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(c) 2020 Jon L Gelman, All Rights Reserved.

Monday, July 20, 2020

Coronavirus (COVID-19) - The workers' compensation community should support TTSI

The workers' compensation community should play an active role to contain the spread of COIVD-19. Labor, Industry and insurance companies must be encouraged to participate in contact tracing, testing and supported isolation [TTSI]. All reports of illness and incidents of COVID-19 should trigger reportable investigations that are co-ordinated with local and state health agencies. Communication with employees should be encouraged for testing, isolation and expansion of contact testing.


Recently, Dr. Ashish Jha, K.T. Li Professor of Global Health and director of Harvard Global Health Institute,  announced the launch of “The Path to Zero: Suppressing COVID-19 through TTSI.” Robust contact tracing, testing and supported isolation (TTSI) across the nation will provide pandemic safety and get the United States economy back on track. How to get it done, and how to pay for it.


The following is a press conference on coronavirus (COVID-19) from the Harvard T.H. Chan School of Public Health with Ashish Jha, . 


Summary:

With a TTSI package of $75 billion, the nation’s governors would be equipped to deliver a suppression strategy and the nation as a whole would benefit. Each month of collective national quarantine cost $150-$300 billion, in addition to compounding social costs of unemployment and social unrest. Our phased reopening in conditions where case incidence remains high ensures a long and slow recovery, not a V-shaped recovery. Achieving suppression would accelerate recovery. This investment would quickly pay for itself.


ASHISH JHA: Good morning, everybody. I hope everybody can hear me OK. So I'm going to just make a few high level remarks. And really, I think the richest part of this will be the question and answer, which I suspect will be most useful to all of you as well. But let me sort of say three, four things that are at a high level.

First of all, emerging from the July 4th weekend, I think we are looking at very difficult days and weeks ahead. We are averaging about fifty to fifty five thousand new cases of the virus being identified every day. A week ago, Dr. Fauci warned that we might get to 100,000. And that's when we were about forty to forty five thousand. So you just in that last five, six days, we have seen an increase and nothing of that has happened in the last week makes me think that, you know, that we have made the kind of changes we need to really bend this curve. So lots of infections ahead.

Second is that we are starting to see in large parts of the country, hospitals really starting to hit capacity. So one part of the initial argument was, well, maybe this is just testing. I think we had pretty good evidence that it was not. Then the second argument was, well, maybe this is just young people and they don't really get sick. And while clearly it is true the younger people are less likely to get sick, there are enough people now getting sick that whether it's Texas, Florida, Georgia, other places, Arizona, we're seeing really a lot of hospitals hitting up against capacity.

Third quick point I want to make is we have seen a pretty flat mortality curve or the number of deaths has not been increasing. And I expect, unfortunately, that in the days and weeks ahead, we are going to see increases in the number of people dying from this virus because death always lags hospitalizations by a couple of weeks. I'm hoping that we will not ever get to a point where we have the level of deaths that we saw in the worst days in New York. Partly because we've gotten better at treating the disease. But I am worried that we're going to see an increase.

Let me make just two more quick points. One is that the data on masks is really just getting better and better. There is a new study out this morning that I tweeted about data from Germany, but there have been now a whole bunch of studies in the U.S. and elsewhere that showed that the rules that mandate mask wearing have a pretty substantial effect on lowering case growth. And then last but certainly not least, is I want to talk about some work that we released last week. We did it just before the July 4th holiday. I suspect some of you might have missed it. It's really two very complementary pieces of work. One is the Path to Zero metrics. And the second is work we did with National Public Radio, where we released our testing targets for each state. And I'm going to take a minute to talk about both of those things.

So, on the testing targets, what we laid out was the number of tests per day that each state has to do to either mitigate the virus or to suppress the virus. And the way to think about it is mitigate is really just about kind of keeping the virus at bay. It doesn't really let you open up your economy fully, but it also prevents large sort of runaway outbreaks. Suppressing the virus is really getting the numbers down so low that we can have much of our economic activity back, people are not getting sick on an ongoing basis. You might occasionally have an outbreak, but but mostly things are really under very tight control. We estimate that for the country, we need about a million tests a day to do mitigation and a little over four million tests a day to get to suppression levels.

And that gets us to the Path to Zero. The Path to Zero is work that we have done in very close collaboration and really under the leadership of Danielle Allen, who is at Harvard's Safra Center. And Professor Allen has led a group of us to from across the country, academics, think tanks, to really come together around metrics for how we get our country back to a level of virus control where we can have our economy back. And the motivation behind that work is there a lot of groups out there from AEI to Hopkins to NTI to every acronym you can think of that has put out their own report. And one of the things that is really clear to us was that conceptually we were all on the same page, even if there were small differences in our metrics and our targets. And so what Danielle has done really remarkably well is bring people together and get to a pretty high degree of consensus around how we should be thinking about labeling counties and states in terms of how much of an outbreak they have and then really thinking about what do we need from a testing, tracing and supportive isolation strategy to get the country to green. So we have together basically labeled every county as either green, yellow, orange or red with very specific set of policy recommendations of what needs to happen to go from red, orange to yellow to green with the hope that we can keep the whole country green. All of that information can be found on the Harvard Safra Center website or the maps. And a lot of the details are also on the website that the institute runs, our institute runs called globalepidemics.org, and those links are all in here.

And so a lot happening, both bad news in terms of where things are heading, but good news in terms of what is possible if we as a country really just get our act together and start taking the virus seriously and doing the things that we need to do to get the virus under control. So let me stop with that and get into Q&A.

MODERATOR: First question.

Q: Hi. Thank you so much for doing this. I have two questions I think are related. First, what are the public health implications of the president and other leaders downplaying the severity of COVID 19, saying ninety nine percent of cases are harmless, saying that the outbreaks are really just increased testing. Wondering how this could influence the behaviors as people. And then secondly, if you could just talk about what are the reasons the U.S. is doing more poorly in containing this than other countries? Is it a lack of leadership or a lack of a national strategy, or are there other reasons?

ASHISH JHA: Yeah, so there's those two questions are unfortunately tied. But let me start with the first. So it's very, I think, harmful to have a lack of clear communication and to underplay this virus, because ultimately a large part of how well we control the virus is going to depend on people's behavior. And to the extent that you have leaders who are trusted by large segments of our population saying it's not a big deal, that it's all about testing or that most people, most people do fine, and for 99 percent people, it's harmless, it does two things. It says there isn't an outbreak out there or not much of one. And second is, even if you got infected, it'd be no big deal at all. We know both of those are not true. And so then public health folks like me, other political leaders, governors, mayors are having to go up against the president or against other political leaders. And it just creates confusion and makes it hard for people to know whom to trust. If we could let science and evidence really drive our decision making, it would help bring the virus under control. It would save lives. It would help open up our economy. But we're not doing any of that. And that's making it much, much harder.

So that gets to the second issue of why. And there are a couple of ways of answering that question. But when I look at other countries and say, what have they done that we haven't? I could give you a list of things. But the single most important thing I would say is other countries have taken it seriously and we have not. And what that means is if you've taken it seriously, some countries have had a very aggressive shut down. We have not. Other countries have taken a very aggressive strategy on testing and tracing and isolation. We have not. And then some countries have universal masking laws and we don't. So obviously, every country that has been successful at squelching this has taken a slightly different approach. There is no one formula, but the one theme that underlies all of it is taking this seriously. They've gotten ahead of the virus and have not been playing catch up the way we have. And we still have plenty of time to catch up and get this virus under control before the fall, before we even start thinking about opening schools for the fall. But if we're going to continue the path that we're on right now, it's going to be very hard to open schools, it's going to be very hard to open our economy. And it's going to be very hard to avoid having hundreds of thousands of Americans, more Americans, die.

Q: Thank you so much.

MODERATOR: Next question.

Q: Thank you very much for doing the call as always. So I'm wondering what you make of this debate going on over airborne transmission and this article in The New York Times that suggested that WHO is being hidebound on this issue. What do you make of their position and about this this kind of, you know, seemingly undecided aspect about the importance of airborne transmission?

ASHISH JHA: Yes, I don't know how undecided it is. I know that WHO's official stance is what it is in the article. So let me first lay out the science and then let me lay out why I think WHO was stuck and why I think WHL, as well intentioned as it may be, is getting this wrong.

So the big debate, to the extent that there is one, I don't know that there is one anymore but there was earlier in the disease outbreak, was is this primarily about droplets versus how much of this is aerosolized? And the functional difference here is droplets come from sneezing and coughing and they are large droplets and they fall to the ground or they fall onto surfaces. And so the key strategy is wash your hands and fomites sort of and surfaces become the major way stuff is spread, unless, of course, someone coughs or sneezes on you. What we know from now, I think, plenty of data that aerosolized transmission, which happens while people are speaking, while people are singing, they actually are pretty substantial sources of spread. Aerosols can hang out in the air for much longer. They can go further than six feet. And all of the data we are seeing from bars and from indoor locations, the choir practice that led to 60 people getting infected, I think there's just plenty of evidence that aerosols are really a major source of spread.

And so, therefore, while washing hands is still a good idea, wearing a mask becomes really important and avoiding long term, long term, long duration exposure indoors. Just basically not hanging out indoors with large numbers of people becomes really, really important. I don't know that there's much disagreement in the scientific community. WHO has got a couple of reasons why it gets stuck on this, and I'm very sympathetic to some of their challenges. But again, I think they're getting this wrong. One is they really, really push for a very high degree of certainty. And my take is the evidence is, you know, it's really quite good. But for whatever reason, it doesn't seem to be meeting their threshold for certainty, which I think is clearly too high. And they're not thinking about the cost of getting it wrong. So I think they've drawn a bar that's really too high.

The second, and I'm now guessing but it's a little bit in that Times article, is every time WHO makes recommendations or makes a statement, they're not just thinking about how will this play out in Germany or UK or the United States, but they're thinking about what what implications does this have for poor rural hospital in India or poor rural hospital in Mozambique or in Ecuador or wherever, right? Low and middle income countries. And if you call this aerosol driven, it has all sorts of implications for what kind of ventilation hospitals should be doing and what kind of masks doctors and nurses should be wearing. And they start worrying about all of that. And I think that drives their what I think is an unreasonably high bar of evidence. So I have no questions in my mind about who is right on this, the 239 scientists, including several from Harvard Chan or WHO. The scientists are clearly right, I think, in my mind of where the evidence is, but that's the disagreement. For me, the policy implications here are still very clear. People should be wearing masks. People should not be spent congregating indoors and spending a large amount of time indoors.

Q: And if I can follow up real quick on that. What does this mean, you know, if you're in a hospital in India or Mozambique or wherever, you know, what does this mean in terms of what kind of precautions should be taken at this point?

ASHISH JHA: Yeah, so those are you know, and I think a lot of us worry a lot about transmission, nosocomial transmission, because if those places don't have good ventilation, if people are not wearing the right kind of masks, then I do worry that you're going to see nosocomial infections, you're going to see infections on the floor to doctors and nurses and you're going to see spread throughout the hospital. So this is a challenge. But I think that for - and I'm going to not pick on India, but I'm from India and I think about the hospital in my village where I grew up. If that hospital has poor ventilation and does not protect its doctors and nurses, well, I'm pretty confident that we're going to get into a lot of trouble in those places. So while I understand why WHO's being cautious, I'm not actually sure they're being helpful to those hospitals in those places.

Q: So airborne precautions are needed at this point?

ASHISH JHA: I think so. For healthcare workers, I do.

Q: Thank you.

MODERATOR: Next question.

Q: Thank you. Thank you for your time. I have a question about Florida. How can you explain what's happening in Florida right now and other states, but Florida, I'm here. So a lot of people were saying before that, you know, heat can help fighting COVID because, I don't know, the disease doesn't spread in the heat. But that was wrong, I guess. And what can be done in that state in terms of improving the situation?

ASHISH JHA: Yeah. So let me let me take this opportunity to talk about heat, because Peter Navarro, one of the president's top advisers, raised this issue over the weekend when he said everybody thought that the heat would make the virus go away. I don't think anybody I know thought that heat would make the virus go away. But I do think that many of us believed and still believe that heat has an effect. I think there is plenty of laboratory evidence that the virus does not survive as well in the heat and in UV light. But let's be very clear about what I'm saying. I don't believe that it doesn't survive at all. It's just probably a little bit less efficient in transmission, but certainly not enough to to basically make you feel comfortable that you will not be transmitting. And my sense is a lot of what is happening in Florida, but also in Texas and Arizona and South Carolina is that there's a lot of indoor transmission happening because it is really hot. People are spending time indoors and people are spending time in restaurants and bars. Until recently, nightclubs were open in Phenix. And so even if it's hot, 100 degrees Fahrenheit outside, indoors is pretty cool and dry. And those are very hospitable conditions for transmission. So I think this idea that heat was going to bail us out of of all of this, I think I was clearly over stated and not well understood because in those hot places, people don't actually spend all day outside.

In terms of what is happening in Florida and how to get Florida under control, I do believe that not only do you need a statewide masking law, but you need to enforce it effectively. I don't believe that right now Florida can have certainly not bars. I know Texas canceled, closed bars - I can't remember if Florida has. Certainly no nightclubs. And I don't know that Florida can afford indoor restaurants right now. Outdoors is generally safer for both airflow and heat and sunlight. But I think indoor gatherings of any size in Florida is right now very risky, certainly if people are not wearing masks. But even with wearing masks, I don't know that it's particularly safe.

Q: And what about the beaches? In Miami-Dade, they did close the restaurants, I believe. And the bars will close. But what about the beaches? Because that was the big topic.

ASHISH JHA: Yeah, this is one where I maybe I disagree with some of my public health colleagues. I don't I don't know that I necessarily believe we should be closing beaches. I do think we may need to meter them a little bit. And what I mean by that, is we have to make sure they don't get super crowded. But we think being outdoors is safer. I believe that very strongly. Being out in the sun is and with good air flow is better. Beaches should be relatively safe. Now, if beaches get very, very crowded and large numbers of people are congregating together, obviously you can get spread. There have been instances of spread at Myrtle Beach, et cetera. My guess - I don't know this for a fact - is that a lot of it is probably what people did after they spent the day at the beach. They went out to a restaurant, they went out to bars. That's where a lot of the spread might have been. So if it were up to me, if there was a way to control the crowds on the beaches, I would keep all beaches open.

Q: Thank you so much.

MODERATOR: Next question.

Q: Hi. Thanks. To get back to to some of the issues of comparing the US to other countries. My understanding with Europe is for the most part, what they did is is basically shut down longer and stricter than the US did. So given that, does that mean that now, you know, in some of these states like Arizona, Texas, they should be looking at full stay at home orders again to get on top of this? Or is that or can they do it with. With less like just targeted at bars or at nightclubs or not full stay at home orders?

ASHISH JHA: It's a very good question. And I wish I had an answer for you. I don't know. It's an honest 'I don't know'. I don't know if Arizona and Texas and Florida, just to pick three places with relatively large outbreaks, I don't know if those places will be able to do it without a shelter in place order. What is very clear to me is that every day we kind of dither on on the really aggressive stuff we have to do. It's one day that we get closer to a shelter in place order. And I think politically, as well as for other reasons, shelter in place orders are very difficult. And there are there are going to be politically very untenable in those states. And whether there is political space to do that or not, other people on this call have more expertise on it than I do.

But the question of will they be able to control the virus without that? If all of them could do better on testing and tracing, if - again, their outbreaks are such that that alone won't get them there - but if all three of those states, so let's say Arizona, Texas, Florida, really aggressively implemented and and enforced a universal masking rule, if all of them closed down any real indoor gatherings and pushed hard on testing and tracing, and if they started like yesterday, then I think there is a chance that all of them can get away without having to go to shelter in place. But I'm worried that the longer we take and the more incremental we are in each of these places, the more they're gonna find themselves at some point with no other choice. And that, of course, would be very unfortunate.

Q: Thank you.

MODERATOR: Next question.

Q: Hello. Thank you. My first question is regarding the benefiting from the current experience. What should the world do to prepare for similar pandemic in the future? And what do you think about the mistakes that have been done, the pros and cons of the current situation?

ASHISH JHA: Yes. So thinking about the next pandemic, you know, I have said and I believe we are entering an age of pandemics and we are going to be seeing more of them in the future. And there was a lot of concern about this after the Ebola outbreak in 2015. And I co-chaired an international commission that both looked at what went wrong but really try to think about how do we prepare the world for the next pandemic. And you can wonder how good a job we might have possibly done, given what feels like a pretty substantial mess up in terms of the global response to this pandemic. So what needs to be done?

I think the first and foremost, we need really effective and aggressive surveillance systems around the world. We need countries that can detect, have good laboratory capacity, public health capacity, that can detect disease outbreaks and get on top of them early. Some of the earliest sort of huge successes in this pandemic have been Taiwan, South Korea, Hong Kong, Singapore. Besides being Asian countries, what else really ties them together? That they all sort of went through the SARS outbreak and built up systems that allowed them to respond much more aggressively. Actually, another country that has done a fabulous job, one of the best in the world is Vietnam, also acted aggressively early and had a system in place. So I do think that there are lessons from coming out of this outbreak that if there are other countries are willing to adopt, that will help.

Second is, we just need to make much, much bigger investments in vaccine platforms, in studying viruses. This is stuff we called for and the world moved kind of incrementally forward. But imagine that we had much better progress on coronavirus vaccine than we had, then we could have moved all that stuff much faster. So I think we have to make big scientific investments in the basics of virology and vaccines and platforms.

And third, and this is always the hardest is, you know, there was a global pandemic monitoring board that I think was them or using the Global Health Security Index, ranked all the countries in the world in terms of preparedness. And two of the top countries in the world for preparedness of pandemics was U.S. and the U.K., arguably two of the high income countries that have done the worst job, because one of things that they didn't think about was political inaction and political ineptitude. And unfortunately, that has really hurt both countries. So how to deal with that is a different issue that I think we're all going to struggle with. But we're gonna have to make countries much more politically astute at being able to respond to these things.

Q: Thank you. Great.

MODERATOR: Next question.

Q: Good morning, Dr. Jha. Thank you guys so very much for facilitating this, this is so illuminating. I really appreciate it. So as as Nicole mentioned, Dr. Jha, I am in one of the states that has been struggling. I think that may be an understatement, but I have several questions, if you don't mind.

ASHISH JHA: No, please.

Q: I'll do one at a time. Otherwise, it's a reporter no, no to snow you in with multiples and then figure out if you remember. So where's the disconnect between the scientific messaging and people's behavior? I think we're seeing it across the country, but specifically in Texas and some other states that are experiencing an uptick, it feels like there is some sort of a disconnect. I don't know how else to explain it. How can you explain what we're experiencing here?

ASHISH JHA: So, I don't have a simple answer on that, obviously. I do think that one of the big challenges of this outbreak has been that the very large amount of misinformation that's out there from, you know, that this is nothing but the flu, to it's all going to go away in April or go away over the summer. And combating that misinformation is a challenge. It's a challenge under the best of circumstances. And this is where I look inward and ask, have we as public health people done a good enough job of combating that? And the answer almost surely is no. And, you know, people tend to trust information they get from their friends, from their family. Obviously, Facebook has become a very substantial platform for the spread of misinformation. And the stuff that gets shared by people makes people walk away thinking this is no big deal, that the virus is as trivial and most people do fine and 99 percent of people have, you know, for 99 percent people, it's harmless. So there is a huge communication challenge here. And I've been thinking about how can I be more effective? How can my colleagues be more effective? But I don't know what else to say beyond it's a bit of information warfare, almost, it feels like at times. And trying to counter that misinformation is difficult.

Q: Based on your research, why is Texas in the lead in terms of cases at the moment?

ASHISH JHA: So I think a few things. One is based on the best evidence we have - I mean, look, Texas opened up, I believe, too early. It wasn't as closed and shut down as it probably needed to be. And it's not even my belief. If you look at the president's, you know, the White House's guidelines for opening up America again, Texas did not meet those requirements. It didn't have the testing and tracing infrastructure that the guidelines called for and didn't have 14 days of declining cases pretty consistently as the task force called for. So that, I think, has been one part of the challenge.

I do also think that there has not been consistent communication about masks. I think it opened up too much. So, it wasn't just that it opened up too fast, but bars and restaurants moved through those gates that the White House had set up much more quickly than the data would allow. So this is really a combination of poor policymaking and poor communication that has landed Texas in the spot that it's in.

Q: I have looked at your link to the map of testing, and so I'm looking at Texas right now and it appears based on what your map is showing, that it's below target. Am I - if you would help me make sure that I'm seeing this correctly since this is your map.

ASHISH JHA: Yeah, I'd have to - I'm just - sorry, I have to pull up the map. So the one that we did with NPR that I am guessing, and if I do remember the Texas data, we're pretty far behind where they needed to be in terms of - let me just look up - sorry. And I'm also, by the way, happy to follow up off line about testing in any individual state. But I'm looking at their mitigation target and their suppression target, their testing is well below where they need to be on both of those.

MODERATOR: OK, we're going gonna move on to some other questions, and if you have more questions, just hop back on and we'll get to you after everybody else has a chance. Next question.

Q: Thank you. Thanks for doing this, Dr. Jha. I wanted to follow up on some testing questions and actually I was writing or working on a story about it, and then you guys released the new data with NPR. That was very handy for me. I'm curious, though, about what sort of an increased level of testing would get us that the current level of testing doesn't and sort of how important testing is compared to some of the other steps that need to be taken with social distancing, with mask wearing, with that kind of thing. Obviously, testing is important, but it's only one sort of half of the equation, as I understand it.

ASHISH JHA: Yeah, absolutely. So let's talk about that second part first. Absolutely, testing alone isn't - well, first of all, just testing unto itself and doing nothing with that information certainly isn't gonna get us far enough. And so I want to start by saying testing capacity is really, really important, but it's one part of the equation.

Then the second part of that equation is how you deploy that testing capacity. So that strategy for how you deploy tests has not been well developed and has not been as forthcoming from the from the federal government and with the CDC as it should be. But, you know, who should we be screening? Should we be doing ongoing testing of nursing homes? Should we be doing of meatpacking plants, all colleges and schools? All of that stuff needs to be sorted out. All of that needs a lot more testing capacity than we have. When you start getting into what we're seeing in Houston with long lines for tests, it means a lot of people have marginal symptoms or very mild symptoms are now going to go get tested, but they may still be spreading the virus. So I do think that the lack of testing makes it difficult to control the virus.

But then even if you have adequate capacity, even if you have deployed it effectively, you've got to do something with that. And that's where the contact tracing comes in. And then, of course, with contact tracing, you've got to be able to help isolate people who are positive or need to be quarantined. And you need to find a way to do that in a way that is supportive so people are going to actually be willing to do it. So I do not want to overstate the kind of magical nature of testing. Testing is fundamental, but it's part of a much broader strategy. Now to your other question of how would I rank its importance, it's hard in some ways. Because if you have very little testing capacity, then, yes, you can get to universal masking, yes, we can maintain social distancing, but it's gonna be hard to really manage outbreaks without a sufficient amount of testing capacity. So I do see it as a pretty central component of that entire strategy. But I certainly agree, and I don't mean to emphasize this idea that it unto itself is the only thing as a country that we need to be doing.

MODERATOR: Thank you. Next question.

Q: Hi there. Thank you so much for doing this. Just want to circle back to the conversation about aerosols and The New York Times piece. I'm wondering if you can speak about how important the droplet size is to coronavirus transmission. And if there's any indication that aerosols or large droplets, one might be more effective in transmitting the virus.

ASHISH JHA: Yeah, it's a very good question and I and there are people who spend their lives studying that. Linsey Marr, as she was quoted in the Times is probably the - and actually, Joe Allen at the Chan School are two people have really been doing frontier work on this. My reading of the literature is that aerosols are a very efficient way of spreading this virus. And that's why we've looked at, for instance, super spreader events and events where you've seen large numbers of people get infected. They've almost always been indoors and we think they've been primarily aerosol driven. So if I had to say, you know, how important are aerosols? I think they're very important.

Compared to droplets? The only other point I would make is that there is a gradient here. Because we sort of often thought of the world as aerosols or great or droplets but the bottom line, of course, is that there is a spectrum and I don't know that I can scientifically really weigh and say one is much more important than the other. My sense is both of them are important mechanisms. But much of the transmission that we have seen when we've done contact tracing, when we've looked at what has set off outbreaks, has been, I believe, aerosolized transmission and not necessarily a lot of transmission through fomites of droplets dropping on surfaces and people getting infected. I think that's an important mechanism. But I don't think that there's a ton of evidence that that's somehow more important than aerosols. So I don't mean to punt on your question, but that's sort of how I think about it.

Q: I have one more question. So we you spoke about also about the challenges that this could present to rural hospitals, especially in terms of poor ventilation. Wondering if you can speak about what this could mean for the average person that might not have access to an N95 mask like hospital or health care workers. Is there anything that people should be doing differently?

ASHISH JHA: Are you talking about what hospital workers or health care workers should be doing differently or what like the average person on the street should be doing differently?

Q: The average person when it comes to the ventilation issue.

ASHISH JHA: Yeah. So I think, first of all, we've got to get a ninety five masks to all the health care workers in the country and that, like, I can't believe we're in July and we still are trying to figure out how to make sure that hospitals are well stocked with N95 masks. I mean, at some point we've got to start acting like a developed nation. The second is for the average person on the street, like, I think regular face mask clearly are helpful and there's plenty of good evidence. My general feeling is people should not be spending large amount of time indoors with large in large gatherings. That's the primary lesson coming out of that. So obviously, when you're at home with your family, it's different. But gatherings with friends indoors, especially if you're in an area with a with a reasonable sized outbreak, is probably pretty risky.

The ideal thing, again, if we had been able to muster up a true national response, we would have had millions or billions of N95 masks and people could wear them outside of the hospital. But we don't have that because we haven't. That's not the kind of government response we've had. And so for the average person, I think regular cloth mass are are perfectly fine, but it does mean not spending substantial amount of time indoors when there are a lot of other people out.

MODERATOR: OK, next question.

Q: Dr. Jha. Thanks for taking my question and thanks for doing this call. I have two questions if it's all right. One is about this new antigen test that was approved this morning and another is actually about university reopening plans. I will start with the antigen test, if that's all right. Can you speak to - I've seen some people who have been hailing this new test is really something of a breakthrough for rapid point of care diagnostic testing. Have you gotten a chance to look at this specific test? I understand that a lot of doctors already have the system in place to process that test. Do you think this could really rapidly increase testing infrastructure?

ASHISH JHA: So I haven't looked at the details of this test but let me just talk a little bit about antigen testing more generally and I'm happy to have a follow up conversation. So, I've been very enthusiastic about antigen testing. And the reason is - you've actually alluded to some of them, which is that there's a lot of experience with the use of antigen tests. Until this morning, until you just mentioned this, if you had asked me this yesterday, I would have said, you know, we know there's one antigen test that's been approved through emergency use authorization by the FDA. The problem with it is that its sensitivity is not that great. It was about 80 or so percent. Do you know what the sensitivity on this one is?

Q: I haven't seen the details, but I know the company said it's very accurate. I haven't looked into that.

ASHISH JHA: Very accurate and four bucks buys me a latte. I appreciate that. I need to look at the numbers. But the bottom line is this, again, if we were having this conversation yesterday, what I would have said to you is I am very optimistic about antigen test because there are about 20 companies that are working on them and I don't know which one's going to end up making a great one, but I suspect we'll have a few that will be have sufficiently high sensitivity. And for this one, as opposed to antibody testing, which is really about specificity, this one is about sensitivity. I can imagine and I would have said, again, that before the end of the summer we will have a few that have high sensitivity that are in production where they're widely available. Again, there are a couple of issues here. And I'm not going to speak specifically to this one just cause I haven't looked at the data. What we need, what we want, is to be able to have rapid tests with a high degree of sensitivity so people get, you know, if they get a swab, I don't care as much about specificity because it means if I have to do a confirmatory test, I'm fine. I just don't want a whole lot of false negatives.

And so what I'd like to be able to do is in a doctor's office or imagine before you get on an airplane, you go to the airport and you get a swab, you get a result in 15 minutes. And if you're negative, if it has low false negative rates, you should be all to get on a plane. If it's positive, maybe you need a confirmatory test. And so that kind of mechanism really starts changing the ballgame in terms of how much of our economy we can start opening up. And antigen tests have a tremendous amount of potential for being able to do that in a way that our PCR never did. And so that's why I've been very enthusiastic about this modality. This specific test, I will look up the FDA data on this and I'm happy to have a follow on. What's your question about university opening up plans?

Q: Yeah. So I wanted to ask specifically, you know, the CDC came out with guidance, I think it was about two weeks ago. The big thing that stuck out to me and I think a lot of other people who were reading that was that they did not recommend, actually they recommended against entry screening for all students returning and professors returning to campus. While we were on the call, actually, I saw Harvard put out a statement. I don't know if you can comment on that but they said they are going to bring back some undergraduate students but all classes will be online, which I thought was kind of an interesting thing. I just thought I'd bring that up in case you have anything to offer or insight into that or whether you think classroom lectures are a particularly high risk environment. But really, my question is about entry screening. Do you think that is that an oversight for the CDC not to recommend entry screening?

ASHISH JHA: Yes, I think it's an oversight. I was a bit baffled by it when I read their logic. It seemed to be - well, it's not perfect. Absolutely true, it's not perfect. It's gonna miss stuff. Nothing in this pandemic is perfect. The question is, will it offer a level, a new level of safety that is meaningful. And the short answer is yes, it would. There is also at least a sense that I got, and I don't know if it was explicit or between reading between the lines, that they were worried about capacity, that maybe if all the colleges and universities started doing entry screening, that we would quickly run out of tests. My point is that's not up to the CDC. The CDC should be calling for more testing if we need more testing as opposed to, hey, we don't have a lot of tests, so let's not do the things that are gonna make us safer. So, again, I don't understand the decision making within the CDC, but as somebody looking at the evidence and asking, would it be safer for colleges and universities to open up if they had entry screening? In my mind, the answer is absolutely yes.

MODERATOR: All right. Next question.

Q: Mask compliance in other countries, you mentioned that European countries have had a high degree of that. I'm wondering what some of the, what degree of resistance was seen in some of those countries and what the mandates or enforcement mechanisms look like and to the degree that some of those could be adopted here. Because as we've seen, you can mandate mask wearing, but you cannot necessarily enforce it. So what are there any strategies that Europe used or European countries used that would work well here?

ASHISH JHA: So it has been variable across countries. And what I would say is that a large chunk of like, for instance, there have been places where there has been resistance. I know certainly in Germany and in places there has been resistance, but ultimately places have gotten over that resistance with clear and consistent communication from political leaders who have emphasized the importance of doing so. And then, you know, in terms of enforcement, I just know less about exactly what the enforcement strategies in some of these countries have been.

But on the enforcement issue, you know, it does strike me that people being bring up that, you know, that this is hard to get people to, it's hard to enforce this kind of stuff. And my point is, we have a long history of enforcing rules, like if I wanted tomorrow to walk into a restaurant or a clothing store and light up a cigarette, I couldn't. I mean, I could, but I'd get kicked out. And if I refused to leave and continue smoking, people would call the police and I would then I don't know, get a fine or arrested or whatever. But the point is, we don't do that and we don't do that because there are some very clear rules against lighting up indoors and in retail shops. And if we had very clear rules about wearing masks indoors in public spaces like retail shops and enforced it much of the way we do cigaret smoking or other public health measures, I don't know that we couldn't get there reasonably quickly. You don't need 100 percent compliance. We have pretty close to 100 percent compliance and not smoking in retail shops, at least I haven't seen that violated very often. But even if you got to 90 percent compliance on these things, would make an enormous difference. But I do think that political leaders have to see this not as a freedom issue anymore than smoking indoors is a freedom issue, but as a public health measure that we need.

Q: Thank you.

MODERATOR: Next question.

Q: Thanks for taking my question. I wanted to go back quickly to the president's claim that ninety nine percent of cases are totally harmless. I understand he may be referring to some estimates that the death rate could be less than one percent. Is there a consensus that that's likely the case or is still some uncertainty surrounding that death rate? And what do we know about the harm COVID-19 has caused to others who survive the disease, particularly long term effects?

ASHISH JHA: Yeah. So there's a lot of debate about the infection fatality rate. There's, you know, what proportion of people end up dying who get infected. And it's hard because you can't just look at people who've been diagnosed. We ought to look at people who you missed because you don't have enough testing. A new paper out today in Lancet about Spain's seroprevalence. And based on that, I just put out a little Twitter thread before I got on here. Spain's infection fatality rate is about 1.1 or 1.2 percent. That may be be a little on the high side. I think the broad consensus in the community is that the infection fatality rate is somewhere between 0.6 percent and 1 percent, but it varies a ton based on if you have an older population versus a younger population, how good the health system is.

And then, of course, I also think that that number should come down over time because we're getting better at treating COVID. And so somebody who spends three weeks in the ICU has severe lung damage and would have died two months ago, might now survive. But let's be very clear that if you spend three weeks in the ICU, have severe diffuse lung damage and you survive, it's fabulous that you survived but that was not inconsequential. The data on what proportion of people end up suffering long term effects? Well, first, but we don't have any long term data. This virus has only been around for a little while, but we certainly are seeing more and more cases of people with long lingering symptoms. The amount of lung damage that we're seeing, a lot of CAT scans make me very worried about functional capacity and long term lung function and a lot of these people who survive. And so my best guess, and it is just a guess, is a sizable minority of people who get end up getting infected, don't know 10, 20 percent of people will end up having meaningful long term clinical effects of this virus. But, you know, I'd be speculating beyond that.

Q: Thank you very much.

MODERATOR: Great. Next question.

Q: Hi, thank you for taking the time to do this. I appreciate that. I did want to get an understanding - you mentioned a couple of times that we're getting better at this. Can you tell us a little bit more about how we're getting better at it? Like, are we getting a better understanding of this disease? Maybe talk a little bit about this idea that it's a vascular disease or what we're doing better on that and also what sort of symptoms we're seeing that we didn't understand before.

ASHISH JHA: Yeah, so the data on whether we're getting better is like not so great. We just don't don't have terrific data. I suspect, based on everything I know of what's being studied, that over the next few weeks we're going to get much more definitive evidence that the average person who got infected with the same level of severity on March 1 probably had a higher likelihood of dying than they do on July 1 or August 1. We do have a couple of treatments now that we didn't have on March 1, right. So we definitely - remdesivir didn't hit a mortality benefit, but it did look like it was heading that way and my guess is it's going to end up being a drug that's going to save lives. Dexamethasone, pretty strong mortality benefit and I believe at this moment, barring new evidence that comes out, otherwise, I will end up being a standard of care for people with respiratory distress or respiratory failure.

So those two drugs, plus just a lot of improvements in figuring out how to avoid intubation in people who would have two months ago got an automatically intubated. We've learned a lot about pruning and we've learned about how far you can push people to avoid ventilation, because ventilation has its own downsides. I think we are getting better at managing some of the vascular effects with anticoagulants, though I don't have very good evidence on that. Obviously, we're learning a ton here, but everything I'm seeing, both from my friends, colleagues, I should say, you know, friends too, I guess, who are out on the frontlines taking care of people, as well as the drugs that are coming out, I think your chances of surviving this disease is better today than it would've been three months ago.

MODERATOR: Do you have a follow up?

Q: No, I mean, thank you, can you just explain a little bit better and I apologize if everyone else on this call already understands, this idea of vascular versus, you know, a lung thing.

ASHISH JHA: Yeah, I think we're still sorting it out. Look, the issue around vascular for those of you who have not been following this super closely, is that what we see is a lot of endothelial damage. Endothelium is the lining of the blood vessels. And we're seeing a lot of endothelial damage in this virus. And that leads to strokes. It can lead to heart attacks. It can lead to clots in other places, can lead to clots in the lungs. And so there is this increasing idea that this may be as much of a vascular disease as it is a pulmonary disease. Like, maybe. So I express a little skepticism because we're still learning and I don't know that I'm ready to kind of - I still think there's a very large direct pulmonary effect of this virus based on all the evidence we have. But there is increasing data that the vascular effects are potentially quite substantial. And whether you manage that by just using antivirals, whether using anti clotting drugs like Heparin ends up being a mainstay of this therapy. I think a lot of people are using it but the evidence is still being worked out. So it's a disease in transition, or at least in terms of our understanding of the disease is still in flux. And I think management is therefore a reflection of those changes.

MODERATOR: Great. Thank you. Next question.

Q: Thanks. I was just curious about your read on the reopening process here in Massachusetts, which I'm sure, you know, it just allowed gyms and theaters to reopen in addition to other things that, like indoor dining. Even though we're kind of on the opposite trajectory as states that are seeing record highs in some cases, I guess I'm curious if you have concerns about places like Massachusetts and maybe more broadly like the rest of the Northeast that are continuing to move forward with their reopening plans, even as like the majority of the other states in the country are seeing their cases rise pretty significantly.

ASHISH JHA: Yes. So do I have concerns? I do. Let me provide some context. I think Massachusetts has been much more data driven. Obviously, they've brought their case numbers way low. They would meet the White House's criteria for opening up as I started off with earlier. So there's a lot to like about where Massachusetts is. They've gotten better on testing. They're not where I want them to be on testing, but they've gotten better on testing. So Massachusetts is just objectively in much better shape.

But I started with I still worry and I worry not because there's a ton of evidence that things are going in the wrong direction, but basically because I want desperately for schools to be open this fall. That's not just a professional 'I think it's really good for kids'. It's also just personal. I want my kids back at school. I think it's something lots of parents across the Commonwealth and across the country are feeling. And the single biggest determinant of whether schools will be open this fall will be the size of the outbreak in the community. And so I have been moving towards coming to believe - there's a lot of caveats there - that that it may be a choice between opening bars and restaurants on one hand versus opening schools on another.

And so I think what I would say for Massachusetts is we should watch the data very, very closely. If we start seeing any increase at all, we should track down what's driving it to the extent that it is any kind of restaurants, bars, any indoor gatherings. We're going to have to make some difficult choices as a state. Can we live without indoor dining? Can we live without indoor bars and other gathering places if it improves, our chances of being open schools this fall. To me, it's a no brainer in terms of what is a better societal value. But I worry a little bit about what's going to happen in Massachusetts. Similarly watching Rhode Island, similarly watching New Hampshire. All these places are opening up a bit more. And I think we have to be very data driven about this. And if we start seeing things heading in the wrong direction, I'd like the governors and the leadership of these states to stop and reverse course because I really want schools open this fall.

MODERATOR: Are you all set?

Q: Yeah. One quick thing, I guess maybe how much of that concern is around maybe like states here moving too quickly just in a vacuum with the reopening plans. And how much is it driven by, like, just we're in the middle of a summer, people coming to Cape Cod or Maine or just traveling during the summer and bringing cases from other states?

ASHISH JHA: Yeah, I think my sense is that - and I'm not I'm not an expert on on travel patterns in the Northeast, but my sense is most of the travel that's happening on the Cape or in Rhode Island and stuff is from neighboring states, right. And most of these states, whether it's Vermont, New Hampshire, Massachusetts, Rhode Island, New York, have now gotten to very, very low levels of disease. And so if all of these states can do a good job of keeping the levels of virus very low, then that travel won't be a huge problem. If you're having people from one low level, one low virus level community going to another in general, it should be OK. But we're going to have to watch this all carefully. But your other point that you're raising, which is really important, is what happens in Massachusetts is driven not just by what Massachusetts does, but what also New York does, what Rhode Island does, what New Hampshire does. And vice versa. And so we really going to have to have some regional coordination on this issue.

MODERATOR: Great. Looks like we're out of time, Dr. Jha. Do you have any final thoughts before we end the call?

ASHISH JHA: No, I just want to say great set of questions, and I know I started by just saying we are at a perilous moment, which I believe we are. But I think what this hour has reminded me is that we have all the tools we need to bring this virus under control and we've got to get going, especially if we want to open up our economy at some point down the road and further and to want to get our kids back to school. It's going to be really important to prioritize getting the virus under control now.

This concludes the July 6 press conference.


Click here to listen to the Podcast of the Press Conference


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Jon L. Gelman of Wayne NJ is the author of NJ Workers’ Compensation Law (West-Thomson-Reuters) and co-author of the national treatise, Modern Workers’ Compensation Law (West-Thomson-Reuters). For over 4 decades the Law Offices of Jon L Gelman  1.973.696.7900  jon@gelmans.com  has been representing injured workers and their families who have suffered occupational accidents and illnesses.


Blog: Workers ' Compensation

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Author: "Workers' Compensation Law" West-Thomson-Reuters