By Michael Ainscough, MD, MPH
The federal government has released guidelines for governors to take a three-phased approach to reopening economies and communities in their individual states. The governors of Illinois and Missouri have taken different courses of action. Gov. Parson has delegated that authority to Missouri cities and counties. Gov. Pritzker has retained a one-size-fits-all guidance for Illinois. St. Louis and Chicago will both remain on stay-at-home orders, but the rural areas in the two states will soon be treated differently.
Social distancing and stay-at-home restrictions are indeed working, resulting in a flattening of the curve and delaying the peak of disease in large cities. The number of hospitalized patients in St. Louis was expected to peak on April 25. Chicago is projected to peak in mid-May. As per the federal guidance, an area should have two weeks of decreasing case numbers before the phased reopening, thus Gov. Pritzker extended Illinois restrictions until the end of May.
Waiting two weeks after the peak reduces the risk of a quick resurgence of cases. It also will allow health care capability to recover staff and supplies. Communities will also have time to
stock up on test kits and be ready for more testing and contact tracing.
Increased testing is key, especially in hot spots, to reopening the economy. Without widespread testing, asymptomatic patients will remain unidentified. Testing is critical to find those people and contacts who need to be quarantined, and also to identify areas of high levels of community spread. That data can inform communities and businesses when it is safe to reopen and let more people go back to work.
Relaxing restrictions too quickly could allow a rebound effect or a second wave of infections. Even with all the virus cases so far, it is estimated that over 80% of the population is still at risk for infection. When the economy is reopened, it probably won’t be like flipping on a light switch. It will be more like a dimmer switch to gradually turn the light back on. The first
businesses to reopen will be those that can practice social distancing and meet other guidelines set by the state health department. Schools can reopen in Phase Two of the federal guidelines.
In addition to the test for active infection, another type of testing, antibody testing, is becoming available. Antibody testing (serology testing) shows when people have anti-virus antibodies in their blood. This means they have developed immunity that protects them from being infected again. They could be issued an “immunity or safety pass” to go back to work, even during an epidemic.
Because this is a new virus 1) it is not yet certain that the presence of antibodies confers protective immunity, but that is the assumption, and 2) the test cannot tell us how long the
immunity will last. Some of these tests have also had accuracy problems, giving false-positive results. These unknowns need to be clarified before antibody tests can be used as a reliable tool
for return-to-work screening.
Not all immunity is the same. Immunizations against measles and hepatitis B provide protection for almost a lifetime. In contrast, vaccines for various flu strains provide immunity for only about a year. Similarly, the four mild seasonal coronaviruses do not seem to induce long-term immunity. With SARS and MERS coronavirus, infections produced strong immunity for about 18-24 months. After that immunity waned. Since COVID-19 is a new virus, we do not know exactly how long the immunity will last after an infection. Even if COVID-19 produces 2-year immunity like SARS or MERS, we obviously need a vaccine to prevent future epidemics.
We will likely not have a vaccine by next fall. Instead we will probably have the conditions of relaxed restrictions, a low percentage of the population with immunity, and unknown length of that immunity. Those factors will influence the timing and severity of a second wave. If the coronavirus resurges next fall at the same time influenza season is starting, it could create another great strain on our healthcare system. The second wave of the 1918 Spanish influenza was more deadly than the first, even in St. Louis.
Last week Dr. Anthony Fauci said, “We will have coronavirus in the fall. I am convinced of that. Whether it’s going to be big or small is going to depend on our response” between now and
then. It will depend on the infection rate (number of cases), our preventive measures (degree of restrictions), and the preparation (robust testing and replenished PPE supplies) by our national, state, and local governments in the interval.
If there is a second wave in the fall or winter, it would be very difficult for the federal government to completely shut down the economy again. One possible option during a resurgence would be for vulnerable populations (elderly, chronic conditions, and compromised immunity) to stay home, and everyone else continue to work, whether they had an “immunity pass” or not (with exceptions to be made on a case-by-case basis). Schools may be closed again, and large public gatherings would be prohibited. Second wave? We don’t want to go there.
As of April 27, Washington County has had only 8 confirmed COVID-19 cases, less than any of our neighbor counties. That is no small feat, considering St. Clair County has had 391 cases.
Thank you for all that you have done to prevent the spread of the virus.
Even as the restrictions are eased, it is still wise to be vigilant. Avoid going to hot spots such as St. Louis and St. Clair County. Avoid socializing in groups outside of your family unit. Don’t
cheat. Continue social distancing, wearing face coverings in public, and hand washing.
Social distancing measures are not about individuals; they are about communities working in unison. If we each do our small part, we can keep the infection rates down and avoid a second wave of infections. We are all in this community together.
Michael Ainscough is a local retired physician who has contributed several articles on the coronavirus pandemic. He can be reached at [email protected].