Thus far in the #COVID19 pandemic, the United States has been decidedly behind the curve in our response. This has been perplexing given that we had advance warning. Further, other countries affected more proximally (South Korea, Taiwan, Singapore) had a more prompt and effective public health response. Our relatively ineffective effort in terms of daily deaths is presented graphically below (data current through 4/17/2020).
Singapore, in particular, had been praised by the World Health Organization (WHO) for their ability to limit spread without imposing restrictive lock down measures. That was, until the second wave hit. Since March 17, Singapore’s number of confirmed coronavirus cases grew from 266 to over 5,900.
I remember early in the US epidemic (which was like 8 weeks ago but seems like a lifetime), I was looking for resources on self-quarantine and case isolation. The instructions I posted our Facebook page were from the Public Health Department of Ottawa. I had looked initially to Singapore for their guidance, but upon reviewing their materials I discovered that public health officers came to the homes of those infected with COVID-19. Patients received a box of instructions as well as disinfecting sprays, wipes and masks/gloves needed to effectively clean common areas thus preventing the spread of the virus. So there were no published materials because quarantine instructions were delivered directly(!) to cases.
Unfortunately, in Singapore, these public health officers appeared to have overlooked clusters of cases among migrant workers living in cramped quarters. From this origin, the virus was secondarily able to spread through a city where lock down measures had not been put in place.
The key take away here and one which is applicable to the US as we move towards the minefield that is re-opening, is that the resurgence of cases comes from “overlooked” cases who live in close proximity to one another.
Any thoughts of where similar pockets might be in the US? I can think of some: prison populations, long term care facilities, assisted living, nursing homes, homeless shelters, retirement communities, military barracks, aircraft carriers, submarines, dormitories, and migrant worker housing. No doubt there are many others.
But the good news is that it is far easier to implement control and preventive measures in a cluster outbreak is than it is for a distributed community spread disease. One way to conceptualize the second wave of COVID-19 might be similar to a nationwide foodborne outbreak. In such, epidemiologists first identify institutional settings (e.g., hospitals and schools), as potential sources of a disease. As an investigation continues, cases from a particular institutional settings may point to a common source. Our response can then be predicated on policy and guidelines developed from this outbreak experience and virtual certainty about the etiology of the problem and its mode of spread.
It’s never too late to learn.
[Acknowledging the late Dr. Michael B. Gregg who served as Editor-in-Chief for the classic text “Field Epidemiology” from which this information was gleaned ]