It is time for another update. This past week has brought some new information, but there are still quite a few questions and unknowns. This update will have less of the science aspect and more of the public health aspect addressed as I want to give you a sense of what it looks like our new normal will be going forward.

Some data: For a thought experiment as a way of comparing our number of cases with the rest of the world; I added up the cases for 13 countries in Europe that roughly comprise the same area of the United States. These 13 countries include Italy, France, and Germany as well as Greece, Poland, and Ukraine to give you an idea. As of today, the confirmed number of cases in these thirteen countries is approximately 700,000 confirmed COVID-19 cases. For comparison, the United States has approximated 670,00 confirmed cases of COVID-19. There are many variables that dictate how countries and regions report their cases, but most of the information that we have as this virus spreads over the globe is pointing to the fact that the United States is following along the same course of rate of infection, numbers of recovered cases, and deaths. We are slightly behind the European countries as the virus spread there first.

Since the COVID-19 infection is a novel or a new strain of virus, our best way of estimating what will happen is to follow the other countries in what has come before. It is still evident and very important that we remain vigilant in fighting this virus with the resources we have. We’ve seen the path of devastation that this virus can reap upon us in New York, Detroit, New Orleans and our most densely populated metropolitan cities. And while it is true that certain regions of our country are being affected more than others, this virus doesn’t respect boundaries such as state, city or county lines. There can be “hot spots” in some of our much smaller, less populated cities if the virus infects a nursing home and thus becomes widespread for a particular region. This happened in Orange County, NC, when an outbreak occurred in a nursing home facility and required a concentration of resources to try to contain the spread to the surrounding areas.

In North Carolina, we are seeing that our efforts to flatten the curve and practice social distancing are having a positive effect. Atrium and Novant hospital systems have stopped enough non-essential medical procedures and project that the Charlotte area will have enough beds, equipment, and staff to accommodate a surge in cases at our peak. They stated in a letter that we will not need the additional 600 bed facility offered by FEMA but will continue to monitor the situation. This is excellent news for our region! They also are using the Duke/UNC models of peak prediction and estimating that we will now reach our peak around May 17th. This makes sense, if you visualize the curve and peak flattening, then that will push the peak date out. This is different than the National IHME peak projection of April 17th for North Carolina. While the models differ in some of the data points, they do show similar effects of our efforts in social distancing.

While it is good news that the peak may be pushed out to May 17th, my first thought was that I really didn’t want to have to continue stay at home orders and social isolation well into next month. Many of you probably think the same thing. Physicians are eager to start being able to care for some of their patients again for their much-needed testing such as mammograms, scopes, and imaging along with long awaited for surgeries and follow up office visits. Businesses need to be able to re-open to remain solvent, regardless of when stimulus checks arrive and loans are approved. From a public health stand-point, it is scary thinking about reopening and giving COVID-19 a path for resurgence and destruction. However, between the public and private sector, there have been developments of new testing, more supplies, and innovation that may enable us to open up in phases so that we can get to our new normal. Getting back to normal or the way it was before COVID-19 will be a long process, but there can be a new normal that will allow us to re-open and adapt in a responsible way.

President Trump mentioned in his news conference on Tuesday that there is a new test for COVID-19 that can be self-administered by using saliva. This test was developed using existing technology by Rutgers University and is already being used in New Jersey. Since this test can be self-administered, there will be a decrease in the need for PPP (personal protective equipment) which has hindered our wide-spread testing thus far. The test uses a PCR platform similar to what we’ve been using with the nasopharyngeal swabs. Currently there is the ability to run 10,000 tests a day and the hope is that as more labs come on board, that the capability will be even more tests a day. We will likely still utilize the serology tests to look for IgM and IgG antibodies through a finger prick of blood and maybe the nasopharyngeal swabs too. We’ve been able to get results much quicker in 24-48 hours compared to 10-14 days that we were having to wait last month. This is an evolving situation which I will keep following. We do still have a serious shortage of tests and method of doing widespread testing, but there is some hope that this situation is improving.

There will be a meeting via telephone conference with all the nation’s Governors today (Thursday, April 16, 2020) and President Trump, and the national coronavirus task force team. They will be discussing ideas of how and when to re-open certain states. It will be the individual state’s responsibility to procure testing and equipment as well as develop timelines based on the data and projections from their respective health departments.

Governor Cooper and Dr. Mandy Cohen of North Carolina stated in yesterday’s press conference that the plan for our state to ease restrictions to support economic recovery while protecting healthy North Carolinians will involve testing, tracing and trendsTesting will be needed to identify who has COVID-19, work with public and private partners to increase testing capacity, expand testing sites, and address supply challenge. I’m hoping that today’s conference call with all the nation’s governors will provide some clarity as to how not only North Carolina, but other states will be able to implement this.

Tracing involves acting quickly to stop the spread of coronavirus from those individuals that test positive for COVID-19. To do this, we will need to ramp up staffing and technology to determine who has been exposed when someone tests positive. Our public health department currently has 250 employees that act as “detectives” to interview the person who tests positive and identify all the people they’ve been in contact with in the prior 2 weeks. They call possible exposures and inform them how to quarantine effectively and follow up to make sure guidelines are being adhered to. They are already trained to do this follow up and there is a process in place. We will need to hire many more workers to aid this process as our ability to do widespread testing increases. There is also the possibility of using technology such as apps on our phones to help monitor positive cases and their contacts.

Following the trends in our states, counties, and cities will be important as well. This will let us know when to dial up or down social distancing. Our health departments and COVID-19 task forces will analyze new data, including the number of new cases, hospitalizations, deaths, protective equipment, supplies, hospital capacity, and more. Our new normal will likely involve being adaptable to this data and understand the need for increasing social distancing or being able to ease up on restrictions.

Because this virus is a novel strain of coronavirus and very contagious as well as dangerous for some of our population, our new normal will involve more rapid testing as the saliva tests prove sensitive and specific, utilizing serologic antibody testing to possibly know who has immunity or has already had exposure. Tracing and adapting to the trends will become a part of our everyday life. Restrictions will be eased in phases based on the availability of testing and supplies. More workers will be allowed to return to their jobs and economic recovery will hopefully follow. Retail stores will be able to open but may have some restrictions on capacity. Since some states have more positive cases than others, roadblocks (similar to the ones already on the Texas/Louisiana border) and barriers may be placed to monitor travel and reduce the introduction of infection to some areas. Mass gatherings for concerts, conferences, sports, and churches may be restricted until the fall. The number of people allowed to gather will increase as the data shows it is safe to do so. There is a pilot study of testing and tracing being done with the players, managers, executives, and anyone involved with MLB (Major League Baseball) with the hope of being able to resume sporting events sooner rather than later.

While there is still so much to do, many questions with answers unknown, and a growing frustration and restlessness involved in our social distancing, there is also quite a bit of progress, innovation, and hope that while we might not be able to just switch back to normal at a set date, our new normal is starting to be within reach. In the meantime, try to have patience with our  health departments and their task forces as they develop plans, procure supplies, and monitor trends all with resources that have been underfunded and taken for granted for the past few decades. They will ease restrictions as soon as possible while keeping our public safety and the safety of all our loved ones in mind.

Addendum: White House Guidelines to the individual state’s Governors for phases of re-opening:

Phase 1: For States and regions that satisfy the Gating Criteria:

For Individuals:                                                                                        
Vulnerable Individuals: Shelter in Place
When in Public, Maximize Physical Distance                                                                        
Avoid Socializing in groups of More than 10 people                          
Minimize Non-Essential Travel and adhere to CDC guidelines

For Employers:
Consider special accommodations for Vulnerable Populations
Encourage Telework whenever possible
Return to Work in Phases
Minimize non-essential travel

Specific Types of Employers:
Visits to senior living facilities and hospitals should be Prohibited
Large venues (including sit-down dining) can operate under strict Physical Distancing protocols
Gyms can re-open if they adhere to Strict Physical Distancing and sanitation protocols
Elective surgeries can resume on an outpatient basis

Phase 2: For States and Regions with no evidence of a rebound and that satisfy the gating criteria a second time:

For Individuals:                                                                                                 
Vulnerable individuals continue to shelter in place
When in public, Maximize Physical Distance                                       
Avoid social settings of More than 50 people                                      
Non-essential travel Can Resume                                                              

For Employers:
Continue to Encourage Telework
Close common areas
Non-essential travel Can Resume
Consider special accommodations for Vulnerable Populations

Specific Types of Employers: 
Schools, daycares, and camping sites may Re-Open
Visits to senior living facilities and hospitals should be Prohibited
Large venues can operate under Moderate physical distancing protocols
Elective surgeries can resume on an outpatient and in-patient basis

Phase 3: For states and regions with no evidence of a rebound and that satisfy the gating criteria a third time:

For Individuals:
Vulnerable individuals can resume public interactions, but should practice physical distancing
Low risk populations should minimize time spent in crowded environments

For Employers: 
Resume unrestricted staffing of workers
No criteria yet for mass gatherings and visits to senior living facilities (details to come as more information is gathered)