April 2020 - The Epidemiology Monitor

Special COVID-19 Pandemic Issue Editor’s Note: This has been perhaps the most challenging month in our 40 year history of reporting about news and developments in epidemiology. To cover the news of particular interest to epidemiologists, we have created a special issue which has significantly more content than our regular monthly publication.

No other event in our lifetimes has called upon the knowledge, experience, and expertise of epidemiologists as frequently as the COVID-19 pandemic. Everywhere we turn, epidemiologists are forecasting estimated cases and deaths, being interviewed on television, writing editorials and op-ed articles, and answering questions for a wide variety of audiences.

Never have epidemiologists been in such demand, even though we have more uncertainties than facts about the transmission dynamics and other epidemiologic features of COVID-19 at this point in time. As noted in the NY Times this week, “Our knowledge gaps are still wide enough to make epidemiologists weep.”

This month’s issue captures some of the latest thinking about the best ways to move forward against COVID-19, describes risk factors for hospitalization, recaps what we know and don’t know about the illness, highlights some of the epidemiologists who have been looked to for their insights and advice, and provides summaries of events affecting epidemiologists. Sadly, we have learned of epidemiologists who have become ill or died from

COVID-19. You will find the following stories in this issue:

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Multiple New Proposals For Going Forward ►

State Health Officials & Johns Hopkins

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CDC

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Duke Health Policy Center

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Former Harvard Dean Has A Plan

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COVID-19 Now Leading Cause of Death

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Risk Factors for COVID-19 Hospitalization

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What We Know And Don't Know About SARS-CoV-2

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Pandemic Creates Who's Who In Epidemiology

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Epidemiologists Who Have Died From COVID-19 April 2020

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Volume Forty One •

Number Four

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Multiple Proposals Being Made For Going Forward Against COVID-19 Despite the success of ongoing mitigation or social distancing measures in dampening the spread of COVID-19, the strategy’s high social and economic costs have brought forth a flurry of new proposals for how best to control or even eliminate the disease from this point forward.

How We Got Here After the first appearance of the COVID-19 cases in the US, the initial control strategy was to test ill persons to identify and treat cases, trace exposed contacts, and quarantine persons when indicated. This containment strategy failed to stop the chains of transmission stemming from the earliest imported cases. This occurred for a variety of reasons, including the fact that not all infected persons were symptomatic, and testing with rapid results was not widely available.

As community transmission took hold, the fear that hospitals and other providers would be overwhelmed and that deaths would rise even higher encouraged or even necessitated the use of severe social distancing measures to slow the rate of spread even at the cost of severe economic impact. This mitigation strategy has been widely referred to as flattening the epidemiologic curve. It sought to buy time for hospitals, health care workers, first responders and other service providers by slowing the demand for services and thereby preventing deaths that would have occurred in a completely overwhelmed health system.

Not all countries bought into these

containment or mitigation strategies as the best approaches.

Different Approaches Sweden took a much less restrictive approach with the idea of allowing the population to acquire disease and create a level of population immunity that might become high enough to provide herd immunity against future outbreaks. The United Kingdom also gave consideration to this approach early on until epidemiologic models predicted that this strategy without social distancing measures could produce half a million deaths. The same models predicted over 2 million deaths in the US without aggressive social distancing measures and reportedly influenced the US decision to undertake widespread mitigation. These model estimates of expected deaths have subsequently been lowered to reflect the new realities created by implementation of strict measures in the UK and the US. Crushing The Curve New Zealand took a more extreme strategy to not merely flatten the curve but to crush the curve. The goal here was to implement such strict measures that the imported virus could actually be eliminated and future importations blocked or new chains of transmission contained through testing, contact tracing, and quarantine.

Current Situation Now that mitigation efforts have proven effective in slowing spread in - Proposals con't on page 4

US State Health Officials Join With Johns Hopkins To Propose A Case Finding And Contact Tracing Approach To Contain COVID-19 CDC Also Expected To Propose A Similar Shoe-Leather Approach Despite the US having initially failed to effectively contain imported cases of COVID-19 using a case-based approach (a containment strategy), the Association of State and Territorial Health Officials (ASTHO) has joined with the Johns Hopkins University Center for Health Security to call for a second try.

There has recently been success with social distancing (a mitigation strategy) in some locations, however, the impact on the economy means that strategy cannot be the lynchpin the country relies on going forward. Instead, the joint group is calling for “a robust and comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case.” Their proposal is entitled A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the U.S. Plan Elements According to the new plan, communities in the US will need to 1) test all symptomatic and suspect cases, 2) identify persons who have developed immunity, 3) trace all contacts of reported or identified cases, 4) safely isolate the sick, and 5) quarantine those exposed.

The task is considered doable, however, it will require adding approximately 100,000 shoe-leather investigators and providing $3.6 billion in emergency funding to state and territorial health departments.

The plan justifies its approach based on what it calls “important lessons from overseas responses that highlight just how vital teams of contact tracers and disease investigators will be to our recovery, and the critical role frontline public health workers have played to controlling COVID-19 in China, South Korea, Singapore, New Zealand, and Iceland.”

“...that strategy cannot be the lynchpin the country relies on going forward."

CDC To Weigh In In an interview with National Public Radio, CDC Director Robert Redfield appeared to support the ASTHO/Hopkins strategy by saying that a plan being prepared by his agency will include not only increased testing but very aggressive contact tracing of those who test positive and a major increase in hiring of personnel to do the shoeleather epidemiology work.

Concerns

“...it will require adding approximately 100,000 shoeleather investigators..."

There are many potential concerns about the feasibility of what ASTHO/Hopkins and in all likelihood CDC are proposing. A first concern is whether or not rapid - Approach cont'd on page 4

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-Proposals cont'd from page 2

“...social distancing is saving 1.7 million lives worth $8 trillion for three months of social distancing."

in several of the viral hotspots where SARS-CoV-first appeared, some of the negative impacts on the economy and the quality of life in the US have become clearer. It is apparent that the restrictions imposed by the social distancing strategy must be eased at some future point and discussions have intensified about what the best way forward might be and what the optimum balance is of public health and economic and social measures.

Making these choices will be fraught with uncertainties about the new virus such as whether it will exhibit seasonality or whether it will occur in additional future waves of infection.

Lives Saved Do Far

“The decisions that will be made in the next few weeks must include economists and epidemiologists..."

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A recent Wall Street Journal investigation reports that mitigation efforts in the US have saved more than 100,000 lives by mid-April and will have saved 500,000 lives by the end of the month. Putting the statistical value of a life at $10 million, the benefits of mitigation equalled an estimated $1 trillion by mid-month and $5 trillion by end of April. A second estimate in the report is that social distancing is saving 1.7 million lives worth $8 trillion for three months of social distancing. The cost to the economy is estimated at $3 trillion through 2022 and the article calls this trade-off worth it in an accounting sense. These estimates are derived in part from the work of Alessandro Vespignani and his team of modellers at Northeastern University.

He told the WSJ, “The decisions that will be made in the next few weeks must include economists and epidemiologists and public health people to find the trade-off between those two viewpoints.”

Articles in this issue of the Epidemiology Monitor provide details about some of the new proposals being circulated.

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-Approach cont'd from page 3 diagnostic testing will be available widely enough and quickly enough. It will not be possible to truly launch this strategy without adequate testing resources.

Another concern is the success some countries had with a more case-based approach which included measures not acceptable in the US because of the importance attached to privacy.

According to NPR, Redfield sounded optimistic. He noted the progress we have made with social distancing measures but believes that the best hope until a vaccine is available is to fight back potential new outbreaks with public health workers on the ground.

To read the ASTHO/Hopkins proposed plan, visit: https://bit.ly/3cuwCvk ■

Join us on our Facebook page at: https://bit.ly/2U29gUA

Duke Health Policy Center Calls For A National COVID19 Surveillance System The Margolis Center for Health Policy at Duke University, which includes two former commissioners of the Food and Drug Administration, has joined the ranks of other public health organizations in calling for a switch from a mitigation to a containment strategy to control COVID-19 going forward.

extreme and disruptive physical isolation measures.

The Duke report calls for creating the following capabilities. No time frame is given but it suggests these capabilities will be required “as the incidence of COVID-19 declines.”

“...a very thoughtthrough and detailed working paper..."

Capabilities: The Report In a very thought-through and detailed working paper, the Duke group “describes the features and capabilities of a national surveillance system to mitigate the current COVID-19 pandemic wave and to limit and suppress future outbreaks.” It calls not only for case surveillance but also for syndromic surveillance of spikes and falls in potential COVID-19 related symptoms.

The group recognizes that at present, “not one of the 50 US states currently has surveillance capabilities sufficient to enable case-based interventions at the necessary scale.”

The report notes that developing these capabilities in each state and region will enable the U.S. to move beyond

1) Test and Trace Infrastructure: Capacity for Widespread Diagnostic Testing and Data Sharing to Enable Rapid Case-Based Interventions 2) Syndromic Surveillance: Integration of Test and Trace into an Enhanced National Syndromic Surveillance System 3) Serologic Testing: Capacity to Conduct Widespread Serologic Testing to Identify Reliable Markers of Immunity 4) Rapid Response: Capacity for Isolation, Contact Tracing, and Quarantine To access the report, visit: https://bit.ly/2VkUhJ3 ■

“...not one of the 50 US states currently has surveillance capabilities sufficient to enable case-based interventions at the necessary scale.”

See How Quickly COVID-19 Has Become The Leading Cause Of Death In The US To appreciate how quickly COVID-19 has overtaken cancer and heart disease and all other causes of death to become the leading cause, a graphical visualization of how quickly this occurred is available at the link below. It is called a bar chart race and was developed by Flourish. You can stop and start the visualization at any point by clicking on the lower left and observing the ranking of the SARSCoV-2 as a cause of death at any point in time since March.

Bar Chart Race: Click here: https://bit.ly/2VBR6vq ■

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Former Head Of The IOM And Harvard Dean Calls For A War-Like Fight To Eradicate SARS-CoV-2 In Ten Weeks

“It’s a war we should fight to win.”

The Association of State and Territorial Health Officers, Johns Hopkins and Duke University are not alone in calling for a change in strategy to combat the coronavirus outbreak. In a stunning editorial in the New England Journal of Medicine published on April 1, 2020 entitled “Ten Weeks To Crush the Curve”, Harvey Fineberg, former head of the Institute of Medicine and former Dean of the Harvard School of Public Health, invokes President Trump to say if we are at war with coronavirus, then “It’s a war we should fight to win.”

Crush The Curve Fineberg calls for “a forceful, focused campaign to eradicate COVID-19 in the United States. The aim is not to flatten the curve; the goal is to crush the curve.” This goal is based on the reported success in Wuhan China and echoes New Zealand’s approach which is also reportedly succeeding in eliminating COVID-19 from the country.

Fineberg’s plan has 6 key components to carry out over just 10 weeks.

"We can’t track if we can’t test is the idea."

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1. Establish a unified command.

Fineberg wants a commander appointed by the President with full power to target responses to specific places and times because different regions of the country are at different phases of the epidemic in the US. 2. Make millions of diagnostic tests available.

In this regard, Fineberg’s strategy is similar to that of the state health officers reported elsewhere in this issue. He suggests multiple ways of achieving this such as mobilizing the nation’s research laboratories and organizing dedicated clinical test sites. We can’t track if we

can’t test is the idea.

3. Supply health workers with personal protective equipment and equip hospitals to care for a surge in severely ill patients.

Says Fineberg: “We wouldn’t send soldiers into battle without ballistic vests; health workers on the front lines of this war deserve no less.” He suggests that regional distribution centers could deploy materials to the hospitals in greatest need.

4. Differentiate the population into five groups and treat accordingly.

These five groups are: I. infected persons who test positive II. suspect cases who have typical symptoms but test negative III. exposed persons IV. persons presumed unexposed or uninfected V. recovered persons Once identified, there are different means of treating each of these categories of persons, according to Fineberg.

5. Inspire and mobilize the public.

Fineberg believes there is a role for everyone and that most are willing to do their part.

6. Learn while doing through real-time, fundamental research.

Fineberg concludes his editorial with an exhortation and a bold prediction.

“Rather than stumble through a series of starts and stops and half-measures on both the health and economic fronts, we should forge a strategy to defeat the - War-Like con't on page 8

First CDC Surveillance Data On COVID-19-Associated Hospitalizations Identifies Risk Factors The first set of surveillance data on the characteristics of 1,482 persons hospitalized due to coronavirus disease during March 2020 confirm early reports that the largest percentage of persons hospitalized are adults fifty years of older (74.5%). The overall hospitalization rate for all age groups during the four week period evaluated was 4.6 per 100,000.

Risk by Age Hospitalization rates varied widely by age as shown in the table below with older adults having rates almost 6 times greater than younger adults 1849 and scores-fold higher than children.

Age groups

No. of cases

Hospitalization rates per 100,000

0-4

6

0.3

5-17

6

0.1

18-49

366

2.5

50-64

461

7.4

65 or older

643

13.8

Total

1,482 Comparison with Influenza

When this first four week period of surveillance in this report was compared to the average rate for a comparable 4 week period over five recent past influenza seasons (the first four weeks of the flu season), rates for persons 5-17 years were identical at 0.1 per 100,000, but rates for persons 85 or older in the coronavirus four week period were significantly higher (17.2

versus 2.2-5.4). This suggests the greater severity of coronavirus disease compared to influenza.

Risk by Gender In addition to age, the CDC report found that 54.4% of total cases were male while males account for only 49% of the population in the catchment area represented by the study. The catchment area includes all persons in 99 counties in 14 states and represents approximately 10% of the US population.

In a related study of US pediatric cases, CDC found that a majority (57%) were males. The agency stated “Reasons for any potential difference in COVID-19 incidence or severity between males and females are unknown…the predominance of males in all pediatric age groups, including patients aged <1 year, suggests that biologic factors might play a role in any differences in COVID-19 susceptibility by sex.”

Underlying Conditions Only a small percentage of cases (12%) had data on underlying conditions. Of these patients, the most prevalent underlying conditions were hypertension, 49.7%, and obesity, 48.3%. These underlying health conditions are very similar to those found for hospitalized influenza patients in recent past flu seasons.

“...older adults having rates almost 6 times greater than younger adults 1849 and scores-fold higher than children."

“…the predominance of males in all pediatric age groups, including patients aged <1 year, suggests that biologic factors might play a role in any differences..."

These findings for case numbers are reasonably complete however not all cases had medical record abstractions completed by the end of March and thus some of the findings about - CDC Data con't on page 8

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-CDC Data cont'd from page 7 underlying conditions may change.

Also, clinical outcomes data will be added after the abstractions are completed.

"These data support recent media reports that African Americans are being disproportionately affected by coronavirus disease..."

"...the person to be appointed as commander of the effort needs to have the full confidence of the President..."

According to CDC, “ongoing monitoring of hospitalization rates, clinical characteristics, and outcomes of hospitalized patients will be important to better understand the evolving epidemiology of COVID-19 in the United States and the clinical spectrum of disease…”

Risk by Race/Ethnicity In addition, data were available by race/ethnicity for 580 or 39% of the study population.

Race/Ethnicity No. of cases White 261 Black 192 Hispanic 47 Asian 32 American 2 Indian Alaska Native Other or Unk 46

% 45 33.1 8.1 5.5 0.3

7.9

These data support recent media reports that African Americans are being disproportionately affected by coronavirus disease likely due in part to the higher prevalence of the underlying medical conditions already shown to be risk factors. In the catchment area population, blacks account for only 18% of the population. Both whites and Hispanics were underrepresented in the hospital surveillance data.

Time to Hospitalization

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In a small subset of patients with available data on admission, the

surveillance data found the median interval from symptom onset to admission was 7 days. To access this Morbidity and Mortality Weekly Report, visit: https://bit.ly/3evxl1e ■ -War-Like cont'd from page 6 coronavirus and open the way to economic revival. If we act immediately, we can make the anniversary of D-Day on June 6, 2020, the day America declares victory over the coronavirus.”

Realistic?

Several objections to Fineberg’s proposal can be raised, perhaps the major one being how realistic it is to make millions of tests available in a very short period of time, and whether or not it is possible to effectively categorize the entire population into the five groups described. Interviewed on television by MSNBC’s Brian Williams, Fineberg expanded on his plan by emphasizing that social distancing will only be good enough to reduce the spread of coronavirus and not stop it.

For getting ahead of the curve and eliminating COVID-19, aggressive testing, categorizing people into the five groups he described, and acting on that information will be key, he said.

Fineberg told Williams that the person to be appointed as commander of the effort needs to have the full confidence of the President, to understand government, the health scene, and federal/state relations, to be decisive and respected. Potential candidates he named included former Department of Health and Human Services Secretary - War-Like con't on page 9

Hopkins Epidemiologist Recaps Both What We Have Learned And Still Don’t Know About SARS-CoV-2 Johns Hopkins University epidemiologist Justin Lessler was interviewed in the NewYorker to help highlight what we have learned about coronavirus in recent weeks and what still remains uncertain. Here are the key items of information.

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

How well do asymptomatic persons transmit infection

What we have learned



Will there be a marked seasonality







Countries need to combat the virus or health systems will get overwhelmed as happened in Italy and Spain Social distancing stay-at-home orders seems to be working in different places, including the US A path forward for the US could be one focused on testing as learned from South Korea

What we still don’t know 

What percent of the population has been infected

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The mortality rate per infection

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How much immune protection is obtained from an infection



How long does immune protection last

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How effective will be the level of community or herd immunity

How fast does the virus spread…what is the reproductive number (R naught)

To read this interview visit: https://bit.ly/3erwWNr ■

“Our knowledge gaps are still wide enough to make epidemiologists weep."

NY Times April 18th

-War-Like cont'd from page 8 Secretary Mike Leavitt and former Defense Department head Ash Carter.

Fineberg added that the country needs to prevent the miscommunications, misunderstandings, and lack of coherence in the attack on coronavirus.

“We need the A team,” he said To read the editorial and plan, visit: https://bit.ly/2VjW6WP ■

“We need the A team..."

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Epidemiologists In The Spotlight Pandemic Creates An Unofficial Who’s Who In Epidemiology Today

"...an estimated 90% of the cumulative deaths in the US between now and August 2020 might have been prevented..."

No other event in our lifetimes has called upon the knowledge, experience, and expertise of epidemiologists as frequently as the COVID-19 pandemic. Everywhere we turn, epidemiologists are forecasting estimated cases and deaths, being interviewed on television, writing editorials and op-ed articles, and answering questions for a wide variety of audiences. Never have epidemiologists been in such demand, even though we have more uncertainties than facts about the transmission dynamics and other epidemiologic features and parameters of COVID-19 at this point in time.

During these times, some epidemiologists have become darlings of the media and some considered heroes in providing reliable, objective, and trustworthy information to an anxious public in various countries. Some have generated many new followers on Twitter. In monitoring the pandemic for our readers, we have collected a sample of contributions made by epidemiologists around the world. It constitutes an unofficial Who’s Who in Epidemiology today.

Value of Mitigation Applied Early

"...it needs the authority and voice that‘s been withheld from it the past three months."

Britta Jewell, research fellow in the department of infectious disease epidemiology at Imperial College London and Nicholas Jewell, chair of biostatistics and epidemiology at the London School of Hygiene and Tropical Medicine and a professor at the University of California Berkeley, provide a graphic display of the impact social distancing can have, even if applied as little as one or two weeks earlier. According to their calculations based on a model developed by the Institute for Health Metrics and Evaluation, an estimated 90% of the cumulative deaths in the US between now and August 2020 might have been prevented by putting social distancing policies into effect on March 2, two weeks earlier than March 16, when there were only 11 deaths in the entire country. They also utilize the natural experiment of a delay of one week in Tennessee compared to Kentucky in implementing lockdown measures to illustrate clearly the impact of mitigation tactics applied earlier than later in an outbreak. https://nyti.ms/2VDEyDZ

On CDC Disappearance Thomas Frieden, former CDC Director published New York Times op-ed on April 12, 2020 writing “The CDC has the knowledge and expertise to limit the spread of the coronavirus, but it needs the authority and voice that‘s been withheld from it the past three months. It is not too late to limit the devastation of our nation’s health and economy. But the administration must support and follow the guidance of the CDC—and it must do so now.” https://nyti.ms/2RNUP7X

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- Spotlight con't on page 11

-Spotlight cont'd from page 10

Counting On Herd Immunity Roman Prymula, a respected epidemiology expert in the Czech Republic has made headlines locally for making a surprising U-turn in favor of allowing the population to return to normal gradually to enable a controlled spread of COVID19 and a gradual building of herd immunity while continuing to protect the vulnerable groups. He based his change of mind, as reported in the Czech media, because he believes China has provided incorrect data and the death rate in Italy is lower than initially calculated (not 15 percent but 2-3 percent). https://bit.ly/2Kggm5c

Straight Talk and Hard Truths Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota writing in the New York Times opinion page stating “It’s too late to avoid disaster, but there are still things we can do. Our leaders need to speak some hard truths and then develop a strategy to prevent the worst.” https://nyti.ms/3eAm93i

“Our leaders need to speak some hard truths and then develop a strategy to prevent the worst.”

Media Criticisms Gregg Gonsalves, assistant professor of epidemiology at Yale, was the subject of an article at Fox News.com for criticizing New York Times reporters for the headline of a story they wrote suggesting there was an unsettled debate about the importance of testing for coronavirus. In an exchange of tweets after the story ran, Gonsalves said “Your collective reporting on the political aspects of this have been off-the-mark. Everything is a Punch & Judy show, and the real story of the absolute and continuing failure of the response to #coronavirus gets obscured in your reporting as “who’s winning the day” in DC.

“...his advice was to get folks out of nursing homes..."

Need Infection Rate Information Michael Mina, assistant professor of epidemiology at the Harvard School of Public Health and its Center for Communicable Disease Dynamics made a number of observations about the pandemic during a conference call with the media, according to the Harvard Gazette. Part of his advice was to get folks out of nursing homes because he believes the virus is much more transmissible than we have been able to document, and control in those circumstances is “an extraordinary feat.” He added “We have to get to an order of magnitude understanding of how many people have actually been infected. We really don’t know if we’ve been 10 times

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-Spotlight cont'd from page 11 off or 100 times in terms of the cases. Personally, I lean more toward the 50-100 times off, and that we’ve actually had much wider spread of this virus than testing…numbers are giving us at the moment.”

Government Fumbles “I would say that governments have been incredibly slow in responding, almost without exception."

Larry Brilliant, an epidemiologist who worked internationally on smallpox eradication, co-founded Seva Foundation to treat eye disease in poor countries, led Google’s philanthropic efforts at one point, and helped create the movie Contagion to show what a serious pandemic could do to society was interviewed on April 1 for a podcast by The Economist.

When asked if the governments are taking the pandemic seriously enough, he replied “I would say that governments have been incredibly slow in responding, almost without exception. I think that your government in the UK [...] began on a misguided mission to allow or think that they could allow everybody or a large number of people to become infected, in an effort to reach the epidemiologist’s Holy Grail of “herd immunity”.

I think my government [in America] fumbled, almost unforgivably, in the way they mangled the distribution of test kits; in the way that our leadership pretended that the outbreak could be brought down from five to zero and it would not be a problem after a while. And it continued to underplay how important it was, as “a hoax,” until finally confronted with the stark reality.” https://econ.st/2Kif4GK Brilliant was also interviewed for the podcast Soul of the Nation on a moral response to COVID-19. https://bit.ly/3bjXwpP

"...he has become the de facto spokesperson for any information related to the illness."

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High Profile in China Zhong Nanshan, is being called China’s leading epidemiologist sometimes referred to as the nation’s “SARS hero” by Chinese media, according to The Diplomat, a publication covering the Asia Pacific region. In 2003, while SARS left China’s health authorities and government officials struggling to rebuild public trust, Zhong was hailed for his integrity. This was largely due to his public admission that the virus was not as under control as state media portrayed.

The Diplomat reports that “Despite his advanced age (born in 1936) Zhong has been appointed to lead the National Health Commission’s investigation into the novel coronavirus. By extension, he has become the de facto spokesperson for any information related to the illness. Beyond his work tracking and studying COVIDhe - Spotlight con't on page 13

-Spotlight cont'd from page 12 19, he has given multiple interviews to Chinese and English language media. He is an obvious choice for the position, as the Communist Party tries to highlight its efforts to manage the crisis in a transparent, decisive manner…” https://bit.ly/3eAnebm

Epi Predictions Marc Lipsitch, Harvard professor of epidemiology and director of the School’s Center of Communicable Disease Dynamics has been in the news for the COVID19 projections his academic group have provided that intermittent social distancing may be needed until 2022. In an informative interview in USA Today, Lispsitch said we’re in a dilemma—if we relax the restrictions we can expect a resurgence, and if we keep the restrictions in place it will be economically disastrous. What to do? He thinks we can try to bring down cases in each locality to a point where they can be controlled individually. But the epidemic will likely appear in more than one wave and people are confused about that thinking if you stop it once you’re done.

“It’s ultimately a political choice, and science is one input.”

Asked directly, so how long will people have to hunker down? Lipsitch said “It’s not a scientific choice only. It’s ultimately a political choice, and science is one input.” Asked, so how do you see things playing out, Lipsitch gave his longest reply— “If I had to make a prediction about how the interaction between social and scientific and public health factors will play out, I think there's going to be fatigue at some point. Some places are going to let up either after they've controlled the first peak or before they've controlled the first peak. Cases will reemerge, and because people are so tired of social distancing, it will take until the intensive care units are overwhelmed in that place to get people to crack down again, and then there will be some cycles of that. There are ways to try to avoid that, but they all involve this very long and destructive process of social distancing. It's easy to say as the public health person, this is what we need to do for public health. But I'm acutely aware that there are also other considerations, and I don't see a really good answer.”

“I don't see a really good answer.”

Controversy In Sweden Anders Tegnell, Sweden’s chief epidemiologist and reportedly the architect of his country’s “social distancing light” or “soft” approach (allowing population - Spotlight con't on page 14

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-Spotlight cont'd from page 13

“...this is a big risky experiment with the entire population that could have a catastrophic outcome…"

immunity to develop more naturally) has been fending off critics. Sweden sought to shelter the elderly and vulnerable but has left stores and offices open and waiting to see what happens. According to the European Centers for Disease Control and Prevention, Sweden has reported over 1200 deaths through April 16 compared to only 72 in Finland with half the population which is often used as a comparison because it took more stringent measures in the Helsinki area. Other Scandinavian countries have also reported significantly fewer deaths with rates per 100,000 much lower.

Joacim Rocklov, a professor of epidemiology at Umea University is quoted in the Wall Street Journal saying “this is a big risky experiment with the entire population that could have a catastrophic outcome…It is risky to leave it to people to decide what to do without any restrictions…”

A recent op-ed in one of the important newspapers by 22 physicians urged the government to lockdown the country as is being done elsewhere. Tegnell has rejected these arguments and has debated critics, according to a recent account in Canada’s National Post. It concludes by saying about Tegnell, “One wishes good luck to the temporary helmsman of the Swedish ship of state as he argues that icebergs are not really his department.” https://on.wsj.com/2RKqmru

Burden Unimaginable

"My hat just goes off to all the people who are doing all this work.”

After offering to come out of retirement to help with COVID-19 control efforts, Bill Hall's offer was immediately taken up by his former health department. He told local media “I am a roving epidemiologist. What that means is that I’m available to travel to whichever district in the Eastern Region of the state that is in the greatest need of epi manpower. According to the paper Hall spends his days interviewing COVID-19 patients and their contacts; trying to locate contacts who might have been exposed to the virus; and doing patient followups, case reviews, case monitoring, and data entry, among other tasks. Additionally, he provides guidance to health care facilities and physicians about testing criteria.

He said “The burden created on the health care and public health system is unimaginable…My hat just goes off to all the people who are doing all this work.”

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Please help The Epidemiology Monitor keep the community informed by sending relevant news to us at this address for inclusion in our next issue. people@epimonitor.net

Died: Sefik Pasagic, epidemiologist in Bosnia-Herzegovina, age 60, of COVID-19 complications. He was a former World Health Organization liaison in Sarajevo, according to the NY Times. The paper reports his wife has written that his death was caused by the poor health services in his country and a local journalist agreed by saying ““All over the world people stay home to protect their public health care system, only we are staying home to protect ourselves from ours.” https://nyti.ms/2ROWeeD [Editor’s Note: Medscape has been keeping In Memoriam: a list of healthcare workers who have died of COVID-19. In addition to Sefik Pasagic above, it includes the following epidemiogists. Readers who know of other colleagues affected by COVID-19 are asked to send the information to editor@epimonitor.net] Luigi Ablondi, 66, Epidemiologist, Former General Manager of the Crema Hospital, Cremona, Italy https://bit.ly/2xxJPoC Nasrim Kodin, 72, Professor of Epidemiology, Depok West Java Indonesia https://bit.ly/3crgr1W Bambang Sutrisna, 71, Professor of Epidemiology, University of Indonesia, Jakarta Indonesia https://bit.ly/2Vilpbt Appointed: Pauline Mendola, as chair of the Department of Epidemiology and Environmental Health at the School of Public Health and Health Professions located at University at Buffalo. Jean Wactawski-Wende, dean of the school, said about Dr Mendola, “Her dedication, hard work, and impeccable scholarship have led to remarkable success. Her body of work fits perfectly into our mission and adds to the department’s research portfolio in several areas, including maternal and child health.”

Interviewed: Deborah Morton, California State University San Marcos chronic disease epidemiologist for her views on the pandemic. She told the interviewer “Many epidemiologists are being consulted and living in the spotlight as experts for how to proceed and predict the future of the pandemic. A highly unusual and historic situation.”

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Notes on People, continued from page 15 Recovered: W Ian Lipkin, John Snow Professor, Epidemiology at Columbia University and Director of the the Center for Infection and Immunity. He had traveled to China to assist with the SARS-CoV-2 outbreak. Lipkin told CNBC in late March it was after his self-quarantine was over that he became ill, developing symptoms that include a “terrible headache” and a “persistent cough that I still have to this day…It takes your breath away…It’s 12 days into this illness for me and my voice is abnormal. I’m still coughing and I don’t have the usual energy level. But I did not require hospitalization, and I’m grateful for that.”

Interviewed: Wendy M. Bamberg, on COVID-19 lessons and challenges by Contagion Live. Dr Bamberg is principal and medical epidemiologist with Medical Epidemiology Consulting. She provided a useful description of the phases of the current outbreak and how strategies need to adapt. She used an analogy to clarify the difference between mitigation and containment strategies. She said, “For football fans, this might be analogous to zone defense instead of man-to-man.”

Recovered: Michael Saag, age 64, an epidemiologist at the University of Alabama at Birmingham, became ill with COVID-19 in mid-March and recovered. He was interviewed on National Public Radio, and he wrote very descriptively about his experience in the Washington Post. He told NPR “Everything broke loose. I ended up with fever, chills, headache. By the time the morning arrived, I was better and I could function and think clearly, but then cruelly and relentlessly, the symptoms came back every single day in the late afternoon. And it just repeated itself. It felt a lot like "Groundhog Day." I didn't know if each night I would deteriorate and have to go in the hospital or whether I would survive the night. “ https://n.pr/3anDfya https://wapo.st/2RQmiGd Died: Raoult Ratard, Louisiana state epidemiologist at age 75 of causes unrelated to COVID-19, although he was fighting but not leading Louisiana’s outbreak as the state epidemiologist, according to a Louisiana State Health Department spokesman. The Department said “Dr Ratard was a force withing the Department of Health and our whole region. He trained future generations of epidemiologists and set Louisiana on the path forward to respond to public health outbreaks.” https://bit.ly/3cuNPoG

Honored: Zhong Nanshan, epidemiologist and head of the Chinese National Health Commission’s expert panel investigating COVID-19, as the inaugural winner of the 2020 Being Edinburgh Award. The award highlights positive news about members of the Edinburgh alumni community.

Near Term Epidemiology Event Calendar Every December The Epidemiology Monitor dedicates that issue to a calendar of events for the upcoming year. However that often means we don't have full information for events later in the year. Thus an online copy exists on our website that is updated regularly.

To view the full year please go to: http://www.epimonitor.net/Events Alternately you can view individual months online:

MAY

JUNE JULY

VIRUS UPDATES FOR PENDING EVENTS We are attempting to update our online epi event calendar to reflect cancellations and postponements. Many organizations have yet to update their event information.

If your organization has made decisions please let us know so we can keep our calendar as clean as possible. Thank you - mailto:events@epimonitor.net

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