From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

The U.S. response to the COVID-19 Pandemic – The August Update (2020)

Mathew Alexander¹, Lynn Unruh², Andriy Koval²

¹School of Medicine, Virginia Commonwealth University
²Department of Health Management and Informatics, University of Central Florida

Overview of key events and findings

Eight months have passed since COVID-19 was introduced to the U.S., and the outlook remains bleak. The U.S. continues to lead the world in COVID-19 cases and mortality. In late July, the U.S. hit yet another milestone, surpassing 150,000 deaths. The Centers for Disease Control (CDC) recently estimated that the total number of cases may be six to 24 times as high as the number of confirmed cases based on antibody testing, indicating greater community spread than previously detected.

At the height of the March/April lockdown, 42 states had stay-at-home orders in place. By the beginning of June all states began reopening, even though many did not meet reopening criteria. Since then, daily records in cases continue, particularly in Florida, Arizona, California, and Texas. Several states have reached hospital and ICU bed capacity. PPE shortages remain in hospitals and doctors’ offices. Existing health disparities continue to be exacerbated. African Americans account for 12% of the population but 22% of COVID-19 deaths. There are also notable disparities in testing site accessibility, including less sites in communities of color.

Testing issues persist. 700,000-800,000 Americans are tested per day, but cases are outpacing capacity, and cities are restricting who can get tested. Shortages of testing supplies and delays in test result reporting are hindering adequate contact tracing. Financing surveillance and other non-diagnostic testing is becoming a dilemma. Rapid antigen and pooled testing approaches are promising, but have not offset existing challenges.

May, June, and July shed light on other important findings. As of early June, nearly $100 billion in relief funding had yet to be distributed to healthcare providers. No new federal COVID-19 legislation has been passed since April. Several Southern and Sun Belt states that prematurely reopened are not only the new hotspots, but are also reporting higher mortality rates in younger populations. 5.4 million workers lost their employer-sponsored health insurance between February and May. Aforementioned Southern states have been the hardest hit by coverage losses.

Given recent surges in cases, many states have pared back reopening plans. As of early August, 17 states imposed new restrictions and seven paused reopening. The uptick in cases and growing evidence on aerosol transmission has led to stricter masking policies. More than 30 states have a universal mask policy. School reopening is underway, though the majority of the largest school districts will use telelearning.

Reflections on the U.S. response

Inaction and the lack of a scientifically-informed, unified response have contributed to the sustained spread of COVID-19 in the U.S. Several countries that experienced similar or worse peaks in cases during the first few months of the pandemic have largely recovered. By June-July, governmental leadership devolved nearly completely to state and local governments, with organizations like the National Governors’ Association playing an active role in coordinating state governments. Inconsistent messaging and misinformation have flowed from the top down. Politicization of masking and other public health measures has contributed to the lack of collective action. Most recently, the Georgia Governor banned all local masking mandates in the state. Other questionable decisions have been made, including a recent White House decision to bypass the CDC in data collection on hospitalizations. Testing and contact tracing capacity have increased, but test reporting delays impede timely tracing. The lack of a national testing and tracing strategy is a major contributor to these issues, and raises concerns about potential vaccine administration.

There are a few silver linings nonetheless. Care delivery is returning to pre-pandemic levels. Telehealth utilization has greatly increased, and several temporary flexibilities (e.g. originating site, provider eligibility) may be made permanent. Emerging treatments (e.g. remdesivir, dexamethasone) have improved care for seriously ill COVID-19 patients. States and local governments are leading the way. Several states, for instance, banded together to create the first multistate testing strategy and deliver rapid antigen tests.

Looking ahead

Vaccine development is making headway, with some candidates entering phase 3 clinical trials and the U.S. determined to distribute 300 million doses by January 2021. A potential vaccine won’t be a silver bullet, but will play a vital role in returning to normalcy given the inadequate public health and health system response. Key questions around vaccines are safety, efficacy, prioritization, accessibility, and affordability. Patient volumes are increasing, but U.S. Census data has illustrated that delayed medical care has remained at 40% during the pandemic. School reopening leads to the larger question: will schools stay open? The convergence of reopened economies and uncontrolled community spread has created a new group of at-risk essential workers to monitor (e.g. teachers, barbers). Flu season is approaching, adding another wrinkle to diagnostic capabilities. If continued outbreaks and recent moves by major employers to extend work-from-home to summer 2021 are any indication, the fight against COVID-19 in the U.S. is far from over.

The U.S. response to the coronavirus pandemic – Original response (May 2020)

Mathew Alexander¹, Lynn Unruh², Andriy Koval²

¹School of Medicine, Virginia Commonwealth University
²Department of Health Management and Informatics, University of Central Florida

Timeline of key events

The U.S. response to COVID-19 began in early January with the creation of a 2019-nCoV Incident Management System and a briefing on the novel coronavirus by the Centers for Disease Control (CDC). The first case of COVID-19, a recently returned traveler from Wuhan, China, was subsequently confirmed on January 21^st in Washington state. In the weeks following, the White House established a “Coronavirus Task Force” and the Department of Health and Human Services (HHS) declared a public health emergency. During January and February, limited public health measures (e.g. airport screening, self-isolation for travelers returning from high-risk areas) were implemented.

Despite these early actions, the U.S. quickly fell behind in its fight against coronavirus. A host of issues, including a defective batch of tests and late enlistment of private labs plagued initial testing development and capacity. Production and distribution of treatment supplies, personal protective equipment (PPE), and expansion of bed capacity for COVID-19 cases also proceeded slowly in February. By late March, nearly a third of facilities were almost out of face masks, 13% were out of face shields, and about 25% were completely or nearly out of gowns.

To deal with shortages, several measures were taken. State and local public health laboratories and private labs were awarded Emergency Use Authorization by the FDA to develop tests in February. The U.S. safety net of medical equipment supplies—the Strategic National Stockpile—was tapped. However, the stockpile ran low by the end of March and distribution of supplies was uneven, with only some states receiving all the supplies they requested. The President declared a National Emergency on March 13^th, allowing for the waiver of some federal regulatory requirements (e.g. state licensures requirements for providers) and the Federal Emergency Management Agency to provide financial and physical assistance to states and localities. Additionally, the Defense Production Act directed manufacturers to make ventilators.

Actions were also taken to prevent further community spread. Starting in mid-March, all travel from Europe, except for returning U.S. Citizens and permanent residents, was suspended, the State Department suspended routine visa services, and Canada, Mexico, and the U.S. agreed to temporarily restrict all non-essential travel. On March 16^th, the President implemented a 15-day voluntary national shutdown (later extended by 30 days), limiting mass gatherings to ten or less and recommending the closures of public places (e.g. schools, businesses). Implementation and enforcement were left to the states. By the end of March, 29 states had issued stay-at-home orders, 30 closed all non-essential businesses, 39 prohibited either all gatherings or those with greater than ten people, 44 closed restaurants/bars with the exception of takeout/delivery, and 47 mandated statewide school closures.

In addition, Congress passed four major legislations in March and April:

• Coronavirus Preparedness and Response Supplemental Appropriations Act: provided $8.3 billion for COVID-19 preparedness and response, including $2.2 billion to the CDC and more than $560 million for states and local jurisdictions.
• Families First Coronavirus Response Act: provided $3.5 billion for benefits such as insurance coverage of coronavirus testing, paid sick leave, nutrition assistance, and unemployment.
• Coronavirus Aid, Relief and Economic Security Act: provided $2 trillion with $150 billion for the healthcare system and $150 billion for state and local governments.
• Paycheck Protection Program and Health Care Enhancement Act: provided emergency loans to small businesses, plus $75 billion to hospitals and $25 billion for testing.

With the 45-day voluntary shutdown set to expire on April 30^th, the White House released a three-phase “Guidelines for Opening Up America Again” in mid-April providing guidance to state and local authorities on how to ease physical distancing measures while mitigating risk of additional waves and protecting vulnerable populations. Several states, particularly southern ones, reopened in late April/early May despite not meeting gating criteria and lagging in physical distancing and testing. Georgia, for instance, was 42^nd in testing in the country at the time of reopening. As of May 7^th, 26 states had started easing social distancing measures.

Early findings and reflections on the U.S. response

Notable missteps and inaction contributed to the lack of effective containment. The slow development and distribution of tests throughout February and delayed use of physical distancing, resulted in an explosive growth in cases in March, creating an even greater strain on the infrastructure needed for treating the virus. As testing increased, delays were noted in test reporting, often due to supply shortages. Prominent health policy experts, physicians, and state governors continue to cite the need for increased testing, ranging from 430,000 to tens of millions of tests daily. The U.S. also has yet to hit the testing capacity benchmark prescribed by the World Health Organization of a positive rate around 10%. Epicenters have had significant shortages of hospital beds, treatment supplies, PPE, and healthcare workers. As the production of ventilators and PPE proceeds, states find themselves in bidding wars and price gouging is occurring. The sharing of leadership between federal and state governments and an ad hoc private group has been uncoordinated, with the exact roles, authorities and responsibilities often unclear and shifting. In some instances where the federal government should clearly have taken the lead (as instructed by national pandemic response plans and emergency laws) such as the procurement and distribution of supplies, the responsibilities shifted to states.

However, there have been some notable wins. Several models have demonstrated the efficacy of stringent public health measures taken in March and April in “flattening the curve”. New York, the hardest hit state, has finally seen a sustained decline in cases. Testing capacity has increased, with 1-2 million people being tested weekly as of late April. Testing sites are also more accessible. As of April 21^st, over 600 drive-thru testing sites were available nationwide. Certain states have further started testing a wider range of individuals– e.g. asymptomatic first responders, healthcare workers, and essential employees. Research output and collaboration has been immense: more than 100 treatments and vaccines are in development and several clinical trials are underway. Aforementioned legislative actions have been pivotal in softening the economic ramifications (e.g. stimulus checks, small businesses loans) and strengthening the health system response (e.g. expanded telehealth, additional funding). Community support for frontline workers has been commendable, including donating homemade masks and offering free meals and transportation.

Looking ahead

May will bring further insights as states ease social distancing, but we may not see the repercussions until the summer months. Testing needs will change as states reopen, including accurate serologic testing for surveillance and identification of potential immunity and matching available testing capacity to those that need it (e.g. close contacts, asymptomatic individuals in high-risk environments). Contact tracing will play an essential role and states are increasing their capabilities (e.g. training and deploying more contact tracers, creating online apps). Other important areas to watch include non-metro areas, which have been the most recent hotspots, and long-term care and other institutional facilities, which have been disproportionately affected during the first few months. Finally, the long-lasting impact of this crisis on systemic issues – namely, employer-based health insurance, surprise medical billing (which HHS appears to have banned in late April for COVID patients), and general pandemic preparedness – remains to be seen.

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