19 Things We Need to Conquer the COVID-19 Pandemic: Part 1

By Andrew L. Concoff, MD, FACR, CAQSM

In response to numerous conversations with both UR members and friends, I have created a list to summarize our views of the required elements of a comprehensive strategy to turn the tide of the COVID-19 pandemic in the United States. First, a few caveats. This endeavor may be less likely to identify a directly useful strategy for use in the everyday management of a private practice clinic. I would refer you to the prior articles in this series for that purpose. Rather, it is hoped that we may all derive a modicum of comfort from attempting to get our arms around the challenges we face together. 

I certainly have no greater ability to enact the elements of such a scheme than any of you. In fact, some of you may have considerably more influence than I do.  Like many of you, however, I have made a rather deep dive into the topic in an effort to gain some understanding (in lieu of control over it) and to provide the most salient content possible in supporting your daily battle in the clinic.  Along the way, we have encountered numerous topics and concepts that have not been adequately addressed in scientific research, media coverage, or in public policy.  Accordingly, the installments in this series will sequentially count down the list of needed inputs related to COVID-19 that I would incorporate, “If I Ran the Zoo.”

19. Integration of novel epidemiologic data-gathering approaches into public policy decision making with near real-time feedback

  1. Early predictors of hot spots
    1. Map of abnormal digital temperature curves38
    2. Assessments of Social Distancing Efficacy based upon smartphone data:
      • Degree of limitations in distance travelled39
      • Social distancing scoreboards based upon smartphone data40
      • Community mobility reports41
  2. Contract tracing through smartphone Bluetooth technology-tracking interpersonal interactions42
  3. Comprehensive, disease-related data coordination and analysis
    1. U.S. COVID-19 testing results
      • Official statistics are currently neither uniformly measured nor available
      • The COVID Tracking Project43
        1. Volunteer analyst curated
        2. Accuracy uncertain
        3. Positive and negative test results (total tests) reported by state
    2. Comprehensive clinical trial results summary and interpretation
      1. TranspariMED44
        • COVID-19 Trials Tracker
        • Local COVID-19 Trial Resources
        • COVID-19 Evidence base
          1. Analysis of 382 COVID-19 Trials
            • 379 of which are from China
      2. A panel of experts should be assembled for formal adjudication and publication of real-time evaluation of the results of hundreds of COVID-19 clinical trials as they become available

18. Standardization of COVID-19 data reporting for media and governmental public communications

  1. In the information age, valid data must be promptly collected, collated, and presented to the public to include:
    • Tests performed per capita
      1. States have not collected COVID-19 data uniformly36
      2. Only total positive cases are typically reported in the media, not the negative cases
      3. This approach fails to provide the required information to preliminarily estimate prevalence and testing intensity and penalizes states that have been more active in testing by suggesting more widespread disease where testing is more robust
      4. Testing indications should be clearly communicated
        • Testing only symptomatic patients has resulted in a dramatic underestimation of the number of patients infected37
    • Test data should be standardized across locations: nationwide, by state, county, and city
    • Positive results and negative results reported indicating the intensity of testing.
      1. In the absence of this data, those states or counties that test less intensively will be assumed to have fewer cases
    • Data should be presented as social distancing-time-adjusted rates of hospitalization, intubation, hospital discharge, and death as a function of per capita testing intensity
  2. Official data should be made public, available, and easily accessible for research use
  3. No spin, no politics, just valid and transparent data to save lives by driving timely policy decisions

17. Adequate and proportionate patient/employee financial assistance

  1. Relevant COVID-19 Bills to date have provided35
    • Providing Recovery Rebates for Individuals: Cash rebates
      1. $1,200.00 provided for individuals and $500 per child
    • 401(k) provisions:
      1. Up to $100,000 loan if you of family member tests positive for COVID-19 or if you suffer economic harm
      2. 10% Tax on such loans is forgiven
    • Unemployment compensation amount increased
    • Student loan relief:
      1. Six-Month deferral without interest or penalty
    • Low-income households:
      1. Assistance with paying heating and cooling bills
    • Renters
      1. Eviction prohibited for lack of payment of fees x 90 days
  2. Significant additional stimulus measures are needed to allow employees to weather the COVID-19 storm
    1. Bills passed to date are stop-gap measures not stimulus packages
    2. Need further, sequential aggressive bills to preserve and reinvigorate patient/employee finances to include: 
      • Guaranteed sick leave for all employees
        1. Encourage those with COVID-19 to stay home to prevent the spread
        2. Provide income for those with COVID-19
      • Extension of unemployment insurance
      • Robust and universal coverage for all COVID-19 testing, treatment, and any future vaccinations regardless of insurance status
  3. Significant risks for patients in the COVID-19 era include:
    • Financial toxicity: direct negative health outcomes associated with increased costs / decreased income from non-COVID-19-related diseases during the Pandemic and its fall-out
    • Lack of access to care for non-COVID-19-related medical care and procedures
    • Cost-related nonadherence: inability to pay for prescribed medications to treat co-morbid conditions may lead to negative outcomes
    • The disproportionately severe impact of COVID-19 infection among vulnerable populations has been noted including the poor, elderly, uninsured and otherwise disenfranchised as well as among ethnic minority populations
      1. Mediated, at least in part, by inadequate control of common, comorbid conditions
        • Hypertension
        • Diabetes mellitus
        • Chronic pulmonary disease
        • Cardiovascular disease

16. Adequate and proportionate small business financial assistance

  1. COVID-19 Bills to date (4/22/2020) provide35
    • Employee retention tax credit
      1. Under 100 employees can claim wages and health insurance costs for all employees
    • Small Business Administration (SBA) Loans
      1. Roll-out was inefficient, chaotic, and potentially biased
        • Relief from payment of principal, interest, and fees x 6 months
        • Paycheck Protection Plan (PPP)
        • Economic Injury Disaster Loan (EIDL)
    • Funds have been exhausted
      1. Criteria applied to apportionment remain unclear
      2. Certain businesses that are not small by most metrics were included
  2. Substantial additional measures are required for small businesses to weather the COVID-19 storm:
    • Bills passed to date are stop-gap measures, not stimulus packages
    • Need further, sequential, aggressive bills to preserve and reinvigorate small business finances or risk an extinction level event for certain types of small business
    • This crisis represents an existential crisis for small businesses across the country

To be continued in part 2 – #15 to #11

Stay safe, stay healthy, stay United. 

REFERENCES:

35.  U.S. Congress. Summary of COVID-19 bills and available resources.  Accessed at https://www.wyden.senate.gov/imo/media/doc/Summary%20of%20COVID-19%20bills%20and%20Available%20Resources.pdf; accessed on 4/6/2020

36. Hickok K. States aren’t testing uniformly for coronavirus. That’s creating a distorted picture of the outbreak.  LiveScience https://www.livescience.com/coronavirus-testing-us-states.html; accessed 3/29/2020

37. Kolata, G.  Coronavirus infections may not be uncommon, tests suggest.  New York Times, 4/21/2020; https://www.nytimes.com/2020/04/21/health/coronavirus-antibodies-california.html?referringSource=articleShare

38.  Kinsa. US health weather map: https://healthweather.us/?mode=Atypical; accessed 4/6/2020

39.  Thompson SA, Serkez Y & Kelley L.  How has your state reacted to social distancing?  New York Times, 3/23/2020;  https://www.nytimes.com/interactive/2020/03/23/opinion/coronavirus-economy-recession.html?action=click&module=Opinion&pgtype=Homepage

40.  Unacast, Inc. Social distancing scoreboard: Compare your community’s social distancing activity to its activity prior to COVID-19.  https://www.unacast.com/covid19/social-distancing-scoreboard; accessed 4/6/2020

41.  Google.  COVID-19 mobility reports:  see how your community is moving around differently due to COVID-19.  https://www.google.com/covid19/mobility/; accessed 4/6/2020

42.  Apple and Google Collaboration. “Privacy-preserving contact tracing” https://www.apple.com/covid19/contacttracing; accessed 4/22/2020.

43.  The COVID Tracking Project. https://covidtracking.com/; accessed 4/6/2020

44.  TranspariMED. All COVID-19 clinical trials at a glance.  https://www.transparimed.org/single-post/2020/03/27/COVID-19-clinical-trials-information-sources; accessed 4/6/2020

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