close contact with infected people, and to quarantine, or self-isolate these contacts until we are sure that they have not contracted the infection. The state and county health departments are quickly building capacity to box-it-in. To be successful, they will need to work in close collaboration with each other, and the public will need to be ready to cooperate. Once box-it-in is fully operational, we will be well-prepared to use this same strategy when vaccines and curative medicines come available.
First, the pace of testing must increase dramatically. The Governor signed bills to make this happen but we are not where we need to be yet. The message to the public will change about who will be tested and when. Currently, hospitalized cases and health care workers have had access to limited testing. People with mild illness stay home and don’t get tested. With box-it-in, we will work towards testing all people with symptoms. Some estimate that we will ultimately need 3 to 30 times the testing that we currently have. To begin with, as we grow testing capacity, we will need to prioritize those with coronavirus symptoms.
Second, we must agree to isolate. Isolate means that, for those of us who fall ill with COVID-19 symptoms (confirmed by testing), we will agree to isolate at our home, up to 14 days, until the symptoms resolve and we are virus-free. The county health department will help support our isolation, with information and materials on how to prevent passing the coronavirus to members of our household (masks, sanitation, hygiene) and linkage to medical care we may need to get well. In Germany, connecting cases to care early on prevented people from severe illness, respirator use, and death. Health departments will also have to grow their capacity to support individuals in isolation. This may include arranging alternate housing if isolation is not possible at our homes, and helping with other needs to successfully isolate while ill - food, shelter, childcare, sick leave. And, to be most effective, to end isolation we need testing to ensure that cases are virus-free.
Third, we must participate fully in contact tracing. That means that, if we get COVID-19, we will help the health department warn people who had contact with us when we were shedding virus. Contract tracing lets the person ill with COVID-19 (the index case) help safeguard the health of others. The health department staff meet with the index case, and through a strictly confidential process, they’ll identify all individuals who may have been in close contact with the index case before symptoms started. For a respiratory disease like COVID-19, this means people who might have shared airspace or other close contact. The most highly exposed people are household members. Studies in China found that 13 to 19 percent of family members got infected from the index case. Other close contacts might be coworkers and friends. On average, index cases identify 10 people for tracing. The state health department announced that it will expand its capacity for contact tracing by hiring and training another 250 contact tracers to add to the 250 people already at local health departments. Contact tracing does have its challenges though. Until capacity is increased, we may have to prioritize highest risk contacts. Tracing depends on building trust and collaboration between the public and the health department. Some index cases and contacts may be hard to find. And, to be most effective, we need testing to determine if contacts are already infected and should be counted as index cases, or are currently uninfected.
Fourth, we must agree to quarantine. Quarantine means that, if we get a call from the health department letting us know that we have been exposed to the coronavirus, we will agree to a 14 day stay-at-home quarantine during which we will monitor ourselves once a day for fever and other symptoms. If testing is available, we will get tested. The health department will support us like they help the index case, so we can successfully complete quarantine. If we get sick, they will help us get linked to care. We would then become an index case and we would help the health department find our contacts. And, to be most effective, to end quarantine we need testing to ensure that contacts are virus-free.
By building a tight box around cases and their contacts we capture emerging infection. We also help people get linked to care earlier (better prognosis) and to keep them from spreading infection further. There is strong evidence that closer monitoring of people infected with the coronavirus can detect pneumonia early, and prevent silent hypoxia. That will keep people off respirators and lower the death rate. If we can also combine that with new treatments to shorten the duration of the illness, we have something substantial to offer index cases and the networks of exposed contacts who are at high risk of infection.
We have embraced less-than-100%-perfect prevention measures and together these measures have helped slow the epidemic. But we need to do more. We are in this together. We can protect ourselves and each other. It is time to go after the virus and box it in.
Rachel A. Royce, PhD, MPH, is an infectious disease epidemiologist with more than 30 years of
experience designing, directing, and managing research in epidemiology and public health
practice. Her work has primarily focused on tuberculosis, HIV/AIDS, sexually transmitted
diseases, health disparities, and preterm delivery as well as the design of tools for evaluation of
public health programs. Dr. Royce currently is a private consultant. This is the fifth column that she has written for the News of Orange about the coronavirus pandemic and what it means for residents of Orange County.
o help people understand the outbreak, the local situation, and how to protect themselves and our community.
March 26, 2020. Measures of personal hygiene that we can take to protect ourselves and our community. http://www.newsoforange.com/community/article_4d2ed676-6f68-11ea-8cb5-a74ab9d17afb.html
2 April 3, 2020. Stay at home orders. http://www.newsoforange.com/community/article_84b09340-75b3-11ea-a44b-ff85b96ca8e1.html
3 April 13, 2020. How coronavirus spreads through droplets. http://www.newsoforange.com/community/article_0e71076a-7d8c-11ea-9277-4bb2aff8ef1b.html
April 17, 2020. Face masks. http://www.newsoforange.com/community/article_0b22213c-80e0-11ea-8087-4b593a231731.html