Hard Truths From Infectious Disease Specialists

Ken Terry

April 04, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's  Coronavirus Resource Center.

We should expect more deaths from COVID-19 than previously predicted, leaders of the Infectious Diseases Society of America (IDSA) said at a press briefing Friday.

The models on which the current national estimate of US mortality from COVID-19 are based assume that optimal social distancing will be practiced across the country, said Rochelle Walensky, MD, vice chair of IDSA's HIV Medicine Association and chief of the infectious diseases division at Massachusetts General Hospital in Boston. Under that scenario, the White House has said, the range of mortality would be 100,000 to 240,000 deaths.

However, Walensky noted, "We're not properly social distancing. We're not doing enough. And in that case, the models were wrong. Our prevention activities were not as robust as the models suggested, so the number of deaths will be higher."

When the number of COVID-19 cases declines, Walensky cautioned, some degree of social distancing will still be needed. "We can't think about not social distancing anymore until we can understand what it means to go from mitigation back to containment [of the coronavirus].

"When we go from mitigation to containment, that means that anyone who is symptomatic has access to a test, and we have to make sure that a person who tests positive is able to self-isolate and that we can 'contact trace' all of those people. We're talking about blanketing tests so they're universally available to anyone at any time."

Thomas File Jr, MD, president of the IDSA and chair of the infectious disease division at Summa Health in Akron, Ohio, added, "As we go back from mitigation to containment, everyone is anxious to get back to business as usual. But I'm not sure we'll ever get back to business as usual. The whole concept of promoting good health practices is going to have to continue even after we're in the downslope. By that, I mean staying home if you're sick, washing your hands, avoiding touching your face. We'll have to continue those practices, even if there's a downslope of this virus epidemic in our country and in the world pandemic."

Test Accuracy

Walensky noted that the COVID-19 test now being used in hospitals is only 70% sensitive for negative results. "Therefore, we're doing results review for every patient we take off precautions from the hospital to make sure they're not a false negative."

She clarified, "We believe the test is pretty good if it gives you a positive result. We think we can trust that to say the person really has the disease. But if it gives a negative result, the reported sensitivity of that is only about 70%."

One reason for this, she said, is that there can be a sampling problem if the clinician doesn't stick the test swab far enough into someone's nose. "Second, as patients get sicker, the virus migrates from the nasopharynx to the oropharynx and into the respiratory tract. We don't know, when it migrates down, whether it has left the nasopharynx."

Patients aren't being retested near the end of their clinical course, although that would be ideal to ensure they were free of infection, File said. "After people are afebrile for a certain period of time, usually after 14 days, we've considered that they've resolved their illness to the point where we can reduce the quarantine aspect of their care," he said.

Infected healthcare workers, on the other hand, are not only quarantined for 2 weeks but also must have two negative tests, 24 hours apart, before they're allowed to return to work at Massachusetts General, Walensky said.

Social Distancing Works

With most of the country on some form of lockdown, Walensky stressed there is abundant evidence that social distancing can slow the spread of COVID-19. "There have been empirical data going back to the 1918 flu epidemic that demonstrate that social distancing measures delayed the peaks in mortality, had lower mortality, and took longer for that mortality to happen," she said. "We also have new data from China showing the infectivity of the SARS COVID virus. We know from those data that social distancing almost halved the infectivity and the reproductive number of SARS."

The Trump Administration has signaled that everyone in the most infected areas will soon be urged, but not required, to wear masks in public. Walensky emphasized that people should continue to adhere to social distancing even if they wear masks. Also, she noted, "You're not protecting yourself if you wear a mask, you're protecting someone else from something you might transmit to them asymptomatically and unknowingly."

Walensky acknowledged that "vulnerable communities," including the poor, have less ability to socially distance than other people do. "They may not have the space, and they may have more need to go to work and get paychecks. And, where less social distancing is occurring, we're seeing a higher incidence of the epidemic."

Walensky said she hasn't seen any triaging of patients by their ability to pay for care. But some vulnerable groups have less access to healthcare than more affluent people do, File noted.

A reporter asked Walensky whether doctors are collecting observational data on the effects of hydroxychloroquine, which was recently approved by the Food and Drug Administration (FDA) for emergency use against COVID-19, and whether the data would be useful if they did. She said that 35 clinical trials of the drug are now being conducted, and a lot of physicians are already prescribing it. However, she added, "We need a big observational cohort, because not every hospital has the capacity to look through these charts and see what people got."

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