As the number of confirmed coronavirus cases in the United States topped 1 million and states began reopening, USA TODAY’s Editorial Board spoke on Tuesday with Dr. Tom Inglesby, a leading expert on pandemics and infectious diseases. Inglesby, 53, is director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Questions and answers have been edited for length and clarity:
Q. In recent days, we've seen Georgia and about a dozen other states start to reopen. Are they jumping the gun?
A. I am concerned about the speed of reopening in the last week. It would be good, in addition to the daily case counts for each of those states that are now beginning to reopen, to be able to see their hospitalization rates, their ICU bed usages and the number of deaths that are occurring on a daily basis.
Q. Where are we in the arc of this crisis?
A. I think we're past the first peak where we were kind of caught unawares and before we had our systems in place. We had shortages of PPE (personal protective equipment), which still exist, but they were even more dire. We didn't have diagnostic testing. We didn't have an awareness of how fast it was going to spread. In some places we're still at a plateau. I don't think we have really turned the corner. If you look at the number of states around the country, there's something like half of the country still has rising case numbers every day. So I think on average, we're probably at a plateau or maybe slightly past the first peak.
Q. Given that, is this the right time to start reopening?
A. It depends on the specifics. It's not an easy yes or no. How are they going about it? Are they going about it in a step-wise fashion, where they're thinking about things that are lowest risk first and then gauging how well they do over the coming two weeks? Or is it kind of a quick resumption to normal? That would concern me more, because I think if we recreate the conditions that we had in the beginning of March around the country, then we're going to have a higher risk of going back there again and having those kinds of peaks again.
Q. How important is diagnostic testing?
A. This epidemic is going to continue to be a major challenge for states until they have a relatively complete picture of the number of COVID cases that they have. Places in the world where we've seen greatest success — places like New Zealand and South Korea and Taiwan and Singapore — have all had a very good handle on the number of cases they have, including mild to moderate illness, and they've also had very strong contact tracing.
Q. Which states have seen sustained declines?
A. A very small number of states have had at least a couple of weeks of reduced transmission or lower daily case counts. Alaska, Hawaii, Vermont and Montana are really clear examples of that. Even there, though, it would be good to know what capacities are in place to be able to handle an outbreak.
Q. The virus doesn’t recognize state boundaries. Does it make sense to approach this on a state-by-state basis?
A. There is logic in approaching it on a state-by-state basis. We have a huge country, and the country is going through terrible economic consequences because of this. It's not going to be a perfect system. We are not going to reduce the epidemic, in any place, to zero before we have a vaccine and there's been widescale vaccination. So the country is going to have to tolerate a level of risk and spread in order to have any resumption of any of the functions that we had before. Even now, even with this level of lockdown, we're still seeing in the order of 25,000 to 30,000 new cases a day in the country, but it's not evenly distributed. It's definitely happening in some places, in a more intense way, than others.
Q. Isn’t travel between states a problem?
A. There will always be movement between states, and there will be importations (of disease) between states, and I don't think that's going to be possible to stop. I think the cost of trying to stop that would be too high. It's a trade-off. But given the size of the country, and given the distinctions between the places that have such intense disease and places that have relatively good control, it makes sense to have local decision-making around this.
Q. Every day when you turn on cable TV, you see the Johns Hopkins numbers displayed on the right-hand side of the screen. But do those numbers convey a misleading degree of precision?
A. The Hopkins map is created and managed by a person in a different department than mine. She's a colleague, and she's wonderful. I don't want to take any credit for it, because it was her idea, and she runs it with a team. I think what she would say if she were here would be that they don't intend to over-convey precision, but they do try to get every report of anyone who's sick or who has died from COVID and collect that basically a couple times a day. That's the method they use.
Q. How do the deaths and confirmed cases we see on the Hopkins map compare with what we think are the actual number of deaths and the actual number of infections?
A. I think if my colleagues were here, they would agree that the numbers that are being reported in terms of deaths and illnesses do not reflect the sum total in any way of what's happening in the country for many reasons. First, because in most places in the country, we don't have the bandwidth to be testing mild or moderate cases of COVID. So we know, at this point, there's been a very, very important undercounting of total cases.
Q. And deaths?
A. With deaths, because those people have been very sick (and most have) been hospitalized, there is probably less undercounting. But there still will be substantial undercounting of deaths as well, because many people either died at home or weren't able to get tested because of a decision in the city or lack of testing. I do think that we are undercounting cases substantially. We're undercounting deaths by some portion as well, which we don't yet know exactly what that is.
Q. So how many infections are there in the United States?
A. As a rough calculation, if we presume that the case fatality rate of COVID is 1%, and there have been 50,000 deaths in the United States, that would then mean that there had been something on the order of 5 million cases, and we've officially diagnosed something closer to 1 million.
Q. If you divide reported deaths by diagnosed cases, you get a case fatality rate of 5.8%.
A. I don't think any epidemiologists or scientists believe that to be the case, given the amount of undercounting going on. (Dr. Robert Redfield, director of the Centers for Disease Control and Prevention) has said that he thinks in the end (the fatality rate) might be more like 0.3% to 0.5% as opposed to 1%. If that were the case, then perhaps the number of people who've been infected in the country is closer to 10 million or 12 million.
Q. When do you see us getting back to normal, the way things were before everything shut down in March?
A. It's hard to know how we're going to. This is kind of a big, first ever attempt to go through this. We may have to go through some hard knocks along the way. I hope we can find a place that we get closer to normal than where we are. But I don't think we're going to have complete normal — no masks, fully back to social — before we have a vaccine.
Q. Where are we in terms of coming up with a vaccine?
A. The vaccine is crucial for the country and for the world. Right now, the three major funders of vaccines are the U.S. government, then the Chinese government, and an organization in Norway called CEPI, the Coalition for Epidemic Preparedness Innovations, that has become the default driver of vaccines in Europe. The World Health Organization is tracking about 83 or 84 vaccine candidates.
Q. Will a vaccine protect everyone?
A. Generally speaking, it's rare for any vaccine to be fully effective. Some vaccines are extraordinarily effective. The new shingles vaccine protects something like 99% of people who get it. But for the seasonal flu vaccine, the vaccine effectiveness is something like 40% to 60%. It’s not what we want, but it's a difficult vaccine. It's difficult to generate the immunity that we want. Hopefully, this (COVID-19) vaccine will be much higher and we'll get actual hard data around that.
Q. Does the public understand how long it will take to get a vaccine to them?
A. People say that a vaccine will take 12 months to 18 months. I think it would be useful (to have) a more detailed laying out of the schedule from the U.S. government. Developing a safe and effective vaccine is the first set of steps. It's quite complicated. It's obviously crucial, but it's not the entire process. Once we have the vaccine, it needs to be made on massive scale, and then it needs to be filled, finished into vials. Then it needs to be distributed, and we need to think about a whole allocation process. It's still early, but I think it's appropriate to start having more public discussion and transparency about the timelines.
Q. It sounds like a huge undertaking.
A. This whole process is definitely unprecedented. The scale of this will be unprecedented. Companies are never asked to make hundreds of millions or billions of doses of vaccine in the first year they've created a vaccine, so it's not just the technical difficulty of getting a safe and effective vaccine, but it is, as you say, the scale up, which will be massive, then the distribution challenges.
Q. While we’re waiting for a vaccine, what can the average person do?
A. If we can continue to wear masks when we're in indoor spaces in public, if we can continue to be mindful of being 6 feet away from each other, and if we can telecommute even if we're allowed to go to work, those things alone could make a big difference.
Q. And if we stop doing those things?
A. If we stopped everything, then numbers will go up. We don't know how quickly, but we would risk getting to a point where we couldn't care for people with COVID and potentially other people who have other life-threatening illnesses, because intensive care units in the United States are full on a normal day without COVID. People also have pneumonias, they have flu, they have strokes, they have heart attacks. They need intensive care units for lots of reasons, and if they become completely full with COVID patients, then we will be at risk of not being able to care for people from other, regular life-threatening illnesses.
Q. If I get the coronavirus and recover, will I be immune?
A. We have to make sure that we don't give people false reassurance that they're completely out of the woods. We hope they are. We hope that tests will show that they are, but it's too soon to say that.
Q. What if we let the disease run its course to build up herd immunity?
A. This pandemic doubles in size every five days in its natural state. It's not doing that anymore because countries around the world and states within the U.S. have put in unprecedented social distancing measures. The models consistently have shown around the world that if you do nothing to try to stop it, then, first of all, your epidemic peak goes up very quickly. But the overall mortality of 0.3% to 0.5% is only if you have access to the critical care you need.
Q. How much do we really know about social distancing?
A. We don't really have, at this point, best practices for social distancing. We don't really have any modern experience with it. We now have some experience over the last couple of months, and we've been able to observe the experience of countries and places within countries. So going forward, it's appropriate for states to start planning to lift social distancing measures when they have the right conditions in place. But we just have to be communicating clearly to people that their individual responsibilities haven't changed, and that we have to measure carefully to make sure that we're not reigniting a major epidemic.
Q. What should that communication sound like?
A. I don't think any governor is going to be able to say, or should say, that things are going back to normal. That's not correct. What they should say as they're reopening is: We're going to move ahead. There are risks to moving ahead, but there's certainly a risk to not, and we're going to be as careful as we can as we go ahead. We're going to measure carefully, and we expect everyone to make a full commitment to personal social distancing so that we can manage through this difficult time for the next year, or hopefully maybe less, until we have a vaccine.
Q. Is it reasonable to think that we will have a distributed vaccine by July 2021?
A. There are ways that there will be some vaccine possibly proven to be safe and effective by the end of this year. And then it would depend on how fast we can make it and distribute it. (But) it could be that none of them work, in which case, all timelines are off, and you're back to the drawing board.
Q. What lessons have we learned already?
A. For things that we're going to require to get through global or national emergencies, I think this pandemic has really created a strong argument for (domestic) production of certain critical goods. To have one or two or three suppliers for the world, for some essential products, just doesn't make sense.
Q. Do some people have natural immunity to COVID-19, meaning that because of genetics or some other factors they could be exposed to the virus but not get the disease?
A. It's possible we'll be able to sort that out with COVID, but at this point, there is no clear genetic protection. We haven't discovered that yet. We may discover it as numbers get larger and science proceeds.
Q. Is this going to have a permanent change on how we interact with each other going forward?
A. I hope not. On a normal year, I don't think we need to stop shaking hands, and I don't think we need to stop being close to each other. I hope that after we have a vaccine that we can get back to normal, that we can get back to where we were. I think we'll do things differently. Hopefully, we will transform, even further, our ability to make medicines and vaccines in a crisis. It's unacceptable for the world that it could take us 18 months to make a vaccine for this, but that's where we are. But with enough investment, maybe we can actually shrink that down to six months. Maybe we can shrink it further. I don't think we should accept where we are in terms of medicine and vaccine development.
Q. Is there the political will to do that?
A. We talk about NIMBY — not in my backyard. The other term that people have used is NIMTO — not in my term of office. If politicians think that they can get through and not pay attention to things, then no one claims responsibility for it. Hopefully, our national leaders will now see the need (to invest in public health).
Q. Vice President Mike Pence said recently that the epidemic could be largely behind us by Memorial Day weekend.
A. I don't know exactly what was intended by that statement, but we are not, at all, past the epidemic. I think there is a clear risk, in all states, of numbers going up again, depending on partly the nature of the virus, but also mostly about what we do and whether we can control it with our public health capacity and our diagnostics. We're going to have a risk of this pandemic throughout this year. Each state is going to have to be driving forward with eyes wide open.
Q. Will the hot, humid summer weather put a lid on the outbreak?
A. I don't think that any of us should think that there's going to be this quiet period between now and September or October. I think it all depends on what states individually do, and there isn't, yet, any persuasive evidence that there will be a summertime lull. Miami, for example, is a place in the country which is really suffering from COVID. It's sunny and humid there. Singapore has experienced disease, although they got good control of it. The World Health Organization does not believe there is any evidence of seasonality to this. And they're sitting, looking at data from around the world. The National Academy of Sciences in the U.S. has studied this and doesn't believe there's any evidence of seasonality yet. Maybe we'll be surprised. That would be a wonderful surprise, but I don't think we should bank on it.
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