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Baylor College of Medicine

Reaching an Inflection Point

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Sept. 16, 2020

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Dear Members of the Baylor College of Medicine Community,

It feels to me like we are approaching some sort of inflection point. Our hospitals appear to be out of danger of being overwhelmed. State leadership is signaling plans to begin to relax some restrictions, and local leadership made some cautious and preliminary steps in that direction as well. HISD has started virtual school, and is about a month away from resuming face-to-face instruction. We are making halting, careful steps to safely reclaim more of our pre-COVID-19 lives. Leaders are struggling to make responsible decisions, while continually – and very appropriately – chanting our new mantra: mask and distance, mask and distance.

Last week I reflected on balancing our pride in all we have collectively accomplished in this battle against SARS-CoV-19, with what should be a sense of humility driven by what we do not know. That theme becomes even more important as we start to make decisions to relax various restrictions. Done thoughtfully, we promote the well being of our children and encourage the economic health of those who have been impacted by the viral-induced slow-down. Done poorly, we will promote another surge, and with it significant health consequences.

Starting with the positive, the Texas Medical Center (TMC) data continues to improve. The number of new patients admitted to TMC facilities continues to trend downward, and is approaching levels seen in April and May. With fewer admissions, as existing patients are discharged (or unfortunately, expire), the census in TMC affiliated hospitals is falling. We are still a week or so away from seeing what kind of Labor Day impact we might experience, but so far, so good. This is unequivocal positive news, based on solid numbers.

The new community cases is a different story – good news in that the trend is in the right direction, but concerning in we are not entirely confident in the data. Over a month ago, we started to notice some inconsistencies in the case rates. The data from the Texas Department of State Health Services (DSHS) reflected an increase in the number of people being tested, but all of our local labs – Baylor included – were seeing a decrease in testing volume.

It has now been well documented this disconnect had a good explanation. DSHS found itself responsible for an unprecedented demand to receive, organize and report testing data from hundreds of labs across the state. This was a task for which it appears they were ill equipped to manage, falling far behind in accurately assigning testing results to individual counties and municipalities. Since that time, they have upgraded technology, and are playing catch-up entering a backlog of test results. This week DSHS announced a significant overhaul of processes, data quality assurance and reporting formatting which should produce more reliable results.

As a result of DSHS data issues, when we look at the reported new cases today, the numbers include cases from June, July and August, or even earlier. The unfortunate consequence is our current new cases are probably being overstated – we are doing better than we think. Also, in retrospect, because cases were not being entered in June and July, we were in even worse shape then than we knew.

At some level, this is not as bad as it might be. We are probably doing better than we think today. We already survived June and July when the numbers were understated. However, at this inflection point, it is disturbing we do not have confidence in a major benchmark. We are trekking through the wilderness with a broken compass. We are flying a plane in poor visibility conditions with an unreliable altimeter. Are we at 5,000 feet or 500 feet? I am not a pilot, but it seems to me some precision in this metric is important, as our new case rate number will be as we make decisions to reopen schools and relax other restrictions. Again, hopefully with the DSHS changes, this problem is behind us.

So now we are contemplating the reopening of face-to-face schools, armed with incomplete and evolving information. Decision-making is relatively easy when you have all the facts. Critical decisions are much more difficult based upon incomplete or conflicting information. This is the unfortunate position in which we find ourselves. State and local governments, local school boards, and – most significantly – millions of parents are struggling to make the best decision for children across the nation. Most are showing an appropriate level of caution.

In closing, I would like to offer a few thoughts on what communities, schools and parents can do to maximize success of school reentry, and recommend some specific resources.

What can communities do?

  • Mask and distance. Continue to push good viral control practices in the entire community – not just among students, teachers and parents. SARS-CoV-2 is every bit as infectious as it ever was. We are nowhere close to achieving herd immunity, either through spread of infection or vaccination. Masking and maintaining appropriate distancing (6 feet or more) is inconvenient, but a small price to pay to get our children back to school.
  • Do not resume full face-to-face school until your community has a sustained low rate of disease. The new community cases should be steady – or ideally declining. New cases should be at a low enough level so health departments can realistically perform contact tracing. In Harris County, that is about 200 cases/day (we are currently at 744 per the county website). If you live in communities outside of Harris County, the consensus number seems to be somewhere between 2-8 cases per 100,000 population.

Controlling the disease through contact tracing is like rowing a leaky rowboat. If the boat has a slow leak (low disease incidence) you can bail out some water every few minutes, keep rowing and be safe. On the other hand, if the boat has a gaping hole in the hull, you can bail as fast as you can, but you are going to sink. If we are in a high prevalence environment, SARS-CoV-2 will overwhelm even the best-designed defenses, and outstrip the ability to perform contact tracing. We cannot put our children in a sinking boat.

The current lack of confidence in DSHS data – hopefully resolved – make this more difficult, but the uncertainty demands we proceed cautiously.

What can schools and school boards do?

  • Refer to Baylor College of Medicine's "Guide to Reopening Schools." Baylor developed a guide to help walk school leaders through critical questions. Where will masking and distancing tend to break down? (bathrooms, cafeterias, entrances, buses). What issues are important to assess in a school's physical plant? (air flow; water systems). How do I keep teachers safe? (cloth masks and face shields). How do I manage symptomatic or exposed students and employees, and when is it safe to bring them back?
  • Establish teacher/employee monitored e-mail address for COVID-19 questions and concerns. Even with the best policies and training, there will be many specific questions that arise. Establish a dedicated email address to receive these questions, and commit to a timely response. Ideally, engage an objective, third party expert panel to assist with the subset of more complex issues and novel problems. The availability of rapid and reliable answers to teacher and employee questions will help to quell the inevitable anxiety that many will experience as schools reopen.

What can parents do?

  • Get involved. Like many other components of the educational process, active involvement of parents in their children's schools will drive better outcomes. Pay attention to communication from your school. Is there a well-articulated plan for returning to the classroom? Does it seem thoughtful and comprehensive? Is communication frequent and transparent? Based on the experience to date with colleges and universities, the re-entry process will usually go well, but some schools have challenges. Frequent and open communication between parents and school leadership will be key.
  • Get educated. That is, learn the basics about COVID-19, so you can begin to separate fact from fiction and opinion. Baylor provides a free online resource that is actually geared towards K-8 science teachers. However, it also a good source of unbiased, factual and accessible COVID-19 information.
  • Assess your child's unique situation. This pandemic is forcing parents to make hard decisions. Does my child learn well on-line, or do they need the face-to-face structure of the classroom? Is my home even equipped to provide a good on-line learning environment? What is impact of home-based learning on my child's social and emotional well-being? If schools are not open, how can I return to work? Parents of children with special needs will have even more complexity to work through. Involved parents who understand the unique needs of their children are really the only ones in a position to answer these questions, and strike the right balance for their child. The CDC developed a good self-assessment checklist to help guide parents, caregivers and guardians through this process.

So as we move towards in-person instruction, let's draw on lessons from our COVID-19 past. We have proven we can do the hard work of engaging entire communities to band together to control the virus. Our knowledge continues to rapidly expand. We should be humbled by a clear-eyed recognition of what we do not know, but that humility should not lead to paralysis and inaction. We can and will pull together to get our children back to school, thoughtfully and safely.

(Please feel free to share this message with friends, family and social media using the following link: https://bit.ly/33zlpXx)

James McDeavitt, M.D.
Senior Vice President and Dean of Clinical Affairs