MN health commissioner: 'This is going to unfold over a year or 18 months'

Just three weeks ago, the Minnesota Department of Health reported the state’s first case of the coronavirus. Now, Minnesota’s numbers are up to 398 cases and four deaths. And the United States has the highest number of cases of any country in the world.

At the center of Minnesota’s response to the health crisis is MDH Commissioner Jan Malcolm, who has been a regular at Gov. Tim Walz’s daily updates on the state of Minnesota’s health this week.

While Malcolm said she’s hopeful that social distancing will help in the long term, it hasn’t been able to “bend the curve” fast enough. A lot more cases of the virus are coming, and hospitals are working to make room.

Malcolm answered questions from Politics Friday host Mike Mulcahy and MPR News listeners about what we might expect from the rapidly changing situation. Here’s an excerpt from that conversation. The excerpts have been lightly edited for clarity.

You talked this week at a news conference about how we’re no longer bending the curve. Are you expecting a big surge of patients in hospitals? How will this play out, and for how long?

That's certainly what has been confirmed as these U.S. totals go up.

And what we're seeing here in Minnesota … [is] that because of the national lack of a comprehensive testing ability since January, we are a little hampered in knowing exactly how much disease is out there.

We've said all along [that] we know that for all the positive test cases that we can confirm with laboratory tests, we know there's more out there.

We've known for some days now that we have community spread and that we really need to be acting under the assumption that that this is widespread in all of our communities, whether or not you're in a county that has laboratory confirmed cases or not. We need to be acting as though we all are at low risk for exposure, because it's spreading in the community.

And one of the things that's difficult about this — I know everybody is looking for precise numbers, but there's just such a range of estimates out there about … how in every case that you can confirm, how many people might you assume are out there that don't have a confirmed laboratory test?

Those ratios just are really, really wide. So we really hesitate to say how many cases we think are out there, but we're planning around a range of cases and looking in close partnership with the health care systems at how many of those cases would be expected to be hospitalized.

Globally, we think about 15 percent of all the people that get infected need hospitalized level of care and about 5 percent of the total cases need ICU-level care.

As we get a better sense — and I think we'll get a better sense with each passing day — of how much community spread there might be, we can project forward from that, in terms of the number of folks who might be hospitalized over what period of time.

The onset between the time someone is infected and the time they show symptoms can be anywhere from two to 14 days … So as we get more cases, our estimates will get a little more precise.

It sounds as if the situation isn’t going to get much better. Are you just forced to go forward with the cases you're seeing?

It's kind of past the point when we can really bend the curve. I think that's true for this first wave. We are still very much hoping to bend the curve over the entire course of the epidemic. But in terms of saying [that] we can do something to prevent this first wave — I think, at this point, it's too late for that.

With the degree of community spread, that's all around the country and in Minnesota. So we have to prepare for an expected significant number of people being sick and needing hospital care over the next several months. But that's not going to be the end of the epidemic. This is going to unfold over a year or 18 months. And then we would expect over that period of time to be bending the curve or flattening the curve, as we say.

We actually have made some good progress on increasing our ability to test in the laboratory.

The state public health lab has been ramping up testing ever since we began testing. And additional laboratories are coming online in Minnesota, as well. The Mayo Clinic has has built up a significant amount of capacity. Certainly they serve as a national resource, but they're an important part of our Minnesota capacity.

Several other organizations of our health care systems locally are developing the ability to do testing in their laboratories. Many of our clinics and hospitals have contracts with laboratories nationally that are doing a fair amount of the testing.

So we actually have a fair amount of of capacity on the laboratory side. But now, the problem is the the supplies that are available — or not available — in the clinics and hospitals to actually collect the samples. So this global supply chain challenge has been and continues to be really vexing.

And we have to keep chasing the next thing that's going to be in shortage and try to anticipate that and build up the capacity. So the limitation on testing now is, to some degree, [on] the laboratory end, but equally much on the health care provider front end. We’re working on both.

The state has 235 ICU beds. Asking people to stay at home gives you more time to come up with more. How many more do you think you can add? How long will it take? And what are some of the challenges in doing that?

We're really getting better insight into those numbers — literally hour by hour. The health care systems around the state are just doing a terrific job of collaborating with us and with each other to get more real-time numbers.

Just to be clear, the available ICU bed number means literally the beds that aren't full today — and that number fluctuates day to day and hour to hour.

One thing that the hospitals are doing, and we're working with them on, is developing plans to move people out of the hospital — that are ready for discharge or maybe need a lower level of care for monitoring, to free up more of those beds for the critically ill, and converting some of the non-ICU beds into ICU beds.

That that work is is ongoing right now as the flu season winds down. More of those ICU beds, which are today occupied by flu patients, some of them will be freed up from the flu, but filled up by COVID patients.

We are working right now to get a good estimate with the health care systems about how much surge capacity they can create with the work they're already doing — just kind of moving things around — and where there might be the need for building up some alternative care sites to to help take some of that load off of the hospitals.

There’s a shortage of testing materials. But what about other medical equipment, like masks and gowns?

Minnesotans can feel good that we've got a structure in place through what are known as regional preparedness coalitions that now are linked together through a statewide coordinating center that's co-located with our state emergency operations center in downtown St. Paul.

So, we are getting better data all the time about what the supply situation looks like on the front line, and are developing systems to make sure that we get what [personal protective equipment] we have as we are making requests from the strategic national stockpile.

There's the strategic national stockpile. But the governor has also said he wants us to redouble our efforts in coordination with the health care systems — to to not only rely on the strategic national stockpile, but to be finding ways to procure this equipment. To really make sure that we understand everything there is to know about managing the supply chain, and talking with Minnesota companies that are manufacturing these products.

You know, they're ramping up capacity. And that's a wonderful thing. Some companies [aren’t] typically in the business of producing this equipment, but they could retool to produce some of what we need. So all of those conversations are going on right now.

How will I know if I came into contact with someone who has the coronavirus?

That's … why it's so important that we find positive cases as quickly as we can, both to make sure that those people get the care they need, but also to follow up with any of their close contacts.

So how it works is like this: We've got a really strong team of epidemiologists who follow up on each case that we're able to identify.

It starts when we get notification of a positive case. We try to immediately make contact with the patient themselves and do a detailed interview to ask them: What are their symptoms? When did they first notice their symptoms? Where have they been? Have they been traveling? Who have they been in contact with?

We look for contacts within the 24 hours prior to them noticing that they were symptomatic, and then following up with with all of the people that we can identify that might have been in contact with that person for the day prior to becoming symptomatic.

And then we can classify those contacts into people who are high risk or medium risk or low risk.

A high risk exposure would be somebody in the same household or an intimate partner. A medium risk might be somebody else who was in close proximity to a known case for more than an incidental contact.

So if you're in the same room with someone or passing by in the store [or] in the hall, that's a low-risk exposure. But if you're in close proximity to somebody for more than an incidental amount of time, that would be a medium risk. And you would be advised then, and we try to get in touch with everybody within 24 hours.

But obviously that gets more difficult as there are more cases and wider circles of contacts. … But all family members and close contacts are asked to quarantine for 14 days. And others who would be in the medium or lower risk are are called in and advised as to what to do.

I’ve heard that anti-malarial drugs could be a treatment for the virus. Is that true? And are there any other drugs in the works?

Part of the challenge here is, because this is a new virus, there aren't any known or established anti-viral treatments that that are proven [to be] effective against COVID-19. There are some clinical trials that are already beginning that some folks who are hospitalized are getting as part of a clinical trial.

There's a lot of research activity going on to try to develop new treatments. And that's one of the things we hope — that, by buying time, as we're trying to do with a lot of this social distancing strategy, and encouraging people to work from home, to not circulate much at all, except for very limited activities in the next couple of weeks, and then continuing to discourage larger gatherings and especially in kind of densely crowded spaces like bars and restaurants and so forth — why we're doing all these things to try to buy time is, in part so that we can build up the health care capacity … and so that researchers have time to help develop some of these anti-virals.

There's nothing [that] is effective that can be broadly deployed at this point, but there's a lot of work going on and we're hopeful that with all this activity that the pace of development of effective treatments will be rapid. But we still have to just do what we can do to prevent the spread of illness to begin with, and to take to take these really basic but effective personal actions to try to protect ourselves and to protect each other.

How much of a strain is this putting on health care providers, especially doctors and nurses?

That is … such a big priority of the work we're doing, to try to make sure we can build up health care capacity to be able to handle the influx of cases that we have to expect — just based on the degree of community spread that we see.

Making sure that health care workers have the equipment that they need and that we can figure out how to how to support them is just so, so very important.

They are there on the front lines. They're putting other people before themselves.

The stress that this adds, I'm sure is enormous.

The care and support to our health care workers is certainly one of our highest priorities. And I know the health care systems are are looking at that, too.

How do they deal with staffing pressures and how can we how can we help rotate staff? Are there things that we can do? [That] volunteers can do, to help do some of the functions that need to support health care providers?

One thing I would mention [is that] the Walz-Flanagan administration, the Department of Education, our children's cabinet have worked so hard to make sure that we are building up and supporting day care providers. [That’s] just an example of how important it is for our health care workers that need to be at work and are working long hours to have a place for their kids.

So that's one of the ways that that our administration is really trying to do what we can to support child care providers in our schools who are serving as critical resources to families, even when they're not doing in-classroom teaching, to try to extend the capacity of of those critical workers to keep doing what they are doing for us.

I think I just recovered from the coronavirus. Can my plasma be used to help people?

That's a very generous instinct. And it's right-on in terms of one of the areas of promising science.

They're being worked on right now, the development of antibody tests so that we can get folks who who have recovered, who now have some immunity and who now are not an infectious risk to others to be able to to do two things: Both return to work and restart our social activities, but also potentially to, as you say, donate plasma that could be useful in treatment.

There are actually some folks working on that right now. There's not anything that exists today, but it's it's under development. That's one of the things we're trying to figure out how to do, is to be in touch with people who who have had the disease [and] do exactly that.

I would suggest that you talk with your your provider about the specifics of what symptoms you've had, and see if they have any suggestions about how you might plug into any of those coming trials.

What are you seeing in nursing homes? Are you seeing clusters of cases? Are nursing homes ready for this?

That certainly has been and is a top priority for us.

I really want to commend our long-term care providers around the state who have taken this very seriously and have been working hard for four weeks, to try to get ready.

Having observed what happened in Seattle, we know how quickly something can get out of control in a congregate living setting.

Our long-term care providers have been working with us to ramp up infection control procedures. They proactively put in place visitor restrictions, which I know is really hard for families and residents, but it's for the protection of the residents and the staff.

We have had cases in in a number of congregate living settings, including skilled nursing facilities and assisted living and memory care units. And we've got a pretty tight protocol in place when when we get cases in a long-term care setting: A series of very specific things happen, and a team of nurse, case manager and epidemiologists are assigned to check in with that nursing home or assisted living right away, and daily to be advising them on … essentially just having everybody shelter in place within the facility.

There's a lot going on. But it is very much a an area of concern, an area of focus as we know how very vulnerable that population is, and how important it is to move quickly. So I think we're doing a lot and continue to be really concerned about that as a potential vulnerability.

Social distancing is putting pressure on the economy. Do you have any sense how long it will last?

I think that, as the governor has said, we're really trying to be smart about this and and strategic about how long the kind of community-wide social distancing lasts, versus how long we stay focused on environments that are of higher risk for it for transmission.

I can't say much beyond the fact that the orders that are in place now are for specific periods of time.

But the governor has always said we will continue to assess based on the best information we have at the time about whether those orders need to be extended. That will just depend a whole lot on what we learn in the next couple of weeks from our own community and from from success, potentially, in other communities that are doing doing things some similar or some different than what we're doing.

So I think it's everybody just needs to kind of stay tuned and stay flexible, and we'll keep you updated as much as we can.

How will you be able to judge whether the social distancing and the “stay home” order has actually worked?

We're trying to build a whole number of indicators to track how much has social contact been decreased — and there are interesting ways to measure that through traffic, through other metrics.

So that's one of the things that we try to make estimates of. If we reduce social contact by a certain percentage, what does that do to the transmission rates, and so forth?

We'll see it in the in the case counts and in people seeking health care with a several-week lag time.

But we're also not just relying on laboratory-confirmed tests. There are other data systems that we can look at to see what's happening in emergency rooms, what's happening with just some of the regular disease reporting that we get into the department.

We're going to try to pull information from every angle to try to get as real-time an indication of whether things are working as we can. But that's going to be also affected by the fact that there's a lag time between exposures and development of symptoms and then seeking care that would lead us to to identify a case.

How do you respond to people who believe this is all an overreaction?

Well, we understand, that people are concerned about the disruption to daily life — [and] very, very aware of the economic consequences of all of this.

But I guess it's probably natural to say, ‘Well, we don't have that many cases in Minnesota’ or ‘We don't have any cases that we know of in our county. So isn't this an overreaction?’

But the problem is this: We are vulnerable as a community to this. We don't have any immunity to this new virus. And without antivirals or a vaccine, which is a good year [or] year and a half away, we really, truly are all susceptible to this.

And if we don't take action now, we know from watching other countries and other communities that things can can drastically change — and change quickly — and that almost everybody around us will be sick. And [it’s] true [that] for many of us, it'll be a mild illness. But for some, it's really life-threatening and we need to protect them as well as ourselves.

Health officials for weeks have been increasingly raising the alarm over the spread of the novel coronavirus in the United States. The disease is transmitted through respiratory droplets, coughs and sneezes, similar to the way the flu can spread.

Government and medical leaders are urging people to wash their hands frequently and well, refrain from touching their faces, cover their coughs, disinfect surfaces and avoid large crowds, all in an effort to curb the virus’ rapid spread.

The state of Minnesota has temporarily closed schools, while administrators work to determine next steps, and is requiring a temporary closure of all in-person dining at restaurants, bars and coffee shops, as well as theaters, gyms, yoga studios and other spaces in which people congregate in close proximity.

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