A Message on COVID-19 from WorkSTEPS Chief Medical Officer Dr. Ben Hoffman

The Herd Immunity Debate – Focus on the Business Implications

According to Google Trends, searches including the term “Herd Immunity” spiked in popularity last week. The spike (which is even more impressive for the misspelled “Heard Immunity”) was in response to a proposal that suggested we should strive to reach herd immunity to COVID-19 by allowing people to become infected and thus become immune to the disease. In the past 10 days, the proposal has – like so many things these days – become a source of political division, distortion, and confusion.

I have zero interest in the politics surrounding the proposed approach. However, I’m very interested in helping to clear up the confusion for our many business customers. I’ll begin with a bit of background and will then dive into the practical considerations and business implications of the proposal.

Background

As you likely know, Herd Immunity is a public health term that has traditionally been used in relationship to vaccination, referring to the proportion of a population that needs to be vaccinated in order to stop the spread of a particular infectious disease. The vaccination threshold to achieve population protection largely depends on how contagious a disease is. Measles is extremely contagious, so up to 94% of the population needs to be vaccinated to achieve herd immunity. For COVID-19, estimates converge in the 60 to70% range.

About ten days ago, a group of scientists from esteemed organizations published the Great Barrington Declaration (the Declaration). The gist of the declaration is:

• When considering pandemic-related policies, it is important to look at total harm, including morbidity and mortality impacts of the virus itself, as well as harms that come from closing businesses and schools, and of social isolation. Lockdown related harms fall particularly hard on underprivileged populations.
• Because COVID-19 is very dangerous to some but not to others, we should use a “Focused Protection” strategy which: A) Focuses on protecting those who are vulnerable; while B) allowing others to go about their normal lives. Schools and universities should be open for in-person instruction, bars and restaurants should be open, and even concert and sports activities should resume.
• In going about their lives, low risk people will get sick, but the vast majority will not become seriously ill. The risk of serious illness, the authors say, is not unlike risks people routinely accept when they drive or cross the street.
• Allowing low-risk people to naturally achieve immunity by getting sick will not only reduce harms done by lockdown policies but will accelerate achievement of herd immunity once a vaccine is widely available.

Practical Considerations and Business Implications

Unsurprisingly, the proposal outlined above has been embraced by those who have resisted restrictive policy measures to slow the spread of the virus. Also unsurprisingly, public health advocates and architects of policies designed to curb the spread of disease are appalled by the proposal. A strong counter-argument to the Declaration can be found in this opinion piece.  

People have chosen sides in the ideological divide over the Declaration, but ideology is not what matters here. What matters to businesses is the practical implications of a “Focused Protection” approach. Is it something that should affect their policies and practices during this pandemic? Here are my perspectives:

• 1. A “Total Harms” view is helpful. I’m in full agreement that pandemic policies should be informed by a consideration of potential harms of the virus and of restrictions that may be put in place to curb the spread of the virus. At WorkSTEPS, our focus from the very beginning has been on providing information and insights to help businesses achieve the twin aims of keeping people safe and maintaining operations to the extent possible. We help our clients balance the often-conflicting demands of safety and operations every day.
• 2. The idea of protecting only vulnerable people sounds good but falls apart in the real world. If we think of vulnerable populations in a limited way (e.g., only those who are old and frail and live in nursing homes), the idea of somehow segregating them for special protection seems feasible. The reality is not so simple. People can be vulnerable to serious illness from COVID-19 for a range of reasons, including chronic diseases, obesity, and medications that suppress immune systems. Further, many people who are not vulnerable live with or care for people who are, so the risk equation for them becomes more complicated.
• 3. Employers can’t discriminate based on vulnerability to COVID-19. Even if you could know which employees (or customers) are vulnerable (and you can’t), you cannot forbid them from coming to work or doing business with your enterprise. You have to assume that anyone in the office, on the shop floor or walking through your door might be vulnerable or have a vulnerable person in their life.
• 4. Because anyone can be vulnerable, company policies and business practices must protect everyone. This final point brings us to the conclusion that – regardless of ideology – companies have a duty to protect their employees and customers from COVID-19. What does that mean? Well, it means implementing a comprehensive prevention strategy, including evidence-based testing protocols, measures to assure good ventilation of indoor spaces, and promoting flu vaccines to reduce complicating and costly cases of flu this year while also laying the groundwork for a strong COVID-19 vaccination push once vaccines become available.

It’s worth noting here that about 1:10 minutes into a video posted on the Declaration website, the authors of the proposal admit to personally wearing masks when out shopping because they do not know if the people around them may be vulnerable. Even the authors’ ideas about “normal lives” account for the fact that we can’t know who is or is not vulnerable among us.

I understand why the Great Barrington Declaration quickly gained attention. It’s an attractive vision. However, based on the logic outlined above, the idea of “Focused Protection” simply isn’t useful to businesses. Company leaders will be much better served if they focus their limited time, attention and resources on the COVID-19 prevention measures highlighted in point #4 above.

If you find this Brief helpful, please pass it on to your colleagues. And as always, I encourage you to let us know if there are topics you’d like to see us address in the WorkSTEPS COVID-19 Brief.

Ben Hoffman, MD, MPH
Chief Medical Officer, WorkSTEPS

For more from Dr. Hoffman, connect with him on LinkedIn.

Medical:

‍

National: Public health experts caution the public that the fall and winter months could bring a surge in the coronavirus pandemic. The majority of states are reporting increases in new infections. The U.S. recorded roughly 58,000 new cases this week Monday and recorded roughly 69,000 cases last week Friday. As of this week, more than 37,000 people were hospitalized. COVID-19 hospitalizations were growing by 5% or more in 37 states as of Sunday.

‘At a breaking point’: New surge of COVID-19 cases has states, hospitals scrambling, yet again. As hospitalizations for COVID-19 inch up around the country, some states are readying plans for field hospitals. Communities are delaying reopening plans and even imposing new measures, though some governors remain opposed to additional restrictions. Deaths — currently standing about 220,000 — have not surged again yet, but that might just be a matter of time.

The current rise in coronavirus cases around the U.S. is reminiscent of the summer crest and has flashbacks to the emergence of the national crisis in the spring. There are attempts to characterize what’s happening — a third wave or a third peak of a single wave that never fully ebbed — but whatever your semantic preference, cases are racing up in many states and breaking daily records in the Midwest and Mountain West. They’re even creeping up in places that experienced the brunt of the earlier outbreaks, like Massachusetts and New York.

Nearly 300,000 more: On Tuesday, the CDC published a report showing 300,000 more deaths from late January to early October than expected during an average year. The report found that the majority (66%) of the excess deaths are due to the coronavirus. More deaths from all causes occurred in older populations. The age group with the highest average percent increase (26.5%) in fatalities was adults aged 25-44 years. This percentage increase reinforces risk of spread among young adults and the need to address the trend.

Winter in the northern United States will soon drive even the most diehard outdoor diners and backyard socializers indoors, bringing with them heightened risk for contracting and spreading COVID-19. The worry is not just that people might mingle more closely inside, but that the air they breathe will make the virus more dangerous.  Cold, dry air facilitates the spread of the coronavirus, and the social distancing that helped outside won’t be as effective indoors, scientists said.

High rates of asymptomatic infection in nursing facilities: A large, multistate study of coronavirus in skilled nursing facilities (SNFs) found high asymptomatic and presymptomatic infection, underscoring the value of universal testing to identify and isolate cases. Researchers used electronic medical record data and daily infection logs from around 350 SNFs to identify PCR confirmed cases from March 16 to July 15. They identified 5,403 cases with 40.6% classified as asymptomatic, 19.1% presymptomatic, and 40.3% symptomatic at the time of testing. SNFs in counties with higher prevalence had higher counts of asymptomatic and presymptomatic cases than those in counties with lower prevalence.

Kidney impairment and COVID-19 outcomes: Last Friday, researchers published findings showing that COVID-19 patients who have chronic kidney disease (CKD) or develop coronavirus-related kidney injury in the intensive care unit (ICU) were more likely to die from COVID-19 than other patients. The retrospective study included 372 adult COVID-19 patients in 4 UK ICUs from March 10 to July 31. Of the 372 patients, 58% had kidney impairment, 22% of which was CKD and 78% was developed during hospitalization. Researchers theorize that this may be because the virus causes inflammation in the kidney blood vessels.  

Studies show possible protection from blood group O: Two retrospective studies published last week showed evidence indicating that people with blood type O may be less susceptible to infection and experience milder disease. A Danish study compared data from around 473,000 COVID-19–positive individuals finding fewer infected people with blood type O and more people with A, B, and AB types. Researchers hypothesize that the presence of virus-neutralizing anti-A and anti-B antibodies on mucosal surfaces of some type O people may be correlated to the relative protection for this blood type.

Mitigation / Suppression:

Outbreak at hockey game: After a recreational ice hockey game in Florida, an outbreak occurred among the players. Teams A and B, consisted of 11 players each (six on the ice and five on the bench), and included men aged 19–53 years. During the 5 days after the game, 15 people (14 of the 22 players and a rink staff member) experienced symptoms of coronavirus; 14 players were infected with the COVID-19.

UK Plans COVID-19 'Challenge' Trials That Deliberately Infect Volunteers: Britain will help to fund trials using a manufactured COVID-19 virus to deliberately infect young healthy volunteers with the hope of accelerating the development of vaccines against it.  The government said on Tuesday it will invest 33.6 million pounds ($43.5 million) in the so-called human challenge trials in partnership with Imperial College London, laboratory and trial services company hVIVO and the Royal Free London NHS Foundation Trust.

COVID-19 survives 9 hours on skin: Left undisturbed, the new coronavirus can survive many hours on human skin, a new study has found. To avoid possibly infecting healthy volunteers, researchers conducted lab experiments using cadaver skin that would otherwise have been used for skin grafts. While influenza A virus survived less than two hours on human skin, the novel coronavirus survived for more than nine hours.  Both were completely inactivated within 15 seconds by hand sanitizer containing 80% alcohol.

Corporate:

Holiday celebrations: On Monday, the CDC offered the following considerations to help protect individuals and their families, friends, and communities from COVID-19.

• Community levels of COVID-19 – Higher levels of COVID-19 cases and community spread in the gathering location, as well as where attendees are coming from, increase the risk of infection and spread among attendees. Information on the number of cases in an area can be found on the area’s health department website.
• The location of the gathering – Indoor gatherings with poor ventilation pose more risk than outdoor gatherings. To increase ventilation open windows or doors.
• The duration of the gathering – Gatherings that last longer pose more risk than shorter gatherings.
• The number of people at the gathering – Gatherings with more people pose more risk than gatherings with fewer people. The size of a holiday gathering should be determined based on the ability to reduce or limit contact between attendees, the risk of spread, and state, local, territorial, or tribal health and safety laws, rules, and regulations.
• The locations attendees are traveling from – Higher levels of COVID-19 cases and community spread in the gathering location, or where attendees are coming from, increase the risk of infection and spread among attendees.
• The behaviors of attendees prior to the gathering – Gatherings with attendees who are not adhering to social distancing (staying at least 6 feet apart), mask wearing, hand washing, and other prevention behaviors pose more risk than gatherings with attendees who are engaging in these preventative behaviors.
• The behaviors of attendees during the gathering – Gatherings with more preventive measures in place, such as mask wearing, social distancing, and hand washing, pose less risk than gatherings where fewer or no preventive measures are being implemented.

US Emergency Sick Leave Act tied to reduced COVID-19 cases: The emergency sick leave provision of the Mar 18 bipartisan Families First Coronavirus Response Act (FFCRA) appears to have reduced the spread of the virus. A study published last Thursday found that states where workers could get up to 2 weeks of paid sick leave showed 417 fewer confirmed cases per day.

The Work From Home WorkSTEPS Medical Team:

Ben Hoffman, MD, MPH
Chief Medical Officer
‍

Tony Nigliazzo, MD
Medical Director
‍

Loraine Kanyare, MSN, MPH, RN
Director of Case Management
‍

Robert L. Levitin, MD
Physician Consultant
‍

Lynda Phillips, LVN
Nurse Case Manager
‍

Codey Church, LVN
Nurse Case Manager
‍

Kerry Womack, LVN
Nurse Case Manager
‍

Chuck Reynolds
Strategic Communications Consultant

‍

This Guidance (“Guidance”) is provided for informational and educational purposes only. It is not intended as Legal Advice or Medical Advice. Adherence to any recommendations included in this Guidance will not ensure successful diagnosis or treatment in every situation. Furthermore, the recommendations contained in this Guidance should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the medical condition. Similarly, this Guidance is based on current advice, comments, and guidance from the EEOC, CDC and the CMS made publicly available. The ultimate judgement regarding the propriety of any specific employment action must be made by the company and attorney in light of all of the circumstances presented by the company, state and federal rules existing at the time and the then current state of the National Pandemic. This Guidance and its conclusions and recommendations reflect the best available information at the time the Guidance was prepared. The results of future studies or changes in rules, regulations or laws may require revisions to the recommendations in this Guidance to reflect new data. WorkSTEPS does not warrant the accuracy or completeness of the Guidance and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Guidance or for any errors or omissions.

‍