Could you help me understand what public health departments’ roles are in this pandemic?

Could you help me understand what public health departments’ roles are in this pandemic? Do they have the infrastructure and support they need to do their jobs right now?

Chris Kemp, M.S.:

Public health departments DO NOT have the infrastructure, support, or resources to respond appropriately to the pandemic. In an ideal world, a single positive case is reported to local health departments and begins a cascade of events that includes strict quarantine of the individual and comprehensive contact tracing, during which every person the positive individual came into close contact with (say, 15 minutes or more in an enclosed space) is identified, contacted and also quarantined.

[As a society,] we have failed to do this on every level, and we're still not doing it. For the first weeks/month of the pandemic, we didn't even have enough available tests. Other countries -- Iceland, New Zealand -- have shown that it is possible to respond appropriately by committing significant resources to the effort.

Why do some groups of people get Covid-19 at a higher rate than others?

Why do some groups of people get Covid-19 at a higher rate than others? I’m thinking about communities of color in particular. Does it have to do with their actual immune response, or is it more about their access to resources, or… something else?

Chris Kemp, M.S.:

Higher rates of infection in black communities are a true symptom of systemic inequality. It has nothing to do with their immune response.

Generally speaking, [due to a history of systemic inequality,] people of color disproportionately occupy lower socio-economic groups. As a result, they're more likely to live in communal housing and in multi-generational households, with fewer opportunities for social distancing.

Many of them are employed in jobs that provide fewer opportunities to work from home, or to stay home and receive sick pay when sick, and are less likely to have health insurance. They're more likely to rely on public transport where social distancing is difficult.

The risks of infection are also less likely to be communicated adequately to them. The resources they need to prevent infection — such as masks and sanitizers — are less readily available to them.

Finally, if they get sick, research shows they're less likely to receive adequate care.

What's more, the co-morbidities that increase the chances of a negative outcome, such as diabetes and obesity, have a higher incidence in black populations. Literally nothing is weighted in their favor during a pandemic.

Resources:

National Congress of American Indians Resource List
Resources for Immigrants During the Coronavirus
The African American Policy Forum Resource List
AXIOS: The coronavirus economy will devastate those who can least afford it
The Colorado Trust: Pandemics Thrive on Inequality
Centers for Disease Control and Prevention: Coronavirus: Resources for Homeless Shelters
Nonprofit Quarterly: COVID-19: Using a Racial Justice Lens Now to Transform Our Future
Health Affairs Blog: Health Justice Strategies To Combat COVID-19: Protecting Vulnerable Communities During A Pandemic
Health Equity: Responding to Healthcare Disparities and Challenges With Access to Care During COVID-19
Health Equity Initiative: COVID-19 Is a Health Equity Issue
Health Equity Initiative: Paid Sick Leave Policy and the Impact on Health Equity
Human Rights Watch: US: Address Impact of Covid-19 on Poor
Kaiser Family Foundation: Key Facts about the Uninsured Population
The Marshall Project: Tracking Prisons' Response to Coronavirus
Pew Research Center: As coronavirus spreads which U.S. workers have paid sick leave - and which don't
UN News: Racism and xenophobia are ‘contagious killers’ too
World Economic Forum: Coronavirus: A pandemic in the age of inequality
World Heart Federation: Preventing COVID-19 spread in poor areas
ReachMD: Not Just a Pandemic: Why COVID-19 Is a Health Equity Issue
Region 2 Public Health Training Center (PHTC): COVID19: Using a Health Equity and Human Rights Lens to Protect Vulnerable Populations during this Pandemic and Beyond

What are your thoughts on a safe return-to-school/work strategy?

See questions here and throughout the body of this text.

What are your thoughts on a safe return-to-school/work strategy?
For example, much has been made about kids going back to school in staggered days (every other day, with half of the kids two days and the other half the other two days) – which seems to me like it won’t make anything but trouble for parents, will expose teachers and support staff, and overload teachers with in-person and online curricula, while only accomplishing a reduction of the number of kids in a classroom per hour.

Jack Lipton, Ph.D.:

Based on all of the plans I’ve read about so far, I don’t think there’s a “right” answer yet. A lot is still going to happen with this virus before school starts, so what I do feel that I know for sure is that it’s going to be problematic.

Developing hybrid or virtual learning is to reduce the risk of transmission from person to person. However, we’d be reducing the risk a little bit, and only for the students, not the teachers. The teachers will be the most vulnerable, and they’ll have a continuous parade of not only students but also support staff, and vice-versa. That means that for adults in the K-12 system, we’re only reducing risk through the use of PPE and distancing, as much as each is able to be used and practiced during their often unpredictable day-to-day interactions with children. The risk is not mitigated in a significant enough way to make that make sense for me.

At the same time, I think there are inherent problems with going fully online. Mental health responses in children in isolation — especially in high-stress situations — are severe. Plus, socioeconomic disparities and levels of technical competence will advantage the most well-off students, deepening the very inequities responsible for exposing those people at a disproportionate rate. I only have fears about this type of learning choice, though I’ll note that I’m a neuroscientist, and would defer to my colleagues in public health and education to come up with solutions that might be able to mitigate some of the losses.

I will say that this 4/10 model from Dr. Uri Alon seems particularly attractive to me.

Chris Kemp, M.S.:

Generally speaking, schools will have to remain flexible and respond to the data. School boards have made decisions already, but in August and September they'll need to practice some flexibility based on local data.

The health department reports cases and deaths every day around 4 p.m.; school boards and superintendents will base decisions on these tallies. Unfortunately, without some sort of surveillance testing, schools will only know a pupil is sick if the pupil is symptomatic, feels unwell, and then tests positive.

There is a chance we will see a return to lock-down and distance learning, or some combination of half days, or days on/days off, or staggered classes —several different approaches have been suggested. Prepare now to be flexible.

Important note: as a parent with elementary and middle school kids, I'm very encouraged by some early data that seem to suggest not only that kids aren't infected at anywhere near the rate adults are, but more importantly that kids don't transmit the virus to adults very often. Iceland beat the virus with some pretty extreme contact tracing that gave researchers insights into how the virus is transmitted. Very few cases seemed to pass from children to adults.

Is there an age when that changes? It seems like elementary schools might be able to breathe a sigh of relief here, but high schools might have to factor in more of a transmission factor.

It's hard to try to parse out the data but I think kids are much less likely to contract the virus all the way through their teenage years. Kent County Health Department lists data in age groups by decade, so 1-10 and 10-20, and so on. Both of those age groups show significantly lower, like much much lower, rates of infection and even lower levels of mortality. Phew. The CDC has even wider age brackets with all kids dumped in a 0-24yrs group. The mortality in that group is almost nonexistent. The one bright spot in this.

In our high school, we have lots of rooms without windows/fresh air. Is this an issue?

Yes, this is a potential issue. Prolonged periods in poorly-ventilated spaces do seem to be a factor in virus transmission.

Is band class an issue, with lots of students blowing air around?

I think bands should practice outside and maintain social distancing guidelines to whatever extent possible.

What is contact tracing, why is it important, and how is it done?

From Johns Hopkins Bloomberg School of Public Health:

Contract tracing is a core public health function that public health agencies have done for years. Diagnostic tests can confirm whether a person is infected with an illness. Contact tracing involves finding out who the infected person had contacts with so that those individuals can be alerted that they are at a risk of developing the illness and at risk of potentially infecting others in the community.During contact tracing, the contacts of the infected person are generally called up, asked if they're feeling sick, and advised to self-quarantine for a period of time. During the quarantine period, the health of the contacts can be monitored and health care or other services could be provided to them if they do develop symptoms. Also, it is important to make sure that people who have been exposed to the illness are not circulating in the community and further spreading the disease.

Anita Cicero, JD, is deputy director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health.

How related is Covid-19 to the flu?

Patrick Bardill, Ph.D.:

SARS-CoV-2 is not closely related to the influenza virus that causes the flu. They share some characteristics, as both are respiratory viruses with lipid membranes, but there are many differences based on other characteristics that indicate they are not closely related.

Jack Lipton, Ph.D.:

I think people associate Covid-19 and influenza for a couple of reasons.

One, diseases have cycles that start somewhere geographically and move somewhere geographically, and the annual flu migrates from East and Southeast Asia, and generally end up in Europe and the Americas several months later.

Two, there have been a lot of political discussions that connect the two based on fatality rates. The reality is that there is no relation between the two at all. It makes people comfortable to try to find equivalence, in order to better understand something unknown. In doing this with Covid-19 and influenza, people connect the two diseases in a manner that downplays the seriousness of Covid-19. Influenza sounds innocuous to them — and makes it feel less scary. This is ultimately detrimental to all of us, as it encourages others to take the novel coronavirus less seriously.

I have a condition, but it's under control. Am I still considered high risk?

I have epilepsy, and due to the meds I take I have to have a lot of bloodwork done on my liver and kidneys. With this info, would I be someone considered high-risk during the pandemic? They say people with high blood pressure, diabetes, COPD, etc. are high-risk, but are they high-risk if their conditions are treated and under control?

Alison Bernstein, Ph.D.:

CDC does not specifically mention epilepsy in their list of known or likely high-risk categories.

I think that people are still considered to be in a high-risk group even if symptoms are under control because the underlying condition is still present. It’s important to recognize that risk is a population-based measure so it doesn’t apply to an individual.

https://scimoms.com/population-risk-individual-risk/

What should we anticipate regarding flu season?

Alison Bernstein, Ph.D.:

This is hard to predict. It is possible that increased diligence on hygiene and masking will help to slow the spread of flu this fall. The same things that prevent spread of coronavirus also prevent spread of flu. But people have also delayed vaccinations during the pandemic so if fewer people get the flu vaccine this could push things in the other direction. Getting your flu vaccine is still important, because keeping people out of hospitals as much as possible will help us fight COVID.

Resources:

https://medicalxpress.com/news/2020-05-covid-flu-season.html

https://www.cdc.gov/flu/season/faq-flu-season-2020-2021.htm

What is most important to keep in the fronts of our minds about this virus, so we don’t fall back into easy routines?

Michigan has done well in flattening the curve. While that’s great, we see all around us that people have become complacent. It’s almost as if they don’t realize that the curve has flattened because we’ve been under stay-at-home and mask-use orders. Even in our vigilant family, I find us forgetting to carry masks and sanitizer lately. What is most important to keep in the fronts of our minds about this virus, so we don’t fall back into easy routines?

Alison Bernstein, Ph.D.:

This is hard balance between maintaining vigilance but also not allowing anxiety and fear to overtake your life. Checking the COVID modeling websites regularly should be enough to trigger fear and anxiety but this is not healthy. So the question becomes, how do we maintain vigilance but also take care of our mental health?

My opinion based on my personal experience and many years of therapy are that we make consistent changes by developing habits and making it easy to keep them. Put your masks in the same place every night, keep one in your purse or work bag, and in your car. Keep hand sanitizer in all those places. This makes it easier to remember and lowers the amount of effort required to maintain these habits.

Chris Kemp, M.S.:

It will be back.

Why are some regions of the country more affected than others?

Why are some regions of the country more affected than others? Beyond the obvious population density issue in places like NYC, it seems like some regions are simply not as hard-hit despite a lack of stay-at-home orders. I’ve read that it doesn’t have to do with warm weather, so what else is at work?

Chris Kemp, M.S.:

There are numerous possible explanations for the pattern of infection. Ultimately, all regions will likely be affected to the same degree.

Communities with more elderly demographics might see higher rates of mortality (see parts of Florida and New Jersey). Cities with very poorly-functioning infrastructures are going to see higher rates of transmission, fewer people obeying stay-at-home-orders, and higher rates of mortality (see Detroit and Flint). Even so, the likelier explanation is that states and regions with less robust testing record fewer cases ... but the cases are there, undetected.

As we've seen this week in Texas, California, and Florida, regions that were hit less hard to begin with will catch up given the chance.

The pandemic does also have a socio-political component. Research shows that blue states obeyed stay-at-home orders with more compliance than red states, and we're seeing the effects of some of those differences now.

What determines whether a virus disappears or becomes endemic?

From Johns Hopkins Bloomberg School of Public Health:

Two main clues help us predict whether a virus is going to stick around. First, we consider the virus’s origins. If it came from animals and could still be circulating in animals, then no matter how good we are at getting rid of it in humans, animals could always bring it back. That’s true with influenza: Even if a certain strain disappears, a new one might emerge from animals—as we’ve seen with avian viruses.

But with a major outbreak like COVID-19 already underway in humans, the big question is how good humans are at developing immunity. And, if they gain immunity, does it stick, or does it fizzle out over time—leaving the door open a crack for the virus to return? As the first cases get further and further out from the point of infection, that data will give us a better idea of what to expect.

Emily Toth Martin, PhD, MPH, is an associate professor of epidemiology at the University of Michigan School of Public Health.

What does “preparedness” in a country really mean?

From Johns Hopkins Bloomberg School of Public Health:

Preparedness starts with funding. That’s how everything else gets done—by having resources available to prepare for these kinds of rare but highly impactful events.

Public health departments would use that money to ensure expertise in emergency and pandemic planning. That’s key not only for the public health preparedness, but for preparedness in hospitals and long-term care facilities as well.

The money could also be used for supplies. In the US, we’ve heard a lot of about the Strategic National Stockpile which contains critical medicines and supplies needed during public health disasters. Having the resources to ensure we have extra supplies on hand is crucial.

Preparedness also means having policies and guidance ready to pull off the shelf during crises, rather than starting from scratch. That could include telework policies at an institutional level, or advance thinking on actions like the triggers that would indicate a need to close or reopen schools.

Caitlin M. Rivers, PhD, MPH is a senior scholar with the Johns Hopkins Center for Health Security and an assistant professor in the Environmental Health and Engineering department of the Johns Hopkins Bloomberg School of Public Health.

How has The Circle been working out?

Lisa Hayes:

A few weeks ago, I wrote about our family’s Circle — the plan we have for reconnecting now that our state is opening up. Many people have asked how it’s been going, and the answer is — mostly fine. We didn’t assume it would be problem-free, and we’ve learned that what we thought would be the toughest parts are, in fact, the toughest parts. To me, that means it was a smart exercise to really think it through ahead of time and prepare ourselves for a little bit of stress. I’ll take that little bit of stress over the stress of not having a plan any day.

Here’s where it’s been tricky: People feeling awkward speaking up, and people feeling unwilling to truly commit to full caution in the moments when they want things to “be normal again.”

For example, my girls were at their dad’s house, and their grandparents — his parents — stopped by. Those grandparents don’t practice distancing, wearing masks, or increased hygiene, and they’ve been having a number of social interactions both in Florida and Michigan without using precautionary measures. Despite one of my kids saying she wasn’t going to fall into risky habits (she put on her mask and stayed six feet away), everyone else in the household (guiltily and awkwardly) allowed the grandparents to take over. Jack and I found out about this from the kids, after we’d already been with them for a few days — so we were all exposed to an unknown factor. We reached out to the other members of our Circle (whom we had not seen since before the exposure) to let them know we wouldn’t be getting together again until 14 days had passed or we had a negative test.

We’re also seeing incidents where Circle members want to “better enjoy” the moment. We all know our overall risk is low, so it’s tempting to give in to a happy hug or to leave the mask off during an encounter. It takes a lot of conscious choice-making in the moment, along with preparing ourselves prior to venturing out, to ensure we don’t break our Circle’s rules.

After being isolated for so long, these opportunities to connect with others are incredibly tempting for all of us, and we know we may not be perfect all the time. But as committed Circle members who truly love and care for one another, the best thing we can do is protect each other. This won’t last forever. The ramifications from getting and passing on Covid-19 just may.

Our takeaway after our first few weeks is that in order to keep our commitments to our Circle family, we have to all become more confident standing our ground. That means we’re role-playing what to say in those high-stress situations, we’re practicing extreme caution while out so we contribute to the “new normal,” and we’re staying informed so that we don’t become complacent.