How does coronavirus enter the body, and why does it become fatal for some compared to just a cough or fever for others?
Federal health officials warned leaders on the White House’s coronavirus task force this week that reopening the nation will require a massive capacity to test, track and treat people for the ongoing threat of the new coronavirus.
Their guidance contradicts President Donald Trump’s stance that the country could widely return to normal in a matter of weeks, at least in some states.
“It's going to be very, very soon,” President Trump said at a press conference Tuesday, “sooner than the end of the month.”
Recommendations under development by the U.S. Centers for Disease Control and Prevention, copies of which were obtained by USA TODAY along with other internal documents, largely follow a playbook that public health experts have been advocating for weeks.
The recommendations, which are separate from draft guidelines reported by The Washington Post Tuesday, were presented in a slideshow to task force leaders on Monday. The slides highlight specific benchmarks local communities need to meet before lifting their restrictions.
The message delivered behind closed doors deepens the wedge between the administration’s public comments about a May reopening and the reality understood by scientists and public health officials, including those within the CDC. The experts fear a chaotic next chapter, in which still-inadequate testing levels could contribute to waves of disease crashing over America.
In conversations with a dozen scientists, USA TODAY found that states are falling short of the measures laid out by the CDC.
“We can’t move into the next phase of response before we are able to understand where this virus is, who has it and to make sure to isolate cases,” said Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security. “Without that, we won’t be able to sufficiently control the virus.”
In a statement to USA TODAY, White House spokesman Judd Deere did not address the CDC recommendations or how the administration responded to them. He said President Trump wants the country to reopen as soon as possible. “But he has been clear that scientific data will drive the timeline on those decisions,” Deere said.
Social distancing through the end of April was supposed to protect the health care system from getting overwhelmed and buy time to prepare for living with a virus for which a vaccine may not be available for a year or longer. All but seven states have issued stay-at-home orders.
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Experts say three steps will be critical to successfully reversing those orders: Widespread testing for both the disease and its antibodies, tracking and isolating new coronavirus cases, and, in time, treatment advances to make future COVID-19 infections less dangerous.
The CDC told the task force leaders Monday that communities that want to reopen must be able to test 100 percent of symptomatic patients who have been exposed and rapidly investigate new cases. Hospitals need healthy staff and infection rates need to show consistent and significant declines for 28 days from the peak.
In addition, hospitals should have adequate hospital staffing, ventilator supplies, and protective equipment, according to thresholds recommended in the CDC's slide presentation Monday.
A separate series of CDC documents obtained by USA TODAY offer more detail about the government’s ambitions to help some of the states that appear to be the least affected as part of a pilot program. On Wednesday, senior officials at the agency presented a narrower plan to deploy federal healthcare workers to about nine states.
Teams of federal health officials will travel to places like Kentucky and West Virginia to figure out if they have truly low infection rates or just poor access to testing and help make sure they don’t become hotspots, according to the documents. A large portion of the plan focuses on boosting local technical capabilities to help health officials identify and trace infections.
The CDC’s approach lays out a federal framework for the states, contrasting sharply with Trump’s erratic statements this week as he sparred with state governors over who would make the call to reopen America.
But in a country where state boundaries are blurred by commuter rails and cheap plane flights, experts cautioned that inconsistencies in regional judgment calls and the corresponding resources could undermine the nation’s effectiveness at containing the disease. If one state or county reopens at a different pace than a neighbor, the disease could surge.
“It will literally cost lives,” said Jeremy Konyndyk, a senior fellow at the Center for Global Development who led the Obama administration’s response to the Ebola outbreak.
Better testing in February might have precluded the mass shutdowns by the coronavirus epidemic before it spiraled out of control. Reopening America puts testing front and center again, as the nation’s best defense against repeat waves of coronavirus outbreaks.
The CDC’s plan recognizes the need to test everyone with symptoms who has been exposed to the virus, so they can self-isolate. It also anticipates routine testing for health care workers and in facilities like nursing homes, whose residents are particularly vulnerable to outbreaks. Surveillance data is required to ensure communities spot emerging outbreaks and rapidly respond with more limited social distancing closures.
The mitigation guidance does not address testing for antibodies to the virus, known as serology testing, which can reveal who already has recovered from infections. Guidance on those tests, which may be used as markers of immunity, was given in a previous meeting.
Serology tests are not yet widely in use. No one knows how reliable the information gained from them will be, and ethical questions surrounds their use – including whether antibody markers should determine who returns to work.
The CDC plan expects a level of testing that is not yet a reality for many communities. The White House has not addressed problems still hobbling the robust testing system envisioned.
In many places, tests to confirm a coronavirus infection have been prioritized for health care workers and the severely ill.
“I don’t see a path to reopening unless the testing issue is fixed,” Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Center for Health Security. “We have been complaining about testing for at least a month and nothing happened.”
Most of the nation’s coronavirus tests are now being processed through commercial laboratories, which have rapidly scaled up their capacity after regulatory delays in the epidemic’s early stages in the U.S.
Yet federal authorities have yet to address ongoing shortages of supplies such as nasal swabs and the reagents used to process the tests. Labs are scaling up even as questions remain about how they will be reimbursed, with some private and government programs not fully covering the costs, said Julie Khani, president of the American Clinical Laboratory Association.
“We have this disconnect,” said Khani, whose organization represents commercial titans such as Quest Diagnostics and LabCorp. “While everyone agrees that more testing is needed, there has not been the necessary focus and a provision of dedicated funding.”
The CDC did not specify exactly how many tests American needs to safely move past social distancing. A ballpark figure of 750,000 tests per week was proposed in a report co-authored by former U.S. Food and Drug Administration commissioner Dr. Scott Gottlieb last month for the American Enterprise Institute.
Capacity appears to be approaching that level, with the clinical laboratory association’s members running 75,000 to 100,0000 tests daily for much of the month. But recently, they have been left with unused capacity. On Monday, these labs reported processing nearly half as many tests as they had one week earlier. Khani said labs are now trying to get the word out to doctors that they can handle more.
Disparities in access to testing and how widely it is being offered has left public health and medical professions without a clear view of the viruses spread.
A rapid test rolling out across the country can confirm COVID-19 infections in as little as five minutes and has been highly touted by the administration, including an unveiling on the White House lawn. The toaster-size technology looks to play a role in the CDC’s plan for use in health care settings with severely ill patients.
John Wiesman, secretary of the Washington State Department of Health, told reporters Wednesday that he is looking to the federal government to help get more tests online and then provide money and personnel to investigate as more cases are confirmed, which could come in waves.
“What we know now is just a fraction of what’s out there,” he said. “The public health system has to scale up and scale up quickly, thus the call for federal resources.”
Public health officials warn that the current blood tests for the coronavirus on the market are creating confusion among patients and doctors. (April 13)
An army of public health workers will be needed to keep tabs on anyone newly infected with COVID-19 – along with every relative, friend and neighbor they may have been in contact with.
The work of contact tracing is considered more art than science, and there are no shortcuts. Scientists think one infected person can spread the virus to two to three others. A single case could turn into 59,000 infections over 10 rounds of ongoing spread.
The CDC acknowledges the need with plans to create a “COVID-19 Corps” staffed by a mix of federal workers at the CDC and training programs for an unspecified number of new hires at the state and local level, as reported by the Washington Post. The plan offered no specific numbers or financial support.
Experts, however, say staffing up requires a massive investment and is unlikely to be ready to roll out widely across the nation for at least five or six weeks – well beyond the May 1 or May 15 dates mentioned in the draft plan reported by The Post.
The nation needs a new workforce of 100,000 contact tracers, according to a report released last week by researchers at the Johns Hopkins Center for Health Security. At that scale, the effort would require $3.6 billion, researchers projected. They called for an infusion of emergency funding from Congress.
Their estimates are not just theoretical; they’re based on what has worked in other countries. In the Wuhan, China region where the outbreak started, 9,000 contact tracers were rapidly deployed to curb the spread in a city of 11 million.
The Chinese teams meticulously tracked down those exposed to others with confirmed cases, scrutinizing tens of thousands of contacts each day. They followed up with tests and medical observation, and quarantining people infected who displayed no symptoms. China also relied on big technology and artificial intelligence.
The chronically underfunded U.S. public health infrastructure is combatting the new coronavirus outbreak after shedding 50,000 workers since the 2008 recession, according to a survey of state and local health departments cited by the American Public Health Association in an article for StatNews.
Massachusetts is among the few states well into plans to hire up. Many more will be able to do so within the coming weeks assuming they receive federal funding and guidance, said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, which represents the nation’s public health agencies.
“It’s doable by June if everybody really gets focused on it,” he said. “The states don’t have the money to do this right now.”
From a shortage of intensive care beds to depleted supplies of surgical masks and gowns, the nation’s health care system has struggled since the start of the epidemic to respond to the surge of COVID-19 patients.
The CDC expects communities to have adequate health care capacity in place to reopen but is vague on how to fix a broken supply chain. That could further exacerbate the fighting among states and with the federal government over limited supplies.
“That should have never happened; it all should have been federalized in a fair distribution,” said U.S. Representative Donna Shalala, a Miami Democrat who ran the U.S. Department of Health and Human Services under former president Bill Clinton.
Shalala has been working with Congressional Democrats on legislation presenting an alternative plan to reopen the country.
She envisions a well-coordinated system in which the federal government provides scientific guidance and money to help cash-strapped states reopen their economies. States would submit detailed plans for review and approval by the federal health department and be reimbursed for costs such as the additional testing, staffing and protective equipment for health care workers.
Dr. Josh Sharfstein, a former deputy commissioner at FDA and now vice dean for public health practice and community engagement at Johns Hopkins University, said the legislation could compel states to submit plans to the CDC to approve and then fund them, which would create standards.
“It would definitely help bring up the floor,” he said.
Internal CDC documents show the agency is working on a dashboard approach with green and red displays to help states assess the indicators crucial to leaving lockdown mode – and when problems may be rising again. The information would be visible to nearby jurisdictions, too.
Within a month or two, Shalala also thinks medical treatment may be available to blunt the disease. Scientists are exploring the use of anti-viral drugs to target the virus, as well as therapies to address how immune systems respond to infection.
Trump has repeatedly championed the drug hydroxychloroquine as a breakthrough –without medical proof. One of the first rigorous studies of a related drug, chloroquine, found it so dangerous to patients’ hearts at high doses that the trial was quickly shut down.
Doctors are using some drugs on an experimental basis, and more than 100 clinical trials are underway. But currently they lack evidence to recommend any particular medication to treat COVID-19, according to new guidelines from the Infectious Diseases Society of America.
Reopening the country too quickly could simply replay the federal government’s errors in responding to the threat too slowly as the new coronavirus spread early this year.
“People have died,” Shalala said. “It has to be a national approach working with the states.”
Letitia Stein and Brett Murphy are reporters on the USA TODAY investigations desk. Contact Letitia at email@example.com, @LetitiaStein, by phone or Signal at 813-524-0673 and Brett at firstname.lastname@example.org or @brettMmurphy.
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