Aug. 10, 2020 -- The U.S. just sailed past the 5 million mark for confirmed cases of COVID-19. The coronavirus continues to spread in dozens of states. And Americans who’ve spent the last 4 months in various stages of lockdown are frustrated and exhausted.

“Where we are is the worst possible place right now,” says Jeffrey Shaman, PhD, a professor of environmental health sciences at Columbia University Mailman School of Public Health. “Unless we develop the collective will without the leadership of the federal government to control this, we're really in for a rough ride.”

Former FDA commissioner Scott Gottlieb, MD, says we could see 300,000 deaths by the end of 2020. “Right now, we have close to 1,000 casualties a day; so if we don’t change that trajectory, you could do the math and see where we are towards the end of the year,” he told CNBC.

Even though 5 million confirmed cases may seem like a huge number, it’s only 1.5% of the U.S. population. If the true number is 10 times higher, as research suggests, that still leaves plenty of room for the virus to spread. In order to reach herd immunity, where enough people have become immune to the virus to protect everyone else, we’d need more than 200 million people to be either infected or immunized.

Amesh Adalja, MD, a senior scholar at the Johns Hopkins University Center for Health Security, compares the situation to 2009’s H1N1 influenza pandemic, which infected 61 million Americans within a year. “This is an endemic virus, it’s not going anywhere. In the absence of a vaccine you’d expect a high percentage of the population to be infected. Everyone is susceptible,” he says.

There's Still Time

As dire as the situation feels, the country’s path isn’t set in stone. “It’s possible we’ll hit 10 million cases, but we’ve demonstrated it’s also possible to not hit 10 million. Game changers can happen. We already know a lot that we can do to prevent cases,” says Denis Nash, PhD, executive director of the CUNY Institute for Implementation Science in Population Health in New York. “I’m an optimist. I don’t think we have to accept we’ll hit 10 million.”

Shaman also believes we can change course. “All the tools we need to control this virus are out there,” he says. “Once it’s crushed, you can keep it down.”

A growing number of experts have renewed calls for a national response. Recently, more than 150 prominent medical experts sent a letter to the Trump administration, congressional leadership, and state governors. “Shut it down now, and start over,” the letter urged.

Among the measures those experts recommended:

  • Close all nonessential businesses.
  • Limit restaurants to take-out only.
  • Keep people home, going out only for food, medicine, and exercise.
  • Make masks mandatory, indoors and out, wherever we interact with others.

Those measures should be lifted -- and lifted slowly -- only when case counts are low enough for the country to effectively test and do contact tracing when someone tests positive, the letter said.

“Why not get it over with, pull the Band-Aid off fast?” says Shaman. “Do a 6-week lockdown and crush the virus down. Then, when you have it at really low levels -- under 500 cases a day in the U.S. -- reopen in an organized fashion.”

Many experts don’t feel a nationwide lockdown is necessary -- but a coordinated national response is. At the end of July, the Johns Hopkins Bloomberg School of Public Health Center for Health Security issued a report, “Resetting Our Response: Changes Needed in the US Approach to COVID-19.”

coronavirusgraphicstatefederal-1It says, “The COVID-19 pandemic is a challenge far beyond what any 1 state, territory, or community can handle alone. It is only our collective action that will generate the change necessary to regain control of this epidemic, avoid cascading crises in our healthcare system and economy, and save great numbers of lives throughout the United States.”

The report calls for stay-at-home orders “where healthcare systems are in crisis,” mandated masking, and restrictions on indoor gatherings. Where the virus is surging, it recommends closing high-risk indoor settings like bars, restaurants, entertainment venues, gyms, religious spaces, and offices that can’t effectively manage the risk.

The Association of American Medical Colleges, a nonprofit organization of medical schools and teaching hospitals, issued its own report calling for a national response, “The Way Forward on COVID-19: A Road Map to Reset the Nation’s Approach to the Pandemic.” Among its recommendations: Establish national standards on face coverings, stay-at-home orders, and reopening protocols for businesses and schools.

Right now, 37 states have positivity rates above 5%, which means that for every 100 tests, at least 5 people have tested positive. Nationally, the rate stands at 7.5%. The World Health Organization recommends keeping a locale’s economy closed until the rate drops below 5%.

The Need for Improved Testing

All these experts also call for the country to improve testing as quickly as possible. Right now, shortages in testing supplies and lab capacity have led to a massive backlog. That means some people are waiting a week or more for their results. If they’re not showing symptoms, they could be spreading the virus while they wait.

“Tests are useless if they’re not actionable,” says Adalja. “These outpatient tests that take 8 days to come back are worthless.”

On July 22, the National Institutes of Health announced an “unprecedented effort” to create rapid-results tests. They aim to have 6 million daily tests available by December. Now, we’re doing only around 767,000 tests per day on average, roughly 43% of the number experts say we need to control the spread of the virus.

Until we have enough supplies and testing, the backlog will persist if we don’t prioritize testing, Adalja says. “For example, someone who has to get a test because their boss is making them versus someone who actually has symptoms,” he says. “If those get treated the same way in terms of how quickly they’re run, we need to come up with a prioritization strategy.”

The other challenge still facing us: contact tracing, which seeks to track down all the people who were in close contact with someone who has newly tested positive. In areas where the virus is spreading widely, contact tracers can’t keep up with the demand. But countries like South Korea, which has managed to control the virus, can do extensive tracing.

In June, CDC Director Robert Redfield told Congress the country would need 100,000 contact tracers in order to track the spread of the virus. At the time, he estimated we had around 28,000. Without a national effort, each state handles its own tracing programs, so there’s no current, official tally.

“Contact tracing is just not feasible or effective in situations where there's a lot of spread happening. Assuming that every jurisdiction can eventually get to a place where they have reduced spread to a manageable level, you’re going to need contact tracers,” says Nash. “There’s no reason why the country can’t start planning, even though they can’t use them right now.”

Treatments and Vaccines

Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, says there’s a chance we’ll have a vaccine by November, according to The New York Times. But even if that happens, an approved vaccine may not put an end to the crisis. In a WebMD reader poll, less than half the respondents said they’d get a vaccine within the first year that it’s out -- and less than one-third would do so in the first 3 months. Another poll, from Morning Consult/Politico, found that nearly two-thirds of Americans say a vaccine should be fully tested before being released, even it if means a delay.

“The reality is, this is a very rushed production of a vaccine,” says Shaman. “If we get a vaccine and it seems to be effective and it tests through safe in a clinical trial, that’s great, but nobody’s had the time to look at the long-term consequences of the vaccine.”

Given both the hesitation and the potential production issues involved with producing enough vaccines for everyone who wants one, it seems likely to take some time to reach herd immunity.

“I do think a vaccine will be a game changer,” says Nash. “But since a vaccine will not be 100% effective -- they never are -- if herd immunity comes at 70% of the population being immune, we’ll probably need to vaccinate 80 to 85%, depending on how effective it is.”

If a vaccine won’t be a quick fix, finding effective treatments would help in the meanwhile. There are some promising treatments, including remdesivir. The drugmaker, Gilead, recently announced that a trial found it lowered mortality risk by 62%. It wasn’t a randomized controlled study, considered the gold standard, but the results are promising, says Shaman.

“We’d really like something that’s even more effective,” he says. “If you have a treatment, it would be great if it’s 90% effective or higher. At that point, you’re looking at something that maybe lets us go back to where we were.”

Some steroids are also proving useful in certain severe cases, and there are numerous trials taking place for other options, but as of now, we still don’t have a cure.

The Personal Approach

Even without government restrictions, there’s plenty each of us can do to help stop the spread. If you have to leave home, take into account the level of community transmission where you are. In areas where the virus is surging, the local government may not have called for an official lockdown. But if your circumstances allow for it, stay home as much as possible.

You may need to work, go shopping, or see family, but you can still take precautions:

  • Before going out, weigh the risks: How necessary is this trip? Are you or a member of your household at high risk for a severe case? What precautions are they taking at the place you’ll be visiting? Will you be able to stay 6 feet away from other people?
  • Wear a mask indoors, even if you’re 6 feet from others. Evidence is growing that the virus can remain in the air for much longer than we first thought.
  • Shop online as much as possible, but if you do go in person, schedule your trips for less crowded times. If a store feels too crowded or people aren’t wearing masks, leave. Carry hand sanitizer with you, if possible, and wash your hands as soon as you come home.
  • Consider forming a COVID bubble with another family whose precautions match your own. Socialize only with them.
  • Don’t eat in restaurants where there are widespread cases -- opt for delivery or takeout. If things are calmer where you are, check the restaurant’s prevention practices before you go, and choose outdoor dining. Keep your mask on the whole time, except for when you’re eating. Avoid dining indoors. “Indoors is much worse than outdoors,” Fauci told MarketWatch. “If you’re going to go to a restaurant, try as best as you can to have outdoor seating that is properly spaced between the tables.”
  • Don’t go to bars. Period. Alcohol loosens inhibitions, which can lead to loosened social distancing measures.

The Importance of Masks

When you go out, always wear a mask. It protects those around you -- and may also protect you. On Meet the Press, Adm. Brett Giroir, MD, assistant secretary for health at the U.S. Department of Health and Human Services, said, “Wearing a mask is incredibly important, but we have to have like 85% or 90% of individuals wearing a mask and avoiding crowds.” Doing so “gives you the same outcome as a complete shutdown.”

“Individually, people need to accept masks as a way of life,” says Shaman. “This is not about civil liberties, it’s about the safety of those around you. It’s akin to not wearing a seatbelt, or putting up your tray table on an airplane. These are protocols designed to keep you and those around you safe.”

Without a mandate or leadership at the national level, it may be impossible to convince mask naysayers that they’re necessary -- until the coronavirus hits close to home. “Unfortunately, many people need to believe that it could really happen to them and their community before they’ll change their behavior,” says Nash.

“Core issues of American identity seem to be at the center of this,” he says. “We’re a very individualistic nation -- we tend to care about the rights of the individual over the collective good. That’s always been at the core of our identity, and in public health crises, it’s going to be our downfall.”

Show Sources

Jeffrey Shaman, PhD, professor, environmental health sciences, and director, Climate and Health Program, Columbia University Mailman School of Public Health.

Denis Nash, PhD, executive director, CUNY Institute for Implementation Science in Population Health; distinguished professor of epidemiology, CUNY School of Public Health.

Amesh A. Adalja, MD, senior scholar, Johns Hopkins University Center for Health Security.

CNBC: “Dr. Scott Gottlieb: U.S. coronavirus deaths could reach 300,000 by year-end if trends continue.”

CNN: “Shut down the country and start over to contain Covid-19, US medical experts urge political leaders.”

Johns Hopkins University of Medicine: “Which States Meet WHO Recommended Testing Criteria?”

CDC: “COVIDView: A Weekly Surveillance Summary of U.S. COVID-19 Activity, week 30.”

NBC News: “COVID-19 tests: There's an insurmountable backlog of virus tests. A rapid test could help.”

National Institutes of Health: “NIH leadership details unprecedented initiative to ramp up testing technologies for COVID-19.”

The New York Times: “Is Your State Doing Enough Coronavirus Testing?” “Large vaccine trials begin in the U.S.,” “Masks May Reduce Viral Dose, Some Experts Say,” “A Viral Epidemic Splitting Into Tiny Pieces.”

The Hill: “CDC director: US has about 28,000 contact tracers, needs 100,000,” “GOP, Democratic relief packages $16B apart on vaccine funding.”

Time: “The Company That Makes Remdesivir Says It Considerably Reduces COVID-19 Deaths.”

MarketWatch: “Dr. Fauci tells MarketWatch: I would not get on a plane or eat inside a restaurant.”

NBC News: Meet the Press.

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