By UCLA Prof. Jeffrey D. Klausner, CalMatters, 4-7-20
Despite the worst fears of the COVID-19 pandemic, the novel coronavirus has not spread broadly in the general population, though it has been severe in some settings. Many of the outbreaks have increased rapidly, peaked, and some have now declined. In California, the number of new cases has been relatively low and steady with recent increases likely due to increased testing rather than increased transmission. While the state’s initial “shelter-at-home” sledgehammer approach might have been defensible in a time of substantial fear and uncertainty, it is time now to reconsider.
The broad use of social distancing fails to account for the nuances in the spread of the coronavirus. The World Health Organization currently categorizes the spread in each country as “local,” not “generalized,” even as it has ignited devastating epidemics in some major cities and localized regions. As of April 6 there have been more than 15,000 reported cases in California that are highly concentrated within a few counties and more than 350 deaths. In a population of about 40 million, that is about 38 cases per 100,000 residents. A recent study estimated the death rate per infected to be 0.66% or about 1 death in 150 infected, much lower than the earlier estimates but still 6 times more deadly than the flu.
Like any response to an emergency, ours must be data-driven and not emotional. We must re-evaluate the current social distancing policies and accelerate plans to lift these interventions in localities with little transmission and end restrictions that have little value, such as closing beaches, parks and hiking trails. The localized nature of outbreaks means we can respond locally, based on testing data and case rates using proven methods of disease control, such as testing, isolation and contact notification. We can focus resources on protecting those individuals who are most at risk — the elderly and those with chronic diseases including lung and heart disease, immune suppression, obesity and diabetes. We can achieve this with better monitoring in nursing homes and assisted living facilities, visitor restrictions, resident and employee testing, isolation of cases, continued social distancing for those at risk and policies that support paid leave and work or schooling at home.
Our hospitals have been preparing for weeks. While there has been an increase in admissions, few California hospitals are overwhelmed. Fortunately, the substantial reduction in seasonal influenza transmission has resulted in fewer influenza-related emergency room visits, hospitalizations and intensive care unit admissions. That decreased burden on the health system is substantial and further assures hospital capacity. We should respond to California’s epidemic with continued actions designed to maintain awareness, promote personal behavior change such as staying home from work or school if ill, covering coughs or sneezes, and handwashing. We must increase case finding through unrestricted and expanded testing, including the use of home-based specimen collection, isolation of those infected and routine notification and testing of contacts.
We should embrace technological solutions that facilitate registration for testing and timely online access to test results and contact notification. We should test health care workers and first responders who have been exposed or have recovered with antibody tests to determine who is immune and can safely return to work. Other infectious disease epidemics that I have helped respond to in my lifetime followed similar patterns from uncertain policies like exclusion of HIV-infected individuals in school settings to a transition to evidence-based public health disease control strategies based on disease surveillance, case-finding through testing, contact notification and treatment or isolation.
Now that our understanding of how the virus spreads is improving, it is time to let the observed case rates and distribution of cases drive a more limited, focused response. As our knowledge and resources to control the coronavirus pandemic have increased — we need to use them strategically, protect the vulnerable and enable Californians in low transmission areas to get back to work and school.
Source: https://calmatters.org/commentary/its-time-to-reconsider-californias-shelter-at-home-policy/
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*Dr. Jeffrey D. Klausner is a clinical professor of Medicine and Public Health at the University of California Los Angeles. He is a former medical officer at the Center for Disease Control and Prevention, JDKlausner@mednet.ucla.edu.
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Editorial Comment: Note that it was not so long ago that the national estimate of the eventual number of deaths was put at 100,000 to 240,000 even with social distancing, etc. See "Coronavirus May Kill 100,000 to 240,000 in U.S. Despite Actions, Officials Say" from the NY Times:
https://www.nytimes.com/2020/03/31/us/politics/coronavirus-death-toll-united-states.html.
Now that estimate is being sharply downsized. See "CDC director downplays coronavirus models, says death toll will be 'much lower' than projected":
https://abcnews.go.com/Health/cdc-director-downplays-coronavirus-models-death-toll-lower/story The NY Times puts the number of deaths up to the present (as of 4-8-20 AM) at over 12,000. But these fatalities are highly concentrated. New York has about 45%. Over half are in New York and New Jersey. In effect, the New York City metropolitan area has become the Wuhan of the U.S. (The NY Times' numbers are updated regularly and are at:
https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html.)
Given all the uncertainty about testing availability and resulting numbers, we won't have a clearer picture for some time. However, it is hard to see the NY Times' fatality and case numbers getting anywhere near the old projections. Meanwhile, the economic numbers are preliminary but are also truly alarming. The impact on education from K-12 through higher ed (and including UC) will be long-lasting, particularly when the effects on state and local budgets are known and felt.
There is a temptation to evaluate the current crisis through the lens of anti-Trumpism because of evident leadership failures at the federal level. Rather than that approach, however, it is better to take a dispassionate "clinical" view, as the Klausner op ed above suggests.
-Dan Mitchell
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