This letter was originally published as an email to local elected officials and is being republished with express permission from Greg Gelembiuk for the purposes of spreading awareness and informing the public.
I am writing to express my concerns about the Public Health Madison Dane County reopening plan. It appears to have no valid scientific basis.
As many of you know, I’m a scientist in the life sciences (at UW-Madison). I have a PhD in Integrative Biology with a minor in Statistics. I have two decades background in the field of Virology, specifically working on pathogenic viruses that infect primates, including humans. My current field of research is evolutionary genomics. I’ve been following Covid-19 research in great detail. I’m stating my background to make clear that this is an area of professional expertise for me.
The following letter contains four main topic areas.
Reopening now is very ill advised.
The reopening criteria for the Forward Dane plan are severely flawed and lack an adequate basis in science.
The types of sites allowed to reopen and the types of events permitted under the Forward Dane plan are very problematic.
There is a way to reopen safely.
1. Currently, Covid-19 is not under control in Dane County. The plan to begin reopening Tuesday is, IMHO, insane.
Four of six Badger Bounce Back plan criteria (Evers’ plan for reopening Wisconsin) are now flashing red. That plan was deficient – but the fact that most of the criteria are now red should give everyone pause.
Over the last two weeks, the number of new cases has been rising in Dane County (in tandem with Wisconsin as a whole).
Hospitalizations for Covid-19 are now clearly rising in Dane County. I’ll note that hospitalizations provide an important metric that’s not just reflective of testing levels. Yet we’re reopening Tuesday – a recipe for a lot of infections and deaths.
Hospitalizations throughout Wisconsin are trending upward.
The Imperial College London report issued yesterday estimates that Wisconsin currently has the tenth highest Rt (effective reproduction number – a measure of epidemic expansion) in the U.S., and that the epidemic is not under control here. For those unfamiliar with the work of the Imperial College London modeling team – it’s offered some of the best and most highly respected Covid-19 modeling available.
We know from many historical examples, in the U.S. and elsewhere, what happens when social distancing orders are relaxed in the middle of an epidemic, when most are still susceptible to the disease. For example, from the 1918 flu pandemic:
As you can see in the graphs above, brief reopening led to a surge of cases, and it was very difficult to control – with the wave of infections continuing long after more restrictive rules were re-implemented.
That’s also what the Imperial College London model projected near the beginning of this pandemic. Here’s a model predicting what happens when social distancing restrictions are lifted (see green curve).
Current models that don’t show a huge second wave are assuming that, after stay-at-home orders are lifted, people will socially distance almost as hard as when they were in place. An abundance of news reports from around Wisconsin (noting packed bars, huge crowds at events, etc.) indicate that this assumption is incorrect.
I think it’s clear that the reopening plan for Madison and Dane County is being driven by politics (I would guess in substantial part reflecting lobbying by the Wisconsin Chamber of Commerce) rather than science, since there’s no scientifically defensible reason for reopening at this point.
Just to make fully clear how much damage Covid-19 can wreak if it hits an area full force, here’s a graph from New York State in mid-April.
This virus is a sledgehammer in many cases. The best estimates show it killing about 1% (and quite possibly more) of all people it infects. This is what our current local plan will be adding to:
Beyond deaths, a far, far greater proportion of infected people are hospitalized, and many end up with permanent disabilities (due to kidney failure requiring dialysis, strokes, reduced pulmonary capacity, etc.). The long-term morbidities have received too little attention – here’s one article on the topic: “The emerging long-term complications of Covid-19, explained.”
2. The Forward Dane criteria for reopening (and advancing through the phases) are grossly deficient.
Here are guidelines for reopening, for use by frontline decision-makers, developed by a team of experts. I urge you to read through this. https://covid-local.org/
As it notes; “COVID-Local and the Frontline Guide are a joint project of the Global Biological Policy Program at the Nuclear Threat Initiative (NTI), the Center for Global Development, and the Georgetown University Center for Global Health Science and Security, in collaboration with Talus Analytics. The team is comprised of experienced experts in disease outbreak as well as former public health officials, and the tools were developed in response to calls from local governments for more information on how to protect their communities.”
It was put together by a team of deeply experienced experts and former public health officials,– e.g. Ashish K. Jha, MD, MPH (Director, Harvard Global Health Institute, K. T. Li Professor of Global Health, Harvard T.H. Chan School of Public Health, Professor of Medicine, Harvard Medical School), Jeremy Konyndyk, MSFS (Senior Policy Fellow, Center for Global Development; Former Director of Foreign Disaster Assistance, USAID), Rebecca Katz, PhD MPH (Professor and Director, Center for Global Health Science and Security, Georgetown University), and multiple others.
I’ll note that many countries (South Korea, New Zealand, Taiwan, etc.) use criteria even far more stringent than this, but these guidelines were designed to be broadly acceptable to local governments across the U.S. (many of which are itching to reopen), while retaining a grounding in science.
Importantly – note that the criteria in the guidelines are both more stringent and more specific than most of the Forward Dane reopening criteria. Click the “Metrics Scorecard” tab in the guide to see all the metrics in detail.
For example, Forward Dane has a criterion “Lab reporting timeliness and contact tracing.” For “green” it only requires “More than 85% of all new cases are contacted within 48 hours of their test collection.” That can be satisfied merely by informing cases, within two days, that they’d tested positive. It includes absolutely no specific requirement on success of contact tracing – the metric that all epidemiologists recognize as essential.
In contrast the guideline specifies “95% of close contacts are elicited, located, tested within 24 hours” for phase 4 (with the same content but only requiring 90% and 24 hours for phase 3, and 75% and 48 hours for phase 2 – the initial reopening step). That’s an entirely different criterion. A. It has a much shorter timelines for anything other than the initial phase – and studies show that for epidemic contact tracing, time is of the essence (in part because the period of maximum Covid-19 contagiousness is short). B. Even more importantly, it specifies a requirement that the large majority of contacts actually be tested within that timeframe. It’s a completely different criterion and scientifically defensible (while no competent epidemiologist would ever endorse anything like the Forward Dane criterion).
Another contrast – to even begin the reopening process, the guidelines require at least “At least 30 contact tracers per 100,000, as well as case managers, care resource coordinators, community health workers.” The Forward Dane criteria include no such requirement at all.
People in long-term care facilities are being killed off in high numbers. The guide specifies that to even begin reopening “% of cases reported from long-term care facilities <20% over last 28 days” (dropping to <10% for phase 3 and <5% for phase 4). The guide also specifies a requirement of “sufficient testing, quarantine, isolation in long-term care facilities” to begin reopening. Forward Dane has no such criteria for protecting at-risk populations.
The trend criterion also differs in a key way between the guide and the Forward Dane plan. “Green” in the Dane plan requires “Stable or decrease of COVID-like syndromic cases reported within most recent 14 day period.” Note that, as mentioned above, confirmed Covid-19 cases and hospitalizations are clearly increasing in Dane County. The Forward Dane plan never specifies a definition of “COVID-like syndromic cases” and doesn’t provide any data for this metric on its website. I would guess that they’re using CDC Emergency Department Syndromic Surveillance data (which includes a metric for Covid-19-like illness). If that’s the case, it’s highly problematic to use that as the sole trend criteria – since it’s restricted to emergency department visits and is somewhat subjective, especially given the nonspecificity of many Covid-19 symptoms. The numbers would be affected by shifts in diagnostic expectations/fashions among physicians (e.g. whether to classify a patient with a runny nose as showing symptoms that are influenza-like verses Covid-like versus something else). Also, at this point, I’d expect everyone showing up at a Dane County emergency department and classified as a “COVID-like syndromic case” would get tested – and the test outcomes provide much more solid, objective data of actual Covid-19 incidence. Meanwhile, the guide specifies “Sustained decline in daily cases for 21 consecutive days, as reflected in the 5-day rolling average.” Under this criterion, and given the currently increasing number of confirmed cases in Dane County, it appears that we would not now be reopening.
A critical difference is that the guide has bidirectional arrows across the phases. You move backwards if things become worse. In contrast, the Forward Dane plan appears to only ratchet forward. There’s nothing about moving backwards when the epidemic spikes. From the logic of the progression specified in the Forward Dane document, things can grow worse when we’re in a phase, with criteria going red (e.g. cases increasing beyond 20 a day, “Covid-like syndromic cases” rising, etc.), and it appears that we’ll then just wait in that phase until the criterion for the next higher phase are met. That’s kind of nuts. It’s essential that there be clear criteria and a mechanism established here for moving backwards – since we’ll probably need to do that very soon.
I’ll add that one specific metric that should be incorporated is sewage sludge monitoring for the virus, as this is now recognized as an important leading indicator. As a recent study noted:
We report a time course of SARS-CoV-2 RNA concentrations in primary sewage sludge during the Spring COVID-19 outbreak in a northeastern U.S. metropolitan area. SARS-CoV-2 RNA was detected in all environmental samples and, when adjusted for the time lag, the virus RNA concentrations were highly correlated with the COVID-19 epidemiological curve (R2=0.99) and local hospital admissions (R2=0.99). SARS-CoV-2 RNA concentrations were a seven-day leading indicator ahead of compiled COVID-19 testing data and led local hospital admissions data by three days. Decisions to implement or relax public health measures and restrictions require timely information on outbreak dynamics in a community. — Peccia et al (2020)
3. The types of sites allowed to reopen, and the types of events permitted, under the Forward Dane plan are very problematic.
As you’re probably aware, Covid-19 can be transmitted by respiratory droplets. Those droplets are emitted even when people breathe, but far more are emitted when people speak, cough, or sneeze. As a recent study found, “normal speech generates airborne droplets that can remain suspended for tens of minutes or longer and are eminently capable of transmitting disease in confined spaces…. we estimate that 1 min of loud speaking generates at least 1,000 virion-containing droplet nuclei that remain airborne for more than 8 min. These therefore could be inhaled by others and… trigger a new SARS-CoV-2 infection.” A single sneeze is estimated to generate about a thousand droplets that are greater than 500 microns in diameter (along with a vastly greater number of smaller droplets). Given the average concentration of virus in oral fluid of infected individuals, inhaling a single such large droplet is easily sufficient to infect the average person. Moreover, it is now known that about half of Covid-19 transmission is from people who are asymptomatic at the time. In many cases, there’s no way to tell an infected person from an uninfected person, other than molecular testing.
As Erin Bromage (Associate Professor of Biology at the University of Massachusetts Dartmouth) noted:
Any environment that is enclosed, with poor air circulation and high density of people, spells trouble… Indoor spaces, with limited air exchange or recycled air and lots of people, are concerning from a transmission standpoint. We know that 60 people in a volleyball court-sized room (choir) results in massive infections. Same situation with the restaurant and the call center. Social distancing guidelines don’t hold in indoor spaces where you spend a lot of time, as people on the opposite side of the room were infected. The principle is viral exposure over an extended period of time. In all these cases, people were exposed to the virus in the air for a prolonged period (hours). Even if they were 50 feet away (choir or call center), even a low dose of the virus in the air reaching them, over a sustained period, was enough to cause infection and in some cases, death. Social distancing rules are really to protect you with brief exposures or outdoor exposures. In these situations there is not enough time to achieve the infectious viral load when you are standing 6 feet apart or where wind and the infinite outdoor space for viral dilution reduces viral load.
The twitter threads here and here by Michael Otsuka (Professor, Dept. of Philosophy, Logic & Scientific Method, at the London School of Economics) discuss some of this further. Interior spaces where multiple people are present – buses, churches, classrooms, etc. – are known to be Covid-19 transmission hotspots. And as Otsuka notes “Two meters is not some universal magic barrier.” Here is a table (from this publication) of some of the types of settings linked to clusters of cases (outbreaks):
Analysis has found that transmission can occur both indoors and outdoors, but indoor transmission is much more common, since concentrations of viral aerosols end up much higher indoors. As William Schaffner, Professor of Preventive Medicine at Vanderbilt University, notes: “This virus really likes people being indoors in an enclosed space for prolonged periods of close face-to-face contact… It’s people coming together in groups that matters.”
Dane County has already permitted churches to reopen. Throughout this pandemic, churches have been a primary site for superspreader events (infecting masses of people). The world’s worst superspreader events have been at churches – e.g. South Korea (Feb 9/16) >5,000 cases, France (Feb 17) > 2,500 cases, etc. A few related articles:
Gyms are also being allowed to reopen as of Tuesday. Studies show evidence of high rates of Covid-19 transmission with heavy athletic exertion (given heavy breathing, etc.). For example, the abstract of one report posted by the CDC: “During 24 days in Cheonan, South Korea, 112 persons were infected with severe acute respiratory syndrome coronavirus 2 associated with fitness dance classes at 12 sports facilities. Intense physical exercise in densely populated sports facilities could increase risk for infection. Vigorous exercise in confined spaces should be minimized during outbreaks.” I’ll also note that this occurred despite universal use of masks in South Korea.
As of Tuesday, it appears that schools in Dane County that wish to reopen can do so. Teachers have very high exposure rates.
Interactive version of this data visualization is below.
A few tidbits I’ll add on things that could and should be done – with South Korea as an example:
4. There is a way to reopen safely – repeated ubiquitous testing and intensive contact tracing.
I won’t go into length here about that, since it’s a long topic in itself. But it’s the approach that multiple expert panels have specified in their reports (on how to reopen the U.S.), and that epidemiologists and many economists have been advocating for. Basically, almost everyone would be tested, about once a week. One expert panel report from Harvard discussing what’s needed “Roadmap to Pandemic Resilience: Massive Scale Testing, Tracing, and Supported, Isolation (TTSI) as the Path to Pandemic Resilience for a Free Society” [excerpt: “We need to deliver 5 million tests per day by early June to deliver a safe social reopening. This number will need to increase over time (ideally by late July) to 20 million a day to fully remobilize the economy.”]
There are some technical and logistical hurdles, but none that are that huge if there were the political leadership and will to do this. Even now, protocols such as SwabSeq could be scaled to this level, and as more technical advances in testing are rolled out (antigen-based testing, surface plasmon resonance-based testing, Crispr-based testing), it should become ever easier. With SwabSeq, it should be possible to bring the cost per test down to close to the $1 range (and it could be run at a place like the UW Biotech Center). Though it would be most effective to do this at the national level, there’s no inherent reason it couldn’t be implemented at the local level (of a municipality or county).
The current approach to reopening presents a false choice – either staying in lockdown indefinitely or risking one’s life. That there’s a far better feasible choice is not widely enough recognized.
As economist Paul Krugman noted in a column in the New York Times this week:
“As far as I can tell, most epidemiologists are horrified by America’s rush to reopen the economy, to abandon much of the social distancing that has helped contain Covid-19. We know what a safe reopening requires: a low level of infection, abundant testing and the ability to quickly trace and isolate the contacts of new cases. We don’t have any of those things yet.
The epidemiologists could, of course, be mistaken. But at every stage of this crisis they’ve been right, while predictions of a quick end to the pandemic by politicians and their minions have proved utterly wrong. And if the experts are right again, premature opening could lead to hundreds of thousands of deaths — and backfire even in economic terms, as a second wave of infections forces us back into lockdown.”
I’ll close with this thought from evolutionary genomicist (Professor – University of California, Davis):