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
As many states begin to reopen their economies, it is too early to tell from the statistics whether they are moving too quickly. We consider the risks posed to workers not wearing masks in large offices, the risks scientists are considering for speeding the vaccine development process, and multiple policy responses to the pandemic.
Epidemiology and Treatment
As of Friday, May 15, data from the COVID Tracking Project showed that the 7-day average (smoothed) number of new daily cases continued to fall, to 22,540 from 25,895 a week earlier. This 15% decline occurred in the midst of a 27% increase in the smoothed number of tests. These 332,883 tests lie far below the target of 900,000 tests per day we discussed last week. Here in Texas, one of the earliest states to relax social distancing, the smoothed number of new cases rose 21%, from 868 to 1,048. The smoothed number of tests rose 35% to 24,125 on Friday, which is slightly below the 27,282 recommended for the state. However, news broke on Saturday that the state is combining both viral and antibody tests in its test counts, whereas states are expected to only report the former.
The New York Times used smartphone location data from the company Cuebiq to determine that 25 million more American residents ventured more than 300 feet from home last week compared to the preceding six weeks. The increased movement occurred both in states that did and did not lift stay-at-home orders. Normally 20.7% of Americans stay home on a given day. The rate reached a peak of 43.8% in April, and last week 36.1% stayed home. The increase in movement may not be cause for alarm if people practice social distancing.
Erin Bromage, an associate professor of biology at the University of Massachusetts Dartmouth, has published a blog discussing the situations and locations where one is most likely to be infected with the coronavirus, which has received over 14 million views. He cites multiple peer-reviewed research papers that emphasize the dangers of unmasked workers sharing air space with an infected person. In one study of an 11th floor call center in South Korea, 94 of 216 (46%) workers contracted SARS-COV2 from just one employee over the course of one week. This finding raises our anxiety, as we have heard that some companies in Houston are requiring their workers to return to the office. We have not found a peer-reviewed study on the effectiveness of masks in preventing spread of the virus in large offices. However, a New Yorker piece by Atul Gawande provides detailed information on the potential benefits of masks in many situations.
Scientists face unique challenges in developing a safe and effective vaccine for the coronavirus. There is relatively limited understanding of the virus, because it is so new. Yet the urgency generated by the pandemic has spurred several vaccine candidates that employ new approaches that in theory should work but have never been used. Rigorous clinical trials are essential, to avoid vaccines that could be ineffective or accidentally give patients the virus instead of protecting them from it.
One option for speeding up the clinical trial process is a controlled human infection trial, where one “challenges” healthy volunteers with the virus to determine if the vaccine works. It was first proposed in March, but the idea has since gained momentum with other scholars and policymakers. However, there is no cure for COVID-19 and treatments are limited. Therefore, a trial would put patients at risk of severe consequences if the vaccine does not work. Other unknowns include how to grow the virus itself without contamination from other pathogens, what is the best route/method to challenge patients, how much of the virus one needs to challenge patients, and how to effectively manage challenged patients so they do not cause localized outbreaks.
Over the past several weeks we’ve seen increasing reports of a mysterious inflammatory illness in children with links to the novel coronavirus – initially in the UK, then New York, and now across Europe and the U.S. The CDC’s May 14 health alert formally described reporting criteria for Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19. In many ways MIS-C looks like a well-described childhood illness called Kawasaki’s Disease except that the MIS-C patients are more critically ill. One small study of children with Kawasaki’s Disease in 2005 linked it with coronavirus but multiple other subsequent studies did not confirm the connection. Per the CDC’s alert, the New York State Health Department has already identified 102 children with the syndrome. The national number of cases will increase, as awareness and the number of COVID cases rises. This syndrome requires understanding and particular consideration in future models of the health care needs for the pandemic as it will disproportionately affect pediatric care facilities.
Policy Response
On Friday, the White House unveiled Operation Warp Speed, a massive effort to finish developing, then to manufacture and distribute a proven coronavirus vaccine as fast as possible. The chief scientist will be immunologist Dr. Moncef Slaoui, who is reported by STAT News to own $10 million in stock options for Moderna, which we noted is one of the companies in the race to develop a coronavirus vaccine. Through this program, the federal government will invest in manufacturing all of the top vaccine candidates before they are approved.
While we applaud any effort by the administration to bolster vaccine development, it falls far short of the $70 billion Advance Market Commitment proposal we mentioned last week. The AMC for a coronavirus vaccine was proposed by a team led by 2019 Nobel prize winning economist Michael Kremer, an expert in vaccine markets. In a Zoom presentation, Dr. Kremer explains that 14 vaccine candidates are necessary for a 90% chance of having at least one vaccine available within 18 months. He derived this estimate after consulting with scientists in the vaccine industry. A large portion of the AMC funding directly finances 80% of each vaccine firms’ manufacturing capacity. As we noted last week, scientists are developing vaccines that work in multiple different ways, and each requires its own specifically designed manufacturing plant. The AMC plan lays out pricing incentives to spur faster vaccine development and a strategy for international collaboration.
On Monday, a Wall Street Journal article noted that most Asian countries are not allowing mild COVID-19 cases to self-isolate at home. Instead, mildly ill patients must move to dormitories or other public facilities designated for quarantine. The concern that patients with mild cases can readily spread the disease is underlined by an Italian study, which found that more than one in five people who tested positive since April 1 were likely infected by family members. New York and Chicago have publicly funded programs to house infected patients in hotels, but we are unaware of a national program to fund this concept.
On Thursday, CNET reported that the FBI is investigating the targeting and compromise of U.S. organizations conducting COVID-19-related research by PRC-affiliated hackers. These actors have been attempting to identify and illicitly obtain valuable intellectual property (IP) and public health data related to vaccines, treatments and testing. The CNET article also noted a fivefold increase in cyberattacks on the World Health Organization in April. Last week Reuters reported that Iran-linked hackers targeted U.S. drugmaker Gilead, which developed the coronavirus drug Remdesivir.
We learned from a technology columnist last week that contact tracing is being developed at the state or public-health system level. The apps are meant to be opt-in, even though estimates suggest that 60% of the population would need to be enrolled for the technology to work. The apps employ different technology and provide different levels of privacy protection. For example, Bluetooth-enabled apps could exchange anonymous codes between nearby phones throughout the day and notify you if a phone carrier you were near tested positive for the virus. A location-based app might track your whereabouts throughout the day and ask for personal information, so that a contact tracer can find you in case you visited a location where someone tested positive. The article cites former CDC head Tom Frieden as being concerned about how feasible or useful such apps would be.
We have finished a week when the White House has allotted only $10 billion toward coronavirus vaccine funding and when experts have told us that we need to spend $70 billion to achieve a 90% chance of developing a vaccine in 18 months. The House passed a $3 trillion coronavirus relief bill that will not pass the Republican-controlled Senate. The bill contains $75 billion for coronavirus testing and contact tracing, even though we mentioned last week that some economists recommend that we quickly offer $100 billion to manufacturers to produce more tests. We echo Dr. Rick Bright’s testimony before a House subcommittee this week: “Without better planning, 2020 could be the darkest winter in modern history.”