Answering Your Questions On The National Surge In Coronavirus Cases

Stan Bunger
June 24, 2020 - 2:18 pm

    As we continue to navigate these unprecedented times KCBS is getting the answers to your questions about the coronavirus pandemic. Every weekday morning at 9:20 a.m. we're doing an "Ask An Expert" segment, focusing on a different aspect of the situation each day, sponsored by Sierra Pacific Financial Advisors.

    Today we're looking at the rising cases in the U.S. with Harvard University epidemiologist Dr. Eric Feigl-Ding. He is also a senior fellow at the Federation of American Scientists.

    Let's start with your reaction to what we've just heard from the Governors of New York, New Jersey and Connecticut this morning: a 14-day quarantine imposed on visitors from nine states. Do these targeted quarantines work?

    We know that testing, contact tracing, quarantine are the traditional measures, so we are pretty sure that this may have an important effect. The tricky issue is, will we need to expand the number of states that we have these restrictions on? Will other states also need to do the same thing, not just New York, New Jersey, Connecticut. Maybe also Massachusetts and other states will want to protect their citizens from this epidemic. And the hardest thing is, how do you enforce this? We don't have borders within the U.S., are we going to do border checks? Are we going to do SIM card ID checks that check if your SIM card has been to any of these other restricted states? These are very tricky. I don't know if we have the solution to answer them yet, but I think technically these are really good potential solutions to slow down the epidemic.

    Pulling back just to this question of whether people from hot spots are flooding into cool spots, if I can use those terms. Where would you draw the line, or how are officials drawing the line to say what's a danger zone and what's not?

    You can go by cases per capita. I think the states that they listed, a lot of them are Sun Belt states and southern states with very low mask wearing and high surging rates of incidence. I think there's different ways you can define them. The issue is America's just so porous. We're like a big ship without any bulkheads in between, unlike Europe has between countries. And if one ship is leaky and taking on water, are we flooding the entire ship? That's the rationale of why we're doing this, potentially, to bulkhead ourselves away from any compartments (or states) with really high epidemics.

    Let's get into the questions from our listeners, which have been emailed in to askus@kcbsradio.com. What have other countries done since we seem to be failing to successfully flatten the curve?

    I think it's a combination of things. First of all regarding testing, the U.S. now has pretty high testing levels. We have over 500,000, which is about one test for every couple hundred people. But it's not just the amount of tests, but when. South Korea aggressively tested very early and with testing you can do contact tracing, which we're not doing well, and of course the quarantine that comes with it. And just so you know, some countries like Korea and Iceland and European countries are testing so much that their positivity - the percentage of tests that return a positive result - is under 2%, 1%, 0.5%. That is how much you should be testing. In the U.S. right now our overall positivity is around 4.5-5% and it's actually going up. 

    So testing, especially early testing, contact tracing, which only a few states are doing and not fast enough to stop the transmission chain, and mask wearing. Mask wearing is so critical. Obviously there are social distancing measures and some countries are much more aggressive. We are basically getting social distancing fatigue. And so if you're not going to do the lockdown anymore we need at least 90-95% prevalence of mask wearing and the U.S. is not even close to that, especially in the hotspot areas. You either close down your government and society and businesses, or you wear masks. And wearing masks is not very invasive but it's being politicized and becoming a political football. We just need to wear masks and we can stop the epidemic if everyone wears it.

    My job site in Mountain View is still COVID-free, but these stats are giving me the creeps. From a record 4,500 on Sunday to 6,000 reported yesterday - these are the California statewide numbers - we’re on an exponential curve. How much of this is due to increased testing? I’m 68 and asthmatic; should I go home?

    All these are really good questions. Some people are actually dismissively saying that these numbers are just because we're doing more testing. That's only partially true. In all these hotspot places, the actual rise in cases clearly, by far outstrips the small rise in testing. And once you see the curves diverge you'll realize, "oh my god, the epidemic really is growing." I think the same thing is happening in California. It's surging, but not as fast as some of these Sun Belt states. But it is not just due to testing per se, which oftentimes what Trump and Pence are using to dismiss and play ostrich with this epidemic that's looming.

    What would you tell someone who says, I'm 68 and asthmatic and these numbers worry me?

    I say if you are high risk, then you should stay home as much as possible. You should avoid public places. You should have food delivered, groceries delivered if possible. Have a trusted family member go out shopping for you. And again, encourage everyone around you to wear a mask. Because my mask protects you, your mask protects me. And that is the safest way to go about this in this day and age.

    How come the deaths aren't spiking even though cases are spiking? Is it treatment? Is there a lag?

    That's a very good question and it's oftentimes asked. Death is a lagging indicator. Cases, just so you know first of all, are already delayed about one to one and a half weeks because it takes about five days to develop symptoms on average, and then get tested and get test results. So testing is about one week after infection. And then death, it depends but it could extend anywhere from two and a half to three to four weeks after. So we expect deaths to catch up later. 

    Also, we're already several months into this epidemic and we already know how to treat people much better than at the beginning. So we know, for example, how to improve the pressure settings on the ventilators for better survival, we also know about remdesivir, we also know about the blood clotting issues that are causing a lot of people to die. We've now proven that an anti-inflammatory steroid works for people needing oxygen and ventilators but does not work for prevention. So we know how to reduce the mortality now. But only to the extent that we don't overflow our hospital beds and our ICU beds. Because once we're over capacity then quality of care gets worse. So there's a combination of reasons, but I expect mortality to pick up in the next two, three, four or five weeks after the incidence initially ticks up.

    What is the hospitalization rate for COVID-19 positive cases? What is the mortality rate now compared to three months ago?

    The mortality, I think we have to look at long term trends for that, if people are surviving better. I'm guessing our treatment has made a difference on that. But in terms of hospitalizations, I think we are finding cases much earlier because of better testing so the hospitalization will drop. Because in the old days, we were finding cases who were basically about to croak if we didn't get them into a hospital bed and hence the hospitalization rate was much higher. But now because we're finding cases much earlier - which is good because the earlier you find it the earlier you stop the transmission chain by quarantining them - our hospitalization rate is dropping. So in many ways these changing statistics are really good. I'm hopeful.

    As a retired RN it makes common sense to actually enforce isolation and quarantine. In the UK there are large fines if you break quarantine. Do the same here, and for goodness sakes everyone young and old be considerate of others and wear a mask. It is a public duty for us to protect each other.

    What would you think - is there a slogan, is there somebody who could carry the message to break through what you mentioned earlier, the politicization of the notion of wearing a mask?

    Yeah. First of all, political leaders must be consistent with public health leaders. If public health leaders are advocating for this but political leaders are dismissing it, that is the worst formula. Because it then becomes a political symbol. "Don't wear a mask if you wanna be a man" or "it's a sign of weakness" or "I don't need it." People will see our leaders aren't wearing it and go, "I'm not going to wear it." That's just one. But I think also celebrities. Again, we're trying to reach people who are more conservative, more libertarian, who are anti-mask. And I think there's a lot of misinformation. For example, if you're wearing masks you're going to have carbon dioxide poisoning. That is one of the most ridiculous notions given how doctors and nurses use masks everyday in the hospital and they're not poisoning themselves at all. So there is misinformation warfare that's also going on. Partly by accident, partly because potentially there's foreign actors who are trying to do this. But we have to trust scientific leaders. But you know how often misinformation, false information about a conspiracy will go around the world three times before the truth will have the chance to put its boots on, right? We're in a new age where we as scientists, as policymakers, need to fight misinformation just as fast as the bots and the misinformation warriors carry out their propaganda.

    Alameda County has said you can have up to 12 people, not necessarily in your household but in what you'd call a "social bubble". This listener asks, how do you maintain a safe bubble? Can you create one without testing? I have family that has been home for three months except for a few doctor's appointments and restaurant visits with masks and precautions, who would like me to visit. What can we do to be safe visiting or staying over at a family members house? Can we be safe inside with social distancing and masks in the house?

    Social bubbles are very tricky. It's about how much trust you have. Because it's a circle of trust, right? That everyone who joins the bubble must adhere to the rules that they do not interact outside the bubble to create this little quarantine community. But there's always risks that someone will break it, which then endangers everyone. I believe you could have it, as long as you can have good trust. In God We Trust but for everyone else, wear masks. I'd still emphasize that everyone should wear masks and follow distancing and not have karaoke and disco parties indoors. I think if you do outdoor barbecues and keep a reasonable distance and wear masks, I think that's much more reasonable than indoor gatherings in close confinement.

    At my workplace with people moving around the office area it's hard to keep six feet away. Not everyone wears a face mask or covering. Is it required to wear face masks in the workplace as it is in public around others?

    The answer to the last part under orders here in California is yes. I guess the bigger question is, how do you navigate a landscape where not everybody is playing along?

    Yeah, this is where it's really tricky and we don't have good answers. Obviously policy leaders need to set these rules and have enforcement. Virginia has these rules and the other day Trump and Pence visited their campaign headquarters in Arlington, Virginia. But the problem was that technically the District Attorney could not prosecute it because it falls under Department of Health enforcement. The Department of Health does not have the capacity to enforce these workplaces that are breaking the rules around mask wearing. So in the end it becomes a toothless policy and that's obviously something states have to reform.

    In absence of that I think companies need to show leadership and internally enforce it. And if half the company does not and the leadership of the company does not, I think that's something you could potentially sue for if it goes against health guidelines. Also, N95 masks.  Because unlike cloth masks where I protect you, you protect me but half the people don't wear it so no one is really being truly protected, N95 grade masks do protect. That said, they should be prioritized for healthcare workers. So as long as healthcare workers in your area have enough, then procuring N95 and KN95 masks, as long as they're not fake, are potentially useful because they protect you from inhaling the virus particles.

    Recently France's chief scientist declared the virus under control. At the same time, the EU is considering barring U.S. visitors to Europe because of our handling of the virus. My question to you is, as an epidemiologist, what can you say about the U.S. is handling the virus compared to other countries?

    The U.S. is handling it very poorly. Compared to the EU countries, the U.S. has a way way worse trajectory. We're trending up again across the whole country, not just the hotspots, while the EU is keeping it low and trending down for the most part. With the exception of Sweden, because they tried to pursue a dangerous herd immunity approach, which you should never use without a vaccine. And they're plowing through without distancing and endangering them. But besides that, I think this looming EU ban against U.S. travelers is, I would say, the ultimate slap in the face. Because it says all our U.S. tourism dollars are not worth it, we would rather lose all the U.S. tourism dollars that come to Europe because you guys are just too dangerous to our economy. And it's an ultimate slap in the face against American leadership in containing this epidemic. I hope it doesn't happen but I wouldn't fault them, given that we know the U.S. is a hotspot just like New York, New Jersey and Connecticut realized these Sun Belt states are a hotspot as well and put in travel bans against those states.

    Yeah and just to amplify - and you can correct my numbers if I'm wrong - but I think right now the European two week moving average is about 16 new cases per 100,000 people, here in the U.S. it's something like 106 and much higher than that in a number of other states. Is that roughly right?

    Yeah, roughly. We're talking about orders of magnitude different. This is why the U.S. is in such extreme trouble compared to the rest of the world. I think we're going to be in this perpetual purgatory unless we have amazing testing and contact tracing and distancing, which at this point besides testing we don't have enough of. Or mask wearing, we don't have enough of that. And any of these other countries have aggressive, across-the-board public health measures that support all of this. The U.S., it does not and poor leadership in signaling you should wear a mask, which Europe does. So altogether I do not see the U.S. safely reopening for schools easily in the fall, especially in many parts of the country. Meanwhile in Europe, Austria for example, kids are already back at school for several weeks and they do not have outbreaks and they expect in the fall kids will be attending school as normal. And that is what is ultimately at stake here. We're not only killing our elderly generation but we're also harming our future generation by keeping them out of schools for such a long time. I'm all for containing the epidemic, but we have to consider the effect on children is ultimately the price that we are playing. Please, please wear a mask for the love of our kids.

    I heard that one of the potential vaccines will begin a phase three trial in July. What is a phase three trial?

    A phase three is a much larger scale trial, where they're proving not only that it works on a limited level but does it actually prevent infection on a huge population level. We're talking about thousands of people - 3,000 or 5,000 people - and see how much the epidemic drops among those who are immunized versus a control group that is not immunized. It's a large scale randomized trial, not just a handful of 40 people. So I'm hopeful, and there are dozens and dozens of trials that are underway worldwide. We just need to find one that works and one that's affordable for everyone. Many countries are trying to ensure affordable vaccines for all, that billions of people will receive them for free. But the U.S. right now has not made that guarantee. I think U.S. pharma companies need to make that guarantee, that it will be free or at-cost. Because if we don't conquer the epidemic worldwide, nationwide the entire world and our entire country will still remain at risk and it's just not worth it.

    This interview has been edited for clarity.