4/3/20: SCIENTIFIC EVIDENCE SUPPORTS COVID-19 TRANSMISSION THROUGH TALKING, BREATHING. NATIONAL MEDICAL EXPERT OFFERS SIX-STEP PLAN TO DEFEAT COVID-19 BY EARLY JUNE. MORE ON THE TOWN COUNCIL’S DECISION TO MEET NEXT WEEK.

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The coronavirus may be spread through an infected person’s breathing and talking, as well as through droplets generated by a person’s coughing and sneezing, according to an expert scientific panel of the prestigious National Academy of Sciences.

In a letter reportedly sent to the White House last night, Dr. Harvey V. Fineberg, M.D., Ph.D., chairman of the Academy’s Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats, wrote: “Currently available research supports the possibility that coronavirus could be spread via bioaerosols generated directly by patients’ exhalation.”

(BREAKING NEWS: While writing this post, we received an updated briefing from The New England Journal of Medicine (NEJM). Included in it is an editorial by Dr. Fineberg titled, “Ten Weeks to Crush the Curve,” in which he recommends taking six steps to “mobilize and organize the nation,” in order to defeat COVID-19 by early June.  See below for more details. You may access the article at https://www.nejm.org/doi/full/10.1056/NEJMe2007263?cid=DM89429_NEJM_COVID-19_Newsletter&bid=179900194.)

While research of aerosol transmission is limited, Dr. Fineberg said in his letter that studies in China and at the University of Nebraska suggest that aerosolized droplets produced by an infected person when he or she talks or breathes could be suspended in the air long enough for another person later to inhale them. The second person could have been standing well clear—beyond the currently recommended six feet of physical distancing—of the infected person.

The question, Dr. Fineberg noted, is how long the virus can be suspended in the air—a question that is not yet answerable. No projection on how long the virus may linger has been made yet, but air circulation, he said, is definitely a factor.

“If you generate an aerosol of the virus with no circulation in a room,” Dr. Fineberg wrote, “it’s conceivable that if you walk through later, you could inhale the virus.”

Outdoors, however, he said, “the breeze will likely disperse it.”

Dr. Fineberg, 74, a trained internist, is a former dean of the Harvard School of Public Health and a former president of the Institute of Medicine.

In his NEJM editorial, published April 1, Dr. Fineberg challenges analysts who assume that the COVID-19 pandemic must play out over a period of many months and that economic recovery will take even longer. He writes, instead, that “with a forceful, focused campaign to eradicate COVID-19 in the United States,” we can “crush the curve” we are trying to flatten—just as China did in Wuhan–and we can do it nationwide in 10 weeks.

FINEBERG’S SIX-STEP PLAN FOR ERADICATION

We summarize the six steps outlined by Dr. Fineberg in his NEJM editorial—which laypeople can easily read and understand—as follows:

1) Establish unified command

Dr. Fineberg writes that “The President should surprise his critics and appoint a commander who reports directly to the President.” This person must have the President’s and the American people’s confidence and must carry “the full power and authority of the American President to mobilize every civilian and military asset needed to win the war.”

Dr. Fineberg also asks every state governor to appoint an individual state commander with “similar statewide authority.”

2) Make millions of diagnostic tests available

Everyone with symptoms must be tested, Dr. Fineberg argues. “The nation needs to gear up to perform millions of diagnostic tests in the next 2 weeks. This was key to success in South Korea.”

3) Supply health workers with PPE and equip hospitals to care for a surge in severely ill patients

Dr. Fineberg writes: “We wouldn’t send soldiers into battle without ballistic vests; health workers on the front lines of this war deserve no less. Regional distribution centers should rapidly deploy ventilators and other needed equipment from the national stockpile to hospitals with the greatest need.”

4) Differentiate the population into five groups and treat accordingly

The five groups Dr. Fineberg identifies are:

*People who are infected

*People who are presumed to be infected (have signs and symptoms consistent with infection who initially test negative)

*People who have been exposed to the virus

*People who are not known to have been exposed or infected

*People who have recovered from infection and are “adequately” immune

How he proposes to manage these five groups is somewhat complicated. People with severe disease or at high risk would be hospitalized. He also suggests establishing infirmities by using empty convention centers to care for people who have mild or moderate disease and are at low risk and converting “now-empty hotels into quarantine centers to house those who have been exposed and separate them from the general population for 2 weeks.”

Being able to identify those who have recovered and “are adequately immune,” he says, “requires development, validation, and deployment of antibody-based tests.”

5) Inspire and mobilize the public

Dr. Fineberg writes: “We have begun to unleash American ingenuity in creating new treatments and a vaccine, providing a greater variety and number of diagnostic tests, and using the power of information technology, social media, artificial intelligence, and high-speed computing to devise novel solutions. These efforts should be intensified.”

He also recommends that everyone wear a surgical mask outside of home.

6) Learn while doing through real-time, fundamental research

“Clinical care would be vastly improved by effective antiviral treatment,” Dr. Fineberg says, “and every plausible avenue should be investigated. We did it with HIV; now, we need to do it faster with SARS-CoV-2. Clinicians need better predictors of which patient’s condition is prone to deteriorate rapidly or who may go on to die. Decisions to shape the public health response and to restart the economy should be guided by science.

Guided by science. Period.

The governors of New York, New Jersey, Connecticut, Michigan, and California, among others, have been asking the White House for a national plan for coping with and defeating COVID-19 in the United States. Dr. Fineberg has offered one, and it’s based on science and the basic tenets of public health.

“If we act immediately,” he concludes, “we can make the anniversary of D-Day on June 6, 2020, the day America declares victory over the coronavirus.”

THE BEACON’S AND MY OWN PERSONAL RESPONSE

Dr. Fineberg’s report on aerosol transmission supports a position earlier stated by The Beacon that it is too soon to know everything there is to know about the new coronavirus’s transmission.

The restrictions imposed by governors and other elected officials on the strength of what mostly state and local government public-health officials—who are part of a system that has failed—are advising them are not necessarily foolproof. They are based on the best evidence they have to date, but not on all of the evidence.

The six-step plan that Dr. Fineberg outlines in his NEJM editorial is what my late father would have called public health. Dr. Fineberg is trying to build an infrastructure and to give it what it needs to succeed.

Long before he died in 2014, my father was bemoaning the collapse of the public-health system in the United States. He especially abhorred the corruption of the office of the U.S. Surgeon General, who once was an elite scientist-physician in charge of the U.S. Public Health Service, not a partisan political appointee. There was a time when the Surgeon General could have been the commander about whom Dr. Fineberg speaks. But no longer.

My late father was a brilliant scientist-physician, a medical pioneer in the field of clinical pharmacology (drug discovery by rational means, not chance), and a 20-year member of the then-militarized U.S. Public Health Service. He did wondrous things at the National Institutes of Health as a leader in the Heart Institute in the 1950s and 1960s, during what is known as the Golden Age of Research and Development.

He also distinguished himself later in the pharmaceutical industry, overseeing the development, among other therapeutics, of the antihistamine, Allegra. (An aside: He was very familiar with the old anti-malarial drugs that have been in the news. He knew the people who did the clinical trials with them.)

I learned a lot from my father, especially during the six years that I spent researching and writing his biography. He was among the medical elite in this country, as well as internationally—just like Dr. Anthony Fauci, another brilliant scientist-physician at the NIH whom I respect and trust.

I wish my father were here for me to ask him about COVID-19. He was an encyclopedia of medicine and all biological sciences and would give me sound and informed advice.

This much I know: My father always asked of any topic of argument, whether scientific or otherwise: What is the evidence? That’s the critical question. What is known? What are the facts?

Science is about the facts; it is about reason. It is not about supposition and bias.

We don’t know yet what’s in store with COVID-19. We have to follow the scientific evidence, some of which is well-known—for example, the virus’s genome and how it enters the body’s cells—and some of which is emerging, such as why the vast majority of the people dying from COVID-19 are men. We have to make decisions based on reliable evidence, and we don’t make assumptions when evidence is lacking.

We also have to have a well-reasoned, organized, and coordinated national public-health plan, which the President and his coronavirus task force have yet to give us.

SOUTHERN SHORES TOWN COUNCIL: Yesterday, The Beacon addressed the Town Council’s upcoming budget workshop session, which was postponed from March 24 to next Tuesday, April 7, at 3:30 p.m. We spoke about the burdens placed on the public if it wishes to join in the discussions of this meeting, which is top-heavy with important, but non-essential business items, including approval of a beach nourishment project and the implementation of no-left-turn weekends this summer.

(According to Tommy Karole, the chairperson of the cut-through traffic exploratory committee, his committee never finalized and sent a report to the Town Council, nor did it provide cost estimates.)

We characterized this meeting as a business-as-usual meeting being held during conditions that are anything but usual and that are in flux. What we do know for sure is that people are suffering financially, physically, and emotionally now; businesses are shuttered and may remain closed for months yet; and the start and strength of our summer tourist season are in doubt.

I have no doubt that Mayor Tom Bennett and the rest of the Town Council are cognizant of the changed circumstances, especially the economic conditions. Decisions they make on Tuesday may well be conditional on the future state of the Southern Shores and Dare County economies.

If I were on the Town Council, I would be considering a tightening of Town expenses and a tax break for Southern Shores property owners next year—a lowering of the tax rate—not a tax increase.

Also, if I were on the Town Council, I would not attend a meeting in person. The risk of my being exposed to the coronavirus, and then exposing someone else, may be infinitesimal, but I would not take that risk—especially since I don’t have to.

Electronic meetings can be held without much difficulty, and they should be held when essential business must be transacted, but not for business that can be held over to another time, when more evidence will be available to make better-reasoned decisions.

TODAY’S DARE EMERGENCY MANAGEMENT BULLETIN offers resources to people who may be experiencing stress and anxiety during the COVID-19 crisis. See Bulletin No. 27 at https://www.darenc.com/Home/Components/News/News/6071/1483.

Ann G. Sjoerdsma, 4/3/20

 

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