The emergence of the omicron variant of the SARS CoV-2 coronavirus opens a new chapter in the ongoing COVID-19 pandemic. Early evidence indicates it is more transmissible than some previous variants of concern. South Africa, however, is experiencing a decline in the number of cases as rapid as the increase that was observed as the number of cases after its detection in November 2021. Additionally, South Africa has not had a high percentage of severe cases, as measured by the number of COVID-19 patients who were hospitalized.[i] Many hope that other countries will experience a similar trend as the omicron variant overtakes previously predominant variants. There are some specific circumstances that distinguish South Africa from the United States and the spread omicron variant could have a very different outcome in the latter country.
Preliminary epidemiological analysis of the spread of the omicron variant in southern Africa, where it was first detected and sequenced, suggests that while omicron is more transmissible it has not caused similar percentages of severe disease observed from some previous variants among South Africans. If this is confirmed, it does necessarily mean that there will be a similar pattern in the United States. There are several characteristics of the South African population that are quite different from other countries such as the United States. First, the population of South Africa is younger than the U.S. population. Based on the pathology observed from the delta and other variants, younger people tend to have less severe disease as a group. Second, because South Africa did not have widespread access to vaccines during the early stages of the pandemic, it is likely that a far larger percentage of the population became infected with SARS CoV-2 and developed some level of natural immunity. It remains unknown if recovery from previous COVID-19 infection is effective in reducing severe disease or death from the omicron variant but such a hypothesis is plausible. Data supporting this hypothesis was reported in an analysis that compared severity of disease for the alpha and beta variants in Qatar during 2020-21.[ii]Thirdly, according to a bulletin published by the U.S. Embassy in South Africa, mask wearing in public places remains mandatory in public places and there are penalties for non-compliance.[iii]The U.S. Centers for Disease Control and Prevention continues to recommend[iv]the use of masks to control the spread of COVID-19 and numerous scientific studies have confirmed mask wearing reduces COVID disease transmission for those who use them.[v] Compliance with mask and social distancing recommendations continues to be much lower in the United States and it is an ongoing impediment to effective infection control.
At the end of the day, infection control (measures such as social distancing and masking in crowded settings) and vaccination provide an effective approach to limiting the number of cases that may arise during the current disease surge in the United States. Early data show that the initial vaccination (two injections of the Pfizer/BioNTech or Moderna or one injection of the Johnson and Johnson) plus a booster provides effective protection against severe disease and death. Vaccination and avoiding exposure to SARS CoV-2 is the best means of preventing disease.
[i] F. Abdullah , J. Myers , D. Basu , G. Tintinger , V. Ueckermann ,
M. Mathebula , R. Ramlall , S. Spoor , T. de Villiers , Z. Van der Walt , J. Cloete ,
P. Soma-Pillay , P. Rheeder , F. Paruk , A. Engelbrecht , V. Lalloo , M. Myburg , J. Kistan ,
W. von Hougenhouck-Tulleken , M.T. Boswell , G. Gray , R. Welch , L. Blumberg , W. Jassat ,
Decreased severity of disease during the first global omicron variant covid-19 outbreak in a
large hospital in tshwane, south africa, International Journal of Infectious Diseases (2021), doi:
https://doi.org/10.1016/j.ijid.2021.12.357
[ii] N Engl J Med 2021; 385:2487-2489 DOI: 10.1056/NEJMc2108120.
[iii]See U.S. Embassy and Consulates in South Africa, COVID-19 Information December 21,2021, available at https://za.usembassy.gov/covid-19-information-2/, on January 2, 2022.
[iv] U.S. Centers for Disease Control and Prevention, Science Brief: Community Use of Masks to Control the Spread of SARS-CoV-2 Updated Dec. 6, 2021, available at https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html#:~:text=A%20study%20of%20an%20outbreak,70%25%20reduced%20risk on January 2, 2022
[v]U.S. Centers for Disease Control and Prevention, Science Brief: Community Use of Masks to Control the Spread of SARS-CoV-2 Updated Dec. 6, 2021, available at https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html#:~:text=A%20study%20of%20an%20outbreak,70%25%20reduced%20riskon January 2, 2022
Early evidence indicates the omicron variant of the SARS C0V-2 virus is more transmissible than some previous variants of concern. South Africa, however, is experiencing a decline in the number of cases as rapid as the increase that was observed as the number of cases after its detection in November 2021. Additionally, South Africa has not had a high percentage of severe cases, as measured by the number of COVID-19 patients who were hospitalized. Many hope that other countries will experience a similar trend as the omicron variant overtakes previously predominant variants. There are some specific circumstances that distinguish South Africa from the United States and the spread omicron variant could have a very different outcome in the latter country.
[1] F. Abdullah , J. Myers , D. Basu , G. Tintinger , V. Ueckermann ,
M. Mathebula , R. Ramlall , S. Spoor , T. de Villiers , Z. Van der Walt , J. Cloete ,
P. Soma-Pillay , P. Rheeder , F. Paruk , A. Engelbrecht , V. Lalloo , M. Myburg , J. Kistan ,
W. von Hougenhouck-Tulleken , M.T. Boswell , G. Gray , R. Welch , L. Blumberg , W. Jassat ,
Decreased severity of disease during the first global omicron variant covid-19 outbreak in a
large hospital in Tshwane, South Africa, International Journal of Infectious Diseases (2021), doi:
https://doi.org/10.1016/j.ijid.2021.12.357
[1] N Engl J Med 2021; 385:2487-2489 DOI: 10.1056/NEJMc2108120.
[1] See U.S. Embassy and Consulates in South Africa, COVID-19 Information December 21,2021, available at https://za.usembassy.gov/covid-19-information-2/, on January 2, 2022.
[1] U.S. Centers for Disease Control and Prevention, Science Brief: Community Use of Masks to Control the Spread of SARS-CoV-2 Updated Dec. 6, 2021, available at https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html#:~:text=A%20study%20of%20an%20outbreak,70%25%20reduced%20risk on January 2, 2022
[1] U.S. Centers for Disease Control and Prevention, Science Brief: Community Use of Masks to Control the Spread of SARS-CoV-2 Updated Dec. 6, 2021, available at https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html#:~:text=A%20study%20of%20an%20outbreak,70%25%20reduced%20risk on January 2, 2022
Several worrying trends emerged during early summer 2021 with respect to the COVID-19 pandemic in the United States. While the percentage of vaccinated people in the United States is among the highest in the world, several factors including the failure of some to get vaccinated, the appearance of a new variant, and the fact that children under 12 are not yet cleared to be vaccinated, leave the country vulnerable to the consequences of the continued spread of the disease. This pandemic will not end until enough people acquire immunity to prevent the spread of the SARS CoV-2 virus.
The delta SARS CoV-2 variant, which evidence shows is more transmissible, has become the dominant variant in the United States and has raised the risk of infection among unvaccinated people. Beginning in the late spring of 2021 and continuing through July 17, the SARS CoV-2 virus infected proportionately (per 100,000) more people under the age of 50 than older Americans. While the percentage of older American who are fully vaccinated is higher than it is for those under 50 years old, it is noteworthy that the rate among those 18-49 years old COVID-19 patients has risen over time and they are now more seriously ill when they get the disease than previously. The positivity rate for diagnostic testing (the number of total diagnostic tests divided by the number of positive test results) has risen sharply since late June. Taken together, these trends indicate the disease continues to represent a public health threat that has not disappeared.
Vaccine coverage in the United States is another area of concern. Approximately 69 percent of adults over 18 years old have received at least one vaccination against the coronavirus. The concern arises because there are significant geographic concentrations where vaccine coverage is far lower. Given the more transmissible delta SARS CoV-2 variant and the majority of new COVID-19 cases occur among the unvaccinated, there is a greater possibility a new mutated strain could emerge. If such a new strain is less well controlled by the current vaccines, an additional surge in cases could result and potentially affect people who have recovered from COVID once or are fully vaccinated. The fact that few other countries have vaccinated their populations at the same rate as the United States means a second wave of the ongoing COVID pandemic could occur.
The use of the Pfizer, Johnson and Johnson, and Moderna vaccines in children under 12 years old awaits the completion of clinical trials in that population. While the safety and efficacy of the vaccines in adults is a positive indication for using the vaccine in children, there are special considerations that must be taken into account due to physiological differences between adults and children in immune function, metabolism, and obviously, size. Determining appropriate dosage and use protocols are more complex than simply scaling the dose by weight. Also, the observation of a few unique COVID-19 symptoms in children must be considered as the analysis of the clinical trial data proceeds. It is likely, however, that a decision on the emergency use authorization of the currently deployed vaccines will occur during the next few months as the clinical trials in children are completed.
The COVID-19 pandemic is far from over. Lack of access and low vaccination rates are indicators that the virus will continue to circulate widely and create opportunities for the emergence of new and potentially more dangerous variants. Although a small number of countries may have been able to vaccinate their populations, that does not guarantee those countries can avoid the consequences of the continuing pandemic. Until children are included in mass vaccination programs, they will remain vulnerable to the spread of COVID-19. Until enough people are vaccinated to deny the virus a large number of susceptible people, the virus will continue to spread.
July 25, 2021
The distribution of the COVID-19 vaccine has allowed a significant reduction in activity restrictions for the United States. With about half of the U.S. population fully vaccinated, businesses have re-opened, travel has resumed, and only the unvaccinated are encouraged to continue infection control precautions in the presence of large groups and in public spaces. It remains the case, however, that much of the rest of the world continues to experience a surge in COVID-19 cases. The continuation of disease spread increases the possibility that new virus variants will emerge that are resistant to current vaccines. This could cause a re-emergence of the virus among vaccinated populations. This is the reason why continued disease surveillance is needed in this country. One approach to population disease surveillance that would not require disruptive testing of individuals is testing for the presence of the virus in sewage or wastewater. This is possible because when people are infected with COVID-19, the pathogen is shed in feces.
Wastewater/sewage testing detects the presence of the SARS-CoV-2 virus in feces. While testing wastewater or sewage would not provide detailed information about the number of new COVID-19 cases that occur, it could answer questions about whether the virus continues to circulate in communities. When that data is paired with diagnostic test data and contact tracing, it would allow local health authorities to focus their disease investigation activities to forestall a major outbreak. There are significant limitations to wastewater/sewage disease surveillance, the most significant one is it is only possible in communities with large-scale and community-wide wastewater treatment facilities. It would not work in areas where such systems do not exist. Nonetheless, it would provide a useful tool to monitor the spread of COVID-19.
The presence of the SARS CoV-2 virus in feces can be detected using PCR (polymerase chain reaction), the same type of test used to diagnose the disease in individuals. If samples are collected from geographically distinct areas of wastewater/sewage systems, it can localize where the new infections are likely to be found. Negative tests would suggest the absence of virus circulation in the tested area although it would not preclude the possibility of the virus being present. Positive tests would indicate the need for public health interventions to limit disease transmission such as enhanced case finding.
There are technical issues that would require resolution to implement an effective COVID-19 disease wastewater/sewage surveillance program; these include defining the most efficacious protocols for sample gathering and data analysis. Using wastewater/sewage surveillance, however, could provide useful insights on how well COVID-19 is controlled in large communities.
June 3, 2021
The Biden administration is proposing wide ranging infrastructure legislation. The bill includes funding for transportation, communications, energy, workforce development, emergency management and response capabilities, as well as other activities related to supporting the U.S. economy. The cost of the proposed legislation is about $2 trillion over 15 years. While most agree that investing in roads, bridges, electricity grids, communications systems, and other physical infrastructure is essential for a fully productive economy, other systems and resources such as workforce training and population health are equally essential for productivity. Everything that supports economic production is a form of infrastructure. By addressing the range of systems and resources that enable an economy to function and be resilient in the face of the various challenges that inevitably arise, this legislation can help restore and strengthen the economy to thrive in the future.
The U.S. economy is complex. It has supply chains and production processes that reach around the globe. Additionally it needs to be responsive to ever changing markets. The U.S. economy and society have experienced fundamental changes since the last time the federal government undertook infrastructure building. The economy is much more dependent on high speed communications and information processing to support current manufacturing requirements such as “just in time” delivery of intermediate goods and inventory control. Investments in infrastructure such as transportation, communications/information, and power generation will make the economy more efficient. Investments in the appropriate stewardship of important resources such as clean air and water will allow the avoidance of paying for remediation in the future. Investment in emergency management and response capabilities will mitigate the impact of natural disasters or other unforeseen events and facilitate a more rapid recovery.
Societal changes have also caused changes in the economy over time. For example, the role of women has transitioned from a focus on unpaid family care-giving to being integrated into every aspect of the workforce. One result has been the emergence of a care-giving sector for children and elders so women are enabled to participate in the wage economy. There have been demographic changes as well, especially in the trend to smaller families with fewer children. Without more entrants into the U.S. labor force, it will not be possible to sustain economic growth and the financial integrity of the social security retirement system. The current economy incorporates such rapid technological changes that workers need to be able to learn and incorporate new skills within short time-frames. This has created a new requirement for ongoing post-secondary training throughout the life span. Assuring all Americans have access and are equipped to participate and contribute to the economy to the maximum extent of their talents and abilities and no one is limited by bias or discrimination optimizes the productivity of the entire labor force. Population health is another aspect of infrastructure. The fact that the U.S. ranking for most health indicators continues to decline remains a hindrance to economic competitiveness, primarily as lost labor productivity and increased healthcare costs.
All of the sectors included in the proposed legislation are critical components of the current U.S. economy. Federal investment in all aspects of infrastructure will have a positive impact on the economy and future competitiveness.
April 14, 2021
Although the Pfizer-BioNTech and Moderna COVID-19 vaccines were developed in less than one year, the underlying technology of mRNA vaccines actually dates back to the early 2000s when medical researchers began to formulate a vaccine to treat cancer. As is the case with virus infected cells, cancer cells display antigens on their cell surfaces that are unique to the disease. The immune system can be “trained” to recognize these antigens with a vaccine and kill the affected cells. Scientists reasoned that if they could create a cancer vaccine, it would only target diseased cells and leave the surrounding healthy cells and organs unaffected. This approach would be less damaging to the body than radiation or chemotherapy, which can cause harm to overall health. After some initial experiments, researchers decided to focus their research efforts to develop an mRNA vaccine because it offered advantages that other therapeutic approaches lacked. Several experimental mRNA vaccines have also been developed in recent years for infectious diseases, including Zika, influenza and rabies. The research for mRNA vaccines has demonstrated the products can be safely administered, easily formulated, and manufactured in large quantities
Among the specific advantages of mRNA vaccine technology compared to more traditional vaccine development approaches are the following. First, mRNA proteins can be synthesized in a laboratory, which means the chemical and physical structure of the desired antigen could be manufactured with a high degree of accuracy to correspond to the antigen of interest. Secondly, because of the characteristics of the vaccine mRNA and how it interacts with living cells, there is no possibility of causing any unintended genetic mutations. In fact, the characteristics of the vaccine mRNA are such that it does not enter the cell nucleus, which is where the cellular DNA genetic code exists. Thirdly, the mRNA can be packaged so that it could be easily absorbed into cells (but not the nucleus), perform the necessary function of replicating the antigen, and then degrade as part of normal cellular processes. Lastly, enveloping the mRNA inside a lipid (fat) carrier has proven to be safe to administer. An additional advantage is that the mRNA can be quickly modified to match any antigen changes, which is important since coronaviruses are RNA viruses and prone to rapid mutation.
The mRNA cancer therapy proved to be effective in targeting and destroying cancer cells throughout the body and extended survival for those patients who were treated. After the SARS-CoV-2 coronavirus emerged in late 2019, scientists decided to translate the mRNA vaccine technology in an effort to address the pandemic and resulting social and economic crisis. While health authorities will continue to monitor vaccine recipients for adverse events and long-term efficacy, the vaccine has provided a way to bring the pandemic under control and a return to a more normal life.
February 15, 2021
The development of the Pfizer-BioNTech and Moderna COVID-19 vaccines during November 2020 is clearly good news. Early clinical trial data indicates the effectiveness of these vaccines for preventing serious disease is over 90 % and no significant safety issues have been noted. It must be stated, however, that there is insufficient data to address the questions of the length of the immunity conferred by the vaccine and whether successful vaccination will prevent someone from spreading the disease to others. These questions are critical for planning the public health policies for disease prevention during the period between vaccine introduction and effectively controlling COVID-19. During the interim period, efforts to prevent disease spread must remain in place to prevent a resurgence of the pandemic.
The measure of effectiveness for the vaccine clinical trials were the prevention of serious disease or death and based on the observed data the vaccines prevented that outcome for more than 90 % of the participants who received them. Determining the length of immunity requires monitoring the study participants over an extended time and measuring the longevity of antibodies and other immune system components. Given the trials were only initiated several months ago, more time is needed to answer that question. Determining if the vaccine prevents both serious disease and disease transmission also requires long-term data collection. The critical issue is whether the vaccine successfully prevented any disease spread from occurring between vaccine recipients and others. Answering this question requires identifying vaccine participants who were exposed to the SARS-CoV-2 virus after vaccination and determining if they transmitted the infection to someone else. Since less than 10 percent of the vaccine recipients became ill with the disease, there is insufficient data to ascertain if anyone who did not display symptoms but was nevertheless infected went on to spread the disease. We have already observed that the SARS-CoV-2 virus can be transmitted by people who are asymptomatic so this is a very important issue for public health planning.
All of this means until there are definitive answers for these questions, preventive measures such as mask-wearing, social distancing and hand-washing will be necessary to ensure COVID-19 does not continue to spread. While a successful vaccine is a great achievement, it will not allow an immediate return to interacting in the same ways as before COVID-19.
Two unexpected anomalies have emerged since early July 2020 with respect to the continuing COVID-19 pandemic. First, the emergence of 97,000 cases among children provided evidence children can become infected, though they may not exhibit serious symptoms of the disease. As we approach the fall and the resumption of primary and secondary education, this poses serious challenges for educators as they plan instruction for the upcoming academic year. Second, the surge in cases, especially in regions and less urban areas that had not seen significant numbers of people afflicted with COVID-19, shows smaller communities are as vulnerable to the spread of COVID-19 as the original outbreak hotspots on the east and west coasts. These two events are reasons why it is critical to expand testing and fully implement preventive measures in all communities to reduce the spread of disease. The management of the pandemic as the summer ends and we move toward the height of influenza season will profoundly affect how and if pre-pandemic levels of economic activity can be achieved in the near-term. It could also have an impact on the costs of the pandemic.
A sharp rise in cases and deaths has been noted recently, often in communities with limited resources and among populations who face significant health disparities and suffer disproportionately with serious illness. When the SARS CoV-2 virus first arrived in the United States in early 2020, the greater New York City region, Seattle, and large metropolitan areas of California were most immediately and severely affected. Once the virus spread to other large cities such as Chicago, state governments began to implement stay-at-home orders and closed all but essential businesses; schools were also closed. This had the effect of reducing the spread of disease, but also precipitated a severe economic decline. By the early summer, the rapid rate of COVID-19 spread had abated in the early hot spots and those areas which had not seen a large number cases began loosening restrictions and re-opening businesses. The two months in which the restrictions limited non-essential commerce created a “pent up” demand for a return to more normal economic and social activities. The arrival of warmer weather and the traditional vacation travel season led to many people to abandon precautionary measures. The surge in the number of new COVID-19 cases began shortly after the Memorial Day holiday and accelerated through the Independence Day holiday. Retrospective analysis of COVID-19 spread since the early summer indicates much of the spread can be traced to clusters of people interacting in close proximity. Anecdotally, there are numerous reports and photographs of crowded events preceding a local spike in cases. Additionally, ongoing research on the pathology of SARS-CoV-2 infection found that a large number of persons, both adults and children, have asymptomatic infections. This complicates the identification of infected people and they unknowingly infect others. Some communities have re-imposed some restrictions in an effort to regain control over COVID-19 spread. However, with more than five million confirmed infections and likely a large number of asymptomatic ones, it will be extremely challenging to limit further spread.
The combination of child susceptibility and the absence of symptoms during infection could drive a significant surge of cases after schools re-open. Without effective diagnostic testing, it is impossible to know if students are infected and at risk of spreading the disease. While the children may not be sick enough to require treatment or hospitalization, without continuous surveillance testing, these children could become silent spreaders of disease to older family members who are more likely to suffer severe effects of COVID-19 disease. The essential elements of controlling the disease are identifying cases and preventing those cases from spreading it to others in all school settings.
Another significant related challenge of SARS C0V-2 virus infection is long-term effects are not yet well understood. The eight months that COVID-19 has been recognized is not long enough to collect sufficient data for an accurate assessment. However, anecdotal reporting provides important evidence that the long-term effects are significant. Among adults, prolonged lung damage, heart, kidney and neurological damage from blood clotting, and cognitive decline were observed. In some instances, these effects were observed in patients who did not have severe acute disease. Children who experience a Kawasaki-like inflammatory syndrome during the acute phase of COVID-19 infection may also experience long-term effects. As more data is gathered from COVID-19 survivors, still other medical issues may be discovered. At a minimum, patients experiencing prolonged symptoms may be prevented from returning to their normal activities, thus causing economic losses and social consequences. In addition, those patients who experience post-infection cognitive or neurological symptoms will also incur additional medical and rehabilitation costs. The costs of long-term management of these effects could prove expensive. Again, the best strategy for reducing illness, death, and potential future lingering after-effects is identifying cases and preventing further disease spread.
Re-opening schools for in person instruction and businesses for pre-pandemic economic activity in the absence of effective disease transmission control measures would trigger a return to the crisis experienced during the early days of the pandemic. What is required to resume many pre-pandemic activities safely everywhere is to follow the public health recommendations of hand hygiene, masks, crowd avoidance, and social distancing and make the investments that will mitigate COVID-19 spread including physical barriers to block droplets, sufficient diagnostic and surveillance testing, effective contact tracing, and modifying interior ventilation to improve air exchange as required. It will not prevent all deaths, but it will reduce the massive toll of illness that has occurred during 2020 as well as the additional costs associated with addressing the long-term effects of disease. Some of these mitigation measures will also have the advantage of reducing the health consequences of seasonal influenza and other respiratory infections.
During the seven day period ending on June 17, ten states reported a spike in the number of reported COVID-19 cases in the United States. These states were North Carolina, South Carolina, Georgia, Florida, Alabama, Wisconsin, Illinois, Texas, Arizona, and California. Six of these states: North Carolina, Georgia, Florida, Illinois, Texas, and California, have large populations of African Americans. African Americans Latinos, and indigenous Americans experience a variety of health disparities that have made the impact of COVID-19 much worse for them on a population basis than for Caucasians. While all of the reasons why these states have experienced significant increases in the number of COVID-19 cases are not known, increased interactions among people after various states reduced stay-at-home restrictions, and decreased adherence to social distancing and mask wearing are likely to have played a role. Additionally, clinical research indicates some disease transmission occurs when no symptoms are present, so people spread the virus without knowing they are infected. The current challenge is to reduce disease spread, especially among African Americans, and other people of color, who have been shown to be more vulnerable to severe disease. Data from the U.S. Department of Health and Human Services report 55.5 percent of non-Hispanic blacks in comparison to 75.4 percent of non-Hispanic Caucasians used private health insurance during 2017;[i]9.9 percent of non-Hispanic blacks in comparison to 5.9 percent of non-Hispanic Caucasians were uninsured.[ii]Access to health insurance and, by extension healthcare, is one of several significant health disparities that contribute to a higher rate of chronic disease among African Americans. Chronic diseases are associated with more severe COVID-19 outcomes. Similar disparities exist for other marginalized groups.
The SARS-CoV-2 virus will not be eliminated in the near-term. Even if a successful vaccine is developed it requires protection of more than 70 percent of the world’s population to eliminate the disease. Producing enough vaccine doses for more than seven billion people will likely cause bottlenecks which will take time to resolve; perhaps the most significant of these will be the limited vaccine production capacity. Universally applied mitigation strategies that should be implemented to minimize the adverse effects on disadvantaged communities include more diagnostic testing to identify cases and quarantine of newly infected persons to interrupt transmission within populations. Antibody testing in specific geographic areas is needed to determine and understand the how prevalent COVID-19 disease is in specific communities. Improved healthcare access is needed to reduce health conditions that adversely affect the course of disease and provide early treatment to limit health deterioration if infection occurs. Also, more personal protection equipment (PPE) is needed for all workers who have essential and public facing jobs that place them at greater risk for virus exposure.
In the absence of continuation of the strict lockdown measures that allowed the trajectory of the COVID-19 pandemic to be reduced, we can expect that the number of infected persons will continue to increase. While the lockdown prevented the U.S. health system from being overwhelmed, it did not alter the infectiousness of the virus and thus, it continues to spread. The maintenance of social distancing and mask wearing can curb virus exposure and transmission. These measures, especially in those areas having a spike in the number of cases, along with the mitigation strategies mentioned above, and research to find effective treatments and vaccines will improve outcomes for everyone.
[i]See: https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61
[ii] Op.cit at 1.
COVID-19 has sparked the most profound economic crisis unrelated to armed conflict since the 1918 influenza pandemic. Fortunately, there is now far more scientific understanding of disease dynamics to inform the best practices for returning to normal activity. Following are some important considerations for a return to the interactions that underpin the economy.
· Implementing comprehensive disease surveillance. This includes adequate clinical testing to provide an accurate knowledge of who and where newly infected persons are and tracing the contacts of confirmed cases. In the United States, this required level of testing has not been reached. Additionally, it is critical to know who has immunity by testing for antibodies. Anecdotal data suggests there is a significant percentage of infections that are not accompanied by symptoms of disease. Antibody tests are essential for anyone returning to a work situation that precludes the possibility of social distancing.
· Collecting and analyzing virus samples over time. This includes genetic analysis of samples both within communities as well as samples from distant places to provide an understanding of how the virus is mutating. The SARS CoV-2 is a pathogen that can mutate quickly and some mutations directly affect whether a recovered person can effectively fight a new exposure to the virus. This is the reason why health officials monitor new influenza virus strains every year. As with seasonal influenza, if the virus mutates in specific ways, it is possible to acquire a new infection even though one has suffered a previous infection.
· Analyzing clinical data to ascertain why certain characteristics predispose some people to more severe disease. Based on the case reporting, we know that African Americans, Hispanics, and those with pre-existing chronic diseases have much higher rates of death and severe illness than others. A comprehensive analysis of patient health status will help protect those who are most vulnerable to serious disease after exposure to COVID-19.
The consequences of the COVID-19 pandemic have caused more economic dislocation than any event other than war since the beginning of industrial age. However, a failure to thoughtfully and adequately plan for a return to economic production will ultimately be more costly in both lives and treasure.
The COVID-19 virus has spread widely, both inside China and to the rest of the world. One possible transmission pathway that should be considered as part of the ongoing epidemiological investigation is the clandestine movement of wildlife and people across international borders.
Illicit international wildlife trade has been documented to occur and China is actively involved in the sale of wildlife in its live animal markets. Other coronavirus outbreaks, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were traced to a wildlife source when those diseases “jumped” to infect humans. A second possibility is the undocumented movement of persons across borders through human trafficking, the illicit drug trade, or other criminal activity. Human trafficking is recognized as a serious problem with many victims being trafficked to provide labor. The illicit drug trade and trade in other controlled products continues to occur because it is highly profitable.
COVID-19 infection has become a significant issue of international concern, both due to its impact on public health as well as on international economics. Investigating how the virus is moving from its source in China should include all possibilities because a thorough understanding of transmission dynamics is essential to controlling the disease.
The exposure to a novel coronavirus in Wuhan, China triggered an outbreak of human disease during December 2019. As of February 10, 2020 there were over 40,000 confirmed cases with over 900 deaths.[i]Genetic sequencing of the novel coronavirus shows it is related to both the severe acute respiratory syndrome (SARS) virus and the Middle East respiratory syndrome (MERS) virus,[ii]which caused human outbreaks in China during 2002 and in the Middle East during 2012. All three coronaviruses have a zoonotic origin. Coronaviruses exist in a variety of wildlife species and the current outbreak is believed to have jumped from animals to humans. In light of the current situation and a history of other coronavirus diseases jumping to humans, the Chinese government ordered the temporary closure of live wildlife markets as a disease control measure. Such markets pose an identifiable risk to human health and the permanent closure of live wildlife markets should be considered.
Close proximity interactions between non-domestic animals of varying species in live markets pose significant human health risks. They provide an opportunity for the spread of infectious diseases between the caged animals and humans who visit the markets. Among the post-outbreak findings from the SARS and MERS outbreaks was that the viruses adapted to humans once it spread within communities. Although much remains uncertain about the current coronavirus outbreak, previous experience suggests a similar human adaptation is possible. Additionally, the fact that the outbreak emerged in a densely populated city such as Wuhan and has spread among people who have not had direct contact with the live wildlife markets raises concerns about its epidemic potential.
Placing several Chinese cities under quarantine, as the government has ordered, could reduce the spread of the novel coronavirus disease outside the most severely affected areas. However, the effectiveness of a quarantine as a control measure is questionable as time passes for logistic (supporting the quarantined population with food and other essential goods) and social/political (the willingness of the population to suspend their usual activities) reasons.
Although it may too late to affect the course of the current outbreak, the permanent closure of live wildlife markets should be considered as a public health policy intervention. Eliminating close interactions among wildlife species and the subsequent exposure of the animals to humans could reduce the risk of another novel disease emerging. History suggests there may be other coronavirus outbreaks with similar characteristics and consequences in the future if no preventive action is taken.
[i]Case counts provided by World Health Organization, available at www.who.inton on February 10, 2020.
[ii]Roujian Lu and others, “Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding,” The Lancet, Published online January 29, 2020 https://doi.org/10.1016/S0140-6736(20)30251-8
Revitalizing infrastructure remains an important imperative for the federal government. Legislation to support the rehabilitation and improvement in transportation, power generation, telecommunications and other nationwide systems could facilitate economic growth and improve population welfare. Although health infrastructure does not receive as much attention in discussion of national infrastructure priorities, it is an essential component that will support the national economy and also improve lives. Any policy proposal to fund infrastructure improvements should include health infrastructure, especially in the areas of workforce, data systems, and crisis response; these areas were identified by a federal study as being critical parts of the national health infrastructure.[i]
While the United States spends about one sixth of its GDP on health related expenses, it still does not reap the same level of tangible benefits as other peer developed countries that spend much less on a per capita basis. Additionally, the emergence of climate change and exotic zoonotic diseases challenges to U.S. heath infrastructure in novel ways. A modern U.S. health infrastructure will need to develop capabilities across human and animal health to optimize benefits to the U.S. economy and residents.
Currently, there are workforce shortages in a variety of health fields including physicians[ii]and veterinarians[iii]. As the U.S. population ages, there is increased demands for health services. Also, for reasons that are not yet clear, the health status of younger Americans is worse that it was for previous generations of Americans at the same age and may be an additional cause of increased health service demand. [iv]Climate change has resulted in changes in disease patterns among animal populations. Previously unknown pathogens will likely increase the demand for veterinary clinical services including animal disease surveillance and outbreak management. Further integration of human and animal health, or “one health” infrastructure, will be essential for building additional health capacity.
Modernization and improvements of health systems, particularly in the areas of telecommunications and cybersecurity will support the needs of health infrastructure by improving medical record keeping and information access when patients are treated. Disease patterns will be identified and outbreak response can be occur more quickly. The recent approval for the merger of CVS Pharmacy and Aetna health insurance suggest a shift from large medical practices to retail health settings for routine healthcare. If stand-alone clinics become an increasingly popular source of preventive and well-being health services, more reliable and comprehensive access to individual medical records will facilitate optimal care.
Effective crisis response to health emergencies requires support from other critical infrastructures because the immediate requirement is to deploy resources as quickly as possible for rescue and recovery. Depending on the nature of the health emergency, such as hurricane response for example, rescue workers may need to get to disaster areas quickly to restore basic health services. Affected health infrastructure may require transportation, telecommunications, and electrical power systems as well as possibly erecting temporary clinical facilities to resume operations. A different health crisis may require specialized clinical isolation and treatment facilities be created to contain a widespread infectious disease outbreak. To the extent that a rapid and efficient response will minimize deaths and more severe health consequences, collaborations between various infrastructure stakeholders would ideally include exercise for a variety of health crisis scenarios.
Health systems and infrastructure are an important area of the overall U.S. infrastructure and must be an integral part of planning nationwide updates and modernization.
[i]See Healthy People 2020, Public Health Infrastructure, https://www.healthypeople.gov/2020/topics-objectives/topic/public-health-infrastructure, accessed on June 9, 2019.
[ii]Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Physicians and Surgeons,
on the Internet at https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.htm (visited June 06, 2019). See U.S. Department of Health and Human Services, Health Resources and Services Administration, https://data.hrsa.gov/topics/health-workforce/shortage-areas, accessed on June 9, 2019.
[iii]See Journal of the American Veterinary Medical Association, https://www.avma.org/News/JAVMANews/Pages/181215e.aspx?PF=1, accessed on June 9, 2019
[iv] See Blue Cross Blue Shield, “The Health of Millennials,” https://www.bcbs.com/the-health-of-america/reports/the-health-of-millennials accessed June 9, 2019.