Learning from the COVID-19 Battle to Fight the Modern Pandemic War

13 min read

“If you’re going through hell, keep going,” Winston Churchill is reputed to have advised during the early days of World War II. This advice is equally relevant for the current Covid-19 pandemic as it affects owners, staff and residents of affordable housing buildings and complexes, especially those dedicated to senior living, and truly, the entire population.

“We will get through this,” Dr. Michael T. Osterholm assures. “The next six to eight months are going to be a challenge, and it will not be easy. But we do have choices about how we go about it. Our job is to minimize the casualties. Right now, the United States is on fire, and it’s getting hotter!” Osterholm, a world-renowned epidemiologist, is founding director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota and a member of President-Elect Joseph Biden’s Covid-19 Advisory Council. (Full disclosure, he is also this writer’s coauthor of the book Deadliest Enemy: Our War Against Killer Germs.)

Despite some hopeful signs, the present war is far from won. After a temporary slowdown, between Labor Day and Election Day, the United States has experienced a fourfold increase in the daily case rate. Though an estimated 80 percent of the cases are mild or asymptomatic, the illness and death the virus has already caused is unequaled by any infectious outbreak since the 1918-20 worldwide influenza pandemic. It will continue to burn as long as it has human fuel to consume, and so far, with all of the suffering, economic dislocation and death, it has only infected about 15 percent of the population, meaning we are nowhere near the level of herd immunity necessary to bring the transmission rate down to manageable levels.

Given the pandemic fatigue that has already understandably set in, a reality check is in order.

In the second week of November came encouraging news from the Pfizer pharmaceutical company that its Covid-19 vaccine, developed in conjunction with Germany’s BioNTech, had achieved a 90 percent level of protection versus the placebo in a doubled-blind Phase 3 clinical trial. Moderna Therapeutics, using a similar new “messenger RNA” (mRNA) technology, announced its own results on November 16, declaring its early analysis suggested a nearly 95 percent effectiveness. Nine other candidate vaccines, using a variety of approaches, are in the final stages of testing. These were all welcome developments throughout the scientific and public health communities.

But what exactly does 90 or 95 percent efficacy mean? The truth is, we don’t know yet. Does it prevent fever, chills and loss of taste? Does it prevent more serious illness, hospitalization and death? With influenza vaccines, those most at risk, the elderly and health compromised, tend to respond least effectively. So what will these vaccines do with the elderly and those with comorbidities? What is the durability of the protection? Few researchers believe it will be permanent, as it is with the most effective vaccines, or will we need booster doses or revaccination every year? It is already likely that two initial doses will have to be given, about three weeks apart. We also don’t know how common reinfection will be, and whether a second case, as with infectious diseases like dengue, are likely to be more severe than the first. We can’t wait four years to find out all the answers; we’ll have to start deploying it as soon as it is authorized and made available.

Yet that in itself presents formidable challenges. Ramping up production will take months, so at best it will be spring before a large segment of the American public can be vaccinated. The Pfizer vaccine, for one, must be refrigerated at -94 degrees and then injected in less than 24 hours after being taken out of cold storage, so the logistics are daunting, particularly outside of urban areas.

Most public health experts, Osterholm included, believe that vaccines will provide our best and most effective defense against SARS-CoV-2, the virus that causes Covid-19.

The good news for the senior living sector is the presumed prioritization of vaccination supplies. Doctors, nurses, other healthcare workers and other first responders understandably will be at the top of the list. But seniors, one of the most vulnerable cohorts, should be a high priority, along with their caretakers and the staff members who come in contact with them. This is significant, because as of the middle of October, 79 percent of the Covid-19 deaths have occurred in those greater than age 65. Of those, 44 percent have been individuals age 74 or younger.

Given the current political climate and the strong anti-vax sentiment among certain groups, many public health experts expect a fair degree of skepticism and lack of trust regarding a Covid-19 vaccine and reluctance to take it. However, the U.S. Food and Drug Administration represents the highest level of regulatory science, and unlike some public officials in the Trump Administration, FDA Commissioner Dr. Stephen Hahn has been exemplary in his adherence to rigorous science and resistance to political influence.

Some Good News
Despite these grim statistics, there is more good news for the senior population. Though we don’t yet have effective preventatives against the virus, the learning curve for how to care for those in intensive care and with severe disease has been impressive. Understanding the use of antiviral drugs, such as remdesivir, and steroids, such as dexamethasone, as well as various management and nursing techniques, have cut the hospital mortality rate to a quarter of what it was in April. These improvements have also kept more ICU patients off ventilators, which have their own disadvantages and adverse effects, such as the possibility of air leakage in the lungs.

Swapping Air
Until, as Dr. Anthony Fauci puts it, “the cavalry arrives” in the form of safe, effective, and widely available vaccines, we must depend and rely on human behavior to control transmission. After eight months, we still have no national plan and the White House and its Coronavirus Task Force have consistently given out conflicting, contradictory and often downright erroneous information. President-elect Biden has taken the pandemic seriously and his advisory council is in the process of formulating a much-needed national strategy. In the meantime, it is up to governors, mayors and those caring for and interacting with vulnerable populations to take matters into their own hands.

Most important in this effort, in the words of Dr. Osterholm, is the avoidance of “swapping air.” While there is some evidence of the virus adhering to surfaces, and it always is a good idea to wash hands frequently and avoiding touching the face, the overwhelming amount of transmission is effected through the air—small droplets and aerosols. This doesn’t mean that congregate living facilities should let up on frequent surface disinfection and other mitigation strategies, but it does underscore the centrality of air in infection control.

Masks, of course, are highly recommended, and they have a certain efficacy in both directions, preventing the wearer from spreading viral particles and protecting the wearer from receiving them. But it must be emphasized that they are not the total answer. With the exception of tight sealing N95 masks, which are still in short supply, uncomfortable to wear for long periods and should be reserved for frontline healthcare personnel, other types of masks provide only partial protection. Several layers of cloth are good, but even surgical masks allow aerosol-sized particles to enter in around the sides. The most important single weapon in avoiding air swapping is distancing. Clearly, this is not possible in every situation, especially when dealing with a sick or frail patient or resident, but it should be observed to the degree possible.

Best Practices
We will not go into the scientifically based advisability of a four-to-six-week stay-at-home order because socio-politically, we know that is not likely to happen. Therefore, we must deal on the smaller level, which in this case means every affordable and senior housing congregate setting.

Due to the increasing daily numbers of cases in the United States, testing and contact tracing on a wide scale is neither possible nor effective. But within the confines of a senior living facility, they are both useful and recommended in certain instances. A negative test on an asymptomatic individual, whether resident or staff member, is only a “snapshot” good for a day or two. But, if a resident or staff member is displaying clear or likely Covid-19 symptoms, he or she should be tested using the best test available, the PCR (polymerase chain reaction) and then given immediate medical care or hospitalization as indicated. Then, anyone who has had contact with the patient, even if asymptomatic, should be tested and subject to appropriate quarantine if they test positive. We should note here that the standard quick point-of-care tests tend to yield about a 30 to 50 percent false positive, so they are not nearly as reliable as PCR.

Until vaccines are widely available, all of the best practices outlined in previous articles in Tax Credit Advisor should be maintained. These include as much noncontact communication with residents as possible, which in turn means working toward much more robust interactive systems and broadband wiring in residential buildings.

In designing new structures or retrofitting older ones, flexibility of walls and space use should be considered, especially in areas, like dining facilities and lounges, where numerous residents are likely to congregate. Several large affordable housing owners have advocated for more balconies and openable windows. And modern, zone-controllable HVAC systems have become a major priority.

On a more immediate level, Osterholm’s concerns about swapping air will be particularly important this holiday season. While the summer provided opportunities for outside and balcony-centered community gatherings, this will not be so easy during the cold weather months. Indoor air is far more “dangerous” than outdoor air. For management and service coordinators, this means that visits from outsiders, even close family, should be seriously questioned and even discouraged. If the goal is to create a “bubble” around vulnerable residents, any penetration of that bubble is a potential threat, and as we now know, much of the Covid-19 transmission has been through asymptomatic individuals or those who have not yet manifested symptoms. All family reunions this year, including Thanksgiving and Christmas dinners and New Year’s celebrations, should be avoided. The CDC’s Morbidity and Mortality Weekly Report (MMWR) recently reported the case of an asymptomatic 13-year-old girl who transmitted to numerous guests at a wedding she attended, a number of them developing serious illness.

“Feel empowered to say no,” Osterholm advises. Feel empowered to do the right thing. This is love at its very highest level.”

If family visits are a must, all participants should self-isolate for 14 days in advance.

At the same time, managers must—and generally already do—recognize that loneliness is an enormous negative factor in itself, so all possible checking up on, and safe communication with, residents should be encouraged.

One of the main takeaways from all of this is that we should not think of Covid-19 as a one-off or once-in-a-hundred-year event. As world population steadily increases, as international commerce and supply chains grow steadily more interconnected, as natural habitats that protected animal reservoirs for exotic viruses are encroached upon, as international border crossings top a billion a year and airplane travel can take us anywhere quicker than the incubation period of any microbial threat, the chances for epidemic or pandemic at any time or place radically increase. It is therefore incumbent on every industry and business sector, affordable and senior housing included, to plan for every infectious eventuality in terms of staff training, facility design and contingency drills.

Also, it is important to acknowledge that the effort so far has taken a huge physical and emotional toll not only on healthcare workers and first responders, but also on caretakers and all of the management and staff dedicated to keeping residents and each other healthy and safe.

The Next Few Months
As Osterholm has pointed out, until we can begin to neutralize the coronavirus through mass vaccination, we remain in significant danger. As the case numbers grow, the likelihood of becoming infected rises correspondingly. He sees a confluence of pandemic fatigue, pandemic anger from those who do not believe the pandemic is real, and the fact that the winter will force more activities and interactions indoors as contributing to even greater transmission. “Any indoor group activities are playing with fire,” he comments.

Our healthcare system, particularly ICUs in many places, are already in danger of being overwhelmed. What happens if the rate of those needing intensive care doubles over the winter? “We are quickly approaching a shortage trifecta,” he states. “First, it’s not even the ICU beds; it’s the professional care staff that is in short supply. These are the people who have been responsible for greatly reducing the mortality of the virus over the past months. Second, we still do not have a sufficient stockpile of PPE—personal protective equipment—for all of the healthcare workers who need it. And third, because of the pandemic and interruptions to the international supply chain, we are close to lacking many of the drugs we need, such as sedation drugs for intubation. For example, we have no substitute for propofol, and it is becoming increasingly hard to get.

“CIDRAP did an extensive study and identified 156 drugs and pharmaceuticals critical to the armamentarium that are needed within hours to sustain life or prevent death. All of them are generic, and the majority are only manufactured overseas, mainly in India and China. We are therefore constantly at risk of running short of any of these agents, which will mean we can’t prevent otherwise preventable deaths. The convergence of the three elements I mentioned with a huge surge of cases could be devastating.” This dilemma must be solved before the next pandemic hits.

Clearly, there are no perfect solutions to the current one until the vaccine arrives. Though public transport of any sort involves risk, caretakers have to get to work. Though indoor spaces are more problematic, people have to buy food and clerks have to administer the stores. Certain contact areas are essential, as are certain workers, regardless of the severity of the outbreak, so compromises have to be made. The key point, as Osterholm puts it, is “Humans can’t afford to give up before the virus does.”

Current and reliable information on all aspects of the Covid-19 pandemic is available at cidrap.umn.edu.

Story Contact:
Mark Olshaker