RUTHFULLY YOURS

While discussing many pandemic-related issues with friends and colleagues, we were reminded of the quip of journalist and satirist H.L. Mencken: “For every complex problem, there is an answer that is clear, simple, and wrong.”

As we battle the SARS-CoV-2 virus, and the illness it causes, COVID-19, the “fog of war” continues on both the medical and epidemiological fronts. On the public health side, different studies, especially those that involve modeling, seem to reach conflicting, or at least ambiguous, conclusions. And politicians and pundits have jumped in to make the fog denser, with many policy prescriptions contaminated by misinformation, ideological spin, and partisan politics.

Obtaining clarity about many aspects of COVID-19 has been elusive. Dr. Anthony Fauci has emphasized the virus’s unique “protean manifestations”: “I have never seen a virus in which you have 20 percent to 40 percent of individuals who could have no symptoms at all, to individuals who get mild illness and do not need to go to a hospital, to people confined to their beds at home for weeks with multiple post-viral syndromes,” he said.

SARS-CoV-2 is also unusual in being able to infect a broad spectrum of body tissues beyond the respiratory tract, including the digestive tract, neurons that mediate smell and taste, kidneys, and most critically, the heart and lining of blood vessels.

Infection often leads to widespread inflammation and tiny clots, which cause secondary deleterious effects. Moreover, an Italian research study found that upwards of 85 percent of patients who had been hospitalized have persistent, sometimes serious aftereffects that can drag on for an indeterminate amount of time, and possibly permanently. (The virus is too recent to know conclusively.)

The clear lesson is that efforts to prevent infection are critical. But, absent a vaccine, which is still likely far off, that’s complicated and involves difficult cost-benefit calculations.

Widespread Rapid Testing Is Crucial—And Expensive

The modes of transmission for this virus remain somewhat unclear, with scientists still working to understand the amounts of virus that constitute an infectious dose, and how infected individuals spread infectious virus.

Recent evidence suggests that SARS-CoV-2 can pass from person to person both in large droplets that travel only short distances and also in tiny droplets (smaller than five microns in diameter) called aerosols that waft through the air and that can linger longer and travel further. A better understanding of those phenomena is critical, because the expelled droplet size (which varies across breathing, speech, singing, yelling, sneezing, and coughing) determines the distance of travel and duration of presence in the air.

These uncertainties make it difficult to evaluate transmission mitigation measures. One initiative, however, is of indisputable value: ubiquitous, frequent, and rapid-response testing for active infection, especially in places where transmission is potentially high (e.g. offices, school buildings, gyms, stores, etc.).

Dealing with known infected individuals is a much easier proposition than coping with the impact of potentially infected people who can spread the virus while waiting for test results, and individuals who become ill and spread the virus while in the pre-symptomatic stage or who are asymptomatic and see no need to be tested.

This implies a need to refocus our testing capacity and implementation on screening for infected individuals in something close to real-time.

This can now be accomplished rapidly and inexpensively with antigen tests that detect virus proteins (as opposed to the PCR tests that detect virus material, RNA, or fragments thereof). Because they are currently less accurate than PCR tests, however, their primary value is in screening, rather than diagnosis. Biweekly testing of everyone at schools and in certain workplaces with such tests, especially on pooled samples, could detect COVID-19 infections early on and keep the number of new cases to a manageable level, or even cause them to disappear in some locations.

This transformation won’t be easy or cheap. Among the hurdles facing widespread, repeat screening is the scarcity of such tests; and a national screening strategy likely would require at least 25 million fast tests per week, according to Jonathan Quick, who heads pandemic response for the Rockefeller Foundation. On July 16, the foundation released a national COVID-19 testing plan that calls on the federal government to spend $75 billion to provide 30 million screening and diagnostic tests per week.

A New COVID Infrastructure

Other kinds of interventions to lower virus transmissibility won’t come cheap either. One example is the improvement of indoor ventilation and filtration systems. Evidence is mounting that transmission of the virus outdoors in amounts that can cause disease is generally rare. Of course, close gatherings for extended periods (e.g. in stadiums) increase the risk, but many outdoor venues have sufficient air movement to dissipate and dilute potentially infectious levels of viral particles.

Most transmission of the virus at levels that are infectious occurs indoors, so federal programs that encourage HVAC improvements, by direct or indirect subsidies, would be a sound investment that should reduce the incidence not only of COVID-19, but also of flu and colds. Presumably, such programs would be focused on workplaces, houses of worship, schools, and other places where strangers congregate.

Measures for which the cost is relatively low and the benefits are potentially huge include: regular masks for those with an average risk of being spreaders (especially indoors in stores, etc.), N95 respirators for those at greatest risk of contracting COVID-19 (especially indoors in environments with strangers), and distancing to the maximum extent feasible. Clearly, some situations such as workplaces and schools will have to find the optimal workable tradeoff between distance and density.

Avoiding indoor gatherings where movement is limited and exposure times are long (bars, arenas, large parties, etc.) is preferable, but the risk will depend on many factors, not the least of which is the degree of community spread in individual locales. (If the incidence of new cases and testing positivity are high, the risk of further spread is high.) These include the quality of ventilation and filtration, the feasibility of wearing masks (harder when eating or drinking is involved), and the demographics of the group. The tradeoff, of course, is that limiting these gatherings could bankrupt businesses and increase the public’s feelings of isolation and frustration.

Researchers at the University of Colorado, Boulder have modeled the risk of infection from SARS-CoV-2 aerosols in various scenarios, such as an indoor gathering, an energy-efficient office, a classroom lecture, strenuous outdoor activity, a subway ride, and so on, with and without masks. The graphs of estimated risk of infection versus time of exposure to those scenarios are instructive.

Don’t Be Stupid

It remains uncertain which additional interventions would be cost-effective, except in special environments such as long-term care facilities, where specific protocols can and should be implemented, given the hugely disproportionate death toll in people over age 75, especially if they have comorbidities. Additional interventions must also meet the test of not causing more harm than good, exemplified by restricting access to healthcare for non-COVID needs.

In formulating policy, at the top of the list of things that must be avoided are inconsistencies, illogic, and downright stupidity. The imposition of arbitrary, scientifically baseless constraints erodes public trust and deepens pandemic fatigue. (Should we even have to say that?)

Michigan Governor Gretchen Whitmer has provided some worthy examples: a prohibition on people traveling from one of their houses to another of their own properties; a restriction on motor-boating, although sailing and rowing were permitted; and the requirement that large stores close off areas that display carpeting, flooring, furniture, gardening supplies, and paint.

In Honolulu, taxpayer-funded outdoor spaces—beaches, parks, and hiking trails—are shut down, while indoor businesses including retail stores, restaurants, gyms, tattoo shops, and massage parlors that have less ventilation and more person-to-person contact are open.

Finally, the Wisconsin Department of Natural Resources (DNR) is mandating its employees wear face masks during video conferences, even if they are home alone. The department secretary admonished employees, “wear your mask, even if you are home, to participate in a virtual meeting that involves being seen—such as on Zoom or another video-conferencing platform—by non-DNR staff . . . Set the safety example which shows you, as a DNR public service employee, care about the safety and health of others.” This is reminiscent of the sublime British TV spoof of government, “Yes, Minister.”

Worst of all have been statements from politicians and even some public health officials that the motivation behind dangerous large gatherings—whether political rallies or activists’ demonstrations—should take precedence over public health considerations.

Such actions and statements severely undermine the credibility of those “in charge.” This kind of behavior needs to stop in order to inspire confidence in interventions that are actually useful. There are signs it already may be too late.

Getting through the worst of the pandemic won’t be easy, but we need to be smart, resilient, and disciplined, and go where the data take us.