The evolving nature of the COVID-19 pandemic has required a nimble response from government health agencies, including in the Virgin Islands, where officials have relied on guidance from the Centers for Disease Control and Prevention on how best to combat the virus.
But a federal response that has been widely criticized as deeply flawed, and recent national headlines indicating political appointees at the Department of Health and Human Services asked the CDC to revise, delay and even scuttle weekly reports they believed were unflattering to President Donald Trump – including its morbidity and mortality weekly reports – has left many asking if anyone can have confidence in the agency’s guidance and its numbers.
The federal issues came to a head on Wednesday when Michael Caputo, the top Health and Human Services spokesman and a longtime Trump loyalist, announced he would take a leave of absence following an inflammatory Facebook post on Sept. 13 about left-wing “hit squads,” and a possible armed insurrection after Election Day on Nov. 3, among other assertions. Caputo’s lead science advisor, Dr. Paul Alexander, will be leaving the department.
While political involvement in the CDC’s mortality reports is concerning, said Dr. Brett Ellis, director of the Territorial Public Health Laboratory, “there does not appear to be any manipulation of numbers, just ‘spin,’” he said, via email. In the Virgin Islands, the Health Department has tested all deaths that have occurred in the territory’s hospitals since the onset of the pandemic in March, in an effort to ensure a true picture of the virus’s reach, said Ellis.
“We have confidence in the CDC and their support has been invaluable,” said Ellis. “There have been instances in CDC guidance that have not been as conservative as some states have made and we will continue to base decisions on the data and guidance from all reliable sources,” he said.
That does not include the Institute of Health Metrics and Evaluation, or IHME, at the University of Washington, which recently reported that the Virgin Islands could become the virus hotspot of the world, with anywhere from 39 to 515 deaths by year’s end.
“IHME has frequently been off and is often criticized. At one point in April, it had predicted that deaths would stop this summer. In some cases, it over-predicts. It was previously shown it was incorrect 70 percent of the time. We are concerned that this influential COVID-19 model uses flawed methods and shouldn’t guide U.S. policies,” said Ellis.
Much like hurricane forecasts, coronavirus models become more uncertain the further out they project, said Ellis, or when taken on their own instead of as an “ensemble,” or weighed together with other models.
“CDC recommends to use a combination of all available models. These change frequently and most do not do well if predicting out more than a few weeks. There is a lot of uncertainty because we have low case and death numbers,” said Ellis, but current ensembles forecast one virus fatality a week into October in the Virgin Islands.
With 1,232 positive results out of 18,682 COVID-19 tests since the start of the pandemic, the territory’s infection rate stands at 1.232 percent per 100,000 population, according to Health Department data as of Sept. 16.
Ellis said the Virgin Islands conducted 6,700 tests each of the last two months and has allocated 7,000 tests per month – surpassing federal guidelines to test at least 2 percent of the population per month – though that might become more difficult as money and supplies run thin.
“We need more tests. We need more providers to be able to obtain test supplies on their own. We have enough funding for the short-term, but the current award of $4 million for laboratory and epidemiology is likely not enough for the entire 24-month award. It should be enough to get us through this first wave and until there is another federal appropriation. To increase testing to the levels that we would like, it will not last 24 months,” said Ellis.
“If test positivity is 5 percent or below, I am confident we are doing enough testing. … When our rates are higher than 5 percent and have reached 10 to 15 percent, then it is extremely difficult to have enough testing when there is significant community transmission,” he said.
If cases approach the higher threshold, “the idea would be to test every health care, long-term care worker and business employees with increased frequency. Even up to once a week. Unfortunately, there simply are not enough tests available,” said Ellis. “I would like to see the territory have the capacity, when needed, to test double our current testing. … Doubling or tripling testing would put the V.I. back on the top in terms of testing per capita. We are working tirelessly to try to obtain additional supplies commercially, expand testing by providers/clinics and obtain additional supplies from the federal government,” he said.
That raises questions about the safety of reopening the Virgin Islands to tourists, as Gov. Albert Bryan Jr. has indicated he will do on Sept. 19.
Bryan ordered a shutdown on Aug. 17, the second since March, due to a spike in cases after reopening to leisure travel on June 1. Four residents of the Queen Louise Home for the Aged died, and eight more were infected in one week during the August surge. The territory’s death toll currently stands at 19, and the Virgin Islands remains on the CDC’s list of places for travelers to avoid.
However, Health Department data shows the primary source of novel coronavirus transmission is from close contact and community spread, not tourism, said Ellis, adding that it is not realistic for the Virgin Islands to keep its borders closed.
“COVID-19 is already here in the territory. The majority of cases have been due to close contact and community transmission – 616 and 437, respectively. Travel has only been 87 cases,” said Ellis. “While it may be possible to completely eliminate COVID-19 if we close all doors in the territory, and the USVI was previously successful in eliminating cases for a period of weeks, the reality is that we cannot keep our doors at home, and businesses and tourism permanently closed. The territory needs to function and be able to keep cases and mortality low.”
While testing at all airports prior to departure would be helpful to prevent anyone who is infectious from traveling, said Ellis, “unfortunately, testing supplies are still severely constrained in the USA and the federal government did not make this a priority. There is still very little information available about the number of airline passengers that may be infected on the day they travel. It is more likely that the person becomes infected in the time period following travel and, in many cases, in the place they traveled. It is a better use of limited to resources to be able to detect cases and conduct contact tracing,” said Ellis.
The Health Department initially entertained a $1 million contract in June for the electronic tracking of the virus by local tech startup Avera, but that turned controversial when the company’s inexperience and ties to Bryan’s daughter were revealed. Health now has 12 full-time contact tracers who are doing the work in a more traditional fashion, Dr. Esther Ellis, territorial epidemiologist, said in an interview last month.
The tracers use their phones and questionnaires to track down those who may have been exposed to the virus, said Esther Ellis. They have a Bachelor of Science degree, at minimum, she said, and their work is funded by the CARES Act as well as the CDC Foundation, an independent nonprofit created by Congress to mobilize philanthropic and private-sector resources to support the work of the Centers for Disease Control and Prevention.
In a bid to curtail the potential spread of the virus by travelers, the government requires air arrivals from designated “hot spots” to have negative test results, and all passengers will undergo temperature checks and complete health questionnaires including their names and contact information. In July, Bryan also announced an online portal that allows visitors to upload their health screenings and test results before they travel.
Barring a change in federal policy, the guidance in the territory is more effective at limiting transmission, said Brett Ellis, including “use of masks, social distancing and limiting opportunities for persons to congregate without a mask and without social distancing, such as an indoor bar. There is growing evidence that those activities that occur indoors are at greater risk for transmission.”
Ellis is hopeful those practices also will limit the spread of the flu, which could complicate the coronavirus response.
“Flu is of greater concern in the mainland where the cold comes with people being indoors more often,” said Ellis. “Our local concern has more to do with flu cases overwhelming COVID-19 testing supplies. We intend to increase screening for flu prior to COVID-19 to prevent this,” he said, as well as encourage flu vaccines to help reduce the risk. “It may also be possible that flu is lower this year due to COVID-19 and local practices.” Flu season in the Southern Hemisphere – usually a predictor of how severe it will be in other parts of the world – has been extremely low, Ellis added.
In the meantime, the Health Department will continue testing, and urging the community to follow social distancing guidelines and to wear their masks. “It has been the most stressful challenge I have faced in my career in public health,” said Ellis. “It has been exhausting. But I would surmise it will ultimately be the most rewarding challenge in my career.”