COVID-19 Science Update for March 26th: Five Trends Shaping Medium-Term Policy
Even if a COVID-19 vaccine were invented tomorrow (it won’t be), our experience with the virus shows how underprepared we are for this kind of public-health emergency.
This article constitutes the March 26th, 2020 entry in the daily Quillette series COVID-19 UPDATES. Please report needed corrections to [email protected].
Until today, these updates have begun with a rundown of the latest global data for COVID-19 published at Our World in Data (OWD). As of this writing on Thursday morning, however, the March 26th numbers have not yet been published at OWD. (However, for those interested, there do seem to be recent updates at the website of the European Centre for Disease Prevention and Control, whose reports have formed the statistical basis for OWD daily tallies since March 18th.)
So I will skip the daily rundown of new numbers and proceed directly to the thematic focus of today’s update: a broad-stroke, point-form summary of some of the policies that, even at this early stage, seem likely to inform our global response to COVID-19. Until now, the focus was almost exclusively on the short-term response to the pandemic. But now that social and economic lockdowns in affected countries have somewhat dampened the exponential spread of the disease, there is more latitude for discussion of medium- and long-term solutions.
In the material that follows, I describe five emerging ideas that seem especially important.
1. We need more intensive-care beds.
Neil Ferguson—primary author of the Imperial College report I detailed yesterday—today gave evidence to a UK parliamentary committee in regard to the country’s ICU capacity. As New Scientist described it:
The need for intensive care beds will get very close to capacity in some areas, but won’t be breached at a national level, said Ferguson. The projections are based on computer simulations of the virus spreading, which take into account the properties of the virus, the reduced transmission between people asked to stay at home and the capacity of hospitals, particularly intensive care units.
Ferguson also predicted that, thanks to the UK government’s belated but strenuous interventions, total UK deaths would likely be less than 20,000, and could be much less. All of this comes as good news, especially considering the somewhat apocalyptic tone of his own report, which contained figures showing ICU capacity being exceeded by an order of magnitude. But it also highlights the need for more ICU capacity. Indeed, Ferguson’s own report showed that the UK’s surge-level ICU bed capacity is only eight per 100K population, while his worst-case scenarios would require ICU capacity on the order of 20 to 30 times that amount.
If, as many expect, the COVID-19 pandemic recedes over the late spring and summer before a possible seasonal resurgence in the fall, all nations must use that interregnum to not only vastly increase physical ICU capacity—including many more ventilators—but also train the specialized staff required for scaled-up operation. Even if a COVID-19 vaccine were invented tomorrow (it won’t be), our experience with the virus shows how underprepared we are for this kind of public-health emergency. COVID-19 won’t be the last pandemic we face.
2. We need to increase our testing capacity.
Genomic sequencing is one of the great miracles of modern science. Within days of COVID-19’s initial detection in China on December 31st, 2019, the virus’s entire genome sequence was acquired, and then shared with the WHO on January 10th. And by late February, 10 kit types for detection of COVID-19 had been approved by China’s National Medical Products Administration. By the end of that month, producers had the capacity to distribute as many as 1.65 million tests per week.
Yet here we are, a month later, and many residents of much wealthier OECD nations cannot get tested in a timely fashion. This shortfall is costing us new cases and lost lives. The uncertainty associated with not knowing whether one has the disease also is taking a psychological toll on many people, and is one of the reasons why a sense of panic is still somewhat widespread. By way of anecdote: A symptomatic individual known to me here in Canada waited hours on the phone to speak with a (clearly overworked and harried) nurse who bluntly informed him that tests were available on a limited basis, and only to those whose symptoms matched a prescribed list (which itself is problematic given the variability in symptoms associated with COVID-19).
Multiply this case by millions, and you have a sense of what the lack of testing capacity is costing the world. Self-diagnosed false positives create anxiety. Self-diagnosed false negatives discourage self-isolation among infected individuals. As I’ve noted in a previous update: A massive testing regime doesn’t seem to be a necessary component of COVID-19 suppression. But the countries that have scored the most decisive successes in quashing a crisis that has already started generally tested the population vigorously.
Fortunately, the era of quick, self-directed testing may soon be at hand, at least in some countries. In a few weeks, in fact, you might even be able to get testing kits on Amazon. According to London’s Telegraph, British MPs have been informed that “the [UK] public will be able to conduct ‘game-changer’ coronavirus antibody tests at home within a matter of days,” and that “3.5 million tests had been bought and would be available in the ‘near future.’”
Jonathan Kay
3. We need to systematize international travel restrictions.
Yuval Noah Harari recently wrote a thought-provoking piece in the Financial Times decrying the ad hoc nature of the travel bans that have emerged over the last month. “Suspending all international travel for months will cause tremendous hardships, and hamper the war against coronavirus,” he notes. “Countries need to co-operate in order to allow at least a trickle of essential travellers to continue crossing borders: scientists, doctors, journalists, politicians, businesspeople. This can be done by reaching a global agreement on the pre-screening of travellers by their home country. If you know that only carefully screened travellers were allowed on a plane, you would be more willing to accept them into your country.”
Unfortunately, as Harari also notes, there is little prospect for any kind of rational international agreement on this issue because “a collective paralysis has gripped the international community. There seem to be no adults in the room… In previous global crises—such as the 2008 financial crisis and the 2014 Ebola epidemic—the US assumed the role of global leader… When it banned all travel from the EU, it didn’t bother to give the EU so much as an advance notice—let alone consult with the EU about that drastic measure.” (On a related note, G7 foreign ministers have been hampered in their efforts because—and I am not making this up—US Secretary of State Mike Pompeo insisted that they publicly identify COVID-19 as the “Wuhan virus.”)
Even once the COVID-19 pandemic subsides, its discouraging effect on international travel will remain with us for years—in part because many travellers now (rightly) feel they have little certainty about whether a sudden disease outbreak will leave them stranded abroad once an airline or government suddenly suspends all flights. Here in Canada, initial (and justifiable) calls to limit flights to and from China were predictably denounced as racist. Once the pandemic became more serious, intake protocols at airports were spotty and random; thousands of foreign travellers became stranded; and the federal government even briefly adopted an odd policy by which illegal migrants would be permitted to enter Canada while most otherwise legal migrants would not.
Harari is correct that, on an international level, some sort of systematic understanding must be reached in this area. But on the national level, more basic steps would help, too—such as adapting airport architecture to the periodic necessity of mass-screening travellers for identifiable medical conditions. At Pearson airport in Toronto, international travellers seeking to pick up their checked luggage are greeted by a vast plain of carousels that stretch out over an area the size of many football fields. Yet when it comes to vital medical screening, this imperative often is relegated to hastily composed advisories taped up on walls and a handful of screening workers operating out of random alcoves.
4. We need to focus on viral load, not just the virus itself.
There has understandably been enormous attention paid to who has been infected with COVID-19 and who has not. But even among those who have the virus, there seems to be a wide variation in viral load—the amount of measurable virus in one’s sputum. As researchers argued in a fascinating (and underreported) study published on March 8th, variations in viral load—and viral “shedding,” i.e., the expulsion and release of new virus particles that may infect others—could influence the spread of the disease. The sample size was small and the research is at an early stage, but this description of the research published at STAT is still worth quoting at some length:
The researchers monitored the viral shedding of nine people infected with the virus. In addition to tests looking for fragments of the virus’s RNA, they also tried to grow viruses from sputum, blood, urine, and stool samples taken from the patients. The latter type of testing—trying to grow viruses—is critical in the quest to determine how people infect one another and how long an infected person poses a risk to others. Importantly, the scientists could not grow viruses from throat swabs or sputum specimens after day 8 of illness from people who had mild infections. ‘Based on the present findings, early discharge with ensuing home isolation could be chosen for patients who are beyond day 10 of symptoms with less than 100,000 viral RNA copies per ml of sputum,’ the authors said, suggesting that at that point ‘there is little residual risk of infectivity, based on cell culture’…In some cases, people test positive for weeks after recovery, the WHO has noted. Those tests are conducted using PCR—polymerase chain reaction—which looks for tiny sections of the RNA of the virus. That type of test can indicate whether a patient is still shedding viral debris, but cannot indicate whether the person is still infectious.
As I noted in yesterday’s update, COVID-19 exhibits a heavily clustered transmission pattern that reproduces itself in a fractal-like way at different orders of geographic magnitude—from nation all the way down to local and family units. (Indeed, a new cluster has been found. My daily Telegraph news feed today informed me that the UK’s first COVID-19 case is now believed to have been an IT consultant who went on a ski holiday to the—low vowel load—town of Ischgl, Austria. Also: “The Tyrolean resort has been linked to outbreaks across Europe and is now under criminal investigation for an alleged cover-up.” And in a flourish that conjures memories of from the 1970s, “The Telegraph has obtained an exclusive video shot inside a bar famed for its raucous après-ski party scene.”) When a more thorough analysis of this clustering effect is rendered by virologists and epidemiologists in coming months, it may become apparent that this effect is produced by variations in viral load/shedding. If so, antiviral drugs that reduce COVID-19 transmission, if successfully identified and tested, might help bridge the gap until a vaccine is found.
Last week, the correspondence section of the Lancet carried an intriguing report by Spanish infectious-diseases experts Oriol Mitjà and Bonaventura Clotet, in which the authors argued that “the current COVID-19 emergency warrants the urgent development of potential strategies to protect people at high risk of infection—particularly close contacts and health-care workers, among others—even if more robust data on antiviral therapies is yet to come.” In this regard, they described a parallel with rifampicin being administered to individuals exposed to invasive meningococcal infection, and oseltamivir for those at risk of pandemic influenza. (An example, they didn’t mention, but which came to mind, was the development of antiviral therapies for HIV-positive women in the early 2000s, which lower the maternal antepartum viral load and have thereby saved untold thousands of lives.)
Candidate medications for suppressing COVID-19 include the antimalarial drug hydroxychloroquine, on which clinical trials are ongoing. While Donald Trump’s suggestion that hydroxychloroquine and azithromycin may offer a quick cure for COVID-19 is obviously premature, there is research to suggest these drugs may become part of the long-term solution, especially among people who live or work with older or otherwise vulnerable individuals.
5. We need flexible, graduated policies that reflect the pandemic severity at any given time.
As I noted yesterday, one unrealistic assumption embedded in the recent Imperial College report is the idea that public behaviour will operate in a rigidly sawtooth way, with restrictions on social and economic life firing on and off like binary switches. That’s simply not how human beings act in the shadow of a once-in-a-generation medical scare. But unfortunately, this is how governments often act, going from laissez-faire to lockdown in a matter of days.
One early prototype for the kind of flexible and graduated policy that all nations may eventually adopt is provided by New Zealand, which now has a system of four COVID-19 “alert levels”: (1) Prepare, (2) Reduce, (3) Restrict, and (4) Eliminate.
At Level 1, which is appropriate for “sporadic imported case” and associated household transmission, the prescribed measures include physical distancing and a ban on mass gatherings of 500 or more people. At Level 2, which corresponds to the formation of isolated clusters, border measures become more strict and non-essential travel within New Zealand is limited. If community transmission takes place, or there are multiple clusters (Level 3), schools and public venues are closed. And at Level 4 (the current level), the society basically goes on lockdown.
Many of us have been living in our own local version of Level 4 for many days now. But that can’t go on forever, and we’re going to have to find ways to create and enforce policies that reflect the ever-changing COVID-19 risk level. New Zealand’s policy offers a good template for lawmakers everywhere.
