​ Cover story two

A dual pandemic

Real virus—fake news

By Kristen R. Ehresmann, MPH, RN, and Sarah Lim, MBBCh

ince the first reports in early January of a cluster of cases of pneumonia of unknown etiology in Wuhan, China, the novel coronavirus SARS-CoV-2 has exploded across the globe and caused the greatest public health crisis in over 100 years. The Minnesota Department of Health (MDH) identified the first case of COVID-19 on March 6, 2020, and by mid-September, Minnesota had 90,000 reported cases and 2,000 deaths. As we continue to see high rates of community transmission and our case numbers and deaths increase, it is clear that COVID-19 will be part of the fabric of daily life in Minnesota well into 2021 and likely longer.

Two fronts

We are battling dual pandemics: a virus that has sickened and killed millions, including the young and healthy, and an avalanche of misinformation that at best seeks to minimize the danger and at worst calls the entire disease a hoax. False medical information has spread online with other outbreaks of infectious disease—2009 H1N1, Ebola, Zika, measles—but COVID-19, along with the resulting public health guidance, has become uniquely politically divisive and suspect. Institutions such as the CDC and the FDA are no longer seen as neutral and independent. Nearly half of all Americans say they definitely or probably would not get a COVID-19 vaccine if it were available today. The simple act of wearing a mask is seen in some quarters as a partisan political declaration instead of a basic public health measure to slow the spread of the virus.

We must be clear: COVID-19 is absolutely not “just the flu.” Data from the MDH shows that since that first case in March, over 7,100 patients have been hospitalized, including 2,000 who were treated in the ICU and 2,000 who have died. It is important to note that severe illness and deaths have occurred in every age group, even those with no underlying conditions. One of the first cases in Minnesota was an Ironman triathlete in his 30s who ended up on ECMO (extracorporeal membrane oxygenation). While he survived, his case offered proof of the risk posed by SARS-CoV-2 to younger, healthier people as well as those aged 50 and older.

​Your patients need to hear from you that this is a real and urgent concern.

Even the youngest age groups are not safe—as cases of COVID-19 increase, we are seeing more cases of the rare but severe complication known as multisystem inflammatory syndrome (MIS-C) in children. There have been 24 confirmed cases of MIS-C since the pandemic began, all of whom have required hospitalization and, in some cases, prolonged stays in intensive care. There is growing evidence of long-term health consequences to SARS-CoV-2 infection, including myocardial damage, pulmonary scarring, and strokes.

Finally, when researchers from the University of Minnesota examined age-adjusted COVID-19 mortality, the excess mortality seen in communities of color, particularly Native Americans and Black people, shows significant racial disparities in the effect of this pandemic.

Countering misinformation

How do we begin to address these dual pandemics: the real virus, and the fake news? To start with, despite claims in the media, relying on herd immunity through natural infection is not the answer. Herd immunity is the epidemiologic principle that when a sufficient proportion of the population has immunity to a disease, through prior infection or vaccination, the likelihood of disease transmission to susceptible individuals is reduced. Simply allowing herd immunity to develop by waiting for infections to occur in enough of the population is not an appropriate strategy for COVID-19. The current seroprevalence rate in Minnesota is unknown (though a study is underway), but in early spring a nationwide study reported in JAMA estimated it at only 2.4% overall in the Minnesota metropolitan area. While the rate is almost certainly higher than that now, we are still very far away from the threshold necessary for herd immunity, estimated to be about 50% to 70%. The cost of herd immunity through natural infections will be even more cases, more illness, and more death. Also, while the duration of natural immunity remains unclear, so far infection does not appear to provide life-long immunity, as proven by several cases of re-infection. Rather than relying on natural immunity, vaccination of the population will be necessary to manage the spread of COVID-19.

While we wait for a safe and effective vaccine, testing, contact tracing, isolation, physical distancing, and masking are the pillars of our control strategy for COVID-19. The practice of isolation and quarantine in the management of infectious disease outbreaks goes back at least to the Middle Ages and probably longer, and is key to beating back COVID-19. Anyone with symptoms of illness should be counseled to stay home and be tested, with positive cases advised to isolate. The benefit of testing, apart from diagnosing those who are ill, is that it allows the identification and quarantine of pre-symptomatic contacts, who are believed to be responsible for 50% of viral transmission. Everyone should be encouraged to comply with requests from the health department to identify contacts for contact tracing, and it should be emphasized repeatedly that even if you have an asymptomatic or mild infection, you may still transmit to others who may be more vulnerable.

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When isolating and quarantining an entire population is not realistic, we must rely on other measures, specifically limiting the size of gatherings, maintaining physical distance from others, and wearing a face covering. An MDH review of COVID-19 community outbreaks in Minnesota found that they are invariably tied to events where people are gathering in large groups, not social distancing and not wearing masks. A compelling example of the impact of not following this guidance was a wedding held in southwest Minnesota at the end of August. Two-hundred and seventy-five individuals (over the executive order’s limit of 250) celebrated indoors in a crowded restaurant without social distancing or masking. At the time of this writing, 77 cases and one hospitalization have been linked to this event. These cases have included health care workers and teachers, further illustrating how the ripple effects from a single event spread out to affect other settings like health care and schools. We understand that early messaging about masking from public health was contradictory to the current guidance; however, this early recommendation was made before there was clear evidence of the risk of asymptomatic and pre-symptomatic spread and when concerns about the lack of PPE for front-line health care workers were at a peak.

“Myths”

We do not have the space here to debunk all of the myriad myths about mask-wearing that have popped up on social media and beyond; suffice it to say that we have not seen epidemics of mask-related illness in health care workers who wear them for hours to do their job. We also understand the lockdown fatigue that so many people are experiencing and the desire to visit and socialize with our friends and loved ones, but we must not forget the risk that these gatherings pose.

The issue of therapies for COVID-19 has also been affected by politicization and misinformation. Hydroxychloroquine was touted as a miracle therapy by some before definitive data emerged showing its lack of efficacy. This misinformation even led to the death of a man in Arizona who ingested fish tank cleaner in the misguided belief that it would work as prophylaxis. Other theories about dubious, unproven, or flat-out dangerous treatments have circulated, including bleach, UV light, cow urine, colloidal silver, and the dietary supplement oleandrin. In August, when the FDA issued an emergency use approval for convalescent plasma over the objections of leading scientists from the NIH that the evidence for its efficacy simply was not there, it was widely seen as having bowed to political pressure, raising major concerns about the vaccine approval process.

​Wearing a mask is seen in some quarters as a partisan political declaration.

Positive indications

The good news is that in the midst of the storm, treatment for COVID-19 has drastically improved. Alternative management strategies for acute hypoxic respiratory failure such as high-flow oxygen and prone positioning can avoid the need for intubation and invasive ventilation. The groundbreaking RECOVERY (Randomised Evaluation of COVID-19 Therapy) trials in the United Kingdom showed that dexamethasone significantly reduces mortality in patients with severe illness, and it is now part of standard recommended therapy.

The investigational antiviral drug remdesivir has shown moderate efficacy in clinical trials, and after an initial period of scarcity in Minnesota when the drug needed to be allocated to patients based on clinical priority, is now widely available.

Finally, initial reports of monoclonal antibody therapies have been promising. All of this is a far cry from the early days of the pandemic, when clinicians had little to offer patients other than supportive care and a grab bag of potential experimental therapies.

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Speaking to patients

So what can we do? All of us in the health field are on the front lines of fighting these dual epidemics, whether we are caring for patients or working behind the scenes in the laboratory or in public health. If we do not provide accurate information, conspiracy theories and fringe views will fill the void. It is important that we all reinforce science-based messaging as well as the evolving nature of the pandemic. We are continuing to learn more about how this virus spreads and how it affects the human body, and as we learn, we adapt our guidance. Changing guidance may be frustrating for both physicians and the public, but of course the study of a novel virus that was unknown to science nine months ago will result in evolving data and evidence. We understand that this is how science works, but our patients may not. Above all, your patients need to hear from you that this is a real and urgent concern; you are a trusted source of information, and your words and opinions have more power than you think. It is vitally important that you continue to reinforce the important messages of testing and contact tracing; staying home when ill or waiting for test results; and following measures such as masking and social distancing. Be prepared to discuss the value and worth of vaccines (including flu shots) in anticipation of an eventual vaccine approval. Your front-line efforts make a difference!

Kristen R. Ehresmann, MPH, RN, is an epidemiologist and director of the Infectious Disease Epidemiology, Prevention and Control Division at the Minnesota Department of Health. Ms. Ehresmann has led numerous outbreak investigations, published in peer-reviewed journals, and been an invited speaker at national meetings. She currently oversees the epidemiologic response for COVID-19.

Sarah Lim, MBBCh, is a board-certified infectious disease physician who was previously an assistant professor in the Department of Infectious Diseases at the University of Vermont. She is now working as a medical specialist at the Minnesota Department of Health on the COVID-19 response.