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Baylor College of Medicine

Mystery

Master
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Aug. 13, 2020

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Dear Members of the Baylor College of Medicine Community,
 
This has been a good week. Unequivocally, with no modifiers. Let’s pause for a moment and appreciate good news. Although we have not yet won the war, we have prevailed in all the recent skirmishes. Today, I would like to review the Houston numbers over the past week, highlight a mystery, and think about what needs to come next – short and long term.
 
The COVID-19 utilization data from the TMC hospitals this week shows consistent improvement, which in retrospect has been encouragingly steady for the past 3-4 weeks. Total daily hospitalizations (ICU and non-ICU admissions, based on a 7-day rolling average) peaked at about 350 daily new patients.  With a steady decline, that number is now about 150.  This is excellent progress, but it is important to remember that for most of May and June the number was closer to 50. There is still work to be done.
 
It is time for Houston to shift its focus and messaging.  For most of the spring and summer, the story has been “change your behavior to prevent the hospitals – and especially the ICUs – from being overrun.”  Although there are still a large number of very sick COVID-19 patients in our hospitals, we are not currently at risk of health system failure, which is very good news.  However, if we are to prepare for what is to come – reopening of physical schools, fall and winter holidays, cold and flu season, inevitable public fatigue with behavioral restrictions – we need to stop the cycle we have observed for the past six months.
 
Here is what our regional pattern has been.   We skate up to the line where health systems are at risk of failing (to our collective credit, they never have).  We respond by slowing down the economy and ramping up the urgency of our “masking/distancing” message.  We nervously wait a few weeks to see the impact of the changes made.  Did we do enough?  Hospital numbers improve.  We breathe a sigh of relief, and to a degree start to resume our prior habits and rhythms of life.  It is this last step in the cycle we need to change. When we relax, the community disease metrics deteriorate, the hospitals start filling up again.  We have repeated this cycle twice in six months.  I desperately want to avoid a third cycle.
 
To that end, Dr. Klotman and I, along with others, have advocated with the TMC to change the focus of our daily published metrics.  All of the hospital data is still there, but we have added a number of “dial” slides that highlight some different metrics.  You can access the slide deck every day via this link. I would encourage you to familiarize yourself with it, and share it widely.
 
The point of these changes is to shift our community focus away from “what do we need to do to keep the hospitals from being overrun?” to “what do we need to do – in a concrete and sustained manner – to get COVID-19 reduced to the point that we can safely open schools and resume some normal semblance of our prior lives?”  To that end, we are focused on three metrics.  
 
First, the R(t) or R-value – the estimate of viral infectivity in the community.  If R(t) is greater than one, we are losing, and we will see viral spread.  If R(t) is less than one, we are winning.  Today we are winning, but we have seen this metric cycle widely in the past.  It is a priority to keep the R less than one.
 
Second, new daily community cases (for Harris and surrounding counties).  We are currently running above 1,500 new COVID-19 cases per day, which includes the full spectrum of people, from those who are entirely asymptomatic, to those critically ill in hospitals.  We need to drive this number down below 200 cases per day.  This is a level at which our public health colleagues assure us they can realistically perform effective contact tracing.
 
Third, positivity rate for testing done by TMC institutions, including the Baylor labs.  This is a rough measure of viral prevalence in the community.  Our positivity rate is currently above 10%.  It needs to be at or below 5%.
 
When we hit these three metrics consistently (14 days), we should be able to safely – but cautiously – reopen schools.  Please help to spread this message to your friends, families and circles of influence.  The more people who realize we need to buckle down for the long haul, the better chance we have of living well as we wait for a safe and effective vaccine.
 
Allow me to shift gears for a moment.  I would also like to briefly highlight a mystery in this week’s data, and use it to make a broader point.  The state of Texas tracks the total number of people in the Houston metropolitan area who are tested on a daily basis.  This include people tested by our labs, other TMC labs, commercial labs, etc.  Over the past 6 weeks, that number has average around 12,000 tests per day, and has ranged from 8,000 to 14,000.  Suddenly, about a week ago, we saw a sharp increase in the number of people being tested.  Over the past 4 days, this has ranged from 24,000 to 31,000, a doubling or trebling of the baseline.  The mystery is when I look at the data from individual testing sites – Baylor, TMC facilities, city and county testing sites – the demand for testing, and the number of tests performed has actually decreased.  What is the source of the very sharp increase in testing?
 
I have a theory, and I think it is a good one.  Houston-based colleges and universities are all starting back.   Most, if not all, are requiring testing of students and staff before returning to campus.  Some are mailing out home testing kits.  This probably represents thousands, if not tens of thousands, of tests that will be performed in a compressed time frame.
 
I bring this up not because this mystery is particularly important.  Rather, it is because it has been so difficult to get a definitive answer.  Public health systems are relatively fragmented and data systems variable and poorly integrated.  This is not a criticism of our public health officials, who across the country are doing an admirable job in challenging circumstances.  But it does cause me to reflect on our national preparation for this pandemic, and more importantly, our preparation for the next one.   We should have learned some important lessons about what we need to effectively respond to an epidemic.  There will inevitably be another one day, and we could see a pathogen more contagious and/or deadlier than SARS-CoV-2.  It would be irresponsible not to use the real-time lessons we are all learning to inform our planning for the future.
 
To that end, I would like your opinion.  In exactly five words, what do our nation, states, communities and organizations need to do to be better prepared next time?  If you are on Twitter, please post your response and include the hashtag #TheNextPandemicBCM in your text.  If you are not familiar with hashtags, this gives everyone the opportunity to see everyone’s responses in real time.  Alternatively, email me at svpclinical@bcm.edu, and I will post any unique responses.
 
I’ll start, following up on the mystery theme:
 
Good data drives good decisions. #TheNextPandemicBCM
 
I hope a global lesson learned is we need a better national infrastructure to report data in a consistent format, in a timely manner, that is reliable.  In addition, the data needs to be presented in a manner that is easily digestible and understood by the general population.  Data which is perceived as inconsistent or unreliable, or which cannot be understood by the layperson, drives poor decisions, delays necessary action, invites debate as to what is “true” and erodes the public trust.  On a relatively small scale, the data provided by the TMC, Baylor and other TMC affiliate institutions have helped to fill this need.
 
So, if you were advising one of our presidential candidates, or local leadership, or a company executive on preparation for the next global pandemic, what is your priority?
 
Five words.  #TheNextPandemicBCM
 
Finally, many have asked if they can share these messages.  Please feel free to share widely.  You can use the following link to post to social media: https://bit.ly/3iEdRZz.
 
Let us hope the good trends continue.  Stay well.
 
James McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs