A Message on COVID-19 from WorkSTEPS Chief Medical Officer Dr. Ben Hoffman:
Ignore the Chatter and Keep Your Eye on the Ball
Science made some high-profile unforced errors in the past couple of weeks.
First was the hydroxychloroquine debacle, and then this week the World Health Organization indicated that asymptomatic and pre-symptomatic transmission of COVID-19 is very rare, only to walk those comments back the next day. And all that transpired just days after the WHO joined the CDC and others in finally recommending that “The general public should wear non-medical masks where there is widespread transmission and when physical distancing is difficult.” – a change in guidance based in part on concerns that people who are asymptomatic or pre-symptomatic can still spread COVID-19.
These events are troubling enough on their own, but their significance is greatly magnified by the fact that they provided anti-science media personalities and outlets with rocket fuel to launch stories aimed at discrediting scientific data and evidence-based policies focused on preventing the spread of disease and death.
And, while the attention of our nation has understandably turned to the killing of George Floyd and related protest marches and riots, the recent loosening of restrictions in many states has resulted in a predictable rise in Covid-19 cases and eruption of Covid-19 hot spots in many parts of the country. In much of the country, the problem is getting worse!
Batter Up
As a professional who is tasked with protecting employee and customer health while your company ramps up operations and returns people to work, you’re like a batter at the plate. Your goal is to connect with the ball – to implement policies and practices that are effective because they’re based on facts about COVID-19 and evidence about how to mitigate its spread.
That’s tough enough, but your job is made harder by all the distractions trying to get inside your head – the distracting chatter of the catcher, jeers from the crowd and doubts in your own mind about whether you’re doing the right things.
Keep Your Eye on the Ball
This moment is a test of focus and leadership strength. In the midst of distractions and conflicting demands, you need to focus your organization on what matters and commit people down and across the organizational chart to comply with policies and practices that will help your business reopen and recover without compromising the health of your people and your customers.
Here are some best-practice tips to help you (and your organization) keep your eye on the ball:
- Position your COVID-19 strategy as a critical enabler of returning people to work and resuming/accelerating operations. Despite our country’s psychological pivot to re-opening, the threat of a COVID-19 outbreak remains and is higher than ever in some places. An outbreak can be very disruptive to business and damaging to employee morale and customer goodwill. Your prevention strategy is not an impediment, but an enabler of a return to robust business activity.
- Be able to explain the evidence-based rationale for your policies and practices. Having a firm evidence base will enable you to not only explain the policies and practices you have in place, but to know how best to adapt policies to accommodate operational realities. Understanding your evidence base will also enable you to defend against the whims of news cycles that can threaten to distract your organization from focusing on what needs to be done to protect worker and customer health.
- Provide accurate, timely and location-specific updates on the COVID-19 threat. Improvements in testing capacity have led to more accurate and timely localized reporting. Use county-level data to keep key company stakeholders up to date on threat levels around your different locations and build in systems to alert leaders and to tighten policy compliance when threat levels are rising. Useful county-level data and trend graphics are available from Johns Hopkins and The New York Times.
- Monitor your strategy and be proactive about policy changes. The pandemic is far from over, and we will be continually learning about how to best protect people from disease and prevent disruptive outbreaks. New insights may imply doing more of some things and less of others. Being on top of changes will enable you improve the efficiency and effectiveness of your strategy by focusing your organization on doing only what matters.
From early on in this crisis, our goal with this newsletter has been to provide you with the information and insights you need to develop, implement and regularly update your COVID-19 strategy and related prevention policies and practices. If you’d like to learn more about our COVID-19 services, click here.
And don’t hesitate to let us know if there is a COVID-19 question you have or topic you’d like to see addressed in this brief.
Be well and stay safe.
Ben Hoffman, MD, MPH
Chief Medical Officer, WorkSTEPS
For more from Dr. Hoffman, connect with him on LinkedIn.
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Medical:
COVID-19 cases surged globally as many reopen their economies. In the U.S. cases seem to be easing in previous hotspots like New York City and taking hold in less dense areas of the country. 20 states and Puerto Rico have seen an increase in their reported number of cases in the past two weeks: Alaska, Arizona, Arkansas, California, Florida, Hawaii, Idaho, Kentucky, Missouri, Montana, New Mexico, North Carolina, Nevada, Oregon, South Carolina, Tennessee, Texas, Utah, Vermont and Washington. Unlike in the early days of the pandemic, it is not so simple to say that big cities have been hit hardest. On a per capita basis, the places with the most cases have been small cities and rural communities in the Midwest and South. The biggest known outbreaks have been in nursing homes, food processing plants and correctional facilities, all places where social distancing is difficult.
More than 7 million cases of COVID-19 and over 400 000 deaths have now been reported to WHO. Although the situation in Europe is improving, globally it is worsening. On Sunday, more than 136 000 cases were reported, the most in a single day so far. In countries seeing positive signs, the WHO Director-General warned in his media briefing yesterday ‘the biggest threat now is complacency’.
Pediatric Multisystem Inflammatory Syndrome
Two recently published studies provide new analysis of pediatric multisystem inflammatory syndrome (PIMS) associated with COVID-19 in children. The first study, published in Eurosurveillance, describes the results of a nationwide surveillance effort in France conducted March 1-May 7. The researchers identified 156 potential cases of PIMS over that period, including 79 confirmed, 16 probable, and 13 possible cases (48 were ruled out based on the study’s case definition). The PIMS incidence in France peaked several weeks after the national COVID-19 peak, which suggests that PIMS may be a “post-infectious manifestation” of COVID-19, and the geographic distribution of PIMS cases largely correlated with COVID-19 incidence. Based on a maximum estimated COVID-19 incidence in French children (defined as those under the age of 15) of 5%, the researchers estimate the risk of PIMS to be fewer than 2 cases per 10,000 children.
The second study, published in The BMJ, looked at the clinical presentation of PIMS in Paris, France. The prospective study identified 21 PIMS patients in Paris between April 27 and May 11. Of these children, 12 presented with Kawasaki disease, and 16 presented with myocarditis. Among these patients, 9 reported previously experiencing “viral-like symptoms” (e.g., fever, headache), and the mean duration between these symptoms and the onset of Kawasaki disease was 45 days. In total, 8 (38%) of the PIMS patients tested positive for SARS-CoV-2 infection during the study, and only 1 had symptoms consistent with COVID-19 during the study. In contrast, 19 of the 21 (90%) patients tested positive for IgG antibodies, indicating prior infection. The delay following viral symptoms and the prevalence of IgG antibodies relative to active infection further support the idea that PIMS is a post-infectious manifestation of COVID-19. The researchers also observed disease severity in these patients, with 17 (81%) of them requiring intensive care and 11 (52%) requiring mechanical ventilation. Notably, 57% of the patients were of African ancestry, but further data and analysis are needed to characterize any potential association.
Lancet, New England Journal Retract COVID-19 Studies, including one that raised safety concerns about malaria drugs (STAT News). The Lancet, one of the world’s top medical journals, on Thursday retracted an influential study that raised alarms about the safety of the experimental COVID-19 treatments chloroquine and hydroxychloroquine amid scrutiny of the data underlying the paper. Just over an hour later, the New England Journal of Medicine retracted a separate study, focused on blood pressure medications in COVID-19, that relied on data from the same company.
On Tuesday, experts at the WHO walked back a previous assertion that transmission of the virus by people who did not have symptoms was “very rare.” The original comment at a WHO briefing on Monday, said that it was based on just two or three studies and that it was a “misunderstanding” to say asymptomatic transmission was rare globally. Studies have estimated asymptomatic spread could be responsible for 40 percent of the transmission; the current best estimate from the CDC is 35 percent. This research prompted many countries, including U.S to endorse universal mask use for everyone.
Mitigation / Suppression :
Social Distancing Impact
Two new articles were published in Nature today that describe the effects of social distancing and other interventions on the COVID-19 pandemic. One article used data from 1,717 different interventions at the local, regional and national level in the United States, France, Iran, Italy, South Korea, and China. They concluded that interventions in these countries may have prevented 62 million confirmed COVID-19 cases worldwide, which corresponds to an estimated 530 million total SARS-CoV-2 infections. These include 4.8 million confirmed cases (60 million infections) in the United States alone.
The other article focused on interventions in Europe through May 4, 2020, when some countries began to relax national social distancing measures. Considering available data from serological studies, the researchers estimated the true number of infections in order to evaluate the effects of social distancing policies on transmission and mortality. This study found that nonpharmaceutical interventions, including national “lockdowns,” could have averted approximately 3.1 million COVID-19 deaths across 11 European countries.
Experts are concerned that the public has hit a coronavirus fatigue as the U.S. continues to reopen the economy and protesters hit the streets to demand justice. CDC director Dr. Redford verbalized concern to congress that the agency’s public health message is not resonating. The top U.S. infectious disease expert, Dr. Fauci, communicated a bleak assessment of COVID-19 spread and devastation around the world describing it as his “worst nightmare”. “In a period of four months, it has devastated the whole world,” Dr. Fauci said. He attributed the rapid spread to the contagiousness of the virus and extensive world travel by infected people.
US Remdesivir Supply
The U.S. government is coordinating with Gilead Sciences to facilitate increased production and distribution of remdesivir, the only drug that has been demonstrated to provide treatment benefit for COVID-19 patients in a randomized clinical trial. Gilead previously donated its available remdesivir inventory to the US government; however, this supply is expected to be exhausted by the end of June.
A Combination of Research and Practice: PCR testing is a valuable asset in the COVID-19 fight. But it must be used and interpreted correctly. Repeat PCR testing after a positive test has very little utility and does not indicate any clinical status. Misuse may cause unneeded prolonged quarantine and prolonged furlough.
Corporate:
WHO Updates Mask Guidance
The WHO released updated guidance on mask usage last Friday, including information on who should use a mask and when masks should be worn, as well as the materials or type of mask that should be used. The new recommendations deviate from previous guidance in a few key areas, particularly for areas experiencing widespread SARS-CoV-2 transmission. The WHO now recommends that masks be worn by all health personnel seeing patients in areas of widespread transmission, not just clinicians treating COVID-19 patients. In areas experiencing community transmission (a step below widespread transmission), individuals at elevated risk of severe COVID-19 disease or death, including those over the age of 60 or those with underlying health conditions, should wear medical masks whenever physical distancing from other people is not possible. The general public should wear masks in crowded areas when physical distancing from other people is not possible in areas experiencing widespread transmission.
FDA Reissues Emergency Use Authorizations Revising Which Types of Respirators Can Be Decontaminated for Reuse. In response to public health and safety concerns about the appropriateness of decontaminating certain respirators, the agency is reissuing certain emergency use authorizations to specify which respirators are appropriate for decontamination. Based on the FDA’s increased understanding of the performance and design of these respirators, the FDA has decided that certain respirators should not be decontaminated for reuse by health care personnel. (FDA, 6/7/20)
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.
