The Interview: Oakland health officials on pandemic
By Lisa Brody
In a wide ranging interview, Downtown news editor Lisa Brody spoke to the two leading health experts in Oakland County, health officer Leigh-Anne Stafford and medical director Dr. Russell Faust, to help readers figure their way through the current COVID-19 pandemic, understand testing numbers and policy determinations, why the virus is more dangerous indoors than out, how long to quarantine for now, and how soon vaccine help will be on the way for Oakland County residents.
Let’s first talk about the goals set by the medical community in terms of positivity rate from COVID-19 testing, which seems to be the basis for public policy in terms of lockdowns or determining when certain categories of business can reopen. Without a national standard or goal, there seems to be a variance among the states. Michigan, from what we can learn, has a five percent positivity test rating as a goal, while some medical authorities suggest it should be three percent. In the state of New York, for example, the governor there has a goal of nine percent while the mayor of New York City has set a goal of three percent as a measure that the infection rate is under control. What is the test positivity rate goal in Oakland County and how was that goal determined early on in the pandemic?
FAUST: The positivity rate is based on the World Health Organization (WHO) which says five percent. So based on global data, it speaks to or it relates to the transmission rate. It relates to infectivity. Without getting into the epidemiology of this, positivity relates to the amount of transmission you can expect in the community. Obviously, lower is better. But the World Health Organization and CDC have determined that five percent in a community is a great goal to get control over our transmission through the community. Obviously, we’d like it to be zero. But in Oakland County, when we had good control in the two and three percent positivity rate kind of level. Right now, we’re just barely above 13 percent. But I think across the state, I think Dr. Khaldun (State of Michigan Chief Medical Director) mentioned that we’re about 15 percent across the state of Michigan right now. And shockingly there are states that are in the 70, 80 and 90 percent positivity rates. We’re talking about the Dakotas.
But we really should talk about how accurate that notion of a positive rate is. That is over the number of positive results and negative results. And the problem is that we really don’t get the negative results reported. Now the CARES Act mandated that all diagnostic test results be reported to the health department. And they’re just not. That’s a legal mandate, but we don’t get those results. And in fact, if we did, the actual positivity number would be lower. That would be a wonderful thing. We use the numbers that we are able to collect, and we calculate the rate.
Presumably, the proportion of negatives that we don’t get has been relatively steady. There’s so many urgent cares and pharmacies, physician’s offices, that don’t have the history to report test results because the things they test for aren’t reportable diseases. They’re just not used to it – they don’t have the mechanism.
It’s the doctor’s offices?
FAUST: It’s the urgent cares really.
So if you go out to get a test today, chances are you’d go to urgent care or maybe even the pharmacy. You’d get a rapid antigen test. And that’s a diagnostic test – not particularly sensitive of a diagnostic test. But that diagnostic test is rapid. You get the result in less than 30 minutes, and go on your way. But if that result is negative – chances are very high it would never get reported to us. Very often, the only way we get even a positive result is not being reported by your computer, but by a patient, or by their employer, or by their school, if it’s a student, or their college if it’s a college student
There seems to be some legitimate debate as to whether testing rates are truly reliable. What do the daily numbers really mean? Do people who have a rapid test as well as a standard COVID test count as one test or two tests? What if they’re both positive – does that count as two positives? If multiple tests by the same individual are mixed in with test results, how does the medical community accurately determine where the community is at on the infection rate?
FAUST: No, then it’s considered a confirmatory. But it depends on whether or not they have symptoms. If they don’t have symptoms, and they’re just curious, or they had an exposure, and they’re not symptomatic. And they go and get one of these rapid antigen tests, and that’s negative, and they follow up with the gold standard molecular PCR test – polymerase chain reaction test – and that’s positive, then that’s one positive result, and that one is negative. One negative result.
If multiple tests by the same individual are mixed in with the test results. How does the medical community accurately determine what and where the community is at on the infection?
FAUST: Our epidemiologists do a pretty good job and screening for repeat testers. There’s a small number of people out there, who are let’s just call them the ‘worried well’, continue to go back for more tests, and we basically screen them out of the database.
STAFFORD: We have a wonderful dashboard with maps. We look over maybe a 30-day period, because, although people tend to get tested, they might get tested every two weeks. That way we can really look at a set number of days over the last 30 days to see what the most recent cases are. So, yes, it may have duplicates in there, where they might have one negative and then come back and be positive. Our epidemiologists, they go in and make sure there’s no duplicates.
FAUST: Some of the day-to-day accuracy is not 100 percent, which is why we set it on the dashboard as the running seven-day average. What happens is that we’re not the only people doing the testing. If we relied strictly on the testing of our drive-thru test sites, we would have accurate day-to-day data.
What happens is there’s a number of labs testing within Oakland County. A huge number, like 15 or 20 different labs test throughout Oakland County. Many of them don’t report on a daily basis. They will, quote, “batch” the results, and then dump them on a certain day. So we’ve had days where we’re just cooking along on a daily average of 50 cases a day. And suddenly, we’ll have 400 the following day. That’s because one particular lab, or maybe a couple labs, have just dumped into the database, all of their cases for Oakland County.
In terms of testing data, one area of concern is that test results are taking too long to be returned, which therefore skews the average daily test numbers upon which public policy is set. Further, if there is going to be a valid contact tracing efforts, wouldn’t that effort be hampered by delayed return on test results? For example, my boss and his family, they just found out yesterday, nine days after they had been exposed and went for tests. Thankfully, they were negative – but nine days. If there is going to be a valid contact tracing efforts, wouldn’t that effort be hampered by this delayed return on test results?
STAFFORD: The state actually added this to their data set, because they found this to be a problem. There are many labs that are able to return results in 36 to 48 hours. For instance, the lab we’re currently using here, we’re 48-hour turnaround, generally. We may have one or two, they get extended out maybe an extra day. There are many labs out there that are still running a quick turnaround, but then there are other labs that get overwhelmed quickly. And instead of saying, okay, we have too many samples, they just keep running them and trying to catch up. And I know, early on, we ran into this quite a bit. It got better. But now as this spike in the increase has occurred – I think the labs are just sometimes overwhelmed. And sometimes the urgent cares are able to take more patients and are pushing onto the labs when they get overwhelmed. It definitely hampers contact tracing. And I know, that’s why it’s important that as we talk through our media, and our top points is that if you’re ill, or you had traveled, or you’ve done maybe a high risk behavior, like traveled on an airplane, or visited to a restaurant that was extremely crowded, and maybe the precaution is that until I get that test result, I’m going to stay home. If I’m ill or I’m sick, I’m going to stay home, because COVID is very real. It’s in the community. And so people taking that little bit of responsibility to say, Yes, I want to get tested.
And it’s important that we get test results back quickly. That’s definitely part but also that knowing that COVID is in the community. And if I’m participating in those activities that I also need to maybe stay at home for a few extra days to see if result or symptoms are going to just show up. That’s why the state added that to their data.
What other factors do health officials rely on when setting public policy during a panedemic, such as available ICU capacity?
FAUST: Absolutely. Hospital capacity, ICU capacity. Even though we recognize that percent positivity in the community is inaccurate, we also understand that the trend reflects what’s happening in the community with regard to transmission. So we consider that. We have our own numbers that are direct through our own laboratory at Oakland County Health, from our drive up and in testing that we perform, so we have a fairly good sense of what’s going on in the community, because we get all the results we give ourselves. So we get a true percent positivity.
I think our true percent positivity at the drive thru, I think it’s somewhere between eight and nine percent right now. Certainly lower, because we have all the negatives as well as the positive, so we have an accurate rate.
We have a very accurate sense because we have such great partnerships with hospital systems within the county. We have a very good ongoing sense of what they’re seeing in the emergency rooms. How many are ending up in the ICU; how many end up on ventilators.
Do you think there is an amount of undercounted individuals who’ve been afflicted with COVID, who were never tested or never went to see their doctors?
FAUST: Always a possibility. I wouldn’t be surprised to learn that there’s some number of people that are infected and not tested.
STAFFORD: Another piece to that, too, is that early on in the pandemic, the testing was so restrictive. I believe early on there were a lot of people who were not tested and diagnosed with COVID-19.
FAUST: And frankly, we still don’t have ready access to testing. We don’t have all the tests we would like to have. You name the test machine and I can tell you which supplies are in limited supply.
Do you feel like you have a realistic estimate of the number of COVID cases in Oakland County or Michigan?
FAUST: No, I don’t think they are substantially different from the numbers that are reported. Again, that would not be surprised if there were people that are infected but are not being tested.
My hope is that they’re not out in the community – that they’re staying home if they feel like they have the flu or a cold.
There has been a lot of dissension and disagreement over the best way to deter spread of the disease. From a strictly health and medical point of view, what do you and other experts recommend? Why is that? Why are masks so important? Should people still stay six feet – or farther – apart?
FAUST: Let me let me just jump in and say, I disagree with your premise. I don’t think there is any controversy or dissension in regard to the transmission of this disease. Every single health expert out there is very clear and how we can do this. It isn’t rocket science. You can do it with masks, distancing, washing your hands, not collecting in large groups of people. I don’t think there’s any dissension or controversy in that. Those recommendations have been pretty clear from the very beginning. Unfortunately, I think some of those have been politicized. And that’s unfortunate, but I think the medical experts are very clear on how to prevent transmission.
Are there certain kinds of masks that are better for non-medical folk?
FAUST: You don’t need a N-95. To clarify, the masks are to protect those around. Even the simplest mask helps filter out some respiratory droplets, potentially, if you’re exposed, but they’re mostly there to protect those around you. You have COVID-19 infection; you’re not aware of it. But if you’re wearing a mask, it captures, it prevents spread of those respiratory droplets while you’re speaking, or coughing, or singing or whatever, it catches those respiratory droplets out to that natural limit of about six feet, sometimes more if you’re yelling, less if you’re just mumbling, but overall, upper respiratory droplets from humans drop off at about six feet. But the mask is to capture those droplets. It’s mostly for those that are exposed to them while they speak.
The CDC recommends if you’re going to wear one of those cloth masks that’s it’s triple layer mask. If it’s one of those neck gators that people pull up over their face as a mask that it’s is triple layered cotton. The paper or polyester surgical masks are great masks to wear. And they will protect those around you.
Why do some people test positive and remain fairly asymptomatic and yet others take a terrible turn and get very, very sick?
FAUST: We’ve had this discussion in the medical community now for months – for the whole length of the pandemic. There are multiple theories. The facts that we do know is that early on the people who are really severely affected and were reasonably young – 40s, 50s, and otherwise healthy, intact immune systems, they seem to be the ones that ended up on the ventilators, and really struggled and even potentially died. And you’ve heard about this so called cytokine storm that they described and that became the cause of their demise for these otherwise healthy people. In the hospitals now, the medical community is getting really experienced, and getting really good, in managing that, and you don’t really hear about in the last few months, because when somebody with an intact immune system enters the hospital, they suppress that cytokine storm, they reduce that risk and that potential with some fairly simple and common inexpensive medications, and keep people much healthier and off the ventilators.
In addition, the antivirals early on were unavailable, and have become increasingly available. Now, as soon as you’re hospitalized, and it appears that you know you’re positive for COVID-19, they start that immediately. So those are a couple explanations.
Other theories in the medical community really have to do with two things. Firstly, the viral load early on – we just didn’t have any PPE. There were no masks to be had. And I think the EMS and fire rescue folks that were being exposed, to the physicians that were being exposed, the family members who were being exposed to somebody who was positive, had a very large viral load when they did become infected, and it was much more challenging for their bodies to fight that off. And now, I’m heartened to see, the majority of our community in masks when they’re out and about. So now when people do become infected by a coworker at the lunch table or something, most of them have a very low viral load when they show up positive. That’s fantastic.
And the other thing is, we haven’t reached, quote, ‘herd immunity,’ but there’s some number of people that’s clearly been infected, and clearly recovered. And that helps keep the viral load down as it’s passing around out there.
Once someone has had COVID, are they immune for life?
FAUST: That’s clearly not the case. There are published cases of reinfections now. It’s obviously way too early to know about the for life issue. The CDC, its early data suggests that natural immunity, once you’ve been infected, wanes over some period of months. We won’t know for some time. They’re doing antibody follow ups on some people who have been infected, and now we’ll be doing antibody follow ups on people who have been vaccinated. We won’t know for some time now. Years.
There are now pending legislative proposals in Lansing that would allow the 83 counties in Michigan to determine how to manage the pandemic, rather than using the zone or regional approach the state has taken in the early days of this pandemic. Do you favor one approach over the other? Please explain your preference.
STAFFORD: I think it’s important that we look at things in a statewide basis. I think it’s important that we look at local epidemiology. But I also think that we have to take a common practice across all counties, because if one county is doing something very different than another county – as a health officer if I decided to say, we’re not going to do sports anymore in Oakland County. However, another county around us in southeast Michigan decides but you can do sports in my county, you know what, the parents are going to pick up and head to another county. So I think there has to be an agreement across the state or it doesn’t work. Because what’s going to happen is the pandemic is going to continue, and that virus is going to continue to spread, because they’re just bringing it back. That’s for anything. I’m not pointing out parents – I’m a parent myself. I think there has to be some consistency. If in a certain county we have statewide regulations and recommendations and shut downs, and then in our own county, we have some very specifics that we need to maybe really hone in on – for instance, if we have a real problem in a certain school, or we have a certain problem at a certain business or a gym, then that would provide the local the ability to say, ‘Okay, now we’re going to shut down this to try to stop the virus from spreading.’ I think it’s very important, though, that we continue to have it statewide, and then also have the local authority to modify or change or be more restrictive, if needed in our own counties.
FAUST: Let me just jump in and say, I think it’s always helpful to have guidance at a national or federal level, from, for example, CDC, or even the president. It could have been radically different if there had have been good, cohesive leadership on the federal level.
The CDC is now saying seven to 10 days for quarantine if you have been in contact with someone who is positive for the virus as opposed to 14 days which has been the standard. How long should someone quarantine if they’ve been exposed to COVID? How long should they isolate if they have tested positive? Once positive, how long are actually they contagious? Why do recommendations change?
STAFFORD: With the virus being new, regulations and recommendations were put in place. Fourteen days – you sometimes become symptomatic between day two and day 14. Things are going to change as we get better data. But the 10-day quarantine – the recommendation, the standard is still 14 days. They’re still suggesting that because they’ve seen cases for symptoms start on day two, and go on all the way to day 14. So it’s really important that we emphasize that the standard is 14. But the majority of the individuals that will generally get sick after exposure – it’s somewhere between an average of seven and nine days. What they find is they’re pretty sure the majority of the cases at day 10 have started to show some type of symptoms. However, that doesn’t mean you stop watching for symptoms. And so those additional four days, days 11,12, 13 and 14, you still need to be very vigilant while watching for symptoms.
FAUST: That’s an important thing to tell people.
The CDC did put seven days out as an official option. That seven-day piece requires testing. If we think about the person that wants to reduce their quarantine period to seven days, in Oakland County, or even Michigan, the most readily available test right now is them going out to an urgent care or their doctor’s office or a pharmacy and getting a rapid antigen test. And they’re trying to reduce their quarantine – they don’t have symptoms yet. If they have symptoms, well, that’d be a different story – they’re not reducing their quarantine.Those rapid antigen tests are not very sensitive. In fact, they’re not designed to test anybody without symptoms. I mean to emphasize that. These things were not designed to test someone without symptoms, none of these rapid antigen tests.
DHHS after really careful consideration and consultation with the medical directors across the state and the health officers across the state, and their own outstanding epidemiology team at state, elected to wait on the seven-day option, continue assessing and make the 10-day option available for people, and I think that’s reasonable.
It’s close to 90 percent will be captured by day 10 once they’re exposed. It’s something like 98, or 99 percent, out of the 14 days, inside the incubation period. As long as those people continue to practice safe precautions.
Explain why the air indoors is more dangerous with the virus than outdoors, and how that affects things like restaurants, movie theaters, exercising, shopping, socializing, and all the other activities we enjoy.
STAFFORD: This is a respiratory virus. So when we’re indoors, we tend to be closer together. Once we go indoors, we’re in closer, usually tighter knit places. And so the virus can easily travel when somebody is closer together. That’s why we talk about the six feet, social distancing. What people tend to do when they’re outside a little bit more is they have more space to spread out. It’s more about the virus traveling between people and when you’re outside it has more ability to not travel as quickly or, you’re not standing as close to someone else.
FAUST: It’s about the respiratory droplet risk and transmission and when you’re outside, if you don’t feel a breeze – there’s a breeze wafting those droplets away and you’re much, much less likely to become infected within the six foot distance when you’re outdoors, and that’s the problem when we bring everything indoors with cold weather. I will tell you the other problem is the influenza risk. So everybody needs to get their flu shot this year. It’s not good to become infected with influenza and COVID. I don’t care what your age bracket is, it doubles your mortality risk.
There have been conflicting reports as to whether younger children can get COVID-19, whether they are carriers, and whether it is in their best interest to be educated in-person at the elementary level, rather than virtually, as some are falling behind academically, socially and emotionally. Some recent studies have shown that the feared major spreader event as a result of schools opening has not proven to have taken place. From a health department point of view, what do you recommend?
STAFFORD: What the data has shown us as kids are in the classroom, sitting beside one another, wearing masks the following social distancing, at least six feet, or trying to maximize the space, parents keeping their kids home when they’re sick, hand washing hygiene, the inside of the classroom – we are not seeing the transmission. It’s when the other social aspects of school – lunch time when people are maybe not wearing their masks and eating and talking to one another. And when they’re outside playing if the masks are not enforced, we see some transmission there. So the data has shown us that early age kids, elementary and middle school, are not transmitting it in that type of situation.
However, there are a lot of school districts that have decided to go virtual, and we support the school districts that decide either way. There are many situations in which a school district has to look at the situation. We have been meeting with superintendents since June. We meet with them weekly now since August, and we have worked through all of these situations that they’re going through. It’s not just about whether or not a child in the classroom is transmitting it. There are so many activities outside of schools that cause teachers, kids, other staff to be exposed and therefore have to be quarantined outside of school. So there’s an operational situation and problem that these superintendents in the school districts have to deal with. We support school districts knowing about their community, and what their school district can do.
The one thing I would like to say is that, although we haven’t seen the data, and so we haven’t said everybody should shut down, if you have more space to spread their kids out. And if they have a problem in their school, at least the ongoing transmission in the school, that is when we will step in and say, ‘we need to pause in person learning, because there’s transmission.’
At the beginning of the pandemic, last March and April, we were all wiping down our groceries and packages. Now we’re being told we don’t need to do that, that COVID is an airborne virus. Explain what that means. Should we still wipe everything down? When I go into Kroger should I still wipe down my cart? What about my packages and groceries before I put them away?
FAUST: We know that COVID-19 is transmitted by respiratory virus, that is we inhale it into our nose or mouth droplets that are in the air to become infected. Now, that doesn’t mean that we should be cavalier about touching the surfaces that somebody has sneezed or coughed on and then touching our nose or mouth or face. We still need to be vigilant about those issues. But early on, we just didn’t have the science, we didn’t know that it’s not transmitted by inanimate objects that have been touched. This is not measles – this is strictly respiratory droplet transmission. We used to have groceries delivered and let them sit on the porch for three days before. Not necessary – but it’s still a good idea to practice good hygiene, with regard to washing your hands, wiping down the cart before you use it. Not touching your nose and mouth, trying not to touch your mask – I know that that’s a tough one. They keep getting the adjusted. If you just touched the doorknob or the car, the elevator buttons and now you’re touching your mask. We still need to be vigilant about routine hygiene because guess what, this is not the only infectious agent out there. There’s still measles, there’s still other things that we need to be cautious about.
Some people who have recovered from an initial bout of COVID, whether they had a severe or minor case, continue to report disturbing symptoms – from heart and lung issues, fatigue problems, blood clots, and numerous other health issues. Some call these post-COVID symptoms “long haulers” disease. Is this real? How long does it last? What can you tell readers about this, and what should individuals do if they find themselves experiencing some or all of these symptoms?