If indoor spaces had adequate air cleaning, most airborne transmission could be negated, making it unlikely for any pathogen to cause a pandemic

Re great Morawska et al article @ScienceMagazine, @sri_srikrishna & I rethink current approach in 2 ways
(1/6)
science.org/doi/10.1126/sc…
(1) Air cleaning must stop long-range spread by calibrating filtration to remove the amount of pathogen emitted in superspreading (not based on # of people in the room)

For many pathogens, most infectious particles are accounted for by relatively few hi-emitting infectors (2/6)

The most systemic & sustainable 'solution' to the pandemic is to implement clean indoor air -- eliminate virus from the air enough that risk is always low

A big barrier to this in real life is that there was no guidance on just how clean is clean enough?

jamanetwork.com/journals/jama/… For years, CDC and ASHRAE, the bodies responsible for putting forward standards, were unwilling to do so

As a result, schools, businesses & other didn't know what to do. Some put one HEPA filter in a room & hoped it was enough (it wasn't)

Thanks @Bob_Wachter for sharing such a personal situation that allows us all to learn

What strikes me is that so many factors in how you’re navigating this situation are beyond the means & agency of our most vulnerable yet are being thrust on them to manage on their own

(1/6)

https://twitter.com/Bob_Wachter/status/1523539589603889152

The judgements you expertly made are ones that are currently being put on all individuals irrespective of their knowledge & comfort with Covid

Just like we wouldn’t leave it up to individuals to determine what traffic rules to follow, guidance should be clearer

(2/6)

I've been working in a hospital in a low-income area for the past several nights

From talking with our many unvaccinated Covid patients, there are 2 general responses I've heard as to why they weren't vaccinated...

(1/4) 1) Several people said they knew vaccination was *important* but never perceived it as their *most immediate* need until they got sick

Had we been going door-to-door, eliminating the burden on them to search out & get vaccinated, most felt like they would have gotten it

(2/4)

We've never meaningfully addressed spread in high-risk workplaces despite this likely being a major driver of the pandemic

In communities like mine, workplace spread seeded transmission in crowded multi-gen homes with at-risk elderly & others working in similar settings

(1/6)

https://twitter.com/celinegounder/status/1367138404551585799

Most of our 'standard' strategies -- cloth masks, "stay-at-home", distance -- do nothing to address this cycle of transmission

(2/6)

1/ Just heard @CDCDirector on @CNN @drsanjaygupta push back on the proposal @AbraarKaran @sri_srikrishna & I put forward on the gov't sending N95-caliber masks to every home (cnn.com/videos/health/…)

A quick rebuttal

THREAD 2/ Dr. Walensky's counterpoints to this idea seem to be:

- N95-caliber masks aren't necessary; multi-layer cloth + 6 feet is good enough

- access to masks is not a bottleneck

- N95-caliber masks are hard to wear for long periods

We're deploying vaccines like we do annual flu shots rather than the mass vaccinations done in Africa & Asia where millions are vaccinated in weeks

Years ago, Joe Rhatigan & I studied these campaigns. They offer several lessons that can inform what we need in the US now

THREAD 1/ Be proactive

Instead of passively waiting for people to come get vaccinated, we need to search them out & go to where they are & keep following up until they opt out or are vaccinated

We should be rolling out the vaccine like we do the Census, even going door-to-door

In 2014, I was on a 'task force' convened by Guinea's President to forge a nat'l Ebola response

Cases were spiking, it was a polarizing election year &, though many efforts were happening, there was no overall strategy or unified response

Here's how we set up the response

1/15 The first step was to establish a clear chain-of-command leadership structure under the National Ebola Coordination Cell with Dr Sakoba Keita as its head

All partners (eg, WHO, MSF, other ministries) & all response activities had to go through the Cell

2/15

(1/3) The 3 greatest health challenges of this century - pandemics, non-communicable diseases, health effects of climate change - will require

(1) health systems premised on primary care that integrate population health

(2) stronger mechanisms for global coordination & action

https://twitter.com/stefanswartpet/status/1313025659527139328

(2/3) #1 can be achieved by merging best practices that thus far happen in isolation into integrated systems that leverage technological- connectivity, AI, automation- tools to orchestrate/facilitate high-quality replicable execution at scale

(More soon @OptimizeHealth_)

(1/5) To put Trump being started on dexamethasone in perspective, we do it for patients when they become hypoxic

Some patients I've had are on remdesivir/dexa like Trump is now & only require a touch of oxygen (eg, 2L) for a day or two & then come off it. (2/5) Even when on oxygen, they may look, feel, talk etc. like they're fine & you wouldn't know they were hypoxic unless you took off the oxygen & saw their O2 saturation

(1/4) Other than the experimental antibodies, Trump has gotten what - remdesivir, dexamethasone - we give to our Covid patients with hypoxia (2/4) From the way questions were answered, the fact that dex was started (which can have side effects including confusion) & he was on supplemental O2 suggests to me that his O2 may have been lower than they are letting on

Supplemental O2 usually isn't given unless O2 sat <90%

1/ A hang-up on rapid tests that I've heard is that it'll be difficult for health depts to track results

Decentralized screening makes that difficult but stopping spread should be the overwhelming priority; monitoring indirectly helps stop spread but is a secondary consideration

https://twitter.com/ashishkjha/status/1305252579786530818

2/ We shouldn't hold up something that can stop transmission because it will be harder to monitor or collect data on

The current counterfactual is that we're missing most infections anyway & neither stopping onward transmission from them or getting any data on them

1/ This is an important point - models are not all bad/good or about prediction but rather tools for guiding what needs to be done

In the Ebola epidemic, we modeled spread in each locality to plan where we needed testing sites & calculate how many treatment beds may be needed

https://twitter.com/DrTomFrieden/status/1303405492883075073

2/ There was a lag between determining a need & getting it established so the best we could do was use modeling to start deployment &, if transmission shifted & changed, we revised our models & adjusted our projections & plans

1/ I work in a hospital with a steady flow of Covid. Just a few weeks ago, we were overcapacity- more ICU patients than beds, more Covid patients than isolation rooms, more telemetry patients than telemetry beds

This was in August when we usually have a lull in overall caseload

https://twitter.com/ScottGottliebMD/status/1302593895088480257

2/ In pre-Covid winters, we typically fill to capacity & periodically have to 'surge' not even because of flu but other respiratory viruses & environmental triggers for chronic lung disease

If that happened a few weeks ago, there'd literally be no way to manage the patient load

There is real-world data showing that what we are doing right now isn't working

Widespread serial rapid screening hasn't been done before bc regulatory agencies have blocked it. At minimum, many more cases will be caught early

And remember, nothing has to work 100% to get R<1

https://twitter.com/JClinMicro/status/1302590654694993920

And here is some modeling data that suggests that rapid testing in this manner could have reduced the number of infections in the West African Ebola epidemic by *a third*

nature.com/articles/natur…

9 months isn't quite 'warp speed' but I'll take it

#DailyQuickTest @AbraarKaran @EricTopol @amymaxmen @michaelmina_lab @j_g_allen @ZoeMcLaren @PaulSaxMD @BhadeliaMD @celinegounder @JeremyKonyndyk @nataliexdean @alexismadrigal @yayitsrob @ashishkjha @KatherineJWu @apoorva_nyc @K_G_Andersen @paimadhu @cmyeaton @T_Inglesby @zeynep @HarvardGH

1/ Still learning about new Abbott rapid test but a few immediate impressions from what's circulating
- high sensitivity & specificity
- can be used - like device-based rapid tests already with FDA authorization (BD, Quidel) - at workplaces, schools etc.

prnewswire.com/news-releases/… 2/ BD & Quidel rapid tests can't do frequent home screening as needed to really paralyze transmission because (1) they require devices that are difficult to scale to every home & (2) require nasal swabs & processing steps that may be difficult for many people to do on their own

1/ Based on our work on Ebola & Zika, when Covid hit in January, we called for mass screening with rapid tests as a way to stop Covid in US & globally

>21m cases & 750K deaths later, this approach hasn't been used but still could help stop the pandemic

hbr.org/2020/02/we-nee… 2/ In @washingtonpost, @sri_srikrishna @AbraarKaran & I discuss how tests that provide fast results, can be decentralized widely to people's homes & used frequently to detect more infections quickly can close the window of transmission & paralyze spread

washingtonpost.com/outlook/2020/0…

1/ Frankly the pushback hasn't only been regulatory; many 'experts' haven't agreed or understood this approach

For 6 yrs, @sri_srikrishna & I have written extensively about it as a go-to strategy for uncontrolled epidemics & for Covid in Jan, Feb & March

hbr.org/2020/02/we-nee…

https://twitter.com/michaelmina_lab/status/1292324334825017344

2/ There is a big problem effectively translating scientific ideas into policy

We published conceptually the same idea @TheLancet @TheLancetInfDis @bmj_latest @BulletinAtomic @nytimes as well as almost verbatim for Covid @HarvardBiz

That wasn't enough

hbr.org/2020/01/what-w…

We have the tools & know-how to get to 'Zero Covid' within weeks to months:

1. Smart but stringent targeted lockdowns now

While in lockdown:

2. Mass produce rapid test strips
3. Mass produce more protective reusable masks
4. Set up local surveillance & contact tracing systems 5. Ideally while locked down:

- use rapid tests to do universal screening as frequently as possible (ideally daily) for 2 wks

- Anyone+ is isolated (ideally outside home) & contacts traced, kept locked down & again screened for 2 wks & so on until transmission chains is ended

1/ 13 REASONS WHY...

...we can't wait for a vaccine or tolerate slow declines & need to shift to a more aggressive 'zero Covid' approach that aims to get cases down as low as possible as quickly as possible 2/ Reason #1: Preventable deaths

~160K Americans dead - the most in the world

We're on pace for too many more families to be on the receiving end of FaceTime calls like the ones my patients about to be put on ventilators make to see loved ones in case they don't make it thru