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By some models, Texas has passed its peak in deaths from coronavirus infections. But before people can get back to work, public health experts are issuing a stark warning.
Multiple waves of infection are coming, they say. As officials begin to discuss how to ease restrictions here, they must also focus on minimizing the next peak to prevent another sharp rise in infections and deaths from COVID-19, the disease caused by the highly contagious virus.
The only way to accomplish this is to contain the epidemic through “widespread testing, extensive contact tracing and centralized isolation,” according to the Population Health Advisory Committee, or PHAC, a volunteer group of local physicians and public health professionals that came together to offer science-based advice to city officials.
As it exists now, the public health system is ill-suited to that task, said Dr. Vince Fonseca, a member of PHAC who served as the state’s chief epidemiologist during the 2009 H1N1 flu pandemic, which spread near San Antonio.
READ: Population Health Advisory Committee’s summary of strategies
“Almost for sure, (the coronavirus) is going to come back in the fall,” Fonseca said. “We as a community need to acknowledge we have not resourced our health department, just like every city, county in the state hasn’t.”
Metro Health Director Dawn Emerick said that officials here are scrambling not only to find enough testing kits and supplies, but also even to assess the testing capacity of other health providers in the county.
“We just don’t know,” Emerick said. “And we have to call everyone manually. That’s just how bad it is in terms of infrastructure. This is what happens when you don’t invest in public health. When you have cuts, infrastructure goes away.”
After years of federal cuts, local and state health departments across the country have lost nearly a quarter of their workforce since 2008, according to the National Association of County and City Health Officials. A $484 billion coronavirus relief package approved this week by the Senate would provide $25 billion for testing, but researchers say that’s a fraction of what’s needed to reopen safely by the summer.
“We’re all really trying to figure out how do we scale up testing,” Emerick said. “That’s an issue across the country. There’s a reason why everyone is struggling with testing.”
Mayor Ron Nirenberg said the ability to test, trace and isolate enough patients is critical to restarting economic activity.
“Our primary goal in reopening carefully is to ensure we don’t end up in the same or worse situation than we’re in now,” Nirenberg said, “avoiding a second wave of the infection that would force additional closures and further stunt the economy.”
Since stay-at-home orders were issued last month, at least 71,000 people have filed for unemployment in Bexar County, and 1.38 million people have filed claims in Texas. Last week set another record for one-week jobless claims in Texas, with 325,000 new unemployment claims. Nirenberg wants to see a 14-day decline in new infections before lifting economic restrictions designed to stop the spread of the virus.
But the number of new cases here continues to climb. Bexar County has recorded a total of 1,126 cases since the outbreak began — up 46 from Tuesday to Wednesday. Thirty-nine people have died since the first local case was reported March 13.
Nirenberg and Bexar County Judge Nelson Wolff have named Emerick and others to a panel of medical experts who will advise them next week on when it’s safe to begin easing stay-at-home restrictions. The COVID-19 Health Transition Team, which is separate from PHAC, is led by Dr. Barbara Taylor, an infectious disease specialist at UT Health San Antonio.
The team will work with a separate panel convened by Nirenberg and Wolff, dubbed the COVID-19 Economic Transition Team. That committee must put together a plan by May 1.
“We were called upon as health experts to deliver guidance based on data and our knowledge of the community, but that is really the beginning of the process,” Taylor said.
The health transition team will strive to forestall a second wave of infections. But it would be a mistake, Taylor said, to believe that sacrificing the economy is the only way to save lives.
“I actually think these things are incredibly intertwined,” Taylor said. “Severe economic hardship obviously undermines the health of our community. By realizing these things are intersectional rather than opposed, we can come up with plans that help promote both.”
That’s the aim, at least. But reopening will be a delicate task, experts say, one fraught with risk in the face of a virus that is both poorly understood and highly contagious. Even the continuation of social distancing — as ruinous as it is to the economy — isn’t enough to stop the spread.
“If we shelter in place without testing people with mild or no symptoms or without identifying likely positives through tracing, the emergency declaration will have limited impacts on suppressing this virus,” a recently revised PHAC document warned. “Instead, we merely shift the peak.”
Without adequate testing, public health officials are blindfolded to the disease, unable to locate infections and stamp out clusters before they spark larger outbreaks.
To contain the virus, experts say communities should test nearly everyone with mild or severe symptoms, as well as an average of 10 people who were in contact with each person who tests positive.
An average of 565 tests are conducted every day in Bexar County by both public and private labs, according to Metro Health. And local officials are in talks with Texas MedClinic and the Texas Military Department to expand drive-thru testing sites.
Yet testing here continues to be hampered by a scarcity of resources — not only nasal swabs, but also necessary collection tubes.
“You can swab all you want,” said Emerick, the metro health director. “It’s the transport media that’s a problem.”
Labs are overwhelmed, she said, and some are having trouble acquiring the chemicals required to run the tests.
“Some of the larger labs, they’re just getting hammered,” Emerick said. “We need more labs online. People can pressure us, ‘You need to test more, test more, test more.’ Hold the phone. I can’t collect specimens if I can’t run the tests.”
Fonseca said state officials should clamor for the federal government to send more tests that deliver results within minutes.
“They just can’t make enough,” he said. “Right now we haven’t heard a loud enough voice in Texas as a whole so we can get in front of the line for more of these rapid tests.”
Some are pinning hopes on a separate blood test that could identify those who have developed antibodies to COVID-19 and allow them to return safely to work. The Food and Drug Administration has allowed about 90 companies to sell antibody tests that have not yet been vetted by the government.
Health officials have since warned that some are making false claims about flawed products. Many of the tests have found antibodies in people who actually have none, and researchers are not yet certain that those who have recovered from COVID-19 are even immune.
In Laredo, health officials obtained about 20,000 antibody tests before finding them to have a reliability of only about 20 percent. The company selling those tests had advertised an accuracy rate of 93 to 97 percent, said Rafael Benavides, a spokesman for that city.
“I think it’s concerning,” Taylor said. “Any test that we don’t know the parameters — how many false positives and how many false negatives — and also fundamentally we need to understand what the antibodies mean. We can think about it as something that could make a difference in the future.”
Emerick also was wary.
“I could show you the number of solicitations that we get, where it’s just email after email after email about antibody testing,” she said. “None of those antibody test results are required to come to the health department. Who’s going to regulate this?”
Contact tracers wanted
Testing is critical, but the trail of the disease doesn’t end there. To suppress the virus, health officials must also identify the recent contacts of those who test positive — and then test and isolate those contacts as well, experts say.
Some Asian countries have used digital surveillance to track patients and alert contacts. But privacy concerns in the United States limit this approach.
Councilwoman Ana Sandoval, council liaison to the health transition team, suggested looking to Massachusetts. That state has budgeted $44 million to hire 1,000 people to trace the contacts of its COVID-19 patients.
“That’s not out of the realm of possibility for a place like San Antonio to do,” said Sandoval, who earned a master’s degree in public health from the Harvard School of Public Health. “That could definitely happen here.”
Metro Health has about 30 people engaged in contact tracing at any given time, but more are needed — between 250 and 300 in all, Emerick said.
The job would require communicating with the contacts of anyone who tests positive to warn them of their potential exposure, connect them with public health resources, and then monitor their symptoms until they either test negative or are beyond the two-week incubation period for the disease.
“The skills needed can be taught, no public health experience is necessary, and a high school education suffices,” the PHAC document said. “Case investigators and contact tracers receive training on the basics of disease transmission, how case isolation works and quarantine of contacts.”
Cherise Rohr-Allegrini, an infectious disease epidemiologist and a member of the health transition team, said she’s heard from people who want to help.
“I’ve had probably 40 students contact me asking to volunteer to do contact tracing,” she said. “And there’s more out there. It’s not that hard to learn how to do it.”
“Stay home” has become an urgent command in the coronavirus era. But lessons learned from Wuhan, China, where the outbreak was first reported, suggest that a twist on the adage might be required to defeat a virus that tends to cluster in families.
“If you lock down and restrict people to their homes, well, most people don’t live by themselves,” Fonseca said.
As a result, authorities in China placed patients with even mild symptoms in temporary isolation facilities. People who had come into contact with anyone who was infected were sent to hotels for quarantine.
About 800 hotel rooms in Bexar County are available for people who want to isolate away from their families, and the city will provide transportation. This week, though, just four people were using the service.
Unlike in China, authorities here won’t force people from their homes, so health officials must make isolation services more “attractive,” Fonseca said.
He suspected that patients might be reluctant to leave their families.
“In order for me to do something different, my social role has to be completely taken over by someone else,” Fonseca said. “So we probably have to figure out, what are the barriers, and lower the barriers.”
But local health officials might be running out of time to enhance containment measures.
On Wednesday, Gov. Greg Abbott said in a series of interviews that he could make an announcement as soon as Friday about reopening some Texas businesses, including restaurants, hair salons and retail outlets. He said the re-openings would go into effect a week after his announcement.
This could preempt deliberations by the health and economic transition teams appointed by Nirenberg and Wolff.
“Their purpose is to set the terms of engagement,” Nirenberg said before news broke about the governor’s plans. “Lay out the field on which we have to play …the conditions and circumstances that they say need to be in place for us to safely reopen.”
Reopening too soon could prove catastrophic, the mayor added.
“You don’t cut your parachute off because you slowed your descent.”
Staff Writer Diego Mendoza-Moyers contributed to this report.