Coronapod: The overlooked outbreaks that could derail the coronavirus response

Benjamin Thompson

Welcome to Coronapod.

Noah Baker

In this show, we’re going to bring you Nature’s take on the latest COVID-19 developments.

Benjamin Thompson

And we’ll be speaking to experts around the world about research during the pandemic.

Amy Maxmen

I really don’t know how this plays out. We also don’t know a ton about this virus, so there’s so many open questions. I just have a really hard time making predictions because I don’t know how the outbreak is going to change.

Benjamin Thompson

Welcome to episode eight of Coronapod. I’m Benjamin Thompson, once more in the South London basement, and I’m joined, as always, by Noah Baker and Amy Maxmen. Noah and Amy, how are you both doing today?

Amy Maxmen

I’m doing good.

Noah Baker

Yeah, I’ve spent an awful lot of time in my little pillow fort today because I’ve been recording various bits of voice overs for films and a few other things, so it’s been quite a comforting if not warm day for me.

Benjamin Thompson

Yes, the duvet fort does tend to raise the temperature. I’m actually in shorts right now, just to paint some pictures with words. All three of us are able to isolate, and I think we have been doing so for the duration we’ve been recording this show, but it’s not necessarily the case for everyone and all populations and, Amy, something you’ve been looking at this week is groups who maybe can’t help but congregate and the efforts that people are putting in place to try to protect them from COVID-19.

Amy Maxmen

Right, so, we live in a way where we’re quite privileged to be able to isolate and do our podcasts from home, and I think a real lack of attention has been put on people who can’t isolate, who either have to go to essential jobs that are quite dense or they live in shared places – these are like nursing homes or homeless shelters. So, we know for a fact that the biggest outbreaks in the US has been in these sorts of places. They’ve been in nursing homes. They’ve been in meatpacking plants. They’ve been in jails. Anywhere where people don’t have the agency to just say, ‘I’m going to go and keep to myself or just be in a bubble with my family.’

Noah Baker

That’s a really dangerous situation for those people, but one of the things that you’ve been looking at is how that could also fit into the wider public health situation for everyone because it’s not just a horrible situation for those people to be in. There may be broader impacts of this.

Amy Maxmen

Yeah, exactly, I think the truth is these are very vulnerable places, so it’s terrible for the people who are there or who work in these places, and it also means in as much as we are one society or one country or one world, we can’t get rid of the outbreak by letting these things happen. I think a strong example is Singapore. They did so beautifully in their response. They really stomped it out. But then they realised they had an explosion of cases among migratory workers who were in extremely crowded dormitories with something like 12 beds per room. When you overlook these places, it’s bad for everyone.

Benjamin Thompson

In particular, you’ve been looking at researchers and medics working with homeless populations in the US. What sort of numbers are we maybe talking in terms of disease burden in this population?

Amy Maxmen

So, not a ton is known about what’s going on in homeless populations because there’s been a huge lack of testing. I started getting interested in this because I’ve been reporting on testing and a number of the groups I’ve been talking with – the University of Washington, the University of California, Berkeley, the University of California, San Francisco, Boston University – a lot of them have this enormous testing capacity that a lot of hospitals don’t really want, but they’ve been now working with communities to see how else their tests can be used. And what they’re finding, I think the overall look is just it’s there and there’s a lot of cases. So often, the testing criteria right now in many places is that only people with symptoms are tested, so a homeless shelter might screen everybody’s temperature and then if somebody has a fever, then they get a COVID test. Well, what these groups are finding is that the number of people who are asymptomatic – and let me go back to that in a second – is really high, more than half of the people. In one shelter in Boston, 147 people tested positive. Only one of them had a fever, and a low number – I think something like 8% of them – had a cough, which means just screening by taking people’s temperatures and assuming you’re going to catch it like that is going to be way too slow. By the time that happens, it’s out of hand before you’ve even noticed it. I said let’s come back to the part about asymptomatic because a slight caveat there is that anybody who works with the homeless has told me that there’s such a high baseline of health problems so a lot of people have a cough anyway, so it’s kind of hard to say ‘completely asymptomatic’ because it’s more that it’s just also hard to distinguish it from normally just feeling bad.

Noah Baker

And I guess this kind of problem of asymptomatic spread, that exists in the whole population, but it’s amplified so much by these close living quarters of these people, and that’s what really makes a difference here.

Amy Maxmen

Exactly, so the transmission dynamics that you’re going to get in a group setting, any group setting – whether that’s a jail or a nursing home or a homeless shelter or any place where there’s dense conditions – you’re going to get a higher rate of spread.

Noah Baker

Out of interest, there’s an awful lot of modelling that’s been done about how the virus might spread among communities. Has there been much epidemiological work done that takes into account these sort of close living quarters or people that live in these ways?

Amy Maxmen

That’s a great question. Even before the outbreak began, one of the researchers I’ve talked to before, Helen Chu at the University of Washington, she had actually started a study to look at how influenza moves through homeless communities because that was exactly her thought. We need to model the spread of this and also think about what do we do to stop that spread. If we can understand the transmission dynamics then we can stop, say, an influenza-like pandemic. And then this actual pandemic hit, which isn’t the flu but is also very transmissible, so what she’s trying to do and what other researchers I’ve talked to are trying to do is to do exactly that, to model the spread of how this moves so they can figure out how often do you have to screen people, how many people have to be screened and also, if they could get data on the speed of transmission in different settings. To be clear, in the US, people who are homeless have different situations. There’s sort of shelters that might house people who are recently out of jail. There’s shelters where people who are homeless can come in and out. In California, 70% of the homeless are unsheltered, so they actually sleep in what we call tent cities or encampments. And then now, in the US, a lot of states have begun trying to move some homeless people into big stadiums where they have cots spaced out six feet apart. There’s also been moves to distribute face masks. But this is all done sort of without much evidence about what has an impact. I mean are people safer outdoors or are they safer indoors? And for the face masks, I talked to one researcher who is studying transmission dynamics in nursing homes. A lot of the residents in these nursing homes just can’t really wear face masks well. She was sort of describing how a man who has dementia is wandering around with his face mask kind of around his neck, it has coffee stains on it, and she just thought some of the things that she’s learning might be similar to in homeless shelters. It sounds great to say everybody should wear a face mask, but you and I both know we’re talking about how we don’t want to go hiking with a face mask on. Now, imagine if that’s your everyday life and you already have these huge concerns over your head like having no home. A face mask is just not going to be your number one priority. So, there’s a lot to be said about trying to back up the recommendations with real evidence.

Benjamin Thompson

You talk about care homes there and, certainly here in the UK, there’s been a lot of talk about a lack of access to face masks and personal protective gear. Are resources an issue in efforts to try and stop this virus among the communities you’ve been looking at?

Amy Maxmen

Yeah, they’re a huge issue. So, number one, we know that we have a testing shortage. That is very real. But some of the researchers I’ve talked to, even when they have the tests, a pushback that they’re hearing from counties and states is that they don’t really want to survey lots of people in, say, a homeless shelter because there’s a lack of research about what to do if they do test positive. So, if you have somebody who tests positive, now they don’t have a home so you can’t isolate them. They don’t have health insurance so getting them medical care is an issue. Maybe you have to also provide food or some sort of income, and the same thing with people who are low socioeconomic status. If you’re telling them not to go into work, they need to have some sort of income to support that.

Noah Baker

I guess in a world where there is a limited number of tests for whatever reason that may be, because of these increased transmission dynamics of people living in close quarters for these various reasons, is there an argument to be made that public health response should focus more on those people with its limited testing resource than it should on others because they have this increased transmission dynamic? They could be acting almost as a reservoir that could cause a problem further down the line. Is a test on someone living in close quarters more valuable than a test on someone else, which is a horrible thing to say because, of course, a test is valuable everyone?

Amy Maxmen

I think there’s a real case to be made and I think this is exactly the kind of thing that could use research. I get emails from the various health departments in California saying, ‘Okay, now we have all these tests, anybody can get tested. Enter your ZIP code and you’ll find a testing spot nearby.’ I think they are prioritising people with symptoms. But yeah, I feel like there should be some real thought here about where we’re going to get the most bang for our buck. Certainly, people they test, that’s true, but testing somebody like me who, let’s say, I don’t have any real symptoms but I just want a test. Certainly, those resources could be better spent and I’d like to see a very thorough kind of assessment about how this works.

Noah Baker

I spoke yesterday to the head of NIDA, the National Institute on Drug Abuse in the USA, Nora Volkow – you’ll hear more from that interview later in the show – but one thing that she raised to me which she was very, very concerned about is that people that have substance use disorders, people that suffer from addictions, are being somewhat overlooked at the moment, and there is very little data about how people that are, for example, addicted to methamphetamines might have a different risk or a different transmission dynamic when it comes to COVID-19, and at the moment, they’re just desperate for data. So, they’re putting out calls asking for more data from all of their grantees to study this because they can’t model it until they know more about what’s happening, but the concerns are very much there.

Amy Maxmen

Yeah.

Benjamin Thompson

Has anyone given you any thoughts on long-term strategies? I only say because here in London, a lot of hotels, which of course, aren’t being used by paying customers, are being used to shelter and to house people who are homeless, but of course, as we talked about the other day, people are looking to reopen the economy and these hotels will eventually start reopening as hotels, and many of these people will see themselves potentially back on the streets and then we’re back to maybe square one in terms of disease transmission and so forth. What have people been telling you about ways that they could try and mitigate that?

Amy Maxmen

Yeah, as far solutions go, the same thing is happening here. Counties are buying or renting out hotels and motels or even dorms, they’re talking about, to house the homeless, and I think that’s a great move. It’s still not as much as we need and there’s still a lot that are empty, so I think before thinking about what do we do when everybody’s back, I just think a lot of the people I’m talking to are just saying, ‘Let’s just freaking use these places and worry about what happens when everybody has to go back later.’

Noah Baker

I’ve seen quite a few news reports of cities in the UK that have no people sleeping rough anymore. They have found ways to house the rough sleeping population in Bristol, for example, which for me, made me feel warm and happy that that was happening and that there was a method that was found to do that. However, my concern is, well, they can do it right now because hotels are empty, but what happens when this all goes away? It’s not like homelessness has been fixed, which is kind of the thing that makes me feel warm. Oh, now we can find a way to fix this whereas previously we couldn’t, which is actually maybe kind of depressing.

Amy Maxmen

No, it is an interesting point that I forgot to mention that, thanks. Somebody I was speaking to who works with the homeless regularly, she was like, ‘Maybe this shows like we can actually do stuff here. It doesn’t necessarily have to be in hotels but there’s other vacant buildings and vacant homes.’ So, she’s saying this shows we can actually give people temporary places to live and they’re also trying things like telemedicine and new ways to get medical care to people. So, right, this kind of shows if there’s a will, there’s a way to do this. We just happened to need a pandemic to show that it’s really important.

Noah Baker.

Again, what a mixture of feelings about the phrase ‘we needed a pandemic to show this is important’.

Amy Maxmen

I prefer no pandemic.

Noah Baker

I think I agree with you there. I think we all prefer no pandemic.

Benjamin Thompson

I mean you’ve spoken to researchers on the ground who are working with homeless populations, for example. Are we able to draw parallels with other groups who are unable to avoid congregating, like in prisons, for example?

Amy Maxmen

Yeah, I mean the data we do have from the US is that prisons have been a huge source of outbreaks. It’s one of the top three sources of outbreaks. The CDC put out a report yesterday about prisons. I think what was kind of shocking to me was the lack of data they have. A number of jurisdictions – I think 30% of jurisdictions in the US – don’t report their prison data. But okay, all of those caveats aside, we know that there’s about 5,000 infections among detained people and then another almost 3,000 among staff who work in prisons and 88 deaths of incarcerated people along with 15 deaths of staff members. So, that’s collected from the US but it’s certainly an underestimate for the reasons that I said. So, what prisons are trying to do here is a lot of prisons are letting inmates out early and they say it’s people who were convicted of non-violent crimes, but I spoke to one person who runs transmission homes for people who are out of prison and who have to now get on their feet again, and so they help them find jobs and also give them a place to live in the meantime because a lot of times they don’t have somewhere to go. He’s having to turn them away because the prisons here aren’t testing people before they release them and in addition, he doesn’t have the resources or ability to test people unless they have, say, a fever, which we know is not a very good way to detect COVID, so he’s afraid to let them in because it could infect his whole group.

Noah Baker

It’s such a difficult situation. I feel like different social groups all have so many specific things that need to be thought about that affect them in different ways, and it’s difficult for someone like an epidemiologist to capture all of that information, but it’s really necessary because they could be really significant.

Amy Maxmen

Yeah, and I think the researchers I’ve talked to, what they really want to do is make evidence-based policy. Even if it’s, as I think one researcher Margot Kushel at UCSF, the way she put it to me was like, ‘We just at least need to figure out the best of the bad choices.’ So, the ideal choice is everybody gets their own home or their own apartment. Now, if we don’t have that, what is the best choice we can make? And another researcher pointed out to me that we might see similar things, very different but similar in that as the economy opens up, a lot of schools want to open up in September. University colleges, they definitely want to start work again. Researchers at labs want to get back in their lab and do work. So, what he was pointing out is we also need a similar kind of system for how often do we screen, how often do we test, how do we make this less deadly when people start getting back together and what if the dorms fill up again? There needs to be some kind of evidence-based system for stopping the spread of COVID within those groups.

Noah Baker

Absolutely, I know here in the UK, so much of how any kind of large-scale and centrally controlled response to anything is based around a postcode. It’s sort of part of our system. You need to have an address in order to be able to access everything. Like even in my life, I mentioned on the podcast last week that I live on a narrowboat, so that means that in London that I have no fixed address, and so I have no postal code and so I can’t register at a doctors. They won’t let me because the whole system is based around a postal code, and it’s the same for people who have no fixed address in London because they are homeless, for example.

Amy Maxmen

Oh, that’s interesting. For this story, I had actually reached out. Doctors Without Borders is working with the NHS to, I think, have homeless clinics, but I wasn’t able to find out much more about how they’re working more broadly. I think it might just be on the clinical side of it.

Noah Baker

And don’t get me wrong, we do have a social care system which does have ways to get around this, but it’s still hard when you want a big, global response to try and get around these sorts of problems.

Amy Maxmen

For sure.

Benjamin Thompson

Well, let’s bring it home again, team. Let’s talk about good things this week, and I think it’s probably my turn to go first this time, and my good thing this week is a personal one, I have to say, and here we are in, what is it, week eight or nine of lockdown, and my darling wife said to me, ‘Let’s go on a date. Where do you want to go?’ To which I obviously looked at her quizzically like, ‘Somewhere else in the flat?’ And she said, ‘No, anywhere you want. Where do you want to go?’ So, we spent the evening going to the Taj Mahal and we went to the Colosseum in Rome, we went to the Louvre. The Rijksmuseum in Amsterdam has an amazing app where you can have a little look around some of the art there, and it was nice to spend an evening with some aesthetic beauty, and looking at Rembrandt’s The Nightwatch on an iPad mini, that’s the way to look at that painting, right? I mean it’s one of the greatest paintings of all time and looking on a screen that’s about three inches across is definitely the way to take it in. But just for a sweet couple of hours, it was nice to remember that there is a world outside of the South London flat.

Amy Maxmen

That’s cute. I love it.

Benjamin Thompson

Amy, how about you? What have you got for us this week?

Amy Maxmen

Well, I have to admit I secretly like enjoy dark humour. I just do. I’ve reported Ebola in a couple of places and I have heard some funny jokes, and I think somebody once told me during the Ebola outbreak, ‘If we’re not laughing, we’re crying.’ So, I got a text from a friend that I had met in Nigeria and she texted me this new list of words to introduce to the Oxford English Dictionary and it’s funny so I’ll read a couple of them. Coronacoaster – the ups and downs of your mood during the pandemic. Quarantinis – experimental cocktails from whatever random ingredient you have left in the house.

Benjamin Thompson

Oh, I have had a coronatini or two in the last few weeks, don’t get me wrong.

Noah Baker

I actually want to interrupt you because my one good thing is coronatinas. That is it. Because I have to say, I’ve been working an awful lot more than regularly this week and my coronatini at the end of my day has been amazing, and we’ve been having to get more and more creative, shall I say, with what goes into the coronatini because we’ve been running out of spirits, and I actually found a bottle of honey rum. It is very sweet.

Amy Maxmen

That’s perfect.

Noah Baker

But it worked. It was delicious. So, I have surprise coronatini every day at the end of the day and it is bringing me joy.

Amy Maxmen

That is hilarious. That is super hilarious. Let’s see if she has any other funny ones here. There’s a whole bunch of them. Furlough Merlot, which needs no explanation. Coronadose – when you’ve overdosed from bad news from consuming too much media on the pandemic. This is me. The elephant in the Zoom – the issue during a video conferencing call that nobody mentions that one participant has dramatically put on weight.

Benjamin Thompson

Goodness me.

Noah Baker

That’s also me. You just keep listing me.

Amy Maxmen

Laughs. Have you noticed I don’t use video for our calls?

Noah Baker

Laughs. Oh dear.

Benjamin Thompson

Wonderful, well, let’s leave it at that then, both. Amy and Noah, thanks so much for joining me and look forward to talking to you both next week for episode nine of Coronapod.

Amy Maxmen

Thank you.

Benjamin Thompson

More from Amy next week. Up next now, Noah’s back and he’s been finding out how the pandemic has affected substance misuse treatments and research.

Noah Baker

Nora Volkow is the head of the National Institute on Drug Abuse, or NIDA, in the USA. NIDA’s mission is to develop interventions which can prevent and treat addiction and drug use disorders. But since the COVID-19 outbreak hit, the research they fund has been really significantly impacted, and Nora herself is deeply concerned about how the coronavirus could impact those with drug use disorders. I called her up to find out a bit more, and started by asking her specifically about those concerns.

Nora Volkow

Yes, certainly, I mean I think there are two components to it. One of them is the scientific component. I mean we’re a scientific agency. But the other side of it is the consequences that COVID has for people suffering the diseases that were studying, the people that are out there right now living this sort of nightmare.

Noah Baker

Okay, so, first off, how is the science being impacted, the research projects that NIDA funds?

Nora Volkow

Many of the laboratories have had to close down. Many of the clinical projects are, right now, on hold because they cannot recruit patients because their hospital systems cannot accommodate for research. So, from the perspective of research, this is slowing us down enormously. But even more urgent and tragic is the reality that people that are suffering from addictions, and their families, are having to struggle with COVID. Drugs – whether it’s legal like alcohol or tobacco smoking or illegal like cocaine, methamphetamine or heroin – produce marked damage to our body, and particularly vulnerable are our lungs and our heart and our cardiovascular system and our immune system, all of which are basically targets of COVID-19. And as a result of that, there is an enormous concern that people that are addicted to these drugs, that are taking them regularly, are at a greater risk of having much worse outcomes, much more adverse outcomes.

Noah Baker

The concerns are there. Are there people in NIDA or elsewhere that are trying to study that clinically at the moment?

Nora Volkow

We are asking for urgent submission of supplements among grantees that can start to look at this because the epidemic is too new for us to understand how someone that has substance use disorders is responding to the COVID infection itself. The substance that has been studied the most is cigarette smoking. So, we have several reports from China. There have been a couple of reports that have started to emerge from other countries. The data is very mixed. Overall, if you look at it, it does appear that people that have COVID that were smokers have higher mortality rates and worse outcomes. But then there are some papers that are hinting at the possibility that the risk of infection may be lower among those that are smoking cigarettes, perhaps because nicotine could have a preventative effect, and that’s an interesting theory that needs to be investigated.

Noah Baker

And what about other drugs? Do you have any data on things like opioids?

Nora Volkow

We have no data on opioids, the same thing with methamphetamines or cocaine. These are drugs that produce massive vascular constriction, so we’re specifically, right now, requesting researchers to put supplements to their current grants so they can start to evaluate how COVID his affecting their patients, and we want this to emerge rapidly because there is an urgency to gain this knowledge so that we know how to treat it.

Noah Baker

And beyond the physiological impacts, there’s also a real risk to people that are currently undergoing treatment for substance use disorders. Trying to access that treatment is pretty tricky at the moment.

Nora Volkow

As part of social distancing, the support systems that normally holds them together, helps them hold together – including syringe change programmes, including group therapy like Alcoholics Anonymous – are basically no longer present. Also, the support systems that provide them with their therapy, for example, whether it is methadone, the methadone clinics are actually curtailing the number of patients that they can see on a given day. These are structural factors that have changed the social systems that we rely on that are very important for all of us but crucial for people that are fighting with a problem with substance use disorders and that are aiming to achieve or are in recovery, and indeed, we are getting reports in treatments programmes that patients that have been stable for a long time are relapsing.

Noah Baker

And there’s one more potential risk which you have highlighted which is really about the overlap between those with substance use disorders and other social factors. Tell me about that.

Nora Volkow

When you take drugs, you actually undermine not just your social systems but actually your standing in a society, and as a result of that, the likelihood of you becoming homeless is much greater and also the likelihood to be engaged in the justice settings. Whether it is homeless or you are in prison or jail, those are environments where infections actually can very rapidly disseminate.

Noah Baker

Right now, around the world, epidemiologists are modelling the impacts of COVID-19. They’re trying to find out more about the way the virus is spreading. Is there much of an understanding of how people with substance use disorders might fit into modelling like that?

Nora Volkow

That type of modelling has been done for infectious diseases, including the substance using population, most notably for HIV and the other one for which there has been a lot of modelling done is for hepatitis C. For both of these infectious diseases, drug use, most notably injection drug use but not just limited to injection drug use, are very significant sources for fast dissemination of an epidemic. But what is it for COVID in drug using populations? The risk for infection is, to my knowledge at this point, unknown as it compares to that of other populations that are not taking drugs.

Noah Baker

A lot of scientists around the world are responding, a lot of agencies are responding to the outbreak and they’re trying to do what they can. What is NIDA’s priority right now and what’s your priority in response to the COVID-19 outbreak?

Nora Volkow

My priority, first of all, is to ensure that evidence-based treatment and prevention that relates to substance use disorder and its comorbidities are deployed and implemented and sustained. That’s the priority. How do you do that? We all have to come up with solutions in vivo, in life. But learning from it, evaluating the outcomes so that then we can select which ones are the ones that lead to the best results, is what science does, and that’s what we’re building, hopefully through these supplements to grantees that we have, across different set ups.

Benjamin Thompson

Nora Volkow there. If you’d like to find out more about her life and work, Nature published a profile on her a few weeks back, and I’ll put a link to that and everything else we’ve talked about in today’s show notes. That’s it for episode eight of Coronapod. Don’t forget you can reach out to us on Twitter - @NaturePodcast – or on email – podcast@nature.com. There’ll be a corona-free edition of the regular Nature Podcast on Wednesday, and we’ll be back with episode nine of Coronapod next Friday. I hope you can join us then. Until next time, I’ve been Benjamin Thompson. Stay safe.