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Former CDC director: There's a long war ahead and our Covid-19 response must adapt

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CNN's Shimon Prokupecz reports.

Posted: Mar 20, 2020 9:50 PM
Updated: Mar 20, 2020 9:50 PM

Different times call for different measures. When Covid-19 hit China, I was concerned, as were many public health professionals, about what could happen and urged rapid action to understand more and prepare. But few of us anticipated the catastrophic impact the new virus has had in Wuhan, in Italy and may soon have in many other places.

For most people, there is simply no frame of reference for this pandemic. Never in our lifetime has there been an infectious disease threat as devastating to society. Never in our lifetime have we seen a rich country like Italy face the need to ration respirators. And never have we seen the fear that millions of health care workers around the world feel about being infected by the virus -- justified fear we must address.

What we're learning about the novel coronavirus

We learn more about this virus by the day, often by the hour and most of the news is bad. Here are five things we've learned in the past week:

  • The virus is much more infectious than influenza or the SARS virus, which it closely resembles. This week, new data showed that SARS-CoV-2, the virus that causes Covid-19, can live on contaminated surfaces as the SARS virus can, so it may spread, sometimes explosively, from doorknobs, elevator buttons and contaminated surfaces in hospitals and elsewhere. But we also learned that, unlike SARS, patients become highly infectious before they become seriously ill, explaining at least in part why Covid-19 acts like a super-SARS, far more infectious than its vanquished cousin.

  • It's not just older people with underlying conditions who become very ill and can die. Younger adults, previously healthy people and some children develop viral pneumonia. Although prior reports suggested that 80% of people got only mild disease, it now appears that about half of these people, despite not needing hospital admission, have moderately severe pneumonia, which can take weeks or longer to recover from.

  • Explosive spread will almost certainly overwhelm health care capacity in New York City and elsewhere, and lead to the inability to save patients who could otherwise have been saved. Today's severe cases are in people infected 10 to 14 days ago who got sick five to six days ago and have steadily rogressed to severe illness. That means cases will continue to skyrocket for weeks after spread stops. Not only won't there be enough ventilators, there won't be enough supplies for the ventilators, hospital beds to support patients -- or health care workers to help patients.

  • Health care workers are in peril. Thousands were infected in China, more than 3,000 have been infected in Italy, protective equipment is in short supply in the United States, and as health care becomes overwhelmed, it becomes harder to provide care safely.

  • It's going to get a lot worse. Not only is the global economy in free-fall but supply chains for essentials, including medicines, are disrupted. Even China, which has successfully tamped down spread, is only now reopening its economy -- which produces components of many medicines people rely on -- and very slowly.

This is a war. And in war, strategy is important. The leading concept, now remarkably widely understood, is flattening the curve. This is an important tactic to protect patients and health care workers from a surge that can overwhelm our hospitals, increase death rates and put health care workers' lives at risk. But it is not a strategy. A month ago today, my organization, which focuses on preventing epidemics, published a concept of operations showing the shading of containment into mitigation, and the need to pause contact tracing when it became impractical and scale up social distancing interventions (see link for details.)

Today, learning from another month of experience from around the world, particularly China and South Korea, we recognize a third phase of the response: suppression of episodic outbreaks. In this new third phase, extensive testing and alert clinical systems can identify cases and clusters promptly, intervene extensively and suppress spread before widespread societal harms occur.

The revised approach also recognizes that this is going to be a long war, and that we need to address the extensive risks to societal continuity, including health care for people with ongoing medical needs such as hypertension and diabetes, and the vulnerability of the supply chain for medicines and supplies.

China has outlined an analogous approach, based in part on their experience with cases re-imported from other parts of the world. In China, Hubei province faced a peak that overwhelmed health care services, but other provinces were able to avoid this through aggressive containment (the purple curve below). China remains largely locked down, with only gradual reopening, and is urgently expanding health care capacity, preparing for possible clusters or larger outbreaks in the future.

There are five priorities essential for successful implementation of the third phase of this strategy.

Extensive testing and contact tracing. China has tested millions of people and traced more than 685,000 contacts. Contact tracing requires skilled public health professionals -- and sophisticated data management. Testing is required in multiple venues:

  • Health care facilities. Every patient with fever or cough and every patient requiring mechanical ventilation or with signs or symptoms of pneumonia.
  • Contact tracing. An army of skilled public health workers, potentially empowered by new data streams such as cell phone location trails, are needed to identify exposed people, who must be isolated for 14 days after exposure. How widely a circle of contacts to track, and how and how often to test contacts will depend on emerging information about who spreads the infection and when in the course of their illness.
  • Drive-through. Quick, safe, convenient drive-through testing facilities, as pioneered by South Korea, reduce the burden on health care facilities, reduce the risk to health care workers and others who patients may come into contact with, and identify infections among contacts and others.
  • Surveillance. We need tracking systems, including the Influenza-Like Illness system, to find spread and monitor trends. Syndromic surveillance systems will need to be tuned to detect possible clusters, and signals investigated immediately.

Prepare for health care to surge safely. Every community in the country needs to ramp up the ability to safely care for large number of patients with minimal risk to health care staff. This means not only flexing up the number of beds and availability of oxygen and ventilators, but every aspect of health care including staffing, equipment, supplies and overall management.

Preserve health and routine health care functions. We need to increase the resilience of both our people and our health care facilities, as rapidly as possible.

  • Increase personal health resilience. Underlying conditions greatly increase the risk of severe illness. This isn't just bad for patients who get infected, it will take up scarce health care facilities. There has never been a better time to quit smoking, get your blood pressure under control, make sure that if you have diabetes it's well controlled, and -- yes -- get regular physical activity. (Being active outside for at least 15 minutes a day also helps with vitamin D levels. Of all of the various proposed measures to increase your resistance to infection, regular physical activity and adequate vitamin D levels probably have the most scientific evidence to support them -- and can be done safely.)
  • Massively scale up telemedicine. We need to reduce the number of people attending health care facilities while at the same time preserving and improving health. The Administration issued flexible and constructive guidelines for Medicaid, but much more is needed. Patients -- especially those who are uninsured or who don't have a regular source of care -- need to be able to refill prescriptions, get medical advice and find a clinician readily.
  • Fix supply chain weaknesses. This is crucial for masks and other personal protective equipment, ventilators and supplies for ventilators, and laboratory materials. This is a good time to look at a core list of medications and ensure that the safest and most effective ones are available. For example, in another area where my group works globally, we've discovered that instead of 30 or 50 medications for high blood pressure, three would do for nearly all patients. Let's make sure we have life-saving medicines and worry less about which companies are making them.

Learn intensively. If there is one key lesson from past epidemics, it's that getting real-time data is essential for a great epidemic response.

  • Most urgently, we must learn how best to protect health care workers from infection.
  • We need to know who is most at risk for spreading the infection, and at what point in their illness -- so that we can target contact tracing most effectively. This will help determine how wide a circle of contacts to track, and how and how often to test.
  • Who is at the highest risk for severe illness and death.
  • What works to reduce infection? What public health advice is being followed, and what is the impact? Some countries require that all patients, even those with mild illness, are isolated in facilities. (This could be done, for example, in college dormitories). Is this necessary and effective? Should it be extended to close contacts to prevent them from spreading the infection? The answer to these questions will depend in part on answers to other questions, such as how often people who never have symptoms, or people who are just beginning to get sick, spread infection.
  • Are there rapid point-of-care tests and how accurate and timely are blood tests for coronavirus infection?
  • Is immunity protective? Even if antibodies are reliably produced, this doesn't necessarily mean that recovered patients are immune from a future infection.

For these questions, the US Centers for Disease Control and Prevention and state and local health departments, as well as public health agencies around the world, are crucial. They are the intelligence officers needed to guide our strategy and tactics, and they need to be both at the table when decisions are made and at the podium when policies are explained

And these are just the epidemiological questions. We also urgently need to know whether treatments work. The preliminary report on the value of chloroquine and azithromycin needs to be rigorously addressed. The disappointing finding that two anti-viral medications didn't improve survival in severely ill patients is a sobering reminder that until there are rigorous studies, we won't know how best to treat patients. Even if we can't dramatically improve outcomes, a treatment that reduces the need for intubation could save many lives.

A safe and effective vaccine is of greatest importance. The world must do everything possible to develop a vaccine, while also recognizing that this may or may not be possible.

Adapt to a new normal. The Covid-19 pandemic will change our world forever. Until it is controlled, we will all need to change how we wash our hands, cover our coughs, greet others and how close we come to others. We will rethink the need for meetings and conferences. We will need broadband for all as a public utility like mail or water. We will need to support the vulnerable, even if only because their illness can risk our health.

Our strategy to mitigate the impact of Covid-19 will necessarily evolve as we learn more about the virus and the effectiveness of different interventions.

In a fourth phase, a vaccine, if one can be found, or global elimination efforts, if they can succeed, would either end the pandemic or, if not, force us to adapt to the continuing threat for the indefinite future. We face weeks and months of fear and tragedy. Leaders at every level must be frank that this is frightening, unprecedented and irrevocably changes how we provide care and prepare for the future. But it is also a time to recognize that we are all in this together -- not only all in the United States, but all of us globally. Spread anywhere in the world increases risk everywhere. We have a common enemy, and, working together with a common strategy, we can build a new normal that minimizes risk, maximizes collaboration and commits to shared progress.

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Illinois Coronavirus Cases

(Widget updates once daily at 7 p.m. CT)

Cases: 1677939

Reported Deaths: 27996
CountyCasesDeaths
Cook63537311208
DuPage1083221378
Will913951127
Lake801071088
Kane68469872
Winnebago41117561
Madison40130597
St. Clair36293598
McHenry34762330
Champaign27034197
Peoria26956368
Sangamon25767287
McLean23033219
Tazewell20666331
Rock Island18872361
Kankakee17943249
Kendall16221113
Macon15321251
LaSalle15052287
Vermilion14418201
Adams13167152
DeKalb12169134
Williamson12069174
Whiteside8307183
Jackson809394
Boone794883
Coles7895124
Ogle757989
Grundy739486
Franklin7335115
Knox7297169
Clinton7129102
Macoupin6965106
Marion6929144
Henry664277
Effingham6618100
Jefferson6561143
Livingston598498
Stephenson585493
Woodford577192
Randolph5560100
Christian535682
Fulton527376
Monroe5252103
Morgan5079100
Logan495374
Montgomery491881
Lee478960
Bureau443191
Saline434469
Perry433775
Fayette431264
Iroquois421777
McDonough374161
Shelby348748
Jersey336253
Lawrence333433
Crawford333230
Douglas328137
Union307248
Wayne304363
Richland280057
White280033
Hancock274035
Clark266540
Cass266330
Pike265258
Edgar260149
Clay259254
Bond257425
Ford245659
Warren244266
Carroll236838
Moultrie235733
Johnson228832
Wabash217219
Jo Daviess216129
Massac215850
Mason214452
Washington212528
De Witt206230
Greene205340
Mercer204736
Piatt202314
Cumberland190226
Menard172313
Jasper161321
Marshall141521
Hamilton134122
Schuyler108310
Brown106610
Edwards104218
Pulaski104212
Stark81628
Gallatin7889
Alexander72512
Scott7126
Henderson70614
Calhoun6932
Hardin60616
Putnam5654
Pope5536
Unassigned1622433
Out of IL130

Indiana Coronavirus Cases

(Widget updates once daily at 8 p.m. ET)

Cases: 1005797

Reported Deaths: 16449
CountyCasesDeaths
Marion1353572119
Lake663011164
Allen57820801
Hamilton46296464
St. Joseph44311613
Elkhart35888509
Vanderburgh32214480
Tippecanoe27898258
Johnson25056445
Hendricks23854359
Porter22890365
Madison18724409
Clark18540252
Vigo17449303
Monroe15242199
LaPorte15124250
Delaware15043261
Howard14719289
Kosciusko12285147
Hancock11709175
Bartholomew11602180
Warrick11287189
Floyd11082215
Wayne10965253
Grant10051220
Morgan9457176
Boone8913116
Dubois8263131
Dearborn820893
Henry8200152
Noble8017106
Marshall7916135
Cass7528121
Lawrence7447171
Shelby7176119
Jackson697289
Gibson6584115
Harrison647591
Knox6418106
Huntington6385100
DeKalb630699
Montgomery6252110
Miami592298
Putnam580078
Clinton574971
Whitley564255
Steuben560676
Wabash5324104
Jasper529879
Jefferson510297
Ripley499886
Adams481576
Daviess4670114
Scott438574
Greene424496
Wells423088
Clay422060
White418164
Decatur4164102
Fayette406187
Jennings386661
Posey376644
LaGrange357678
Washington357651
Randolph344499
Spencer339543
Fountain334760
Sullivan328652
Starke316470
Owen314170
Fulton309467
Orange293564
Jay284145
Franklin265443
Perry265352
Rush261332
Carroll261133
Vermillion257754
Parke231126
Pike228843
Tipton227559
Blackford192642
Pulaski183457
Crawford159223
Newton157848
Benton150217
Brown146147
Martin138219
Switzerland134911
Warren121016
Union107016
Ohio84513
Unassigned0540