To help illuminate the path forward, Ms. associate digital editor Roxy Szal spoke with Dr. Rekha Murthy, MD—an expert in infectious diseases and healthcare epidemiology, vice president for medical affairs, and associate chief medical officer at Cedars-Sinai—to bring about some clarity in a time of confusion.
Murthy and Szal talked testing capabilities; what differentiates coronavirus from other infectious diseases, like the flu; the feasibility of herd immunity; and what’s giving her some much-needed hope.
Roxy Szal: I’m seeing a lot of reporting that testing capabilities vary widely—at worst, scarce, and at best, uneven. What is your reality? What is causing these “testing deserts”?
Dr. Rekha Murthy: There have been differences across states.
In California, there has been a significant ramp-up in testing—I think we’re probably doing more testing than many states both in terms of the community clinics that have opened up—and that also might vary based on county-by-county.
In LA County, for example, there’s been a significant uptick in testing; community sites have been opened and many of the health care facilities have engaged. At Cedars-Sinai, we’re all participating in offering the community testing through our drive-through—I think we have done more than 5,000 or so already.
There’s no doubt there were delays early on that were a significant setback—but as a whole, we seem to be moving in the right direction.
Testing is going to be an important component of this next phase as we come out of this acute crisis mode—until we get a vaccine in place, or have both the testing and the public health infrastructure to be able to help manage this next phase of the pandemic control.
The components that are going to be important to continue are the preventive measures. We’re going to have to do that until we have a vaccine: the social distancing, physical distancing, hygiene, masking—this will all be part of a kind of a ‘new normal’ of how we interact.
RS: And how long do you picture that “new normal” being the normal?
RM: I would say until we get vaccines available and are able to provide some assurance of immunity for enough of the population to achieve a likelihood of reducing transmission, like we have done with other vaccine-preventable diseases—like measles or chicken pox.
RS: What sets this virus apart from others?
RM: This is a completely novel virus that we’ve not encountered before, so we don’t have a population that has immunity to it.
What we know about this virus is that it’s very infectious. It spreads through close contact, and it has a long incubation period—a median of five days or so, but can be up to twelve days.
It has these nuances that set it apart from the other typical viruses—like influenza, which has a very short incubation period; if you get exposed to somebody, you get sick pretty quickly.
These droplets that carry the virus from somebody who is infected when they cough or sneeze, either land on your face or they land on a surface nearby. Then somebody touches the surface and touches their eyes, nose or mouth.
The way it is transmitted, coupled with the long incubation period, are unique elements of this particular pandemic and this virus—and the fact that it causes serious illness, and that it can cause mild illness in many people. We know that 80 percent of people don’t get really sick, so we have this population of people that might be harboring it, but have mild enough symptoms they don’t really notice. But they could be infectious to others by virtue of coughing or sneezing.
Those are factors that I think set this apart—and the fact that we have no immunity. To get to that level of enough people having immunity, that being exposed, it reduces the risk many people being infected at one time. It requires this concept of herd immunity.
RS: Can herd immunity be obtained in a realistic amount of time?
RM: Herd immunity refers to the concept that if enough people in a population have immunity from either infection or vaccine—even if it’s short term—it will reduce the risk and pace of transmission in a population that may lead to outbreaks or a pandemic.
So how do you slow that transmission? The only way to really achieve that is to have enough people with immunity—and it’s roughly thought that 70-90 percent of people need to have a level of immunity to be able to achieve a significant risk reduction.
That’s been successful with other vaccine-preventable diseases like measles or chicken pox or polio. That’s the reason for these mass vaccination campaigns, and they’ve been successful for the most part, right? Other than little pockets now—we don’t see that. Although we do see that when we had these measles outbreaks, that one inadvertent exposure could cause multiple people being infected.
I think that the only way to achieve that level of herd immunity is through a robust vaccine campaign, and that’s why the emphasis on vaccines is so important. It’s unlikely that we are going to get proper control of this pandemic until we get vaccines in place.
RS: Is there a way out of this that doesn’t involve widespread testing or a vaccine?
RM: Short of having the vaccine, everything else we do is going to be contingent on identifying, isolating and contact tracing—to be able to furlough or quarantine to be able to contain the spread.
What we have experienced in the last two months is that it came on so quickly, there wasn’t an ability to rapidly respond before it overtook us. And the only way to help contain and manage not overwhelming our health care system—as we saw happening in Italy and New York—was to do early public health interventions.
At that point, neither did we have the testing capacity available nor the testing, nor did we really have a robust public health infrastructure in place in order to be able to chase all of these down.
The only way to achieve some of that is what happened in California first, and that was the social distancing—the shelter at home—cutting back on elective surgery, for the health care systems to be able to manage the onslaught. At Cedars-Sinai, that meant mobilizing our care delivery models to prepare for COVID, even having our staff stay home unless they were needed. All of those public health measures and health care system preparedness helped to slow the spread and blunt the curve—not flatten the curve necessarily, but blunt the curve.
Now we’re in the next phase of control which is mitigation—which is going to require the things that would have been helpful up front if we had the ability to keep up with it. So testing, contact tracing and isolation will be able to prevent bursts and pockets of little outbreaks or big outbreaks. Maybe not to the same level that we had, but we have to do all of them.
In California, for example, we are seeing a significant improvement, and a decline in number of deaths.
But there are pockets where we are seeing an increase in a number of cases. Those are in vulnerable, high congregate settings, like nursing homes. And so there needs to be a continued vigilance to prevent those outbreaks from continuing.
RS: What can we expect from these states engaging in early reopenings? Are you seeing any warning signs?
RM: There was disturbing news from China in Wuhan, and in South Korea: Even with all of the aggressive control measures that were taken that appear to have made a difference, and life was resuming and some of the restrictions were being lifted, it’s very worrisome that in those very areas, there’s been a reemergence of cases. I would consider those as some early warning signs.
I think that’s what we’re going to have to learn from. The key message is that while we can have these models and thresholds, it’s not exactly clear what is the right threshold, what’s the right balance—even in the best of circumstances with social distancing policies, we know it’s challenging to maintain. We’re seeing pockets of that here in California with the beaches: It’s not something our public is used to or comfortable with, and it takes a lot of discipline. I think we have to keep our eyes open and learn and monitor these trends and be able to intervene again and reinforce or reinstitute measures as needed.
But even in states that are relaxing, it will require a combination of being able to offer adequate testing to identify cases, and being able to mitigate those cases with a public health infrastructure that protects the vulnerable.
RS: CDC guidance tells employers to test for symptoms—specifically fever. But according to the WHO, 80 percent of infections are mild or asymptomatic. How effective are these symptom-based strategies if so many carriers aren’t showing symptoms?
RM: Eighty percent of people have mild to moderate illness. But the number of people if you test randomly carrying it seems to be very, very low—and it seems to depend on where you are. For example, in the height in the New York experience, maybe more people weren’t carrying it, but they were having a tremendous amount of community transmission. So, in the setting of low community transmission, it is not clear whether testing people with no symptoms provides any valuable information.
What the CDC has done is to expand their list of symptoms. So early on, we thought it was a primarily flu-like illness with fever, cough and shortness of breath—but now we’re recognizing that more and more people may have milder symptoms like a sore throat; some mild chills; a subjective fever, not a high fever; a loss of smell or taste; and even gastrointestinal symptoms like nausea, vomiting or diarrhea.
So there may be other clues in this syndrome that may precede the typical respiratory illness. And in a small number of people, they may just have those non-specific symptoms and never develop a true respiratory illness. There is a real spectrum of illness for this virus, which makes the scale of this illness broader than we once recognized.
And that’s important information to educate our public and our clinicians—so the CDC has expanded some of those symptoms.
RS: Could someone that is infected could go undetected into work, after passing these thresholds being set up in businesses that are reopening? Or are you saying that some sort of symptom will likely appear?
RM: There are definitely people with mild symptoms that may not recognize that they may have COVID—but reality is our new norm is going to require social distancing, physical distancing.
I think masks are a reality—the reason we advocate for wearing masks out in the public is because that it helps contain the secretions or inadvertent coughing or sneezing with someone who might have COVID-19, and they may not realize it because they have mild symptoms.
With some people, it certainly seems that some people may have virus in their upper airway until they develop symptoms, for perhaps a day or so.
So absolutely, there can be people who have it transiently before they become ill. That’s the reason why the distancing and the masking and the hygiene are all so critical.
RS: What’s your take on colleges and schools re-opening in the fall?
RM: I know that there’s active discussion underway, and a lot of those decisions are going to be dependent on the ability to establish the appropriate preventive measures, the ability to support students—both in terms of their education, but also managing their interactions: How is dorm life and campus life being put in place without a vaccine?
If we are able to have a vaccine in place by September, there may be a different threshold—but at the moment, it doesn’t look like that will be here for maybe a year, so I don’t know.
I think it’s going to be a challenging conversation, and it might depend on the establishment of what public health infrastructure may be in place with testing, contact tracing, isolation and being able to separate students. So I wish I had an answer for that one.
RS: What are some success stories you’ve seen—either policy-wise or healthcare-wise, nationally or globally?
RM: Clearly, we all acknowledge that we’re dealing with a completely unprecedented experience in our generation—and yet what we’re seeing is that we need to be able to rely on science to help us determine direction.
It’s definitely important, on a national and international scale, to see that the information in science is moving so quickly, in terms of the response and scientific development with the vaccines and therapeutics.
At Cedars-Sinai, we have active research going on, and we’re applying the research protocols to our patients. The rapidity of scientific development and the technologic changes that help support delivery of patient care. For example, using telehealth has had a tremendous response in the U.S., which is extremely reassuring and positive.
From a human side, we are seeing a tremendous amount of resilience—despite the concern and fear, we are really able to see our workforce really pull together and do different kinds of jobs, if their regular job is put on hold. People just want to help.
Also, the recognition of health care workers as really being people who are dedicated to their jobs is really coming to the forefront. I think it’s been a really long time since there was that kind of awareness.
At the end of the day, we need to look at the places that have looked at science, and used the science to help drive some of the decision-making—and also benefit from being able to use available information. Here in California, we had lead time after seeing what was happening in New York and Italy, and we were able to buy time by implementing those actions early.
And if one steps back to look at how quickly things transpired in New York and the correlation with the early interventions in California, the unfortunate experience in New York led to some decisions here that translated to a potentially slowing-down of the infections.
Now, we’re not ever going to know ever if things would have been the same without those actions—but we have to look at the data we have.
RS: Our readership has greatly expanded since coronavirus. Anything else you want people to know?
RM: First of all, that it’s important that we don’t ease up on the protective measures. We are not out of the woods. This is still a crucial time, and until we have a vaccine available, we have to continue to use the information and preventive measures we have: wearing a mask in public, washing hands, social distance, physical distance, not touching your face—that’s a habit that is so hard to break, and we don’t often think about that.
Secondly, I think knowing that this is really the new normal for probably some time. And things may get worse in the fall when flu season is back, so we may have an overlay of not only flu, but also COVID-19 as people go back to being closer together.
Thirdly, its really important to stress that as unfortunate as it is, there’s a lot of fear. And now that we have tried to open up, we in the health care system are dealing with people who are afraid to go to the hospital, even though they may need to.
I think an important message is not to delay health care during this time—especially for people who have chronic conditions—and to make sure they connect with their health care providers to get the care they need. That’s an important one. Hospitals are making sure that there are patient safety measures; there is a lot of effort to keep people safe and make sure that the individuals who need health care are getting it.