Pandemic playbook

Jennifer Nuzzo, DrPH, SM, senior scholar at Johns Hopkins Center for Health Security, has spoken widely about the novel coronavirus and the COVID-19 pandemic. As a follow-up to her expert panel presentation at APHA’s COVID-19 Conversations webinar, “The Science of Social Distancing, Part 2,” Nuzzo answered a few questions for Public Health Newswire.

Q: COVID-19 has had a major impact on the U.S. What can we do to stop the disease from spreading further?

A: Right now, the top priority for the U.S. is to continue to apply community-wide social distancing measures to slow the rapid acceleration of COVID-19 cases in our country. The number of cases reported by the United States has now exceeded those of every other country, including China. 

The steep rise in infections is threatening to overwhelm health systems in several cities. Those places in the U.S. that haven’t yet found a surge in cases will likely see it soon. Though there’s a perception out there that densely populated areas of the country are at greatest risk of having case counts rise above health care capacity, I am also very worried about the impact in other areas — for example, rural communities that may have fewer health care resources to start. It may not take many cases to overwhelm local health capacity in many areas of the United States.

If they work like we hope they will, these social distancing measures may help to slow the spread of infection such that demand on health care resources stays below the upper limits of the capacity of the health system.

Q: How do we know when to end distancing and stay-at-home orders?

A: These measures, while absolutely necessary now, are not a cure for this pandemic. Community-based measures will not stop the spread of COVID-19. They are at best like a pause button. As soon as we begin to release them, the case numbers will start to rise.

We can’t maintain all of these measures forever, because they are very disruptive. But we may have to maintain some measures for quite awhile. I don’t see us going back to having mass gatherings any time soon, and I am particularly concerned about protecting vulnerable populations. We’ll have to do some level of cocooning in high-risk congregate settings, such as long-term care facilities, for as long as the virus is circulating and we don’t have medicines or vaccines to protect patients who are most likely to become severely ill.

We must work to identify a next phase of action for dealing with COVID-19 cases that occur as social distancing measures are relaxed. This will have to involve more complete identification and isolation of new COVID-19 cases. This will require more testing than we can do now. 

We also need to have the ability to trace and monitor the contacts of cases so that we can swiftly identify and isolate any additional cases that occur. The capacity of state and local health departments to conduct contact tracing is quite limited, so we’ll need to figure out how to expand those resources — perhaps through the use of new technologies and also through the addition of personnel.

Q: How can the federal government integrate its response efforts with state and local governments?

A: This is important, and in my view is largely not happening. It seems like much of the action that is happening at state and local level is not being coordinated by the federal government. There are reports that states are having to seek resources, like access to diagnostic supplies and personal protective equipment on their own.;

In effect, states are having to compete with each other for these resources, which is not ideal. We need a coordinated national response that doesn’t leave any state behind.

A key limitation in our response is our lack of national surveillance for COVID-19. I recently wrote an op-ed, which argues that in order to know when and how we can begin to dial back on our community-based social distancing measures, we need to establish a better understanding of both the extent to which COVID-19 cases are occurring in our communities and the capacity of the health system to respond to them.

Unfortunately, persistent limitations in testing has meant we have only a limited measure of the COVID-19 cases that have occurred. We also don’t have sufficient surveillance to assess health care capacity and to determine the degree to which health facilities may be stressed. We need better ways of tracking the availability of tests and the proportion of the population that has been tested.

Q: How do we minimize transmission in health care settings?

A: This is a difficult one, largely because there are severe shortages of the tools that should be used to limit infection in health care settings — personal protective equipment.

Given these shortages, it is essential that anyone who is ill, but not sick enough to require hospitalization, stay home. Don’t try to go to a hospital or health facility to be tested unless directed to do so by a clinician.

The last thing health facilities need is for sick people who don’t require medical attention to show up unannounced, where they may spread their infection to others. Also, people who are not infected may be exposed to the virus while they are there.

Q: What are we learning from the community-level interventions that are being done?

A: The community-wide measures that state and local governments are implementing are unprecedented. Some communities do close schools and businesses when they experience outbreaks, such as seasonal influenza, but these are usually limited in geographic scope and duration. 

The closest experience to what we are seeing now probably occurred during the 2009 influenza pandemic, when many schools and some businesses across the nation closed, but most of these measures only lasted for a few days.

We have never before done the experiment where we’ve tried to slow the spread of a disease that is facing our entire nation through large-scale, sustained closures of schools, businesses and restriction of movement.

I do hope we can gain some insights into whether and how these measures worked and what were their impacts on our society. It’s hard to do these studies — especially now when we are in the midst of crisis — but we need to at least document what happened. 

We may not be able to disaggregate which measure had which effect, but we can at least record what happened and try to assess what the secondary and tertiary impacts may have also occurred. I am hearing both positive and negative outcomes — traumatic injury may be lessened, but the impacts on children’s health may be heightened. We also know a lot of routine medical care is being postponed and we should try to understand what this means for overall public health.

We should strive for a better understanding of this so that we can anticipate and hopefully mitigate these effects should we ever have to employ these measures again.