SUNDAY ISSUE: THE CORONAVIRUS IN GEORGIA

JULY 31, 2020

Dear Gov. Kemp:

Last week, Georgia set records for new COVID-19 diagnoses and current hospitalizations, and deaths are climbing. Georgia health care workers are increasingly concerned about the direction of the pandemic in our state. Earlier this month, over 1,400 of us wrote you to express our concerns, and today some 2,150 of us write to ask again that you revisit your strategy for combating the virus. 

We appreciate that managing the state of Georgia is an enormous task and that you are trying to balance controlling the virus against damage to the economy and the livelihoods of workers. We share your concerns, as economic well-being directly impacts the health of our patients. We firmly believe that if policy decisions are made based on science, economic benefits will follow. Likewise, this pandemic began with a new virus about which we knew very little, and we understand that keeping policies in line with the rapid accumulation of scientific knowledge continues to be a challenge. Now is the time to update policies to align with current science.

Although our current strategy is falling short, the good news is that there are concrete steps that you can take to dramatically curtail the surge without completely shutting down the state. Your actions in April were effective in flattening the curve of cases and preserving our fragile hospital infrastructure. The recent surge of cases associated with decreased social distancing is placing our hospitals at risk again, and aggressive actions are urgently needed.

Here are the troubling facts we now must confront: 

■ We reached a new peak of 4,813 COVID-19 cases on July 24, and a peak 7-day average of 3,745 on July 24.

Prior to your shelter in place order on April 3, the highest number of cases reported per day was 1,085 on March 31. Also, compared to March-April when most cases were in few counties, now cases are occurring in urban, suburban and rural Georgia.

■ Our current hospitalizations have increased substantially since June 13, reaching a new record of 3,188 on July 29 and more than 3,000 patients hospitalized with COVID-19 every day since July 19. Hospitals are increasingly on total or ICU/CCU diversion across the state.

■ Our ICU capacity statewide is strained, with only 12-16% of beds available statewide, and half of hospital regions having 15 or fewer ICU beds available on July 20.

■ Deaths also are moving upward, with 82 reported on July 24, the second-highest daily report ever. We know that deaths lag behind cases and hospitalizations by weeks, and that a strained hospital system also will increase deaths.

■ Our percent positivity for tests has risen as high as 17.1% on July 23, when the ideal is below 5% and a level above 10% raises a red flag. This increasing positivity rate underscores that new cases are a result of worsening community transmission, not simply more testing, and that cases are being missed and their contacts never traced.

■ Due to the sheer size of the outbreak encompassing multiple states, our testing infrastructure is strained and wait time has increased substantially with many individuals reporting that it takes up to two weeks to receive results, effectively eliminating the benefit of contact tracing.

According to the July 14 White House Coronavirus Task Force report that is provided to governors weekly, Georgia is now in the “Red Zone” of states for which more stringent steps are recommended.

“Disease trends are moving in the wrong direction in Georgia,” according to the Task Force. Georgia qualifies for “Red Zone” status by having over 100 cases per 100,000 population as well as test positivity above 10%.

The Task Force made the following recommendations for Georgia: 1. Mandate statewide wearing of cloth face coverings outside the home.

2. Allow local jurisdictions to implement more restrictive measures.

3. In all counties with 7-day average test positivity greater than 10%, close bars and gyms, require strict social distancing within restaurants, and limit gatherings to 10 or fewer persons.

In addition, the Task Force recommends specific actions aimed at increasing testing access, decreasing turnaround time for tests, intensifying contact tracing, protecting seniors in long-term care facilities, and improving public health messaging about risk of serious disease in all age groups.

We endorse the Task Force recommendations, with modifications, as they mirror those we made in our letter of July 2.

We have added some additional caveats to the recommendations cited above, and we have added some additional recommendations. Our current recommendations and rationale are as follows: 

We recommend a temporary statewide face covering requirement outside the home, and for outdoor situations in which social distancing of at least 6 feet cannot be maintained.

Governors of 30 states, including those of Texas, Alabama, Arkansas, Ohio and Indiana, have implemented face covering mandates. We applaud you for wearing a mask whenever you are in public and for encouraging the use of masks by the public. Unfortunately, this has not been enough to achieve widespread mask usage in Georgia. The CDC recently published an article entitled, “Universal Masking to Prevent SARS-CoV-2 Transmission — The Time Is Now,” emphasizing the importance of universal masking to control the pandemic.

Evidence shows that face coverings are effective in preventing virus spread and that mandates are substantially more effective than recommendations in decreasing transmission. Projections estimate that new cases would decrease by as much as 40,000 if 95% of Americans wore masks until November 1. A recent survey by the Medical Association of Georgia found that 87% of 1,300 physicians completing the survey said they believed Georgians/visitors should be required to wear a face mask or covering. Furthermore, CDC Director Dr. Redfield said recently that if everyone wore a face mask we could control this epidemic in 4 to 8 weeks.

Why not mandate face coverings in Georgia for an 8-week period? 

We recommend that you close bars and nightclubs, and prohibit indoor dining as well as gatherings of more than 10 people, including at houses of worship.

While we understand your reluctance to shut down the state due to economic repercussions, the repercussions of not controlling the virus will take a heavy toll on our economy, as well as our health. Maintaining physical distance is nearly impossible in bars and nightclubs, which are ripe settings for viral “superspreading,” especially among younger persons in whom the surge of cases is now concentrated.

The risks of dining indoors have been well-documented, as people cannot be masked while eating. Numerous outbreaks across the country — including in Georgia — have been associated with indoor worship services. 

We recommend that you empower elected officials around the state to institute more stringent requirements as appropriate for their jurisdictions.

As you have pointed out, the pandemic affects different areas of the state differently. There now are local epidemics all over Georgia, each with different characteristics. Local control of local epidemics is essential, and elected officials must be empowered to institute measures to avoid and manage transmission in their diverse communities. 

We recommend that you greatly expand testing and contact tracing in the state.

Lines for testing are so long that working people cannot devote the hours needed to stand in them.

Appointments are booked for days ahead in many locations. In some rural counties, people are being referred to sites that are hours away. Turnaround time for test results is sometimes over two weeks, eliminating the benefit of contact tracing. It is time to consult with local experts on mechanisms for expanding the capacity of academic and hospital labs around the state, and to collaborate with academic, hospital and public health labs that have capacity out of state. Testing sites must be rapidly expanded throughout the state, and contact tracing must be expanded in collaboration with local communities and reported with transparency, as is done by states such as Oregon.

Finally, we strongly recommend that you take action to eliminate Georgia’s racial and ethnic disparities in COVID-19 cases, hospitalizations and deaths.

Resources must be targeted to the most impacted communities, specifically African American and Hispanic/Latinx communities. Data must be appropriately collected in order to understand our local epidemics. As of today, Georgia’s most impacted racial group is “unknown,” and this is unacceptable.

While we understand the complexities of collecting data on race and ethnicity through large commercial laboratories, the state must mandate and enforce the collection of these data, and make the data public.

We also invite you to visit one of the many hospitals currently caring for patients with COVID-19, and we are happy to arrange such a visit. By acting decisively now, you can save thousands of lives and avoid illness for hundreds of thousands of Georgians. Your actions will have immediate impact, although it may take weeks to see cases decrease substantially. As cases decrease, the strain on testing, contact tracing and PPE availability also will lessen, improving the efficiency of all of our systems.

Decreased cases will lead to improved economic outcomes and allow us to more safely open schools in the fall. 

Thank you for your thoughtful consideration of this urgent matter.

Melanie Thompson, M.D., Thacker, Thompson, and Bernard, M.D.

Jesse Couk, M.D., chair of Infectious Diseases, Shepherd Center.

Carlos del Rio, M.D., distinguished professor and executive associate dean for Emory University School of Medicine at Grady Health System.

Sophie Lukashok, M.D., president, Infectious Diseases Society of Georgia.

Wendy S. Armstrong, M.D., professor of medicine, Emory University School of Medicine.

Jonathan Colasanti, M.D., MSPH, assistant professor of medicine and global health, Emory University School of Medicine.

Yolanda Wimberly, M.D., MSc, senior associate dean, graduate medical education/Grady campus and professor of pediatrics, Morehouse School of Medicine.

On behalf of some 2,150 Georgia health care workers, signatures attached. (A list of the signers is on AJC.com/opinion.)

CC: Kathleen Toomey, M.D., commissioner, Georgia Department of Public Health 

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