Lessons Learned from being at the First Wave of the Covid-19 Epidemic in the US


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Hilary Godwin, Ph.D., Dean, University of Washington School of Public Health and Professor in the Department of Environmental & Occupational Health Sciences

In early March 2020, Seattle was considered to be a “hot spot” for the COVID-19 epidemic in the United States. A month later, Washington was one of the first states to have demonstrated success at “flattening the curve”. This presentation will explore important lessons learned that might be of value to other jurisdictions and what challenges we still face as we transition into the “post peak” phase of the epidemic in the Puget Sound.

Transcript:

John

Thank you for joining today’s S3 Webinar, Lessons Learned From Being at the First Wave of the COVID-19 Epidemic in the US. Our speaker today is Hilary Godwin, PhD. Hilary is the Dean at the University of Washington’s School of Public Health as well as a professor in the Department of Environmental and Occupational Health Sciences. I now hand it over to our host.

John

Over to you, Hillary.

Hilary

Thank you. Thanks everybody who’s logged in for the invitation to come and speak with you today. When I was originally asked to give this presentation, we were feeling pretty smug about how things were going in terms of COVID-19 here in Washington and Seattle, because it was shortly after we had hit this point where modeling suggested that we had been successful in flattening the curve, and I would say we, like many other regions of the country right now, are not feeling quite so smug. So, some of it’s going to be lessons learned, and some of it’s going to be… What I talk about today is going to be more along the lines of how do we deal with the resurgence of cases that we’re seeing.

Hilary

I thought it’d be helpful to just go through the timeline for those initial months as a start. Probably everyone remembers the end of December there was an initial reports of a cluster of cases in Wuhan, China. Shortly thereafter in January, the first reported case in the United States was reported here in Washington, in Everett, which is just north of Seattle. Then right at the end of January, the WHO declared a public health emergency globally.

Hilary

It wasn’t until late February that we started seeing community acquired cases in Washington. Again, we are one of the first states to report those community acquired cases. We were fortunate to pick them up. Some of the reasons that we, in retrospect, that we picked up those community acquired cases earlier than other regions did had to do with two things. One was a physician who ignored the CDC guidance at the time, which recommended only testing for people who had been traveling near the site of the original outbreak in Wuhan or in China, and we had a physician who was looking at a cluster of cases in a nursing facility here in the Puget Sound region and saw cases that looked suspiciously like COVID-19 and sent in tests to the CDC. All the testing was done at the CDC at that point. So, that was one way that we caught early on community acquired cases that we now know were circulating in most parts… many big cities in the United States at that point and just going undetected.

Hilary

The other way that we were fortunate was that we have an ongoing study here in the Seattle area that’s being led by researchers at the University of Washington and the Fred Hutch that’s called the Seattle Flu Study, and they too picked up one of these early community acquired cases right around the same time. Right at that same time, right as we were starting to see those cases, Washington started restricting gatherings. This is one way in which we were pretty different from many states.

Hilary

Our governor and our local elected officials here in Seattle and King County… So, King County is the county that Seattle’s in, and our local public health department serves both Seattle and King County. So, you hear me talking about the public health Seattle and King County, because they’re one group. They work very closely, hand in hand, the elected officials with public health, both at the local level and at the state level here in Washington, and we have really great both public health leadership. We have some of the best local and state health officials in the country, so we’re very fortunate that way. We also have great elected officials who believe in public health and listened and worked closely with public health officials.

Hilary

Back when the first case was reported in Everett, even though we weren’t seeing community acquired cases because we weren’t basically looking for them at that point, during that interim phase, our local health department and state health department were already gearing up for response, so they were monitoring individual travelers coming in from China, asking them to monitor for symptoms, to report back, to self-isolate, and checking in with those individuals on a regular basis, providing them with services.

Hilary

We here at the University of Washington School of Public Health have a student group that is led by Janet Baseman, our Associate Dean for Public Health Practice. It’s called SEALs, Student Epidemic Action Leaders. They were pre-trained and had previously deployed in other much smaller outbreaks, and they deployed from the moment that we had the first case reported to help provide assistance to our local health department to do some of that initial tracking.

Hilary

It’s pretty much as soon as we saw the first community acquired cases, our local officials jumped on that. Our governor jumped on that and started restricting large gatherings. Shortly thereafter, the University of Washington announced a switch to courses online. We were the first major educational institution in the United States to do that, again, because we have a really strong health science schools. Our six health science schools are all top ranked.

Hilary

We work closely with our senior administration here and very closely with our local health officials, and so we were sort of lock in step with what they were recommending and switched to online classes very early. Shortly thereafter, we started seeing clusters of outbreaks in our K-through-12 schools. Initially, we just had local closures when there’d be a case detected, but as we started having more cases, Washington quickly, our governor moved to close down K-through-12 schools just shortly after WHO declared COVID-19 a pandemic.

Hilary

Then in mid-March our governor declared a stay home order, which we call Stay Home, Stay Healthy. That was our first phase. We saw pretty quick response that I’ll show you in a second in terms of cases coming down. We were fortunate, because because of those quick responses that we did not swamp our healthcare capacity the way that we saw in other regions like New York. Like I said, we were feeling pretty good about our response at that point and pretty happy when we started to see a decrease in both cases and then also deaths associated with COVID in early April.

Hilary

This is a plot of the number of cases, new cases, per day as a function of time for King County, which again, that’s the county where Seattle is located. You can see that late March, early April, we had our peak in cases. Also our peak in deaths was around the same time. Then we started to see this what we called flattening of the curve, which is what we had… modelers had predicted would happen if we implemented social distancing constraints like the stay home order.

Hilary

One thing I guess I would point out about this is for those of us who are not epidemiologists and modelers, I know I was not super happy to see that the curve came down much more slowly than it had risen. Actually, that was exactly what the modelers predicted, that you see we had gotten into this exponential phase of growth, which is very hard to contain, and even putting in full stop measures like a stay home order, we still see the sort of return being very slow, much slower than the original rise was. For those of you who haven’t frequently looked at these, you see these weekly peaks that result from we just don’t have as many cases reported over the weekend, and so every Monday you see a big peak in cases that are sort of the catch-up for the weekend, so that’s also very consistent with what you see in other jurisdictions as well.

Hilary

We were feeling pretty good about this until we hit early, well, actually, until we hit late June, because there’s a lag time between when you see the cases ticking up. It takes about two weeks for us to get complete data, so you can see here this is a screenshot from Public Health Seattle and King County’s dashboard from yesterday, and you notice that they gray out here. The recent dates, the data may be incomplete, and I would say recent dates, the data are incomplete. We always have a lag time where it takes us about two weeks to be really confident that we have complete data. So, anytime you see a down tick in cases in this gray window for any jurisdiction, take that with a grain of salt. That’s just a function of the delays in data reporting that we are all subject to. So, it wasn’t really until sort of towards the end of June that we started to be confident that this was a real increase and not just sort of noise in the data. By then of course we’re back in this exponential phase and worrying about what to do in response.

Hilary

I should point out that the situation is worse than it was in April for much of Washington as a whole, so if you look at where we are in King County, depending upon what the real data are for this week, we’re not quite back to where we were at the beginning of April, but for the State of Washington as a whole, these are data from the dashboard from the Department of Health for the State of Washington, again, confirmed case counts as a function of time. You can see that we’ve now surpassed the daily case count from what we had in early April.

Hilary

That’s a function of the resurgence of cases in the Puget Sound, which is what I just showed you, along with areas that are more rural that weren’t part of the initial surge in cases that we saw that are seeing the very first part of that and having difficulty containing it. Some of our rural farming communities in Yakima County and Benton and Franklin County are seeing their very first surge of cases and are at this point exceeding their healthcare capacity and are transferring patients back over to the Puget Sound for treatment, where we are not at this point exceeding our healthcare capacity. I should say that this is exactly what the modelers predicted would happen if we didn’t change… didn’t make significant changes or if we reopened too quickly. So, there’s a combination of the resurgence, which is from reopening and lifting up restrictions, and then the spread of cases into rural areas.

Hilary

I also want to point out that we’re not alone here. The number of new cases is also going up in most other parts of the United States. This is a lovely graphic from NPR showing a color schematic of by date new cases versus two weeks ago, where the more orange it is, the greater the number of new cases there are, and green means that there are fewer cases than a week ago. Again, across the country, you’re seeing a combination of different factors. Some places are seeing cases for the first time, because they didn’t get hit in sort of that initial first part of the wave the way Washington, California, New York did, and other ones are just seeing a resurgence after having seen a decrease, and we believe that’s due to increased mobility and reopening, as was predicted from modeling study.

Hilary

I think it’s tempting to ask what went wrong here in Washington, why do we see this resurgence, but I guess part of my lessons learned is it’s probably more appropriate to ask what hasn’t changed, what’s still the same as it was before that we haven’t come up with a solution to, so we’re seeing just a return of caseload. To talk about that, I think it’s really important to think about the reasons that we resorted to using social distancing in the first place and the fact that they are mostly still valid.

Hilary

The reasons that we resorted to social distancing efforts had to do with features of COVID-19 that are profoundly different from what we see from, say, normal cold or seasonal flu. So, the first of those is, unlike our seasonal flu, we don’t have a vaccine, and because it’s new, we don’t have a unity for most of our population, and that’s still the case. Our estimates are that perhaps 10% of the US population has been infected with COVID so far. That’s nowhere close to the 70 to 90% that we’d need in order to have herd immunity. Furthermore, we actually don’t know whether, still, whether or not having previously been exposed to COVID-19 confers long-term immunity. We’re starting to see some results come out that suggest that there may be immunity for a couple of months but it may start to wane after that. That does not bode well both for ability to develop herd immunity and for ability to develop a vaccine that would last for long periods of time. Those things are still challenging.

Hilary

The other challenge that we had when COVID first hit was the lack of availability of widespread testing. So, because many of you are in the biotech industry, you undoubtedly know that it takes time. Just like it takes time to develop a vaccine, it takes time to develop a new test, not quite as long as it takes to develop a vaccine, and particularly to develop a validated test. So, that was a large part of the initial problems that we have in terms of catching COVID early on in most jurisdictions, whether that test during that very first phase, testing was only being done by the CDC. There was a lag time in terms of getting reports back and the timing, and all of that meant that we just weren’t doing routine surveillance.

Hilary

Like I said, we were lucky here in Seattle to have picked up a case that way. I would hazard to say that probably other jurisdictions like New York, had we had widespread testing and been able to do surveillance testing, that we might have picked up cases sooner and been able to enact social distancing constraints earlier there as well that could have helped. That’s still a factor. We’ve made a lot of progress in terms of the availability of testing, but as I’ll come back to at the end, it still continues to plague us. Our latest concerns are around supply chain related to testing, and those are real concerns, that constraints, we are worried, will continue to constrain our ability to keep tabs on who is infected and making sure that they isolate quickly.

Hilary

Another factor that’s important is something that sounds great when you’re thinking about an individual perspective but is awful from a disease management perspective, which is that approximately 80% of the people who are infected with COVID-19 either have no symptoms at all or have mild to moderate symptoms, and so that’s great if you’re just thinking about it from a human being perspective of, okay, I Just have a one-in-five chance of having really severe symptoms, but it’s terrible from a disease management perspective, particularly because we do see evidence that suggests that individuals who are asymptomatic are able to spread the disease and to transmit disease. That makes it very, very challenging to isolate and quarantine individuals who are infected and then expose to those individuals who are infected. So, it’s very different from, for instance, Ebola, where we didn’t have to worry about people who were infected with Ebola going to the grocery store and infecting other people, but we do have that challenge with COVID-19.

Hilary

Then lastly, there’s the flip side of that 80/20, which is that 20% of people who do exhibit severe symptoms, a really high percentage of those folks require intensive treatment, and that is really taxing on our healthcare system. So, initially, we were also seeing a significant percentage of those individuals requiring intubation. Some of the treatment guidelines are now shifting, but regardless, those individuals who require hospitalization require really intensive attention from our healthcare providers, and so often what we’re seeing in regions is that it’s not even just that the number… We don’t have the number of hospital beds, although those are being exceeded in places like… Well, initially New York but now Arizona and Florida, but also just that each person with COVID is just requiring a huge amount of staff time and personal protective equipment and supplies, which further taxes the healthcare system.

Hilary

That comes back to what we were trying to do with flattening the curve really was to try and bring down that caseload in any particular region so that it was below where the level at which we could provide good care for people in our healthcare system. It wasn’t that we were trying to completely get rid of it, although of course everyone would have loved that, but really it was just trying to get it down to a level where we could continue to provide good care and good outcomes for those people who had severe symptoms. Moreover, that we still had enough healthcare capacity that we could provide healthcare for people who had other emergency healthcare needs, people who got in a car accident or who had a heart attack, who just needed access to our healthcare system. If our healthcare system is completely maxed out with COVID patients, obviously then we don’t have the capacity to deal with those more routine emergency issues, and then the outcomes for those issues become worse as well.

Hilary

Many of those things are still valid. We’re doing better in terms of testing, and we maybe have a little bit better idea about treatment, but it’s still really challenging, and in some areas, I know in Seattle, we ramped up very quickly to increase our healthcare capacity and to make sure that we had isolated wards for people who had COVID, but we’re seeing challenges with that in many regions of the United States still.

Hilary

Then, given this audience, I figured it’s worth also talking about the testing limitations. Again, you guys are probably more familiar with this than most audiences that I talk to, but for a lot of people right now it’s very confusing why… To me, the challenges that we have with testing are just inherent to testing for infectious diseases. So, one of those is that the type of testing that we use for whether people are currently infected, which in this case, is PCR based test or antigen based test, only come up positive if the person has a high enough viral load, and that’s normal. That’s the way those tests work, but it means that we frequently see in the case of COVID, people who test negative and then a few days later test positive. So, communicated to the general public that just because you had a known exposure to someone with COVID, you need to continue quarantine even if you come up negative, and you probably need to get a repeat test even if you come up negative, has been super challenging. It’s been a real challenge in terms of management of this disease.

Hilary

Then on the flip side, it’s taken much longer for us to have widespread serology testing or antibody based testing to let us know about who’s been previously infected, but again, the challenge there is it’s really important information from a surveillance perspective and a understanding how widespread the disease has been so far in making accurate predictions going forward to have good population based antibody tests, but it’s less useful from a clinical perspective, because we don’t know whether someone turning up positive from an antibody based test means that they are immune to further infection or how long they would be immune to further infection. Those are all challenges.

Hilary

I’m noticing there’s some questions in the chat box, and I just want to reassure you guys, I’m going to come back to you. I’ve saved a lot of time for the end to answer questions, but I’m going to try and get through the rest of these slides first, and then we’ll come back to you guys.

Hilary

So, what have we learned about coronavirus is spread? Another part of the challenge is that initially the guidance that we were putting out was based upon what we knew from other similar types of coronaviruses and respiratory pathogens, and now we’re shifting to guidance that is based upon what we have learned specifically for COVID-19, and so that’s led to some confusion.

Hilary

So, what we currently know is that the primary route of exposure is through droplets, which means that people who are within six feet of each other for long periods of time, so more than a couple of minutes, are at greatest risk for infection and transmission. But there are also possibilities in terms of transmission still through droplets and then through surfaces, particularly if people touch their faces, so we’re still really pushing on good hand hygiene.

Hilary

What’s not shown in this info-graphic from the World Heart Association, is that there’s also data coming out suggesting that for enclosed spaces, that aerosol transmission can be an issue, so if you’re in an enclosed space with a group of people and the air handling system, you don’t have enough air exchanges or there’s a pattern of air circulation, you may not have to be within six feet in order to get transmission. You might have people at longer distances transmitting, and so that provides further challenges as we look at reopening schools and workplaces as well.

Hilary

We have learned some measures that are really good at reducing the risk of transmission of COVID-19. Obviously, the really best one is people staying home, which is what’s shown on the left here. So, absolutely critical that people with any kind of symptoms stay home, but because we have so many people who are asymptomatic or have low levels of symptoms, this is why those stay at home orders have been so effective. In the absence of being able to test everybody, having people stay home is the way to really clamp down on transmission.

Hilary

Again, because droplet transmission is the major route, having people stand six feet apart and wear masks if they are coming within six feet of other people, and now we’re actually just saying, just wear a mask if you’re out in public, because people weren’t good at judging the timing of how long they were within six feet of people, and we were seeing just too big of an increase in transmission. We know that those are effective strategies.

Hilary

I should say with the masks, our initial reaction for many of us was wearing a face covering is not helpful in terms of reducing your own risk, because we were thinking from a more traditional perspective of comparing them to N95 respirators, and N95 respirators are great at personnel protection, protecting you from other people. Surgical masks and cloth face coverings, by contrast, are more… provide a little bit of protection for the wearer but are more focused on protecting other people from you.

Hilary

In early phases of the pandemic, we didn’t recognize how important that protecting other people from you, who might be an asymptomatic carrier was, and so there wasn’t as much focus on wearing face masks. That has now shifted, because we now have some good data to support that wearing face coverings does a great job of reducing transmission from asymptomatic people who are wearing the mask, to other people, and also we’re seeing some evidence that it does provides some protection for the wearer as well. Then finally, making sure that people are checking their symptoms. That’s what this final graphic on the right is, and that where cleaning workplaces are really critical as we’re looking at opening up schools and workplaces and are important mechanism for containing transmission.

Hilary

The other thing that we know from the data that we’ve seen is that there’s some individuals who are at greater risk for severe symptoms. Those include people over the age of 65, people with prior heart disease or lung disease, like COPD, individuals with diabetes, individuals who are morbidly obese, and so it’s particularly important to protect those individuals and to minimize their risk of exposure.

Hilary

As we moved forward in terms of thinking about, okay, how are we going to deal with this, once everyone shut down, then I think we all hit this point of we were like, “And now what, what do we do?” The sort of beginning of the reopening phase was guidance that was released by the White House on April 16th that provided a general framework for reopening with the idea that you would start some activities, make sure that you didn’t see too much of a surge in cases, and then slowly progress to reopening more things.

Hilary

But ultimately the decisions were left to the states and the governors, and that’s because, if you recall from your eleventh grade history class, civics class, that under federalism, one of the powers that’s reserved to state governments is the protection of public health and safety, and so ultimately within our system, it really is the decisions of states and governors about whether to follow that guidance that is really federally.

Hilary

Similar to many other states, our governor here in Washington State, Governor Inslee, announced a phased return to a reopening for the state. That was announced in early May, where you can see here the idea that individual counties could petition to progress to the next phase if their own statistics looked good, if they met certain criteria, and that high-risk populations should continue to stay home through phase three, but that we would start reopening different businesses and allow greater gatherings of people as we progressed through the phases.

Hilary

One constraint that the state put forward was that each county needed to stay at each phase for a minimum of three weeks, and that was to ensure that we had time for that data lag to come forward so that we could see whether or not the increase in mobility and the increase in reopening was having an impact on disease transmission. I think with all of us agreeing that three weeks was a bare minimum for starting to see those effects and the realization now that there’s actually perhaps even a longer lag in those.

Hilary

One of the real challenges that all of us are facing is how to decide when counties or states can move to the next phase. Within the State of Washington, the Governor’s Office indicated that five different categories of data would be considered, disease activity, testing capacity and availability, case and contact investigations, our ability to identify who’s infected and to have them isolate, and then to contact people who had been in contact with them and to ask them to quarantine to make sure that they were quarantining, and following up to make sure that they didn’t have symptoms. Looking at risks to vulnerable populations, for instance, people in assisted living facilities and long-term healthcare facilities, and then also how our healthcare system was doing in terms of readiness.

Hilary

One of the complaints that we’ve heard pretty loud and clear from people is that there’s a lot of data being considered and that it’s not super clear to the average person looking at this website, looking at these sort of dials, to figure out when we might likely move to the next phase. That’s because it’s a hard decision to make. It’s really a complex decision-making framework. Within King County, Seattle and King County, our local health department actually came up with what I think is a really nice key indicator summary where they use very similar types of metrics, so for COVID-19 activity there’s four different metrics, not just the number of cases, but is it growing or shrinking. Is the risk of being hospitalized changing? Is the risk of death changing? Then really called out specific targets clearly indicate what our current status is and then with either a red triangle to indicate we’re not meeting our target or a green circle that we are meeting it, and then actually showing the data, again, with this gray bar showing uncertainty, the period of uncertainty, because we don’t have complete data.

Hilary

It’s much more transparent to people, for instance, looking at this, that we’re not doing too good right now in terms of… This is again from yesterday. We’re not doing too good in terms of our COVID-19 activity in terms of our targets, so we’re definitely not ready to move forward to our next phase. But I think the question that we still are grappling with is do we need to move back, and we’ve seen that around the country as well.

Hilary

I should also point out that the other thing that we’re seeing, so these are the other… the second path of that page… and the metrics for testing capacity and healthcare system readiness, we’re doing pretty good right now in terms of healthcare system readiness. This does not include beds. My understanding is that this does not include beds that are taken up by people coming from other counties, like Yakima County, so our actual availability is not quite as good as this.

Hilary

Then there’s also the testing capacity. Are we testing enough to detect most cases? We were doing really great in terms of both the number of tests that we were running locally, because we’d stood up local testing sites in the hard-hit communities, and also our ability to turn those around quickly. Just check on the time. We’re worried about the trends there, and that has to do in part with supply chain problems. Our metrics are not only impacted by what’s going on here but also by our response to other counties and helping out our nearby counties, which of course we should be doing and are doing, but also by what we’re starting to see as supply chain issues in terms of reagents for testing from hard hit areas starting to affect even these regions that are less hard hit, and our ability to do broader testing, which is really critical to having a sense of whether or not we’re catching cases as they emerge is now being impacted as well.

Hilary

Then I just wanted to point out that we’re also being hit by some new changes in terms of demographics that is also being seen in many parts of the country. One is that young adults are now driving the latest cases in Washington, so this is confirmed cases by age group. It used to be that this was dominated by older adults, and the more recent cases are dominated by young adults below the age of 40. In those regions where this demographic shift occurred first, like Yakima County, we’re now seeing those cases spreading out to older populations, presumably due to cohabitation of people, people living together across generations. So, although initially, in terms of hospitalizations and death rates, we see lower hospitalizations and death rates for this group, as they start infecting their parents and their grandparents, we’re now starting to see more hospitalizations tick up and expect death rates to tick up as well. An even greater lag there in terms of the impact.

Hilary

Then I also wanted to emphasize that we, like other areas, are seeing the pandemic reinforcing existing health inequities. So, in this case, I just wanted to show you this again, data from the Department of Health, which has a really nice equity dashboard. You can see that in our state Hispanics only make up 13% of the total population of Washington and yet represent 44% of reported cases to date in terms of COVID-19. That has nothing to do with any natural predisposition towards this disease. There’s no biological basis for this other than the existing health inequities and access to care and differential rates of disease that are due to our systemic inequities in terms of healthcare and health equity that we have in the United States. We’re seeing that most significantly for Hispanics but also for our Black communities and our Native communities as well, and I know in other regions the impact on Black communities is even greater.

Hilary

So, lessons learned. The critical one is that this is a new virus, and the virus is in charge, so for the most part we really need to take into account the data that we’ve seen. We need to realize that we’re still learning and somehow figure out a way to more accurately communicate to the general public that we are still learning, and so our advice is going to change as we learn more, and that things that we don’t expect are likely to happen, and that’s sort of our new normal.

Hilary

Also, the realization that we not only have to take into account data but also the constraints that we have with regard to data, and really one of those big ones is the time lag in seeing cases and then an even further lag in terms of seeing hospitalizations and deaths. That really influences not only what decisions we make but when we make them. We have to sort of preemptively make the protective decisions. Otherwise, we get into a point where it’s really fast exponential growth and it’s very hard to contain.

Hilary

We’re still at a point where our non-pharmaceutical interventions like social distancing, isolation quarantine, are our best tools, but we desperately need help from biotech and pharma to bring new tools, whether it’s new testing, improving the reagents supply chain. Better yet, vaccines and better therapeutic. We really need those new tools in order for things to fundamentally change in terms of how we’re coping with this disease.

Hilary

The other thing that we’ve seen is that individual behaviors are absolutely critical to the spread of this disease, and so people wearing face masks, people limiting their gatherings with other people, those are the big predictors of whether or not we see these resurgences and cases. We know everyone is really tired of staying home, but it’s going to be even more critical as we head into the fall that we get good communication out to people, that it’s not just their own health but our collective health and well-being that is dependent upon their actions.

Hilary

Another really important point that we don’t always talk about but is absolutely essential, is it’s not about getting rid of risk. We’re not trying to get the cases down to zero just because it’s virtually impossible, but also because it would take so much shutting down of our economy that it’s not worth it. So, it’s really about managing trade-offs strategically. So, when people say, “I don’t like wearing the mask. I feel uncomfortable wearing a mask,” my response is, “It’s so much better than us not being able to have people return to work.” The same thing with, I understand people would like to have bars open, but at some point the trade-off for us is going to be having bars open or having schools reopen. It’s so critical to our kids that they be able to receive an education that bars are a lower priority. So, it’s really about managing those trade-offs strategically.

Hilary

We’re seeing more and more that there needs to be coordination across state lines. I mentioned that under federalism, protection of public health and safety is a right that’s reserved to the states, but we need the federal government to help with managing supply chains and also providing consistent guidance so we don’t have this fractured system that we currently have, and we have more coherent messaging about what works and what doesn’t work. In the absence of that, we’re starting to see states form coalitions, but that remains a huge challenge for us here in the United States.

Hilary

Then finally I would say, the thing that’s happening in terms of the differential impacts on vulnerable populations, the realization that COVID-19 and the social justice movement that we see ongoing right now are absolutely intertwined, and the solutions that we develop need to take that into account.

Hilary

With that, I think that’s it for me. I’m going to go to the questions. I’m going to try and call up the time. Okay, we have at least 10 minutes for questions. Okay, so the first question was, “The COVID cases in your K-through-12 schools, were they all adults, or were there cases in children?” Yeah. So, what we see both in daycare and in schools is that the individuals with the most severe symptoms tend to be adults, and children tend to have less severe symptoms. That being said, we have seen cases here in Washington and the Puget Sound region, the Seattle region, of what has been reported nationally and internationally of children having these very severe… It’s very unusual but very severe response to COVID-19, so it’s not as though children are completely immune. It’s just that in most cases kids have less severe symptoms.

Hilary

The next question is, “Do you think in the fall we will see the recurrence, and do you think the second wave will be worse than the first?” Yeah, this is a great question. I should emphasize that what we’re seeing right now in the United States is still the first wave, right? It’s the first wave for many jurisdictions, particularly the more rural areas of the United States that weren’t hit early on. It’s just hitting those areas now for the first time. Also, for those of us who were hit early on and managed to flatten the curve, we’re just seeing a resurgence as we start to lift up those restrictions that we imposed, because we don’t have significant other changes in place.

Hilary

Then the question is, do we expect another wave to hit in the fall, and I think many of us do expect to see a recurrence in the fall. So, a second wave is somewhat dependent upon whether or not COVID-19 ends up behaving much the way seasonal influenza does and sort of circulating globally seasonally, and we just don’t know whether that’s the case. Some of that has to do with having kids in school, and so how we end up dealing with online education versus in-person education for K-through-12 and the extent to which kids are transmitting COVID-19, all of that will probably impact that.

Hilary

What I can say with pretty high certainty is that we will see seasonal influenza in the fall, and that has many of the same symptoms, and if we don’t have widespread testing available for both influenza and for COVID-19 then we’re going to have to be quarantining individuals with flu-like symptoms regardless. Certainly having seasonal flu is going to complicate our ability to respond to COVID-19. Regardless of whether or not we see a new resurgence or we’re just still continuing to battle this first wave, all of us… Most of us within public health expect the fall to be pretty challenging from a disease containment perspective. Yeah, whether the second wave will be worse than the first, that has a lot to do with whether it comes at the same time as seasonal influenza and whether or not we have built up sufficient capacity and whether we have other tools in our portfolio at that point.

Hilary

Okay, the next question was, “Is the University of Washington opening up to on-campus classes in the fall?” We are using a hybrid model. Approximately 80% of our classes will be online, so all classes that are above 50 people automatically are online because of the state guidance that we have currently and what we expect to be in place in the fall. For smaller classes, we are currently planning for those type of classes that either have to be taught in person, like lab classes, or where the mode of instruction really is better suited to in person, so that’s that 20% of our classes.

Hilary

We have scheduled rooms for those. They’re in much larger rooms than they normally would be. That limited our ability to have those classes, and so we had to do some prioritization. We’ve had them in larger classes so that people can have that six feet of social distancing, and we do have a masking requirement. We also have a testing protocol that we’re working on developing, and we expect to have lower residence hall rates as well just because a fair number of people are opting to take their courses entirely online. We’re at this point planning to be hybrid, but it depends on how the levels of transmission are in our community when we get to the fall quarter. We’re kind of fortunate we’re a quarter school and not semesters, so we have a little bit of breathing room to sort of see how things go.

Hilary

Are we seeing people contracting COVID twice? It’s a little hard to tell at this point from the studies that I’ve seen whether it’s that people are contracting COVID twice or whether it’s that they just have… They had low levels of viral load and tested negative and then had sort of an uptick in their first infection. The jury’s still out on that and something that we’re still not sure about.

Hilary

Next question, “Do you think that we as a country or society are better prepared to deal with the second wave of COVID or another pandemic?” In some areas we are better prepared, and I can tell you specifically about how we’re doing in Seattle. We dramatically increased our healthcare capacity for dealing with and isolating COVID cases. We’ve dramatically increased our contact tracing and case investigation abilities. We’ve dramatically increased our testing capacity. All of those things are great and we are better prepared.

Hilary

What we’re seeing in terms of this uptick is that doesn’t mean that we can just go back to normal or even go back to some semblance of normal. Right now we’re at about 60% of our normal sort of mobility in society, and we’re already seeing that uptick in terms of cases. Clearly, we still need to have some constraints, and we’re trying to figure out what those are, what are the things that we need to prioritize and what are the things that we can scale back on.

Hilary

Next question is, “How important is the role of contact tracers and will they have a long-term role to assist in data collection?” Contact tracing is, for the way that we manage infectious diseases in this country and all countries that I’m aware of, is absolutely critical at this point. We don’t have the kind of automated technology that allows us to be able to do this without having human beings manually contacting people when they find out that they’re positive, explaining to them about isolation protocols, finding out who they’ve had contact with, and then contacting those individuals and encouraging them to self-quarantine.

Hilary

It’s absolutely critical, but it only works if we can get the information quickly enough, right? So, if people aren’t out there for four or five days while we’re waiting for test results to come back and testing other people, that’s a failure. That’s a failure if we can’t get people, if we don’t have people’s trust and they don’t pick up the telephone or tell us who they’ve interacted with, and it’s also a failure if we can’t convince people to isolate and quarantine. There’s a lot of challenges there, but it is an absolutely essential piece of the puzzle.

Hilary

The next question is, “What stage is Washington at currently?” Washington is this interesting model. We’re a little different from other states. We don’t have a statewide stage. Each county is allowed to petition to progress to the next stage when they meet the criteria that are set by the Governor’s Office, and so from the get-go, those counties… At that time, King County, that had a lot of cases stayed at stage one for longer, whereas other counties that didn’t have very many cases and that never had very many cases, that could move ahead to stage two.

Hilary

Many of those counties that moved ahead to stage two have already moved on to stage three. King County, we moved to stage two, and then we started to see this uptick in cases, and so we’re… I don’t want to stay stuck at stage two, but we’re holding tight at stage two right now trying to get things back under control before we would consider moving to the next phase. It really depends upon which county you’re in. It’s not a statewide thing. I guess time will tell whether or not that was a good approach. It seems to be working well for us right now, and that’s how we’re handling it.

Hilary

The next question, “Is the reason why when finally mandating masks outdoors in public spaces that we remove the conditional if social distance is not practicable? This gives too much for individuals to play dumb.” Yeah. That is something that varies from state to state. In Washington we had exactly what this person described, which was the conditional if you can’t socially distance, and I agree. It didn’t work. We just had people not wearing face masks because they’re like, “Yeah, I can socially distance.” So, we now have mandatory face masks requirement if you’re out in public in Washington. We’re hoping that works better. The reality is that I think all of us are trying to see if we can get away with less restrictive measures and reliance on people’s goodwill to move things forward. When that fails, then we put in more restrictions. That’s sort of where we are.

Hilary

That is entirely different from, for instance, the way China dealt with it. They have a much more totalitarian government, and so they just cracked down absolutely from the beginning, and they’ve seen really good outcomes as a result of that. It’s just I think probably not something that in the United States would be… It’s not the way our government structure works and would not be acceptable to most people.

Hilary

Okay, the last question, “What are the total number of deaths in Washington from COVID?” I’m going to look it up for you right now. Washington, I should have this off the top of my head but I don’t. All right. I’m on the Washington DOH site, and our total number of deaths from COVID are not showing up here. Confirmed deaths in Washington State, 1,400. It’s 1,421 and confirmed cases is 43,000, so we’re doing worse than many other states but better than others. Yeah, we’re sort of in the middle of it.

Hilary

With that, I’m going to turn it back to John, because that was the last question. But thank you all. Just to summarize, I guess my… Whoops, stop screen share. I didn’t realize I was showing you guys my desktop here. Thank you all again. I think lessons learned, we need help from your industry. We will continue to need help from your industry in many different ways, and we also need help from you individually in terms of communicating good science to the people around you and encouraging them to stay the course and try and be patient with what is really a truly unprecedented time in the world.

Hilary

With that, John, I turn it back to you.

John

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