The Public Health Response to COVID-19 and Preparing for the Next Pandemic

It has been almost nine months since the global COVID-19 pandemic was declared by the World Health Organization on March 11, 2020. We should not be complacent around the world and in the United States with death rates of over 1,200,000 and 250,000 respectively due to COVID-19. These deaths do […]

It has been almost nine months since the global COVID-19 pandemic was declared by the World Health Organization on March 11, 2020. We should not be complacent around the world and in the United States with death rates of over 1,200,000 and 250,000 respectively due to COVID-19. These deaths do not include the increases in excess deaths and overall morbidity. Our hospitals, medical workers and the economy should not bear the brunt of this pandemic. Failing to take better measures will greatly increase the burden of suffering for millions of people around the globe. This may be a time of continuing infections, which may become entrenched within the global population much like influenza has done. The measures that we adopt, or fail to adopt, will determine the future direction of all our lives.

Most countries have inadequate healthcare systems to deal with this pandemic. Counties with little or no resources need to use basic measures and alternative options for the treatment and prevention of COVID-19.  Those in charge of the COVID-19 pandemic are trying various responses as the world enters a new critical phase. In this phase, the exponential increase in new cases, as well as the possibilities of new mutations, has changed the dynamics of this pandemic. Hospital overuse does not contribute to an adequate containment strategy and spends too much on too few people. We must improve our responses to meet these global challenges.  

Given the large efforts required to increase our global health infrastructure enough to stem the tide of this pandemic and possible future pandemics, some may give up and let nature run its course. There may be rational arguments for this approach much like letting the forest fires burn to remove the dead wood and lower brush from forests. Ethically and morally, letting people die from this pandemic is repugnant to us. Philosophically, what makes us human is to struggle against the whims of nature, which can be arbitrary and cruel. Lockdowns have contained the outbreaks of COVID-19, but they devastate the underlying economies. The major burden of this pandemic must shift from hospitals and the economy to public health measures. Much of this work still needs to be done. Ideally, once the outbreak is contained, preventative measures such as effective cleaning, mandatory wearing of masks and gloves, proper air treatment and circulation, testing, tracking and localized lockdowns will be enough to further contain the outbreak. If done with rapid, accurate and reliable testing and rapid follow-up contact tracing, as well as, increased preventative measures and cluster outbreak containment, full lockdowns might be preventable. Some countries and states have learned these lessons.  Now is the time to reassess the effectiveness of our responses to reduce or prevent the further spread of infection. Hopefully, these guidelines can improve the overall response to the COVID-19 pandemic and prevent the most severe consequences.  

Billions of dollars have been spent toward reducing the impart of this pandemic without a clear understanding of where this money could be spent most effectively. Too much money has been spent on vaccines (over 50 vaccines in development). Vaccines might eventually offer us some degree of protection, but we should not rely solely on them. During the 2018-2019 influenza season, 49.2% of people ages six months and older got a flu vaccine, according to the Centers for Disease Control and Prevention. This is well below the 70% target the Department of Health and Human Services set for the entire population. We should not expect much better responses to COVID-19 vaccines. Also, the logistical problems are large and the amount of vaccine available will probably be relatively small compared to the global requirements. We need to be aware of the dangers of over commercializing vaccines and other therapeutic treatments without checking their true effectiveness. We must avoid the advertised hype from those with vested monetary interests in these outcomes.  Recently an inexpensive nasal spray was developed that prevented COVID (SARS-CoV-2) virus transmission in ferrets (see references below). This demonstrates that there may be inexpensive treatments worth considering. We invest more in drug repositioning, new drug development or other methods to reduce or destroy the virus and increase our overall options for both treatments and prevention.

Testing remains a central issue for our ability to find and track COVID-19 cases in the population. Improving testing and tracking still offers us the best investment, but this requires significantly strengthening our public health systems as well as enforcing effective preventative measures. Although we now have many more tests, we have yet to understand how to best administer them and track the results (see Critical Issues in Testing below).  With no clear guidance about how to use this information to contain this pandemic, many are floundering with this information overload. No one is completely up to date regarding the essential research being done. It should be a coordinated global effort to monitor and timely summarize the latest scientific and health updates by the experts at the Center for Disease Control (CDC) and the World Health Organization (WHO) together with those academic and medical centers studying infectious diseases and their treatment. However, the websites of these organizations are overwhelmed trying to keep up with recent developments and are not capable of handling this task. Perhaps the major internet companies could supply the talent and data analytic experts who are needed.

Since one definition of health includes the ability to have more options for all areas of our lives, including those areas of physical, psychological, financial, and social health, bold ideas are needed to organize community structures to deal with the disruptions caused by COVID-19 outbreaks. This may require new ideas, such as letting our local schools serve as community resource centers where citizens can get information, food, and/or testing for COVID-19 and providing in home resources for those who must quarantine. Leadership is critically important in implementing these new solutions.  Instead we have had knee jerk reactions to multiple impending crises in acute hospital care and our local and national economies. We can and must do better.

Conclusion:

Effective public health measures can control this pandemic, but these measures must evolve into something that people can live with.  Total isolation is not a good solution. Lockdowns, although effective, are economically impractical. If we do not use lockdowns, then we need to invest in and promote stronger preventative measures. This will improve our abilities to fight this pandemic while reducing or minimizing the economic pain. Bold new ideas are needed to improve and strengthen our public health systems to respond to the global COVID-19 pandemic. Public health professionals must provide the leadership to effectively control this pandemic. Hopefully, these guidelines will improve the overall response to the COVID-19 pandemic and prevent the more drastic consequences, that may destroy our hospitals and the economy.

Richard G. Lanzara, MPH, Ph.D.

Critical Issues in Testing (Note that progress has been made in many of these areas, but more research and follow up is needed):

a) Make testing available to those populations most at risk and report the infection rates of local populations.

b) Standard controls, which should be run with the regular tests, are necessary to determine and ensure the accuracy and reliability of tests so that we can compare tests. The seven-day moving average may not be the best metric to use for public health rapid responses. Better statistical reporting needs to include a metric such as the net increase in new cases.

c) Determine the best timing for testing. For example, if someone was potentially exposed, when is the best time to test and how many tests should be done? Obviously if they were asymptomatic before and were just exposed, an initial COVID-19 test will probably come back negative since the incubation period is about two weeks. Then when is the next time this exposed person should be tested as a prudent follow-up? Two weeks? One week, or sooner? Research should study better ways to test after a potential exposure. Otherwise testing may provide a false sense of security. Is it best to wait a few days after an exposure and then test every other day or so after a potential exposure? These are important questions to answer to catch potential spreaders. These questions are not so simple to answer. They point out the problems that arise with little or no awareness of these issues and suggest that current testing protocols may miss possible infections.

d) How often to test? There are some people who are getting tested much more often than others. This might have to be discouraged so that testing resources are available for those who need it most. Ironically, waiting in long lines to be tested at local facilities might not be a best practice for preventing the spread of contagion.

e) Testing surfaces around the community should also be done. Also, testing before and after cleaning to measure the effectiveness of cleaning. Testing needs to be available around the clock, more rapidly and accurately.

f) Data analytic experts are needed. Perhaps those people with big data analytic skills from the large internet companies would help in the data collection and reporting.  

g)  Better home testing with directions on how to get support and follow up if the test is positive.

Critical Issues in Science (Note that progress has been made in many of these areas, but more research and follow up is needed):

a) Increased research into areas such as what types of living models can serve as standards for studying COVID-19? This includes such things as cell cultures, animals, eggs, etc.  

b) Finding which animals are susceptible to COVID-19 infection (dogs, cats, mink, ferrets, …).

c) Finding and monitoring those areas in the world where interspecies transfer may lead to an increase in infectivity, such as pigs, chickens, or pets to humans. How effective are these areas being monitored?

d) Research the most effective environmental measures to control the spread of COVID-19.

e) What is the metabolic/life cycle of the virus in humans? Are there any mutations that affect these?

f) What is the role of inflammation in the progression of the disease (use of anti-inflammatory drugs, dexamethasone, etc.)?  

g) Where would be the best targets for pharmaceutical or other interventions?

h) What are the best prophylactic treatments (zinc, vitamin D)?

i) Research into chemical methods that may be used in vivo should be investigated with preliminary animal studies. Although these treatments are not popular with the entrenched commercial interests, it would be of great service to global health if safe, effective, and cheap therapies were discovered. This is how many of our medicines from the past were initially discovered. Some scientific studies suggest that this might be possible (see reference links below).

Online references and general information:

Google COVID-19 recent news – https://www.google.com/search?q=COVID-19&source=lnt&tbs=qdr:w&sa=X&ved=2ahUKEwjhoKbyiZfsAhWnd98KHUP_BXYQpwV6BAg1EB0&biw=1518&bih=749  

CDC COVID-19 – https://www.coronavirus.gov/

NIH COVID-19 – https://www.nih.gov/coronavirus

NIH National Library of Medicine – https://www.ncbi.nlm.nih.gov/sars-cov-2/

Bio-IT World – http://www.bio-itworld.com/

BioSpace – https://www.biospace.com/

NEJM COVID-19 – https://www.nejm.org/coronavirus

Wikipedia Coronavirus disease 2019 – https://en.wikipedia.org/wiki/Coronavirus_disease_2019

PLOS COVID-19 Updates – https://plos.org/covid-19/

Researchgate COVID-19 research community – https://www.researchgate.net/community/COVID-19

Prevention:

https://www.biospace.com/article/inexpensive-nasal-spray-prevents-covid-19-infection-in-ferrets-shows-promise-for-human-trials/  

Risk assessment and reporting:

USA – https://covid19risk.biosci.gatech.edu/

Global – https://ourworldindata.org/coronavirus#coronavirus-country-profiles 

For European countries, this is a useful link that shows individual countries in Europe and has a metric labeled “crude cumulative incidence” which could be helpful in comparing countries – https://who.maps.arcgis.com/apps/opsdashboard/index.html#/ead3c6475654481ca51c248d52ab9c61

-Note that you must select the individual countries

separately and not together (only one should be highlighted in yellow).

Pharmacological treatments:

https://jamanetwork.com/journals/jama/fullarticle/2764727

https://www.goodrx.com/blog/coronavirus-treatments-on-the-way/

Potential treatments:

https://pubs.acs.org/doi/10.1021/acs.jmedchem.0c00606

Drug repositioning for COVID-19 –

https://scholar.google.com/scholar?as_ylo=2020&q=drug+repositioning+for+covid+19&hl=en&as_sdt=0,33  https://www.google.com/search?q=drug+repositioning+for+covid+19&source=lnt&tbs=qdr:m&sa=X&ved=2ahUKEwj6v5j-2JPtAhXypVkKHXn6AUYQpwV6BAgJECI&biw=1536&bih=704

Vaccines:

https://www.goodrx.com/blog/coronavirus-covid-19-vaccine-availability-live-updates/#vaccine-development

https://www.healthline.com/health-news/heres-exactly-where-were-at-with-vaccines-and-treatments-for-covid-19#Vaccine-development

SARS-CoV-2 infection, disease and transmission in domestic cats:

https://www.tandfonline.com/doi/full/10.1080/22221751.2020.1833687

Chemical methods: https://scholar.google.com/scholar?as_ylo=2020&q=chemicals+used+in+medicine+COVID&hl=en&as_sdt=0,33

methylene blue –  https://scholar.google.com/scholar?hl=en&as_sdt=0%2C33&as_ylo=2020&q=methylene+blue+medicine+COVID+&btnG=  

NAC(N-Acetylcysteine) –  https://scholar.google.com/scholar?hl=en&as_sdt=0%2C33&as_ylo=2020&q=NAC+medicine+COVID+&btnG=  

Ozone – https://scholar.google.com/scholar?hl=en&as_sdt=0%2C33&as_ylo=2020&q=ozone+medicine+COVID+&btnG=  

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