Medical Experts on Fighting COVID-19: Prepare for a Marathon | New Hampshire Public Radio

Medical Experts on Fighting COVID-19: Prepare for a Marathon

May 7, 2020

A drive-through testing site at Pease International Tradeport in Portsmouth.
Credit Dan Tuohy/NHPR

While New Hampshire gradually loosens COVID-19 restrictions in hopes of restoring some sense of economic normalcy, the state should also be assembling an army of public health officials to trace the contacts of people infected with the coronavirus.

That's according to Dr. Michael Calderwood of Dartmouth-Hitchcock Medical Center and Dartmouth's Geisel School of Medicine. "That's going to require a public health infrastructure we have not yet had and we need to develop,  he says. 

 

 

 

 

“That is something New Hampshire is working on. It's something every state in the country is working on. But it's an investment in public health that really the country has not focused on for many years. And that's where we need to begin to think about where we're spending our dollars," Calderwood said on The Exchange

 

Dr. Calderwood and Matthew Fox, professor of epidemiology and global health at the Boston University School of Public Health joined the Exchange to discuss what scientists are learning about the virus. (For audio and trancript of the full conversation, see below. Excerpts in this introduction have been edited slightly for clarity.)

 

Calderwood said New Hampshire has greatly increased its testing capacity over the past month (Dartmouth-Hitchcock has been a key partner in that effort), broadening the criteria for getting tested and allowing for more people to get tested.

 

“We went from a period where our case counts were doubling every four days to now spacing that out to doubling every three weeks. And really, we do see a significant impact in terms of this flattening of the curve,” he said.

 

Still, he said, "We need to think of this as a marathon, not a sprint. We need to look ahead to the next 18 to 24 months, which is a fairly long outlook, and think about this as not a single up and down, but as series of peaks and valleys that will be different in different areas of the country.“ 

The worst is not behind us but may yet be ahead, he said. 

 

We need to get to a vaccine very quickly. Oftentimes, vaccines take years to develop. The timelines that are being talked about are the most rapid that anyone has ever seen. This really is our moon shot or our polio vaccine, our ability to really show that science can meet that demand. But we do need to be careful that we're not rushing to a vaccine that may be harmful. -- Dr. Michael Calderwood, Dartmouth-Hitchcock

According to a recent report by the Harvard's Global Health Institute, New Hampshire does not yet meet testing targets but does meet the recommended positive test ratio. 

A model by the Centers for Disease Control and Prevention includes the assumption that the infection rate will increase up to 20 percent in states that re-open.

 

When it comes to reopening the economy, Fox suggested a national approach would be safer, rather than the patchwork state-by-state process now underway.   He says scaling up testing should be a top priority, in part because it would help identify asymptomatic carriers of COVID-19.

 

“The asymptomatic people who get the disease but don't experience any symptoms, or those who experience very mild symptoms, are what makes this such a challenging disease to control," he said. “Because if you only isolate those who are having severe symptoms or even anyone who has symptoms, you're not going to be able to control the virus.”

Air Date: Wednesday, May 6, 2020

GUESTS: 

Dr. Michael S. Calderwood, Associate Chief Quality Officer at Dartmouth Hitchcock Medical Center and associate professor of medicine at Dartmouth’s Geisel School of Medicine. His specialties include infectious disease and hospital epidemiology. Visit here, for COVID-19 information provided by Dartmouth-Hitchcock.

Matthew Fox, Professor of epidemiology and global health at the Boston University School of Public Health.   Visit COVID-19 Response, BU School of Public Health's site for COVID-19 related news, resources, and frequently asked questions.

 

Transcript:

This is a computer-generated transcript and may contain errors.

Laura Knoy: 

From New Hampshire Public Radio, I'm Laura Knoy, and this is the exchange. Two months into the Coronavirus pandemic, there's still so much we don't understand,from how the virus evolves to questions about cloth masks. Many Americans still feel in the dark about the virus and the disease it causes, COVID-19. That's partly because medical experts hadn't seen this virus before, and it's turning out to be more powerful than many had thought. Today, hat science is still learning about the coronavirus Exchange listeners, it's a great chance to get your questions answered.

Laura Knoy:
Our guests are Dr. Michael Calderwood. He's associate chief quality officer at Dartmouth Hitchcock Medical Center and associate professor of medicine at Dartmouth's Geisel School. And his specialties include infectious disease and hospital epidemiology. Also with us, Matthew Fox, professor of epidemiology and global health at the Boston University School of Public Health. Welcome to both of you. And Dr. Calderwood, I'll start with you. Here we are almost two months into this this crisis. And many Americans are saying, look, what is it going to take to get us out of this? Is it medicine? Is it a vaccine? Is it continuing the shutdowns? Is it so-called herd immunity? What's it going to take? Dr. Calderwood.

Dr. Michael Calderwood:
Thank you. Great question, one we're all really trying to wrap our minds around. You know, I think we need to think of this as a marathon, not a sprint. And I really do think that we need to look ahead to the next 18 to 24 months, which is a fairly long outlook. And think about this is not a single up and down, but series of peaks and valleys that will be different in different areas of the country. And so areas where we're in a more urban environment and more dense populations, we may see disease spread more quickly, particularly early on. And then areas that are more rural may experience things later. And there's been this question about a second surge or peak occurring next fall or winter. And what we're really trying to understand is how many of those we'll need to experience before we have enough immunity or exposure in the populations that folks have already been exposed and are less susceptible, or there's a vaccine developed or we have more therapies that are available. And all of these are still unknowns. So there are a series of models and we're really trying to get our best guess as to which one we're following at any given time.

Laura Knoy:
Well, and I'll definitely ask both of you to follow up a little bit later on what you said. Dr. Calderwood. You know, 18 to 24 months, I'm imagining that a lot of stomachs are dropping right now among our listeners hearing that it could possibly be that long. But Professor Fox, want to bring you into it, too, just broadly, and then we'll get into details. What is it gonna take to get us out of this?

Prof. Matt Fox:
Well, thank you for having me. I think that the the future of how we deal with this is going to be a combination of things. That that there is going to be no one answer that gets us back to anything close to normal immediately. But I think that if we focus on a combination of tried and true public health strategies, we can start to return to a more normal life. So that's going to be the things that we've been doing so far. So focusing on good hand hygiene and disinfecting households and workplaces, but also maintaining social distancing as much as we can, even as we go back to opening up the economy. And then also focusing on strategies for identifying cases and identifying where outbreaks are taking place. So that's increasing the amount of testing that we're doing and then identifying cases, isolating them and finding the contacts of people who have been around people who are infected so that we can also isolate those people and hopefully reduce the amount of transmission that's occurring in the community.

Laura Knoy:
Wow. So it sounds Professor Fox like kind of more of the same? Is that what you're saying?

Prof. Matt Fox:
It's more of the same. But I also think it's going to be scaling up to a much larger degree than we're doing now. So if we're going to if we're going to go back to a more normal economy, then we have to have a large number of people who are dedicated to identifying cases and tracing all of their contacts so that we can actually start to get ahead of things. We currently don't have enough people who can fulfill those roles at the moment. And so we're really talking about scaling our public health efforts on a scale we've really never done before.

Laura Knoy:
Here's another big question that I know a lot of people ask me, because I host this show so people think that I know more about this than perhaps I do. But immunity. That's a question that I'm getting a lot. Dr Calderwood. If someone has had COVID 19. Are they immune?

Dr. Michael Calderwood:
So this is the kind of billion dollar question. And I tend to think of it more like immunity that you would get, say, from the flu vaccine. And when we think about those who've been vaccinated, so let's just think about the flu. And I want to comment: This is not the flu. This is much more severe than the flu. But those who get vaccinated can still get the flu. Fewer number of get it, those who get it are less likely to end up in the hospital or in the ICU or ventilated. So there is some attenuation of the severity of illness. But whether it completely blocks you from ever getting COVID 19 again is yet to be determined. And I think the other thing is that we know that the virus shifts over time. And so there may be changes in the virus that impact what that prior exposure and immunity from that prior exposure mean.

Laura Knoy:
Yeah, because if the virus is mutating, right. Dr. Calderwood, correct me if I'm wrong, this is so disappointing to say, but you could have sort of version one, but not version two. Is that what you mean?

Dr. Michael Calderwood:
That is correct.

Laura Knoy:
And why is this Dr. Calderwood not known yet for sure? Because this seems to be a really key point, that if someone has had it, what the extent of their immunity is.

Dr. Michael Calderwood:
Part of this is related to the testing, and so we know that there are individuals that have recovered, left the hospital and then come back into the hospital and test positive again. And oftentimes the test is looking for pieces of DNA that may actually be present from dead virus. And so you're not actually reinfected. The test is just detecting pieces of DNA that are still present. So that is one theory that it's actually not a reinfection, just prolonged detection of the original infection. But the other thing I'll say is this is a new disease. You know, we feel as if we've been dealing with this for eternity. But it really has only been a matter of months. And, well, I'm seeing science come out on this, both peer reviewed and increasingly non peer reviewed, at the most rapid rate I've ever seen. There's a lot we don't know about this virus because it's so new.

Laura Knoy:
That's for sure. So if having COVID 19, Dr. Calderwood doesn't give you 100 percent immunity, can we even really talk about hopes for what's called herd immunity, where so many people have had it that it doesn't have anywhere to go?

Dr. Michael Calderwood:
So I think when we talk about some of the antibody testing that is being developed, what that will give us a sense is how much of the community has at least been exposed once, versus those that would be completely naive to this infection. And as we have more and more that have been exposed and therefore have some degree of protection, they may be less likely to spread it. And that will help with transmission dynamics such that things will slow down so that as we have higher percentages of the population, whether that be 60 percent or 70 percent, there are a number of questions around what that number has to be, but as it gets up much higher than it is now, we will be able to see slower transmission dynamics such that it's not doubling as quickly as it is now.

Prof. Matt Fox:
And Professor Fox, a question for you, related. How do we work with this? You know, the possibilities that having had COVID 19, you know, Dr. Calderwood saying that doesn't mean that you won't get it again, but there is some possibility that you might not or that you would get it in a less extreme way. How do you even work with that, though, Professor Fox, given that we really don't know who's had this disease and who hasn't? I mean, dozens of people probably had what felt like a flu back in February and early March. They were turned away for testing. They were told if you hadn't been in China or Italy, you probably just have the flu. I mean, I've heard dozens and dozens of these stories. You know, I didn't feel good in February. I had all the symptoms of COVID. The doctor told me no. So how do we even work with the possible benefits of immunity if we have no idea who has had this disease and who has not Professor Fox?

Prof. Matt Fox:
So I think one of the main things that it does is it changes the way that we do our public health messaging. So we until we know and have really good information and good studies on whether or not there is immunity and how long that immunity lasts, I think we have to counsel people that just because you've been infected doesn't necessarily make you immune. We certainly have, reason, based on previous experiences with other viruses, that there would be some amount of immunity, at least for some period of time. But we don't want to counsel people that you could just therefore go back to life as normal just because you experienced the infection. And so we want to be very careful to send out the message that continuing to wear masks, maintaining social distancing, continue to be really important parts of of maintaining transmission at a level such that the health care system can continue to care for those who get sick.

Laura Knoy:
What type of work, Professor Fox has been going on at Boston University that relates to this idea of immunity and the research around how you work with that information?

Prof. Matt Fox:
So there's quite a bit of research that's been going on at our university. A lot of it is actually has been focused on the policy side of things. How are different states actually dealing with the infection? What are the strategies and states have been using? A colleague of mine, Dr. Julia Raifman, has put together a large database that details the entire country and the strategies that have been used so that it's easy to identify the strategies that are being used, so that when we get to the point of having a bit more experience with the virus, we can try and test which of these strategies has been most effective, because as was pointed out, we're we're not going to get out of this very quickly. And so we need good information on which of these strategies is most effective. And having access to the information on what's been done so far is going to be the best way we can get at that information.

Laura Knoy:
Well, speaking of research, Dr. Calderwood, Dartmouth is working with the Mayo Clinic and others on a plasma therapy using the blood plasma of people who have recovered from the disease. So what's the bottom line of how that might work?

Dr. Michael Calderwood:
So this is the idea that you have certain antibodies that can be pulled from those who've recovered and provide a jumpstart to the immune system, to those who are acutely ill and have not yet developed their own immune response. It is still experimental It is one of a number of clinical trials that are ongoing, but it is one that we are participating in.

So what does that mean, Dr. Calderwood? And I hear you want to be cautious and I completely get it. Does that mean if I had COVID 19 and I recovered from it, someone who was ill could take something from my blood and that would help bolster their immunity? It wouldn't necessarily cure them, but it might help them out?

Dr. Michael Calderwood:
Yes, that's usually part of a series of therapies. And so when treating someone for COVID 19, we have antiviral medicines that help to disrupt the entry of the virus into cells or to kill the virus at various points along the way. Those are all being investigated. Now, we had some early suggestions last week about promising outcomes for a drug called Remdesivir. There are a number of other ones that are being studied. There are also protocols that look at medicines that help to rein in the kind of surge of an inflammatory response early on. That's why people were excited about things like Plackendael and other and other medicines. But the real question now is what combination of those is really most beneficial?

Laura Knoy:
What's this been like for you Dr. Calderwood, I'll ask you first, but Professor Fox I want to hear from you, too. You know, I hear you talking about all these therapies and people are excited about this and they're excited about that. But you do have to be so cautious. Has it been kind of like a roller coaster or up and down? What's this been like for you, just personally, Dr. Calderwood, as someone who really wants to help people out and wants to find something that will help people get over this?

Dr. Michael Calderwood:
You know, I think that there it's what's really exciting is to see the speed at which things are moving along. And there's a lot of excitement around diagnostics and a lot of excitement around therapeutics as well as vaccines. And anytime something like this happens with such a large number of people being infected with a new disease and then a large number of people continuing to die, the real question is how quickly can things happen? And I want to just be careful that it needs to be a question of how quickly can things happen safely. And so, we'll come to the vaccine in a second, but from the therapy side, oftentimes things go through years of clinical trials that help us to really understand the pros and cons of any therapy and any therapy will have side effects. And there are times that those side effects are worse than the actual benefit of the therapy. And so that really is what we were learning early on around things like hydroxychloroquine, which I referred to earlier as Plaquenil. And we saw a lot of harm from this therapy. And it may have been worse than the actual benefit from that. Remdesevir, which is the one that was reported on last week, we had one trial come out that ended early and was underenrolled and didn't show a benefit. And then we have another that we have preliminary data but the trial is still ongoing and has not been published or peer reviewed. It is encouraging but a lot of the endpoints that we're being looked at were a bit mixed. And so we have to be thoughtful that there's a lot of excitement about this drug. We continue to study this drug, but we want to not jump on any one given miracle and give up on the ability to look at other things. From the vaccine side. I will just say, I think we need to get to a vaccine very quickly. Oftentimes, vaccines take years to develop. The timelines that are being talked about are the most rapid that anyone has ever seen. And I think that this really is our moon shot or our polio vaccine, our ability to really show that science can meet that demand. But we do need to be careful that we're not rushing to a vaccine that may be harmful, either in the trial, in the lead up, in terms of infecting people with something that we can't treat, or getting something to market that either can't be manufactured in the level we need it or has problems with manufacturing that cause harm.

Laura Knoy:
I definitely want to ask both of you about the vaccine but I appreciate what you're saying about everybody kind of anxiously looking for what you called the moonshot. Dr. Calderwood. Professor Fox, just personally, what's this been like for you -- you know, everyone really wanting this thing to be over, to be better. Dr. Calderwood mentioned hopes for this and then they're dashed and hopes for that medicine, and then it turned out to be not so good. What's this been like for you as an epidemiologist?

Prof. Matt Fox:
It's been a challenging time. You know, science, by its nature, is slow and careful and methodical. And we don't have that luxury right now. Things are moving at a pace that we've never really seen before. The closest thing I think that we could probably look to is the pace of research that went on with HIV. And that's nothing like what we're doing now, where we're going from things happening on a scale of years to things happening on a scale of weeks to two months. And, you know, the problem that comes with that is we have to make a tradeoff between speed and quality. Hopefully we don't compromise much on quality. Hopefully, we are able to keep quality of the research that's coming out quite high. But inevitably, there will be cases where mistakes will be made and we just need to to keep our eyes on that. The other thing I would say is people very much are looking to the the epidemiologists for information about the future. So the questions of, when is this going to end? And in order to answer questions like that, we have to build models that predict the future. And those models inevitably come with uncertainty. And epidemiologists are trained to focus on the uncertainty more than we are on our best guess. But that's not what people really want and that's certainly not what planners need. So it's a challenging time to balance the desire to do slow, careful science with the need for fast information.

Laura Knoy:
And Professor Fox, just clarify for me, please: What is herd immunity and is that something to look at in terms of getting the country and the world out of this?

Prof. Matt Fox:
So herd immunity is the idea that if enough people are have been infected and have developed immunity, and again that issue of immunity isn't totally known.

Laura Knoy:
Big question mark.

Prof. Matt Fox:
Yeah. But let's say that if you become infected, you recover, you have developed immunity, if enough people are immune within a population, then the disease starts to die out on its own. And the reason for that is, epidemiologists think in terms of somebody called R or not, which is the number of infections that each person is transmitting to other people. And that number depends on how much contact people are having, how easily the virus transmits but also it depends on how many people in the population are susceptible, and if the number of people who are susceptible starts to drop because more and more people have had the infection and recovered, there just isn't enough people to come into contact with to spread the virus to many new cases. And therefore, the virus starts to reduce in terms of the number of new cases on its own. And certainly it's part of the strategy, but the reason that we didn't seek to get herd immunity within the population as quickly as possible is that a new virus like this would burn through the population at such a fast speed that the number of people who get severe illness would overwhelm the health care system. And so what you need to do is really manage the way in which the virus is moving through the population. And that's what lockdowns are really focused on, is the idea of slowing the transmission so that we can allow it to go through the population slow enough that we can really manage the severe illness.

Laura Knoy:
Yeah. And it sounds like from what Dr. Calderwood told us earlier, though, Professor Fox, that maybe we can't count on herd immunity this time because we really don't know if you get immunity after you've recovered from COVID 19.

Prof. Matt Fox:
And I think that's right at the moment. But I do think that information is going to become clear to us over time. How much immunity is actually developed from recovering from the infection? And so over time, that picture should become clearer and hopefully we'll have a better sense whether herd immunity can actually be achieved. But even if you don't achieve full herd immunity, things do start to to slow down. Even with with just an increasing number of people who have immunity and so hopefully we can we can manage things better through a better understanding of how much immunity exists.

This is the exchange, I'm Laura Knoy. Today, what scientists are still learning about the coronavirus. We're talking with Dr. Michael Calderwood, associate professor of medicine at Dartmouth's Geisel School of Medicine, with a specialty in infectious disease and international health. Also, Matthew Fox, professor of epidemiology and global health at the Boston University School of Public Health. And both of you, before we go to our listeners. Let's talk about the vaccine. And Dr. Calderwood, as you know, many people are looking at news of this, grabbing onto something that they might hope for. But this is a virus. Viruses mutate. So, Dr. Caldwell, how effective would a coronavirus vaccine really be?

Dr. Michael Calderwood:
So I think it really depends a lot on the target. And so there are a number of different approaches to developing a vaccine, and I'm excited that many labs and research groups around the world are kind of looking at different approaches. The one that tends to be the quickest to develop is where you target a protein on the surface of the virus that creates those spikes that many have seen in these photos of the corona virus. The problem is, is that those are the areas that are most variable when there are mutations. And that's the reason that for other viral vaccines, like the annual flu vaccine, we need to update it over time as things mutate. It is kind of more long lasting if you can develop a vaccine against parts of the virus that are more conserved. But that is more difficult. And there are also groups that are looking at novel techniques, such as injecting the code that would allow your body to kind of turn on and produce certain proteins that your immune system could then respond to. And we don't yet know which of these is going to be the most successful. But I think the other important question is, which one's going to be the most Long-Lasting?

Laura Knoy:
So in terms of how we've typically gone after viruses with vaccines, it sounds like you're saying, Dr. Calderwood, that we may need to take a new approach to doing this, given the power of this virus and given mutations.Is that right?

Dr. Michael Calderwood:
That is correct.

Laura Knoy:
So should scientists even bother with a vaccine at this point? Dr. Calderwood. Or should they focus more on treatment so people don't get horribly sick and die, given all the uncertainties around a vaccine and whether it even works or not?

Dr. Michael Calderwood:
No, I think the vaccine is is critical. And, you know, even if it provides some level of protection. And again if the vaccine can even reduce the number of people that are infected by 50 percent or reduce the severity of illness among those that do get infected, that would be a huge benefit to those that are trying to kind of address how this is affecting the community, both here in the US and worldwide, but also how we're able to handle this in a health care setting.

Laura Knoy:
All right. Well, let's go to our listeners. Bob's calling in from Concord. Hi, Bob. You're on the air. Welcome. Go ahead.

Caller, Bob:
Good morning. Hi. I have a question for your guests, and that is, what is Japan doing that seems to be just so amazingly effective and doesn't seem to be what most other countries are doing? And is this something that they could try to repeat here in New Hampshire and or other states in the US?

Laura Knoy:
Bob, thank you for calling. And Professor Foxing I'm going to throw that to first. There has been a lot of coverage about different countries that have taken different tactics which have been more or less successful. What can you tell us there are Professor Fox?

Prof. Matt Fox:
So I wouldn't I wouldn't focus specifically on Japan just because obviously things change by the country. But I would focus more on the general patterns of what's happening in other countries, particularly in many different countries in Asia. So in China, South Korea, Japan, Thailand, Vietnam is another one where they have had very effective public health approaches to dealing with the outbreak of the corona virus. So that entails the same kinds of things that we should be doing here in the United States. So lockdowns, where you're asking people to increase social distancing to a very large extent, you're scaling up effective contact tracing for identifying sick patients and isolating them. You're scaling up testing to a very large degree so that you can test anybody who needs it, but you can also test people. Anytime you identify cases, you can start to test the people around them as quickly as you can. And then the other things that some of these countries have done that's been very effective that we could consider here but has some problems, is using technology to try and do contact tracing, so apps that could be on your phone that have location tracking, which can identify where you have been and people, other other people that you've been in contact with allow for very effective identification of people who you come in contact with if you've been infected. Of course, we have different values in the United States around privacy and therefore such solutions may not be as easy to implement in the United States. But I certainly think we need to be considering them if we are going to start to reopen the economy.

Laura Knoy:
So the message a couple of weeks ago, Professor Fox from the CDC and the state was, look, we don't have a lot of testing kits we don't have a lot of the materials that work with those kits, but you know, bottom line is, if you don't feel good, stay home, don't rush to your doctor's office and take up precious resources and time getting a test. I just wonder how you feel about that, because, again, for the most part, during this crisis, people have been discouraged from getting tests unless they're sort of in dire straits or they work at a health care facility.

Prof. Matt Fox:
So we have had a shortage of tests. There's no question about it. And therefore, when you have limited resources, you have to make prudent decisions around who you're going to test. And therefore, I think those were reasonable strategies in the early days of the epidemic. We are scaling up testing, so we are increasing the number of tests we're able to do on a daily basis throughout the country. We're doing, you know, about a little over, I think, 250000 tests per day in the United States. But ultimately, that's not going to be enough if we want to be able to return to a more normal daily life. We need to be doing tests in the millions per day because we need to be able to respond very quickly to outbreaks as they're occurring. You know, in areas with a lot of transmission, that's going to be a real challenge. But in areas where there's less transmission going on, you really want to clamp down on those outbreaks as quickly as you possibly can. So the strategy to get us to a more normal approach is a tool kit of public health approaches. But scaling up testing is key among them.

Laura Knoy:
Well, so as health professionals and Professor Fox, I'll start with you, but I want hear from you, too, Doctor. How do you feel, Professor Fox, about the moves by many states, including New Hampshire, to lift some of the social and economic restrictions that have been in place? This is the message we're going to see from states around the country this month, opening up little by little by little.

Prof. Matt Fox:
So let me start by saying I'm very sympathetic to the to the reasons that people want to start opening up. The hits that this has caused to the economy have been very difficult and it's very difficult to maintain social distancing. There was guidance put out by the federal government around when opening up could start to occur. And we haven't really met those targets yet. So it does seem to be a bit premature. That said, if this is going to happen, it needs to come along with strategies for managing the inevitable increase in cases that are going to occur once you open up the economy, once you start to send people back to work, we know that that is going to lead to more transmission and an increase. So if we're going to do that, we need effective plans in place to implement those public health strategies to mitigate the impacts. Otherwise, we run the risk of the large second wave happening early and the potential need to reconsider going back to extreme social distancing.

Laura Knoy:
Wow. Yes. And that relates to something I saw just in The New York Times today. One model of the Centers for Disease Control and Prevention includes the assumption that the infection rate will increase up to 20 percent in states that re-open. And Dr. Calderwood, I have to ask you this, too, as a doctor who is trying to tamp this thing down, how do you feel about moves to reopen?

Dr. Michael Calderwood:
I think a lot of the points that were made are where we've been thinking. You know, I think we need to get away from thinking of this as a binary choice between things being opened and closed. And think about the ability to slowly reopen parts of our economy, parts of society, in a measured way, particularly as we look out at what the experience will be for New Hampshire. I will say that the stay at home order that was put into place had a huge impact here in the state of New Hampshire. And we went from a period where our case counts were doubling every four days to now spacing that out to doubling every three weeks. And really, we do see a significant impact in terms of this flattening of the curve. And so rather than exponential growth, things are growing more literally. And the reason that is important is that we did not overwhelm our health care system like other places have seen, particularly in New York. But it does mean that we are going to push out the experience in New Hampshire for months and months. And we're predicting that we're going to see kind of the peak of our cases into the fall rather than in the spring that we've been through. And so the idea is we can't really stay closed for that long. We need to begin to think about rational approaches to opening things up closely, tracking our local experience and then think of this like a pendulum that we need to make sure that as we open things up, if things start to increase, that we have levers we can pull and shift things back a little bit to protect our people but also allow them to get out and do all the things that we need to do as part of our day to day lives. It will not be normal, but I don't think what we've had in place for the last month and a half is really going to be sustainable for the duration.

Laura Knoy:
What data do you think Dr. Calderwood is necessary before some restrictions can be lifted? And I hear you. Nobody's talking about, you know, going from A to Z. There's a little bit more open here and a little bit more open there and lots of precautions. But what information do we need before we start to do this?

Dr. Michael Calderwood:
So I think the first, as was mentioned, is around the ability to do testing and we have really increased our ability to test individuals in the state greatly in the past month or more. And a lot of that had to do with US academic medical centers developing their own tests. We've seen that around the country. The testing capacity has increased over the past few weeks to a month or so. And we are now able in the state of New Hampshire to really increase the groups where testing is available. That will help us to get a better sense of those who are infected.And as was said, once we know those who are infected, we need an army of public health professionals to then track down the contacts of those individuals and make sure those folks are staying at home if they themselves are becoming ill or getting tested, and that we're creating these concentric rings of identifying where the disease is spreading and trying to limit that spread. That's going to require a public health infrastructure that we have not yet had. And we need to develop. That is something New Hampshire is working on. It's something every state in the country is working on. But it's an investment in public health that really the country has not focused on for many years. And that's where we need to begin to think about where we're spending our dollars.

Laura Knoy:
So, Dr. Calderwood, I've heard about two standards, CDC standards and also a Harvard standard that many people are referring to as we look at states that are starting to open things up again. A recent analysis by the Associated Press found very few states. I think it was 10, actually met that criteria set by the CDC and the medical experts at Harvard. New Hampshire was not among them. So I just wonder what you think about that. Dr. Calderwood and Professor Fox I want here from you too. But go ahead, Dr. Calderwood.

Dr. Michael Calderwood:
Yes, you know, I think that there are different things that we need to make sure that we have. And as one I mentioned was the testing. One is the ability to contact tracing. Those are things that have definitely improved. The other is an understanding that not every state is the same. And well, in New Hampshire, we have population centers, Manchester being one, where we will have more rapid spread, it is much more easy to practice social distancing in states such as New Hampshire and Vermont. And so we have not seen the same spread. We do not expect the same zero prevalence, meaning the percent of the population that thus far has been exposed as some other states. I think the ongoing issue is going to be around travel and how that impacts things, particularly as we go into the summer months. And so that, I think, is the big discussion we need to be having. I know a number of camps have shut down and we need to think about how people are going to vacation homes and what impact that might have. And no model can truly predict that. And so that's why as I said before, I really think we need to do this in a metered approach and look at the impact of each decision. But in terms of kind of a checklist of we need to meet each of these things, we are in a much better spot now as a state than we were a month ago.

Laura Knoy:
Well, it's interesting, although I'm reading now about rural hot spots and even disruptions to the food supply, when these big meatpacking plants and other food processing plants in the more rural parts of our country have become hot spots. So partly I'm encouraged to hear you say that it's easier to social distance in New Hampshire, but partly I'm just wondering, you know, is it just not our turn yet? Dr. Calderwood, what do you know what I'm saying?

Dr. Michael Calderwood:
No, and I think that is exactly right. That's why I did mention that as we look out and think about when New Hampshire may be hardest hit, we are talking about late August through early October. And I think we do have to be aware that the worst is not behind us, but may yet be ahead. And we need to continue to prepare for that. And so I'm not suggesting anyone stop any of the very kind of aggressive preparedness efforts. But at the same time, we have to be cognizant of the big impacts. And so if I just focus on health care, there are a number of individuals who have kind of put off very essential medical care because they're afraid to come into the health care setting, not understanding that our experience in New Hampshire is not the same as, say, in Boston or in New York City. And so we do want to kind of emphasize that we are tracking this very closely. We're screening everyone coming through the doors. Everyone is wearing masks. But at the same time, the health care facilities here in the state are open for business and are quite safe. And we want to be careful that folks that really need medical care are coming in to get the medical care, whether that's for COVID or any of the other things people need care for, because we are seeing a downstream effect that people are putting off what actually would be lifesaving treatment, often out of fear and we need to be careful about that unintended consequence.

Laura Knoy:
Well, and we are in the middle of May going to do a whole weeklong series on the impact of the health care system here in the Granite State, sort of relating to some of the issues that you just raised. Dr. Calderwood. But Professor Fox, I'd just love your thoughts, too, on this broad idea about opening up and how you view it.

Prof. Matt Fox:
A couple of different thoughts. I would echo so much of what Dr. Calderwood said. But I would also add that I think we need to be thinking about this on a national scale. When you when you think about the restrictions that were put in place in New York, where we're having the worst outbreak in the country, that is to the benefit, obviously, of New York to try and reduce the transmission there. But it's also a benefit to all the places that people from New York who were infected would be going that would be seeding outbreaks in other places. I don't mean to pick on New York, Massachusetts or any other state where there's an outbreak happening. And so coordinating exactly how we're going to reopen the economy is really critical. But I do also agree with the point that you certainly have different dynamics going on in different states. More rural areas definitely have different transmission patterns than do urban areas. And we want to be very thoughtful about the ways that we do this. But I think the biggest thing that we need to do is we need to have plans in place. We need to have businesses that are going to reopen, have plans for how they're going to protect both their customers and their employees. States need to be thinking about how they are going to reduce the amount of transmission that's happening in public transportation. Obviously, hospitals and health care providers need to be thinking through their plans for infection control. So it's really thinking about this on a national scale and how we're going to coordinate the reopening of the economy. That's going to be critical. And then the last thing I would say is, while we're doing all those things, we also need to be thinking about just how do we scale up all of the public health approaches that we need to, how do we ensure that people have access to masks, how do we ensure social distancing continues even when people start going back to places that they really want to go to, beaches and restaurants and things like that, how do we ensure that we have enough people who can go out and effectively identify the cases and isolate them?

This is the exchange, I'm Laura Knoy. This hour, how scientific understanding of the coronavirus keeps evolving, from how it spreads, who might be immune. We're also looking at some of the possibilities around treatments, medicines and vaccines. Helping us out this hour, Dr. Michael Calderwood, associate professor of medical medicine at Dartmouth's Geisel School. He's got a specialty in infectious disease and international health. Also, Matthew Fox, professor of epidemiology and global health at the Boston University School of Public Health. And both of you: Deb emails: If you are someone who has the virus but is asymptomatic, how long will you have the virus and for how long are you infectious? Deb, that's a question a lot of people have had. So thank you. And Dr. Calderwood, can you answer that?

Dr. Michael Calderwood:
Yes. And this is actually an area where we've had some change in guidance over the past week. And so I'm really thinking about that period maybe being a few days longer than folks have previously been talking about. So originally when we were looking at individuals who developed symptoms and probably had a period of pre-symptomatic disease prior to that, we were looking at a week after the development of symptoms in folks who had had three days of recovery, meaning improving respiratory symptoms and fever. And so that seven days is when we began to think that they were no longer infectious. Now we're looking really at a 10 day window. And that speaks to the fact that we are identifying people earlier on in their disease, including increasing testing in individuals who are asymptomatic that may be undergoing therapies where their immune system is going to be compromised, people who are coming in to get chemotherapy, folks who are going to undergo certain higher risk procedures. And so now we're looking at 10 days. And what we do know is if you are to swab people, that you can detect the virus by a PCR method, which is looking at DNA for a longer period of time and in folks who have underlying health issues where their immune system is not as strong, you can often detect that DNA for a longer period of time. And so it makes sense to begin shifting things out. But as of today, we're using 10 days, even amongst those who are asymptomatic, to define the period in which you're contagious to others. Now, others in your family may need to quarantine for longer because they could be exposed anywhere in that 10 day period.

Laura Knoy:
Well, and I'd like to ask you to, Professor Fox, about the asymptomatic nature of this virus and in terms of the public messaging around it. Early on, Professor Fox, we were told, stay at home if you don't feel well. Of course, people shouldn't go out if they're sick. But I wonder if the constant repetition of this phrase, Professor Fox, created a false sense of security for people who feel fine.

Prof. Matt Fox:
I do think there is the possibility, but I think that the the asymptomatic people who get the disease but don't experience any symptoms or those who experience sort of very mild symptoms are what makes this such a challenging disease to control. Because if you only isolate those who are having severe symptoms or even isolating anyone who has symptoms, you're not going to be able to control the virus. And this is why the the increase in testing is so critical and contact tracing is so critical, because if you are only testing those people who have symptoms, you're going to miss a proportion of the population and don't know at this point exactly what that proportion is. But you're going to miss a proportion of the population who can continue to transmit the virus. And so if you do scaling up of contact tracing, you can identify those symptomatic cases fairly easily and then you can identify the contacts of those people who experienced symptoms and test those people to see if they are infected, even if they never experienced the symptoms. Then you can more effectively isolate the people who are able to transmit and hopefully bring down the the state of the infection.

Laura Knoy:
So that asymptomatic person and not their fault.They feel fine. They can go to work. They could bag your groceries, Professor Fox, and pass on the virus to you. Is that correct or am I overstating that?

Prof. Matt Fox:
No, that is certainly possible that if people are asymptomatic but are able to transmit, then they could potentially be passing on the virus. I will say we don't we still don't know what proportion of transmissions are happening this way. And therefore, we do want to continue to get out the message that people should certainly be isolating whenever they have symptoms. But again, scaling up of our public health approaches is going to allow us to identify those who are able to transmit the virus, even if they're not experiencing the symptoms.

Laura Knoy:
Well, and so to me, that says, and this is pie in the sky, obviously, Professor Fox, but to me that says just test everybody. I mean, I feel fine today, but, you know, I have to go to the drugstore later. I'm going to wear a mask, but I don't want to infect someone. So should we just test everybody, Professor Fox?

Prof. Matt Fox:
Well, certainly, if if we had the resources available to us, we would we would absolutely want to test absolutely as many people as we could. But that's a really tall order, because not only would you have to be testing everyone, you'd have to be testing everyone over time. And it's not a really probably effective way to be using the resources that we have available to us when we can really only be doing somewhere in the neighborhood of two under fifty thousand tests per day in the US right now. But, you know the goal doesn't have to be to identify and stop every single infection. The goal is to identify as many infections as we possibly can and isolate as many as we can so that we're slowly bringing down the transmission,not that we're gonna stop all transmissions from occurring completely. And then we will have a health care system that can effectively manage these cases and prevent the severe consequences.

Laura Knoy:
One of the aspects of this that's been a little bit of a relief for parents is that mostly older people seem to suffer the most. But then we got an email from someone who says, I read an article recently that said some children who have COVID 19 have developed blood pressure problems and inflammatory syndrome. I appreciate this person writing in. I too Dr. Calderwood have read more recently about strange infections in children. What do we know about this so far?

Dr. Michael Calderwood:
So whenever you have this many infections, you are going to begin to see atypical manifestations. And while, it is true that, in general, those who are younger children, adolescents and young adults tend to have less severe disease, we are beginning to see some who go on to develop, so for instance, in young adults it had been reported that some have had early episodes of things like stroke. Now, that is not common, but it is scary when you begin to read stories like that. In young children. We're seeing inflammatory conditions and inflammation of blood vessels that can be seen in changes in the fingers and the toes. That's usually an early warning sign and a reason to get tested. I think one thing and again, going back to what you said at the beginning, that this is a virus that, you know, last year we knew nothing about.Now we're trying rapidly to learn about every day. We learn new things each day. And so there are definitely inflammatory side effects from the virus. And we're understanding the long term implications for that. But what I would say is, particularly in those who are young, I would still list those as quite rare.

Laura Knoy:
All right. Well, both of you, many more questions we could have talked about. And I hope to be able to talk to you again, because this is evolving, changing. But you have really helped us out today. Dr. Calderwood, thank you so much for being with us. I appreciate it. Thank you very much. That's Dr. Michael Calderwood, associate professor of medicine at Dartmouth's Geisel School. He's got a specialty in infectious disease and international health. And Professor Fox was very good to talk to you, too. Thank you for your time.

Prof. Matt Fox:
Thank you for having me.

Laura Knoy:
That's Matthew Fox, professor of epidemiology and global health at the Boston University School of Public Health. And you've been listening to the Exchange on New Hampshire Public Radio.

The views expressed in this program are those of the individuals and not those of NHPR, its board of trustees or its underwriters. If you liked what you heard, spread the word. Give us a review on Apple podcasts to help other listeners find us. Thanks.