Just one day after the World Health Organization designated the novel coronavirus outbreak a pandemic and one day before President Donald Trump declared a national emergency in the United States, the Boston University School of Public Health (SPH) convened experts in infectious disease, public policy, and ethics and human rights to discuss everything that's known about the illness that's come to be known as "COVID-19"-and what needs to happen next to stop its spread.
The March 12 open seminar, organized by SPH dean Sandro Galea, took a scientific approach to understanding the rapidly spreading respiratory virus that has drastically upended life in the United States and around the globe. Total worldwide cases have surpassed 125,000, and more than 4,000 people have died, sparking widespread school closures, major public event cancellations, economic uncertainty, and fear and confusion about how to physically and financially adjust to the threat.
"When such challenges emerge, it's important to take a measured approach, guided by data, and working with our best scientists and scholars," said Galea, who is chair of Massachusetts' statewide Emergency Task Force on Coronavirus & Equity. "Now is the time for public health to provide leadership and clarity."
The seminar gathered together experts from across BU and the city of Boston, including Ronald Corley, director of the BU National Emerging Infectious Diseases Laboratories (NEIDL); Nahid Bhadelia, medical director of the Special Pathogens Unit at Boston Medical Center and director of infection control at the NEIDL; Rita Nieves of the Boston Public Health Commission; Davidson Hamer, an SPH professor of global health; and Wendy Mariner, a BU expert on health law, ethics and human rights.
Corley and Hamer untangled the details on what scientists know-and don't yet know-about the new strain of coronavirus. Similar to the 2003 SARS and 2012 MERS coronaviruses, evidence strongly suggests the novel coronavirus (SARS-CoV-2) that causes COVID-19 originated from bats and possibly spread to humans through pangolins, a mammal native to China-but the most recent research on this zoonotic pathway is still inconclusive, said Corley. What is clear is that novel coronavirus cases accelerated almost four times as fast as SARS due to the former's high viral load.
"There's a chance that this virus actually is more transmissible early on, even when people are asymptomatic, which is one of the major concerns," said Corley. He said many questions remain: What factors create immunity following infection? Can we find biomarkers to test for predicted disease outcomes early in infections? What are the best models to test the most promising therapeutics and vaccines that researchers are racing to identify? How can the global community become more proactive in its response to the next virus?
Hamer also expressed concerns about the unknowns around this virus, including potential asymptomatic transmission.
"That's worrisome," he said. "If someone doesn't have symptoms and they go through airport-based or other forms of public screening, they may not have any symptoms to complain about," which could lead to asymptomatic transmission. He said most studies suggest the virus is fairly infectious, and warned, "If there aren't control measures, it could lead to a virus running through a community where as many as half to two-thirds of a population becomes infected."
Nieves said Boston-a city of 695,000 residents that balloons daily to 1.2 million when including commuters and visitors-began developing a thorough preparedness plan, statewide testing abilities, and an extensive public health infrastructure weeks before the city identified its first confirmed novel coronavirus case at the beginning of February. The city has also identified 18 presumptive coronavirus cases, all linked to a Biogen conference on March 6.
"We were among the first five cities to get a case," said Nieves. "Since February 28, the Department of Public Health has [been] testing for COVID-19 at the state laboratory, and that has really made a difference for us."
Bhadelia, who specializes in infection control of communicable diseases and treated patients in Sierra Leone during the West African Ebola epidemic, described the inevitable burden that the American healthcare system will grapple with if coronavirus cases continue to increase at exponential rates.
"In every epidemic, healthcare workers become the linchpin; they're the interface between the community and the hospital," said Bhadelia. "We're a population that is existing with everyone else in the community, so we are dually at risk." When healthcare workers develop disease symptoms and are forced to stay home, the workload worsens for the remaining clinicians and patients, she said.
"At any given time in Massachusetts, there are about 3,000 to 4,000 hospital beds open, at most," Bhadelia said. Citing epidemiologic predictions that 40 to 70 percent of the population could contract the virus, she said, "If you start doing the numbers, you quickly realize we do not have anywhere near the capacity to take care of tens of thousands of COVID-19 patients who might need hospitalizations at the same time."
Furthermore, she said, healthcare workers are facing public health challenges beyond initial care of patients who contract the virus. What happens when high-risk patients don't have a stable home to return to after they're discharged? Or what happens if they must return to a household with more vulnerable family members? What is the return-to-work policy for healthcare workers?
"In the end, my thoughts are that this illness will be mild," she said. "But we want to protect those within our community. And that's where personal responsibility and preparedness come into play."
Mariner brought up the burden that quarantines place on employed patients.
"People need resources that make it possible to comply with reasonable public health recommendations," she said, explaining that three policy and legal issues need to be addressed: financial protections, health services and health insurance, and community and social services.
"Social distancing is a wonderful recommendation, but not everyone can afford to stay home from work, especially those who live at the poverty level or paycheck-to-paycheck," said Mariner, noting that only 10 states and the District of Columbia require paid leave for workers. Massachusetts allows 40 hours of paid sick leave, but that is not even half of the mandatory 14-day quarantine required for anyone exposed or potentially exposed to the virus. She suggested new policy changes that would suspend expenses, such as rent or utility payments, could also help ease the burden on people.
She also noted the need for greater testing capacity that would clarify quickly whether a patient requires additional medical care or could be sent home.
"The FDA does have authority to rapidly approve new tests that are developed by state and private entities and they can do that fairly quickly," Mariner said. "Although they did not do so originally, they are working on it now." She also said that Medicaid eligibility requirements should be waived to ensure that the most vulnerable populations have access to preventive care.
Also, community programs should provide child care services or meals for children during school closings, she said.
"Some schools are providing students with computers to take home so they can do distance learning, but what about kids that don't have Wi-Fi at home? What about kids that don't have a home?"
The seminar ended with a brief Q&A session led by Patricia Hibberd, professor and chair of global health at SPH, in which the experts reiterated the critical need to expand testing capabilities.
"When we look back and write the history of COVID-19, the testing is going to be one of the biggest disasters that we write about," said Bhadelia. "If we had scaled this up to thousands of tests the way other countries did, we could have isolated COVID-19 in particular geographic areas and put all our public health resources there to ensure those areas had the capacity and ability to do what they needed to do."
Adapted for The Brink by Kat J. McAlpine.
