APPA COVID-19 Message Following the July 24, 2020 APPA Town Hall

An occasional blogpost from Lander Medlin, APPA’s Executive Vice President

Testing & Tracing, Aerosolized Particles & the Serology of the Virus

July 27, 2020 — The resurgence of coronavirus cases now tops 4M.  On cue, and as predicted, we recorded another horrendous milestone:  over 1,100 American deaths for a fourth day in a row!  Let’s look back at the beginning point (March):  we reached 1M known cases in 99 days; then 2M 43 days later; and, 3M 28 days after that; and now 4M occurred in just 15 days.  This is growth in transmission and spread at an exponential rate and pace!  ALL adding significant, unbearable stress on the healthcare system.  The positivity rate remains unfathomably high.  The curve is spiking ever upward.  There is no solace for herd immunity either, with no places near achieving the level of exposure to which the virus would stop spreading.  So what do we do?  

It may sound simple, but I cannot emphasize enough, everyone must Follow the 3 Ws:  Wear a Mask; Wash your Hands; Watch your Distance.  Then, Box in the Virus through:  Strategic testing; Rapid contact tracing; Effective isolation; and Support quarantine.  This is the comprehensive response needed to get a handle on transmission and the rate of spread.  There is some hopeful news for better diagnostic testing by year-end and potential vaccines in multiple stages.  What is even more hopeful?  We are learning more about the virus and how to successfully treat it.

Economically speaking, new state unemployment claims rose last week to over 1.4M amid new fears of a downturn.  Plus, the additional unemployment benefits are set to expire this week. 

The United Nations referenced the disruption to education as unparalleled.  Clearly, it’s a historic and defining moment, bringing radical change to our entire system.  Education’s face-to-face reopening plans have gotten even more complicated with COVID’s rapid spread and the many steps necessary to mitigate and minimize hot spots and clusters on our campuses.  There remains much preparation from facilities to ensure we follow the science and make decisions with enough time for effective implementation. 

This is indeed an untenable position for us.  That said, the results of APPA’s latest survey on Testing, Tracing, HVAC & PPE: Needs, Challenges & Lessons paints the picture.  Make sure you visit APPA’s COVID-19 Resource Center for a summation of your colleagues’ responses and the details so many institutions provided for your review and use in managing your own response to COVID-19 and reopening strategies. 

Hence, we engaged one featured panelist for APPA’s 17th Town Hall to share his knowledge, expertise, and professional advice on the health and safety aspects of the coronavirus that can be applied to your organization’s cleaning and disinfection protocols, and add to your HVAC systems strategies.  You will quickly see there is NO simple solution, but rather some thoughtful advice and guidance.  As COVID has reshaped our very way of life, the road to reopening will take leadership and collaboration, an aligned culture and a measured approach to managing the health and science realities of the coronavirus. 

Panelist:

• Michael Huey, MD, Associate Professor of Family and Preventive Medicine at the Emory University School of Medicine, member of the COVID Task Force of the American College Health Association

Dr. Huey brought his long-time epidemiological experience and expertise to bear providing his medical assessment of the serology of the virus now versus what we knew this past March, his documented advice on testing and contact tracing, and the latest research and information available on aerosolized particles.

Some highlights from this Town Hall gleaned from Dr. Huey’s wealth of knowledge follow:

• Knowing some key concepts about the coronavirus’ virology and epidemiology informs your decision making.  There are in fact seven strains:  four cause colds, and three cause severe illness that is indicative of COVID-19 – a novel virus.  No one is immune.  We develop immunity through infection or vaccine.  The fuzzy red things sticking out are the antigens, the proteins that interact with human cells, that attach like a key into a lock, targeting cells and organs such as the lungs, heart, GI track, and central nervous system.  There is a capsule/lipid envelope that surrounds the genetic molecule of the virus, like a rug, which is highly susceptible to soap and water.  That is why we constantly stress good hand hygiene.
• The most critical symptoms are fever, shortness of breath, loss of taste and smell, and general diarrhea and nausea.  In fact, people get GI symptoms prior to developing severe and lower respiratory tract issues which is clearly an early warning sign.  The contagious period of this virus extends prior to the onset of symptoms.  That pre-symptomatic infectious period is 24 to 48 hours and will spread the virus.  Of those infected, 98% will develop symptoms within 12 days.
• An article titled “Coronavirus, The Hammer and The Dance” provides a helpful description of what transpires with the virus, its spread, and how we should manage it.  Upon outbreak and a rising curve, the “hammer” represents the 3-7 week shutdown of society.  Once the curve goes back to almost zero, you start the “dance” until you have a vaccine or herd immunity from infection (leaving 70% of people immune).  The dance is about watching the case numbers for 2-4 weeks as you slowly open up, stepping forward (one or two steps).  However, if the numbers start rising again, you take a step back (one or two steps).  Sounds like a dance – right?  The U.S. initially fared well with the hammer.  Unfortunately, not so well with the dance.  We took too many steps forward and not enough steps back.  We did not respond quickly enough to changes in incidence of the disease.  Now this is where we are.
• Since everyone is at-risk, with some populations more so than others (older and/or chronic medical conditions), if you feel ill, take five minutes to assess your symptoms using the CDC self-assessment tool.  ACHA’s Guidelines for Reopening is also a wonderful tool and has already been posted to the APPA website. 
• The road to recovery is going to be long, 12-18 months or more, requiring a gradual resumption of activities based on your institution’s situation and the local public health conditions of your community.  Your institution must demonstrate the capacity to do widespread testing, contact tracing, isolation, and quarantine of ill and exposed individuals.  Do not forget to identify those people in your community who are connected to your campus.  Prepare your response to the likelihood of a local rebound and ways to protect your most vulnerable populations. 
• This “new normal” requires a meticulous adherence to public health practices, including hand hygiene, physical distancing, proper cough and sneeze etiquette, face coverings in public, symptom assessment, temperature checks, and frequent disinfection of common and high-traffic areas.
• Institutions planning to reopen need to have the capability to offer diagnostic testing to those who need it, and prioritize testing for people with symptoms.  You can’t say we can’t test!  This must be coupled with high-intensity contact tracing, isolating those with COVID, and quarantining close contacts.  Get newly diagnosed people interviewed within 24 to 48 hours and trace their contacts within 24 to 48 hours.  Know your capacity for testing in your area.
• The key to testing is timing, sensitivity, and specificity.  There are two types of tests (diagnostic and immunity).  With respect to diagnostic testing, there are two kinds.  The RT PCR test (molecular nuclei acid test) is best, but results take 10-12 days.  The antigen tests are more rapid tests with an ideal turnaround time of 24 to 48 hours, so understanding your lab’s volume and capacity is important.  Ensure you actually have access to rapid turnaround because you can’t manage a case unless you know it’s positive or not.  Sensitivity is the likelihood that a negative test is a true negative.  Specificity is the likelihood that a positive test is a true positive.  These good lab tests are close to 100% specific and most of them are approaching 98% sensitivity.  Yet, there are other rapid tests that can be done and turned around in 20-30 minutes.  Although they are 100% specific, unfortunately these rapid tests run about 80% sensitive.  Since we use them to determine whether someone is really negative and can release them, there is a 20% chance that it’s a false negative.  That’s a big gap – one in five people.  For the second type, immunity testing, there are the antibody tests that tell us whether we are immune.  We don’t know enough about immunity at this time and, therefore, cannot use it to make critical decisions for grouping students, returning employees to the workplace, or screening. 
• The CDC does not recommend routine mass screening for anyone.  Rather, immediately test people who are ill, identify contacts of positives, isolate the positives, and quarantine close contacts.
• Definitions:  “Quarantine” is for people who are exposed but are well; “isolation” is for people who are infected; and, “self-observation/self-monitoring” is for people who have high-risk conditions or are exposed, but maybe not exposed to the degree that they meet the criterion for quarantine.  Criterion for quarantine is exposure of less than 6 feet or 15 minutes or more during the actively infective phase of an index case’s illness. 
• Your local/state health department makes the decisions about how you’re going to manage isolation and quarantine for who and when.  Criteria for getting out of isolation is now 24 hours with no fever without the use of medicine that reduces your fever, your other symptoms have improved, and at least 10 days have passed since your symptoms first appeared.  You can test out but that depends on testing availability, turnaround of test times, and the local conditions on the ground.
• Contact tracers must be expertly trained as they conduct in-depth interviews; determine when a case was infectious; figure out all the people, activities, and locations during that infectious time for the index case person; contact the exposed people; and assign a 14-day quarantine.  Some institutions are actually requesting individuals identify their 10 or 12 most common contacts in daily campus life now, before they get infected. 
• When deciding on quarantine, a PCR test is ideal because it’s maximally sensitive and maximally specific which helps you determine who is already infected but not symptomatic.
• Manage isolation and quarantine through containment and surveillance by providing support for their basic needs (food, clothing, bedding, etc.), psychological needs, and basic monitoring.
• Signage should NOT say, “COVID-19 Quarantine Area,” which violates HIPPA and FERPA regulations, outs individuals, and scares others.  Just note, “Authorized Personnel Only.” 
• If not reducing density to single dorm rooms, you might pair negatives and retest for symptoms.  However, if one gets quarantined due to an exposure, all “roommates” must be quarantined.
• Waste water sewage testing in your residence halls can be efficacious.
• “Pool” testing is a good option.  Utilize approved FDA tests.  If it’s positive, then you must test each person; however, most will probably be negative.
• Aerosolized particles (proteins) are a game changer!  Yes, lab researchers retained the proteins’ infectivity and its integrity for up to 16 hours in respiratory-sized aerosols.  Therefore, facilities professionals should have a multi-pronged approach to their indoor spaces and HVAC systems:  reduce space densities; increase ventilation; dilute indoor air with fresh outdoor air; install MERV 13+ filters addressing system compatibility; require face masks; apply 6-feet physical distancing; maximize non-HVAC measures such as effective surface and space disinfectant cleaning; and, if necessary, take rooms off-line to break the chain of transmission.
• Post signs about symptoms and hygiene on buildings, through social media outlets, and everywhere people look. 
• Create an emergency plan for possible outbreaks on your campus and your surrounding community.
• Remember your marginalized populations and address their health disparities as best you can.
• Review high-risk employees and positions.  Handle each on a case-by-case basis, protect their privacy, engage general counsel as needed, and assess job assignments for potential exposure to COVID-19.
• If an employee discloses their situation to you, which they are not required to do, you must protect their privacy unless they give you permission or there is an overwhelming directive from the public health department, i.e., they get sick.
• Mental health well-being is critically important during a pandemic.  The stressors are especially magnified in your people on the front line.  Ensure support services are available and well-communicated. 

We are losing the battle!  I’ve shared statistics on infections, hospitalizations, deaths, and hot spots.  Hats off to the medical workers, researchers, front-line workers, and neighborhood heroes.  They are all doing their part.  What about the rest of us?  Yes, the science is evolving.  We are just seven months into this nightmare.  BUT, we have been given the low-tech tools that current science shows can save lives and give struggling businesses a fighting chance.  Denial has left us in a state of calamity, yet a solution is sitting right there staring us down.  No one will save us from ourselves.  Let’s muster the courage, sheer resolve to meet the moment.  Remember, we are in this together and together will be the only way we find our way out of this.* 

• July 24 APPA Town Hall Recording
• Latest Survey Results on Testing, Tracing, HVAC & PPE: Needs, Challenges & Lessons
• Register for Future Town Halls
• Register NOW for APPA’s ”Virtual Facilities Summit” – August 3-5, 2020
• Sign up for APPA’s Professional Development Summer Series

*Paraphrased remarks from Lester Holt (NBC Nightly News)

E. Lander Medlin
APPA Executive Vice President