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Duke health experts call for patience, testing, improved federal coordination in pandemic battle

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Sudden reopening would jeopardize progress made thus far

This is Day 50. It feels like Day 500.

A new coronavirus, which technically isn’t even alive, has outwitted us. The COVID-19 pandemic has paralyzed the state and the nation, vanquished our economy and killed 40,000 people in the U.S. — including 235 in North Carolina — and another 131,000 worldwide, all of whom were loved by someone.

How do we gain the upper hand over an invisible pathogen that moves stealthily and with no regard for its target?

On April 21, three doctors affiliated with Duke University discussed the prospects for reopening the nation, the inconsistent federal response, and clarified the nuances of testing, both for coronavirus antibodies and active COVID-19 infections. The conversation was held via videoconference with the media.

Dr. Michael “Dee” Gunn [2] is an immunology professor at the Duke University School of Medicine. From a medical perspective, people advocating a premature opening of the economy, Gunn said, “are advocating that every person in this country become infected with coronavirus.”

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Dr. Michael “Dee” Gunn, professor in immunology, Duke University School of Medicine (Photo: Duke University)

Reopeners are primarily far-right conservatives inspired by the likes of Infowars’s  Alex Jones and other discredited conspiracy theorists. They have staged numerous demonstrations nationwide to protest not only states’ stay-at-home orders but also science.

Yet the public’s impatience is expected. “No one has shown them the light at the end of the tunnel,” Gunn said. “It would be very beneficial if at the federal level someone said, ‘This is the schedule we’re on,’ and give people an expectation to work with. As it is now, [the message] changes every day. No wonder everyone is frustrated.”

The Trump administration has whipsawed the public with conflicting messages that are driven by politics, not science. Even though he had been briefed to the contrary months earlier, President Trump said in early March that the virus was no worse than the flu, and would soon “disappear.” Instead of disappearing, over the next six weeks 40,000 people in the U.S. died and in the hardest-hit areas, the entire medical system was overwhelmed with cases.

Despite the president’s assurances that plenty of testing and medical equipment were available, there have been severe shortages of both, resulting in a Lord of the Flies-like competition among states for ventilators, masks and protective gowns. 

The sideshow continued in late March, when Trump said the country would open by Easter. Then under pressure from public health officials, Trump postponed the date until May 1, which experts said was still too soon. Shortly afterward, Trump said he had “total authority” to reopen the country, an assertion that has no constitutional basis. Then he backtracked, and put the onus on state governors to decide how to lift their stay-at-home orders. 

But Trump soon undermined the states’ efforts; within a day via Twitter he incited demonstrations against the governors in several states where stay-at-home orders are in place: Minnesota, Michigan and Virginia. 

Like a virus, those demonstrations spread to other states, including North Carolina. U.S. Rep. Dan Bishop of the ninth congressional district and State Sen. Vickie Sawyer, both Republicans, are among the elected officials who attended the protests. Gov. Roy Cooper has said as long as protesters remain six feet apart — the standard recommendation for social distancing — the demonstrations are allowed.

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Dr. Thomas Denny, chief operating officer, Duke University Human Vaccine Institute (Photo: Duke University)

Dr. Thomas Denny, chief operating officer of the Duke Human Vaccine Institute, [5] said the country should be reopened gradually or risk higher rates of infection and death. “I’m concerned that in this rush we’re forgetting everything we’ve learned,” Denny said. 

“I know there are a lot of people who have lost their jobs. They may be motivated by that, and I understand, but we need to address the economics on a national level and take this slower.” There could be “rings of containment and rings of loosening,” based on health data, Denny said.

While the reopeners are seizing their moment in the spotlight, most people in America are quietly — and nervously — trying to avoid becoming infected. A recent Washington Post-University of Maryland poll found that of 1,013 people surveyed, with 57%  saying they are “very” or “somewhat” worried about becoming infected and seriously ill from the coronavirus. Multiple polls [6] have found that Americans are more worried about reopening the economy too quickly than too slowly.

“What the federal government needs to do right now is to come up with a coherent plan,” Gunn said. “The American people are willing to sacrifice for the common good. The government needs to say, ‘We’re asking you to buy into it. That’s who we’re going to get control of this virus.’”

Testing free-for-all must be reined in, better coordinated

Gaining control of the coronavirus will require widespread testing: One type to determine if someone has an active infection and should be treated and isolated; another to detect antibodies in the blood, which indicate the person has been infected at some point in the past.

The Centers for Disease Control and Prevention initially shipped thousands of flawed test kits that had been made in a contaminated lab. Subsequently the FDA fast-tracked millions of antibody testing kits — some that had never been verified — to county health departments, only to learn later that many of them were faulty. 

“It’s been a free-for-all,” Gunn said. “Every company that could put out a test, did. There’s not been the quality control that this needs. We need a national coordination.”

Test kits, enzymes, chemicals, reagents, protective gear for health care workers administering the tests: All of these must be manufactured en masse, quickly but precisely. 

“It’s a complicated test,” Gunn said. “It’s not instant. We need to develop tests that are sensitive enough so that we have rapid results like pregnancy tests.”

Once reliable antibody tests are available, first responders and health workers should be the first to receive them, Denny said. “Hopefully if we have another surge we’ll have a better understanding of the risk those individuals have.”

It’s nearly certain that even in states where the number of reported cases is declining, there will be another surge in the fall — or sooner, depending on how quickly the stay-at-home orders are lifted.

A robust tracking system, including painstakingly tracing an infected person’s contacts could help contain smaller outbreaks, Gunn said. “It’s like a forest fire. Once it’s under control, it’s a matter of managing the hotspots.”

And there will be hotspots. Since the virus is new, scientists don’t yet fully understand how it behaves. For example, simply having antibodies for the virus doesn’t mean you are immune to it, Gunn said. 

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Dr. Chris Woods, co-director of the Center for Global Health at Duke University (Photo: Duke University)

And after people recover, it’s unclear who is immune and how long people shed the virus. “What risk that poses is not well understood,” said Dr. Chris Woods, co-director of the Center for Global Health at Duke University [8] and chief of the infectious diseases division Durham VA Medical Center.  “We’re still learning a lot about how it’s transmitted, and whether or not there is a change in the virus that makes it more transmissible or more or less virulent over time.”

An estimated 7,000 people in North Carolina have tested positive for COVID-19. That is likely an undercount because of the testing shortage. Moreover, many people with mild or moderate symptoms don’t go to the doctor so their cases aren’t counted. But even if 1 million North Carolinians have had the disease in some form, that’s still only 10% of the state population. That means 90% of North Carolinians would be vulnerable.

“We need to understand the background rate of immunity,” Woods said. Without the benefit of “herd immunity” — which occurs when large numbers of people have become immune to the disease and provide indirect protection for people who haven’t yet had it — “we would expect periodic outbreaks of disease but we would have public health tools to contain it.”

While the federal government, especially the CDC, which has been nearly invisible throughout the crisis, needs to provide funding and technical support, the burden of containment will likely fall to the states and county health departments.

“It will be costly and it will take a lot of people to execute these plans,” Denny said. “The local health departments are very important to identify who are most at risk —like low-income people, who typically see more health problems — and then work out a plan. It’s going to take time.”

This story has been corrected to show that 7,000 people in North Carolina have tested positive for the coronavirus.