In the midst of our self-quarantining and social-distancing, we ask ourselves: What will it take to gain control of these coronavirus infections, and how long will it be until we can resume something approaching our normal lives?
As everyone is very aware, we are dealing with an infectious disease that can be deadly, may require intensive care and has been multiplying at a rapid rate. So rapidly that we have resorted to the drastic measure of social-distancing. From a public health view this is like amputating an infected leg because there is no other treatment available to save the patient.
The stay-at-home, 6-foot separation and other social-distancing methods are used when we do not have other tools to stop an epidemic. There is no vaccine available in spite of serious coronavirus outbreaks in the past, including SARS in 2003 and MERS in 2012.
Doctor Anthony Fauci, the Director of Allergy and Infectious Disease at the National Institutes of Health (NIH) has been “cautiously optimistic” that we may have an effective vaccine available in 12 to 18 months. However, keep in mind that there was an urgent concern to develop a SARS vaccine in 2003, and we have no vaccine for that deadly disease 17 years later. So we cannot rely on a vaccine to curb this infection right now.
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There are other tools that can be used to fight an epidemic besides social-distancing or a vaccine. These include medications and more public health measures. There has been much speculation about drugs like hydroxychloroquine, and Remdesivir. But they are not yet proven effective for treating coronavirus infections. So that leaves us with public health measures for now.
In the absence of a vaccine and effective medications, the key is to move carefully beyond social-distancing to a more traditional public health response. In addition to the federal Centers for Disease Control (CDC), every state has a public health department as well as local public health programs. Traditionally, these programs carry out a variety of important measures that are routinely applied to other infectious diseases such as influenza, measles, rabies, etc. One of the most effective tools carried out by public health departments is contact tracing. This technique has been used to fight epidemics going back more than 100 years.
Contact tracing usually begins when a health department receives a laboratory report or information from a hospital or clinic that someone has a reportable disease, for example tuberculosis. Once confirmed, public health will reach persons involved in the case to confirm the disease and to identify others who may have been exposed to the infected person in order to determine if those others are already infected or should be quarantined because they may become infected. Contact tracing requires a lot of detective work. It involves identifying cases using well-established case definitions, and reaching out to all contacts using well-defined criteria. It is labor-intensive, requiring lots of case workers.
A most important question is how and when we can move beyond social-distancing and into comprehensive contact tracing. This should be the next phase in our fight against the virus. In order to successfully move into this next phase, three essential things must be in place: First, the number of new cases of coronavirus infection has to be reduced to a manageable level. That level depends on the next two factors.
Second, there must be widespread, easily-obtained and reliable testing, at no cost to the individual. This must include rapid testing for active infection, such as the nasal swab test for the virus (PCR) and the blood test for antibodies to coronavirus (ELISA). Both types of test are necessary. The virus test is necessary to identify people with active infections. The antibody test is necessary to determine how many persons have already had the infection and are now presumably immune to coronavirus. Experts have estimated that we need an availability of 750,000 tests per week to address these essential factors.
Third, we need enough skilled public health field workers to carry out this time-consuming and challenging work. Interestingly, Apple and Google have teamed up to develop a computer application for citizens to use that could potentially speed up the reporting and contact tracing of cases, thus helping to address the shortage of public health field workers.
We have carried out social-distancing in spite of its heavy burden on all of us, economically and otherwise. This method is working. We should prepare to move swiftly, but carefully, into the next phase of fighting this disease. The next phase must include sufficient numbers of public health field workers and coronavirus tests to properly carry out contact tracing. But we must ensure that the rates of coronavirus infection are under sufficient control before we reduce social distancing and move into this next phase. This means that we must continue social distancing for weeks or even months. Otherwise, we will risk a predictable increase in the number of new cases.
America appears to be finally waking up from what one scientist referred to as “sleep-walking” this pandemic. The disorganization, delays and mistakes that have been made at the highest levels of our government have been reported in detail. Let us hope and, more importantly, expect that our government will make the right decisions and actions moving forward.
Stephen M. Hessl, MD MPH, is a retired physician living in Carbondale. He graduated from the University of Colorado School of Medicine in 1968 and is board certified in internal medicine and preventive medicine. His entire career was devoted to work in public institutions, including the U.S. Army, the Illinois Department of Public Health, Cook County Hospital and Denver Health. His primary interest has been in the prevention and treatment of occupational diseases.