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Philly Experts Weigh in on What to Expect in Next Six Months of COVID-19

“We’ll really have a good sense of people having the flu, coupled with coronavirus on top of it, and how it affected our morbidity and mortality. We’re participating with delivering the flu vaccine. We’re hitting high-risk populations.”

by Tom Avril, The Philadelphia Inquirer / September 21, 2020
AP
(TNS) - With 2020 dominated by a deadly, unpredictable virus that no one had even heard of a year ago, most of us would rather look forward now than back. Forward to the day when all children can go back to school, all workers can commute without fear, all businesses can open without masks, gloves and temperature checks. In short, the day we go back to normal.
 
But for at least the next half-year, experts agree, pandemic precautions will still be very much with us. To get expert perspectives on what lies ahead, Inquirer reporters spoke with:
 
A Philadelphia surgeon who quickly saw that some of the city’s most vulnerable residents could not get the coronavirus testing they needed, and did something about it.
 
A scientist whose team hopes to soon find better therapeutics to help the most desperately ill COVID-19 patients.
 
An intensive care physician who, having gotten the most desperately ill patients through the disease, now worries about the second wave.
 
A nursing leader who led the fight for adequate protective gear for front-line workers.
 
An environmental scientist who helped explain how the virus moves in the air — and who says what we all should be doing to protect ourselves.
 
Like so many people, Ala Stanford is still amazed at how quickly life changed this year because of the coronavirus.
 
“In March, my twins just had a birthday. On March 10, they turned 10, we were going out to dinner, to celebrate, I was letting them buy what they wanted at GameStop. By March 13, everyone was out of school,” she recalled.
 
"At first, they were saying this is only [spread] through person-to-person contact. You had to be in direct contact with someone from China, Germany, Italy, France. [Otherwise] you were fine, and it didn’t affect you.
 
“A lot of folks, particularly African American folks, went on with their lives. This was something rich people got, who traveled overseas and took cruises. Then all of that changed.”
 
For Stanford, everything changed on April 3, when she read “that there were more African Americans being diagnosed and dying in the city of Philadelphia than any other race.”
 
"That’s when it, for me, when it struck me. That’s when it became personal. My friends were calling, and these are friends who are professionals, educators, doctors, even, that couldn’t get a test. They had insurance, but they kept being turned away [at hospitals]. I reached out to my friends at hospitals, to say, ‘Hey, what are you doing? What’s the deal?’ ”
 
Stanford’s response was to start the Black Doctors COVID-19 Consortium, which provides free coronavirus clinics in some of the Black neighborhoods hit hardest by the virus.
 
“I had been operating as a pediatric surgeon, but all surgeries were canceled because they were only doing emergencies. There was nowhere I needed to be. Except testing. Except being out in the community.”
 
There was no need for her to explain how deadly this virus could be.
 
"Most people knew that, because it was their family members that were dying. They could literally be coming from a funeral, and then coming to get in line to get tested. We would go to the churches to test people, and we would start with a prayer or a moment of silence. You’d listen to the pastor say, ‘I’ve had a funeral every day.’ "
 
As for the next six months, Stanford sees her mission growing only more complex.
 
"I think in six months, that I will still be right here, still testing for coronavirus. We’ll be at the end of flu season. Starting Oct. 13, we’re giving out flu vaccines — plus coronavirus testing, antibody testing, and voter registration.
 
“We’ll really have a good sense of people having the flu, coupled with coronavirus on top of it, and how it affected our morbidity and mortality. We’re participating with delivering the flu vaccine in both Philadelphia and Montgomery County — we’re hitting all the high-risk populations. They notoriously have a hard time reaching the Black and Latinx population.”
 
As we wait for a COVID-19 vaccine, what would help, she said, is removing the barriers that keep people from getting tested.
 
“Anytime, 24 hours a day, day or night, any person should be able to walk into any hospital and get a COVID test. Regardless of your insurance, regardless of whether you have an appointment or not. And it needs to be widely known. That’s what needs to happen, and it’s not happening.”
 
The mission, she said, goes well beyond the pandemic.
 
“I’m not just here for coronavirus. I’m at this point committed that we’re going to work on the health outcomes to change the disparities that exist in the Black community in Philadelphia.
 
"We have to change the narrative that Black people are sicker, they die younger, they’re noncompliant [with medication], and they use the ER for primary care. All of that can and should be changed, and some of it is just not true.
 
“The idea that the reason why African Americans are more likely to die from coronavirus is because they don’t take care of themselves or they have preexisting health conditions — it may be a factor, but it’s not the primary reason. It’s the bias that exists in the health-care system, coupled with the lack of access, coupled with the lack of empathy. Someone’s poorly controlled hypertension isn’t what prevented them from getting a COVID test.”
 
— Aubrey Whelan
 
Research labs around the world have spent the last six months trying to identify existing drugs that could be repurposed to fight COVID-19.
 
So far, only remdesivir – the antiviral that Gilead Sciences shelved after it failed to work against Ebola – has been a success story.
 
University of Pennsylvania microbiologist Sara Cherry has hard-earned insights into why COVID-19 drug discovery has been so difficult, and why breakthroughs could be on the horizon.
 
One challenge: safety. In labs like hers that are certified to work with very scary germs, scientists have to don double layers of gowns and gloves, plus a respirator resembling “a big hat that lets you breathe through a vacuum cleaner on your back.”
 
Because doing experiments under those conditions can be difficult, researchers everywhere started out testing drug molecules on a particularly user-friendly line of monkey cells called VERO, Cherry explained. It was easy to infect VERO cells with the coronavirus, add a potential drug therapy, and measure the results.
 
That’s how an old, inexpensive malaria drug called hydrochloroquine, or HQC, was discovered to block infection – or so it seemed.
 
“It would have been fantastic if it were true,” Cherry said. “But we are not VERO cells. We are humans. We were misled early on because we were using cell models that are different from what happens in the human body.”
 
A related obstacle: finding the right animal model to unravel the mysteries of the new virus.
 
Early on, researchers figured out that the virus uses a cell surface protein called ACE2 to break into human cells and begin replicating. But it took longer to discover that the virus cannot use the ACE2 made by mice to infect the rodents' cells.
 
The virus can infect hamsters, Cherry said, but hamster models don’t have as much complementary analytical technology as mouse models. That has hampered efforts to understand how the coronavirus can cause life-threatening clotting problems and immune overreactions.
 
More recently, genetically engineered mouse models with human versions of ACE2 have been created.
 
“These will really help us to understand how these more complex [complications] evolve in human infection,” she said. “I think we will find effective therapeutics” in the next six months.
 
— Marie McCullough
 
Alarmed by the early reports of jammed hospitals in China and Italy last winter, U.S. hospital administrators took stock of their ventilators and counted how many specialists were available to operate them. Engineers even started to build makeshift devices as a backup, in one case using a lawn-sprinkler valve.
 
Meghan Lane-Fall worried it would not be enough.
 
A critical-care physician in the Penn Medicine system, she warned that in hard-hit areas, a shortage of the high-tech breathing machines might present physicians with an unthinkable choice: deciding who would live and who would die.
 
That did not happen. In Philadelphia and beyond, hospitals generally have had enough ventilators for those who needed them, despite close to 400,000 hospitalizations nationwide. Lane-Fall credits the creative use of other breathing devices, social-distancing measures that prevented thousands of cases, and a better understanding of how to treat the disease.
 
“We ended up being OK,” she said.
 
That doesn’t mean the projections were alarmist or wrong, said Lane-Fall, who works in the ICUs at Penn Presbyterian Medical Center and the Hospital of the University of Pennsylvania. Hospitals had to be ready for the worst, doubly so with a virus that no one knew much about.
 
And with flu season on the horizon, Lane-Fall worries that hospitals could face a renewed crunch in the fall and winter. Though there might be enough ventilators, some hospitals may have trouble finding room to keep contagious patients isolated. Back in the spring, hospitals in the Penn system set up tents to streamline patient intake, but that could be a tough sell during colder months. And space is needed for non-COVID-19 treatment as well, now that more patients are coming in for care that may have been delayed earlier in the pandemic, she said.
 
As for treating severely ill COVID-19 patients, intensive-care nurses and doctors have made great strides since March, learning that many patients in respiratory distress can recover without a ventilator. Some get high-flow oxygen through a nasal cannula, a plastic tube that rests in the nostrils. At Penn, a few were fitted with astronaut-style breathing helmets, ordered by one of Lane-Fall’s colleagues who had contacts in Italy.
 
But generally the sickest patients still need to go on “vents” — requiring that breathing tubes be threaded down their throats — and it remains unclear why some fare so poorly compared with patients with other respiratory diseases, Lane-Fall said.
 
For some reason, the metabolism of these patients goes into overdrive — with grim consequences.
 
Their bodies burn through more of the sedatives that are administered to keep ventilated patients calm, so they need higher doses. As a result, they stay motionless for longer periods, and their muscles atrophy.
 
“They lose a lot of weight,” Lane-Fall said. “It’s almost like they’re using their own bodies for nutrition.”
 
Effective drugs remain elusive. Among the few proven to help are steroids, which tamp down harmful inflammation. But careful timing is key, as the drugs suppress the immune system.
 
“I’m not looking for a silver bullet,” Lane-Fall said. “I’m not expecting to see one.”
 
— Tom Avril
 
The region’s nurses are not optimistic about the next half-year, says Maureen May, president of the Pennsylvania Association of School Nurses and Practitioners.
 
“We all think of the next wave coming,” said May, who represents 8,500 unionized nurses and health-care workers in the state.
 
The first six months of the pandemic were traumatizing for people in her profession, said May, a nurse at Temple University Hospital. She has concerns that the psychological scars on fellow nurses may linger for years.
 
Addressing the emotional and mental strain the pandemic has caused in health-care workers will be a priority in the months ahead. The union has created webinars for members about the challenges they’re facing, May said, but she also thinks that her members will know what to expect should the virus surge again.
 
“We didn’t the last time,” she said.
 
What may be equally difficult, though, is addressing the tensions between hospital management and staff. As the virus first spread through the region, health-care workers said their concerns about not having enough protective equipment seemed to fall on deaf ears. Initially, some hospital managers even discouraged nurses from wearing their own protective gear, requiring them to wear hospital-issued equipment workers felt was inadequate.
 
The disconnect between management and nurses led to retirements, May said.
 
“We as nurses and we as health-care professionals, we believe that we’re expendable in the eyes of corporate America,” she said.
 
Temple University Hospital, which serves some of Philadelphia’s poorest communities of color that have been especially hard hit by serious cases of COVID-19, was inundated with patients in the spring. Hospital staff was left dangerously understocked with masks, gowns, and gloves, she said. Tensions between workers and the hospital were exacerbated when Temple provided nurses with Chinese-made masks that didn’t hold up under the rigors of patient care.
 
Temple has replaced the faulty masks and secured reliable sources of medical supplies since then. “How they manage their supply chain changed and with that we were able to experience better protection,” May said.
 
May is also hopeful the coming months will see progress on legislation to help health-care workers who contract the coronavirus. A bill from Republican State Reps. Frank Farry of Langhorne and Martina White of Philadelphia, under consideration in the legislature, would aid front-line health-care workers in disability claims resulting from COVID-19 infection by putting the burden on employers to demonstrate the worker didn’t catch the illness through their jobs.
 
— Jason Laughlin
 
Charles Haas, a professor of environmental engineering at Drexel University, was among 239 scientists who persuaded the World Health Organization to concede that the coronavirus may be transmitted in microscopically small droplets that are released into the air just by talking or breathing.
 
Their July letter and the WHO’s response heightened awareness of the challenges of curbing the pandemic. Now, many places are upgrading heating and cooling systems, installing powerful air filters, and experimenting with germicidal ultraviolet lights.
 
But last week, Haas talked about the simple, low-tech measure that has been proven effective — one that will be needed even after vaccines and therapies now in development become available.
 
“Masks do work,” said Haas. “We should have a masking mandate. It’s a darn shame it’s become so politicized.”
 
Six months ago, amid a dire shortage of medical-grade face masks, federal and state public health officials told Americans they didn’t need to cover their noses and mouths when leaving their homes. That wisdom, the experts insisted, was based on scientific studies; masks were important only for front-line health-care workers.
 
The advice soon changed to: Wear a mask so you don’t infect those around you.
 
Last week, Robert Redfield, director of the U.S. Centers for Disease Control and Prevention, told lawmakers he wears a mask to protect himself from others.
 
“I might even go so far as to say that this face mask is more guaranteed to protect me against COVID than when I take a COVID vaccine,” Redfield said.
 
Haas believes these mixed messages have fueled resistance to mask-wearing.
 
“There was a lot of poor messaging by health departments that you wear a mask to protect others,” Haas said. “I think it was a mistake to not stress, at the outset, that you wear a mask primarily” for your own good.
 
Questions surrounding vaccines – how soon, how effective, how safe – have also become politicized, which could deter people from rolling up their sleeves, Haas said.
 
“A lot of work has to go into messaging so that people will comply,” he said “That means the message has to come from trusted messengers. And different communities will have different messengers that they trust.”
 
Because vaccine effectiveness and availability are expected to be limited at the outset, even those who get immunized must be urged to keep masking and physical distancing, especially indoors.
 
“We have to look at this as layers of protection," he said. "Here’s an imperfect analogy: We didn’t stop wearing seat belts when we got air bags.”
 
— Marie McCullough
 
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©2020 The Philadelphia Inquirer
 
Visit The Philadelphia Inquirer at www.inquirer.com
 
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