Almost all of us check the news each day to get some bearing on the COVID-19 pandemic. In the United States, new cases and deaths from the disease have had declining seven-day moving averages since April 10 and April 21, respectively, meaning our peaks in both new cases and deaths have passed and we are on the slow descent.
Because testing is largely not done or reported on weekends, and deaths lag new-case discovery, most major U.S. media outlets have removed the “scoreboard” banners of COVID-19 cases and deaths and, while the pandemic remains in the news cycle, the stories have begun to focus on the social and economic implications of policy.
The Trump administration missed an opportunity, in terms of epidemiologic reporting, by failing to mandate a daily U.S. hospital census of COVID-19 cases. Hence, there are still concerns about overloading hospitals, such as a recent overrun in Montgomery, Ala. This is a sharp reminder that test-positive cases and deaths do not adequately inform leaders about the need for hospital beds. Only uniform reporting of hospitalizations and bed capacity from all hospitals could serve this need.
Fortunately, there has been no explosion of hospitalized cases in areas that have loosened restrictions or opened the economy, suggesting the virus is passing through communities unabated and that low-inoculum spread is leading to more mild cases not requiring hospitalization.
There has been a great emphasis on testing; however, besides detecting more cases, this has not had an impact on hospitalizations or deaths. The reason is that most patients hospitalized are tested in the hospital and not at community sites. Conversely, those tested at ambulatory sites rarely become ill enough to warrant hospitalization.
Additionally, there is no outpatient treatment endorsed by state medical boards. The only oral medications with suggested, yet unproven, efficacy — azithromycin and hydroxychloroquine — have restrictions on use in most states. As a result, nearly every American who contracts COVID-19 gets no treatment at home to reduce the severity, duration or communicability of the disease.
At most community testing sites patients must have characteristic signs of COVID-19 infection, including fever, cough and malaise, and many sites require a doctor’s order. Unfortunately, it takes from five to seven days to receive the test result at most community centers — a time frame that is far too late for contact tracing and isolation. One can imagine how many contacts would accrue in a mildly symptomatic adult while awaiting the test result, making contact tracing impractical.
The Centers for Disease Control and Prevention (CDC) now uses a term “COVID-like Illness,” or CLI, to describe cases that have features of the disease but are test-negative. Repeated testing or bronchoscopy finds COVID-19 in some cases; in others, the diagnoses remain a mystery with lingering fear of a false negative test, which can occur up to 30 percent of the time. The CDC has no suggested quarantine or next steps for CLI. Likely, CLI is COVID-19 in a large fraction and these people go on to spread the virus in a low level to the next victim.
In my view, COVID-19 testing policy is not being applied in the right place. For example, there are no government mandates or medical society guidelines for regular testing of hospital, clinic or nursing home staff or patients. Despite cases of workers spreading the virus from one nursing home to another, we still do not have a policy to protect seniors from workers carrying the virus. In most regions, nursing home residents account for 30-50 percent of COVID-19 deaths.
Critically ill COVID-19 patients may stay in the hospital for weeks, but hospital administrators have not turned their attention to testing and surveillance programs for their workers. To make matters worse, there are no proven neutralizing antibody tests that could indicate “immunity” to COVID-19. An executive order mandating surveillance testing in hospitals and nursing homes would apply testing where it is needed, help protect workers and patients, and go a long way toward restoring confidence among people who want to seek care at clinics and hospitals but are afraid of contracting the virus.
So, what is the endgame for COVID-19? It appears the virus’s low-inoculum spread now is yielding more mild or asymptomatic cases. Hospitalization rates are flat but steady. Younger persons appear to be fueling the spread with little real or perceived personal risk. Since there have been no documented serious double cases — meaning the same patient becomes hospitalized two discrete times for COVID-19 with a long period in between — it is reasonable to assume that once infected, there is some immunity.
Hotspots appear to be any gatherings that include potentially infected younger individuals and unprotected elderly. This means younger staff in senior homes, church services, college sporting events, and so forth. Should we worry about college kids at a big pool party? It depends on whether they will mingle with older adults or family in the next two weeks. Where the young meet the old is where the spark for serious COVID-19 cases occurs.
Should we shelter in place until there is a vaccine? If one considers that few common viruses are amenable to vaccination strategies — and certainly no coronavirus in history has been thwarted by medical science — the answer is probably not to wait for a miracle. We need to end our isolation and begin to cautiously navigate. Personal responsibility and judgment must carry the day. Those 60 and older should take precautions regarding any gatherings. Each of us should be symptom-perceptive and, if ill, be able to cancel work or leisure events, including travel tickets, without consequences. Conversely, each at-risk person should carefully consider the risks when going out in crowds and to events.
The slowly declining COVID-19 activity suggests we are on a course for months to years as the virus passes through large populations. Limiting the spread and arriving at zero cases is an academic pipe dream. Policymakers should turn their attention to hospitalization data and get the right reporting, work with hospital and nursing home administrators to make institutions safe, and find age-based suggested standards of practice that are reasonable to allow our country to get back on its feet.
Peter A. McCullough, MD, MPH, is vice chairman of medicine at Baylor University Medical Center and a professor of medicine at Texas A&M College of Medicine in Dallas. An internist, cardiologist, and epidemiologist, he is the Editor-in-Chief of “Cardiorenal Medicine” and “Reviews in Cardiovascular Medicine.” He has authored over 500 cited works in the National Library of Medicine.