POLICY BRIEFING – WEEK IN REVIEW

Last week Brief19 covered a new report from the National Academies of Sciences, Engineering, and Medicine (NASEM) with new recommendations for decarceration and steps the healthcare community can take to facilitate inmate reentry into society. Yesterday, The New England Journal of Medicine published a new analysis of the greatest risk factors for inmates in the state correctional system using results from symptom-based and mass testing of incarcerated persons in Connecticut. In addition to the results of the tests, participants were followed for fourteen days to assess clinical status. The greatest risk factors for developing covid-19 were found to be dormitory-style living, Hispanic/Latino ethnicity, and older age. The study also identified heart disease, dormitory living, and older age as predictors of hospitalization; heart disease, older age and immune compromise were also risk factors for admission to intensive care units. The only risk factor for death was older age. Dormitory style housing was the strongest overall risk factor for developing covid-19, which is consistent with prior data supporting the importance of physical distancing which emphasizes the difficulty associated with limiting the spread of infection among incarcerated individuals.  The New England Journal of Medicine. 25 November 2020.

Personal protective equipment (PPE) shortages have been the constant background of the pandemic in the United States. As early as April, Brief19 reported on healthcare workers becoming infected due to shortages. In the absence of a unified federal plan, grassroots movements like #GetUsPPE (now Get Us PPE) gained substantial attention. It and other organizations repeatedly petitioned the President to invoke the Defense Production Act to prioritize increased manufacturing, while federal agencies gave warning that demand for masks, gloves, gowns, face shields, and other needed items continued to outpace supply. In September, the Food and Drug Administration (FDA) published a list of PPE-related supplies in shortage.

Against this backdrop, a new investigation by National Public Radio (NPR) has found that the Strategic National Stockpile (SNS) is still unable to keep pace, citing budget shortcomings, lack of domestic manufacturing, and a global supply chain still in chaos.

The SNS was designed as a stopgap in the face of an overwhelming national or global crisis (of which a pandemic is merely one), meant to be able to provide up to ninety days of supplies during the initial response to a wide range of chemical, biological, or nuclear incidents. Representatives from the Department of Health and Human Services (HHS) list 142 million N95 masks and 22 million pairs of nitrile gloves, of the projected 300 million and 4.5 billion required to fill the stockpile.

Procurers state that many of these necessary prerequisites are manufactured in very few places, and without a domestic source (including those that would be made possible by the invoking of the Defense Production Act), it has been a veritable global auction house to find these supplies. Absent a coordinated effort from the federal government, state and local health entities have been forced to enter this chaotic system and fend for themselves in trying to meet the ever-present need to protect our healthcare providers. But those jurisdictions lack the financial resources needed. And unlike the federal government, they can't just print money to fund these initiatives. National Public Radio. 27 November 2020.

Last week Brief19 covered the new infection milestones that many states were hitting on a daily basis. Unfortunately, the hits keep on coming. According to Reuters, which keeps a daily tally, the United States has now surpassed 250,000 total deaths. While it is reassuring that the case fatality rate had a 30 percent relative decrease, this has been somewhat blunted by the news that an estimated 3.2-3.6 million Americans are currently infected and contagious with covid-19. It is important to note that these numbers are higher than other reported totals due to the community spread of the virus and how these models use metrics to estimate positive tests beyond those reported by state health departments.

Part of the concern originates from the fact that the wave this past fall followed a similar progression to the 1918 H1N1 Spanish Flu pandemic. As the country moves into the holidays, many new cases are anticipated, in spite of new lockdown measures being instituted by many states. While the White House has focused on strategies aimed at protecting high-risk individuals and allowing the development of herd immunity for other citizens, infectious disease experts fear this strategy will result in "many tens of thousands" of preventable death. This comes in addition to previous figures which estimate that around 130,000-210,000 preventable deaths are attributable to prior inaction. Various. 23 November 2020.

Since the evening of November 21st, 94 percent of Californians have been adhering to an evening curfew in order to curb the spread of covid-19. California is hardly the first state to impose such a restriction, though it remains unclear whether such policies can achieve the desired effect.

The fact that various states would seek such new aggressive measures to control covid-19 is not surprising, as the United States is recording record cases and hospitalizations day after day. An assumption underlying these curfews is that bars and restaurants open late are a significant source of coronavirus spread. While they are certainly a potential source of spread, some evidence suggests that a preponderance of transmission occurs in private gatherings, which are unaffected by the curfew. In fact, the earlier closure of bars and restaurants may have the effect of exacerbating coronavirus spread if people gather at home more when unable to go out to public places. The effect of curfews on the spread of the coronavirus has not been closely studied and would be hard to accomplish, given the large number of "confounding variables" that tend to coincide with policies such as curfews. Residents in locations that feel the need to enact curfews may already be altering their other behaviors that spread the virus, making it next-to-impossible to isolate the effect of curfews on disease transmission.

Moreover, the effectiveness of curfews hinges in no small part on enforcement. As infections rise at an unprecedented rate in California, the overnight stay-at-home order will go largely unchecked. Sheriffs in over a dozen California counties including Sacramento County indicated that they would not be determining who, whether in public or private gatherings, is in compliance with health orders related to the curfew and that officers would not be dispatched for that purpose.

This lack of enforcement raises the question of whether the curfew is more of a "cosmetic" change, in lieu of delivering meaningful public health progress with respect to covid-19 transmission. With rising cases, hospitalization rates, and deaths, aggressive efforts are needed to slow the spread of coronavirus. A patchwork of poorly-enforced curfews are likely to be inadequate to that end and may just contribute to "pandemic fatigue." Various. 24 November 2020.