I hope you are doing well during our continued social distancing. The good news is that North Carolina has done an excellent job of flattening the curve so that our hospital systems and healthcare infrastructure won’t be overwhelmed with treating COVID-19 patients. We’ve actually flattened the curve to the point where we probably won’t see a “peak” in cases.

If we continue to practice good social distancing, wearing masks in public when maintaining 6 feet from other people isn’t possible, and washing our hands with soap for 20 seconds often, then we should be well on our way to re-opening North Carolina in a safe, data driven way that will be good for our health and economic future as well. As we re-open into Phase 1, 2, and 3, there might need to be adjustments based on the data, but ideally, we would like to re-open only once so that our businesses can stay open and we can resume many of our normal activities.

Because there is already a lot of news coverage on the 3 phases and my last blog outlined the measures that the White House recommended which NC will follow closely, I’d like to expand and explain the data points that we will need to achieve to make it to the 3 phases. I’ll explain the trends that the NC Department of Health and Human Services will follow and compare where we are currently, and where we need to be. *Slides are from Dr. Cohen’s presentation in the April 23rd press conference.

You can see from the slide above that the Trends we need to follow such as trajectory of cases over the next 14 days, hospitalizations, and testing capacity, among other metrics will determine if we enter into Phase 1 on May 9th after the current Stay at Home order ends May 8th.

The first trend we need to show is declining in the number of visits to the ER with patients that have COVID-19 like symptoms. We are already declining in this area, which is good. The yellow line is our current timeline. It follows the usual blue and white lines from 2 years (2018-2019) prior, but then took an uptick around March when cases of COVID-19 were starting to appear widespread in NC. However, after increasing through March and into April, we are now seeing a steady decline in visits to the ER represented by the yellow line (cases presenting to the ER with fever, cough, fatigue, etc.)

The next trend that the NC Health Department will be following is trajectory of cases in 14 days. The number of new cases in NC is increasing but at a slower rate. At this point we are not seeing a declining of new cases. This is in part because we are testing more, but we should see a decline or a sustained leveling in the number of new cases.

We also need to see a decline/or decrease in the number of positive tests as a percentage of the total number of tests over 14 days. This trend will at first appear as if we have more positive cases than before because we are able to ramp up testing as our labs are capable of producing and resulting tests at a greater volume and at a much faster rate than before. The key when looking at this metric is to see the percentage of positive cases verses the total of people tested go down. We are not yet seeing that, but as we test more of our population, we should see the total # of tests increase dramatically. This will show on the graph that our percentage of positive tests should be declining soon as more tests are done.

   

Again, the yellow line is what we want to see decline as it represents the percentage of positive tests.

Next, the NCDHHS will be looking at the # of hospitalizations as a total. Since this will look at the total number of hospitalizations for all cases, not just COVID-19, we want to see this number at least sustained. We want to make sure that if there is a surge in COVID-19 cases for whatever reason, that our hospitals remain able to handle the number of cases. Currently there are about 400 admissions a day. We would like to see a decreased or sustained level in the daily # of hospitalizations.

Finally, our capacity for testing, tracing, and have the available PPE (personal protective equipment) that we need to do testing, treating, and resume procedures and surgeries that could put some healthcare workers at risk if exposed to a COVID-19 + patient. We will need to have an appropriate volume for 30 days’ worth. We are doing much better on surgical masks, eye protection, and gloves, but still lack N95 masks and gowns.

For Testing: there should be an increase in daily testing from 2,500-3000 people a day to 5000-7000 people testedper day.

For Workforce to Conduct Contact Tracing: there needs to be an increase from 250 tracers that NC already has to ~500 tracers.

NCDHHS is also researching ways to deploy digital tracing technology (such as Apple or Google) to be able to trace the contacts of those persons who test positive.

Finally, we need to have availability of PPE. At least an adequate supply to fill at least 30 days. As mentioned before, we still lack N95 masks and gowns, however our other supplies are growing.

A nice chart which sums it all up is:

So when we hit the above benchmarks, which should be updated on the NCDHHS website: www.ncdhhs.gov, we should be able to enter Phase 1 as early as May 9th. If we continue to hit benchmarks, then we can enter Phase 2 at least 2-3 weeks after Phase 1 or as early as May 23rd or May 30th. It will take at least 4-6 weeks after entering phase 2 and hitting benchmarks for us to enter Phase 3- which would put us at June 20th or possibly before July 4th holiday. We also need to be prepared as these trends are continuously followed in each phase, we might need to reverse course or tighten restrictions rather quickly if needed. North Carolina has done an excellent job so far and I’m optimistic that we can meet our benchmarks sooner rather than later.

Lastly, I wanted to let you know where we stand on the different types of tests as there are so many new types of tests from many sources flooding the market. The serology test that I mentioned last week is done through a finger prick blood test and tests if a patient has antibodies to COVID-19. Most of the serology tests look for IgM which is seen earlier in infection, and also IgG which is seen later in the course of infection and may confer some level of immunity. The thought was that if we tested a patient and they had IgG antibodies, then they could return to work because they their immune system had already built the antibodies needed to fight the infection if they were exposed. The problem with this theory is that the tests haven’t been available for the novel coronavirus or COVID-19, so there are quite a few false positive results on many of the different brands of serology tests. This is worrisome because, a patient could test positive for IgG antibodies for COVID-19 and think that they are safe to return to work or loosen restrictions for exposure. However, since the testing was incorrect, thus a false positive, then they in fact have not been infected yet and wouldn’t be taking the precautions to limit infection. If they then become positive, they could be asymptomatic or with mild symptoms and thus unknowingly spread the COVID-19 to others.

There are many researchers and physicians and lab technicians working around the clock to test the validity of these tests with previous run PCR (polymerase chain reaction) nasopharyngeal testing that detects the virus. There is also an Elisa test that is more reliable and indicates the amount of antibodies present which will be used to compare the different rapid antibody serology tests coming on the market.

There are other unknowns, such as when in the process of the illness a patient becomes immune and how do we accurately measure that point? Also, when does a person stop becoming contagious after acquiring the infection? In someone with a high viral load, they could have viral shedding for many weeks after being exposed.

We do still need to ramp up testing and give as much data that we can to our scientists that are analyzing the data and testing. This will help us in the months or years ahead as we need this information to guide our policies and gain a better understanding about a still much unknown novel coronavirus. The good news is that we have accomplished quite a bit in the short time we’ve been working on this and with the limited testing we’ve had to work with. There are also many researchers working feverishly towards developing a vaccine that will go a long way in either eradicating COVID-19 or reducing its ability to wreak havoc on our health, healthcare systems infrastructure, and economies.

For more info on the status of our covid testing research data, you can go here: https://covidtestingproject.org

Keep up the good work, hang in there, stay at home for a little while longer, wear those masks, and wash those hands. Feel free to ask me any questions or for clarifications. You may also request a particular topic that you would like covered in a future update.