PREPARATION! PREPARATION! PREPARATION!
I was struck at the news conference on Wednesday during the debate about COVID-19 and what to expect in the fall. What struck me was that the argument centered on how strong or even if it “will come back”. Excuse me? The question suggests that it WILL GO AWAY sometime this summer. There is no indication whatsoever that it will go away.
First, there appears to be no “hot weather” effect on the virus spread. Florida is #8 in infections in this country, with Miami and Lauderdale some of the most heavily hit areas.
Second, between April 1 and April 20 the daily infection numbers across the country have only decreased by 10% from 33,000 to 30,000. If that rate actually continues, then we would expect to still see around 20,000 new cases per day by the end of August. And the current numbers have come from a situation in which an extremely large percentage of the US population has been observing stay-at-home orders.
So, as most of the scientists inside and outside the administration have been saying for almost 2 months, any suppression of new case emergence during the summer months will most likely disappear during the fall as people congregate more. This will result in a reverse in the trend of infections from a decreasing amount to an increasing amount. As wisely pointed out by Dr. Redfield yesterday, this increasing trend of COVID-19 infections will be complicated by a new Influenza season. And the only way to try to alleviate some of the stressors on the healthcare system would be for the American people to embrace influenza vaccines at a higher rate than they have ever done before. Of course, if we abandon the WHO, we will not get the information that we so desperately need to allow our vaccine producers to identify the emerging new strains at the earliest point and be able to produce an effective vaccine in advance of the fall season. The WHO provides that information to the collaborating centers, and if we close ours, we won’t get that information.
The greatest concern that I have, and that every single citizen of this country should have, regards our preparation for the coming fall/winter season. If we are not fully prepared, we are positioning ourselves for a true disaster.
Those who ignore History are doomed to repeat it.
Today, we are in the position that we are in because we failed to prepare in advance. You may choose whatever black hat you want to blame; it really is irrelevant. What is relevant is that:
1. We did not have a detailed working plan in place prior to January of this year on how we would respond to an emerging viral pandemic.
2. We did not make a plan or create a planning committee in January or February of this year when the indications around the world were that there was a viral epidemic expanding in multiple countries.
3. We ignored all signs of danger in an attempt to “wish away” the potential danger until containment became impossible and mitigation became the only strategy.
4. We placed our hopes in untested, anecdotal medications as a mystical panacea that would lead us out of danger.
5. We only began to produce supplies when the shortages were so evident that they could not be ignored.
6. We still have not created a committee tasked with forward planning.
The evidence of this lack of preparedness is monumental. The news conferences suggest that the administration is still focused on ventilators and their production. The goal was 100,000 ventilators in 100 days, or 100,000 ventilators available by the beginning of July. After a very, very late start, it appears that we are now on track to hit those numbers. However, there seems to have been little preparatory vision on what will also be needed. There is a focus now on tests. But the focus is on providing test kits, there has been no focus on “reagents”.
Perhaps a little background here is appropriate.
First, you need swabs. These are not Q-tips, but specialized, sterilized and validated collection vehicles.
Second, the swabs need to go into very specific tubes.
Third, the tubes need to have appropriate “transport medium” in them. This is specialized liquid that protects the sample so that it does not degrade before it gets to the lab.
Fourth, the collected samples need to be analyzed. Each manufacturer has their own system including their own reagents, their own delivery systems. Think about the printer in your office. You can’t use HP ink cartridges in your Epson or Brother printers and depending on the model of the printer you need ink cartridges specific to that model. The same is true for the machines that analyze the samples.
Fifth, you need a very specific set of chemicals, most of them are protein enzymes. You need to convert any RNA in the collected sample into DNA using reverse transcriptase; then you need an enzyme to unwind the DNA; then you need a polymerase enzyme to make lots and lots of copies of that DNA, enough to allow you to do a final test, similar to an ELISA as described before. In this case you use a premade copy of DNA that is effectively the mirror image of the DNA that you are looking for. If the expanded DNA that was created in the PCR “polymerase chain reaction” described above is, in fact the image of the mirrored DNA, it will stick to that DNA and you will be able to detect that there was, in fact, RNA from the virus in the original sample.
You can see that there are many different items needed to complete a test, and those items may be very specific to the equipment that you are using. It doesn’t matter how many machines capable of performing tests exist in your city or state, if you are missing even one of those machine-specific items. This is where the Federal Government NEEDS to be involved. They are the only ones who can inventory ALL of the labs around the country and redistribute reagents from places that have too much to places that have too little. They are also the only ones who can inventory the country as a whole to determine what reagents will be in short supply next month and get on the stick to ramp up production of those items. Making enzymes is not an easy process. They have to be grown in living cells, either yeast or bacteria, harvested, purified and prepared for shipment. They cannot be made in chemical factories like pills.
If we continue to react to the pleas of localities and states on a day-by-day basis, without powerful planning for eventualities, we will be caught flat-footed once again in September.
Here are some of the things that I think our government needs to be prepared for, and I will eliminate vaccines and therapeutics because they are givens.
We can assume, on an aggressively conservative basis, that 5% of the country has already been infected. We can assume, again in the same way, that the 50,000 deaths that we will be at in the next few days actually represents a death rate of about 75,000 since deaths lag behind by about 20 days. Within that 5% of the population or about 1% of those infected will die.
If we open up the economy, (and the debate about yes/no or when is not of interest here), most epidemiologists, taking into account the infectivity rate would expect at least 50% of the population to eventually become infected. But if we are careful, and if we open up judiciously those numbers will occur on at a very slow rate. Some areas will be judicious, some will not. Good planning will not “hope it doesn’t happen” but will plan for increased infections.
1. What will the need be for hospital beds, ICU beds, ventilators, oxygen and PPE should the infection rate be 2x what we have seen to date? 3x? 4x? Consider where we were this past month. What will happen if those numbers double, triple or more. WE MUST PLAN; WE MUST PREPARE.
2. What will happen to the food supply if the factories become hot beds of infection? What will happen if the migrant workers are removed from the country, or if their work camps start to become infected? WE MUST PLAN; WE MUST PREPARE.
3. What will happen to the poor whose access to healthcare in their neighborhoods, either urban or rural is overwhelmed? How can those hospitals who were shut down be reopened? WE MUST PLAN; WE MUST PREPARE.
4. What will happen to the food banks that were overburdened already this year? Will we see starvation in this country? WE MUST PLAN; WE MUST PREPARE.
5. What will we do about elections if the infection rate is, in fact 2 or 3 times what it is today in October and November? WE MUST PLAN; WE MUST PREPARE.
6. What will be do if we open the factories, the hotels, the shops and restaurants and nobody buys the products, uses the hotels or goes to the shops and restaurants? Will the owners go bankrupt because they are required to hire back workers who have nothing to do? WE MUST PLAN; WE MUST PREPARE.