With new cases of COVID-19 still rising and protesters clamoring for Gov. Steve Sisolak to loosen the virus’ stranglehold on the state’s economy, the governor’s medical experts say Nevada lacks the “bare essentials” that would warrant even a discussion of reopening.
“I get it. I want my life back to normal,” says Dr. Shabada Asad, a member of the governor’s Medical Advisory Team and director of Infectious Disease at UMC, who cautions that relaxing social distancing rules would give Nevadans “a false sense of freedom” that could be lethal.
“I feel their anger and frustration and in many cases it’s desperation, and I get that, but I’m very scared about what will happen if the city opens and there’s this resurgence,” she said.
The economic and physical well-being of more than 3 million Nevadans relies in part on the advice of the five-member team of doctors and scientists making recommendations to Sisolak on how to reopen the state’s economy at the earliest possible time without reigniting the outbreak.
“He works with us very closely and he takes our recommendations very seriously,” says team member Dr. Trudy Larson, the Dean of the School of Community and Health Sciences at UNR. “We’ve been really impressed and it makes us work harder.”
The governor’s office and the Division of Health did not respond to requests for an interview with the team’s chair, Dr. Ihsan Azzam, Chief Medical Officer of the state. A spokesperson for team member Dr. Paul Sierzenski, Chief Medical Officer of the Acute Care Division of Renown Health System, said he did not have time for an interview.
The governor says he’s looking at a phased reopening by industry rather than location.
“It will be really looking at more essential services or almost-essential services,” Larson says. “As he puts his plans together he consults with us. What we look at is what industries will have the fewest people congregating or needing to be in close contact. So this will be gradual. Very gradual.”
Larson is predicting some reopenings in late May, but admits it may be “wishful thinking.”
It remains unknown when casinos will reopen. Personal grooming services such as haircuts, manicures, and pedicures are not even almost-essential, says Larson, and will have to wait.
And at this point, a big-screen TV may be your best bet for watching the Las Vegas Raiders’ inaugural home game, if pro football has a season.
“Realistically speaking, I don’t think that’s going to be possible,” Asad says of fans packing Allegiant Stadium for an August kick-off. “A lot changes in four months but right now, August seems too close. I hate to be a pessimist, but it doesn’t seem too realistic right now.”
The governor is following “basically the same guidance” issued by the White House last week and endorsed by the Infectious Diseases Society of America, according to Asad. The three-phased process relies on states achieving gateway measures or thresholds before advancing.
“The gateway recommendations are well-thought-out and well-written,” says Asad. “But my question is how to get to those. They are like the bare essentials.”
The “essentials” include a sustained reduction in new cases and a reduction in hospitalizations for COVID-19 over a two week period.
“This is not as simple as the number of cases diagnosed a day in the state,” says Asad. “As your testing capability increases so will positive results. The number to watch is the positive results as a percentage of the total number of tests done every day.”
Currently, only about one percent of Nevada’s population has been tested and about 12 percent of the results are positive. However, testing is available only for those in certain high-risk groups.
Given the current capacity for targeted and limited testing, officials have been reluctant to identify a reliable sample size.
“I’d like to see more widespread testing to be more confident in my results,” Asad said, adding without it, “we are not ready yet” to reopen.
“If we loosen restrictions then what we have to go to is a containment strategy. Right now we’re in a mitigation strategy where everybody is subject to the same rules,” says Larson. “A containment strategy says we can test, we can diagnose, we can isolate, we can contact trace, we can put them in quarantine and wait for them to get sick or not.”
“If we still have over 60 percent susceptible population and we loosen restrictions, bang there it goes,” she says of a spike in new infections.
Widespread diagnostic and antibody testing remain elusive and hampered by the lack of a national strategy.
“It’s been very difficult,” Larson says of a fragmented system that has failed to provide states with the components needed for testing. “In the best-case scenario, we would have very strong, central federal leadership that would provide a strong framework for states to work together, recognizing our boundaries are fluid.”
“Whether that would come from the CDC (Centers for Disease Control), the Surgeon General, somebody who knows how to do this, that would be the best-case scenario,” says Larson.
“We’re trying our best,” Asad says of Nevada’s innovative efforts by Dr. Mark Pandori of the Nevada State Public Health Lab and others to piece together testing kits. “What do you do when you’re told you’re on your own? You make do with what you have and that’s what we’re trying to do.”
The phased plan for reopening calls for rigorous contact tracing, a labor- intensive process usually performed by public health officials that involves identifying and testing the close contacts of a person who tests positive.
“The Southern Nevada Health District does not have the manpower,” says Asad, citing estimates that 100,000 people may be required to conduct tracing in the U.S. “It’s the same for public health districts throughout the country.”
She says the prospect of contact tracing today is “impossible” and that new cases must be reduced to a manageable level.
“If we got to the point where we are seeing fewer and fewer new cases identified, public health officials can catch up and do the contact tracing more effectively,” she says.
New cases in Nevada are rising at the rate of about 100 each day, but have begun to plateau.
“So, we’re being very successful and the only reason we are is because of our current directives. They are working,” says Larson. “But you have to realize there’s still that same level of new cases every day and it will take a while before those cases either turn severe or they don’t.”
Larson says a sustained decline in hospital admissions, which lag new infections by about two weeks, would be “a time that we can start looking for some loosening of restrictions,” along with social distancing “for a really long time.”
“We have done our best to slam on the breaks and slow the outbreak,” says Dr. Brian Labus, an associate professor at UNLV and member of the Medical Advisory Team. “As soon as it starts to slow down, people think the outbreak is over and that we can take our foot off the brake pedal. Slowing down a little is hardly the same thing as stopping, and some version of these social distancing measures will likely be needed for longer than just a couple more weeks.”
Labus, a former epidemiologist for the Southern Nevada Health District, initially downplayed the threat of COVID-19 in social media posts, calling fear of the outbreak “unfounded.”
“There will be some small clusters around the world as people with the disease come back from travel abroad,” Labus wrote on Facebook in late January. “They will infect a family member or two, and maybe a doctor or nurse, but we won’t see anything in the community. The death rate will be pretty low overall. There will be some unnecessary travel restrictions that do nothing to stop disease spread.”
A month later he wrote, “as I said last time, you are not going to get coronavirus.”
He advised against wearing masks other than N95 respirators.
Labus says the revelation of the asymptomatic spread of the virus changed his perspective on the disease.
“The early reports from China were that asymptomatic disease was rare and did not drive transmission. We based our prevention strategy on this, and it turned out to be incorrect,” he said. “This is the unfortunate reality of working with an emerging virus. It takes us a while to understand what we are dealing with but we have to make our decisions based on the best information we have at the time. Without asymptomatic disease, this outbreak would have played out very differently and would have been easier to control.”
The United Kingdom reported on February 24 that scientists had confirmed asymptomatic spread of the virus.
The timing of President Trump’s impeachment trial and the flurry of Democratic presidential caucuses and primaries likely delayed media attention and public response to the emerging epidemic, says Larson.
“We knew it was going to come and we knew it was going to spread through the air. But we didn’t know how fast, how big, how lethal,” she says. “Those are the questions that are not always answerable. But early on I knew we were looking at some real problems.”
“It wasn’t until Washington reported those cases,” that attention was paid, she says.
“Part of it was the government was slow to roll out a test. Part of this is very explainable. Public health funding has been cut for decades now, so when you do that you cut infrastructure that allows for rapid response,” she says.
“When the system of public health is working really well, nothing happens,” Larson says. “That makes it very difficult to advocate. ‘Why do we have all these people doing this? Nothing is happening.’ The reason nothing is happening is because you have all these people.”
“The states have been planning for pandemic influenza for many years, but because it didn’t happen, there’s that preparedness fatigue that happens, so things got dismantled,” she said.
“I thought our state, once alerted, responded well. And responded quickly with strict directives. And I think we are benefiting from those decisions because we don’t have the death rates and the number of cases other states who delayed have seen.”
“All the models had predicted a dismal picture for the state of Nevada,” said Asad.
“It’s quite clear we’ve peaked in Nevada. Anyone who needed a bed got one. Anyone who needed a ventilator has been able to get one. We did not have to resort to the measures in Italy, or Washington or New York.”
But she says hospitals must return to their pre-pandemic state in order to ensure surge capability in the event of a rebound in infections.
“We are operating under a crisis standard of care,” she says, noting previously she would have used a mask, shield, and gown once rather than reusing personal protective equipment as workers do now. “We revised our standards to make do with what we have.”
“That’s not business as usual. That’s a crisis standard of care that would not be acceptable under normal circumstances,” she says.
“We have canceled all our elective procedures. That is a crisis standard of care. People have to go back to normal and the capacity of our hospital has to go back to where we’d have the manpower, the medication, and the equipment that we could deal with a surge in patients,” she said. “It’s only when these requirements are met that we can begin to talk about when to open the city.”
“There are no sides in this battle,” says Asad. “We are all on one side. There are people who are working to make this happen in the fastest but safest way possible.”