COVID-19 experts on “difficult choices” ahead during the pandemic

Andis Robeznieks , Senior News Writer

In their role as “disease detectives,” epidemiologists having been tracking and analyzing the spread of COVID-19 and working to develop prevention, mitigation and treatment strategies.

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Practical answers to lingering questions about the pandemic were provided by a trio of prominent epidemiologists during a recent two-part episode of the “AMA COVID-19 Update” examining the difficulties of investigating the novel coronavirus and best practices for mask-wearing and reopening schools.

The panel discussion, moderated by AMA Chief Experience Officer Todd Unger, offers insights on some of the top issues and challenges surrounding COVID-19.

“One of the big difficulties has been being able to test patients—having testing that's rapid and that's easily available,” said Ilse Levin, DO, MPH, an internist and epidemiologist with the Mid-Atlantic Permanente Medical Group and an AMA trustee. That shortcoming “has really held us back,” she added.

The unfamiliarity of the novel coronavirus made it “more difficult to get a handle on” the disease, said Harris Pastides, PhD, MPH, an epidemiologist and president emeritus of the University of South Carolina, “but science is moving forward.”

“We now understand the pathophysiology and the clinical course of the disease better than before,” said Pastides, who is also an AMA trustee and has worked with the World Health Organization and the National Institutes of Health on public health matters.

There were problems communicating the latest science learnings in the early stages of the pandemic, and that led to the release of incomplete or conflicting messages, said Preeti Malani, MD, chief health officer and a professor of medicine at the University of Michigan.

“It's confusing, particularly, to the general public and the best example is the data around masks,” said Dr. Malani, who is a JAMA associate editor. “Initially it was ‘don't wear a mask.’ Now, it's ‘always wear a mask.’”



Pastides said “we’re rounding the corner” toward collecting enough data that will allow scientists to better understand COVID-19 and create models that can more accurately predict probable outcomes.

“I think the data will show over the next few months what the variabilities and the vagaries really are here, and who’s at higher risk and why,” he said.

Uncertainty remains over what positive test results truly reveal, and this uncertainty is compounded by patients testing falsely negative, said Dr. Levin. Data on hospitalizations and deaths, by contrast, offer more certainty to the severity of an outbreak.

One thing that has become clear: COVID-19 is more than just a respiratory issue and there is more awareness of “a larger inflammatory component,” particularly myocarditis, said Dr. Malani.

“The idea of how we treat is changing, and we're focusing a little bit more on inflammation,” she explained. “Initially, we were very focused on the respiratory issues [because] this was a respiratory virus, of course, and we focused on pneumonia and respiratory failure.”

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The experts also discussed how the virus has mutated, with the newer strain that came through Europe, identified as G614, appearing to be much more virulent than the original strain, known as D614—though it hasn’t been determined if one causes more deaths.

Pastides said it appears that two vaccines won’t be needed.

“The news is hopeful,” he said. “It appears that they're similar enough that they should be covered by a good vaccine.”

Dr. Malani noted that much has been learned since most of the country was staying at home and there shouldn’t be a need again for such a large-scale shutdown.

“I am hopeful that we don’t need to go back to a national situation where everyone is sheltering in place, but there may be communities where we need to sort of scale back reopening,” she said. “To me, it’s really the physical distancing and the masks that are most important.”

Dr. Levin agreed.

“We’ve seen that masks work. We’ve seen that physical distancing works,” she said, adding that outbreaks may still occur in small pockets, and these may require “pulling back a little bit” on local reopening efforts.

“I don’t think we have to go on a completed lockdown again,” Dr. Levin said.

Pastides said protecting senior citizens should be a priority. This includes not allowing them to serve as volunteers in schools, which they may have done before the pandemic. Schools also need to put plans in place for any contingency.

“Every institution needs not only a plan B, they a plan C, D, E, F and G,” he said. “When is an infection rate too high in a classroom? When is it too high for an entire school? If we shut down, are we ready to go online?”

School and college campuses are “built around togetherness and community,” Dr. Malani said, noting that trying to retrofit facilities to provide students with the necessary physical distancing may not be practical.

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A national surveillance system that sounds an alert when infections occur and allows for a quick response is needed, said Dr. Levin, as is better testing with more rapid results.

“We’re still running into barriers,” she said.

Pastides said it helps that the public in general is becoming more committed to wearing masks and washing their hands, but he said a more unified response is needed.

“For goodness’ sake, we have flu season right around the corner,” he said. “We have got to, as a country, come together—not vilify health care professionals, not vilify scientists, and come together as a nation.”

Dr. Malani predicted that more changes are ahead, including some that many people will find difficult.

“The pandemic has really been about difficult choices and there are going to be difficult choices ahead,” Dr. Malani said, adding that kindness, respect and patience will be needed to meet these challenges.