Shelter-in-Place May Not Be Enough to Fight COVID-19, Says Former CDC Doctor

Is the U.S. doing enough to respond to the COVID-19 pandemic? To get some perspective on this question, as well as what to expect from hospitals and whether a vaccine may be available, GLG spoke with Dr. Ali Khan, Dean of the College of Public Health at the University of Nebraska Medical Center, a former Assistant Surgeon General, and former Director of the Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response. His responses below have been edited for length and clarity. With the news changing daily, Dr. Kahn does not endorse this article as up-to-date and accurate to the current situation. His original comments reflect personal opinions.

Can you give us a brief overview of the COVID-19 response measures implemented across the U.S.? Should there be a national order?

The various estimate I’ve seen is that anywhere between 70 and 150 million people in the United States currently have been ordered to stay home – that’s between 20% and 50% of Americans. The orders vary across the United States, including true shelter-in-place orders of “don’t leave for anything but food and medical reasons.” According to cell phone GPS data, there’s been a dramatic decline in people moving across the United States.

We now have a few hundred outbreaks in the U.S. because it’s being managed that way. Outbreaks are hard to predict; our administration is even harder to predict. But in terms of a national response, orders could be fine-tuned based on what’s happening in a community, if coupled with a national public health approach regarding cases and potential contacts. That’s the more critical issue right now. The bottom line: If there are cases in the community that are no longer being diagnosed and not being isolated, they’re just going to continue to create more cases. We’ve simply not learned the right lesson from China about how to respond to this outbreak. We need to layer on a set of public health measures to our national response. We need to do more than just shelter in place to really flatten this curve.

We’ve heard President Donald Trump mention Easter as an ideal date to loosen up the restrictions. What timeline seems realistic?

I look every day at the exponential rise in cases going on in a country to see how long it takes for it to round the bend. The exponential rise falling off seems to take 20 to 25 days in most countries. Even Italy, for example, seems to be rounding that bend right now. But what’s not clear is whether there’ll be a second wave. The second set of data to look at is the modeling data. I look at the data that comes out of Imperial College’s Neil Ferguson, which shows that we need three to five months of everything we’re doing currently if we expect to flatten the curve.

What country could the U.S. learn most from?

According to the World Health Organization, shelter in place isn’t enough to flatten the curve or as a mitigation of containment strategy. We cannot abandon public health measures that are necessary to get this outbreak under control. The Chinese have said the same thing, and we see these lessons in Singapore and in Taiwan. Both didn’t shut down. Early diagnosed cases must be pulled into isolation. High-risk contacts must be quarantined and actively monitored to make sure they’re not infecting other people.

These public health measures need to continue to be layered to influence the number of additional cases. Otherwise, social distancing helps for no other reason than if there are fewer people in contact with those who are sick, fewer new cases will be created. But new cases will still pop up because shelter-in-place policies are not 100% effective. If a sick person is still at home, they’ll spread it within that household.

What are the barriers in testing capacity to date, as well as what an idealized testing scenario looks like?

We have markedly increased testing in the U.S. Last I checked, 400,000 people were tested. That’s a big difference from two weeks ago. However, this is probably tenfold less than the testing we need to do. There are several actions going on across the U.S. to improve testing, including a new 45-minute test and new high-throughput testing. But not everybody can get tested – that’s unreasonable and we would never have the capacity to do that. Plus, it’s a false sense of security because if someone is negative today, it doesn’t mean they won’t be infected tomorrow. We need a good system in place to test who we think may be infected, then isolate them as necessary.

What are some of the limiting factors for healthcare system capacity? What happens if these institutions fail?

Most people recognize that the healthcare system functions like most systems in the U.S.: on a “just in time” basis – including the supply chain. There aren’t warehouses with all sorts of personal protective equipment (PPE) and ventilators sitting around in case they need them. There also aren’t warehouses of doctors, nurses, and empty beds. If 50,000 new patients are added to the system, that may be a challenge, even if elective and other surgeries are canceled. But our system is resilient enough to handle that and maybe even tens of thousands of people who need ICU beds and ventilators. But the primary issue is around PPE, since every hospital patient potentially carries coronavirus.

It comes down to our healthcare system’s structure and the choices we’ve made in responding to this outbreak. Singapore and other places designated hospitals for COVID-19 patients. When patients are screened well, there can be two streams of patients: those potentially with COVID-19 and those without. If medical professionals aren’t dealing with a COVID-19 patient, they can wear just the face mask and gloves.

Another challenge is heart attacks or births can’t be rescheduled. If all the beds and clinicians are occupied, what happens to patients with those conditions?

There’s a lot of potential drugs being investigated for treating COVID-19. What would an approved treatment mean for the spread of this disease?

Right now, there is no approved treatment, but having one could potentially mean two things. One is the number of people who need hospitalization and the number of people who could die would decrease. The other thing is a reduced number of people who are infectious, which could decrease new cases. That’s the strategy we have with HIV drugs. Lots of options out there are undergoing randomized clinical trials. Outside the U.S., there have been a number of broad-spectrum antivirals.

Preliminary reports suggest that the virus RNA might be stable and that this could be good news for vaccine development. However, a vaccine is at a minimum 12 to 18 months away. What’s the possibility of a vaccine for COVID-19?

There’s no guarantee we’ll ever get a vaccine – let’s be careful about saying when it would happen. One SARS vaccine was never developed because patients got worse when they took it. COVID-19 essentially is a new SARS, as both stem from coronavirus. We don’t know whether that’d be true for a new vaccine. I’m hopeful, but I also like to be realistic because there’s lots of diseases we’d like vaccines for that still don’t exist.

If people start to experience symptoms, what should they do?

This is a difficult question for a public health practitioner because 76% of people in America don’t live alone. If someone with symptoms lives with their grandparent or a family member with an immunocompromised condition, diabetes, liver failure, or congestive heart failure, that person may be at risk. The symptoms for most people are fever, dry cough, fatigue. The most concerning one is shortness of breath; depending on its severity, that would put a person into the moderate to severe case. In any case, if someone has symptoms, they should pick up the phone, call the health department, and say, “I think I may be infected. What should I do?”

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About Ali Kahn

Dr. Ali S. Khan is a retired Assistant Surgeon General and is the third Dean at the University of Nebraska Medical Center College of Public Health. He served at the CDC for 23 years as the Director of the Office of Public Health Preparedness and Response before retiring. While at the CDC, Dr. Khan led and responded to numerous high-profile domestic and international public health emergencies, including hantavirus pulmonary syndrome, Ebola virus disease, the Asian Tsunami (2004), and the initial public health response to Hurricane Katrina in New Orleans.

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This article is adapted from GLG’s March 23 teleconference “Preparing for COVID-19 – Former CDC Perspective.” If you would like access to this teleconference or would like to speak with Dr. Ali Khan or any of our more than 700,000 experts, contact us.

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