PART 20. April 20, 2020. CORONAVIRUS. “…nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence.”

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“President Donald Trump said Monday (March 23rd) that he wants to reopen the country for business in weeks, not months, and he claimed, without evidence, that continued closures could result in more deaths than the coronavirus pandemic.

“We can’t have the cure be worse than the problem,” Trump told reporters at a press briefing.

 The statement echoed a midnight Sunday tweet from the president in which he said, “We have to open our country because that causes problems that, in my opinion, could be far bigger problems.”

Trump acknowledged there were trade-offs, “there’s no question about that,” but claimed that, if closures stretch on for months, there would be “probably more death from that than anything that we’re talking about with respect to the virus.”” (A)

“But what is the exit strategy? “We’ve managed to get to the life raft,” says epidemiologist Marc Lipsitch of the Harvard T.H. Chan School of Public Health (HSPH). “But I’m really unclear how we will get to the shore.”…

The number to watch in the next phase may no longer be the actual number of cases per day, but what epidemiologists call the effective reproduction number, or R, which denotes how many people the average infected person infects in turn. If R is above 1, the outbreak grows; below 1 it shrinks. The goal of the current lockdowns is to push R well below 1. Once the pandemic is tamed, countries can try to loosen restrictions while keeping R hovering around 1, when each infected person on average infects one other person, keeping the number of new cases steady.

To regulate R, “Governments will have to realize that there are basically three control knobs on the dashboard,” says Gabriel Leung, a modeler at the University of Hong Kong: isolating patients and tracing their contacts, border restrictions, and social distancing.

Singapore, Hong Kong, and South Korea have all managed to keep their epidemics in check through aggressive use of the first control. They identify and isolate cases early and trace and quarantine their contacts, while often imposing only light restrictions on the rest of society. But this strategy depends on massively scaling up testing, which has been hampered by a scarcity of reagents and other materials everywhere. The United States will be able to do millions of tests per week, says Caitlin Rivers of the Johns Hopkins Center for Health Security. “Although our testing capacity has grown a lot in the last couple of weeks, we are not where we need to be yet,” she says.

Contact tracing is another hurdle, and it is labor intensive. Massachusetts is hiring 500 contact tracers, but a recent report by Rivers and others estimates that the United States as a whole needs to train about 100,000 people…

As to the second control knob, border restrictions, most countries have already banned entry to almost all noncitizens. Quarantining returning citizens, as New Zealand and Australia began to do in the past few weeks, further minimizes the risk of new introductions of the virus. Such measures are likely to remain in place for a while; the more a country reduces transmission domestically, the greater the risk that any new outbreaks will originate with travelers. And foreign visitors are generally harder to trace than citizens and more likely to stay at hotels and visit potential transmission hot spots, says Alessandro Vespignani, a disease modeler at Northeastern University. “As soon as you reopen to travelers, that could be something that the contact tracing system is not able to cope with,” he says.

The third dashboard dial, social distancing, is the backbone of the current strategy, which has slowed the spread of the virus. But it also comes at the greatest economic and social cost, and many countries hope the constraints can be relaxed as case isolation and contact tracing help keep the virus in check…

Choosing a prudent path is difficult, Buckee says, in part because no controlled experiments have compared the effectiveness of different social distancing measures. “Because we don’t have really strong evidence,” she says, “it’s quite hard to make evidence-based policy decisions about how to go back.” But Lipsitch says that as authorities around the world choose different paths forward, comparisons could be revealing. “I think there’s going to be a lot of experimentation, not on purpose, but because of politics and local situations,” he says. “Hopefully the world will learn from that.” (B)

“Still, society can’t stay shut down forever. Public health and state leaders are starting to talk about how and when to relax social distancing guidelines, and President Trump is expected to soon announce finalized guidelines to help states make those decisions. Even then, it’s clear that life won’t go back to normal all at once. The decisions will be staggered, and a lot of it will come down to local and regional circumstances.

“We have to do it strategically and safely,” said Dr. Monica Bharel, commissioner of the Massachusetts Department of Public Health, at a briefing by the Association of State and Territorial Health Officials Wednesday. “The worst possible outcome of reopening public life would be a second wave of this pandemic.”

Public health leaders agree that in order to safely lift social distancing restrictions we must create and sustain systems that can rapidly stamp out any new coronavirus flare-ups so they don’t spiral out of control. Here are five key things health experts say must be addressed as we begin to start businesses and community life up again.

1. Improve rapid testing

2. Massively upgrade contact tracing capacity

3. Create systems to isolate the sick and protect the vulnerable

4. Build up hospital capacity and the PPE supply chain

5. Zero in on effective treatments…

Gottlieb says the combination of effective treatments as well as expanded testing and surveillance would put us in a situation where we can live with the virus, instead of being paralyzed by it.

“I think that [would be] a robust enough set of tools that this could become a livable threat, that we can get back to a fairly normal way of life and be able to mitigate the risk from coronavirus even before we have a vaccine in place,” he says. “Now, life will never be perfectly the same until we have a vaccine that can fully vanquish it.”

There are dozens of compounds being evaluated for the development of a vaccine, but that’s at least a year off.” (C)

“Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it.

The better question is: “How will we know when to reopen the country?”…

Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care…

A state needs to be able to at least test everyone who has symptoms…

The state is able to conduct monitoring of confirmed cases and contacts…

A robust system of contact tracing and isolation is the only thing that can prevent an outbreak and a resulting lockdown from recurring…

This will be a big challenge for most areas. Other countries have relied on cellphone tracking technology to determine whom people have been near. We don’t have anything like that ready, nor is it even clear we’d allow it. The United States also doesn’t have enough people working in public health in many areas to carry out this task…

In suppression, cases will dwindle at an exponential fashion, just as they rose. It’s not possible to set a benchmark number for every state because the number of infections that will be manageable in any area depends on the local population and the public health system’s ability to handle sporadic cases…

Until we get a vaccine or effective drug treatments, focusing on these major criteria, and directing efforts toward them, should help us determine how we are progressing locally, and how we might achieve each goal.

It would also prevent us from offering false hope about when America can start reopening. Instead of guesses, people could have clear answers about when they might be able to go back to a closer-to-normal way of life.” (D)

“CDC PLAN

The Framework for Reopening America provides guidance to state, local, tribal, and territorial governments to adjust restrictive community mitigation measures in a controlled way that supports the

safe reopening of communities when appropriate, supporting Americans reentering civic life.

Why Is the Plan Important to the American People

The strict community mitigation measures the majority of the United States is currently experiencing have succeeded in slowing the spread of COVI-19. This level of mitigation however cannot be adhered to forever, and has negative consequences on economic and long term health outcomes. Lifting stay-at-home orders carefully, on a community by community basis, only when ready, will help extend the gains made from this time of collective social distancing. Coming out of mitigation in a controlled way, with robust monitoring systems in place to contain new cases and outbreaks will be critical to navigating the next phase of this pandemic. Leaders at all levels will need to prepare communities for occasionally returning to stricter mitigation measures for brief periods as needed to continue containing the disease. This plan describes the conditions in which it is appropriate to lift community mitigation measures, the phased steps to reduce community mitigation measures, and indicators to rigorously monitor to inform decisions about adjusting mitigation measures.” (E)

“President Donald Trump announced federal guidelines to reopen the U.S. on Thursday that put the onus on governors of making decisions about their states’ economies…

Under the first phase of the three-phase plan, restaurants, movie theaters and large sporting venues would be appropriate to reopen under certain conditions, while schools, day care centers and bars would not.

The plan, released Thursday afternoon, is designed to “mitigate the risk of resurgence” of the pandemic and to “protect the most vulnerable,” according to the guidelines.

It is “implementable on a statewide or county-by-county basis” at the discretion of each state’s governor — a stark contradiction from the president’s earlier assertion that he had “total authority” to direct governors how and when to reopen.

The guidelines do not suggest any reopening dates, and Trump acknowledged that it would be “a gradual process.”

To begin implementing the guidelines, states must first meet a “gating” criterion that includes a “downward trajectory of documented cases within a 14-day period” or a “downward trajectory of positive tests as a percent of total tests within a 14-day period (flat or increasing volume of tests),” as well as hospital preparedness.

If that criterion is met, states, could then enter Phase One, according to the guidelines.

Under Phase One protocols, large venues like restaurants, movie theaters, sporting venues and places of worship would be allowed to reopen if they “operate under strict physical distancing protocols,” according to the guidelines…

Under Phase One, “all vulnerable individuals should continue to shelter in place” and members of households with vulnerable residents “should be aware that by returning to work or other environments where distancing is not practical, they could carry the virus back home.”

It also calls for the employers to allow employees to telework.

The plan also emphasizes that all people should continue to practice social distancing when in public and that they should continue to minimize nonessential travel.

Phase Two, the guidelines state, applies to states and regions “with no evidence of a rebound” that “satisfy the gating criteria a second time.”…

Phase Three would then kick in for states and regions with “no evidence of a rebound” that “satisfy the gating criteria a third time.”

At that point, “vulnerable individuals” could resume public interactions but should practice social distancing, according to the guidelines. Low-risk populations should still “consider minimizing time spent in crowded environments.”

Only in Phase Three could work sites resume normal staffing protocols without restrictions and visits to senior care facilities and hospitals could resume. People who interacted with residents and patients would still have to remain “diligent regarding hygiene.” Under Phase Three guidelines, large venues could operate under “limited” social distancing protocols, gyms could remain open with “standard” sanitation protocols and bars could operate with “increased standing room occupancy.”

The White House views Trump’s announcement as guidance under which “governors will have to make decisions what’s right for their individual states,” a White House official told NBC News.” (F)

GUIDELINES FOR OPENING UP AMERICA AGAIN (G)

“Anthony Fauci, director of the National Institute of Allergy and Infectious Disease (NIAID) and head of the White House Coronavirus Task Force, spoke on CBS Wednesday night about the developments needed in public health before Americans can safely return to work.

Fauci explained that in order to have a successful rolling re-entry program, where the economy would slowly open back up, we’d need to “test, identify, isolate, get someone who is infected out of circulation, and do a degree of contact tracing” to better monitor the virus’s status.

“The absolute thing that you would need is to be able to respond and contain whatever rebound you get so that you don’t wind up in a situation where you have another escalation,” he told CBS’s Norah O’Donnell…

Schaffner notes that while the emphasis is now on mitigation efforts, reopening the economy will be a question of health departments’ ability to switch back to containment strategies, meaning investigating every case and ensuring the individuals who had contact with infected patients are quarantined. He is not sure that local health departments in all jurisdictions have the resources or energy for a more intensive case-by-base public health follow up, but notes that it would be ideal to avoid future outbreaks.

In terms of reopening public spaces, Schaffner supports the idea of opening the least affected parts of the country in a “rolling fashion,” but to take a gradual approach.” (H)

“Let’s start with the good. Mr. Trump offered a three-phase approach recognizing that reopening is going to be a gradual process. The phases are tied not to strict dates — remember “open by Easter”? — but to achieving metrics.

In addition, the relaxing of emergency precautions will be scaled according to the intensity of the problem within a given state or region. The uncertainty that has dominated the national psyche will be abated by tangible milestones like school reopenings (phase two) and allowing visits to senior living facilities (phase three).

The plan also recognizes that not all businesses and facilities pose equal risks of spreading the coronavirus. Distancing and sanitation at a gym is conceivably more difficult than in a bar, though we should be on the lookout for new research to expand our understanding of that nuance. Therefore, different businesses should be allowed to reopen at a pace appropriate to their risk.

Finally, the plan rightly emphasizes vulnerable populations and senior living facilities. These facilities will remain at a high risk of explosive growth in cases until we can achieve widespread testing, vaccination and immunity. So the plan prohibits visits to them until the final phases and requires strict hygiene protocols when visits do occur.

That’s the good. Now the bad. The plan is a failure when it comes to testing, which everyone recognizes as a linchpin in any effort to reopen the country. It certainly assumes that testing will occur: A key metric for each phase of reopening is the trend in coronavirus cases. Accordingly, within a 14-day period there needs to be a “downward trajectory” of either documented cases or the percent of positive tests.

But there is no requirement that states first show that they have tested enough people to establish that the trajectories they are seeing are truly reflective of population-level trends. Overall, testing has been far too low for these trajectories to be relied on. Even after six weeks, barely 1 percent of the country’s population has been tested for Covid-19 and new daily tests have plateaued around 150,000. This is also not enough testing for effective levels of contact tracing.

More important, the plan calls for measuring a relative decline, and not an absolute threshold for very limited spread. So there could be a 14-day decline and yet the number of new cases could still be too high. We need a firm threshold, such as 20 new cases per one million people, that ensures a low number of new coronavirus cases when we start to re-open.

Another big concern with the plan is that, like the current C.D.C. testing guidelines, it still focuses on testing symptomatic people. If we are to stop the spread, the focus has to broaden to asymptomatic coronavirus-infected people who can be unwitting super-spreaders and ignite a resurgence…

Finally, nothing is mentioned in the “Opening Up America Again” plan about how states should handle a resurgence. There is no guidance on defining a significant uptick in cases or how to respond. As Dr. Anthony Fauci mentioned in the press briefing announcing the plan, there may be instances where states must “pull back.” But what does pulling back entail? How will states know when to do this? There is no guidance.” (I)

“As some governors consider easing social distancing restrictions, new estimates by researchers at Harvard University suggest that the United States cannot safely reopen unless it conducts more than three times the number of coronavirus tests it is currently administering over the next month.

An average of 146,000 people per day have been tested for the coronavirus nationally so far this month, according to the COVID Tracking Project, which on Friday reported 3.6 million total tests across the country. To reopen the United States by mid-May, the number of daily tests performed between now and then should be 500,000 to 700,000, according to the Harvard estimates.

That level of testing is necessary to identify the majority of people who are infected and isolate them from people who are healthy, according to the researchers. About 20 percent of those tested so far were positive for the virus, a rate that the researchers say is too high.

“If you have a very high positive rate, it means that there are probably a good number of people out there who have the disease who you haven’t tested,” said Ashish Jha, the director of the Harvard Global Health Institute. “You want to drive the positive rate down, because the fundamental element of keeping our economy open is making sure you’re identifying as many infected people as possible and isolating them.”

The researchers said that expanded testing could reduce the rate to 10 percent, which is the maximum rate recommended by the World Health Organization. In Germany, that number is 7 percent, and in South Korea, it is closer to 3 percent…

A shortage of test kits and technical flaws in the United States significantly delayed more widespread testing of the virus, letting it spread undetected for weeks. With more than 695,000 cases as of Friday, the country has the highest number of known cases in the world…

“We need to switch from saying to people, ‘if you have mild symptoms, if you’re not feeling super sick, don’t come and stay at home,’ to ‘if you have any symptoms, you need to come in to get tested right away,’ ” he said.” (J)

Governor Andrew Cuomo: (08:44)

How are you building the bridge? It’s going to be a phased reopening, right? During the phased reopening, the priority is make sure you do no harm and keep your eye on the public health issue. That is what is key in all of this. It’s going to be a calibration of reopening based on public health safety and that infection rate. Because what we have done in the reducing of the infection rate is a pure function of what New Yorkers have done and what people across the country have done. When you relax that social distancing, you could very well see an increase in the infection rate. It’s all a calibration to the public health, but it’s going to be a gradual increasing of economic activity in calibration with the public health standards.

Governor Andrew Cuomo: (09:42)

The single best tool to doing this gauging is large scale testing. Test, trace and isolate, it’s what everybody’s talking about. What does this mean? It means you test, you find a positive, you trace back who they were with, where they were, test those people and you isolate the people who are positive. It’s inarguable. It’s just very, very hard to do. It opens this new world of testing. This new world of testing is a new world to all of us by the way. There’s diagnostic testing. Are you positive or negative? There’s then testing for antibodies. Were you exposed? If I find out that you were already exposed and you had the virus, now you can go back to work because you had the virus, you have antibodies.

Where do you do the testing? We’ve been doing testing in hospitals. Frankly, that’s not a great place to do testing. You don’t want people walking into a hospital emergency room who may be positive for COVID. Our drive-thru locations are better, but how do you bring that to scale? Then even if you have the equipment and the testing site and the personnel to do the testing, where do you get the labs to test all of these tests? This is a whole world of questions that nobody has ever seen before.

Governor Andrew Cuomo: (12:06)

The bottom line is, you need large scale testing. Let’s do it. We can’t do it yet. That is the unvarnished truth. I know because New York has been doing this since this started exploring this new world. We have done more tests than any other state. We’ve done over 500,000 tests, which is more than the other states that are near us combined. We’ve been very aggressive here, but in all this time we’ve only done 500,000 tests. Now, that’s a large number of tests, yes. But this is over a one-month period. Even 500,000 tests, you’re talking about a state with 19 million people. You get a sense of the scale of what we have to do here.

Governor Andrew Cuomo: (13:10)

We cannot do it without federal support. I’ve been saying this for days. If you have a state that has a lower need, yes, they may be able to do it. But when you have a state that has to do a large number of these tests, I’m telling you we can’t do it without federal support. I’ve said that from day one. We will coordinate and we have been coordinating all the tests in our state. That’s how we got to that 500,000 number, more aggressive than I think anyone else. We have 228 private laboratories in this state. We will coordinate with them. We’ll make sure that we’re not competing with ourselves because there are a lot of groups that are now testing. New York State Department of Health developed their own antibody test. That test is going to be very important. It’s in our control because we’ll actually do those tests. We don’t need a private lab. We don’t need anyone else.” (K)

““Our best scientists & health experts assess that states today have enough tests to implement the criteria of phase one, if they choose,” Vice President Mike Pence said at a press conference the night of April 17.

But according to the Covid Tracking Project, the US has averaged fewer than 150,000 tests each day so far in the week of April 13, including at both public and commercial labs. That’s an improvement from the early days of March, when the country reported new tests in the dozens and later the hundreds. But it’s not an increase from more recent weeks: In the week of April 6, the country also averaged fewer than 150,000 tests a day.

What the country needs to properly do testing, according to experts, is at least 500,000 tests a day. Some experts call for much more than that — millions or even tens of millions a day — but the general point is that the US needs to be doing multiple times the testing that it’s currently doing to be able to test everyone with symptoms and their close contacts…

The recent slowdown in new tests is driven by shortages in nasal swabs, personal protective equipment, reagents, test kits, and machines needed to run the specific tests required. According to David Lim at Politico, some labs also complain that the Centers for Disease Control and Prevention’s testing criteria — which prioritizes hospitalized patients, health care workers, and those vulnerable to the virus, such as older people — is holding back potential tests, leaving existing testing capacity unused.

To fix the gaps, experts argue, the federal government needs to relax criteria for testing, invest in new supplies and labs, and better coordinate supply chains to address, among other issues, chokepoints. States, with limited resources and little control of the national supply chain, simply can’t do this all on their own.

Such fixes, however, are easier said than done. Experts warn the next phase of testing will be much more difficult than the initial phase, which largely required getting existing labs to start doing coronavirus testing — the low-hanging fruit.

“We’ve made substantial progress ramping testing this month,” Scott Gottlieb, a former commissioner of the Food and Drug Administration, wrote in a tweet on April 10. “But many gains were made by getting players into fight (clinical labs, academic labs). Now we must expand lab capacity, platforms, throughput, test kits. Getting next million tests/week will be harder than getting first.”

This is one reason the plans to end social distancing are so grim: Not only do they suggest that some level of social distancing will be needed for the next year or so (until a vaccine or a similarly effective treatment is widely available) — which we don’t know if the country can sustain — but they call for a level of surveillance and testing the US simply hasn’t yet shown the ability and willingness to build and manage…

But unless something changes, America is simply not meeting the benchmark of aggressive testing that experts say is necessary to start to reopen the country. As eager as Trump is to get the economy going again, the US just isn’t ready to do it in a safe way yet.” (L)

“On Wednesday, Singapore reported 142 new cases of COVID-19 — the highest single-day record for the city-state. In the last week, Singapore had two record-breaking numbers of new infections — with 120 new confirmed cases on April 5 and 106 on April 7, according to data collected by Worldometer — after weeks of successfully controlling the outbreak within its borders.

The new cases have been connected to foreign workers living in compact dormitories, the Straits Times reported. The recent resurgence of infections has prompted the government to implement a lockdown, closing down schools and most workplaces for a month…

Singapore was one of several Asian countries whose coronavirus response efforts were hailed as a “gold standard” of how to bring an outbreak under control.

While many other countries have imposed city-wide lockdowns and ordered citizens to stay at home, Singapore relied on surveillance, quarantine, and social distancing to curb the spread of infection. The city-state boldly resisted aggressive lockdown measures to limit disruptions to companies and workers in hopes of softening the inevitable economic blow of the pandemic…

However, the recent spike of cases in Singapore underscored how easily the virus can spread even with social distancing measures in place — and it may give a glimpse at what the US may be in for if the government lifts the orders too early…

Vice President Mike Pence announced that the Centers for Disease Control and Prevention is considering loosening its guidelines for self-isolation.

Under the proposed guideline, people who are exposed to the novel virus could be allowed to return to work if they are asymptomatic, wear a face mask, and monitor their temperature twice a day, a person familiar with the proposal told the Associated Press.

However, as the Trump administration eyes loosening restrictions, some estimates show that the US has yet to hit the peak of its coronavirus outbreak. Some estimate that it could occur in late April or early May.

Experts, including those on the White House Coronavirus Task Force, warned that lifting restrictions too early could result in a “second wave” of COVID-19 cases in the country.

An epidemiologist told Business Insider that countries might need to impose new lockdowns every three months until a vaccine is available. Lifting lockdown measures could lead to a re-emergence of the virus. As residents emerge from their homes, go to work, take their children to school, and go shopping, people could be asymptomatic but still spread the novel virus to others.

On Wednesday, Dr. Deborah Birx, the White House coronavirus response coordinator, cautioned against reading “early signs of hope” and doubled down on maintaining social distancing measures.

“What’s really important is that people don’t turn these early signs of hope into releasing from the 30 days to stop the spread. It’s really critical,” Dr. Deborah Birx, the White House coronavirus response coordinator, said on Wednesday.

“So, if people start going out again and socially interacting, we could see a very acute second wave very early. We are really encouraging every American to continue to follow the guidelines for these 30 days,” she added.”  (M)

“Sloppy laboratory practices at the Centers for Disease Control and Prevention caused contamination that rendered the nation’s first coronavirus tests ineffective, federal officials confirmed on Saturday.

Two of the three C.D.C. laboratories in Atlanta that created the coronavirus test kits violated their own manufacturing standards, resulting in the agency sending tests that did not work to nearly all of the 100 state and local public health labs, according to the Food and Drug Administration.

Early on, the F.D.A., which oversees laboratory tests, sent Dr. Timothy Stenzel, chief of in vitro diagnostics and radiological health, to the C.D.C. labs to assess the problem, several officials said. He found an astonishing lack of expertise in commercial manufacturing and learned that nobody was in charge of the entire process, they said.

Problems ranged from researchers entering and exiting the coronavirus laboratories without changing their coats, to test ingredients being assembled in the same room where researchers were working on positive coronavirus samples, officials said. Those practices made the tests sent to public health labs unusable because they were contaminated with the coronavirus, and produced some inconclusive results.

In a statement on Saturday, a spokeswoman for the F.D.A., Stephanie Caccomo, said, “C.D.C. did not manufacture its test consistent with its own protocol.”” (N)

“Despite the campaignlike and hopeful title of the briefing — “Opening up America Again” — there’s still a very long road ahead for the overwhelming majority of the country. Consider that the 20 states, including D.C., with the fewest coronavirus cases make up just 11% of the U.S. population.

States with the most cases and the largest populations will have to act like mini-countries. It’s going to produce a patchwork of plans that could wind up looking pretty similar to the red-blue electoral maps, and there are still lots of questions.

1. How do issues with testing impact governors’ ability to meet the benchmarks laid out in the guidelines?

2. Will the reopenings give a false sense of security to rural places?

3. How will employers screen and do contact tracing?

4. How will travel work between states in different phases?

States will likely get to different phases at varying rates. So, how much of a gap will this create between states in different phases? And what about travel between those places? Until there’s a vaccine or a treatment, there’s no way to be sure there won’t be flare-ups or outbreaks that could lead to places with few cases, which may have relaxed restrictions, seeing unnecessary deaths.” (O)

“Across the country, governors are finding themselves caught between increasingly competitive pressures, several said on Sunday, as they balance maintaining restrictions meant to curb the spread of the coronavirus against growing frustration with the restrictions and the economic anguish they cause.

In Maryland and Virginia, governors said stay-at-home orders would have to remain in effect until those states begin to see decreases in the number of Covid-19 cases. Elsewhere in the nation, state officials said they would need to conduct far more testing before easing restrictions, and continue to face shortages of supplies and testing kits.

“We are fighting a biological war,” Gov. Ralph Northam of Virginia said on the “State of the Union” program on CNN. He added that governors have been forced “to fight that war without the supplies we need.”..

Public health experts have said testing would need to at least double or even triple to begin considering even a partial reopening of the country’s economy, and business leaders reiterated the message in a conference call with Mr. Trump last week…

Dr. Deborah Birx, the coronavirus response coordinator for the White House, also pushed back against criticism that enough people were not being tested, saying that not every community required high levels of testing and that tens of thousands of test results were probably not being reported.

She said the government was trying “to predict community by community the testing that is needed,” Dr. Birx said on the CBS program “Face the Nation​” on Sunday.​ “Each will have a different testing need, and that’s what we’re calculating now.”

On the ABC program “This Week,” Dr. Birx said she thought statistics on testing were incomplete: “When you look at the number of cases that have been diagnosed, you realize that there’s probably 30,000 to 50,000 additional tests being done that aren’t being reported right now.”

As some governors look to ease coronavirus restrictions, public health experts say the country needs at least half a million tests per day to safely reopen.

There are currently about 150,000 diagnostic tests conducted each day, according to the Covid Tracking Project. Researchers at Harvard estimated last week that in order to ease restrictions, the nation needed to at least triple that pace of testing.

When the host of “This Week,” George Stephanopoulos, asked Dr. Birx about that estimate, she said current testing levels were adequate.

“We believe it’s been enough in a whole series of the outbreak areas — when you see how Detroit has been able to test, Louisiana, Rhode Island, New York and New Jersey,” Dr. Birx said.

She said that a team at Walter Reed National Military Medical Center in Maryland was calling hundreds of labs around the country to determine exactly what supplies they need “to turn on full capacity, which we believe will double the number of tests that are available for Americans.” (P)

Worth Scanning

Inside America’s 2-Decade Failure to Prepare for Coronavirus

Top officials from three administrations describe how crucial lessons were learned and lost, programs launched and canceled, and budgets funded and defunded.

https://www.politico.com/news/magazine/2020/04/11/america-two-decade-failure-prepare-coronavirus-179574

The lost month. Trump says he took ‘strong action’ in February to stop coronavirus. Here’s the full picture

https://www.cnn.com/interactive/2020/04/politics/trump-covid-response-annotation/

He Could Have Seen What Was Coming: Behind Trump’s Failure on the Virus

An examination reveals the president was warned about the potential for a pandemic but that internal divisions, lack of planning and his faith in his own instincts led to a halting response.

The ‘Red Dawn’ Emails: 8 Key Exchanges on the Faltering Response to the Coronavirus

Experts inside and outside the government identified the threat early on and sought to raise alarms even as President Trump was moving slowly. Read some of what they had to say among themselves at critical moments.

How Anthony Fauci Became America’s Doctor, An infectious-disease expert’s long crusade against some of humanity’s most virulent threats., by Michael Specter, https://www.newyorker.com/magazine/2020/04/20/how-anthony-fauci-became-americas-doctor

The U.S. Approach to Public Health: Neglect, Panic, Repeat. Time to give new life to an old idea: A strong public health system is the best guarantor of good health., by Jeneen Interlandi, https://www.nytimes.com/2020/04/09/opinion/coronavirus-public-health-system-us.html?referringSource=articleShare

The Best Hopes for a Coronavirus Drug. If there is a way to stop COVID-19, it will be by blocking its proteins from hijacking, suppressing, and evading humans’ cellular machinery., by  SARAH ZHANG https://www.theatlantic.com/science/archive/2020/04/what-coronavirus-drug-will-look-like/609661/

What Will U.S. Health Care Look Like After the Pandemic?, by Robert S. Huckman, https://hbr.org/2020/04/what-will-u-s-health-care-look-like-after-the-pandemic

A watchdog out of Trump’s grasp unleashes wave of coronavirus audits. The Government Accountability Office is moving quickly to conduct oversight — and it’s got more protection than other Trump targets, by Kyle Cheney, https://www.politico.com/news/2020/04/20/watchdog-trump-coronavirus-audits-192272

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