Now is NOT the Time to Reduce Social Distancing

by TOM INGLESBY, MD

Tom Inglesby, MD

Editor's Note -- This is a long tweet published by Dr. Inglesby on March 23, 2020, in reaction to the suggestion by President Trump that the time to end social distancing practices may come soon. We have combined the series of tweets and replaced abbreviations with complete words. Otherwise this is a verbatim transcript of Dr. Inglesby's remarks. In last 24 hrs there have been prominent US voices calling for a stop to social distancing, citing rationale that they're worse than impact of COVID itself. It's worth looking very closely at that claim, where we are in US COVID epidemic, and what happens if we stop.

COVID has been spreading with exponential growth in US for some time, and we're just beginning to get an understanding of how extensively. There are nearly 40,000 cases recognized in the US as of today, with about 100 deaths today. A few weeks ago, we had recognized 70 cases total. Some hospitals have said publicly that within a week they will not have ventilators to treat everyone with COVID anymore.

There continue to be big diagnostic limitations. Shortages in reagents, swabs. We don't have rapid diagnostics in many hospitals yet, so it can be days before doctors and nurses can find out if a patient in front of them has COVID. We don't have capacity to diagnose many of the COVID cases that are not sick enough to be in the hospital, so those numbers aren't counted in our national totals. There continues to be terrible shortages in the masks that health care workers need to keep from getting sick with this disease.

How do we gain time to let hospitals get more supplies & prepare for high number of patients? How do we lower the speed of spread of COVID in US? How do we lower the odds that ICUs will run out of vents, hospitals run out of space?

The answer for now is large scale social distancing.

In Asia, we've seen these interventions work to lower pace of the epidemic, lower numbers of critically ill, and lower the number of people who get COVID. In Asia where big social distancing measures have been in place for two months, they have had very strong impact. They've slowed the disease by slowing social interaction.

Left to its own, this disease spreads from 1 person to about 2.5 people, and then they do the same, and so on. For this disease to stop, we need to make it so that the average person spreads it to less than one other person.

These big social distancing measures take time to work.

The impact of big interventions in Wuhan China took about three weeks to start to reverse things. And then everyday after the situation got better. In the US, we're about 7 to 10 days into this, depending on the state.

To drop all these measures now would be to accept that COVID patients will get sick in extraordinary numbers all over the country, far beyond what the US health care system could bear. Many models report that health care systems will be completely overwhelmed or collapse by the peak of cases if major social distancing is not put in place. If a health care system in a given community stops working and can no longer provide care to the ill, the case fatality rate for COVID will be far higher than 1% - we would not be able to care for some or all of the expected 5% of recognized cases that get critically ill. Beyond that, if hospitals were completely overwhelmed, they may struggle to provide even oxygen for some or many of the 15% of recognized cases expected to be "severely ill", let alone provide care for other life threatening conditions.

Anyone advising the end of social distancing now, needs to fully understand what the country will look like if we do that. COVID would spread widely, rapidly, terribly, could kill potentially millions in the year ahead with huge social and economic impact across the country.

Before considering big changes to social distancing measures now, we should, as quickly as possible, get to strongest possible position for COVID response – we are no where near that now.

• We'll need rapid doctors in place in almost every location where a patient can be seen for care.

• We'll need extraordinary quantity, reserve+production lines of masks, PPE so that shortages at hosps and clinical sites around country are no longer possible. We'll need to have more vents on the way. We'll need capacity to provide med care to many more that we can now.

• We'll need to reduce the number of cases to such a low level that we could again do contact tracing & isolation of cases around the country (as they can in many countries in Asia now).

• We will need system of screening at airports so that no person comes into the country with the disease without being diagnosed and isolated.

• We'll need a serology test that can be used to identify those that have been infected and recovered already, and to know how prevalent disease is in the US.

• We'll need to hopefully have therapies developed and in a quantity that we can treat at least the sickest patient with COVID.

Once we have those things in place, it would be a far less risky time to take stock of social distancing measures in place and consider what might gradually be reduced with trial and error. We would have learned more about the experience in Asia as they try to do that.

For now we need to keep production running, doctors offices working, groceries, pharmacies, banks open. It is ok to have science informed dialogue about which businesses need to be closed vs what can stay open in some way if social distancing can be put in place in them. But we need to press ahead for now with closed schools, mass telecommuting, no gatherings, and a strong advisory to stay home unless you need to go out – all are needed to slow this epidemic.·

We also need to put every conceivable economic program in place to help those being hurt by these social distancing measures. And move ahead rapidly to get our country far better prepared to cope with COVID before people recommend we abandon our efforts to slow this virus. Dr. Inglesby is the Director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health. The Center for Health Security is dedicated to protecting people’s health from the consequences of epidemics and disasters. Dr. Inglesby is also a Professor in the Department of Environmental Health and Engineering in the Johns Hopkins Bloomberg School of Public Health, with a Joint Appointment in the Johns Hopkins School of Medicine.

Dr. Inglesby's work is internationally recognized in the fields of public health preparedness, pandemic and emerging infectious disease, and prevention of and response to biological threats. He was Chair of the Board of Scientific Counselors, Office of Public Health Preparedness and Response, US Centers for Disease Control and Prevention (CDC) from 2010-2019. He served as Chair of the National Advisory Council of the Robert Wood Johnson Foundation’s National Health Security Preparedness Index. He was a member of the CDC Director’s External Laboratory Safety Workgroup, which examined biosafety practices of the CDC, the National Institutes of Health (NIH), and the Food and Drug Administration (FDA) following high-profile laboratory incidents in federal agencies. He was on the 2016 Working Group assessing US biosecurity on behalf of the President’s Council of Advisors on Science and Technology (PCAST). He has served on committees of the Defense Science Board, the National Academies of Sciences, and the Institute of Medicine, and in an advisory capacity to NIH, BARDA, DHS, and DARPA.

Dr. Inglesby has authored or co-authored more than 140 publications, including peer-reviewed research, reports, and commentaries on issues related to health security, preparedness for epidemics, biological threats, and disasters. He is Editor-in-Chief of the peer-reviewed journal Health Security, which he helped establish in 2003. He was a principal editor of the JAMA book Bioterrorism: Guidelines for Medical and Public Health Management.

Dr. Inglesby completed his internal medicine and infectious diseases training at Johns Hopkins University School of Medicine, where he also served as Assistant Chief of Service in 1996-97. Dr. Inglesby received his MD from Columbia University College of Physicians and Surgeons and his BA from Georgetown University. He sees patients in a weekly infectious disease clinic. Dr. Inglesby tweets @T_Inglesby