By Vivian Ho, Ph.D.
James A. Baker III Institute Chair in Health Economics
Kirstin R.W. Matthews, Ph.D.
Fellow in Science and Technology Policy
Heidi Russell, M.D., Ph.D.
Associate Professor
Department of Pediatrics and Center for Medical Ethics and Health Policy
Baylor College of Medicine
Most of us have completed our sixth week in isolation. The number of daily new deaths and new cases have both begun declining, but are still precariously high. Covid-19 burden varies dramatically across the country, which partially influences states’ diverging decisions on when and how to relax strict lockdown measures. We update you on these decisions, as well as the latest information we have seen on treatment and testing.
Epidemiology and treatment
On Friday, April 24, The New York Times’ graphs based on seven-day averages indicated that the number of new cases in the U.S. has fallen to roughly 28,000 per day, and the number of new deaths in the U.S. has declined to just under 2,000 per day. Meanwhile, CDC Director Robert Redfield warns that a second wave of the coronavirus could be far more deadly if it coincides with the start of flu season next fall.
In Texas, the number of deaths per day has fallen to roughly 20, and the number of new cases seems to have fallen to under 900, or 31 per one million Texans. Expert health organizations differ in their thresholds regarding when it is safe to ease restrictions, varying from one to 40 new cases per one million people. Thus, it might be safe to ease restrictions May 1, but only if Texas has sufficient testing capacity and contact tracers. The Harvard Global Health Institute’s recommendations suggest that Texas needs to be conducting 44,200 tests per day to reopen. The state’s highest number of tests per day last Friday of 17,469 falls far short. A new report recommends that Texas hire 8,834 contact tracers. There are reports of other states launching aggressive efforts to hire contact tracers, but we have seen none for Texas.
Before this week, the first coronavirus-related death in the U.S. was on Feb 29 in the Seattle area. However, Santa Clara County, Calif., officials announced that an autopsy revealed the death of a resident with no known travel history on Feb 6. Researchers have constructed models indicating that by the time New York City confirmed its first coronavirus case on March 1, thousands of infections were already spreading through that city and elsewhere in the U.S. If officials had known of community spread of the virus so early, there would have been more urgency in February to expand testing, prepare hospitals and get more protective gear.
When Covid-19 data began to come out of China, experts noticed the impact of the virus on those over 70 was higher than in the younger populations. However, in the U.S. a number of incidents have been reported of younger, healthier individuals having severe and even fatal Covid-19 infections. Scientists have hypothesized that this is a result of a “cytokine storm” — where the body ramps up the production of small proteins in the blood that activate the immune system. Studies reviewing data on Chinese patients indicated cytokine storms likely occurred (here, here and here). It’s still unclear why some individuals have more severe reactions; some postulate there is a genetic component. Researchers have launched studies to determine whether the drug Actemra may be effective in fighting cytokine storms.
A common question many are concerned with is if Covid-19 will become another type of recurring disease, like the flu or cold, in need of a new vaccine each year. SARS-COV2 (the virus responsible for Covid-19) is an RNA virus — meaning it uses RNA instead of DNA as its genetic materials. RNA is less stable than DNA and therefore more likely to mutate. However, the mutation rate of SARS-COV2 is lower than other RNA viruses, such as the viruses that cause seasonal flu. This suggests that a single vaccine, rather than an annual one, will be effective.
While most experts predict it will be more than a year before a viable vaccine is available, other experts are proposing old vaccines against other viruses to protect against Covid-19. Vaccines made using live strains of bacteria or viruses have sometimes provided cross-protection against other completely different bugs. However, we are skeptical about one prominent effort to use the oral polio vaccine. In rare instances, the live virus in oral polio vaccines can mutate, causing new outbreaks. (In the U.S., an injectable inactivated polio virus is used).
Policy response
Last week we reported that governors on the East and West Coasts had formed pacts to decide when they would reopen their economies, followed closely by governors of Midwest states. Since then, California Gov. Gavin Newsom announced that he has not yet set a date to ease shelter-at-home restrictions. But he has set a goal to raise the number of coronavirus tests from the current 16,000 daily to testing 60,000 to 80,000 people per day. New York’s Gov. Andrew Cuomo has announced that he is analyzing statewide data to determine when it will fully reopen. He is allowing elective surgeries to take place starting next week in regions without large coronavirus outbreaks. Meanwhile, several mayors of cities in Georgia and health experts are upset with Gov. Brian Kemp’s decision to allow businesses such as hair salons and gyms to reopen. One editorial notes that Georgia has insufficient levels of testing and availability of contact tracers, and the number of new Covid-19 cases is still rising each day.
The Johns Hopkins University’s Center for Health Security has published a report providing guidance for governors on phased reopenings of their economies. The report is both comprehensive and precise. It provides categorical risk assessments for the following seven sectors: (1) “nonessential” businesses,* (2) schools and childcare facilities, (3) outdoor spaces, (4) community gathering spaces, (5) transportation, (6) mass gatherings, and (7) interpersonal gatherings. Each of these categories was assessed along three dimensions: contact intensity, number of contacts, and the degree to which the activities are considered to be modifiable. Contact intensity encompasses distance between people and duration of contact. For example, outdoor public swimming pools are categorized as having MEDIUM contact intensity, LOW number of contacts, and HIGH modification potential. This combination suggests that swimming pools could be reopened with significant modifications to rules. Business-related mass gatherings are classified as HIGH contact intensity, HIGH number of contacts, and HIGH modification potential. The reader is then referred to the World Health Organization’s (WHO) website, where recommended modifications include virtual meetings, or in-person meetings with no international participation, no attendance by high-risk persons, or outdoor meeting places. The report recommends reopening in phases of 2 to 3 weeks, which is the amount of time it will take to see the impact of each easing of restrictions on case counts and hospitalizations. The report encourages governors to weigh the risks and benefits sector by sector, recognizing that scenarios will differ across states and finer geographic locations.
This week former FDA commissioners Scott Gottlieb and Stephen Ostroff provided detailed recommendations to employers to keep employees safe as they return to work. Because the virus spreads easily in crowded spaces, businesses can reduce mass transit volume by encouraging carpooling or deploying corporate vans where hygiene and social distancing are easier to control. Companies should reduce worker density by continuing telework and allowing staggered work schedules. Gottlieb and Ostroff provide multiple other proposals, including maintaining pay when someone agrees to self-isolate or stays home while awaiting a test result.
Last week a test for Covid-19 in saliva (without a nasal swab) was approved, and this week LabCorp received approval for an at-home nasal swab test. As explained in last week’s blog, both tests improve safety for health care workers. These tests are not available over-the-counter; they must be obtained through health care providers. The FDA has been approving tests under the Emergency Use Authorization (EUA) in an effort to speed up test availability. However, even approved tests are not foolproof. This piece in Quartz states that a company essentially just has to show that the test works well enough in a trial with just a few dozen samples.
Two weeks ago we mentioned serologic testing of blood for antibodies to Covid-19, which may be useful in finding people with previous infections. While these tests are being used to measure virus prevalence in some cities, we remind readers that the FDA-authorized antibody tests are approved under EUA rules, and therefore may be inaccurate. To make matters worse, tests falsely claiming to have FDA approval are also available, which could endanger consumers who could gain a false sense of safety from an inaccurate test result. Additionally, the Families First Coronavirus Response Act, which requires insurance companies to waive costs of testing, only applies to FDA authorized tests, potentially leaving patients financially responsible. Approved tests are available on the FDA’s website.
While we are encouraged that the nation has likely passed its peak in terms of new coronavirus cases and deaths, we can’t help but feel we’re backsliding in our efforts to reopen the nation’s economy. Serious safety concerns have emerged regarding Abbott Laboratory’s rapid coronavirus test, which the Department of Health and Human Services is relying on to solve persistent testing shortages. The Centers for Disease Control is allocating only $631 million for states to increase their capacity to do contact tracing and coronavirus tracing. But a recent report recommends $3.6 billion in national emergency funding as a starting point for contact tracing. Clinical trials have been launched for multiple treatments for Covid-19 patients, and we look forward to updating you next week on their status.