Month: May 2020

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Communities Perspectives Planning

Stay the Course

The following is a transcript of my remarks made during the weekly public address of the Office of the Mayor, Bayonne, NJ – May 28, 2020

My name is Michael Rosanoff and I am an epidemiologist and public health professional proudly serving as a member of the Bayonne COVID-19 taskforce, under the Office of Emergency Management and the leadership of Mayor Davis.

I would like to take this opportunity to briefly discuss the journey that we have all been on for the last 11 weeks, since the World Health Organization declared COVID-19 a global pandemic on March 11th, and since Bayonne began implementing efforts to mitigate the spread of the coronavirus in our City.

I would like to discuss where we began, how we got to where we are today, and what we might expect over the coming weeks to months as we continue to address the pandemic in our community.

Bayonne, NJ had its first confirmed COVID-19 case on March 18th. Nearly one week earlier, any parent of a school-age child in Bayonne will know, the decision was made to preemptively close schools. This was a critically important step taken to slow the spread of the virus and to protect our children and teachers.

Shortly thereafter, restaurants were restricted to take-out only, retail stores were closed to customers, and our state’s directives to stay at home began. Essential services like grocery stores remained open, but the number of customers were limited, senior shopping hours were added, and anyone out in public was asked to stay six feet apart. Our world of “social distancing” had begun.

Why did our City and our State take these measures? The purpose was to slow the spread of the virus and “flatten the curve.” This term was used to describe how reducing our exposure to one another could reduce the rate of new COVID-19 infections, and avoid a potential tidal wave of new cases in a short period of time.

The fear was that a rapid surge in cases could overwhelm our hospital system and limit our ability to treat patients, as beds, ventilators, and personal protective equipment were all in limited supply.

Fortunately, we never got to that point in Bayonne. We certainly came close, but our front-line healthcare workers remained strong. Our community remained strong. Because we listened, stayed at home, and followed the social distancing guidelines, we were able to flatten the curve and slow the spread.

This brings us to where we are today. We are at a place where we are seeing a consistent and steady decline in the number of new COVID-19 cases and new hospital admissions. We have met criteria to begin to reopen aspects of society, but will need to do so slowly and in stages.

We should be proud of our collective commitment to slowing the spread of the virus, and be hopeful that the worst is behind us. However, we should not mistake this moment as the end of the pandemic.

While our goal has always been to slow the spread of COVID-19, we also know that it will take more work to stop the spread altogether. What we know about infectious diseases is that a certain percentage of the population needs to have immunity to the virus before we can stop its spread.

Some scientists estimate that 60-80%, or up to 8 out of 10 people, need to have immunity to COVID-19 for new infections to stop. We do not know how many people have immunity to COVID-19 today, but it is likely well under that number.

It is still unclear whether recovering from COVID-19 and having antibodies to the virus is enough to be immune from re-infection. What we do know is that the preferred way of achieving that 60-80% immunity is by finding a COVID-19 vaccine. While there are some promising clinical trials taking place, and the studies are being accelerated, a vaccine is not expected to be available before the end of 2020.

What this means is that we are not out of the woods yet. We shouldn’t be fearful but we must be mindful that the virus is still out there, it is still highly contagious, and it can still cause very serious illness for some people.

As the weather is turning nicer and society begins to re-open, it might be more difficult to adhere to the social distancing guidelines, but we must continue to do so. Though we may no longer be told to stay at home, we are still safer at home.

We must continue to maintain six feet distance from others, not only in supermarkets but at the park, or walking the Bayonne bridge, or anytime we are out in public. And research has shown that wearing a face covering does significantly reduce the spread of respiratory droplets that carry the coronavirus – so continue to wear a face covering in public, and always wear one when you may not be able to maintain six feet distance from others.

Many of us will want to visit with family and friends that we haven’t seen in weeks. The best guidance is to continue to limit your exposure to others outside of perhaps a small and select circle of trusted family and friends. Choose your small circle and stick with it. This is not the time for large gatherings.

Most importantly, we must protect our family, friends, and members of the community at highest risk of severe illness from COVID-19, including our seniors and those with other health conditions.

If we remain vigilant, we will continue to see a steady decline and plateau of new COVID cases through the summer months. But we also must prepare ourselves and our community for the possibility of a resurgence of the virus and another wave of cases, particularly as we get into fall and winter, when we will start to see cases of seasonal flu as well.

While we continue to be hopeful, we must not let our guard down. And if we do start to see a resurgence, we will be ready. Bayonne has demonstrated that, as a community, over the last 11 weeks, we will do what it takes to protect our loved ones and neighbors.

Let’s all continue to recognize the incredible work and sacrifice of our front-line essential workers and emergency personnel. And let’ remember those in our community, and around the country and world, who have lost their lives or family members to this pandemic.

Thank you again for following the guidelines. Please continue to wear a mask, wash your hands, and practice social distancing. And to stay strong as we overcome the pandemic together.

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Perspectives

Is Testing Telling?

It has been one of the chief criticisms of our national response to the COVID-19 pandemic – we need more testing. But what exactly does that mean and will “more testing” provide the answers we seek? Some states and local municipalities are relaxing testing restrictions and making widespread testing available to residents, with or without symptoms. But could this approach actually do more harm than good? And what exactly are we trying to accomplish with more testing? Let’s think about it for a moment.

Antigen Testing

When we hear the word “testing,” more often than not it is referring to diagnostic testing for active COVID-19 infection, aka antigen testing. It is the test to find out whether or not someone currently has COVID-19. It is the test that can be done with a quick nasal swab at a drive-up or walk-up testing site. Until recently, nearly all antigen testing was restricted to people exhibiting symptoms of COVID-19. Many testing sites required a physicians prescription. In the very early stages of the outbreak, only those with symptoms that had either been in contact with a confirmed case or have traveled to China were able to be tested. The exception to all of this has been testing for front line healthcare workers and emergency personnel, who are in regular contact with known or suspected cases.

In the early stages of the outbreak in the US, it made sense to test as many people with symptoms as possible, but we did not have the testing capacity (enough testing kits, trained personnel, testing sites, etc.) at the time. That was a major, and justified, criticism. By identifying as many cases as possible, those who tested positive, especially those with mild symptoms, could be given guidance to self-isolate, as could any others people that may have come into contact with the infected person. The ability to conduct this “contact tracing” has and continues to be a challenge as well.

But there was and remains a major limitation to symptomatic testing – it misses all of the asymptomatic or pre-symptomatic cases, which some suggest could make up more than 50% of all cases (the true number remains unclear). And these asymptomatic cases may have been the “super spreaders” in the early stages of the pandemic before social distancing measures were put in place. One proposed solution to finding asymptomatic carriers is to open testing to anyone, including asymptomatic people. But does this make sense?

Asymptomatic Testing

The problem with widespread asymptomatic testing is that it’s questionable whether it is actually informative for decision-making. An antigen test tells us one thing – do you currently have a COVID-19 infection. If the answer is yes, then that is good news for the health official who can now instruct that patient, and anyone who has been in close contact with that patient, to self-isolate. We can presumably now stop that person from further spreading the virus, whereas otherwise that person may have never even been diagnosed.

But what if that person tests negative? That person may not have the virus at the moment, but could contract the virus later on, be it that day, or that week, or that month. In fact, that person could have been exposed to the virus while waiting to be tested. We wouldn’t know. Thus, a negative test can instill a false sense of security that the person is healthy and safe, when really nothing has changed. A negative test in not especially informative.

Further, it could be a false negative test, meaning that the person has contracted the virus but it may be too early in the infection to accurately detect the virus. This is an even worse case because then that person is likely to spread it to someone else if not practicing strict social isolation guidelines.

Widespread testing can also put a major burden on the healthcare system. It requires trained personnel, personal protective equipment, testing kits, testing sites, and lab equipment. It is worth noting that during the time when testing was restricted only to symptomatic cases, most US states had a positive test rate around 50% or less. With asymptomatic testing, we will have far more negative tests, each requiring the time and resources of the healthcare system. It also has the potential to create a situation that puts healthy people in contact with infected people, while crowding healthcare facility spaces and testing sites.

Asymptomatic testing may make sense in certain situations. Health care workers and first responders who are in daily contact with potentially infected people, should be tested regularly, even in the absence of symptoms. Anyone who has been in recent contact with a known case or a person under investigation (via contact tracing) should also have access to testing without symptoms. Seniors and individuals with underlying health conditions that are at particularly high risk for severe COVID-19 disease could benefit from regular testing (if performed safely). And as we reopen aspects of society, certain types of employees like teachers and day care workers, food service employees, and maybe grocery and retail employees in constant contact with many people, should have access to regular testing.

These represent sectors of the workforce that have the potential to spread the virus widely if infected, but perhaps also represent a more manageable section of the community in terms of size, for which regular testing would be more feasible and practical. How often individuals should be tested is up for debate. But because one test can only tell us whether someone has COVID-19 at that single point in time, the more often the testing the better.

Serologic (Antibody) Testing

Serologic testing, or antibody testing, is the other type of testing that we are hearing about and it may be the type of widespread testing we actually need, though that’s not entirely clear either. Antibody testing looks for the presence of COVID-19 antibodies, which are a signal that the body produced an immune response to a COVID-19 infection. In other words, if you test positive for antibodies, you had the virus.

Based on what we know about viral immunology in general, if your body has produced antibodies to a virus, you have immunity to that virus and cannot be infected again. The problem with the novel coronavirus is that it has been around for less than 6 months and we don’t know for sure if the presence of antibodies means protection from reinfection. It is unclear if you need a certain level of antibodies to achieve immunity. And it is unclear how long that immunity may last. For these reasons, a positive antibody test may not be informative for decision-making about whether it is safe to return to work or relax stay-at-home orders.

It would, on the other hand, help us understand the prevalence of COVID-19 infection in communities, which theoretically could help predict future infection rates. But the latter still requires us to assume that those who have been infected can no longer get or spread the virus in the future.

Currently, antibody testing requires a blood draw (and a trained phlebotomist), which is more invasive and resource intensive than a nasal swap or finger stick. So it is not as easy as testing for active infections. Some commercial labs have made antibody testing available to the general public with and without a doctors prescription, though it is unclear how much these test will cost or if they are covered by health insurance under the CARES Act. More importantly, it is unclear how reliable these tests are. How specific are they to identifying COVID-19 antibodies versus antibodies to other types of cornavirus?

Testing (alone) may not provide all the answers

All in all, antibody testing at this time may not be informative for decision making about when it is safe to return to society. Though it may be the key to safely re-opening communities in the future, should we confirm that the presence of antibodies means immunity. As for widespread asymptomatic antigen testing, it could cause more harm than good, putting a burden on the healthcare system while putting people at risk of exposure, or worse, instilling a false sense of security. And unless we can test nearly everyone, and test everyone on a near weekly basis, and conduct contact tracing on every positive case, then widespread testing just doesn’t make sense.

At the moment, “more testing” alone may not necessarily be the right solution if we cant act on test results. Increased testing has to be done strategically and consistently. It has to be accompanied by the appropriate follow-up including contact tracing and with effective communication to patients about what test results mean and what they don’t mean.

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