How Did We Get to 10 Million COVID-19 Cases?

John Whyte, MD, MPH; William Schaffner, MD


November 09, 2020

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  • Increased testing does not solely account for the increase in the number of cases. While 10 million cases have been confirmed, more people in the United States have had COVID-19 but haven't been tested.

  • The United States has no national, population approach to fighting the coronavirus, nor a determination that we as a nation are going to reduce its spread. In contrast, some countries that have instituted a comprehensive national program are slowly and safely reopening.

  • The focus has been on research into therapy and vaccines, as though we are taking a "clinical, patient-by-patient approach" instead of a public health approach.

  • Testing can provide some reassurance, but tests are not 100% accurate; we still need to be careful about visiting loved ones. Overall, the advice has not changed: social-distance, wear masks, and avoid large-group gatherings.

  • A vaccine will offer only partial protection. Even with an effective vaccine, we will need to continue to wear masks and take other precautions.

This transcript has been edited for clarity.

John Whyte, MD, MPH: Thank you all for joining me. I'm Dr John Whyte, chief medical officer at WebMD. Today marks a grim milestone: 10 million cases of COVID in the United States. To help provide insight as to how we got here and where do we go, I've asked Dr William Schaffner from Vanderbilt University School of Medicine in Nashville, Tennessee, to join me. Dr Schaffner, thanks for taking time today.

William Schaffner, MD: Good to be with you, John. I say "good to be with you," but this is a sad day, indeed.

Whyte: It is. You and I last talked at the 5 million mark. It took many months to get to 5 million, not so many to get to 10 million. I want to just put it out there: Some people have argued that we're at 10 million due to testing, that it's really not that bad; it's just more testing. Help explain to our viewers why that simply doesn't make sense.

Schaffner: It actually makes a little bit of sense, obviously. The more you look, the more you'll find. But what you find is out there, and what we've found actually isn't all of what's out there. So this virus clearly is spreading in a very unrestrained fashion in our communities.

Given that, the more that the virus spreads, the more people will become ill. The more ill, the more hospitalized. The more hospitalized, the more in intensive care units. Then the lagging indicator — there come the deaths. We're doing better in treatment, John, but there will be more deaths. This is very sobering.

Whyte: That's what we're also really looking at. You're right — the number of cases is partly due to testing. But what we're also looking at, which is of concern, is the increase in the hospitalization rates and number of deaths. Even though we've made progress, we're still not on the right course.

Why are we at this point? Is it because of fatigue and people are saying, "You know what, I'm just tired of it. I need to get on with my life"? Is it confusion about what they're supposed to be doing? Is it just a disregard of science? What do you think is the main reason that's driving this continued increase in the number of cases and hospitalizations?

Schaffner: It's a combination of things. It's all the things that you have mentioned, and let me just add a couple more. The first is that we really haven't had a national approach to this infection. It's recognition and then a determination that we were going to reduce its spread. We did not take a population view of all of this. It has been recently recognized that we were not trying to interrupt the spread of the virus. What we're trying to do is put more research into therapy and vaccines. It's almost as though we're taking a clinical, patient-by-patient approach as opposed to trying to protect large communities, states, and our whole country.

You know, Benjamin Franklin did say, "An ounce of prevention is worth a pound of cure." The public health community and infectious disease doctors have been very frustrated. We love taking care of patients, but we would have preferred to have had a national determination that we were going to reduce the spread of this virus as much as possible.

Whyte: Do we need a more comprehensive national strategy recognizing that at the same time? We need to direct resources to local levels and base decisions on what's happening in your community vs my community.

Schaffner: Well, clearly we need a national strategy. It's as though we have an orchestra at the moment, and the timpani is doing something different from the piano, violins, and horns. We need a national conductor that brings all of those disparate elements together so that we can get a harmonious approach.

At the moment, to mix metaphors, we have a crazy quilt, state by state, and even within-state differences. Is there any wonder that there's confusion out there? I have to tell you, I don't like to get into the politics, but the response to this virus has been much politicized. If we had just put the public health people in front and the politicians had stood back a little bit, we would be much better off. We would not have reached 10 million.

Whyte: You always give us good practical advice. We've talked before about the COVID bubble, associating with a group of people that have the same risk tolerance and/or doing the same safeguards. Some people have been saying that if you get tested, and depending upon what everyone's underlying health conditions are, you can go visit elderly loved ones. What do you think is the role of some of these rapid antigen tests? We're even making some progress on PCR. Should we do more testing or consider a test before we visit people, if that's what we feel we need to do?

Schaffner: We can consider testing, but then we have to consider the test. The test has some limitations, as we all know. The rapid tests tend to give false negatives. You're really infected, but the test gives you a get-out-of-jail-free card; it tests negative.

Testing can help us and give us some reassurance, but we have to do all those other things in addition. We have to do the social distancing and the mask wearing, and still be very careful when we meet our loved ones ─ the grandparents, Uncle Frank who's got bad diabetes, and the like. This virus is going to be with us for a long time. There's no quick fix here.

Whyte: There's no real new advice either. It's the same things that you and I have been saying for many months. It's the physical distancing, avoiding large crowds, handwashing, and mask wearing. There's really nothing else, right?

Schaffner: Nothing else for the moment. Let's just assume that we get a vaccine. One of my concerns is that when I speak to my lay colleagues and friends, they think a vaccine is going to be 100% effective, and that once they get vaccinated, they'll be wearing a suit of armor against this virus and can do what they want.

That's a misapprehension because the vaccines are going to be a bit more like the flu vaccines than the measles vaccine. In other words, partial protection. If we had a vaccine that was 70% effective, we in public health would be happy. But that would mean that of every 10 people vaccinated, three would be of uncertain protection. We don't know who those three are. Even when we're vaccinated, we're still going to have to wear our masks, and that gets lots of people grumpy, I'm afraid. It's a hard reality.

Whyte: This is the third time that I've spoken to you over these 7-8 months. I remember early on, when we talked about vaccines, you were somewhat lukewarm, recognizing how long it takes. There seemed to be some preliminary encouraging data. We're at the point now where some of these may only be 50% effective for approval or authorization. As you know, many people are saying they won't take the vaccine, certainly not early on. If vaccines are 50% effective, and only 50% of people take them, that's 25% protection in the community. That's way below what we need in order to think about returning to some sense of normal.

I wanted to talk to you about medicines. The data on remdesivir, in terms of who it's going to impact and the magnitude of impact, aren't as great as we originally thought. Isn't that right? In terms of who is going to most likely benefit?

Schaffner: As more data come in, we've become a little more cautious. It's beneficial, but as Dr Anthony Fauci said right at the beginning, it's not a miracle drug. We're awaiting the results of other therapeutic trials. But let me say this — and we need a little bit of a note of optimism here — there's a little light at the end of the tunnel. Countries such as New Zealand, Australia, South Korea, Japan, and China have instituted a comprehensive national program. Everybody's pitched in; they've worn their masks and have been socially distant. Now, even before vaccines, they're opening up gradually and safely. We haven't done that. We could do that. We know how to do this. These so-called behavioral interventions really do work.

Whyte: We see it in Singapore as well. I do want to ask you about monoclonal antibodies; they have been in the news and there were some encouraging data. Now there's been some mixed data. What are your thoughts on the role of monoclonal antibodies, especially early on in infection of people?

Schaffner: Cross fingers. We're waiting for the results of those trials. I actually am guardedly optimistic, of course. I'm influenced by a colleague right here at Vanderbilt, who's done a huge amount of the basic science: Dr Jim Crowe. My hat's off to him.

We hope that these monoclonal antibodies are one of the therapies that, if given early, may prevent progression to more serious disease. Even if we had that, that would be a terrific therapeutic advance that would help a lot. It would mitigate a lot of those deaths.

Whyte: So let's end with, I hope we'll talk again. But I hope we won't talk at 15 million. How do we get to that point where we start to see that curve going down instead of continuing to go up?

Schaffner: I think we need to keep giving good science-based recommendations. You know, Mark Twain said," You bring a reluctant man down from the second floor one step at a time." Provide information, provide reassurance. If we can get parts of the country to really adopt this, and the rest of the country could see it working, then I think good news might spread. So I keep trying to be optimistic about this and determined at the same time

Whyte: We all need a little bit of that optimism. I appreciate Benjamin Franklin, being from the Philadelphia area, as well as Mark Twain.

Dr Schaffner, I want to thank you for all that you're doing to help educate the public, for always providing nice, practical advice and telling us like it is. We need that candid, transparent perspective that you've been giving us throughout this crisis. So, on behalf of everyone, I want to thank you for what you're doing.

Schaffner: You're very kind, John. Thank you very much, and let's keep trying to get the good word out together.

Whyte: Absolutely. And thank you for watching Coronavirus in Context.

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