A Message on COVID-19 from WorkSTEPS Chief Medical Officer Dr. Ben Hoffman
Looking Back, Looking Forward
I just looked back at the titles of the 50+ Covid-19 Briefs we published since early February, 2020. The review reinforced my feelings after nearly 11 months working to help companies operate safely in the midst of a pandemic – feelings of exhaustion, satisfaction, dread and optimism.
- Exhaustion, because this has been hard for all of us. We’ve had to learn about the virus; formulate, implement and enforce strategies to help keep people safe while enabling business operations to continue; and continually adjust and update the strategies and tactics as new insights about the virus and prevention measures emerged. And, all this has been done in an environment where the aims of public health and economic prosperity have been over-simplified, politicized and pitted against each other!
- Satisfaction, for two reasons. First, we never strayed from our goal of helping businesses balance operational demands with health concerns. Essential businesses did not have the option of closing down; they had to figure out how to operate safely. I think we’ve helped them do that. Second, as bad as things have gotten, they could have been a lot worse. Working with people like you and businesses like yours, we’ve contributed to making workplaces that are often safer than environments employees face in the community or even in their own homes.
- Dread, simply because – even with vaccines beginning to offer protection – this is far from over. Our desire to move on from this pandemic is in conflict with the reality of how long it will take for the promise of vaccines to become the reality of a return to normalcy. There is a lot of heavy lifting yet to be done, and the cultural and political climate is likely to continue making things harder and more complicated than need be.
- Optimism, because if ever the interests of people, businesses and governments were aligned, they are aligned to return to a more normal life. As much as the past year has provided evidence to the contrary, I guess you could say I have faith that enough people will do the right thing in the year ahead to enable us to emerge from this crisis.
Whatever you are feeling as 2020 comes to a close, I hope you feel appreciated for what you’ve done. The work of keeping people safe has been pretty thankless. But, because of the nature of Covid-19 – how easily and stealthily it spreads, and how deadly it can be – there is little doubt that the prevention measures you put in place spared many from illness and saved some from death. I hope you let that truth settle in, and that you can use it to energize you for the work that lies ahead.
We enter 2021 hopeful. I speak for the team at WorkSTEPS in promising that we will strive to continue being a source of credible information and useful insights to help you navigate through the challenges to come.
Happy holidays, and our wishes for a safe, healthy and prosperous New Year!
Ben Hoffman, MD, MPH
Chief Medical Officer, WorkSTEPS
For more from Dr. Hoffman, connect with him on LinkedIn.
Medical
National: Case numbers remain about as high as they have ever been. However, the country is no longer seeing explosive growth, and many states are improving. Deaths continue to increase. California is however experiencing a dramatic outbreak; the state added more than 300,000 cases in the seven-day period ending Dec. 22. This record-shattering increase in coronavirus cases has wiped out intensive care unit capacity in a large part of the state. Over the Christmas week Central and Southern California reported 0 percent I.C.U. capacity. Southern California, its most populous region, and San Joaquin Valley, a central region, have 0 percent I.C.U. capacity, keeping them under a stay-at-home order until at least Dec. 28, the California Department of Public Health said on Saturday. The Upper Midwest has continued to make progress. North Dakota, which a few weeks ago was averaging 1,400 cases daily, was below 300 on many recent days. Florida was averaging 11,000 cases a day as of Dec. 22; Miami has persistently high numbers, and there have been upticks around Jacksonville, Tampa and Pensacola.
Global: At least 412,000 more people have died during the coronavirus pandemic than the official Covid-19 death counts report, a review of mortality data in 35 countries shows — providing a clearer, if still incomplete, picture of the toll of the crisis. Canada, France, Japan, Norway, Spain and Sweden have reported small numbers of infections involving a new variant of the virus, most of them linked to travel from Britain. The strain appears to be more transmissible but not more deadly or resistant to vaccines.
The coronavirus at 1yr: A year into the pandemic, what scientists know about how it spreads, infects, and sickens: A year into the pandemic, STAT is outlining a portrait of SARS-CoV-2 based on what scientists learned as the virus raced around the world, crippling some economies, societies, and health systems in its wake. How the virus cracks open cells and wards off the body’s first-line attack. How it can spread before people start feeling sick. How it’s changed since the dawn of the pandemic, and what, if anything, that means. How the voraciousness of the disease it causes, called Covid-19, reaches not just the lungs but into the heart, brain, gut, and beyond.
Covid-19 Aid and Omnibus relief package: On Sunday, Pres. Trump signed a $900 billion pandemic relief package that will deliver long-sought cash to businesses and individuals. The deal also provides $1.4 trillion to fund government agencies through September and contains other end-of-session priorities such as an increase in food stamp benefits. The COVID-19 relief bill provides $600 checks to most Americans. The bill also includes unemployment benefits and relief payments to families, money for vaccine distribution, businesses, and extends an eviction moratorium that was set to expire this week and more.
Selections from the year in review: Things to remember
Clinical symptoms among ambulatory patients tested for SARS-CoV-2: A CDC study published in late November reported wide overlap between symptoms of COVID-19 and those of other respiratory illnesses. The researchers studied a total of 4,961 patients, 916 tested positive for SARS-CoV-2 via PCR, and 4,045 had respiratory symptoms but tested negative for the virus. Cough was the most common symptom in both SARS-CoV-2–positive and negative patients (86% and 83%). Shortness of breath was reported less often by those with COVID-19 than without (40% vs 47%), and 99% of patients reported fever and/or cough. 59% of persons with COVID-19 versus 19% of persons without COVID-19 reported diminished taste or smell. Generalized symptoms (muscle aches or headache) and gastrointestinal symptoms (vomiting, diarrhea, or abdominal pain) were more common among persons with COVID-19 (91% and 57%) than among those without COVID-19 (83% and 50%). Because of the wide overlap in COVID-19 symptoms with those of other respiratory illnesses, laboratory confirmation of SARS-CoV-2 infection will be key especially for assessing the effectiveness of interventions during periods of co-circulation of COVID-19 and other respiratory illnesses, including influenza.
Long-term Health Consequences of COVID-19: The clinical spectrum of SARS-CoV-2 infection ranges from asymptomatic infection to life-threatening and fatal disease. Current estimates are that approximately 20 million people globally have “recovered”. However, clinicians are observing and reading reports of patients with persistent severe symptoms and even substantial end-organ dysfunction after SARS-CoV-2 infection. Because COVID-19 is a novel disease, the long-term clinical effects of the disease remains uncertain.
The term “herd immunity” is widely used but carries a variety of meanings. Some authors use it to describe the proportion of immune among individuals in a population. Others use it with reference to a particular threshold proportion of immune individuals that should lead to a decline in incidence of infection. Still others use it to refer to a pattern of immunity that should protect a population from invasion of a new infection. A common implication of the term is that the risk of infection among susceptible individuals in a population is reduced by the presence and proximity of immune individuals (this is sometimes referred to as “indirect protection” or a “herd effect”). We provide brief historical, epidemiologic, theoretical, and pragmatic public health perspectives on this concept.
Mitigation / Suppression
US Vaccine Distribution & Administration: On December 11-12, the US Advisory Committee on Immunization Practices (ACIP) met to approve its interim recommendations for use of the Pfizer/BioNTech SARS-CoV-2 vaccine, following the FDA’s issuance of an EUA. The content of the recommendations, published in the US CDC’s MMWR, provide an update to the initial interim guidance published on December 3. ACIP also updated the underlying evidence considered in developing the recommendations. ACIP recommended that the vaccine could be administered to those aged 16 years or older in the US, and that two doses should be administered 21 days apart. ACIP previously also stated that initial doses should be prioritized for healthcare personnel and long-term care facility residents in the first tier of recipients. Notably, the EUA included a provision for pregnant women to potentially be immunized.
Here’s Why Vaccinated People Still Need to Wear a Mask: The new vaccines will probably prevent you from getting sick with Covid. No one knows yet whether they will keep you from spreading the virus to others — but that information is coming.
Summary of Guidance for Public Health Strategies to Address High Levels of Community Transmission of SARS-CoV-2 and Related Deaths, December 2020: COVID-19 pandemic control requires a multipronged application of evidence-based strategies while improving health equity: universal face mask use, physical distancing, avoiding nonessential indoor spaces, increasing testing, prompt quarantine of exposed persons, safeguarding those at increased risk for severe illness or death, protecting essential workers, postponing travel, enhancing ventilation and hand hygiene, and achieving widespread COVID-19 vaccination coverage. These combined strategies will protect health care, essential businesses, and schools, bridging to a future with high community coverage of effective vaccines and safe return to more activities in a range of settings.
Effects of Cocooning on Coronavirus Disease Rates after Relaxing Social Distancing: CDC provides emerging evidence to protect those who are vulnerable through “Cocooning”. As restrictions wax and wane, we need to protect those who are at highest risk: elderly, immunocompromised, etc. This is similar to the UK approach to COVID-19. Cocooning involves incentivizing persons with high-risk underlying conditions to remain at home, helping persons experiencing homelessness to social distance, and broadly encouraging hand hygiene and wearing face masks for persons at high risk for severe illness or death and their caregivers.
Revisiting Swiss Cheese model of pandemic defense: Virologist Ian Mackay created an easy-to-grasp metaphor retooled from a similar model in aviation safety. We shared this in our brief a few weeks ago but it is worth repetition with vaccine administration on the horizon. Multiple layers of protection, depicted as cheese slices, block the spread of SARS-CoV-2, the virus responsible for Covid-19. No one layer is perfect; each has holes, and when the holes align, the risk of contracting the disease increases. Several layers of defense combined – social distancing, and masks, and handwashing, and testing and tracing, and ventilation, and government messaging – significantly reduce the overall risk. The new vaccination will add one more protective layer.
CDC Guidance for Expanded Screening Testing to Reduce Silent Spread of SARS-CoV-2: To reduce SARS-CoV-2 transmission, jurisdictions should consider expanding testing of persons without symptoms (with and without known exposure) to reduce asymptomatic (silent) spread in addition to comprehensive community-wide mitigation efforts and testing of individuals with symptoms consistent with COVID-19. All communities should test close contacts of cases (e.g., depending on case burden and available resources; close contacts should be tested immediately after identification as a contact, and if negative, could be tested again about 5-7 days after last exposure or immediately if symptoms develop during quarantine), and consider implementing a tiered approach to expand testing similar to the guidance for institutions of higher education, high-density critical infrastructure workplaces, select non-healthcare workplaces, and healthcare personnel. This testing will not reduce the 14-day quarantine of close contacts.
Corporate
Worker Safety: The safety of frontline and essential workers, particularly those with roles that cannot be performed remotely, remains a major area of concern for employers and policymakers. The US Occupational Safety and Health Administration (OSHA) has been criticized on multiple fronts for not taking sufficient action to protect worker safety during the COVID-19 pandemic. While OSHA has the ability to raise standards for occupational safety, a federal appeals court recently sided with OSHA’s stance that an emergency temporary standard was not necessary. Since then, many state and local governments implemented their own temporary workplace standards that include enhanced measures beyond those required by OSHA. State-imposed requirements include improved indoor ventilation, increased physical distancing between employees, and routine diagnostic testing. This state-by-state approach to worker safety has created a patchwork of regulations across the US.
Survival on Surfaces: While respiratory transmission is generally understood to be the primary driver of the COVID-19 pandemic, a study published in the journal Virology has raised new concerns for fomite transmission. Researchers from the Commonwealth Scientific and Industrial Research Organization at the Australian Centre for Disease Preparedness analyzed the survival of SARS-CoV-2 virus on various surfaces under controlled laboratory conditions. They found wide variations in survival time based on surface type and temperature. Most notably, infectious virus survived on glass, stainless steel, and paper and polymer bank notes (i.e., paper currency) for at least 28 days at 20°C (68°F). In contrast, viable virus was detected on cotton cloth after only 14 days. As temperature increased, the survival time of infectious virus decreased. At 40°C (104°F), infectious virus lasted less than 24 hours on cotton and less than 48 hours on all other surfaces.
Holiday celebrations: In November, 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.
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
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.
