Emergency Preparedness: Where Did We Go Wrong With COVID-19?

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• Our lack of preparation for the current pandemic was demonstrated by our failure to (1) recognize that the outbreak in China would seed the globe quickly and (2) rapidly distribute diagnostic tests.

• Shelter-in-place orders are a blunt instrument that was necessary to flatten the curve and slow down the outbreak.

• The United States will be able to regain its economic and health security only after a vaccine is broadly distributed across the country. Until then, physical distancing and use of masks will need to continue.

• Researchers will begin testing COVID-19 monoclonal antibodies in the summer for possible treatments or a vaccine.

This transcript has been edited for clarity.

John Whyte, MD, MPH: I know many of you are concerned about our current response to the coronavirus pandemic. But more importantly, how prepared are we for a potential resurgence in the fall or a second wave? I chatted with Dr Luciana Borio, who served on the National Security Council's Pandemic Response Team. She'll tell us exactly how prepared we are. I think you'll want to listen. Dr Borio, thanks for joining me.

Luciana Borio, MD: My pleasure, John. It's great to be here. Thank you for inviting me.

Whyte: You're an expert in emergency preparedness. Can you tell our viewers what exactly that entails?

Borio: Well, it entails many, many things. But the goal is to be able to prevent morbidity and mortality in the setting of an unexpected catastrophic crisis, usually a public health emergency, a public health crisis.

Whether it is pandemic flu, pandemic coronavirus—which affects very broad numbers of people across the US and the globe—or whether it's a more focused epidemic, that's what we do in emergency preparedness.

Whyte: Is that what you were doing as part of the National Security Council's Pandemic Response Team?

Borio: Yes. At the NSC, the National Security Council staff [coordinates] policy. We bring together all of the assets of the US government that have a role to play in biodefense. And I say "biodefense" because a lot of people think that [the NSC] only addresses deliberate threats like bioterrorism.

But biodefense really is agnostic to the origin of a threat, so our job is to prepare, whether it's a man-made, accidental, or naturally occurring event. It brings together all of those components of the US government to work together to have a stronger biodefense enterprise for the American people.

Whyte: Dr Borio, why does it seem that we were so unprepared for the current pandemic?

Borio: We were unprepared for the current pandemic. It's important to put it in perspective. This is the worst public health crisis in the past 100 years.

Whyte: Wow.

Borio: On the scale of 0 to 10, this is pretty close to a 10.

Whyte: But everyone does preparedness drills. Everyone is talking about how we respond to these types of outbreaks. So why is it that we're unprepared?

Borio: It would have been challenging to any system that was better prepared. I think it's important to keep that perspective, that it would have been challenging no matter what. But there are many things that we could have done better.

I think one of the most important points on where we lost our footing was with the issue of diagnostic tests—not being able to rapidly augment, ramp up, and distribute diagnostic tests to detect the cases, to conduct surveillance, to care for patients, to even facilitate the conduct of clinical studies. The diagnostic tests are the backbone.

Whyte: What do you think was the problem there? We just didn't do it correctly or just a lack of skills?

Borio: Two things. One, we always leverage the CDC to get us started, and they have always delivered. It works well because they always deliver. And the demand for diagnostic tests at the early stages of a new epidemic infectious disease is not super-large like it is for a pandemic involving a respiratory disease.

The CDC, unfortunately, was not able to deliver us the tests that performed the way we needed them to perform. And because we have relied on the CDC over and over again, the private sector was not really used to rushing in at the earliest onset to deliver those tests either.

The last time that we relied heavily on the private sector for those tests was during the 2009 H1N1 flu pandemic. But remember that a lot of these tests already existed in the marketplace because they were flu tests that had to be slightly modified to deal with the new strain. This [coronavirus] was a new virus, and they had to start from scratch. They took their time.

Whyte: So testing was an issue. What were the other issues?

Borio: I think the other issue was the failure to realize that by the time the epidemic was recognized in eastern China, that given the features of this virus—highly transmissible respiratory disease—and given the travel volume between the US and China, and how travel takes place nowadays, there was a failure of imagination to realize that this outbreak really seeded the globe pretty quickly. And by the time it was recognized, it was inevitable. The cases were already circulating in small numbers, pretty much across the globe.

So, focusing on the border issues may have helped delay the large introduction of cases into America. But it clearly was not going to be sufficient to contain it. And it's only a temporizing measure. We need to be able to look inward and begin to look for cases here.

Whyte: Let's talk about what's on everyone's mind. How prepared are we today for the current pandemic as well as, potentially, any resurgence or second wave?

Borio: I think we're only going to regain our economic and health security once we have a safe and effective vaccine that can be broadly distributed to the American population, and actually across the globe. There are many companies that are already very avidly engaged in developing those vaccines.

Now, nothing is certain about science. I think it's nice that everybody is leveraging the most advanced technologies that exist today, even those that may not have had a precedent, such as in a licensed vaccine used in a certain platform. We're still trying to see if that might be the solution for this pandemic. And I think that's great.

Whyte: But do we need to be practical, Dr Borio, for a vaccine? Most experts, when you really start to unpack it, are saying it's at least 12-18 months for the broader population.

Borio: Absolutely. It's going to take a while to be able to find out which vaccines work. And we can do it faster in a pandemic, sadly, because there are so many cases. So we're going to do the studies, but then you have to scale up manufacturing. A lot of the developers are already establishing partnerships to do that, to be able to make a lot of it.

They have to be placed in bottles. They have to find the needles and syringes. There's a whole distribution [structure] around that too. So it's going to take a while to make it, to have enough safe and effective vaccine that can be given to everybody who needs it or wants it.

Whyte: So, what can viewers do? I mean, this is something that's going to be with us for a while. I think we have to be realistic, right? We can't all stay locked in, unable to have economic revival, access to food and exercise. What do we do? Give us your advice.

Borio: The way I like to think about this is that we're here today. And we know that we're not going to be able to go back to normal until we have a safe and effective vaccine. So, what do we do in between? There's a lot of confusion, I think, in people's minds about that.

In the beginning, we used a very blunt instrument, which is shelter-in-place. We like to say that we did that because we wanted to avert a catastrophic failure of the healthcare system. We wanted to flatten the curve. But we also did that because we didn't know how to stop this outbreak, how to slow it down to save lives.

So it's slowed down, but it's a really blunt instrument. The most important [thing] is, of course, for people who are sick to stay home and for their contacts to quarantine themselves. And we know that most of the transmission really happens within household settings or congregate settings.

We also have to recognize that a large number of people do not exhibit symptoms when they have this infection and they may be transmitting. They're contributing to the epidemic, so they must maintain some type of social distancing. This is not going to go away. The social distancing or physical distancing is not going to go away.

We're going to have to wear masks. We're going to have to be really attentive to our environment, to environmental hygiene. And I think that the idea of being indoors with a lot of people is going to be a no-no for the foreseeable future.

Whyte: How long is the foreseeable future?

Borio: Until we get a vaccine that is safe and effective.

Whyte: You were chief scientist at the FDA. You know that most trials fail. To do everything right the first couple of times is hard. We definitely should have hope, but that's not a strategy. So, what do you do if a vaccine isn't as effective as we would like or it takes longer?

Borio: We have to be realistic and have other plans too. I think that once we have a very safe and effective treatment, a therapeutic, it's going to be a game changer.

In the summer we're going to begin to see a lot of monoclonal antibodies beginning to get tested. Right now the scientists are really busy tweaking them; it's bioengineering at its best. Those monoclonals are very potent and they could really treat the infection. But they can also act as a vaccine, as a preventive, to high-risk, at-risk populations if they can make enough of it.

I'm an optimist. My job, whether at the FDA or as NSC staff, is to think about what we do if something doesn't work. How do we backstop the situation? I think the monoclonals are going to be really critical.

Whyte: What keeps Dr Luciana Borio up at night?

Borio: These days, I think we need to really remember that science and facts matter and they must inform our actions. We always have options, a set of options to act upon, but they must be informed by the best available science.

There's been a proliferation of clinical research that had been so poorly designed or so underpowered. It really is a waste of resources. And it puts patients at risk needlessly because these patients are volunteering for clinical research with the understanding that this clinical research is well done and that it'll generate knowledge that can benefit all of the population. So I'm really worried about this proliferation of poorly executed and designed research that distracts from our ability to find the cures that we need right now.

Whyte: Are things going to look any different 3 months from now or is that too soon to have any real impact?

Borio: I think we're going to be able to find this optimal balance. We're going to become more accustomed with the new normal that we're experiencing. I think people are going to recognize that there will be more social distancing, more telework, more use of face masks, that the risk outdoors is much smaller than the risk of indoor transmission.

People are getting more comfortable in the outdoors, and they are going to take more precautions indoors because it's needed. Eventually we're going to get this right. We're going to find out exactly what the tools are that we have that are going to work best so that we don't have to feel that we're living in a horror movie sometimes.

Whyte: Well, Dr Borio, I want to thank you for joining me.

Borio: It's my pleasure. Thank you so much, John.

Whyte: And I want to thank you for watching Coronavirus in Context.

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Cite this: Emergency Preparedness: Where Did We Go Wrong With COVID-19? - Medscape - May 27, 2020.