1. As US states re-open, Covid-19 status variation suggests that there is no silver-bullet approach
The United States hit a grim milestone this week, with over 100,000 deaths attributed to Covid-19 as of May 29. Similar to earlier weeks, the country appears to be on a slow ramp down from the peak of the epidemic. As states lift distancing requirements and economic activity resumes, hospitalization and death rates will increase.
So far, there isn't a clear correlation on different state-level re-opening strategies and Covid-19 spread or deaths. States on opposite ends of the spectrum—those with no stay-at-home orders (such as Arkansas) and very restrictive stay-at-home orders (such as Maine)—are seeing different levels of rising cases. Texas has now been open for about 27 days and is seeing a steady decline in Covid-19 cases and positivity rate.
Instead, the data suggests multiple variables are at play, including population density, weather, the date when social distancing began, when the virus reached the population, and more. Policymakers, picking up on this observation, are arguing that in the absence of a single authoritative fix, the next phase of the nation's Covid-19 response must emphasize mitigation, management, and continually preventing hospitals from being overwhelmed.
2. Important national shifts in post-acute care and supply chain are under way
Two critical components in the ongoing mitigation and management portfolio must include fixes to the post-acute system and the supply chain for PPE and drugs.
- The struggling U.S. post-acute sector likely needs more financial support—and some more central regulation. HHS' announcement of $4.9 billion in Covid-19 relief funds directly to skilled nursing facilities (SNF) is the federal government's most significant recognition that SNFs need dedicated support. And yet this funding likely falls short of what is needed to fill major gaps in infection control, as well as sufficient training and staffing to prevent future outbreaks.
In addition to financial and operational challenges, SNFs continue to struggle with a hodgepodge of regulations and guidance at the local, state, and federal level. Based on the sheer volume of inquiries about whether there will be a more unified regulatory approach in future, some type of change in this direction seems increasingly likely.
- Increased domestic sourcing of PPE and drugs can make our supply chain more resilient—but will also drive prices up. Industry leaders and policymakers are moving to invest in domestic, but geographically diverse, sources for both PPE and drugs. The intent is to build out a more resilient supply chain, creating a strategic reserve and reducing reliance on sourcing overseas. But this version of the supply chain will also be more expensive—leaving unanswered the question of who will bear the cost. This question is especially controversial in the context of drug prices.
3. Start any search for international exemplars with a reality check: No country has yet succeeded in the ultimate goal of achieving herd immunity
As the United States continues to try to find its way, many are looking to other parts of the world, hoping to discover strategies or technologies that could be applied here.
Vidal Seegobin and Paul Trigonoplos from Advisory Board's international research team brought answers to these questions—beginning by reminding us all that no country has yet succeeded in the ultimate goal: achieving "herd immunity."
Herd immunity would entail 60-70% of the population having antibodies to the virus, from either having had the virus and recovering or (in future) being vaccinated. Sweden, known for explicitly targeting herd immunity as its policy objective, recently found that only about 20% of people around Stockholm have antibodies. Similar low levels of antibodies are likely even in hard-hit countries; in Spain, about 14% of the population around Madrid now has antibodies. This leaves all countries around the world chasing the same remaining hope: the development of a vaccine.
Furthermore, no country's health system has shown itself to be infallible. As Seegobin said, "The pandemic was a stress test, and it continues to be, and it has demonstrated differing strengths and weaknesses in how we have configured each health system."
4. View country-to-country comparison data with skepticism
Clean outcomes benchmarking across jurisdictional borders is difficult, if not impossible, to do.
- Different governments count things differently. For example, Belgian clinicians are counting as Covid-19 deaths any death that is even suspected as Covid-related. In contrast, until recently, U.K. clinicians were not counting Covid-19 deaths in nursing homes, only hospitals. And across all countries, clinicians have wide latitude to make the call as to whether, when a patient with underlying conditions and Covid-19 passes away, that death should be counted as Covid-19 or not.
- Major country-specific differences also make comparisons hard. Demographic differences affect outcomes; for example, Singapore has a comparatively low Covid mortality rate; however, many of its cases have been cropped up among migrant workers, a population that skews younger and more resilient.Countries may also benefit from having few or no land borders; having a population with a high ratio of single-person households; and traditional greetings that entail bowing from a distance as opposed to shaking hands or hugging.
5. The most important country-level lessons are the ones forged by previous experience
Limitations aside, countries with generally lower Covid-19 rates do tend to have some common approaches that are worth studying. All are based on experience. Countries affected by SARS, H1N1, and MERS have economies of knowledge, policy prescriptions that are ready to go when needed, and a more prepared public that understands what it needs to do.
Experienced countries tend to have built four helpful capabilities in particular:
- A legal framework for how local and central governments should cooperate;
- A central office for communicating risk to public;
- Policies around cessation of privacy protections to allow tracking and monitoring of disease spread and people's behavior; and
- Strong public-private partnerships with manufacturers to ramp up supplies as needed.
Having these elements already in place made the experienced governments willing and able to enact changes and create national protocols swiftly. In this way, Singapore was able to stand up an entry quarantine system, with information going to hospitals and pharmacists, within days; Taiwan was able to activate existing legislative frameworks for public-private partnership to ramp up testing and PPE supplies within a week.
6. What about disease monitoring? First, understand that contact tracing and surveillance are two different issue sets.
Disease monitoring is clearly an area where experienced countries are leading the pack. But to find applicable lessons here, it is important to understand that disease monitoring has at least two major components—contact tracing and surveillance—and that the issue sets for each are quite different.
Contact tracing is a tried-and-true public health practice that the world has used for 150 years. To date, it has been largely accomplished with low or no-tech approaches, such as workers using the phone or driving to interview people. Experienced countries already had a head start in their contact tracing workforce—and virtually all countries are investing in expanding it.
Surveillance is the area where technology is enabling the greatest leaps—and also the area that is most fraught with social issues. Asian countries such as Hong Kong and Taiwan already had compulsory, automated, passive approaches, with no option to forego participation, enabled by policies developed after MERS. They were able to simply "flip the switch" to activate collective data sharing, analysis, and automatic notification to people if they had been in contact with others who might have been infected or if they were in a hot spot.
7. Technology-enabled, opt-in disease monitoring will not be easy
Countries such as the United States, U.K., most of the European Union, and Australia are all looking for ways to improve disease monitoring without having to utilize passive, compulsory surveillance. Mostly that means developing contact-tracing apps that use Bluetooth to notify people when they coming into contact with someone who might be infected or have been around that person for too long. But these are not yet consistent and robust enough to deliver effective disease monitoring. There are a few key challenges posing barriers to their success:
- Low opt-in rates: Ideally 60-70% of the population needs to opt in; Iceland has about 40%, Singapore has only 25-30%.
- Bluetooth challenges: In addition to the reliability challenges familiar to anyone who uses this tech in a car, many parts of the world's population, especially seniors, may not have sufficient access to a Bluetooth-enabled smartphone.
- Delays in app production. The issues here are various, but one major one is a standoff with private industry. Most app developers were counting on Apple and Google updating their operating systems to support apps that track GPS or store data centrally; but these companies have declined to do so. App developers are now forced to deploy their plan B, creating app options that are more anonymous and private.
- App chaos. The world currently has 50+ apps that could possibly track people's data. It is not clear how often those apps will talk to each other; where authority has been devolved to states or municipalities, there will be interoperability and communication issues. This problem has already surfaced in areas such as Ireland and the U.K., where, when people cross the border, they move between two different apps.
8. The world is learning together that it is possible to flex acute bed capacity
Worldwide, early warnings from abroad on ICU and bed capacity were well heeded. Even in countries where occupancy rates are high (upwards of 90%), compared to the United States (which tends to run at about 60-70%), most hospitals were not overwhelmed.
Between canceling elective surgeries and rapidly adding critical care beds, many hospitals are now virtually empty; in the U.K., the 4,000-bed NHS Nightingale facility has so far only seen 60 patients (2% of capacity). In Ontario, the occupancy rate of ICU beds dropped to 40%, from about 80% in less than a month.
Looking forward, the demonstrated ability of hospital systems to scale up and down so quickly is likely to impact thinking about the hospital footprint.
9. Hospitals around the world are in the same position when it comes to bringing volumes back on line
Similar to the experience in the United States, hospitals around the world are reporting that volumes are slowly coming back online as restrictions on elective procedures are lifted. Generally speaking, oncology, general surgery, and orthopedics cases are the ones coming back first; a recent NHS analysis also suggested that cardiac emergency visits are back to normal levels.
International hospital and health system leaders all share the financial and strategic concerns of their U.S. counterparts. They, too, worry that much of the returning volume is driven by backlog; and they are also working to restore the "top of the funnel"—reintroducing care, convincing the public that hospitals are safe. And despite differences in how the markets are structured, lower volumes do represent a financial threat to international providers. Many international markets have a dual public-private system, with private hospitals left to their own devices to find ways to recover lost revenue.
10. To get ahead of a second Covid-19 wave, prioritize these steps now
Hospital and health system leaders around the globe are extremely concerned about the possibility of a second Covid-19 wave—one that arrives while occupancy rates are recovering, PPE supplies are still lacking, and many staff are burnt out.
Looking at countries with more experience and overall better Covid-19 outcomes suggests taking the following steps today:
- Focus testing and disease monitoring disproportionately on urban centers, dense populations—and populations that are underserved. The virus is likely to circulate fast, and unnoticed, among groups with little current interaction with the health system.
- Set up rules in advance for flexing back to suppression strategies. All jurisdictions should have agreement and uniform communications around what benchmarks (positive tests, hospitalization rates etc.) would trigger what policy and social distancing responses.
- Ramp up contract tracing. Absent technology silver bullets suitable for use in western societies, these countries should double down on low-tech solutions, such as hiring man more contact tracers.
Finally, to anticipate what effect winter in the Northern hemisphere will likely have we should all pay close attention to events in the Southern hemisphere, which is now moving into winter and flu season now.
Slide deck: Lessons learned from overseas
In this week's webinar we hosted leaders from our International team to compare U.S. strategies, technologies, and outcomes to those being adopted in other parts of the world.