Friday, April 3, 2020

What Is Next? Covid 19

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Earlier this week, Dr. Bob Wachter, a professor and chair of the University of California, San Francisco’s department of medicine, told us about what trends we should be paying attention to in the coronavirus crisis now.

Today, we’re looking a little further out.

As the chief health officer of Santa Clara County, Dr. Sara Cody announced the first case of coronavirus in the Bay Area in January. Last month, she led the rollout of the nation’s first shelter-in-place order.

My colleague Thomas Fuller talked with Dr. Cody about what lies ahead for California. Here’s their conversation, lightly edited and condensed:

A question about the future: Flattening the curve is a short-term solution. It slows down the first wave, the rate of infections and death, but it doesn’t eradicate the disease by any means. What’s the longer-term solution?

This is extraordinarily challenging. We look at the options before us and none of them are particularly shining and bright — none of the options looks great. We are trying to optimize and do the very best we can given the circumstances.

For example, we do not have widespread testing.

We don’t yet have a widely available antibody test in order to be able to pair someone who is immune and put them out on the front line for all the essential work that needs to be done. We have a shortage of personal protective equipment. We need to be very careful about how we assess our supply, how we estimate what our demand and burn rate is going to be.

Do I hear from you that it’s been so difficult that you haven’t had time to think about how to handle the next waves?

We are already thinking about that. But I’d be lying if I told you that we had exquisitely detailed plans.

There are phases. The very first phase was containment. That was when every single case we had, we absolutely went to the mat. We found every single contact we possibly could. Every case was quarantined under a strict legal order, every case was isolated under a strict legal order. We followed them carefully, their symptoms, visits, tests.

Then at some point the rocket ship takes off and you need to shift strategies. And that’s when we moved to mitigation. That’s when we started doing things like the first order to ban gatherings greater than 1,000, and then moving to gatherings greater than 100, and then finally to the first shelter-in-place order.

The idea is that we slow the train down for a couple reasons. The top level reason is to preserve the capacity of the health care system to care for people who get sick. But the other is if we bend the curve and are able to reduce the case count then we can go back to more refined containment strategies and marry those with the mitigation.

With more testing available, can the shelter-in-place orders be lifted and as soon as an outbreak is identified, a rush to contain it? Are you hoping that’s what comes next?

That’s exactly right. We started out with containment, we are now in very broad-based mitigation.
Eventually if we slow it down enough, when we put together more resources and the numbers are less than 1,000, then we could do some more of the individual case investigations, rapid isolation, and that would be another way to slow things down.

All of this we’re doing while there’s a race to develop a vaccine.

But we don’t know if a vaccine will come or not. We’ve had mixed results with previous coronaviruses.

There’s this paradox that the better you are at managing the first wave of the virus, the more vulnerable you are to the second wavebecause you have so many people who are not immune. Is there a fear for the second wave, that the initial success will not lead to any permanent solution short of a vaccine?

My hope, and I’m generally an optimistic person, is that if we had just a few more tools at the ready we could focus our resources in a more precise way.

For example, if we had antibody tests, if we could stand on that, then we would do a much better job with health care workers.

And we would also be able to understand how much of our population is immune and how much of our population is susceptible. And we could fold that into a model and estimate what might happen in a second wave — and plan.

Can you imagine a world where people who have an appropriate level of immunity are cleared to work — where the immune population would be allowed a different lifestyle than the vulnerable and not-yet-immune population?

I think I’m mostly thinking about it in terms of health care workers because of their intense exposure and because of how critical they are to the work force.

Do you fear an unwillingness to shelter in place? How much of that is going to factor into your decisions?

To go back to a fire analogy, right now where we are is fire over the ridge, fire over multiple ridges. We are just dumping fire retardant over huge swaths of land.

Once we get the fire under better control we can focus and address spot fires in a more focused way and not have to rely on the massive, entire population to shelter in place.

But we also have to understand that our populations are really mobile. Just because we might get things under control in our corner of the land doesn’t mean there won’t be continual importations from other parts of the state or the country or the world. We are a very mobile group.

And this is why, at this point, we can’t plan? We don’t see a way of getting this completely under control?

We all have to just take a very deep breath and understand that this is our new normal for a while.

[Read the latest updates from California on the coronavirus pandemic.]

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