US running out of time to brace its public health infrastructure for the COVID-19 novel coronavirus

By February 20, 2020

Last week, the Senate Homeland Security and Governmental Affairs Committee queried healthcare, disease prevention, and biodefense experts during a hearing about the COVID-19 novel coronavirus outbreak. The take-home message delivered by the witnesses was that the US needs to ramp up its preparedness in a hurry so that if COVID-19 outbreaks emerge on our shores, sick Americans will receive effective care, and spread will be minimized.

COVID-19 severity and transmissibility

The world is grappling with the COVID-19 outbreak, and US public health experts are working with incomplete information to assess the situation, assist globally, and safeguard Americans’ well-being domestically. Amidst the unknowns, the witnesses at Wednesday’s hearing agreed that the case fatality ratio is ultimately likely to be less than the 2.3 percent reported by China’s Center for Disease Control and Prevention. This is because it is very likely that some people who become infected with COVID-19 virus develop no or mild symptoms and do not seek medical care, and so their cases will not be reflected in the reported number of confirmed COVID-19 cases. Indeed, models of the COVID-19 outbreak intended to account for missed cases estimate an infection fatality ratio between 0.3 and 1 percent.

However, the panel cautioned that even if the COVID-19 fatality ratio is actually less than what is calculated from confirmed case data, perhaps 0.2 or 0.5 percent, the average number of people who catch the COVID-19 virus from an infected person – the R-naught – may remain around 2 or more, as indicated by preliminary estimates. The combination of a fatality ratio at 0.2 to 0.5 percent along with a R-naught of 2 or more could make for a particularly devastating disease, causing many deaths among the large number of people the COVID-19 virus could infect.

The progression of the COVID-19 outbreak from a US perspective

There have been 15 confirmed COVID-19 cases in the US, but the panel believes that it is likely there are more that are going undetected, and that flare-ups will soon be observed. According to former commissioner of the US Food and Drug Administration Dr. Scott Gottlieb (1:23:24 mark in video):

“Modeling has shown that the time from first introduction in China, which was probably in November, to epidemic spread was about 10 weeks. If you think that cases were introduced into the US, undetected, in late December or early January, which is probably the case (statistically, it’s quite probable), we’re going to start to see those outbreaks emerge sometime in the next two to four weeks.”

Speaking on a press call last week, Dr. Nancy Messonnier, the director of the US Centers for Disease Control and Prevention’s (CDC) National Center for Immunization and Respiratory Diseases, agreed that at least some person-to-person spread in the US is probable. She said the CDC is gearing up for the COVID-19 virus to “take a foothold in the US,” continuing, “at some point, we are likely to see community spread in the US or other countries.” Later in the week, Dr. Messonnier also announced that five US cities will test patients exhibiting flu-like symptoms for COVID-19 virus as CDC works toward national surveillance for the outbreak.

What the US should be planning for

Expressing concern about a potential COVID-19 pandemic to the Committee, Dr. Luciana Borio, the former director of Medical and Biodefense Preparedness at the National Security Council, said that “we need to brace ourselves for difficult weeks or months to come” because “we’re going to see a lot more cases in the US in the near future.”

Unfortunately, funding for US biological threat preparedness has not been consistent, and the country is not in an ideal state of readiness. The witnesses lamented cyclical investment in public health that has boomed during times of crisis and waned when the biological threat landscape has been uneventful. It would be better to have sustained, well-funded public health infrastructure already in place than to scramble reactively when potential crises such as COVID-19, or Ebola, MERS, and SARS before it, emerge. And so, our healthcare system has only limited surge capacity for caring for high numbers of individuals who may become infected by the COVID-19 virus, or a different emergent pathogen. Although we have a strategic national stockpile of medical supplies and medicines, if stocks were to be expended, the resupply chain is marginal. The capability to rapidly develop point-of-care diagnostic tests – those that front-line healthcare workers could use to get results on site, reducing time to diagnosis – has not been prioritized. While the US has historically risen to the occasion when biological threats present themselves, there is no acceptable reason for being unprepared.

But what about what the US can do, proactively, right now? Witnesses stressed that public health stakeholders should review response plans and responsibilities, ensure both federal interagency coordination and federal, state, and local coordination are primed, test communication systems, assure adequate capacity of diagnostic tests, continue work on therapeutics and vaccines, and clarify how emergency funding mechanisms can be accessed.

The Bipartisan Commission on Biodefense’s executive director Dr. Asha George made the stakes for Americans very clear (1:56:43 mark in video):

“We have to plan for the possibility that we have thousands of cases. In schools of public health, they often train us to look at the data that you’ve been provided, and assume that you don’t have the data – even here in the US – that you don’t have a comprehensive set of data, and then multiply. So we’re often taught to multiply by seven or eight times what you’ve been told. For every one case you see, there are seven or eight out there that you don’t. So that means actually we’d be looking at hundreds of thousands of cases. I think that’s the scale at which we should be planning.”

COVID-19 is of concern, and the best defense is to be prepared and stay informed

Last week, the head of the National Institutes of Health Emerging Pathogens Section, Dr. Daniel Chertow, remarked that “preparedness at the individual level, and at the institutional level, both at local healthcare facilities and healthcare systems within local, state, and national levels, is warranted, and it is ongoing.” To learn about how to be prepared for potential COVID-19 outbreaks, visit ready.gov. To find some answers and stay informed about the epidemic, visit our new FAS COVID-19 novel coronavirus resource page, where we’ll be logging up-to-date information and analysis as more is learned.