INTERVIEW BY STEPHANIE DESMON
The U.S. strategy for fighting COVID-19 has focused on preventing infection. The wildly contagious omicron variant has challenged this approach. What’s needed now, says Emily Gurley, PhD ’12, MPH, a professor of the practice in Epidemiology, is a shift to preventing hospitalization and death.
In this Q&A, adapted from the January 4 episode of Public Health On Call, Stephanie Desmon talks with Gurley about our current costly approach, the challenge of setting new goals in our pandemic response, and strategies that can be more effective for living with COVID in the future.
What happens in 2022? What is the next phase of our COVID strategy and how should we think about it as we move on?
I think what it looks like depends on us. So far, our approach to COVID has been to do whatever we can to prevent as many infections as possible. We've done this through behavior change: masking, social distancing, vaccinations, and contact tracing. They are all mainstays.
I would argue that going into 2022, we might rethink what our public health goal is, for several reasons. The approaches we have now are focused on preventing infection, with no defined goal. When have we met our goal? There's no real accountability, because we don't know what we're aiming for.
Our current approach is also costly in resources, in terms of time and mental bandwidth—in public health as well as the communities we serve. Essentially, our focus is on preventing as many infections as possible writ large across our populations, which I fear is not sustainable.
We lose people along the way because we ask so much. There’s a lot of collateral damage when we have kids missing school. These strategies have lost people their jobs. We must take that into account.
I think one of the main reasons we are trying to prevent as many infections as possible is to prevent hospitalizations and deaths. We have broad agreement that those are the outcomes we want to avoid. I would argue for a shift in our thinking: to make preventing hospitalizations and deaths the explicit goal. If we do that, we can come up with quantifiable public health goals. COVID is never going away. How many hospitalizations and deaths can we accommodate? How many are we willing to accept?
We do this with other infectious diseases, and the time has come to have that discussion about COVID. If we set those goals—and I’m not suggesting it will be easy—we can set up strategies to get there. There may even be multiple pathways to those goals. I think if we really focus on [hospitalizations and deaths], it would change how we use our finite resources.
In practice, what does that look like?
First, we focus on people who are at high risk for hospitalization and death, including people without preexisting immunity—people who are unvaccinated and may never have been infected. We know from hospitalization data that most people hospitalized have not been vaccinated.
How do we reach those populations? How do we get them access to monoclonal antibody therapies that can drastically reduce their risk of hospitalization? Antiviral therapies are not widely available, but they will be.
How do we maximize access to those treatments for people who are at highest risk for hospitalization and death? We need a way to get them diagnosed and treated quickly.
What are the barriers to getting people treated quickly?
One is a diagnosis. In most places in the United States, that's done through a PCR test. Once you have a sample collected, it can take a day or two to get results. Then a physician typically must order monoclonal antibodies. That process can take days.
Antiviral [drugs] work if they're given within three days of onset of illness. We do not have a system where we can use those as a public health tool. If we were to focus on preventing hospitalizations and deaths, we would have to use [antivirals], diagnose people quickly, and reduce the barriers to accessing treatment.
We must maximize the benefit of these technologies and therapies, and there is no way to do that without some reliance on rapid testing.That means making free rapid tests available in every home, and easy to get. We must reduce barriers to treatment.
Are there other places doing this effectively?
Colorado is leading the way here in the U.S. You can have rapid tests delivered to your door; they also have waived the requirement for a physician's order for monoclonal therapy. You can receive treatment if you have a positive test. In the UK, you can get rapid tests at any pharmacy–as many as you want for free. They're considered a public health service rather than a commercial product. That’s a great strategy focused on reducing hospitalization and death.
It’s not that we're not expending a lot of effort on our COVID response. We certainly are, but we are not strategic about where those resources go. To come up with a strategy where we learn to live with COVID, we have to focus on preventing severe outcomes. Our current strategies aren't going to get us there.
What role does contact tracing play in this new approach?
Contact tracing for COVID has, so far, focused on isolation and quarantine, which early in the pandemic was the best strategy we had. The point of contact tracing is to notify you that you've been exposed, so you can be screened for that infection, so that you can be treated.
If we are going to focus on hospitalizations and deaths, instead of focusing on reaching every contact and asking them to quarantine, let's find the contacts that are at high risk. Let's make sure they have test kits and that they know they've been exposed, so if they start feeling unwell, they can get treatment right away.
If we have a strategy where everyone has rapid tests, and if we can agree to tell [our contacts if we become infected], that's always going to move faster than public health. We’ve got to talk to each other.
We must have rapid tests so test results can guide our behavior. I think that people would enjoy having the power to know “Am I infectious today?”
Our public health effort, with this prevent-all-infection strategy, is unsustainable. It’s taking away effort from other important public health problems that we put on the back burner because of COVID. If we shift [our focus], we can cover more ground.
Do you see this paradigm shift happening?
Not really. I've heard more people asking, “What should our plans be?” I haven't seen any moves to articulate, for example, “How many hospitalizations from COVID should we be willing to accept and accommodate?”
That's a serious, difficult discussion to have between health care providers, elected officials, and public health. We have expectations for other diseases, and at some point, there must be a level that is normal, that is expected, that we work toward. I fear that without a goal that we can all get behind, we don't know what success means. If we don't know what success is, we don’t know when we're there.
Stephanie Desmon is the co-host of the Public Health On Call podcast. She is the director of public relations and marketing for the Johns Hopkins Center for Communication Programs, the largest center at the Johns Hopkins Bloomberg School of Public Health.