Four physicians have been meeting on Zoom every day this week to come up with a plan to reopen the state’s largest cities in the midst of a pandemic.
They know the public and business and political leaders are eager to move out from under the stay-at-home lockdown and get back to work.
They know taming the virus will require a level of risk assessment they’ve never attempted.
They also know they can’t afford to be wrong.
“The challenge is to avoid a resurgence of the virus, let people go back to work, and not allow the health care system to be overwhelmed, as it has been in New York City,” said Dr. Manoj Jain, an infectious disease specialist who has been given a leading role in managing the pandemic and reopening in Memphis.
Those are questions Jain and his three colleagues have been asking the mayors and business leaders tasked with deciding when and how to reopen the economies of Memphis, Nashville, Knoxville and Chattanooga.
The “Big 4” mayors have said those plans will be based largely on the expert advice of an infectious disease specialist in Memphis, an immunologist and an orthopedic surgeon in Nashville, and a pediatrician in Chattanooga.
The mayors expect to announce their final plans by early next week.
“The plan has to be data-driven by the science, but it also has to be politically realistic and economically practical. But what happens when the science says one thing and the politics or economics says another? How much risk are you willing to accept?” Jain said.
They’re not looking for answers. They know there are no answers.
The coronavirus is so new and unpredictable, even doctors aren’t sure what exactly must be done to manage the pandemic, prevent another wave of infections, and avoid another lockdown.
They agree containment requires more robust testing, contact tracing and isolation, as well as continuing limits on the size of public gatherings.
But who should be tested, and when, and for what, and by whom?
How many contacts should be traced, and monitored, how quickly and how long, and by whom?
What procedures, if any, can employers — from nursing homes to restaurants — be required to follow to keep their workers, customers and the rest of us safe?
When exactly will it be safe to reopen? After 14 days of steady or declining COVID-19 cases? Or hospitalizations? Or deaths? Are 7 days enough?
And how will they deal with inevitable complications, which occur daily, if not more frequently, in this slow-moving but ever-changing crisis.
The Trump administration and the CDC last week offered opens in a new windowmedical guidelines for reopening, but governors and mayors are being allowed to make their own decisions.
Tennessee Gov. Bill Lee said he wants to start r opens in a new windoweopening rural counties Monday “in a safe and methodical way,” but he’s letting the state’s largest cities develop their own plans.
“I do trust the process we’ve set up to get to those answers,” Mayor Jim Strickland said last week. “And like I’ve done the entire pandemic, I’m going to listen to what the doctor orders.”
“Every encounter may be an infection”
Barry White is ready for the economy to reopen for business, but not for business as usual.
The retired Germantown attorney will continue to avoid restaurants and stores that don’t maintain social distancing and require masks.
He plans to go back to church and to the gym, but only if others keep their social distance to keep each other safe.
He’s ready to move out from under strict stay-at-home orders, but he wonders if the people in charge are ready.
“We are hurting the economy by keeping people in quarantine as a precaution because we don’t know what’s going on with the virus,” White said. ”And when the restrictions are eased, people are going to be reluctant to go back to work or to shop, if there is fear that every encounter may be an infection.”
Reducing that possibility while easing restrictions is the challenge — and the monumental dilemma — facing the four medical professionals advising the “Big 4” task force.
They aren’t just relying on their own knowledge and experience. They are consulting with a wide range of medical experts, including those who also are advising the local city-county COVID-19 task force.
Jain has been in constant contact with Shelby County Health Department director Alisa Haushaulter, as well as public health officer Dr. Bruce Randolph, and chief epidemiologist Dr. David Sweat.
He’s consulting Dr. Jon McCullers, Dr. Scott Strome and other deans at UTHSC.
He’s also being advised by Dr. Jeff Warren, a City Council member, and Dr. Scott Morris, co-founder of Church Health, as well as leading physicians at local hospitals, including Dr. Paul DePriest of Baptist Memorial Hospital.
All agree that reopening the local economy safely, and keeping it open, will require the right testing, tracing and timing.
They don’t necessarily agree on the details.
Testing is the most contentious issue.
Tracing is the most complicated.
Timing is the most critical — not only during the next few weeks but in the months ahead.
“We will have coronavirus in the fall,” Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, opens in a new windowsaid Wednesday. ”I am convinced of that because of the degree of transmissibility that it has, the global nature. What happens with that will depend on how we’re able to contain it when it occurs.”
Jain and other local physicians agree that will depend, in large part, on how safely and carefully cities and states reopen their economies.
“Still a lot of questions”
Earlier this week, the U.S. Food and Drug Administration opens in a new windowauthorized the first at-home COVID-19 test collection kit.
The kit, which will require a doctor’s order, contains nasal swabs and saline. Patients can self-swab, then mail the sample in an insulated package to LabCorp for testing.
“With this action, there is now a convenient and reliable option for patient sample collection from the comfort and safety of their home,” said FDA Commissioner Stephen M. Hahn.
If it works, and if it becomes widely available in the coming weeks, and if enough people use it, the at-home test kit could dramatically change everyone’s plans.
Task force members are confident local labs, hospitals and “safety net” clinics have the capacity for 2,000-3,000 COVID-19 tests a day.
Jain believes that’s how many will be needed here to track and tame the virus in the coming weeks.
But in recent weeks, local labs have struggled with the sudden deluge of COVID-19 tests, shortages of chemicals, and mechanical breakdowns.
In recent days, some local hospitals have run low or run out of test swabs and fluids that preserve specimens for transport to labs. Some are improvising with strep test kits and saline until they find new supplies.
And lately, opens in a new windowpublic demand for COVID-19 testing has declined. Officials believe it’s an access issue.
Last week, they added community testing sites in Hickory Hill, Frayser, Parkway Village and a few other “under-served” neighborhoods.
Meanwhile, Jain and other medical advisers believe that ramping up the use of two other tests will be vital to managing the pandemic in the coming weeks. Both steps could prove problematic.
Rapid-results tests, or so-called “quick tests”, can produce results in less than 15 minutes.
But the test samples from the quick tests, developed by Abbott Labs, must be inserted directly into special machines. There are opens in a new window60 such machines in the Nashville area but none yet in Memphis.
“Walgreens will be offering one location soon, but they will call people with their results within 24 hours instead of having them wait 20 minutes in line,” said Jenny Bartlett-Prescott of Church Health, who is leading the local task force’s testing initiatives. “We can test more people that way.”
Antibody tests, simple blood tests that detect whether someone has been exposed to the virus and might have developed some immunity, are becoming more widely available here.
Dozens of biotech companies and research labs are producing them.
American Esoteric Laboratories (AEL), which is processing a majority of local COVID-19 tests, has told local officials that it has the capacity to process 3,000 blood tests a day.
UTHSC is opens in a new windowdeveloping its own antibody test.
McCullers, associate dean of the College of Medicine, wants 200,000 metro-area residents be tested this summer.
“I’d like to see 10-20% of the general public tested,” he said. “It’s just not part of the strategy for the first wave, it’s part of how we will deal with this on a long-term basis.”
Early results from 3,000 blood tests performed in California show that COVID-19 might be opens in a new windowdrastically more widespread — and less deadly — than swab testing suggests.
But opens in a new windowresearchers disagree about whether the tests are accurate enough at this point to confirm exposure or immunity to the virus.
And new studies in China, where the coronavirus was first detected, showed up to 1 in 3 patients recovered opens in a new windowwithout developing antibodies.
“These tests will be critical in our efforts to manage the virus in the months ahead, but there still are a lot of questions,” Jain said.
“Timing is everything, even in a pandemic”
The “Big 4” physicians have spent a lot of time this week trying to decide how to weigh and measure each city’s readiness to reopen.
How many people are being tested every day in each city?
How quickly are the results of those who test positive being reported to the health department?
How quickly and thoroughly are the contacts of those who test positive being identified, informed they might be infected, quarantined, tested and monitored?
Has there been a steady decline in the number of people who are testing positive for COVID-19 and being hospitalized for it? Are those numbers rising again?
The entire task force will set benchmarks for those questions.
Those benchmarks will determine when and how quickly local businesses, government agencies, medical facilities, schools, houses of worship, and other places will be allowed to reopen — and remain open.
And all of those calculations are subject to change.
The lightning speed at which the coronavirus moves has been matched by the supersonic speed of the scientific and technological efforts to catch and defeat it.
”Everything we know about this virus is changing so fast and so frequently,” Jain said. “You start talking about one thing in the morning, and by the end of the day, you’re talking about something completely different. Making decisions is quite a challenge.”
The “Big 4” physicians have been wrestling with three big decisions.
WHO SHOULD BE TESTED?
Just about everyone agrees that anyone with flu-like symptoms (fever, cough, shortness of breath, loss of smell, or unexplained diarrhea) should be tested and quarantined until the results are back.
But what about asymptomatics?
Many people who are infected with the coronavirus don’t show symptoms for several days; some never do. But they remain infectious for at least two weeks and can pass on the virus to countless others.
“If 1 person spreads the virus to 3 others, that first positive case can turn into opens in a new windowmore than 59,000 cases in 10 rounds of infections,” according to the Bloomberg School of Public Health at Johns Hopkins University.
Last week, Gov. Lee and state health Commissioner Lisa Piercey said opens in a new windowanyone who wants a COVID-19 test should get one, regardless of symptoms.
But public health officials in Memphis and Nashville say they won’t move to asymptomatic testing until they’re sure all those with symptoms have easy access to testing.
“You must have symptoms to be tested,” Strickland told the public last week.
Haushalter and McCullers believe testing asymptomatics is not particularly productive.
They note that people who are infected can test negative for COVID-19 one day, and then positive a day or two or three later, as the virus takes hold and grows. And people who have been infected and recovered can still test positive.
“The test doesn’t always detect live virus, and it can detect dead virus,” McCullers said. “Are you going to test every health care worker and every nursing home resident every day?”
But Jain and the other “Big 4” physicians believe the reopening plans should include “targeted” testing of “high-risk” asymptomatics.
“We should be testing every health care worker, every nursing home resident, and other vulnerable populations, whether they are symptomatic or not,” said Warren, medical director for Trezevant Manor and The Parkview assisted living facilities.
“That’s the only way to find people who are at high risk for infection and isolate them from people who are healthy. That’s how you stop the virus from spreading, but we’re not doing that yet.”
HOW QUICKLY SHOULD CONTACTS BE TRACED?
Many believe contact tracing is the single most effective way to slow and reverse the spread of the virus.
It’s also labor-intensive and time-consuming, especially in the midst of a highly contagious and unpredictable pandemic.
Once someone has tested positive, trained “disease detectives” must work quickly to identify, assess — and possibly quarantine and test — others who have been in direct contact with the infected person.
“Right now we’re essentially doing quarantine isolation in a very unfocused manner across the entire population, sort of a blunt hammer approach,” Justin Lessler, a professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health, told opens in a new windowThe New Yorker this week.
“If we could get that to be targeted exactly at those people who are potentially infected and could achieve … reductions in viral transmission by doing that, I think that would be ultimately the key to being able to go back to something that looks more like business as usual.”
The CDC wants to opens in a new windowdeploy “an army” of contact tracers to help local health departments keep up with rising caseloads and find people who might be infected. They might enlist furloughed census workers or Peace Corps volunteers.
The state has doubled its contact tracing force across 89 rural counties by enlisting volunteers from other state agencies.
The local health department says it has as many as 70 people tracing and monitoring contacts.
The “Big 4” task force is considering raising that number to 100.
National and state officials are looking at the possibility of paying hospitals and doctors to do their own contact tracing.
Baptist Memorial Hospital and Christ Community Health Services have been tracing and monitoring their own cases here.
“By engaging doctors, clinics, and hospitals in the race to identify contacts who have been exposed, we can make dramatic improvements in our infection rates,” opens in a new windowwrote Jain and Dr. Bill Frist, a physician and former U.S. Senator from Tennessee, who has been advising Gov. Lee.
HOW AND WHEN DO WE REOPEN?
Earlier this week, Mayor Strickland opens in a new windowextended the city’s Safer at Home order to May 5 — nearly a week after the governor’s “safer at home” ends April 30.
“Reopening our city and getting our economy moving again is vitally important,” he explained. “But we must get back to business the right way. We cannot squander all the good we have done with our social distancing effort to slow the spread of the virus.”
Strict social distancing has slowed the spread and severity of the virus in Tennessee’s big cities.
It will continue in some form.
For example, Strickland is ordering all “big box” retailers to provide safe social distancing for customers, and masks and hand sanitizer for employees, starting Friday.
Meanwhile, the “Big 4” task force is working on a more detailed and comprehensive plan for how and when to allow non-essential businesses to reopen.
“Timing is everything, even in a pandemic,” Jain said.
The “Big 4” physicians considered two strategies.
One would allow non-essential businesses to reopen in stages — about 25 percent at a time a week or two apart.
The other would reopen by sectors starting with smaller businesses and offices where social distancing is easier, then moving to larger businesses, restaurants, houses of worship and schools.
The Memphis plan likely will be some combination of the two.
The exact date on which the reopening will begin — likely to be in early May — will depend on two critical measures:
- The number of local COVID-19 cases must hold steady or decline over a 14-day period.
- The number of local COVID-19 hospitalizations must hold study or decline over a 14-day period.
The task force considered reducing that to 7 days each, but the mayors prefer to err on the side of caution.
Each phase of reopening will depend on continuing to clear those two 14-day bars.
The coronavirus has a 14-day incubation period. The impact of changes in social distancing, testing and other policies aren’t entirely evident for two weeks.
But the task force isn’t taking any chances.
If they see COVID-19 cases or hospitalizations trending up over, say over a five-day period, they plan to begin tightening restrictions again.
“We can slowly loosen that faucet that we’ve tightened at the right time,” Strickland said last week. “But if we loosen it too much and see a big spike (in cases), we will be prepared to tighten it back up.”
This story first appeared at dailymemphian.com under an exclusive use agreement with The Institute. Photos reprinted with permission of The Daily Memphian.