Resurgence of COVID-19

Resurgence of COVID-19

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from State and Local Conference Calls and Webinars

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Thomas J. Bollyky, senior fellow for global health, economics, and development, and director of the Global Health Program at CFR, discusses the resurgence of COVID-19 cases and the effects of reopening economies around the world. 

Learn more about CFR’s State and Local Officials Initiative.

Speaker

Thomas J. Bollyky

Senior Fellow for Global Health, Economics, and Development, and Director of the Global Health Program at Council on Foreign Relations

Presider

Irina A. Faskianos

Vice President, National Program and Outreach, Council on Foreign Relations

FASKIANOS: Good afternoon to all of you. Welcome to the Council on Foreign Relations State and Local Officials webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR. We’re delighted to have participants from forty-three states with us today. So thank you for taking the time to join us for this discussion, which is on the record.

As you know, CFR is an independent and nonpartisan and membership organization, think tank, and publisher focusing on U.S. foreign policy. Through our State and Local Officials Initiative we serve as a resource on international issues affecting the priorities and agendas of state and local governments by combining analysis on a wide range of policy topics. And we also are the publisher of Foreign Affairs magazine.

We are pleased to have with us today Tom Bollyky. We previously shared his bio with you, so I’ll just give you a few highlights. Tom Bollyky is CFR’s senior fellow for global health, economics, and development, and director of the global health program at CFR. He is also an adjunct professor of law at Georgetown University. He is the author of the book, Plagues and the Paradox of Progress: Why the World is Getting Healthier in Worrisome Ways. His book was included on Bill Gates’ booklist, so I commend it to you all. And he is also the founder and managing editor of Think Global Health, an online magazine that examines the ways health shapes economies, societies, and everyday lives around the world. The site offers useful resources on COVID-19 and other topics, so I again encourage you all to go there. Visit ThinkGlobalHealth.org.

All right. So let’s get to it. Tom, thank you for being with us. We are seeing an increase of COVID-19 cases in many parts of the United States. Can you talk about this trend that we’re seeing and any lessons we can draw from how other countries have handled and are handling the pandemic?

BOLLYKY: Great. Thank you so much, Irina. This is one of my favorite calls to participate in at CFR in this program. I really do enjoy the opportunity to speak with state and local officials who are at the front line of all public health issues really, but this one in particular. So I look forward to this conversation. And thanks to Irina and her wonderful team for organizing it.

So the eyes of the nation are rightly focused on what’s happening domestically with regard to the coronavirus pandemic. This is understandable, of course. It’s what we all experience in our home lives, in our—in our communities. And as state and local officials, it’s where your responsibilities lie as well. But we are not alone, of course, in experiencing this pandemic. There are now over 180 countries in the world with reported cases of coronavirus, thirteen million have been reported infected globally, nearly—or, more now than 570,000 have died worldwide.

There’s no sugarcoating it. The U.S. is anomalous, particularly among high-income countries, in how we are experiencing this pandemic. The U.S. represents 25 percent of all cases—reported cases of the coronavirus globally, and nearly a similar percentage of the number of deaths. New cases of COVID-19, the disease, are expanding at a rate of 1-2 percent daily in the United States. On Sunday, Florida reported fifteen thousand new cases. That’s three thousand more cases than all of Europe combined. So we are anomalous, unfortunately, in that regard.

The U.S. is one of ten countries that represent 80 percent of the increase of reported cases that have occurred in the last several weeks, globally in a number of cases, after plateauing in April have started to increase in May. Most of—we are the only high-income country for which that is responsible for the bulk of this increase. Most of the remainder in countries like Brazil, India, South Africa, and Peru.

That said, again, we are not alone in this. We’re all in the same epidemic curve together. And it’s important as policymakers and members of the interested public that we, in our attempts to surmount this terrible outbreak—or, pandemic, rather—together, that we look to learn lessons from the countries that are ahead of us in this experience.

I’m going to focus my initial remarks on schools, in particular what we’re seeing abroad on schools. Obviously, it’s a topic of interest. We are not alone in having—most communities having shut down schools. Worldwide 1.5 billion school-aged children have been kept home at one point or another by this—by this pandemic. That has, of course, had dramatic educational consequences for the students that have missed the opportunity for in-person learning. It’s, of course, disproportionally affecting the poorest students with the least ability to obtain those services remotely.

It also has dramatic economic and social consequences. In the United States, one-third of our workforce has school-aged children. I have school-aged children. You may hear them on this call. So we all feel this from that perspective. But it’s also been associated with higher rates of abuse and mental illness. So this is having a significant consequence that extends beyond just the educational environments. We all have an interest in addressing this. What can we learn from abroad with how other countries have addressed it?

And the good news in terms of thinking for future is that since June, by early June, rather, more than twenty countries that had shut down their schools have reopened them worldwide. There are several countries that never shut down their schools—Taiwan, Sweden, and Nicaragua. I’m going to draw three broad lessons from those experiences, things to keep in mind in this context. I am going to focus on the lessons that emerge internationally. I will not be exhaustive, although we can talk about some of the research coming out domestically about what to do about schools. But I’m not going to focus on elements of that that extend beyond what we’ve seen internationally. So in my initial remarks I’m going to focus on the international lessons. Not exhaustive.

After this call I am going to send to Irina and her team, and we will post it, and maybe there’s some way to circulate it to the participants, several documents that are going to be important. One is the CDC guidelines that have emerged on children, and infants, and adolescents. I’m also going to circulate a good overview article from Science that focuses on the international experience. And last, from the—from the American Academy of Pediatrics has also put out a set of guidelines. And those are the three documents we’re going to include. And you should definitely reference those.

All right. So let’s get to the three broad lessons. What are we learning from abroad? We are certainly learning that the risk of this virus is lower for children, but it’s not nothing. The experience also differs somewhat for underage children and adolescents. So we have seen uniformly fewer cases in children, but again not none. There have been some. Children under the age of twelve are—appear to be, our latest estimates, one-third or one-half as likely as adults to contract this virus. The risk appears lowest for the youngest children.

In the United States, Spain, China, Italy between 0.5 and 2 percent of the confirmed cases in those countries have been in children. That said, a number of those—a number of countries, including elementary schools in Israel, daycare centers in Toronto, have suffered outbreaks among children. So it’s certainly possible, even if it is a lot less frequent. There is no question the risk of spread is higher for adolescents—thirteen-year-old children and older. A recent study in France found in a high school that antibody testing showed that 38 percent of the students, 43 percent of the teachers, and 59 percent of the non-teaching staff had become infected.

Among the worst school-wide outbreaks we have seen have been in a middle school and a high school in Jerusalem, where 153 students were infected and twenty-five staff in May and June. The studies involving nasal swabs of older children have shown a very similar viral load as to what you see in adults. So that suggests a similar level of contagiousness. In general we have seen less severe outcomes, but again they do occur infrequently. The largest study of pediatric patients remains in China, a study involving roughly two thousand, a little bit under. There, you saw the rate of children developing severe disease with low blood oxygen being around 5 percent. Critical cases involving respiratory distress or multiorgan dysfunction represented—or, occurred at a rate of 0.6 percent.

U.S. data is broadly similar. There have been fewer children requiring hospitalization among overall patients. And ICU, intensive care unit, admissions have represented between 0.6 and 2 percent. That said, there have been severe complications that have occurred in children as young as four, or nine, or twelve. They do appear to be infrequent. Many of you have no doubt read about this multi-inflammatory syndrome that presents with a persistent fever and has been shown to cause damage to hearts and other organs. This is something we’re still studying. It still remains quite infrequent, but it’s real. And that is—that is something to watch moving forward. So, again, lesson number one is risk for school-age children is lower, particularly for children under twelve, but not nothing.

All right. Let’s move onto lesson number two from what we’re seeing abroad. There has been a variety of approaches used on social distancing, masks, and testing that we’ve seen so far, with some success in all cases. Netherlands has cut class sizes, but otherwise did not enforce social distancing in children under the age of twelve when they’ve reopened. They have now extended that policy to children seventeen and under. Denmark and the province of Quebec have assigned children to smaller groups. That’s been the strategy, where they can congregate and interact but it’s smaller groups. You have probably—may have seen, Germany, Canada, and England have all announced a similar bubble model as a way of reducing transmission, where you have smaller groups that don’t interact with other classes as a strategy, so you can potentially isolate effects.

Societies that are more comfortable with masks—China, South Korea, Japan, Vietnam—have adopted them, even for young children. Many countries in Europe at first required masks, but most of them have dropped them for younger-age children, under the age of twelve, and moved to a more optional model. The U.K. and Berlin has been exploring doing regular surveillance testing as a way of identifying cases as they arrive. I am very sorry to report, despite looking I have not found very good studies internationally on special education. If we do find any, we will let you know. But it is, unfortunately, an area where little research has been conducted to date.

All right. Lesson number three, and this is, of course, the hardest—has proved the hardest one for, I’m sad to say, our country—is reducing community spread. All other countries, with the exception of one which I will get to, have suppressed the spread of the virus ahead of reopening their schools. Most that have done so were successful in doing so. There were a few exceptions, the largest one being Israel, where infections have increased steadily after schools reopened. But this also paralleled a similar increase nationwide and it is not clear, as of yet, whether the schools were drivers of that overall national increase or just yet another symptom of that overall national increase. That said, Israel by mid-June had closed down 350 schools.

Other countries have adopted a policy where, you know, they’ve been closer to really crushing the curve, that you’ve heard about, in terms of new daily cases. So when there have been resurgences, they’ve responded quite aggressively in shutting down schools. South Korea closed down two hundred schools when they had a resurgence—or, a spike of cases in Seoul. Hong Kong has also intermittently closed down schools when they had increases in cases. Now, keep in mind their number of cases are quite low relative to the United States, but they have really focused on trying to drive down that number to zero.

All right. So now to the exception. The only exception out there really is Sweden which, again, never closed down schools and has a high rate of transmission and spread throughout. Unfortunately, Sweden didn’t do any testing serological testing to show the different effects of different policies, school policies, for keeping them open. They have had some episodes. In one school, a teacher unfortunately perished, and fifteen—eighteen out of the seventeen staff tested positive in a school about of roughly five hundred students. The one serological test they have done of a couple of thousand did suggest that the virus had been spreading in schools, though it’s not clear how much. Unfortunately, they did not design policies to study this, and that’s their loss but ours as well.

Some caveats about Sweden that I do want to point out, though, is that by and large Swedish—the children in Sweden have much lower rates of asthma, diabetes, and other comorbidities—other illnesses that have been associated with worse outcomes than we do in the United States. So that’s a significant difference. Also unfortunately the U.S. daily rate of cases now is between—this is population adjusted, so per one million people—is 130 to 180. That is higher than it’s ever been in Sweden, let alone any of the other countries we’ve talked about so far today. Israel is climbing now to closer to levels of new cases that we’re seeing in the U.S. but, again, they’ve had to shut down their schools. The numbers look a little bit better on deaths, where Sweden had much higher population-adjusted death numbers than we’ve seen. But it’s now lower than what we have in the United States. And we’re increasing on that metric as well.

I won’t spend a lot of time on policies or other activities in these initial comments for what has happened around resurgences, but I’m happy to do that in the question and answers. I’m really looking forward to hearing what you all are doing with schools. Again, in addition to looking at this through this cross-country comparison and our work at CFR, you know, we all—many of us have children or relatives that are impacted by this in one way or another, and we’re all in this together. It really—it’s a fundamental issue moving forward for our country and our community. So I look forward to learning from you about this as well.

FASKIANOS: Wonderful. Thank you very much, Tom. That was a terrific overview. And let’s go to the group now for questions.

(Gives queuing instructions.)

The first question is from Jeffrey Dahlen (sp). And I you could identify yourself and what state you’re—where you are, to give Mr. Bollyky some context.

Q: Sorry. I accidentally hit the button.

FASKIANOS: OK. Let’s go to Martha Robertson.

Q: Hello. Thank you so much. Martha Robertson. I’m a county legislator in Tompkins County, which Ithaca, New York is the home—the county seat. So Tompkins County, New York in upstate, the Finger Lakes.

My question about schools—and there’s no question of the huge disadvantages of keeping kids out of school and trying to do remote learning. We had the last third of the year with a grandson, a high schooler, doing remote learning with us, and so I can tell you how hard it is. But my concerns is that what about the teachers and the staff? If kid went to school by themselves, that’d be one thing. But it feels to me that people are only talking about health impacts of the children, which are obviously critical, but how do we—how do we, you know, consider this equation without really looking at what happens to teachers and staff? In particular, I’m concerned about asymptomatic or pre-symptomatic children. So what do we know about the prevalence of that in kids, and what happens to their adults? Thanks so much.

BOLLYKY: Great. So a couple of things to point to. I mean, the main answer is we don’t know a lot about asymptomatic spread in children. Again, by what the—all the research that we do have suggests that they spread less frequently than adults. But again, it does happen. They are also, of course, and anybody who spends time with children, or has, can tell you they engage in activities that maximize their chances of spreading, even if they themselves are less likely to be prone to spreading. So that is a real risk.

In terms of—there isn’t a lot of experience. I mean, again, we’ve seen—as you mention, we may have seen, when I mentioned some studies—observational studies—identifying the numbers of teachers and staff who get infected. It happens—or, it has happened in other countries. Particularly given the high prevalence in the United States and depending on your community it’s going to be really important to have personal protective equipment—whether the children wear masks, the teachers may want to do so, or should do so. And this is going to be an important factor moving forward.

Again, we had seen infections of teachers and staff. It’s not entirely—it’s difficult to know for certain, without serological tests, whether that’s come at school or come independently. But we’ve certainly seen this, particularly in Sweden. And we did have that one unfortunate example that I mentioned in Sweden of a teacher perishing at that school amid an outbreak. So these risks are real, and we have to account for them and protect them because, as you rightly suggested, you know, children are only one part of a functioning school. And it will be critical to protect staff and teachers as well.

FASKIANOS: Pamela Pugh, please.

Q: Hi. This is Pamela and I am in Michigan. And I’m a member of the State Board of Education here in Michigan.

My concern is returning to school, obviously, as everyone here. We are concerned with the social, emotional, physical wellbeing of children. My background is public health and environmental health. I’ve studied the indoor environment for most of my research career. My concern, we just had children that returned to Detroit. Eighty-three percent or more African American. The balance is probably—is Latino children. And so, as you all know, Detroit is one of the hardest-hit communities in this country. My concern is we’ve just acknowledged that airborne—or, transmission through airborne—the virus being airborne is real. And so, thank God, we’ve had over two hundred researchers that have come out and said that.

We were just fighting in Detroit around not having adequate ventilation. I guess my question is, what are we doing to address that? Air conditioning may not be the answer, it may actually be a problem. Who is looking at and who is pushing for adequate ventilation plans and that fix, looking at the air quality, looking at the air movement, and the air turnover in these schools, before we force our kids to go into these closed areas, as well as the educators and the people that they will be contacting—parents, grandparents?

BOLLYKY: Really great question, and an important one. The short answer is I’ve seen nothing on that. Domestically, it may be that the CDC has taken it on without reporting it, but I—but I haven’t seen a particular study of ventilation in school systems. Perhaps there’s somebody on this call who has seen it. But we did not, in the review that we did ahead of this call. I will say, with the data, it is still the—people are much, much more likely to become infected through direct exposure of respiratory droplets. As you very rightly said, that doesn’t mean you don’t see airborne spread. But in terms of priorities ahead of reopening in the short period of time, certainly minimizing to every extent possible the possibility of direct exposure infection through respiratory droplets has got to be the priority.

But there really needs to be a greater study of ventilation, particularly in settings or communities where outdoor instruction is not going to be possible, because that is something else that we’ve seen some of internationally, where schools have really looked at the opportunity to educate children outdoors. That’s not something a lot of places can do, and certainly not something they can do indefinitely. So this is going to be important to study moving forward. I’m sad to report I haven’t seen one that’s happened.

FASKIANOS: Sorry. So, Tom, there’s a follow-up from Pamala. Should our children be forced to go to school if we aren’t sure of the indoor air quality and ventilation systems?

BOLLYKY: So, I mean, this is—these decisions really—and this is another point that less emerges internationally but is part of the—should be part of at least our conversation domestically. There is—I have not heard very much support from anyone on the public health side for the idea of a strictly national approach to these issues. Obviously, this should be tied—decided individually by states and communities, depending on what their local situation is with the virus is, what their schools look like, what the environment looks like in terms of the different mitigation strategies that can be employed. It’s going to be a balance of risk no matter what, reopening schools. And that’s something each community is going to have to decide. And there’s going to be a lot of unknowns.

We don’t really know why children aren’t spreading, for instance. We still don’t know, as I mentioned, exactly what is driving this multi-inflammation syndrome. There’s going to be a lot of uncertainties heading into the school year that we will not be able to resolve. And, you know, this is—this is something that will have to be decided by state and local governments. It’s inappropriate to assume that there should be a nationwide approach to these. It’s going to have to be something considered. The balance of the benefits of reopening versus some of the risks. But there are going to be many unknowns under any circumstances as to what this will look like.

FASKIANOS: Great. I’m going to go to the next question, but before I do, Ron Mann (sp) in the chat talk about is comparing case rates might be problematic because—have you balanced that with the amount of testing that’s being done? Because obviously I think here in the United States we’re not doing as much testing as other countries. So have you adjusted for that in your numbers, Tom? And then the other—just a note about UV light and what you know about UV light helping to reduce the spread of virus, especially in enclosed spaces.

BOLLYKY: So on the first question, on comparing numbers of cases, it is true, particularly internationally, that there have been a great variety in the degree of testing being done. That is a little less true on the population-adjusted level, when we’re talking about other high-income countries, like the ones that we have. The U.S. had conducted a great many tests, of course, at this point. We did conduct them, by and large, relatively late in this pandemic. So the bulk of those tests came a bit late. So we’re not comparing quite apples to apples in terms of when the tests occurred.

But I think at this point what most would say in terms of the case numbers for—when comparing to other high-income countries, we’re not expecting to see a great difference in terms of underreporting in those settings. When we’re looking at some low- and middle-income countries, absolutely, there’s a great deal of underreporting. But when we’re talking about many of the East Asian nations that we’ve been talking about, or the European nations we’ve been talking about in this comparison, I wouldn’t expect a great difference in reporting rates.

FASKIANOS: Great. OK, Meredith Childs (sp).

Q: Hi. Thank you for taking my question. Again, I’m Meredith Childs (sp). I am in St. Louis, Missouri. And I’m with one of the health plans, Anthem, working on social determinants of health.

What I’d like to know, or what I’m curious, is anyone collecting data surrounding those supportive services that our children and families are needing in order to deal with all of the ramifications of COVID-19? I recognize and realize just in my area and with the work that myself and my team are performing that definitely housing instability is one of the issues when you are moving from home to home, or couch surfing, or you don’t have housing, or adequate housing, or safe housing at all, then it’s very difficult to do things like practice social distancing. So I’m wondering, is there any information that’s being collected and what type of resources may you be—might you be aware of that is connected to maybe federal funding or assistance to address those issues for our children and families? Thank you.

BOLLYKY: Great. Really great question. So on the federal level there—I mean, in general there’s been an increasing amount of research into the role that social disparities have played in this pandemic, because we’ve certainly seen it in the outcomes. So it’s—there is more research. Some of that is on CDC’s website in terms of moving forward. They’ve been a little bit slow in issuing guidelines, but they are—they are doing it. It is clearly one of the lessons of this pandemic moving forward that in addressing these social disparities or mitigation strategies to address them should be part of any pandemic response and part of pandemic preparedness.

I have not seen as much in terms of resources that really has been to some degree at the state and local level, how different governments have responded to support people in that environment. I will say, more broadly, to tie back to our conversation around schools, as you know for many disadvantaged communities a lot of the social services children access are really through the educational system. So that’s one of the things people have looked at in terms of engaging some of those community—some of individuals that are under less advantaged circumstances and providing these services through those—through those contexts. And that’s going to be important.

I did see someone mentioned, and I did forget to respond to the UV light question, so forgive me for that. It is—one of the thoughts as to why we’ve seen less spread outdoors is UV light. As a general matter UV light is inhospitable to viruses and other microbes. Obviously, you have a lot of air circulation as well. I haven’t seen beyond—haven’t seen many studies indoors. The only thing is, of course, you can’t irradiate a room with UV light with people in it. And in terms of cleaning products by and large people have—there are other options that can be effective in cleaning surfaces. So I’m not sure it’ll play too much of a role in the conversation we’re having. But it certainly is one of the factors that people expect to account for the fact that the virus spreads far less frequently outdoors.

FASKIANOS: Thank you. Let’s go to Heather Hillard next.

Q: Hi. Thank you for taking my question. I am here in the greater New Orleans area, where we are right now competing to be number two or number three with the number of cases we have.

And my question is, the antibody results that are coming back, that if you’ve been exposed, and positive, and recover, that now the antibodies are not as prevalent in people. And even Tom Hanks is saying, because he’s part of the original, you know, study, since he got sick so early on. Do you see an antibody factor in this, that if teachers had been exposed and recover that they could have gone back to teach in classroom, in situ, or is there some aspect of this that it’s not just the nasal testing but there’s another aspect of this with antibodies that we might be able to capture, to provide a safe environment for children and teachers?

BOLLYKY: So the primary—great question and thank you for it. The primary question—or primary use that people have made of serological right now is to get a sense overall of the spread of the virus and the extent of the population being exposed. There are a number of reasons why people have been hesitant to use it as a form of kind of immunity passport for people operating in settings. One is a lot of the serological tests haven’t been particularly accurate. That’s improving over time but has been an issue. The tests of infection are a lot more accurate, particularly the PCR tests of infections are a lot more accurate than the serological tests. So that’s one.

The second reason is you don’t want to give people a perverse incentive to get infected, so they can work. So there have been a lot of reluctance in that setting. The third reason is there is still some open debate—and this ties to your Tom Hanks comment—about the degree to which people clear the virus. We do—you know, for most coronaviruses you would expect to see some acquired immunity. It is—we’re still not one—you still see some anomalous reports of people who had been previously infected testing as not infected and then later testing as infected again. And it’s not entirely clear what’s going on in those cases. They’re not common. But you know, again, this is a novel virus and—a novel virus. And to that extent, we don’t know.

And I saw your comment. And please don’t—I’m saying more for the group, not because I think your question in particular was suggesting that teachers go out and get sick so that they can work. But giving the broader notion why people are hesitant to use serological tests as a condition of employment. But I don’t mean to suggest that you were implying that they should do so in this case. Please.

FASKIANOS: Sorry about that. I’m trying to unmute myself.

Let’s go next to Susan Hairston is up next.

Q: Thank you for reengaging these calls, Irina. I have missed you all. You have really—I’m a councilwoman in Summit, New Jersey. And I have found these calls to be ahead of the curve in information on what’s been happening in the New York-New Jersey-Connecticut area. So glad you’re back. Thank you.

FASKIANOS: Thank you.

Q: And thank you to Thomas for this information. I want to follow up on two questions. We know that there is the racial disparity. And I haven’t heard talk about it with children. And so if you can share specifically if you’re finding that to be the case. And I relate that to the studies that you’ve done overseas. And so I don’t hear anything highlighting what you’ve learned overseas about racial disparities, especially in the countries that you’ve chosen. And I happen to have a call with a client in South Africa who was really speaking about the low incidence that they’re having. However, they are taking it very, very seriously, and in lockdown. And so I wondered if that was how you were relating when you said there’s underreporting happening in other countries. So I don’t want to mucky up my question too much, but I hope I’ve given you enough to go on. Thank you.

BOLLYKY: Great. Well, first, let me start by saying thank you for the kind comments of the great work that Irina and her team are—we are CFR—are doing with these calls, and the other programs they run. We certainly—everyone at CFR certainly agrees they’re doing a really great job, but it’s kind of you to acknowledge it.

In terms of racial disparity among school-age children, I mean, as you probably know domestically there’s been an enormous underreporting by states of this information. So we’ve been really hamstrung in term of making these—having—we’ve been hamstrung in general in terms of having good data broken down by race in many U.S. states. We’ve been even more hamstrung by data breakdown both by race, and age, and gender in many states. So this is really something that I’m hopeful is one of the broader lessons to emerge from this pandemic is to dramatically increase the quality, the timeliness of our public health reporting.

It is true that many of those, as you probably have seen from news reports, still come from faxes. I’m appalled to hear that. I worked at the New York City Department of Health in the mid-’90s, and of course that’s how we were getting these kinds of information then. It is sadly still largely the case. I have not seen enough—I have not really seen anything, I should say, internationally that looks across within country racial disparities. I will say, as you point to South Africa or other countries, South Africa’s testing rates have been a lot lower. I am sad to report, as someone who lived in South Africa for a year and a half, that South Africa is one of the ten countries that is growing fastest currently in number of cases.

So they had been really broadly seen, and many of us were cheered by this, as a success story. And I’m sad to say that is becoming less the case. There have in general in sub-Saharan Africa, the number of—the reporting, testing rates have been a lot of lower. So it makes it a little more difficult. There are countries that people believe may be being successful, but it’s difficult to have a really good handle on it with the low rates of testing that we’ve seen. Overall the continent last week reported a 25 percent increase. And you know, we’ve had a resurgence in this country, so it’s taken some degree of the global attention away from what had been seen as now the epicenter of the pandemic, which is South and Central America, and India to some extent, South Asia. But everyone really expects sub-Saharan Africa, unfortunately, to be after that. And many countries will not have the ability to impose the kinds of social distancing that they did early, from an economic perspective. They just can’t afford it. So this is a—this is going to be a challenge moving ahead.

FASKIANOS: Thank you. Let’s go next to Denise Garner. And thank you very much for that wonderful comment, I should say that. I appreciate it, Susan.

Q: Thank you very much. I am a state rep from Arkansas. My background is in public health and I’m on the education committee, so I’ve been kind of overwhelmed with all of the information coming in.

I really appreciate the information that you’ve given on schools. That will be extremely helpful. We’re in a state that has some out of control spread. We never shut down. We don’t have a mask mandate. We have problems in—with testing supplies, the supply chain. So we’re under-testing. I’m also in a community where undertesting is extremely low. We’ve got percent positivity rates between 30 and 50, very high. And we are also the home of the University of Arkansas, which is getting ready to start. So not only are we starting our public schools, K-12 schools, we’re going to have an influx of twenty-five thousand people into our community of eighty thousand coming from all over, but particularly, 50 percent, from Texas, which is even higher than we are.

So what can we do even locally. I’m trying to help locally because our state had not been—I think we’ve—in my opinion, we have been a little bit—our risk-balance has been toward the economy and not toward health. So in that situation we’re really trying to work locally. So what can we do locally as the university gets ready to start, as our public schools get ready to start? And we have been told that schools will start as usual, and with the blended learning. So there is an option for virtual, and that the university will start as usual. So given that, what do we do? (Laughs.)

BOLLYKY: So it’s a difficult problem. I mean, as we’re starting to see from many states, the decision between the economy and public health is a false one. If people are becoming infected at high rates, if health systems are becoming overwhelmed, you see deaths going up, people aren’t going to be going to restaurants, and bars, and movie theaters under those circumstances. And you’ve started to see some of the states that had reopened—California obviously most notably this week—have pulled back on that in response to resurgences. So just to make that broader point, which you may be appreciative of already, but I think is important to remind everyone.

In terms of moving forward, you know, the most important thing that can be done both for the school setting and the community setting, of course, is to suppress the spread of the virus to every extent possible. It is not rocket science in terms of what the strategies are. And there are all the ones that you know well. They’re where—I mean, my colleague Tom Frieden likes to refer to them as the three Ws, but wear a mask, wash your hands, and watch your distance is a big component of it. And it needs to be combined with strategic testing, isolation and contact tracing, and supportive quarantine, where we can. All these are going to be important moving forward.

But on the broader level, it really is the wearing of a mask, washing your hands, and watching your distance. All these are cheap, for the most part. Distance can be a little bit complicated, depending on housing situations, but for the most part quite cheap. It’s matter of getting people to adopt them. And obviously that has been a bit of the challenge with the degree to which these issues in some communities have unfortunately been politicized. But there really is—there’s no other solution to suppressing the spread in this environment. I don’t think we’re going to see broader shutdowns. As you suggested, these things are moving forward. So it’s really at a local and community level trying to approve—improve their adoption.

You’re right to be worried about university settings. They really have emerged—bars, and fraternities, and sororities in particular—have emerged as great sources of spread. And it’s something that we’re all concerned about. In the school setting, particularly in an environment that’s high burden, I would really advise you look at the American Pediatrics—the Academy of American Pediatric guidelines, which do have a lot of a more tiered structure of the degree to which some of these social protections, nonpharmaceutical interventions for reducing spread, should be adopted in schools. Obviously in an environment which is really high spread, and if you can’t move to remote learning it’s important to adopt as many of them as possible.

One worry I have, in addition to ones you’ve mentioned about testing shortages, is trying to secure protective equipment for teachers, particularly in high-burden settings, in advance. So this is something that really people should be moving towards because particularly in high-burden settings, as another official mentioned earlier, it’s the teachers that are at greater risk. And it will be important, particularly in a setting like that, to do everything we can to protect them.

FASKIANOS: Great. Tom, we’re going to go next to—oh, let me open the list—DeAnne Malterer. And I’ll just draw your attention, there were two comments in the chat section, so maybe you can weave those in, about contact tracing. So let’s go next to DeAnne Malterer. We have several more in queue, so I’m going to try to get to you all.

Q: Thank you so much. DeAnne Malterer from Minnesota.

And I come from a rural part of the state. Is there anything that we can learn internationally to help us deal with what are typical rural disparities in dealing with this disease? Obviously, Minnesota, by the time it gets to be October and November, we’re going to be inside most of the time. And that’s going to be so until we get to April. It’s just the way it is here. Broadband access in rural Minnesota is not good. So we’ve found online instruction, particularly for the kids who need it the most, their access was very limited. And then just lack of daycare in rural Minnesota is a big issue too. Is there anything internationally that we can learn to help us address some of these things?

BOLLYKY: Really great and well-delivered question. So thank you for that, identifying the challenges that you’re facing. So I have not seen great breakdowns between rural—whether it’s in the educational environment or urban environments. There’s been a lot on the spread in terms of mitigation strategies. There’s been less, but we’ll look into it. One thing I will say that is going to be important, you know, much of the U.S. is going to have a rough ride the next four to six weeks. Where you see a rapid increase in cases, an increase in deaths will follow. And people—virus spreads among young people won’t stay there.

I am hopeful, of course, and remain—I am cognitively optimistic. So I will remain hopeful that we are able to suppress this somewhat, because when we do move to the fall we will see resurgences, for all the reasons you’ve suggested. It will also be flu season. So one thing I do want to identify is, boy, is this an important year to make sure as much of the population gets their flu shot as possible, because if, particularly rural health systems that are confronting both a surge in influenza, as well as surge in coronavirus cases—you know, we’re not likely to have a vaccine prior to the beginning of next year. And who knows exactly how long it’ll take to distribute to many Americans. We will have flu shots. And it’s important that people get them.

But you know, this is something where we really need to press state and federal officials for is more on the housing and the isolation capabilities, even in rural environments, to enable people to do distancing, where you do have people in houses that become infected and there’s not an ability to shelter, and for other members of that household, to shelter in place. So this—these are the kinds of things we need to be preparing for now. So I’m glad you’re raising them. I wish—I don’t know what’s happening on the Minnesota state government level. Perhaps somebody else on this call does. But I would love to see more from the federal government in terms of supporting communities that need to make this kind of particularized adjustment to their circumstances.

FASKIANOS: Thank you. Let’s go next to Lee Gilbert.

Q: Lee Gilbert, county commissioner in Rockwall County, Texas.

Are you aware of any studies of perception of the American public, or are we doing anything—and I’ll give you the personal experience here in my county and my precinct. At best, coronavirus is viewed as a 50/50 deal, half the population taking this seriously, following the governor’s orders, local orders. The other half are reluctantly following or not following at all. And how can you stop a pandemic if only half your population participates? Thank you.

BOLLYKY: So this is a—there have been polls and surveys in general to the degree to which people across different states, across party lines, across age ranges view the coronavirus as a threat. So those polls do exist. The main challenge, of course, is you need to see consistent messaging at every level of government around the fact that people should take this seriously. One of the challenges we have with this virus is it is, and I’ll say something that seems odd at first but stick with me, mainly is it’s not deadly enough. It is not deadly enough to inspire the behavior change that we need to see in people, but it is seriously enough and causes serious health consequences enough and it’s deadly to vulnerable and older populations. So it’s not deadly enough to get younger populations to do the behavior changes that we need to see, but just serious and deadly enough to overwhelm health systems and have a disparate effect on the vulnerable and older populations.

And in that sense, you know, much of our pandemic preparedness assumes really high rates of case fatality. And as, you know, the more bad case, worse-case scenarios of what we can see from a pandemic, and what has been revealing about this particular pandemic, is, again, the rate at which it spreads asymptomatically, overwhelms health systems, but isn’t quite deadly enough to get young people to take it seriously has really been a disastrous combination, particularly for this country.

FASKIANOS: Thank you. Let’s go next to Arianna Calderon.

Q: Hello. This is Arianna. I’m District 16’s aide in Florida—Tampa, Florida.

So it is commonly known that the degree of danger from COVID is seen as a bigger threat to people with compromised immune systems. We are all here discussing and debating opening schools for this fall when we don’t have a lot of studies or research to help guide us in how to do that safely. And it is also known that in fall and winter everybody’s immune systems are lower, viruses spread quicker because the temperature is lower. Parents are constantly complaining that when one kid catches the flu everybody in the household gets the flu. So I just want to hear more on, like, your opinion and the studies that you have witnessed and everything on how you think it’s going to, like, affect the fall, because we’ve been dealing with COIVD since, like, February here in the United States. And that was coming out of that season.

BOLLYKY: Yeah. So I will first conceded I was not one of the people who thought this would be seasonal. A lot of coronaviruses aren’t. So I’m a little less surprised to see, but the main reason—we will see resurgences in the fall. And we’ll see them mostly because people are crowded together indoors. And again, the primary way—the overwhelming way this virus spreads is through respiratory droplets through direct exposure. And people being indoors and close to one another is the most likely way that is going to happen. Everybody expected to see resurgence, a second wave, in the fall in the United States. What we hadn’t really expected is the fact that we’ve had this continued churn in between.

That’s important, because what you’d really like to do ahead of the fall is to drive down the community transmission to levels that give your health system a bit of headroom so that if you do see resurgences you can adjust and move personnel around, move equipment around, try to address those hotspots and control them to the extent possible. We’re—you know, last week there was a day when we had nearly seventy thousand cases. We are not in that circumstances in some states, and unfortunately Florida in particular. So this is—we should expect resurgences in the fall. And to the degree that we can’t protect people from influenza, we should expect the consequence of both conditions to hit the health system like a hammer. And it is incumbent on us to do everything we can ahead of that to reduce—to reduce community transmission as low as we can go because there will be undoubtably some amount of spread.

Whatever anyone thinks about the school, to tie this to our topic of conversation, lower risk, high risk, it is not—there will be some risks. There will be some increase of spread that happens with schools. It’s a risk-benefit analysis for communities to identify whether to reopen them. But as we reopen them. But as we reopen schools, as we move to winter, it’s important to get the background rate as low as possible and make as many of the preparations that we’ve talked about here today as possible.

I see we’re out of time. I’m happy to field questions through email or other things. Again, we’ll post those sources for this group. And, you know, thank you for all that you’re doing to combat this pandemic. I’m very grateful to state and local officials for that hard work.

FASKIANOS: All right. I second that. Thank you all for all that you’re doing, and thank you, Tom Bollyky. As Tom said, we will send an email out with the links to the resources that Tom mentioned. I also encourage you to follow him on Twitter at @TomBollyky, and also visit ThinkGlobalHealth.org for more resources, as well as CFR.org. We’ll also include a link to the transcript of this discussion, as well as the webinar. And please let us know how we can continue to support the important work you’re doing. You can email us at stateandlocal@cfr.org. So thank you all, again. Stay safe. Stay well. And we’ll just have to continue thinking through these issues and figuring out the best way to move ahead.

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