Grand Rounds may have taken a vacation last week, but the coronavirus did not. Dr. Bob Wachter returned to his position as moderator this week to discuss the alarming spike in coronavirus cases across the country and in California, as well as the questions surrounding two critical institutions: schools and prisons.
“COVID has put every institution in our lives to the test,” Wachter said, noting the economic toll of the virus. “It’s hard to think of two sectors more challenged than schools and prison.” The solutions, he said, are anything but straightforward.
But, before Grand Rounds experts dove into the complexities of reopening schools and releasing individuals from prisons, crowd favorite Dr. George Rutherford, wielding an arsenal of graphs and maps, stepped in to discuss the increase in cases nationwide.
The first slide, he said, “is the most telling slide about how things have gone sideways in the U.S.,” compared to Europe, Japan, and Canada.
Rutherford described how the U.S. case count has “gigantically skyrocketed,” as more than 59,000 new cases were reported yesterday — the most ever reported in a single day. Five states set-single day records Wednesday for new cases with “massive rises” in the Southeast and South involving young people.
California, too, is troubling, with close to 300,000 total cases. Rutherford said he believes the increase began after Memorial Day.
Community transmission is driving the increase, and those have been triggered by fewer restrictions — especially in Southern California. The most affected groups continue to be Latinx essential workers in families living in low-income, dense housing, a fact well-established in San Francisco as a result of UCSF’s partnership with the Latino Task Force in the Mission.
After showering Grand Rounds viewers with some depressing stats, Rutherford administered a dose of hope when he discussed the decreased COVID-19 transmission and infection rates among children.
Children and the coronavirus
Rutherford cited a study of nasal gene expression that found that children under 10 years of age had significantly less expression of ACE-2 than older children and adults. This gene is important in the physiology of COVID-19 infection because the ACE-2 is the receptor where the coronavirus binds to infiltrate the cell. Hence, fewer receptors equals less disease, in Rutherford’s words.
A mere 1.7 percent of reported U.S. cases are in people under 18 years old, and an Icelandic study suggests there is little transmission among young children. Other studies suggest that most transmission among children occurs from household contacts as opposed to schools. However, Rutherford did mention that the number of cases in children is increasing and that the multisystem inflammatory syndrome associated with COVID remains a problem.
What does this mean for reopening schools? During Grand Rounds, Associate Professor at UCSF’s department of Pediatrics Dr. Naomi Bardach discussed the potential risks and benefits of in-person classes.
Schools’ quandary: remote or reopen?
Despite low infection rates, Bardach noted that “children bear a large brunt of the disparities” of COVID-19, including deepening economic disparities for children with low socioeconomic status, as well as increasing anxiety and depression. Moreover, she noted, entrenched gender inequities mean “women shoulder the burdens” of childcare and homeschooling. There are also signs of increased domestic abuse and intimate partner violence.
That said, the challenges of reopening schools are numerous: transmission, finding the money to buy supplies such as soap and paper towels, and an older workforce – over one-third of the state’s teachers are over 50 years and many have chronic illnesses.
Children, however, seem to be less of a problem. Studies now show, she said, that young children are not aggressive transmitters and, if infected, they have milder symptoms. However, it’s unclear how infectious middle schoolers are. High schoolers appear to be more infectious than young children.
So should schools reopen? Yes, she said during Grand Rounds. The benefits of reopening with safety protocols likely outweighs the risks. Bardach cited a study that quantified those risks. It found that school closures contributed little to epidemic control, preventing only two to four percent of deaths.
“Data suggests reopening is possible with measures in place, especially if adults follow social distancing, masking, and public health recommendations,” she said, adding that symptom screening and testing will be part of the curriculum.
“The disaster happening just north of us”
Next up was Dr. Brie Williams, the founder and director of Amend at UCSF, a program that “works to transform correctional culture inside prisons and jails and reduce the debilitating health effects of those environments” according to its website.
Grand Rounds viewers who thought the national outlook on COVID-19 was grim were hit with a devastating blow as Williams shared statistics about COVID-19 in our nation’s prisons. Today there are over 70,000 cases of COVID-19 among prison staff and residents — a number Williams believes is likely underreported.
Williams then turned “the disaster happening just north of us,” in Wachter’s words: the massive outbreak at San Quentin State Prison. With over 3,400 incarcerated individuals, San Quentin has 427.9 COVID-19 cases per 1,000 people compared to 6.1 cases per 1,000 people statewide.
Williams painted a haunting picture of what a “pretty well-resourced” prison in California looks like: one with overcrowding, antiquated facilities, poor ventilation (often by design), limited staff testing, delayed test results, and terrified residents and staff.
“There are debates about COVID passing through masks,” said Dr. David Sears, Amend’s director of Healthcare Quality, as he discussed how easily COVID can spread in prisons. “Nobody debates if COVID can pass through bars.”
Over 50 percent of San Quentin’s population is over the age of 50 and hundreds have underlying COVID-19 risk factors, according to Williams.
She shared a quote from a prison guard, who said, “we no longer call ourselves essential; we are sacrificial.”
“Residents of course are also terrified,” Williams said, describing how 16 cases of COVID in San Quentin June 13, when the receiver asked Amend for recommendations, exploded to a jaw-dropping 1,477 in a matter of weeks.
Williams traced the outbreak back to May 30, when 120 people were transferred by bus from an Imperial County prison, suffering from an outbreak of its own. Off those, 14 tested positive for COVID-19 on arrival.
San Quentin’s weekly COVID-positivity rate is “quite alarming,” said Williams, who noted that it was almost 75 percent at one point. About 60 people from San Quentin are now in community hospitals receiving treatment, and seven residents have died. The California Office of Emergency Management has established an incident command center and the UCSF Division of Occupational Health has devised a plan for new testing and housing measures. A 100-person field hospital at San Quentin will be opened later this week.
Norway and North Dakota have successfully limited outbreaks in correctional facilities through thinning the prison population, Williams said.
“With overcrowded, unsanitary conditions we will have more and more spread,” Williams said, advocating for the release of “lifers” who have less than three percent recidivism rates and those who have attended tens of probation hearings. “Our society has relied on over-incarceration and warehousing and overcrowding of prison systems, and many people like lifers can be safely released into society.”
See our previous Grand Rounds Coverage here.