The First Cluster - Epi Weekly Update October 12

The cluster at White House is a symptom and a symbol of the federal government’s failed Covid response. From overconfidence in testing, to lack of basic safety precautions in crowded indoor places, to delayed isolation, incomplete contact tracing, and failure to quarantine, there have been so many preventable missteps.

If there’s one major lesson from this particular failure, it’s that testing doesn’t replace safety measures—testing is only useful as part of a comprehensive strategy. There are often false negatives, and even if a result is accurately negative in the morning, someone could still be highly infectious hours later. That’s why it’s important to reduce risky indoor gatherings and to follow the 3 W’s: wear a mask, watch your distance, wash your hands.

Masks are particularly important. It’s worth reading this edition of our Weekly Science Review by the wonderful Dr. Cyrus Shahpar. I learned from it and was surprised by how suggestive the evidence is. In addition to protecting others and yourself, masks may reduce inoculum and make it more likely that, if you do get infected, you won’t get severely ill.

Rapid isolation reduces secondary cases. There’s strong evidence that paid sick leave reduces the risk that people will work while infectious from the flu, and that is almost certainly the same with Covid. The only valid reason to leave isolation is for a medically necessary procedure.

Contact tracing needs to be done quickly and expertly to find all those who have been exposed to the virus, trace the source of the infection, expand the circle of those warned, and stop the outbreak. Let’s rebrand contact tracing and call it what it is: supporting people who got Covid and who were exposed to it. Instead of “case investigator,” why not “patient support specialist”? And instead of “contact tracer,” how about Covid prevention specialist?

Quarantine means not exposing others after you’ve been exposed. Testing negative is not a get-out-of-quarantine-free card—you can be infectious soon after a negative test. But we should be able to optimize quarantine conditions (a walk outside not near others?) and duration (some places exploring shorter quarantines, with rigorous safety measures after 8 or 10 days) based on data.

Here’s the epi curve of the White House outbreak from what has been publicly reported so far. The pattern strongly suggests common exposure on September 26 or 27. An investigation should be able to determine the likely source and identify those most at risk. And of course it’s possible to identify the source of the outbreak—it just requires wanting to and having the expertise.

The White House cluster isn’t over. There are likely to be other cases. Check out this great graphic from Cleveland Clinic. We need a series of measures to reduce risk, prevent illness and death, and accelerate economic recovery. I’ve been calling it a “comprehensive approach,” but does anyone have a better term?

Controlling Covid requires a one-two punch. In addition to practicing safety measures such as reducing indoor gatherings and the 3Ws, we have to do better boxing the virus in after a new case is identified. We do this through rapid isolation, complete contact tracing, and supportive quarantine. That’s the way we prevent cases from becoming clusters and clusters from becoming outbreaks.

In the US, hospitalizations and deaths are slowly trending downward, but that won’t last because cases are steady or increasing in most of the country. Only Maine and Vermont are reassuring. Unfortunately, there will be continued increases in cases, and eventually deaths. There will be 230,000 reported deaths by November 3. A sobering number. We have one of the highest cumulative death rates of all wealthy countries.

In New York City, we’re continuing to see uncontrolled spread in religious communities and increasing risk elsewhere. Note that this is the same community that had extensive spread in the spring - so hopes that a low level of infection will lead to herd immunity are false, and dangerous (more on this next week). The ONLY way to stop spread in this community is to engage the community, support and collaborate on education from within, and encourage religious leaders to establish and manage acceptable isolation facilities.

Some good news is that schools, if run well, don’t appear to be major amplification points for the virus. At Resolve to Save Lives, we’ve been saying since March that we must keep in-person learning as available as possible, which means reducing spread in the community and adapting the school environment and policies.

As the late New York Senator Daniel Patrick Moynihan said, “You’re entitled to your own opinion, but not your own facts.” And to quote epidemiologist William Farr, “The death rate is a fact; anything beyond this is an inference.” The cumulative US death rate has now passed the UK, approaching Spain, highest of high-income countries. Read the graph, and weep.

We cannot become hardened to horror of continuing, preventable Covid deaths. Every life is precious. Who saves a life, saves a world.